Women's Free-text Comments on their Quality of Life: An Exploratory Analysis from the UK Standardisation of Breast Radiotherapy (START) Trials for Early Breast Cancer

Aims

Exploratory analysis of patients' unsolicited written comments in the first 2 years of the Standardisation of Breast Radiotherapy (START) trial quality of life study highlighted a potential effect of non-treatment-related problems on the ratings and interpretation of patient self-reported questionnaires. At 5 years of follow-up all eligible subjects were invited to write comments to further explore these findings.

Materials and methods

Using inductive qualitative methods informed by the exploratory analysis, comments were allocated to relevant themes. Key patient-reported outcome measures (PROMs), clinical and demographic factors were collated for patients who did and did not comment at 5 years and comparisons between the groups explored.

Results

Of 2208 women completing baseline PROMs, 482 proffered comments from 0 to 24 months, forming nine distinct themes, including chronic conditions, life events and psychosocial concerns. At 5 years, 1041/1727 (60.3%) women contributed comments, of whom 500 randomly selected participants formed the sample for analysis. Findings revealed comorbidity, impaired physical functioning and psychosocial problems as key themes, with prevalent adverse effects from local and systemic treatments. Eight new themes emerged at 5 years, including ageing, concerns about future cancer and positive aspects of care. Women commenting were better educated, slightly older and more likely to have had chemotherapy compared with non-commenters. They had significantly worse PROM scores for global health and key quality of life domains relevant to the difficulties they revealed.

Conclusions

Difficult personal circumstances and other health concerns affected many women's PROM ratings at 5 years of follow-up, in addition to ongoing cancer treatment effects. Greater attention to multiple sources of distress and adversity could facilitate personalised care and aid interpretation of PROMs.

Ambiguity in a masculine world: Being a BRCA1/2 mutation carrier and a man with prostate cancer

OBJECTIVE

Increased risk of prostate cancer (PCa) is observed in men with BRCA1/BRCA2 mutations. Sex and gender are key determinants of health and disease although unequal care exists between the sexes. Stereotypical male attitudes are shown to lead to poor health outcomes.

METHODS

Men with BRCA1/2 mutations and diagnosed with PCa were identified and invited to participate in a qualitative interview study. Data were analysed using a framework approach. "Masculinity theory" was used to report the impact of having both a BRCA1/2 mutation and PCa.

RESULTS

Eleven of 15 eligible men were interviewed. The umbrella concept of "Ambiguity in a Masculine World" was evident. Men's responses often matched those of women in a genetic context. Men's BRCA experience was described, as "on the back burner" but "a bonus" enabling familial detection and early diagnosis of PCa. Embodiment of PCa took precedence as men revealed stereotypical "ideal" masculine responses such as stoicism and control while creating new "masculinities" when faced with the vicissitudes of having 2 gendered conditions.

CONCLUSION

Health workers are urged to take a reflexive approach, void of masculine ideals, a belief in which obfuscates men's experience. Research is required regarding men's support needs in the name of equality of care.

Reproductive decision-making in young female carriers of a BRCA mutation

STUDY QUESTION

How do young women, who were identified as carrying a BRCA gene mutation before they had children, approach reproductive decision-making and what are their attitudes towards reproductive genetic testing?

SUMMARY ANSWER

Reproductive decision-making within the context of cancer risk is complex and influenced by personal experiences of cancer. Younger women were not concerned with reproductive decision-making at the time of their genetic test; however, the impact on subsequent reproductive decision-making was considerable and left them with unanticipated dilemmas, such as having children who would be at risk of inheriting cancer predisposition, timing risk-reducing surgery and changing perceptions of responsibility.

WHAT IS KNOWN ALREADY

Individuals carrying gene mutations predisposing to hereditary breast/ovarian cancer have concerns about passing on the gene mutation to children.

STUDY DESIGN, SIZE, DURATION

Qualitative methodology and thematic analysis.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Data were collected through semi-structured interviews with 25 women aged 18-45 who had received a positive result for a BRCA1 or BRCA2 gene mutation while childless.

MAIN RESULTS AND THE ROLE OF CHANCE

Analysis revealed four central themes: (i) the impact of cancer on reproductive decision-making; (ii) motivation for genetic testing; (iii) risk management and timing of planning children; and (iv) optimism for future medical advancements.

LIMITATIONS, REASONS FOR CAUTION

This study explores the views of female BRCA carriers. Further research should explore the views of couples, men, and include samples with greater ethnic and social diversity.

WIDER IMPLICATIONS OF THE FINDINGS

This evidence highlights the need for reproductive decision-making to be addressed at the time of pretest genetic counselling. More information should be provided on reproductive options as well as counselling/support to guide women's reproductive decision-making and prenatal testing options at the time they undertake genetic testing.

STUDY FUNDING/COMPETING INTEREST(S)

This research was supported by Cancer Research UK (Number C1226 A7920) and NIHR support to the Biomedical Research Centre at The Institute of Cancer Research and RMH. The authors have no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

Not applicable.

Targeted prostate cancer screening in men with mutations in BRCA1 and BRCA2 detects aggressive prostate cancer: preliminary analysis of the results of the IMPACT study

OBJECTIVE

To evaluate the role of targeted prostate cancer screening in men with BRCA1 or BRCA2 mutations, an international study, IMPACT (Identification of Men with a genetic predisposition to ProstAte Cancer: Targeted screening in BRCA1/2 mutation carriers and controls), was established. This is the first multicentre screening study targeted at men with a known genetic predisposition to prostate cancer. A preliminary analysis of the data is reported.

PATIENTS AND METHODS

Men aged 40-69 years from families with BRCA1 or BRCA2 mutations were offered annual prostate specific antigen (PSA) testing, and those with PSA > 3 ng/mL, were offered a prostate biopsy. Controls were men age-matched (± 5 years) who were negative for the familial mutation.

RESULTS

In total, 300 men were recruited (205 mutation carriers; 89 BRCA1, 116 BRCA2 and 95 controls) over 33 months. At the baseline screen (year 1), 7.0% (21/300) underwent a prostate biopsy. Prostate cancer was diagnosed in ten individuals, a prevalence of 3.3%. The positive predictive value of PSA screening in this cohort was 47·6% (10/21). One prostate cancer was diagnosed at year 2. Of the 11 prostate cancers diagnosed, nine were in mutation carriers, two in controls, and eight were clinically significant.

CONCLUSIONS

The present study shows that the positive predictive value of PSA screening in BRCA mutation carriers is high and that screening detects clinically significant prostate cancer. These results support the rationale for continued screening in such men.

SPARE: A qualitative study investigating randomization barriers in a Selective Bladder Preservation trial (SBP) (ISCRCTN: 61126465)

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Background: Recruitment to randomised trials is challenging, especially when treatment strategies are complex. While studies have demonstrated barriers to recruitment, few have investigated why patients accept or refuse randomisation. The SPARE feasibility study included such an investigation to highlight difficulties that might be dealt with as the study progressed and to inform procedures for a subsequent phase III trial. Methods: Patients had newly diagnosed invasive bladder cancer and were receiving neoadjuvant chemotherapy prior to invitation to a randomised trial (SPARE) that offered the possibility of radical cystectomy or SBP. Patients allocated SBP received cystectomy or radiotherapy dependent on chemotherapy response. 15 acceptors and 10 decliners to randomisation participated in the qualitative substudy. Methods included recorded transcribed interviews and a ‘framework analysis.’ Results: Both groups experienced initial confusion, ‘muddled’ communication, information overload, and lack of time leading to misunderstandings about the trial. Perceived side effects did not necessarily inform decisions. Decision to participate was seldom made unilaterally. Individual specialist input by, and continuity between, professionals and their patients, appeared to make decision making easier. Acceptors were inclined to altruism and trust in the medical profession, often agreeing to participate with minimum understanding regarding randomisation and/or equipoise and a ‘nothing to lose’ attitude as long as withdrawal from the trial was possible. Decliners tended to opt for radiotherapy, perceived as a rational choice in the context of this trial; many abhorred the thought of surgery that was perceived as undermining and a ‘treatment in reserve.’ Conclusions: Health professionals need to consider streamlining procedures and recognise patient preferences in terms of treatments offered and information received. Recognition of the complexity of communicating equipoise and randomisation may increase ‘informed consent’ levels and recruitment rates. A further qualitative substudy investigating doctor/patient consultations in real time with confidential feedback is proposed to optimise recruitment rates.

No significant financial relationships to disclose.

Communicating genetics research results to families: problems arising when the patient participant is deceased

OBJECTIVES

This study explores communication within families of clinically significant genetics research results, after the death of the patient participant. BRCA2 mutations were found in several men after their death from prostate cancer. Spouses were given the results in a genetic counselling session and asked to inform relatives.

METHODS

Cross-sectional, qualitative exploratory study. Interviews with 13 relatives, including informers and recipients of the information, were analysed using interpretative phenomenological analysis.

RESULTS

Dissemination was hampered when communication channels between relatives were limited, because of family rifts or socially distant or problematic relationships. When informing other branches of the family, relatives approached individuals in the generation of the deceased man, regardless of their risk status, who were then responsible for informing younger relatives. Most people informed by a relative did not seek genetic counselling. The informing relative may not have sufficient authority for the information either to be taken seriously or to challenge individual constructions about the aetiology of cancer. This impeded information transmission to further at-risk relatives. Most participants knew of relatives who had not been told about their cancer risk.

CONCLUSIONS

The implications of this limited efficiency of information transfer among relatives are discussed in the context of a potential role for genetics services in contacting at-risk relatives directly.

Disclosure of genetics research results after the death of the patient participant: a qualitative study of the impact on relatives

When a gene mutation is identified in a research study following the death of the study participant, it is not clear whether such information should be made available to relatives. We report here an evaluation of the impact on relatives of being informed of study results that detected pathogenic BRCA2 mutations in a male relative, now deceased, who had early onset (under the age of 55) prostate cancer. The breast and ovarian cancer risk was unknown to the living relatives. Qualitative analysis of interviews with thirteen relatives indicated that those who had a higher risk perception, resulting from an awareness of cancer family history or experiential knowledge of cancer in their family, tended to adjust more easily to the results. All participants believed that genetics research results of clinical significance should be fed back to relatives. Those who were fully aware of the BRCA2 results and implications for themselves felt they had benefited from the information, irrespective of whether or not they had elected for genetic testing, because of the consequent availability of surveillance programs. Initial anxiety upon learning about the BRCA2 result was alleviated by genetic counselling. Factors influencing those who have not engaged with the information included scepticism related to the relative who attempted to inform them, young age and fear of cancer. Those who had not sought genetic counselling did not attempt further dissemination, and some were not undergoing regular screening. Implications for informed consent in genetics research programs, and the requirement for genetic counselling when research results are disclosed, are discussed.

The feasibility and results of a population-based approach to evaluating prostate-specific antigen screening for prostate cancer in men with a raised familial risk

The feasibility of a population-based evaluation of screening for prostate cancer in men with a raised familial risk was investigated by studying reasons for non-participation and uptake rates according to postal recruitment and clinic contact. The levels of prostate-specific antigen (PSA) and the positive predictive values (PPV) for cancer in men referred with a raised PSA and in those biopsied were analysed. First-degree male relatives (FDRs) were identified through index cases (ICs): patients living in two regions of England and diagnosed with prostate cancer at age ⩽65 years from 1998 to 2004. First-degree relatives were eligible if they were aged 45–69 years, living in the UK and had no prior diagnosis of prostate cancer. Postal recruitment was low (45 of 1687 ICs agreed to their FDR being contacted: 2.7%) but this was partly due to ICs not having eligible FDRs. A third of ICs in clinic had eligible FDRs and 49% (192 out of 389) agreed to their FDR(s) being contacted. Of 220 eligible FDRs who initially consented, 170 (77.3%) had a new PSA test taken and 32 (14.5%) provided a previous PSA result. Among the 170 PSA tests, 10% (17) were ⩾4 ng ml⁻¹ and 13.5% (23) tests above the age-related cutoffs. In 21 men referred, five were diagnosed with prostate cancer (PPV 24%; 95% CI 8, 47). To study further the effects of screening, patients with a raised familial risk should be counselled in clinic about screening of relatives and data routinely recorded so that the effects of screening on high-risk groups can be studied.

Feasibility of familial PSA screening: psychosocial issues and screening adherence

This study examined factors that predict psychological morbidity and screening adherence in first-degree relatives (FDRs) taking part in a familial PSA screening study. Prostate cancer patients (index cases - ICs) who gave consent for their FDRs to be contacted for a familial PSA screening study to contact their FDRs were also asked permission to invite these FDRs into a linked psychosocial study. Participants were assessed on measures of psychological morbidity (including the General Health Questionnaire; Cancer Worry Scale; Health Anxiety Questionnaire; Impact of Events Scale); and perceived benefits and barriers, knowledge; perceived risk/susceptibility; family history; and socio-demographics. Of 255 ICs, 155 (61%) consented to their FDRs being contacted. Of 207 FDRs approached, 128 (62%) consented and completed questionnaires. Multivariate logistic regression revealed that health anxiety, perceived risk and subjective stress predicted higher cancer worry (P = 0.05). Measures of psychological morbidity did not predict screening adherence. Only past screening behaviour reliably predicted adherence to familial screening (P = 0.05). First-degree relatives entering the linked familial PSA screening programme do not, in general, have high levels of psychological morbidity. However, a small number of men exhibited psychological distress.

Men's decision-making about predictive BRCA1/2 testing: the role of family

Men who have a family history of breast and/or ovarian cancer may be offered a predictive genetic test to determine whether or not they carry the family specific BRCA1/2 mutation. Male carriers may be at increased risk of breast and prostate cancers. Relatively little is known about at-risk men's decision-making about BRCA1/2 testing. This qualitative study explores the influences on male patients' genetic test decisions. Twenty-nine in-depth interviews were undertaken with both carrier and noncarrier men and immediate family members (17 male patients, 8 female partners, and 4 adult children). These explored family members' experiences of cancer and genetic testing, decision-making about testing, family support, communication of test results within the family, risk perception and risk management. Implicit influences on men's testing decisions such as familial obligations are examined. The extent to which other family members--partners and adult children--were involved in testing decisions is also described. It is demonstrated that mothers of potential mutation carriers not only perceive themselves as having a right to be involved in making this decision, but also were perceived by their male partners as having a legitimate role to play in decision-making. There was evidence that (adult) children were excluded from the decision-making, and some expressed resentment about this. The implications of these findings for the practice of genetic counseling are discussed.

Fertility, gonadal and sexual function in survivors of testicular cancer

Modern treatments cure most testicular cancer patients, so an important goal is to minimise toxicity. Fertility and sexual functioning are key issues for patients. We have evaluated these outcomes in a cross-sectional study of long-term survivors of testicular cancer. In total, 680 patients treated between 1982 and 1992 completed the EORTC Qly-C-30(qc30) questionnaire, the associated testicular cancer specific module and a general health and fertility questionnaire. Patients have been subdivided according to treatment received: orchidectomy either alone (surveillance, S n=169), with chemotherapy (C, n=272), radiotherapy (R, n=158), or both chemotherapy and radiotherapy (C/RT n=81). In the surveillance group, 6% of patients had an elevated LH, 41% an elevated FSH and 11% a low (<10 nmol l⁻¹) testosterone. Hormonal function deteriorated with additional treatment, but the effect in general was small. Low testosterone was more common in the C/RT group (37% P=0.006), FSH abnormalities were more common after chemotherapy (C 49%, C/RT 71% both P<0.005) and LH abnormalities after radiotherapy (11% P<0.01) and chemotherapy (10%, P<0.001). Baseline hormone data were available for 367 patients. After treatment, compared to baseline, patients receiving chemotherapy had significantly greater elevations of FSH (median rise of 6 (IQR 3–9.25) iu l⁻¹ compared to 3 (IQR 1–5) iu l⁻¹ for S; P<0.001) and a fall (compared to a rise in the surveillance group) in median testosterone levels (−2 (IQR −8.0 to −1.5) vs 1.0. (IQR −4.0–4.0) P<0.001). Patients with low testosterone (but not elevated FSH) had lower quality of life scores related to sexual functioning on the testicular cancer specific module and lower physical, social and role functioning on the EORTC Qly C-30. Patients with a low testosterone also had higher body mass index and blood pressure. Treatment was associated with reduction in sexual activity and patients receiving chemotherapy had more concerns about fathering children. In total, 207 (30%) patients reported attempting conception of whom 159 (77%) were successful and a further 10 patients were successful after infertility treatment with an overall success rate of 82%. There was a lower overall success rate after chemotherapy (C 71%; CRT 67% compared to S 85% (P=0.028)). Elevated FSH levels were associated with reduced fertility (normal FSH 91% vs elevated 68% P<0.001). In summary, gonadal dysfunction is common in patients with a history of testicular cancer even when managed by orchidectomy alone. Treatment with chemotherapy in particular can result in additional impairment. Gonadal dysfunction reduces quality of life and has an adverse effect on patient health. Most patients retain their fertility, but the risk of infertility is likely to be increased by chemotherapy. Screening for gonadal dysfunction should be considered in the follow-up of testicular cancer survivors.

Communication about genetic testing in families of male BRCA1/2 carriers and non-carriers: patterns, priorities and problems

This qualitative interview study explored the way in which information about predictive BRCA1/2 testing and its implications for children is disseminated within the families of at-risk men who undergo genetic testing. Twenty-nine in-depth interviews were carried out with family members [male patients (n = 17), their partners (n = 8) and adult children (n = 4)]. These explored the following themes: experiences of cancer and genetic testing, decision-making about testing and the communication of test results and genetic information within the immediate family. The interviews revealed that both male patients and their partners perceive themselves, rather than health professionals, as responsible for disclosing information about genetic testing and genetic risks to their children. Parents described three different communication strategies for the disclosure of genetic information to their children: complete openness, limited disclosure and total secrecy. The adoption of a particular communication strategy was justified in terms of children's rights to information vs their parental duties to protect their children from anxiety-provoking information. Some of the problems arising from the adoption of different disclosure patterns are identified and the implications for clinical practice are discussed.

The development of an EORTC quality of life questionnaire to assess chemotherapy-induced peripheral neuropathy: the QLQ-CIPN20

Chemotherapy-induced peripheral neuropathy (CIPN) is a common phenomenon, often resulting in serious limitations in daily functioning and compromised quality of life. Currently available toxicity grading systems typically use a combination of clinical and paraclinical parameters and relies on the judgment of clinicians and/or nurses. However, because many of the symptoms of CIPN are subjective in nature, it is only logical that an assessment of CIPN be based, at least in part, on patient self-report data. We report on the development of a patient self-report questionnaire, the CIPN20, intended to supplement the core quality of life questionnaire of the European Organization for Research and Treatment of Cancer (EORTC). Following EORTC guidelines, relevant CIPN-related issues were identified from a literature survey and interviews with health professionals (n=15) and patients (n=112). The resulting 20-item questionnaire was pre-tested in three languages and four countries and is currently being examined in a large, international clinical trial. The EORTC CIPN20 should provide valuable information on CIPN-related symptoms and functional limitations of patients exposed to potentially neurotoxic chemotherapeutic and/or neuroprotective agents.

Men, women, gender and cancer

This paper argues for a gender relational approach in the context of cancer care bearing in mind that conceptual problems are intertwined with methodological approaches. Hitherto, research in the field of psycho-oncology has used a positivist methodology that separates sex from 'gender'. Men's and women's biological difference dictates their sexual destiny. Moreover, adjustment to cancer is conceptualized as lying within the patient, usually women. A contextual framework of a person's experience is negated. A 'gender relational' approach to cancer care underpins the ways in which people enter into a set of socially constructed relationships produced and reproduced through actions with each other and in institutions but never in a vacuum. It is suggested that, by using differing methodologies, such an approach will illuminate the similarities and differences within and between men and women with cancer. It may also help to demystify the conceptual stance that often pathologizes and medicalizes people, especially women, as has been the case in mainstream research. This will pave the way for a clearer understanding of how patients experience cancer in terms of gender and how medical institutions may be contributing to that experience as they too, gender their practice.

Do men with prostate or colorectal cancer seek different information and support from women with cancer?

Male cancer patients' use of a national cancer information service, their requests and key predictors of these over the period April 1996 to March 1998 are presented, in comparison with women. The most frequent requests of 411 prostate, 162 male and 217 female colorectal cancer patients were similar: site-specific information, emotional support, publications, specific therapies. Research or clinical trials (P < 0.05), diet and nutrition (P < 0.001) requests differed between men with prostate and colorectal cancers; complementary therapies (P < 0.05), prognosis (P < 0.05) requests differed between male and female colorectal cancer patients. Among prostate cancer patients, employed men aged 60+ were more likely to need emotional support than retired men aged 70 +; men < 59 years old were more likely to request publications, but less likely to enquire about specific therapies than others. Among male colorectal cancer patients, employed men were less likely to request site-specific information, but more likely to need emotional support than retired men; patients from geographical areas other than Thames were more likely to request publications; patients from manual classes were less likely to enquire about specific therapies than those from non-manual classes. The complexity of information and support seeking behaviour is demonstrated; no pattern was found among men or in comparison with women. Further research is needed to enable development of services that are appropriate to individual needs and concerns.

'Dividing the desolation': clients views on the benefits of a cancer counselling service

This paper describes clients' accounts of the benefits they derived from a short course of cancer counselling provided within a humanist framework. Three hundred and two clients who had attended at least one session of a short course of cancer counselling received an evaluation form, which incorporated both fixed-choice and open-ended questions. One hundred and forty two (47%) clients returned evaluation forms; those who had attended more sessions were significantly more likely to do so. Quantitative data were analysed using SPSS (Statistical Package for the Social Sciences) for Windows and qualitative data using a thematic approach. Almost all clients indicated that they felt they had benefited from counselling. Analysis of the open-ended questions identified nine main benefits of counselling and four key avenues or processes through which clients derived these benefits. Overall, counselling was seen as helping them to work through powerful thoughts and feelings and so to come to terms with cancer and to regain a sense of control in their lives. The benefits of a short course of counselling which clients identified reflect the aims of humanistic counselling which are not well captured by psychiatric assessments or most standard research instruments. In evaluating cancer counselling services, assessments which include these client-defined outcomes may provide a more sensitive way of gauging the value of counselling to a non-clinic population.

An evaluation of a cancer counselling service

The CancerBACUP London Counselling Service offered short-term face-to-face counselling to self-referred cancer patients and their relatives and friends, provided by experienced supervised counsellors working within a humanistic theoretical framework. This study aimed to identify its clients' characteristics, use of the service, extent of perceived benefits and satisfaction with the service. Sociodemographic data were collected in Data Sheets from all 384 clients who booked an appointment over 18 months; they were predominantly female, < 50 years old and from non-manual social classes. Significantly more people in those classes and in the 30-59 age group attended three or more sessions. Three hundred and nine clients who attended at least once were sent an Evaluation Form; 142 responded. The probability of the Evaluation Forms' return was greater for those who had completed more sessions; the great majority of respondents felt that they had benefited, and were satisfied with the service. This study, notwithstanding its limitations, shows that a short course of counselling may be perceived by clients to be helpful; it also raises other issues of value to those involved in cancer services and/or counselling provision.

Faith, hope, and charity: an in-depth interview study of cancer patients' information needs and information-seeking behavior

OBJECTIVE: To explore why cancer patients do not want or seek information about their condition beyond that volunteered by their physicians at times during their illness. DESIGN: Qualitative study based on in-depth interviews. SETTING: Outpatient oncology clinics at a London cancer center. PARTICIPANTS: 17 patients with cancer diagnosed in previous 6 months. Main outcome measures Analysis of patients' narratives to identify key themes and categories. RESULTS: While all patients wanted basic information on diagnosis and treatment, not all wanted further information at all stages of their illness. Three overarching attitudes to their management of cancer limited patients' desire for and subsequent efforts to obtain further information : faith, hope, and charity. Faith in their doctor's medical expertise precluded the need for patients to seek further information themselves. Hope was essential for patients to carry on with life as normal and could be maintained through silence and avoiding information, especially too detailed or "unsafe" information. Charity to fellow patients, especially those seen as more needy than themselves, was expressed in the recognition that scarce resources-including information and explanations-had to be shared and meant that limited information was accepted as inevitable. CONCLUSIONS: Cancer patients' attitudes to cancer and their strategies for coping with their illness can constrain their wish for information and their efforts to obtain it. In developing recommendations, the government's cancer information strategy should attend to variations in patients' desires for information and the reasons for them.

Cancer patients' information needs and information seeking behaviour: in depth interview study

OBJECTIVES

To explore why cancer patients do not want or seek information about their condition beyond that volunteered by their physicians at times during their illness.

DESIGN

Qualitative study based on in-depth interviews.

SETTING

Outpatient oncology clinics at a London cancer centre.

PARTICIPANTS

17 patients with cancer diagnosed in previous 6 months.

MAIN OUTCOME MEASURES

Analysis of patients' narratives to identify key themes and categories.

RESULTS

While all patients wanted basic information on diagnosis and treatment, not all wanted further information at all stages of their illness. Three overarching attitudes to their management of cancer limited patients' desire for and subsequent efforts to obtain further information: faith, hope, and charity. Faith in their doctor's medical expertise precluded the need for patients to seek further information themselves. Hope was essential for patients to carry on with life as normal and could be maintained through silence and avoiding information, especially too detailed or "unsafe" information. Charity to fellow patients, especially those seen as more needy than themselves, was expressed in the recognition that scarce resources-including information and explanations-had to be shared and meant that limited information was accepted as inevitable.

CONCLUSIONS

Cancer patients' attitudes to cancer and their strategies for coping with their illness can constrain their wish for information and their efforts to obtain it. In developing recommendations, the government's cancer information strategy should attend to variations in patients' desires for information and the reasons for them.

Attitudes of patients to randomised clinical trials of cancer therapy

The aim of this study was to test an instrument which might be useful for doctors in explaining the randomisation procedure to an individual patient. The sample comprised 323 patients with cancer attending for out-patient appointments and/or chemotherapy treatment in two major cancer centres in the U.K. 315 patients completed a self-report questionnaire--The Attitudes to Randomised Trials Questionnaire (ARTQ). The results show that the majority of subjects 287 (91.1%) believe that patients should be asked to take part in medical research, but only 242 (76.8%) would be prepared to take part in a study comparing two treatments. If treatment was randomised, only 141 (44.8%) would agree to participate. When given further information about the randomisation procedure, 119 (68.4%) of the 174 (55.2%) who initially said 'no' to randomisation or who were unsure, would change their minds and take part in a trial. The ARTQ discriminated between three categories of patient with the following prevailing attitudes: (a) those who seem comfortable with the concept of randomisation; (b) those with some concerns, who with fuller explanation are prepared to consider randomisation; and (c) those firmly against randomisation and participation in trials whatever information is provided. Prior knowledge of patients' attitudes might assist communication about trials and encourage more doctors to approach eligible patients.

Evaluation of adjuvant psychological therapy in patients with testicular cancer: randomised controlled trial

OBJECTIVE

To determine the efficacy of adjuvant psychological therapy in patients with testicular cancer and to compare the characteristics and psychosocial outcomes of men who agreed to participate with those who declined to participate in a randomised trial of psychological intervention.

DESIGN

Newly diagnosed patients were asked to participate in a randomised trial of psychological support compared with standard medical care. Participants and non-participants completed self assessment questionnaires at baseline and at 2, 4 and 12 months.

SETTING

Testicular Tumour Unit of the Royal Marsden Hospital.

SUBJECTS

73 of 184 (40%) eligible patients agreed to enter the randomised trial (participants) and 81 (44%) declined to participate but agreed to complete further assessments (non-participants). 30 patients wanted no further contact with the researchers.

OUTCOME MEASURES

Hospital anxiety and depression scale, psychosocial adjustment to illness scale, Rotterdam symptom checklist, mental adjustment to cancer scale. Only scores on the hospital anxiety and depression scale are reported for evaluating treatment efficacy.

RESULTS

111 of 184 (60%) eligible men declined to participate in the trial. Patients with stage I disease were most likely to refuse to participate. A patient was less likely to participate if he had low volume disease and was receiving no further treatment. Likelihood of participation was associated with stage of disease and with type of primary treatment (P < 0.001 for heterogeneity). Patients with early stage disease (P < 0.001) and fewer physical symptoms (P < 0.001) were less likely to participate. Psychosocial factors associated with participation included anxious preoccupation regarding disease (P = 0.01). There were no differences in outcome between participants and non-participants during follow up. Patients seemed to gain little benefit from adjuvant psychological therapy. At 2 months change from baseline favoured the treated group in the anxiety subscale (mean difference between groups -1.41 (95% confidence interval -2.86 to 0.03)). This was not sustained when adjusted for factors related to the disease. By 12 months change from baseline seemed to favour the control group (mean difference between groups 1.66 (-0.18 to 3.50)).

CONCLUSIONS

Patients with testicular cancer seem to have considerable coping abilities. Those who declined to participate in the trial differed from those who participated. Those who agreed to participate may comprise the clinical group who perceive a need for psychological support. No evidence was found to indicate a need for routinely offering adjuvant psychological therapy.

Ethnicity and health beliefs with respect to cancer: a critical review of methodology

This paper considers methodological issues raised by investigations into the relationship between health beliefs with respect to cancer and ethnicity. Because what people will proffer in response to a question about their health beliefs and ethnicity depends amongst other things, on the time and place of asking, and the identity, purpose and methodological approach of the person posing the question, we have focused exclusively on British material; also the practical issues discussed are largely relevant to Britain only.

Patients' and doctors' perception of long-term morbidity in patients with testicular cancer clinical stage I. A descriptive pilot study

Patient-based questionnaires were designed with the aim to identify and rank long-term somatic and psychosocial morbidity in patients with low-stage testicular cancer. A further intention was to compare patients' assessments with experienced doctors' general opinion on quality of life items in cured testicular cancer patients. In pilot study I, 103 tumour-free patients ranked items of physical and psychosocial morbidity after having had various kinds of treatment. Though the ranking procedure appeared to cause some difficulties amongst the patients and subsequently was abandoned, the results indicated considerable differences between the patients' and doctors' evaluations. In pilot study II patients were asked to score the different items. The questionnaire of pilot study II was completed by 107 patients from the Norwegian Radium Hospital (NRH) and 99 relapse-free patients from the Royal Marsden Hospital (RMH) with testicular cancer stage I at least 1 year after infradiaphragmatic radiotherapy (n = 94) or adjuvant chemotherapy (2 cycles, n = 26), or patients who had been followed on the surveillance program (n = 86). A total of 93 doctors completed a similar questionnaire, thereby expressing their general opinion on long-term morbidity in comparable testicular cancer patients as seen during routine clinical follow-up. Both the irradiated patients and those on the surveillance program reported slight degrees of Raynaud-like phenomena, neurotoxicity and ototoxicity, most probably representing "background morbidity" in an age-matched general male population. Doctors tended to underestimate their patients' somatic morbidity, but often overestimated the degree of psychological distress, in particular in patients on the surveillance program. Significant differences between RMH and NRH patients with regard to sexual problems and to leisure time activity may be explained by cultural differences in the two countries. The items presented in the questionnaire used identify important issues for patients cured of testicular cancer which may be used in future multicentre trans-cultural studies assessing these patients' quality of life. This will provide sufficient data for psychometric testing and, together with the findings from patients' free comments, support the final design of a testicular cancer quality of life module.

Developing, assessing, and refining quality of care criteria for a CHAMPUS mental health services demonstration

CHAMPUS established a contracted provider arrangement demonstration in the Norfolk, Virginia area. This article describes the development, assessment, and refinement of the quality monitoring criteria used to assess quality of care. Of 3,303 cases reviewed, 66% failed one or more criteria in two levels of review by nonphysician reviewers and were referred to peer reviewers. The referral problem was confirmed by the peer reviewer in at least 57% of the 2,177 cases. The criteria should undergo complete specificity and sensitivity testing, be expanded to include more outcome measures, and be applied to other geographic areas before use by other third party payors.

Weight and age at menarche

In the National Child Development Study (1958 cohort) information on their age at menarche and their weights and heights measured at 7, 11, and 16 years was available for 4427 girls. The distribution of age at menarche was not influenced by social class. Weight adjusted for height did not play an important part in the timing of sexual maturation of the girls in the study. Relative weight (weight expressed as a percentage of standard weight) at the ages of 7 and 11 years explained only 3.2%, and 4.9%, respectively of the variation in age at menarche, and changes in relative weight between these two ages accounted for 2%. Girls with early menarche were more likely to be overweight at ages 7, 11, and 16 years than those with late menarche, although early menarche was also reported by girls who were underweight or of average weight. These findings support the hypothesis that in well nourished populations the relation between menarche and body size is largely regulated by genetic factors and that nutrition is less important.

Can systems measure quality?

The current emphasis on quality is mainly the result of administrative concerns. The introduction of the prospective payment system and the impact of other cost containment pressures have increased the urgency to show that cost savings are not achieved at the expense of the quality of care.

Social class and changes in weight-for-height between childhood and early adulthood

The changes in weight-for-height of those from different social class backgrounds have been examined in the 1958 longitudinal study. Social class differences in the prevalence of overweight and obesity were found to be negligible in childhood but marked by early adulthood, with a greater percentage of overweight and obesity in lower social classes. This different was three-fold among obese men and two-fold among obese women when respondents were classified on the basis of their own occupation. However, a longer term effect of early class backgrounds also emerged. Children from manual backgrounds were more likely to become overweight and obese young adults (7 per cent of those with average weight-for-height at age 7) compared with their non-manual contemporaries (3 per cent). Interestingly, they were also more likely to remain overweight or obese through to early adulthood. Methods preventing weight gain in early life, whilst poorly developed at present, need to ensure that approaches are relevant to young people with lower social class backgrounds.

Who provides health care to children and adolescents in the United States?

Face-to-face visits by children and adolescents in office-based practice in the mid-1970s were studied. Pediatricians, family physicians, and general practitioners accounted for 35%, 6%, and 30%, respectively, of all child visits. Although 40% to 45% of preventive and medical encounters were with pediatricians, only 12% of visits for minor surgery, 20% of visits for psychosocial problems, and 9% of visits for combined medical-surgical reasons were to pediatricians. Only in very young children did pediatricians provide a substantial proportion of care for each of the types of visits. For some common diagnoses (acne, refractive error) most care was provided by specialists other than primary care specialists, but less than 16% of all preventive care visits (including routine eye examinations) was provided by specialists other than primary care physicians. A substantial proportion of the prenatal care and management of minor trauma was provided by family physicians and general practitioners. Although the limitations of the study (including an average response rate of 55%, exclusion of certain specialties and institutional physicians, sampling at different times of the year, lack of control for area of location of practice, and lack of information about response rates of different types of physicians within each specialty) preclude definitive conclusions, the findings raise important questions for future study.

Semi-micro quantitative analysis of complex urinary steroid mixtures in healthy and diseased states

A method for the determination of urinary steroid hormones in healthy and diseased states is described. The use of a Van den Berg all-glass injector coupled to a fused silica column has shown a dramatic increase in sensitivity and a significant reduction in gas chromatography analytical time. The increase in sensitivity also eliminates the need for processing large volumes of urine. The method has proven to be rapid, precise, reproducible and sensitive. Also, column life is increased due to the absence of solvent. This technique has shown to have broad applications in the analysis of such classes of compounds as sugars, steroids, prostaglandins and fatty acids.

A profile of pediatric practice in the United States

We profiled pediatric practice in the United States through a second-order analysis of data gathered in 1977 from 429 practicing pediatricians. Age, sex, board certification status, practice arrangement, and practice location of pediatricians in the United States were evaluated, as well as their patterns of practice. The number of and reasons for visits made to pediatricians by patient age and sex were tabulated. Child health supervision and diseases of the upper and lower parts of the respiratory tract accounted for 84.5% of the principal diagnoses made in 21,784 visits to the sample of pediatricians studied. These data may be useful in planning pediatric primary care residency training program curricula and in making planning decisions regarding the number and distribution of pediatricians nationally.

Breathlessness and psychiatric morbidity in chronic bronchitis and emphysema: a study of psychotherapeutic management

This paper describes a study of the outcome of psychotherapy with patients disabled by chronic obstructive airways disease giving rise to dyspnoea. Forty-three men and 22 women with severe COAD were randomly allocated for 8 weeks to one of three types of psychotherapy or to an untreated control group, and were followed up six months later. The group treated by a medical nurse without training in psychotherapy experienced sustained relief of dyspnoea but tended to undergo less psychodynamic change; psychiatric symptoms were reduced in those receiving supportive, but not analytical, psychotherapy. The psychosomatic mechanisms involved and the implications for medical and nursing practice and for liaison psychotherapy are discussed.