Validation and practical implementation of a multidisciplinary cancer distress screening questionnaire

BACKGROUND

In order to identify cancer patients with psychosocial needs during radiotherapy, a routine screening questionnaire is widely recommended in the literature. Several tools focusing mainly on psychological issues have been developed during the past decade. However, problems with their implementation into clinical routine have been repeatedly reported, due to a lack of practicability for clinicians and nurses. This study reports the compilation of a multidisciplinary screening questionnaire and an analysis of the effectiveness of its implementation into clinical routine at the Department of Radiotherapy, Medical University of Vienna.

MATERIALS AND METHODS

The screening questionnaire is based on a compilation of several subscales from established and validated assessment tools. It focuses on comprehensive information with high a clinical relevance for all professions. In a pilot study, patients' acceptance was assessed qualitatively. Analysis of missing screening data in consecutively admitted patients reflects the effectiveness of implementation and representativity of the data. A validation analysis of the psychological subscales was performed using external criteria and its internal consistency was tested with Cronbachs' α.

RESULTS

Qualitative patient acceptance of the screening questionnaire is good. The overall response rate in the screening procedure was 75 %. Missing patient screening data sets arose randomly-mainly due to organizational problems-and did not result in systematic errors. The psychological subscales identify highly distressed patients with a sensitivity of 89 and 78 %, and an internal consistency of 0.843 and 0.617.

CONCLUSION

The multidisciplinary screening questionnaire compiled in this study has a high patient acceptance, provides reliable and representative data and identifies highly distressed patients with excellent sensitivity. Although requiring additional personnel resources, it can be implemented successfully in clinical routine with benefits for both the patient and the professional team.

Teleradiotherapy of joints in rheumatoid arthritis: lack of efficacy

BACKGROUND

Low dose radiotherapy is commonly used for painful rheumatic conditions in clinical practice. Teleradiotherapy may be a cheap, painless procedure which is applicable to many joints at a time.

OBJECTIVE

To determine if the local application of x rays to inflamed joints in rheumatoid arthritis (RA) affects the signs and symptoms of inflammation.

METHODS

In a randomised, controlled, double blind study, roentgen irradiation was administered in a total dose of 20 Gy during 2 weeks to single joints in six patients with RA who were receiving constant and stable pharmacological treatment with DMARDs and NSAIDs. Single inflamed joints on the contralateral side of the body were used as controls and received sham irradiation. Swelling and tenderness was assessed by blinded investigators before and until 3 months after the irradiation; general disease activity and pain scales were included in the assessment.

RESULTS

No change in the scores for tenderness, swelling, pain, or disease activity was seen. The trial was stopped for ethical reasons.

CONCLUSION

Local roentgen treatment of RA at a substantial dose of 20 Gy was ineffective in this pilot trial.

[Influence of interaural time- and level differences on the binaural interaction components in normal adults]

BACKGROUND

Binaural interaction components of auditory brainstem responses have long been studied and its beta-wave has been shown to be correlated with directional hearing ability. As patients with auditory processing disorders such as patients with some sorts of learning disabilities frequently have difficulties with binaural processing it seems sensible to use binaural interaction components in the diagnosis of these disorders.

METHODS

In order to obtain normal values and to investigate the influence of interaural time (ITD) and level differences (ILD) binaural interaction components were measured in 21 adults. Interaural time differences varied between 0 and 1.2 ms and interaural level differences between 0 and 30 dB.

RESULTS

beta-latencies increased significantly as interaural time differences increased while beta-amplitudes did not change significantly. In measurements with higher interaural time differences detection of the beta-wave was only rarely possible. The effect of interaural level differences on beta-latencies was less pronounced and not significant as well as the influence of interaural level differences on beta-amplitudes.

CONCLUSIONS

In the present study it could be shown that the beta-wave of the binaural interaction waveform is present in almost every normal hearing subject. As amplitudes show a considerable variation beta-latencies seem to be of higher diagnostic value than amplitudes.

Costs of standard and conformal photon radiotherapy in Austria

BACKGROUND

The increasing shortage of health care resources necessitates a more rational use of the funds available. New treatment strategies in radiotherapy generate additional expenses. In this study, the expenses incurred for standard radiotherapy in patients with prostate and lung cancer were compared with those for conformal photon therapy.

MATERIAL AND METHODS

To itemize the direct costs, a distinction was made between pretreatment measures (independent of the tumor entity) and treatment measures proper. The cost analysis was based on a break-down by personnel, material and equipment depreciation costs. Overheads were not considered.

RESULTS

Conformal photon therapy was found to be over 60% more expensive than standard radiotherapy for prostate cancer and over 100% for lung cancer. The additional expenses were attributable to the more expensive linear accelerator equipment and the additional time needed for CT localization and planning as well as for patient positioning and verification during daily therapy.

CONCLUSION

Conformal photon therapy should be examined for its clinical usefulness in dedicated studies and allocated an adequate place in the reimbursement schemes for radiotherapy. If it should be found to produce higher cure rates, other costing procedures, e.g. cost--benefit analyses, should be used for establishing the costs of treatment strategies.

Assessment of intersignal variability for discrimination of atrial fibrillation from atrial flutter

The analysis of endocardial signals obtained from an electrode located in the right atrium enabled by new dual chamber implantable cardioverter defibrillators may be helpful to provide additional therapies such as overdrive pacing or low energy atrial cardioversion for the treatment of concomitant atrial flutter (AFL) or atrial fibrillation (AF). Algorithms for discrimination of atrial tachyarrhythmias based on rate counting are of limited efficacy. The aim of this study was to assess the intersignal variability by using fast discrete wavelet transforms (FDWT) as a new method of discrimination of AF from AFL. Patients with spontaneous episodes of AF/AFL or patients who developed AF/AFL during an electrophysiological study were studied. The endocardial signals were recorded from the high right atrium using a transvenous 5 Fr bipolar electrode catheter (interelectrode spacing: 1 cm). The signals were digitized (2 kHz, 12-bit resolution) after amplification and filtering (40-500 Hz). Within data segments of 10-second duration, 25 consecutive signals were selected and normalized and FDWT was applied. Standard deviations of the wavelet coefficients (SD) from coarse scales (scale 4-8) were calculated. A total of 94 data segments (AF: 52, AFL: 42) from 28 patients were analyzed. SD at each considered scale was higher for AF than for AFL (P < 0.001). SD at scale 8 discriminated between AF from AFL with 100% sensitivity and specificity. We conclude that assessment of intersignal variability of bipolar endocardial recordings using FDWT is an effective method for the discrimination of AF from AFL. The implementation of this tool in a discrimination algorithm of an implantable device may help provide the appropriate differential therapy for atrial tachyarrhythmias.

Discrimination of sinus rhythm, atrial flutter, and atrial fibrillation using bipolar endocardial signals

INTRODUCTION

Analysis of endocardial signals obtained from an electrode located in the right atrium as realized in newly designed dual chamber, implantable cardioverter defibrillators might be used to provide additional therapeutic options, such as overdrive pacing or low-energy atrial cardioversion for the treatment of concomitant atrial flutter (AFL) or atrial fibrillation (AF). Therefore, we developed a computer algorithm for discrimination of normal sinus rhythm (NSR), AFL, and AF that may lead to adequate differential therapy of atrial tachyarrhythmias in an automated mode.

METHODS AND RESULTS

During an electrophysiologic study, bipolar endocardial signals from the high right atrium were obtained in 28 patients during sustained AFL or AF and after restoration of NSR. A total of 286 data segments of 5-second duration were recorded (NSR: 96, AFL: 86, AF: 104). Mean atrial cycle length (MCL), standard deviation of mean atrial cycle length (SDCL), and index of irregularity (IR), defined as the ratio between MCL and SDCL, were calculated for each data segment. A cutoff of 315 msec for MCL allowed discrimination of NSR from atrial tachyarrhythmias with 100% sensitivity and specificity. For discrimination of AF from AFL by using SDCL, a cutoff value of 11.5 msec led to a sensitivity of 99% and a specificity of 90%. Best discrimination of AF from AFL was found for the criterion IR > or = 7.5%, resulting in a sensitivity of 100% with a specificity of 95% for AF detection.

CONCLUSION

The investigated algorithm provides discrimination of NSR, AFL, and AF with high sensitivity and specificity. Incorporation of this algorithm in an implantable automated antitachycardia device may lead to adequate differential therapy in patients suffering from spontaneous episodes of AF and AFL.

[The disease coping of radiation cancer patients compared]

Emotional well-being and physical complaints of 87 outpatients undergoing radiotherapy were compared with those of a variety of other patients. The emotional and physical status were assessed by a list of emotional symptoms (German: "Befindlichkeitsskala") [18] and a list of physical complaints (German: "Beschwerdeliste") [19]. Although they have to cope with a fair amount of physical strain, values of the "oncologic group" rank second lowest, outranked only by healthy controls. The results strengthen the hypothesis of an adaptive denial to cope with the strain of the treatment. In conclusion, concrete suggestions are made for the doctor-patient relationship.

Radiation of jejunal interposition in T3-T4 upper aerodigestive tumours

30 patients with T3 and T4 tumours of the upper aerodigestive tract had their tumours resected by pharyngolaryngectomy. This was followed by reconstruction of a gullet or creation of a siphon as a tracheohypopharyngeal shunt for voice restoration with a free jejunal autograft. All patients were treated postoperatively with 60Co gamma radiation, 6 MeV photons or 7.5 to 10 MeV electrons of a beta-tron, with a dose of 50-65 Gy in the area of the primary tumour and 50-65 Gy to the neck. 4 patients refused further treatment after a depth dose of between 16 and 32 Gy. Local recurrence occurred in 40% of cases. The survival rate was 36.6% (11/30) after a mean follow-up time of 21.5 months, although 2 patients died of intercurrent diseases without recurrence of their tumours. The results obtained justify active surgical intervention with postoperative irradiation even at an advanced stage of the tumour.

[The psychosocial care of cancer radiology patients--the requirement, subjective need and acceptance]

The topic of the investigation was the discrepancy between the documented objective need for psychosocial support of cancer patients on the one hand, and of the patient's little subjective needs on the other, the latter resulting in only low acceptance of care offered. In an empiric study the attitude of 38 radio-oncological patients (29 female, nine male) toward psychosocial support was investigated. The study revealed a tendency, independent of sex, that may be described as a social retreat (e.g. emphasis on personal independence, desire not to burden anybody, to hold back own interests and feelings, to be of help rather to others). We interpret this attitude as a specific reaction of coping with the problem, attempting at self-stabilisation.

Dose estimation in postoperative keloid irradiation with special consideration of ovarian dose

For a long time now, surgery followed by irradiation has been the preferred therapy in the treatment of keloids. Radiation can be administered by means of X-rays (energy level less than or equal to 100 KV), electrons (energy level less than or equal to 5 MeV) or 192Ir wires. The choice of one of these methods depends on the availability of suitable facilities within a short period of time (less than 24 hours postoperatively), and the possibility of adapting the irradiation field quickly and easily to the scar. A further criterion is the dose received by underlying organs possibly, especially the ovaries of women of child-bearing age. It consists of primary and secondary (scattered) parts of radiation and was measured in two standard field sizes for the various types of radiation so as to allow a rapid evaluation. Apart from the types of radiation mentioned above, such measurements were also carried out for 125I seeds. With a field size of 20 x 1.5 cm2 and a surface dose of 10 Gy, ovaries at a depth of 10 cm in the central beam will receive a dose of between less than 1 m Gy in electron therapy to around 1 Gy in X-ray therapy (100 KV).

[Effect of the stress coping mechanisms of oncologic patients on their physical and psychological state in radiotherapy]

An empiric study was designed to investigate how patients cope with radiotherapy and its secondary effects. Subject of inquiry was the influence of variables such as age, sex and individual strategies of coping with stress on the extent of reported strain. 91 cancer patients (66 female, 25 male) undergoing radiotherapy with different diagnoses but comparable history and duration of disease were interviewed concerning physical complaints and impairment of psychic mood at four times: in the beginning, the middle and the end of a 6-week radiotherapy as well as 3 moths afterwards. Additionally general coping strategies were evaluated in the beginning. Results showed that reported impairment (only within the subgroup: women under 50) correlated significantly (p less than 0.01) with a coping behaviour that could be described as a "retreat and giving up".

[Postoperative prevention of hypertrophic scars and keloids using radiotherapy]

A group of 63 patients with keloids or hypertrophic scars were treated with excision and postoperative superficial X-ray irradiation. The cosmetic and functional results were very good in more than two-thirds of these cases. In 10% a relapse occurred, which is in keeping with the international literature. Finally, other radiotherapeutic modalities such as brachytherapy, in combination with hyperthermia are discussed.

Radiotherapy of Morbus Gorham-Stout: the biological value of low irradiation dose

Morbus Gorham-Stout is a very rare disease. A patient with this disease was treated at the University Clinic of Radiobiology in Vienna. The clinical and radiological findings place special emphasis on the radiotherapeutic treatment, and the biological basis of the recommended dose is discussed.

[Sonographic localization of the kidneys for the purpose of radiation treatment of the abdomen: how accurate is this method?]

In 31 patients, the kidneys were located with ultrasonography before urography was carried out. The projection of the medial, lateral, cranial and caudal margins of the kidney were marked on the patient's back with a pellet. On X-ray film, the mean distance between the pellet and margin of the kidney varied from 0.12 to 1.13 cm; nevertheless the standard deviations were high (up to 2.63 cm). In 11 patients, more than one-third of the kidney was located outside the sonographically determined borders; on the left side this happened in 10 patients. We conclude that sonographical localization of the kidneys for protection during irradiation of the abdomen should only be used when other localization procedures cannot be carried out.

[Coping with disease and management of therapy in patients with cancer with special reference to radiotherapy. An overview]

The actual state of research is reviewed, focussing on the psychosocial aspects of cancer. The argumentation is oriented at distinguishable stages during the course of disease. Further topics are doctor-patient-relationship, compliance, coping and the evaluation of psychosocial care.

[Therapy and follow-up using TPA in radio-oncologic after-care in bladder cancer]

Differentiating between a progressive carcinosis and a clinically tumour-free patient, using the data provided by a tumour-marker, is above all else important for the observation of cancer patients whose primary tumour has been surgically removed. The tumour marker TPA was observed postoperatively in 55 patients with carcinoma of the bladder throughout a period of 12 to 36 months before, during and after radiotherapy and compared to the respective clinical condition. Among these patients all stages T1 to T4 of the TNM-system were represented (19) (Tab. 1). Clinical progress remained stationary in 44 cases, whereby TPA was in 19% (n = 8) of the cases in discordance with clinical progress. In 11 cases (7 local recurrences and 4 distant metastasis) clinical progress was observed to be positive, whereby TPA was concordant in 75% (n = 5) of the local recurrences and in 90% (n = 3) of the distant metastases.

[Prognostic factors in the treatment of inoperable orofacial tumors with simultaneous radiotherapy and intra-arterial chemotherapy]

Between January 1973 and April 1982 66 evaluable patients with advanced inoperable orofacial tumours underwent intraarterial Bleomycin and Methotrexate with simultaneous radiotherapy in a prospective study. 32 patients had no previous treatment, 34 patients had initial surgery, radiotherapy and/or chemotherapy. 15 mg Bleomycin were administered through a catheter into the arteria externa carotis daily in the morning. 25 mg Methotrexate were given in the same way at night followed by 3 mg Calcium-Leucovorin i.m. every 8 hours. The cumulative dose was 300 mg Bleomycin and 500 mg Methotrexate. Four hours after the administration of Bleomycin the target volume was irradiated (single fraction 2 Gy, total dose 60 to 65 Gy). The overall response rate was 65% containing 17% complete and 48% partial remission. Destruction of the bone appeared to be the most important index at the start of the therapy. Further prognostic determinants as previous treatment, localisation of the primary tumours (maxilla and mandibula respectively oral cavity and oropharynx) and local regional lymphnode stage missed statistically significance in the survival time, may be due to a possible radiosensitizing effect of the simultaneous chemotherapy. Complete remission turned out to be the most important prognostic factor after the end of treatment. Patients responding with complete remission show a median disease free survival of 56+ months and a median survival time of 82 months. Acute reactions were reversible. Only in 14% of the patients the treatment could not be finished. Better results could be obtained by electron-affinic radiosensitizers and high LET radiation.

[Mammographic and sonographic appearances of traumatic changes in the female breast]

As a result of trauma, or surgery, haematomas develop which are visible and can be demonstrated by sonography; they either regress completely or leave circular foci after a period of days or weeks. Both the new and older lesions can usually be well shown by sonography. During these stages the sonogram may be valuable. Long-standing changes, such as fat necrosis, are best shown by mammography. There are three types of fat necrosis; oily cysts, mixed types or scarring leading to an appearance resembling a carcinoma. Oily cysts may undergo mural calcification leading to liponecrosis macrocystica or liponecrosis microcystica, depending on size.

[Patho-anatomy of lymph vessels of the liver from a roentgenologic viewpoint]

With increased formation of lymph the lymphatic vessels of the liver are detectable on X-ray and can be assessed. Lymphatic vessels of the portal areas and Glisson's capsule and the pathways of the efferent extrahepatic lymphatics are described. Examples of pathological hepatograms in cirrhosis are presented.

[Indications and methods of megavolt therapy in prostatic cancer--evaluation of 98 cases]

A report is given on 98 unselected cases of carcinoma of the prostate, treated at the University Department of Radiotherapy and Radiobiology of Vienna from January 1974 till December 1979. 85% of the patients were over 60 years old. More than the half of them had been subjected to surgery or had undergone hormone therapy before starting radiotherapy. Moreover, more than 50% of the patients showed advanced disease (stages C or D). Local control was achieved in about 95% of cases. Long-term side effects such as irradiation damage to bladder or gut occurred in about 5% patients only. Survival rate was 75.5% after 3 years, 66.7% after 5 years and 46.7% after 7 years. Recommendations as to the management of such an unselected patient group are given. Our modified radiation technique is presented.

Parenchymmuster und Mammakarzinom

500 mammograms were analysed according to Wolfe, with additional mastography group. The mammogram documented a risk pattern which correlated to the statistic increase in carcinoma. Our own experience also showed no correlation between simple mastopathy and carcinoma of the breast. Therefore, the risk pattern should be regarded as part of the known risk factors and should indicate selective screening at a yearly interval, even if clinical examinations are negative.

[Differential diagnosis of saddle-like formations in the gastric fundus]

X-ray examination of the stomach sometimes shows a saddle-like impression of the region of the fundus. This phenomenon is without any clinical importance, but there are many diseases such as hiatal hernia, benign and malignant tumours, inflammatory diseases, and varices which are localised at the fundus. Differential diagnostic problems are discussed.

[Roentgenologic analysis of deglutition--evaluation of 231 cases]

The act of swallowing, which can be analysed by means of radiologically well-discernible phases, is described and placed in anatomic correlation. Several items are of essential importance for regular swallowing: the ability to close the lips, the isthmus faucium, epipharynx and epiglottis and also the action of the lingual punch and the involuntary phase of the act of swallowing induced thereby. During the first phase--the voluntary oral phase--the bolus is prepared for swallowing and the oral cavity is separated from the oropharyngx by the closed isthmus faucium. In the second--the oropharyngeal phase--the involuntary part of the act of swallowing is triggered and the entrance to the nasopharynx is closed. The bolus gets pressed into the oropharynx. During the last, the pharyngo-oesophageal phase, the bolus enters the cranial part of the oesophagus, while crossing the respiratory tract. This step is secured by several mechanisms against the danger of aspiration. Evidence for the occurrence of physiological aerophagia is supplied.

[Sonographic determination of the irradiated pulmonary volume in case of irradiation of the thoracic wall]

In order to determine the irradiated pulmonary volume, comparative examinations by sonography and computed tomography were made in ten patients submitted to postoperative radiotherapy for mammary carcinoma. The physical and anatomical conditions of sonographic volumetry are discussed. In all cases irradiated with tangential contralateral fields, the irradiated pulmonary volume was less than 200 ccm (118 ccm on an average). The sonographic results did not differ essentially from those of computed tomography, so that the sonographic examination can be offered as a simple and sufficiently precise method of documentation within the frame of an individual therapy planning.

[Optimization of dose distribution by use of lead wedge filters in combined electron and photon therapy]

A significantly improved isodose distribution has been reached by the combined application of high-energy photons and electrons, however, there are still problems with respect to the critical organs. It was demonstrated that a considerable progress is possible by the use of lead wedge filters within the frame of this irradiation technique. Recommendations for clinical application are given on the basis of the authors' own practical experiences.

[Mammographic changes in the partially resected and irradiated breast]

Thirtyseven patients with breast cancer stage T1 have been treated by tumorectomy or quadrantectomy and radiation therapy. Mammographic changes as skin thickening and parenchyme reaction were described and put in correlation between the end of treatment and mammography controls. Differential diagnostic problems are discussed.

[Radiotherapy in nasopharyngeal cancer. Evaluation of 37 cases]

37 cases of nasopharyngeal tumors were studied which have been treated from January 1971 through December 1976 at the University Clinic for Radiotherapy and Radiobiology Vienna. These cases were analysed according to local and regional control and survival time. The 5-year-disease-free survival rate for all patients studied is 46%. Local and regional recurrences are discussed.

[Percutaneous radiotherapy of thyroid malignancies. Analysis of 54 cases]

A report is given on 54 cases of thyroid malignancy treated at the University Department of Radiotherapy and Radiobiology of Vienna from January 1970 till September 1977. These cases are analysed according to local control of disease and survival time. The 5-year disease-free survival rate for all histological types was found to be 48%. Local recurrence occurred in 13% of cases. Combined external irradiation and radioiodine therapy is critically discussed.

[The role of radiotherapy in the treatment of the pancreas carcinoma (author's transl)]

Although diagnosis of the pancreas carcinoma is only possible in an advanced stage, it is recommendable to try a radiotherapy as long as there are no remote metastases. If the patients are adequately selected, further if the target volume is exactly localized and charged with a high dose, it should be possible to reach considerably longer survival times. Different irradiation methods with ultrahard photons and high energy electrons are compared with regard to their therapeutic value.

[Significance of double-contrast arthrographic for the assessment of a meniscus lesion (author's transl)]

On-target and hence successful treatment can be effected only if the diagnosis of a lesion of the meniscus is established beyond doubt. In the present study the authors tested retrospectively the significance of arthrography for the assessment of a meniscus lesion, basing their evaluation on the surgical findings, and examined the diagnostic problems involved in internal lesions of the knee, following knee surgery. The study utilized the results of 279 cases of double-contrast arthrography; 76 of these patients were operated upon. Complete agreement between arthrography and surgical findings was obtained in 73.5% of the patients. This figure increases to 81.5% when we disregard insignificant diagnostic factors. No complications were seen in any of the outpatient examinations.

Vertebra plana Calvé

The differential diagnostic problems of a case of vertebra plana Calvé having a rare location in the cervical spine are discussed. The various theories of aetiology and pathogenesis are considered briefly. The differentiation from inflammatory and tumourous diseases of the vertebral column is of great importance for therapeutic reasons. Skeletal scintigraphy was used for the first time for differential diagnosis in the case presented.

[The esophagogastral transitional region--localization of acute and chronic hemorrhages (author's transl)]

Various diseases which can be associated with hemorrhages are located in the esophagogastral transitional region. Emergency endoscopy can contribute significantly to the detection of an acute source of hemorrhage. Roentgenologic examination can make significant contributions toward the further clarification of acute and especially chronic hemorrhages, by assessment of the topographic, morphologic, functional and angiologic conditions. The relevant diseases in this respect are discussed with regard to clinical pattern and significance of the roentgenologic and endoscopic methods of examination, namely, reflux disease, hiatal hernia, cardial tumors, esophageal varices and Mallory-Weiss syndrome. Differential diagnostic problems are demonstrated by means of relevant cases. Brief reference is also made to "operated cardia" and the associated possibility of hemorrhage.

[A contribution to the differential diagnosis of odnotogeneous cysts]

Problems concernint the diagnosis and differential diagnosis of odontogenic cystic lesions of the jaw are discussed with reference to a series of patients and some specially selected cases. The use of isotope examination is often of particular significance in coming to a decision. The position and value of scintigraphy has been demonstrated by referring to the literature and to our own investigations. The often difficult differentiation from certain types of odontogenic tumours is also discussed.

[Diagnosis and differential diagnosis of the terminal esophagus. (author's transl)]

On hand of a few selected cases diagnostic and differential diagnostic problems of the cardia are discussed. Radiological and endoscopical values are presented.