Assessing Spirituality and Religiousness in Advanced Cancer Patients

The aim of this study was to translate the Spiritual Involvement and Beliefs Scale into the Greek language and validate its psychometric properties in a sample of advanced cancer patients treated in a palliative care unit. The scale was translated into Greek with the “forward-backward” procedure. It was administered twice, with a 3-day interval, to 82 patients with advanced cancer. Patients completed the Spiritual Involvement and Beliefs Scale and the Greek Hospital Anxiety and Depression Scale. The scale had an overall Cronbach α of 0.89. Overall test-retest reliability was satisfactory at P < .0005. Satisfactory construct validity was supported between the Spiritual Involvement and Beliefs Scale subscales and Hospital Anxiety and Depression subscales. Interscale and interitem correlations were found satisfactory at P < .0005. These results support that the Spiritual Involvement and Beliefs Scale is an instrument with satisfactory psychometric properties and is a valid research tool for spirituality in advanced cancer patients.

A prospective randomized controlled clinical trial of zoledronic acid for bone metastases

In this study, we assessed the safety, tolerability, and effectiveness of two therapeutic regimens relating to the frequency of zoledronic acid (ZOL) infusion. Sixty adult patients with bone metastases were randomly assigned to two study groups. The first group (group A) received 4 mg ZOL every two weeks, and the second group (group B) received 4 mg ZOL every four weeks. Assessment measures included C-telopeptide (CTX) rate, the Greek Brief Pain Inventory (GBPI), the linear analogue scale assessment (LASA) of quality of life, and biochemical markers. Assessments were made at weeks 12, 24, 36, and 48. Clinical endpoints included effective decrease in bone resorption markers, pain relief, and improvement of mobility status. The follow-up period was 48 weeks. No statistically significant differences between groups A and B were found in overall profile of biochemical markers, Eastern Cooperative Oncology Group (ECOG) performance status, and GBPI score at the end of the follow-up period. Assessment of bone metastases revealed a slight difference between the two groups, however this difference was not statistically significant. These findings indicate that administering zoledronic acid at four rather that two weeks has no significant impact on overall outcome.

The Attitudes of Greek Physicians and Lay People on Euthanasia and Physician-Assisted Suicide in Terminally Ill Cancer Patients

The purpose of this article is to explore the attitudes of lay people and physicians regarding euthanasia and physician-assisted suicide in terminally ill cancer patients in Greece. The sample consisted of 141 physicians and 173 lay people. A survey questionnaire was used concerning issues such as euthanasia, physician-assisted suicide, and so forth. Many physicians (42.6%) and lay people (25.4%, P = .002) reported that in the case of a cardiac and/or respiratory arrest, there would not be an effort to revive a terminally ill cancer patient. Only 8.1% of lay people and 2.1% of physicians agreed on physician-assisted suicide ( P = .023). Many of the respondents, especially physicians, supported sedation but not euthanasia or physician-assisted suicide. However, many of the respondents would prefer the legalization of a terminally ill patient's hastened death.

The Role of the New Imaging Modalities in the Investigation of Menière's Disease

Thirty one patients with Menière's disease investigated with HRCT and MRI of the inner ear are presented. The parameters evaluated were:

a) Pneumatization of the petrous bone, b) Width of the vestibular aqueduct (VA) in its postisthmic segment, c) Visualization of the endolymphatic duct (ELD).

A similar survey was performed in other 50 patients with no previous history of ear disease which served as controls. There was evidence of statistically significant differences in the pneumatization of the petrous bones (p<0.05), as well as the width of the vestibular aqueducts (p<0.001) between the two groups of patients. Also the percentage of the visualized endolymphatic ducts was higher in the control group as compared to the patients with Menière's disease (p<0.05).

Death and Grief in the Greek Culture

None would disagree that death is the great separator. Death has many meanings, and they change with culture and society. In the Greek mythology, the dead journeyed to the Afterlife, ruled by Hades. Death was not perceived as an end in and by itself, but rather as another “world” to belong to. By Classical times there was a rise to burial rituals and commemorative practices, carried out throughout the centuries. Christian religion attempted to change the way the dead were mourned, and preached the immortality of the soul and resurrection of the dead. Nevertheless, the way people grieved and buried their dead has not changed much. The only change is a difficulty in the receptiveness of burial procedures, observed in large cities and in younger population. Today in Greece, the perceptions and practices on grief and death derive both on the ancient and the Christian Orthodox traditions.

Use of the Greek McGill Pain Questionnaire in cancer patients

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

Where do cancer patients die in Greece? A population-based study on the place of death in 1993 and 2003

Several studies have shown that place of death is affected by many parameters. Our objective was to describe for the first time where patients with cancer die in Greece and what has changed between 1993 and 2003. We acquired data on all deaths that were attributed to cancer in Greece in the years 1993 and 2003, and compared these data to the changes in the location of death in the total population. In 1993, approximately 50.7% of men and 50.9% of women cancer patients died in hospital, while in 2003, the respective percentages were 57.3% and 56.1%. The results indicate a trend toward a larger proportion of hospital deaths over this interval. This should be taken under consideration for future planning of end-of-life care in Greece.

Self-efficacy beliefs and levels of anxiety in advanced cancer patients

The aims of this study were to investigate the self-efficacy and anxiety in advanced cancer patients in a palliative care unit. The subject is some 99 advanced cancer patients, treated for pain relief and cancer-related symptoms. Patients completed the General Perceived Self-Efficacy Scale (GSE) and the Spielberger's State-Trait Anxiety Inventory (STAI). The Eastern Cooperative Oncology Group was used to measure patients' performance status. Statistically significant associations were found between GSE, patients' gender, performance status, opioids and all the STAI scales. The multiple regression analysis revealed that self-efficacy was predicted by patients' age, performance status, gender, as well as by their high levels on two STAI scales, in a model explaining 39.7% of the total variance. In advanced cancer patients, self-efficacy is significantly correlated with levels of anxiety, patients' physical condition and demographic characteristics. Also, it seems to be influenced by components of the STAI, patients' age, physical performance and gender.

Illness-related hopelessness in advanced cancer: influence of anxiety, depression, and preparatory grief

The growing interest in the psychological distress in patients with cancer has been the major reason for the conduction of this study. The aims were to assess the relationship of hopelessness, anxiety, distress, and preparatory grief, as well as their predictive power to hopelessness. Ninety-four patients with advanced cancer completed the study at a palliative care unit in Athens, Greece. Beck Hopelessness Scale, the Greek version of the Hospital Anxiety and Depression (HAD) scale, and the Preparatory Grief in Advanced Cancer Patients scale were administered. Information concerning patients' treatment was acquired from the medical records, whereas physicians recorded their clinical condition. Hopelessness correlated significantly with preparatory grief (r = .630, P < .0005), anxiety (r = .539, P < .0005), depression (r = .642, P < .0005), HAD-Total (r = .686, P < .0005), and age (r = -.212, P = .040). Multiple regression analyses showed that preparatory grief (P < .0005), depression (P < .0005), and age (P = .003) were predictors of hopelessness, explaining 58.8% of total variance. In this patient sample, depression, preparatory grief, and patients' age were predictors of hopelessness.

The relationship between quality of life and levels of hopelessness and depression in palliative care

There is growing interest in the psychological distress and quality of life of cancer patients. The aim of this study was to compare the responses of 102 advanced cancer patients on a quality of life scale (as measured by the SF12) with the Beck Depression Inventory (BDI) and the Beck Hopelessness Scale (BHS), as well as the impact of depression and hopelessness on quality of life. Significant associations were found between gender (P=.027), performance status (P=.003), opioids (P=.002), depression (P<.0005), and hopelessness (P<.0005) with the SF12-Mental Component Score (MCS). Gender (P=.07), metastasis (P=.001), opioids (P=.0005), and education (P=.045) correlated significantly with SF12-Physical Component Score (PCS). In the prediction of MCS, the dimensions of age, hopelessness, gender, and performance status were statistically significantly high (P<.0005), explaining 48% of variance. For PCS, the predictor variables were education, metastasis, and opioids (25% of variance). Quality of life, in this patient population, was predicted by the level of hopelessness and patients' demographic and clinical characteristics.

How is sleep quality affected by the psychological and symptom distress of advanced cancer patients?

The aim of this study was to assess the relationship between sleep quality, pain, psychological distress, cognitive status and post-traumatic experience in advanced cancer patients. Participants were 82 advanced cancer patients referred to a palliative care unit for control of pain and other symptoms. A variety of assessment tools were used to examine the prevalence of sleep disturbance, the severity of pain and depression, hopelessness, cognitive function and quality of life. Using the Pittsburgh Sleep Quality Index (PSQI) 96% of patients were 'poor sleepers'. Statistically significant associations were found between PSQI and the SF-12 (Short Form-12) Quality of Life Instrument (MCS, P < 0.0005, PCS, P < 0.0005), depression (Greek Depression Inventory) (P < 0.0005) and hopelessness (Beck Hopelessness Scale) (P = 0.003). Strong associations were also found between PSQI and IES-R (Impact of Event Scale-Revised) (P = 0.004). The strongest predictors of poor sleep quality in this model were MCS (P < 0.0005), PCS (P < 0.0005) and IES-R (P = 0.010). Post-traumatic experience and quality of life seemed to be the strongest predictors of sleep quality in a sample of advanced cancer patients referred for palliative care.

Oral Transmucosal Fentanyl Citrate: Overview of Pharmacological and Clinical Characteristics

Oral transmucosal fentanyl citrate (OTFC; brand name Actiq, Cephalon, UT) is a new opioid formulation that incorporates fentanyl into a lozenge and allows drug delivery through the buccal mucosa. This kind of absorption avoids first-pass metabolism, yielding a bioavailability substantially greater than oral administration. OTFC has a rapid onset of action and a short duration of effect. These characteristics, which resemble the course of a typical breakthrough pain episode, resulted in making OTFC the first opioid analgesic formulation specifically developed and approved for control of breakthrough pain in cancer patients. Apart from that, OTFC has been used in a variety of clinical situations of noncancer pain. This review article presents the synthesis; clinical pharmacology; pharmacokinetic and pharmacodynamic properties, toxicity, and clinical efficacy of this novel agent.

Euthanasia and physician-assisted suicide in cases of terminal cancer: the opinions of physicians and nurses in Greece

The aim of this study was to investigate the opinions of physicians and nurses on euthanasia and physician-assisted suicide in advanced cancer patients in Greece. Two hundred and fifteen physicians and 250 nurses from various hospitals in Greece completed a questionnaire concerning issues on euthanasia and physician-assisted suicide. More physicians (43.3%) than nurses (3.2%, p < 0.0005) reported that in the case of a cardiac or respiratory arrest, they would not attempt to revive a terminally ill cancer patient. Only 1.9% of physicians and 3.6% of nurses agreed on physician-assisted suicide. Forty-seven per cent of physicians and 45.2% of nurses would prefer the legalization of a terminally ill patient's hastened death; in the case of such a request, 64.2% of physicians and 55.2% of nurses (p = 0.06) would consider it if it was legal. The majority of the participants tended to disagree with euthanasia or physician-assisted suicide in terminally ill cancer patients, probably due to the fact that these acts in Greece are illegal.

Psychometric properties of the brief fatigue inventory in Greek patients with advanced cancer

To validate the Greek version of the Brief Fatigue Inventory (BFI-Gr) in a sample of cancer patients, the scale was translated with the "forward-backward" procedure to Greek. It was administered twice, at a three-day interval, to 102 eligible patients with cancer. Together with the BFI-Gr scale, the patients also completed the European Organization for Research and Treatment of Cancer QLQ-C30 (version 3.0) subscales of fatigue and emotional functioning, and the M. D. Anderson Symptom Inventory. The BFI-Gr had an overall Cronbach alpha for the nine items of 0.954. The assessment of the relationships between the BFI-Gr and the other measurements showed statistically significant correlations between all the assessed measurements (r values between 0.47 and 0.76, P<0.0005), except with the emotional subscale of the European Organization for Research and Treatment of Cancer scale. Factor analysis yielded a one-factor solution, explaining 73.6% of the variance. Interitem correlations were high and ranged from 0.567 to 0.882 (P<0.0005). The test-retest reliability of scale showed that the coefficient agreement was 0.901 (P<0.0005). Univariate analysis revealed significant correlations between hemoglobin and fatigue (r=-0.21, P=0.037), and between performance status (P<0.0005) and opioids (P=0.009). These results support that the BFI-Gr is an instrument with satisfactory psychometric properties, and is a valid research tool for cancer-related fatigue in Greek cancer patients.

Demographic and clinical predictors of spirituality in advanced cancer patients: a randomized control study

AIM

To study the influence of cancer patients' sociodemographic and clinical characteristics in their spiritual beliefs and attitudes.

BACKGROUND

Patients' sociodemographic and clinical characteristics may have an important role in their spirituality. Failure to control these factors can lead to a false estimation on patients' spiritual beliefs. Previous studies have found that age, gender and health status associate with spiritual attitudes and beliefs.Design. Survey.

METHODS

The Spiritual Involvement and Beliefs Scale was administered to 82 cancer patients. Demographic characteristics, disease status and treatment regimen were recorded.

RESULTS

Among the most significant correlations were those between gender and all the subscales, cancer diagnosis, existential/meditative subscale, radiotherapy treatment and external/ritual, internal/fluid and existential meditative. In the prediction of spirituality, the contribution of gender, age, years of education, performance status and radiotherapy is high.

CONCLUSION

Acknowledging the specific patients' demographic and medical characteristics, such as female gender, old age, years of education, performance status and radiotherapy treatment, contributes to the prediction of patients' spiritual beliefs and attitudes.

RELEVANCE TO CLINICAL PRACTICE

Addressing spiritual needs in palliative care among the dying needs to be a priority and could be a crucial aspect of psychological functioning, especially when considering certain demographic and clinical characteristics.

The experience of hopelessness in a population of Greek cancer patients receiving palliative care

BACKGROUND

Beck Hopelessness Scale (BHS) has been translated and validated in many languages.

AIM

The validation of the English version of BHS in advanced cancer patients receiving palliative treatment in Greece.

METHODS

The final sample was 112 advanced cancer patients. Internal consistency, item-total correlations, and test-retest using four different approaches were calculated for the assessment of the reliability. Construct validity was used by examining correlations between BHS, Hospital Anxiety and Depression Scale (HAD-Depression) and the Schedule of Attitudes toward Hastened Death (SAHD). Known-groups validity was also assessed by detecting group differences according to disease severity as measured by the Eastern Cooperative Oncology Group (ECOG) performance status. Univariate and multivariate analyses were constructed to explore the relationship between hopelessness, depression, hastened death and the patients' demographic and clinical characteristics.

RESULTS

One factor solution was yielded accounted for 46.64% of the variance. The test-retest reliability was satisfactory (p < 0.0005). Validity as performed using known-group analysis showed good results. Most significant correlations were found between BHS, ECOG (p = 0.018) and gender (p = 0.08). The strongest predictors were gender (p = 0.050) and ECOG (p = 0.045).

CONCLUSIONS

BHS seemed to be a useful instrument to assess pessimistic attitude and hopelessness in a Greek cancer population, with valid psychometric properties.

Depression, hopelessness, and sleep in cancer patients' desire for death

OBJECTIVE

The aim of this study was to evaluate the prevalence of clinical characteristics and risk factors for hastened death in advanced cancer patients.

METHODS

Patients completed the Greek version of Schedule of Attitudes toward Hastened Death (G-SAHD), a sleep quality measure, the Pittsburgh Sleep Quality Index (PSQI), a Greek version of a depression inventory, the Beck Depression Inventory (BDI), a hopelessness scale, the Beck Hopelessness Scale (BHS), and a Visual Analogue Scale (VAS) for the assessment of pain.

PATIENTS

The final sample consisted of 102 terminally ill cancer patients attending a Palliative Care Unit.

RESULTS

Statistically significant associations were found between G-SAHD and patients performance status (ECOG) (chi2 = 8.62, p = 0.003). Strongest associations were observed between desire for death, depression, and hopelessness (r = 0.468, p < 0.0005, r = 0.678, p < 0.0005, respectively). In the prediction of G-SHAD the contribution of "hopelessness" (p < 0.0005), "depression" (p < 0.0005), "use of sleeping medication" (p < 0.0005), and "sleep quality" (p = 0.001) was high (59% of variance).

CONCLUSION

Depression, hopelessness, and sleep quality appeared to have a statistically significant relationship with desire for hastened death. Health care professionals finding desire for death in advanced cancer patients should not only consider depression and hopelessness, but also other factors such as poor sleep quality in their diagnostic formulations in order to provide the appropriate treatment.

Traumatic distress and positive changes in advanced cancer patients

This study investigated the traumatic distress and posttraumatic growth in 58 advanced cancer patients receiving palliative treatment in a Pain Relief and Palliative Care Unit. The patients completed the Greek version of the Impact of Events Scale-Revised and the Posttraumatic Growth Inventory. Statistically significant associations were found among Impact of Events Scale-Revised-Greek "Relating to Others" (r = 0.311, P = .017), "New Possibilities" ( r = 0.248, P = .050), and "Appreciation of Life" ( r = 0.419, P = .001), and the Posttraumatic Growth Inventory scores (r = 0.323, P = .013). Similarly, "Appreciation of Life" correlated significantly with "Avoidance" (r = 0.318, P = .015), "Intrusion" (r = 0.365, P = .005), and "Hyperarousal" (r = 0.398, P = .002). Statistically significant associations were also found between "Relating to Others" and "Intrusion" (r = 0.414, P = .001). The study concluded that in advanced cancer patients, the higher the impact event, the more improvement in their relationships with others, enhanced life appreciation, and more positive consequences after trauma.

Beck Depression Inventory: exploring its psychometric properties in a palliative care population of advanced cancer patients

To validate the Greek version of the Beck Depression Inventory (BDI)-21 items in advanced cancer patents attending a palliative care unit. The scale was translated with the forward-backward procedure into Greek. It was administered twice, with a 1-week interval, to 105 patients with advanced cancer. The patients also completed the Hospital Anxiety and Depression (HAD) scale, while researchers recorded data on demographic characteristics, disease status and treatment regimen. The Greek version of the BDI had overall Cronbach's alpha 0.906. The most significant correlations were found between BDI and performance status (P < 0.0005), gender (P = 0.031) and family status (P = 0.009). The test-retest reliability in terms of Spearman-rho, Pearson-rho coefficient and Kendall's tau-b was also satisfactory (P < 0.0005). Validity as performed using known-group analysis showed good results. The Inventory discriminated well between subgroups of patients differing in disease severity as defined by the Eastern Cooperative Oncology Group performance status. Correlations between the BDI and the HAD scale was 0.544 for the anxiety subscale and 0.657 for the depression subscale. Multiple regression analysis was conducted and predicted that the contribution of gender, family status and performance status to BDI is high. These psychometric properties of the Greek version of the BDI confirm it as a valid and reliable measure when administered to patients with advanced cancer.

Post-traumatic growth in advanced cancer patients receiving palliative care

GOALS OF WORK

To develop the Greek version of the Post-traumatic Growth Inventory (PTGI-Gr), and assess its psychometric properties in a palliative care patient sample.

PATIENTS AND METHODS

The scale was translated with the forward-backward procedure to Greek. It was administered twice, with a 3-day interval, to 131 eligible patients with advanced cancer. Together with the PTGI, the patients also completed the Greek version of the Impact of Events Scale-Revised scale (IES-R-Gr). The reliability was assessed by the internal consistency (Cronbach's alpha coefficients), test/retest (Spearman's r value), and inter-item correlations. Validity was demonstrated by factor analysis, inter-scale correlations, construct validity with the IES-R-Gr, and combined with the Eastern Cooperative Oncology Group (ECOG) performance status.

MAIN RESULTS

The PTGI-Gr yielded a five-factor structure, explaining 73.5% of the variance. Cronbach's alphas for the five factors ranged from .66 to .87, respectively. Overall test-retest reliability was satisfactory with a range between .85 and .92 (p<.0005), and inter-item correlations ranged between .47 and .63. Inter-scale correlations were found satisfactory (p<.0005, p<.005, and p<.05). Validity as performed using combined validity analysis showed good results. Satisfactory construct validity was supported by the correlation analysis between the PTGI-Gr and the IES-R-Gr scales.

CONCLUSIONS

PTGI-Gr is an instrument with satisfactory psychometric properties, and is a valid research tool for the post-traumatic growth of advanced cancer patients.

Oral transmucosal fentanyl citrate in cancer pain management: a practical application of nanotechnology

Pain is experienced by most cancer patients and represents an important issue in the clinical setting. Breakthrough pain is a transitory flare of pain that occurs in most cancer patients on a background of otherwise controlled persistent pain. Treatment of breakthrough pain is a challenging phenomenon. Oral transmucosal fentanyl citrate (OTFC; Actiq, Cephalon, UK), a new opioid formulation with a unique delivery system, utilizing the advantages that nanotechnology offers, reflects the characteristics of breakthrough pain (rapid onset of action and short duration), which makes it an effective treatment to cancer patients who are already receiving opioids and continue to experience such flares of pain. Oral transmucosal fentanyl citrate is specifically developed and approved for the management of breakthrough pain in cancer patients and it has the potential to be a useful tool for clinicians.

Caregivers of Advanced Cancer Patients

To investigate whether the advanced cancer patients' caregivers' depression and hopelessness are affected by patients' demographic and clinical characteristics and by caregivers' sociodemographic variables. Moreover, the relation between cancer patients' and caregivers' depression and hopelessness was assessed. One hundred five patients with advanced cancer receiving palliative care and 96 caregivers were enrolled in the study. The patients and their caregivers completed the Beck Depression Inventory and the Beck Hopelessness Scale while researchers recorded data on demographic characteristics, disease status, and treatment regimen. The analysis showed that significant associations were found between patient male sex and caregiver's depression (P = .007) and hopelessness (P = .002), between patient family status and caregiver's depression (P = .031) and hopelessness (P = .001), and between patient radiotherapy treatment and caregiver's hopelessness (P = .017). Moreover, statistically significant correlation was found between patient's and caregiver's depression (P = .041). Generalized estimating equations showed that the patients characteristics that predicted caregivers' hopelessness were family status (P = .017), radiotherapy (P = .025), and the caregiver's relation to patient (P = .059). The findings suggest that caregiver's hopelessness is predicted by cancer patient's characteristics and that patient's depression is correlated to that of caregiver. The findings provide a base for future research.

Ibandronate reduces radiotherapy-resistant metastatic bone pain in patients with solid tumors: A comparison of i.v. and oral formulations

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Background: Bisphosphonates are used to treat metastatic bone disease (MBD). However, some bisphosphonates are associated with renal toxicity. Ibandronate (IA) is a single-nitrogen, noncyclic bisphosphonate with a renal safety profile similar to placebo in phase III trials. This study compares the effects of i.v. IA 6mg and oral IA 50mg on bone pain, analgesic intake and renal safety. Methods: Recruited patients fulfilled the following criteria: age ≥18, solid tumors with at least one bone lesion, normal renal (serum creatinine ≤1.5mg/dL) and hepatic function, WHO performance status 0, I or II, life expectancy ≥6 months, normal serum calcium or asymptomatic hypercalcemia. Patients were excluded if they were pregnant or lactating, taking nephrotoxic drugs or osteoclast activity modulators. Eligible patients (n=52) were recruited for a two-arm study, with 26 patients per group treated over 6 months. Groups were matched for age, gender, weight, height, blood pressure, site of primary tumor, site and number of bone metastases and number of irradiated sites. Intravenous IA 6mg was administered over 15 minutes every 4 weeks. Oral IA 50mg was administered as a single, daily tablet before breakfast. Studies were ceased on occurrence of new bone events. Primary endpoint was reduction in bone pain and reduced analgesic use. Results: There were no significant differences in patient demographics between the two treatment arms. The percentage of patients receiving i.v. IA that achieved stable or progressive disease was 15.4%; those receiving oral IA attained 11.5% stable or progressive disease. Pain (Brief Pain Inventory questionnaire) and analgesic intake were assessed at baseline, 3 and 6 months. Both i.v. and oral IA caused a significant and sustainable decrease in each of the pain indices (p<0.0005) with no significant difference between i.v. and oral groups. Both i.v. and oral IA treatment led to a trend in decrease of analgesic use. Conclusions: Oral and i.v. ibandronate have comparable efficacy for palliation of bone pain in MBD patients.

No significant financial relationships to disclose.

Exploring the relationships between depression, hopelessness, cognitive status, pain, and spirituality in patients with advanced cancer

The growing interest in the psychological morbidity of patients with cancer has been the major reason for conducting this study. The measurements used were the Beck Depression Inventory, the Beck Hopelessness Scale, the Mini Mental State Examination, the Greek Brief Pain Inventory, and the Spiritual Involvement and Beliefs Scale. The analysis was conducted in 82 patients with advanced cancer. Significant associations were found between pain interference in "mood" and in "enjoyment of life" and hopelessness, as well as between worse pain and pain interference items with depression and cognitive status. Significant correlations were found between hopelessness, depression, and cognitive condition. These findings demonstrate the physical, psychological, and cognitive aspects of patients with cancer.

Sleep quality in advanced cancer patients

OBJECTIVE

The objective of this study was to evaluate the sleep quality of advanced cancer patients and its relationship with pain, depression, and hopelessness.

METHODS

The participants were 102 advanced cancer patients who were on palliative treatment. Patients completed a sleep quality instrument, the Pittsburgh Sleep Quality Index (PSQI); a pain assessment tool, the Greek Brief Pain Inventory; a self-report measure of depression, the Beck Depression Inventory; and, finally, the Beck Hopelessness Scale.

RESULTS

Multiple regression analyses (forward method) have shown that hopelessness (P=.003), "interference of pain with mood" (P<.0005), and strong opioids (P=.010) seemed to influence patients' sleep quality (PSOI). In an additional regression analysis (enter method), the PSQI is significantly related to opioids (P=.013), hopelessness (P=.035), and "interference of pain with mood" (P=.004).

CONCLUSION

Hopelessness, pain treatment, and "interference of pain with mood" may influence the quality of sleep in advanced stages of cancer.

Psychometric properties of the Impact of Event Scale in Greek cancer patients

To develop the Greek version of the Impact of Event Scale-Revised (IES-R-Gr), assess its psychometric properties, and finally to examine the impact of cancer diagnosis to a palliative care patient sample, the IES-R was translated into Greek using the "forward-backward" procedure. It was administered twice, at one-week intervals, to 82 eligible patients with advanced cancer. Together with the IES-R-Gr scale, the patients also completed the Hospital Anxiety and Depression (HAD) Scale. Reliability was assessed in terms of internal consistency (Cronbach's alpha coefficients) and test/retest (Spearman's r value and Kendall's tau-b). Construct validity was demonstrated through association with the HAD Scale, and convergence and discriminative validity and interscale correlations were also assessed. The Greek version of the IES-R had Cronbach's alphas for the intrusion, avoidance, and hyperarousal scales of 0.72, 0.77, and 0.85, respectively. Overall test-retest reliability was satisfactory at P<0.0005. Satisfactory construct validity was supported by the correlation analysis between the IES-R-Gr subscales and anxiety and depression. Factor analysis yielded three factors, explaining 57.26% of the variance. Interscale and interitem correlations were found satisfactory at P<0.0005. These results demonstrate that the IES-R-Gr is an instrument with satisfactory psychometric properties and is a valid research tool for the impact of cancer diagnosis in advanced cancer patients.

Brief cognitive assessment of cancer patients: evaluation of the Mini-Mental State Examination (MMSE) psychometric properties

AIM

The aim of the present study was to validate the Greek version of the MMSE in advanced-cancer patients attending a palliative care unit.

METHODS

The sample consisted of 103 advanced-cancer patients. The questionnaire was completed at baseline and three days later. Together with the MMSE, the patients also completed the EORTC QLQ-C30 Cognitive functioning scale, while researchers recorded data on demographic characteristics, disease status and treatment regimen.

RESULTS

MMSE had overall Cronbach alpha 0.890. Validity as performed using known-group analysis showed good results. MMSE discriminated well between subgroups of patients differing in disease severity as defined by ECOG performance status. Comparison between the MMSE and the EORTC Cognitive functioning scale was statistically significant (p<0.05).

CONCLUSION

These psychometric properties of the Greek version of the MMSE confirm it as a valid and reliable measure when administered to patients with advanced cancer.

Optimization of doses received by the hospital staff and the members of the family of patients undergoing 111In-DTPA-D-Phe1-Octreotide therapy

According to the Euratom Directives (96/29, 97/43), the doses received by the workers as well as the family of patients and third persons during medical exposures, should conform to the dose constraint levels (DCLs), established by the authorities for each group in the context of optimisation. This study deals with the implementation of a radiation protection protocol, concerning the aforementioned group members for patients undergoing treatment with 111In-DTPA-D-Phe1-Octreotide, after intra-arterial infusion. It is shown that by applying this protocol the annual doses to the medical and technical staff are considerably reduced and remain below the established DCLs. Following the post-release behaviour instructions given to the patient, doses to the family and third persons may be kept lower than the corresponding DCLs provided by the National Regulations.

Comparison of pain quality descriptors in cancer patients with nociceptive and neuropathic pain

BACKGROUND

The aim of this study was to explore the differences in the descriptors for neuropathic and nociceptive pain in cancer patients.

PATIENTS AND METHODS

One hundred and eighty-six cancer patients who participated in the study completed the Greek version of the McGill Pain Questionnaire (G-MPQ) for the assessment of their pain quality.

RESULTS

Significant differences were found between type of pain in all G-MPQ classes. Statistically significant associations were found between Present Pain Intensity and type of pain (p = 0.002). Multivariate logistic regression analyses showed that patients who selected the descriptors "pricking" and "annoying" were 2.64 times and 2.2 times, respectively, more likely to experience nociceptive rather than neuropathic pain (p = 0.020 and p = 0.015, respectively). Further analysis showed that sensory seemed to be the most significant indicator for type of pain (95%, CI: 0.911-0.974, p < 0.001).

CONCLUSION

Sensory quality and some of pain descriptors may differentiate neuropathic from nociceptive pain in cancer patients.

Interstitial magnetic resonance lymphography with gadobutrol in rabbits and an initial experience in humans

The purpose of this study was first to evaluate gadobutrol as a contrast agent for interstitial Magnetic Resonance Lymphography (MRL) in rabbits, and second, to extend the study to humans, if the initial results were satisfactory. In our experiment, gadobutrol was injected into twelve white New Zealand rabbits. In nine animals, 0.5 ml of gadobutrol was subcutaneously administered through each foot pad of the hindlegs while in the remaining three animals the agent was given in each foot of the forelegs. In four of the nine rabbits, slight local massage was applied at the site of administration. Subsequently, we proceeded to administer 5 ml (4.5 ml gadobutrol mixed with 0.5 ml hydrochloride lidocaine) into the limbs of two healthy humans. We achieved imaging of four lymph node groups (popliteal, inguinal, iliac and paraortic) in the hind-legs of the nine-rabbit group, whereas, in the forelegs of the remaining three rabbits, three lymph node groups (axillary, parasternal, mediastinal) were depicted. The flow of the contrast agent was significantly faster in the rabbits that received local massage (P<0.02). In humans, normal lymph vessels, as well as inguinal lymph nodes, were depicted in the legs. No side-effects were observed either in the rabbits or humans.

Psychological distress of patients with advanced cancer: influence and contribution of pain severity and pain interference

The growing interest in the psychological distress and the multidimensionality of pain in patients with cancer has been the major reason for the conduction of this study. The aims were to evaluate psychological distress and pain in patients with advanced cancer and the impact of pain severity and pain interference dimensions on the anxiety and depression. One hundred twenty patients with advanced cancer were surveyed at a palliative care unit in Athens, Greece. Greek versions of the Hospital Anxiety and Depression (G-HAD) scale and the Brief Pain Inventory were administered. Information concerning patients' treatment received was acquired from the medical records, whereas physicians recorded their clinical condition. The analysis showed that significant associations were found between pain interference to "mood" and HAD-A (anxiety) (r = 0.252, P = .005) and between pain interference to "relations with other people" and HAD-A (r = 0.474, P < .0005). Multiple regression analyses showed that "average pain" (P < .05), pain interference to "walking ability" (P < .05), "normal work" (P < .05, and "relations with other people" are significant predictors of HAD-anxiety (HAD-A) (P < .0005), explaining 46.2% of total variance. For depression (HAD-D), the Greek version of the Brief Pain Inventory dimension that serve as predictor is "enjoyment of life," as well as the demographic variables of "age," and "gender" (P < .05), explaining 22.2% of variance. Moreover, a further analysis of the pain severity and pain interference scales showed that they differentiate the anxiety of the patients with cancer. In this patient sample, pain interference and, to a lesser extent, pain severity was significantly associated with psychological distress (anxiety and pain), whereas pain interference to "walking ability," "normal work," and "relations with other people" was found to be more prominent and troublesome to patients' anxiety than that to patients' depression.

Prophylactic tropisetron versus rescue tropisetron in fractionated radiotherapy to moderate or high emetogenic areas: a prospective randomized open label study in cancer patients

AIM

A prospective randomized open label study was carried out to evaluate the efficacy and effectiveness of prophylactic tropisetron versus rescue tropisetron in fractionated radiotherapy.

PATIENTS AND METHODS

The study sample consisted of 288 cancer patients randomly allocated (3:4 ratio) into two treatment groups: 120 patients received prophylactic antiemetic treatment with tropisetron and 168 patients received rescue tropisetron. To determine the efficacy of prophylactic antiemetic treatment, nausea and vomiting were evaluated 1 d before radiation therapy (RT), at 24 and 72 h, at the end of every week during RT, and finally 1 wk after RT. Diary cards were used to record the intensity of nausea and vomiting as well as the incidence of adverse effects.

RESULTS

In the odds of nausea and vomiting, statistically significant differences were found between the two treatment groups over time. The incidence of nausea and vomiting were 1.89 (p = 0.009) and 2.19 (p = 0.001) times higher in the rescue tropisetron group than in the prophylactic tropisetron group. Factors that related significantly with increased nausea were primary cancer, rescue tropisetron, and radical RT. Moreover, factors for vomiting were primary cancer type, metastasis, palliative RT, and rescue tropisetron.

CONCLUSIONS

Higher numbers of patients receiving prophylactic tropisetron completed RT with lower incidence of nausea and vomiting than those in the rescue tropisetron group.

The role of physical and psychological symptoms in desire for death: a study of terminally ill cancer patients

The current study assessed the attitudes of the desire for hastened death in terminally ill cancer patients and whether these are determined by their physical and psychological symptoms. The final sample consisted of 106 terminally ill cancer patients attending a Palliative Care Unit, in University of Athens, Greece, between June and October 2004. Significant associations were found between the desire for hastened death (D.H.D.) and 'pain' (r=0.469, p<0.005), 'fatigue' (r=0.591, p<0.0005), 'loss of appetite' (r=0.622, p<0.0005) and 'feeling sad' (r=0.635, p<0.0005). Statistically significant associations were also found between Schedule of Attitudes towards Hastened Death (SAHD) scores, age (r=0.300, p=0.002) and ECOG (p<0.0005). Twenty-six percent of the patients reported high D.H.D. while 41% reported moderate desire. In the prediction of SHAD the contribution of 'pain' (p=0.011), 'lack of appetite' (p=0.012) and 'sadness' (p=0.011) is high (42% of variance). Further findings suggest that D.H.D. is significantly related to 'feeling sad', 'lack of appetite', 'pain' and 'fatigue' after controlling for age, gender and performance status according to ECOG in terminally ill cancer patients.

Intratesticular arteriovenous malformation. Clinical course, ultrasound and MRI findings of an extremely rare lesion on a 7 year follow-up basis

We present the clinical course, sonographic and MRI findings of an intratesticular arteriovenous malformation (AVM) found in a patient during routine check-up for infertility evaluation. Seven years ago, patient's refusal for surgical removal of the lesion led to follow-up ultrasound examinations and finally to an MRI examination. Arteriovenous malformations of male genitalia have been reported in the literature (penis, scrotum, spermatic cord and epididimys). However, this is the second case of an intratesticular AVM and the first one with a long clinical follow-up.

Acute Iliac Artery Rupture: Endovascular Treatment

The authors present 7 patients who suffered iliac artery rupture over a 2 year period. In 5 patients, the rupture was iatrogenic: 4 cases were secondary to balloon angioplasty for iliac artery stenosis and 1 occurred during coronary angioplasty. In the last 2 patients, the rupture was secondary to iliac artery mycotic aneurysm. Direct placement of a stent-graft was performed in all cases, which was dilated until extravasation was controlled. Placement of the stent-graft was successful in all the cases, without any complications. The techniques used, results, and mid-term follow-up are presented. In conclusion, endovascular placement of a stent-graft is a quick, minimally invasive, efficient, and safe method for emergency treatment of acute iliac artery rupture, with satisfactory short- and mid-term results.

Octreotide long-acting formulation (LAR) in chronic loperamide-refractory diarrhea not related to cancer treatment

OBJECTIVE

The effectiveness and improvement in quality of life (QOL) of a long-acting formulation of octreotide (LAR) administration for cancer patients, with chronic loperamide-refractory diarrhea not attributed to medical therapy, were investigated.

PATIENTS AND METHODS

Twenty-nine patients with chronic loperamide-refractory diarrhea were enrolled to receive octreotide LAR at a starting dose of 30 mg i.m. every 28 days until resolution of the diarrhea for a period of 3 months.

RESULTS

Twenty-three patients (79.3%) administered octreotide LAR achieved resolution of diarrhea, while six patients (20.7%) successfully controlled their diarrhea during the study. All patients experienced improved sodium, potassium, albumin and total protein values with improvement in their QOL, as assessed by the Linear Analog Scale Assessment (LASA) (mean values at baseline and at 3 months: energy: 3.2+/-1.1 vs. 6.2+/-1.4; function: 3.1+/-1.3 vs. 6.2+/-1.2; QOL: 3.2+/-0.9 vs. 6.1+/-1.4). No toxicities associated with the administration of octreotide LAR were noted.

CONCLUSION

The administration of octreotide LAR at a starting dose of 30 mg i.m. every 28 days efficiently resolved or controlled chronic loperamide-refractory diarrhea, not caused by medical intervention, in cancer patients and improved their QOL.

Expression of DNA mismatch repair gene MSH2 in cytological material from lung cancer patients

Mismatch repair genes encode for proteins responsible for the correction of bases incorrectly paired in the DNA. Loss of DNA mismatch repair activity has been associated with various cancers including tumors of the lung. In the present study, we have analyzed by immunocytochemistry the expression of MSH2 DNA repair gene in cytological material obtained by fine needle aspiration from a panel of 42 primary lung cancer patients. Specimens included 13 adenocarcinomas, 11 small cell carcinomas and 18 squamous cell carcinomas. Loss of expression or low expression was detected in 6 out of 13 (46%) adenocarcinomas and in 7 out of 18 (39%) of squamous cell carcinomas, although all 11 small cell carcinomas expressed MSH2. Our results suggest that loss of MSH2 expression is frequent in nonsmall cell carcinomas of the lung (P < 0.01, chi2 test). Evaluation of MSH2 expression can be applied for the screening of cytological material from fine needle aspirations from the lung.

Demographic and clinical predictors of preparatory grief in a sample of advanced cancer patients

BACKGROUND

Preparatory grief encompasses grief for losses that have already occurred, are currently being experienced, and losses that will or might ensue in the future after the death, as a consequence of it.

AIM

To examine the relative contribution of demographic and clinical variables in predicting cancer patients' preparatory grief as recorded from the Preparatory Grief in Advanced Cancer Patients (PGAC) scale. Moreover, researchers were interested in determining whether these dimensions were independently and uniquely associated with preparatory grief.

METHODS

Two hundred advanced cancer patients treated in a Pain Relief and Palliative Care Unit completed the PGAC scale, while researchers recorded data on demographic characteristics, disease status and treatment regimen.

RESULTS

The analyses showed that the most significant correlations were found between preparatory grief and age (r = -0.227, p = 0.001), gender (p = 0.006), family status (p = 0.019), performance status (p = 0.010), surgery (p = 0.029), opioids (p = 0.019), and diagnosis (p = 0.038). In the prediction of preparatory grief, the contribution of age, performance status, history of other surgery, gender and opioids is high.

CONCLUSIONS

Awareness of the specific patients' demographic and medical characteristics, such as old age, poor performance status, history of other surgery, female gender, and strong opioids, contribute to the prediction of patients' preparatory grief.

An evaluation of the TSE MR sequence for time efficient data acquisition in polymer gel dosimetry of applications involving high doses and steep dose gradients

The use of magnetic resonance imaging as a readout method for polymer gel dosimetry commonly involves long imaging sessions, particularly when high spatial resolution is required in all three dimensions, for the investigation of dose distributions with steep dose gradients and stringent dose delivery specifications. In this work, a volume selective turbo spin echo (TSE) pulse sequence is compared to the established Carr-Purcell-Meiboom-Gill (CPMG) multiecho acquisition with regard to providing accurate dosimetric results in significantly reduced imaging times. Polyethylene glycol diacrylate based (PABIG) gels were irradiated and subsequently scanned to obtain R2 relaxation rate measurements, using a CPMG multiecho sequence and a dual echo TSE utilizing an acceleration (turbo) factor of 64. R2 values, plotted against corresponding Monte Carlo dose calculations, provided calibration data of PABIG gels dose response over a wide dose range. A linear R2 versus dose relationship was demonstrated for both sequences with TSE results presenting reduced dose sensitivity. Although TSE data were found to deviate from linearity at lower doses compared to CPMG data, a relatively wide dynamic dose range of response extending up to approximately 100 Gy was observed for both sequences. The TSE and CPMG sequences were evaluated with a brachytherapy irradiation using a high dose rate 192Ir source and a gamma knife stereotactic radiosurgery irradiation with a single 4 mm collimator helmet shot. Dosimetric results obtained with the TSE and CPMG are shown to compare equally well with the expected dose distributions for these irradiations. The 60-fold scan time reduction achieved with TSE implies that this sequence could prove to be a useful tool for the introduction of polymer gel dosimetry in clinical radiation therapy applications involving high doses and steep dose gradients.

Technical note: evaluation of dosimetric performance in a commercial 3D treatment planning system

The aim of this work was to evaluate the dosimetric performance of a commercial treatment planning system (TPS) which employs a three-dimensional calculation algorithm (Nucletron Plato version 2.2.3), following the guidelines of the AAPM Task Group 23 (TG23). Seven test cases were used to test the TPS dosimetric performance in homogeneous water. These cases involved absolute dose measurements on central as well as off-axis points situated at various depths, using simple field arrangements, and comparison with corresponding TPS calculations. This comparison yielded differences within +/-2% at all points, for all test cases. To test the ability of the TPS to account for tissue inhomogeneities, corresponding comparisons were performed with the presence of a low-density material in the beam to resemble an air inhomogeneity. Absolute dose measurements and corresponding TPS calculations showed a mean deviation of the order of +/-3.5%, reaching a maximum of 11.5% for small field sizes (5 cm x 5 cm). In summary, observed deviations are well within the set tolerance levels while comparison with previous TPS versions showed that Plato version 2.2.3 is significantly improved, especially in dose calculations in the presence of low density inhomogeneities.

Assessment of Anxiety and Depression in Advanced Cancer Patients and their Relationship with Quality of Life

The growing interest in the mental health and quality of life of cancer patients, has been the major reason for conducting this study. The aims were to compare advanced cancer patients' responses to Hospital Anxiety and Depression (HAD) scale with those to European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30, version 3.0), as well as the impact of quality of life dimensions (as measured by EORTC QLQ-C30) on the levels of anxiety and depression. The analysis, conducted in 120 advanced cancer patients, showed that the most significant associations were found between emotional functioning and HAD-T (total sum of scores) (r=-0.747; p < 0.0005), HAD-A (anxiety) (r=-0.725; p < 0.0005) and HAD-D (depression) (r=-0.553; p < 0.0005). In the prediction of HAD-T, the contribution of physical, emotional, role, and social functioning along with nausea-vomiting, dyspnea, sleep disturbance and gender is high. For anxiety, the predictor variables were physical, role, cognitive, emotional, and social functioning, followed by dyspnea, sleep disturbance, and appetite loss, while depression was predicted by physical, role, emotional, and social functioning, the symptoms of nausea-vomiting, pain, sleep disturbance, constipation, as well as the variables of age, gender, anticancer treatment and performance status. Concluding, psychological morbidity, in this patient population, was predominantly predicted by the emotional functioning dimension of EORTC QLQ-C30.

Comparison of transdermal fentanyl with codeine/paracetamol, in combination with radiotherapy, for the management of metastatic bone pain

Radiotherapy (R/T) is frequently used for palliative treatment of painful bone metastases; however, complete alleviation of pain is not always achieved. This study was designed to evaluate pain management outcomes and quality of life (QoL) measures in cancer patients with metastatic bone pain receiving a combination of R/T and either transdermal therapeutic fentanyl (TTS-F) patches or codeine/paracetamol. A total of 460 palliative care patients with bone metastases who received R/T were enrolled in this prospective, open-label study. The patients were randomized to initially receive a total dose of 120 mg codeine/paracetamol per day or TTS-F patches releasing 25 microg fentanyl per hour. Pain measures were assessed on the basis of selected questions from the Greek-Brief Pain Inventory. Overall treatment satisfaction (scale, 1 to 4), QoL, and European Collaborative Oncology Group status were also recorded. Among the 460 patients, 422 were eligible for evaluation. Pain measures in the TTS-F group demonstrated statistically significant improvements during the study that were superior to those in the codeine/paracetamol group (p < 0.05). Likewise, there was a significantly greater increase (p < 0.05) in the mean satisfaction score for patients in TTS-F group at every visit between baseline and month two. The vast majority (95.8 percent) of patients in the codeine/paracetamol group increased their medication dosage until the end of the study, whereas in the TTS-F group the respective percentage was only 6.1. Both treatments were generally well tolerated, with constipation as the most common side effect followed by sleep disturbances and nausea. The overall frequencies of side effects were higher in the codeine/paracetamol group. The results therefore indicate that TTS-F offers more effective pain relief than codeine/paracetamol, in combination with R/T, in patients with metastatic bone pain, obtaining complete treatment satisfaction matched by improvements in their QoL.

Evaluation of epoetin supplemented with oral iron in patients with solid malignancies and chronic anemia not receiving anticancer treatment

OBJECTIVE

To evaluate the effectiveness and improvement in quality of life (QOL) of epoetin alfa administration supplemented with oral iron as a therapeutic regimen for patients with solid malignancies and anemia of chronic disease (ACD), not receiving chemotherapy and/or radiotherapy.

PATIENTS AND METHODS

A total of 100 patients with cancer-related anemia, not subjected to chemotherapy and/or radiotherapy, were randomized to receive for a maximum of 24 weeks either oral iron, equivalent to 200 mg elemental iron once daily, or epoetin alfa 40,000 IU subcutaneously once weekly plus oral iron once daily.

RESULTS

Patients in the epoetin alfa group had, from baseline to study end, a mean increase in hemoglobin (Hb) levels of 2.4 g/dL, whereas in the control group the mean Hb level decreased by 0.1 g/dL, (p<0.001). Improvement in QOL as assessed by the LASA and the FACT-An questionnaire were greater in patients in the epoetin alfa group than in the control group (mean change, LASA-energy level: 30.4 mm vs. 0.4 mm, -daily activities: 31.7 mm vs. 0.4 mm, -overall well-being. 32.4 mm vs. 4.9, FACT-An: 43.3 vs. 13.4, respectively). As for ECOG score, patients in the epoetin alfa group had a mean improvement of 0.16 from baseline to study end (control group: 0.06). Improvement in QOL parameters and in ECOG scores correlated positively with increased hemoglobin levels.

CONCLUSION

Our results suggest that weekly epoetin alfa therapy supplemented with daily oral iron increases Hb levels and improves QOL in patients with solid malignancies and ACD who are not receiving chemotherapy and/or radiotherapy. This regimen offers optimal therapy in this population taking into consideration physician's convenience and patient's compliance.