APOS Clinical E-Mail Update #13
23 November 2004

In this Update:

What catches teen attention for smoking cessation?

Lipkus IM, McBride CM, Pollak KI et al.  A randomized trial comparing the effects of self-help materials and proactive telephone counseling on teen smoking cessation.  Health Psychology. 2004;23:397-406.

Though rates of teen smoking have declined in recent years, smoking cessation among this group continues to be an important public health priority.  In this study, researchers recruited 402 15 Ė 18 year old smokers from shopping malls in four southeastern states and an amusement park in Florida.  Teens were randomized to receive written self-help material plus a 6-minute video promoting smoking cessation or written self-help material, video, and telephone counseling.  Following a baseline assessment, teens were contacted at four and eight months and asked to complete a brief telephone survey.  Abstinence rates at four and eight months and rates of sustained abstinence at both time points did not differ between the groups.  Rates of sustained abstinence for the self-help, video, and counseling group were 7% and 9% at both time points respectively.

Despite the telephone counselingís lack of effect on cessation rates, several points of fact make this an interesting study.  More than 5,000 teens were approached and a total of just 402 were randomized to one of the two intervention groups. Among the telephone counseling arm, rates of completed calls decreased steadily from 72%, 52%, and 36% of teens for the first, second, and third counseling calls, respectively.  It took an average of 8, 5, and 4 attempts to reach participants for calls one, two, and three.  Teens in the telephone counseling arm were significantly less likely to watch at least some of the video, 44% compared to 62% of the self-help plus video arm.

These data highlight the need for more innovative recruitment and retention strategies among teens as well as more creative intervention approaches.  Once parental consent is obtained, todayís teen is much more likely to be reached by pager or cell phone than by home phone.  And given most teenís level of computer sophistication, they are more likely to be receptive to watching video clips, communicating via email or instant messaging.  This studyís lack of significant findings opens the door for more creative ways to address teen smoking. — KD

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Who uses 70% of all cigarettes smoked in the US?

Grant BF, Hasin DS, Chou SP, Stinson FS, Dawson DA.  Nicotine dependence and psychiatric disorders in the United States.  Arch Gen Psychiatry. 2004; 61: 1107-1115.

Drawing from this representative sample of the US population, the National Epidemiologic Survey on Alcohol and Related Conditions, these researchers show us that patients with psychiatric disorder smoke 70% of all cigarettes smoked in the United States. Nicotine dependent persons comprise 12.8% of the population, 14% among men and 11.5% among women.  About 7.1% have co-morbid psychiatric disorder.

In the general population, alcohol use disorder prevalence was 8.5%, drug use disorder 2%, 12-month prevalence of mood and anxiety disorder were 9.2% and 11.1% respectively.

Among those with current nicotine dependence, the rate of current mood disorder was 21.1%, current anxiety disorder 22%, and the rate of personality disorder 32%. Current alcohol dependence (13.5%) among smokers was greater than alcohol abuse (9.3%), and drug abuse (4.8%).  Smoking was most prevalent among current alcohol and drug users 34.5% and 52.4% respectively.

The sample size was about 43,000. The study employed 1800 lay interviewers with face-to-face computerized personal interviews. The survey response rate was 81%. This study shows the importance of directing anti-smoking efforts to the vulnerable subgroups of the population. It is interesting to think how the rate of psychiatric disorder and comorbid nicotine dependence affect cancer rates. — DG

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Are there ethnic differences in quality of life reports in cancer patients?

Giedzinska AS, Meyerowitz BE, Ganz PA, and Rowland JH.  Health-related quality of life in a multiethnic sample of breast cancer patients.  Ann Behav Med. 2004;28:39-51.

There is a paucity of research about ethnic differences in quality of life following cancer treatment.  Ethnicity and demographic and medical variables typically overlap.  As the authors point out, for example, Latina and African American women are more likely to be poor than Asian Americans and Whites, and economic problems place women at high risk for psychosocial difficulties after treatment has ended.  Thus, research aimed at identifying ethnic differences must control for demographic and treatment variables that are confounded with ethnicity.  As part of a larger study of quality of life and sexuality in breast cancer, researchers recruited 621 early stage breast cancer survivors from Los Angeles and Washington, DC. African Americans accounted for 38% of the sample, Latinas for 13%, Asian Americans for 12%, and non-hispanic whites for 38%.  As a whole, the sample was well educated, had moderate-to-high income levels, and were married or in a significant relationship.

In general, survivors reported levels of quality of life and social adjustment that were comparable to women with no history of cancer.  Survivors were more likely to report that cancer had changed their lives by increasing their sense of both meaning and vulnerability.  Across ethnic groups women were similar in terms of quality of life with a few notable exceptions.  After controlling for demographic and medical variables, Latinas experienced more physical symptoms than Asian or African American survivors.  The quality of life of African American survivors was better than the other ethnic groups in terms of social support, sexual function, and meaning.

This descriptive study provides evidence that quality of life outcomes vary by ethnic group.  However, as the authors note, their focus on broad ethnic groupings limits the generalizabilty of their findings.  Other factors such as acculturation, familial social support, and religiosity must be considered in order to paint a more complete picture of differences among women of color. — KD

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How does Arimidex or Tamoxifen affect quality of life in the first 2 years of treatment for primary breast cancer?

Fallowfield L, Cella D, Cuzick J, Francis S, Locker G, Howell A.  Quality of life of postmenopausal women in the Arimidex, Tamoxifen, Alone or in Combination (ATAC) Adjuvant Breast Cancer Trial.  J Clin Oncol. 2004;22:4261-4271

The large ATAC study at 116 centers from 10 countries showed that post-menopausal breast cancer patients treated with anastrozole (Arimidex) had a 17% lower risk of disease recurrence than those treated with tamoxifen. The anastrozole group had a 38% lower risk in the odds of developing contralateral breast cancer. The hormonal treatment was introduced with a plan for 5 years after surgery, radiation and chemotherapy for primary treatment. Those patients assigned to anastrozole were less apt to withdraw from the study than those assigned to tamoxifen or both medications.

A subgroup of the large trial was followed to assess quality of life and more subtle side effects. These included 335 patients treated with anastrozole, the aromatase inhibitor, and 347 treated with tamoxifen, the mixed estrogen antagonist/ agonist. Overall, there were no distinctions in quality of life measures, but the specific hormonal side effects are important to report. A panel of two surgeons, one specialist nurse, and one oncologist divided 22 symptoms and concerns into four clinical categories.  The findings were amalgamated by two psychologists into vasomotor symptoms, neuropsychological problems, gastrointestinal symptoms, and gynecologic and sexual problems.

Vasomotor symptoms were frequent in both groups. The anastrozole group had fewer cold sweats but similar hot flashes to tamoxifen-treated patients.  In terms of sexual function, the group treated with anastrozole had less vaginal discharge, irritation and bleeding, and the group treated with tamoxifen had less vaginal dryness, pain on intercourse, and loss of sexual interest.  Endocrine-related symptoms were worse at the three months assessment, but improved slightly or stabilized thereafter.

Few patients had neuropsychological problems, and there were no differences among groups. The neuropsychological symptoms were lightheadedness, headaches, mood swings, irritability, lack of energy, and nervous feeling. The data were drawn from the Functional Assessment of Cancer Therapy for breast cancer instrument with the emotional well-being and social well-being subscales of FACT-B and the emotional subscale of FACT-G.

Overall, both hormonal treatments are well tolerated. The vasomotor side effects are notable for both. From this study, we can see the time course of the drop in emotional well-being in post-menopausal patients who have had the burden of primary treatment and then one of the hormonal treatments.  About 11% reported mood swings and 9% irritability. What we cannot easily see here is whether there is a vulnerable group for mood change. — DG

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Who finds more benefit in the cancer experience?

Tomich PL, Helgeson VS.  Is finding something good in the bad always good?  Benefit finding among women with breast cancer.  Health Psychology. 2004;23:16-23.

There is a small, but growing body of research that suggests that individuals with cancer may experience positive life changes as a result of being diagnosed with cancer.  This notion is often referred to as "benefit finding." Who is more likely to perceive benefit from their cancer? Is benefit finding associated with better outcomes over time? As part of a larger study evaluating the impact of a group psychosocial intervention on quality of life in women with stage I-III breast cancer, researchers attempted to answer these questions.  Three hundred sixty four women treated with surgery and adjuvant chemotherapy completed measures of benefit finding and quality of life four months, seven months, and 10 months after diagnosis.  Approximately four months after diagnosis, women of lower socioeconomic status and African American and Hispanic women were more likely to perceive more benefits from their cancer.  Women with stage II disease also perceived more benefits.  With respect to quality of life, women who reported more negative affect reported more benefit finding.  There was no relationship between benefit finding and physical functioning, mental functioning, and positive affect four months after diagnosis.  Over time, benefit finding was related to more negative affect and worse mental functioning for women with more severe stages of disease.  These results indicate that benefit finding may be associated with more negative consequences.  The authors suggest that people who perceive more benefit actually may be attempting to deny their emotional distress or may be unable to acknowledge the severity of their illness.  They also rightly point out that the notion of benefit finding may itself be a socially desirable construct and that asking individuals to report both positive and negative changes as a result of their cancer may paint a more complete picture of the cancer experience. — KD

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How does age affect ability to cope with cancer?

Schroevers MJ, Ranchor AV, Sanderman R.  The role of age at the onset of cancer in relation to survivorsí long-term adjustment:  a controlled comparison over an eight-year period.  Psycho-Oncology. 2004;13:740-752.

Increasing rates of cancer survivorship have prompted researchers to explore the impact of a cancer diagnosis over the long-term. To better understand the role of aging in a patientís adjustment to living with cancer, researchers collected data on 155 individualsí physical and psychological functioning three months, 15 months, and eight years after diagnosis. Cancer survivors were compared to a group of 120 persons with no cancer history from the general population. Findings suggested that patientsí adjustment to cancer was affected by age at the time of diagnosis as well as the normal process of aging. In the short term, patientsí physical functioning was more affected by cancer and by treatment, and in the long term, more affected by aging. Patientsí psychological functioning in the long term was comparable to persons with no cancer history. Younger survivors were more likely to report cancer-related thoughts and a greater search for meaning.  The findings validate previous research demonstrating that younger patients experience more distress and that with the passage of time, many patients derive meaning from their experience.  Perhaps the most significant take away message from this ambitious study is that most cancer patients ultimately are able to cope with their experience. — KD

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Can an oncologist influence how much the patient exercises?

Jones LW, Courneya KS, Fairey AS, Mackey JR.  Effects of an oncologistís recommendation to exercise on self-reported exercise behavior in newly diagnosed breast cancer survivors:  a single-blind, randomized controlled trial.  Ann Behav Med. 2004;28:105-113.

These researchers report on the ONCOlogist Recommendation to Exercise (ONCORE) trial, a single-blind randomized controlled trial of two oncologist-based interventions.  Four hundred and fifty newly diagnosed breast cancer patients who were seeing their oncologist to discuss primary adjuvant treatment were randomized to receive an oncologist exercise recommendation, an exercise recommendation plus a referral to an exercise specialist for a free fitness consultation, or usual care.  Patients were blinded to the primary purpose of the study and told they were participating in a study of "patient-oncologist communication." The exercise recommendation was provided in the course of the consultation.  Patients were told to try exercising 20-30 minutes everyday at a moderate intensity, as exercise could be effective in controlling some of the side effects of treatment.  One week after the adjuvant therapy consultation, participants completed questionnaires designed to assess self-reported exercise behaviors and other psychosocial behaviors.  Patients who completed the questionnaires were contacted by telephone five to six weeks later to again assess self-reported exercise behavior.  In an effort to prevent patients from identifying the primary purpose of the study, baseline exercise data were not collected.

Intention to treat analysis revealed that patients in the recommendation-only group reported significantly more exercise than the usual care group in terms of metabolic equivalent (MET) hours per week at five weeks post consultation (10.1 versus 6.7 MET hr per week and 47 minutes of moderate exercise per week versus 75 minutes).  There was no significant difference between the recommendation plus referral and usual care in MET hours per week or minutes of moderate exercise per week.

Although research is limited, exercise has been shown to positively impact cancer patientsí physical and emotional well being.  Whether a difference of 3.4 MET hr per week of total exercise or 30 minutes of moderate intensity exercise per week will result in significantly difference outcomes for these patients is not known.  However, it is significant that an oncologistís very brief recommendation may be effective in increasing exercise activity. — KD

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DG:  Donna B. Greenberg, MD, Associate Professor of Psychiatry at Harvard Medical School and Psychiatric Consultant in the Massachusetts General Hospital Cancer Center, Dana Farber Partners Cancer Care

KD:  Kristine Donovan, PhD, MBA, Assistant Professor, DIO, Moffitt Cancer Center at the University of South Florida