APOS Clinical E-Mail Update #6
18 February 2004

In this Update:

What belief affects racial disparities in lung cancer treatment?

Margolis ML, Christie JD, Silvestri GA, Kaiser L, Santiago S. Racial differences pertaining to a belief about lung cancer surgery. Ann Intern Med.  2003;139:558-563. 

Many patients with lung disease and lung cancer believe that lung surgery will accelerate the spread of a tumor by exposing the lung to air.  This is particularly true for African-American patients.  This is the conclusion of a multi-center cross-sectional survey study of 626 consecutive patients in pulmonary and thoracic surgery clinics at the Philadelphia Veterans Affairs Medical Center, the Los Angeles Veterans Affairs Medical Center, and the Medical University of South Carolina in Charleston.  The study was designed to select patients from different sections of the US and from VA and non-VA sites.  This belief was held by 38% of patients; 61% were African-American.  Among African-American patients, 19% thought that this was a good reason to refuse surgery.  Physicians could not dissuade14% of patients.  With similar treatment, both whites and African-Americans have similar outcomes in lung cancer.  This belief may affect the decisions and the outcome for African-Americans and may be important to recognize when the staff brings up a plan for surgery.  We do not always know what the patient comes in assuming.  The most skilled approach to the patient allows exploration and consideration of the patient’s assumptions.  This study gives us a clue to one common assumption.

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Will I do something wrong when I give her pain medication?

Letizia M, Creech S, Norton E, Shanahan M, Hedges L. Barriers to caregiver administration of pain medication in hospice care. J Pain Symp Manage 2004;27:114-124. 

We often rely on family members or hired aides to give patients medications at home.  This is a study of caregivers who administer pain medication to hospice patients.  It highlights the fears that complicate care and cause distress.  Besides family members, the caregivers in this study were hired home aides and staff nurses in skilled care facilities.  Addiction, tolerance, and side effects from medications were the concern of more than a quarter of the caregivers.  Fear of doing something wrong and difficulty deciding which or what amount of medications to give were concerns of one-quarter of the caregivers.  These concerns were greater for male and for hired caregivers.  Those less trained, who were not as educated, who were retired, homemakers, blue-collar workers were more worried.  Concern about communication of information was minor.  These researchers developed and psychometrically tested the Caregiver Pain Medicine Questionnaire in 151 caregivers.  Their work reminds us that the concerns and convictions of the person giving pain medication may be a critical variable.  Attention to their doubts, conflicts, and lack of training will mean better pain relief for the patient.

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Do the daughters and sisters of breast cancer patients have cancer-related trauma or post-traumatic stress disorder?

Wellisch DK, Lindberg NM. Identification of traumatic stress reactions in women at increased risk for breast cancer. Psychosomatics 2004;45:7-16. 

Women who have familial risk for breast cancer may feel a personal vulnerability and may remember with emotion the cancer illness of their loved ones.  Reminders invoke intrusive thoughts.  Some adult cancer survivors similarly have traumatic reactions to cancer reminders, but only a minority meet criteria for life-time or current post-traumatic stress disorder (PTSD).  Some women who have a greater risk for breast cancer had traumatic responses like those of cancer patients.  Among 73 women, first-degree relatives of breast cancer patients, average age 43, who attended the University California Los Angeles High Risk Clinic, 4% met criteria for post-traumatic stress disorder, and another 4% had sub-clinical symptoms of PTSD by DSM IV criteria.  The women in the clinic were mostly white, married, and highly educated.  The measures were the Impact of Events Scale-revised, the Spielberger State-Trait Anxiety Scale, and the Center for Epidemiological Studies Depression Scale.  Almost one-third of patients had high scores on the depression measure, and this score correlated with the PTSD score (R=0.34) on the arousal scale (R=.41) but not the avoidance or intrusion subscales. 

Andrykowski MA, Cordova MJ, Studus MJ, Miller TW: Posttraumatic stress disorder after treatment for breast cancer: prevalence of diagnosis and use of the PTSD Checklist-Civilian Version (PCL-C) as a screening instrument. J Consult Clin Psychol 1998;66:586-590. 

Andrykowski MA, Cordova MJ: Factors associated with PTSD symptoms following treatment for breast cancer; test of the Anderson Model. J Trauma Stress 1998;11:189-203.

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If narcotics will not subdue the cough, try paroxetine

Zylicz Z, Krajnik M.  What has dry cough in common with pruritus? Treatment of dry cough with paroxetine. J Pain Symp Manage 2004;27:180-184. 

Sensitization of the cough reflex by a peripheral nociceptive impulse like bronchitis can lead to a persistent dry cough.  This cough, like pruritis and pain, can be modulated by central inhibition.  It is caused by irritated nociceptive C-fiber endings localized in the bronchi and pleural surfaces.  This is the report of 5 patients who had dry cough unresponsive to codeine but responsive to paroxetine within hours.  The dose was 5-10 mg at night.  Two also had pruritis responsive to paroxetine; but that response took 2-3 days.  Paroxetine did not inhibit productive cough.  These 5 patients all had cancer: Hodgkin’s lymphoma, melanoma, non-small cell lung cancer, non-Hodgkin’s lymphoma, and renal cell cancer.  When the cough does not respond to opioids, think about low dose paroxetine as an option.

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Who develops low sodium as a side effect of paroxetine?

Fabian TJ, Amico JA, Kroboth PD, Mulsant BH, Corey SE et al. Paroxetine-induced hyponatremia in older adults: a 12- week prospective study. Arch Intern Med 2004;164:327-332. 

Low sodium developed in 12% of older depressed patients who started paroxetine for depression.  The average age was 75 in this sample of 75 patients.  The sodium became abnormal within two weeks.  Patients who started with a lower sodium and who had a lower body mass index were more at risk.

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If the oncologist gets the report on symptoms and mood, do patients do better?

Velikova G, Booth L, Smith AB, Brown PM, Lynch P, Brown JM, Selby PJ. Measuring quality of life in routine oncology practice improves communication and patient well-being: a randomized controlled trial. J Clin Oncol 2004; 22:714-724

This is a study of an intervention in clinical practice.  Electronic methods of collecting health-related quality of life (HRQL) data from patients in real-time allow the data to be presented to busy oncology clinicians.  These researchers hypothesized that regular repeated collection and feedback of HRQL data to oncologists would improve patient well-being, the content of physician-patient communication, and management decisions.  The study of 286 patients took place at Leeds Cancer Centre Medical Oncology Clinic at St.  James’s Hospital, Leeds, UK.  Patients starting treatment for cancer were randomized to a group with touch-screen HRQL questionnaires and feedback to physicians, touch-screen but no feedback, and no touch-screen.  Patients were the unit of random assignment.  On the touch screen was the European Organization for Research and Treatment of Cancer-Core Quality of Life Questionnaire (EORTC QLQ-C30) and the Hospital Anxiety and Depression Scale (HADS), The screen showed graphs of results over time.  The outcome measure was the Functional Assessment of Cancer -General (FACT-G).  Patient-physician interactions were audio-taped, and the content analyzed.  All 28 physicians in the unit participated.  Physicians referred to the HRQL data in 64% of the encounters and found the data very/quite useful in 43%.  Quality of life was better in the intervention group than the control group.  The emotional well-being of the intervention group was better than the control but not better than the group who used the touch-screen without physician feedback.  The intervention led to more discussion of chronic symptoms and to a positive impact on patient’s well-being.  Explicit use of the information led to clinically significant improvement in patient well-being.

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What is the neurocognitive effect of posterior fossa radiation in children?

Spiegler BJ, Bouffet E, Greenberg ML, Rutka JT, Mabbott DJ. Change in neurocognitive functioning after treatment with cranial radiation in childhood. J Clin Oncol 2004;22:706-713. 

Children with posterior fossa tumors, who had brain radiation in childhood, 30 for medulloblastoma and 4 for ependymoma, were assessed with neuropsychological testing prospectively.  The researchers noted a decline of intellectual function in the first few years after treatment and then a more gradual decline.  Declines were documented in visual-motor integration, visual memory, verbal fluency, and executive functioning.  A 2-4 point decline per year in intelligence scores were noted.

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What is a practical self-report measure of sleep quality in cancer patients?

Beck SL, Schwartz AL, Towsley G, Dudley W, Barsevick A. Psychometric evaluation of the Pittsburgh Sleep Quality Index in Cancer Patients. J Pain Symp Manage 2004;27:140-148. 

A review of 15 studies found 30-50% of cancer patients reported sleep difficulties on one item of a self-report measure.  Disturbed sleep of cancer patients has been studied by polysomnography, actigraphy, and self reports.  By actigraphy, significant sleep disturbance has been noted in cancer patients receiving radiation treatment1 and chemotherapy.2  Daily sleep logs have also been helpful.  This paper discusses the Pittsburgh Sleep Quality Index (PSQI).  Both quality and quantity of sleep were evaluated in a 19-item self-report questionnaire with 7 components: subjective sleep quality, sleep latency, duration, habitual sleep efficiency, sleep disturbances, use of sleeping medication, and daytime dysfunction.  A bed partner may answer 5 other questions.  This instrument takes 5-10 minutes to complete.  A cross-sectional study of 214 heterogeneous cancer patients assessed psychometric properties.  A second longitudinal study added data as part of a study of an intervention for cancer-related fatigue.  The evidence presented supports the internal consistency and construct validity of the PSQI for cancer patients. 

1. Miaskowski C, Lee KA. Pain, fatigue, and sleep disturbances in oncology outpatients receiving radiation therapy for bone metastasis: a pilot study. J Pain Symptom Manage 1999;17:320-333. 

2. Berger AM, Farr L. The influence of daytime inactivity and nighttime restlessness on cancer-related fatigue. Oncol Nurs For 1999;26:1663-1671.

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Can the effect of trauma in the cancer survivor be noted in the brain?

Matsuoka Y, Yamawaki S, Inagaki M, Akechi T, Uchitomi Y. A volumetric study of amygdala in cancer survivors with intrusive recollections. Biol Psychiatry 2003; 54:736-743. 

Some cancer survivors re-experience distressing symptoms or intrusions rather than suffer full-blown PTSD.  The amygdala enhances explicit memory of emotional arousal.  This study compared 35 such breast cancer survivors with 41 control breast cancer survivors and found that the total volume of the amygdala was significantly smaller in subjects who had a history of intrusive recollections.  The left amygdala was more reduced (5.7%) than the right (2.9%).  PTSD may be related to an amygdala hyperresponsive to threat-related stimuli.  The finding was not accounted for by age, height, or major depressive disorder.

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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