APOS Clinical E-Mail Update #7
23 March 2004

In this Update:

What are common symptoms at the end of primary treatment for breast cancer?

Ganz PA, Kwan L, Stanton AL, Krupnick JL et al. Quality of life at the end of primary treatment of breast cancer: first results from the moving beyond cancer randomized trial. J National Cancer Institute 2004;96:376-387.

This study provides prospective information on the concerns of breast cancer patients receiving state of the art treatment. Its data offers a guide to physicians who are telling their patients about the expected longitudinal course of symptoms. Breast cancer patients identified one month after surgery filled out a mailed baseline surveys when they finished primary treatment. Between 1999 and 2002, 558 patients, average age 57 were enrolled. These women had mastectomy or lumpectomy with and without chemotherapy. Tamoxifen was part of the regimen for 55 percent, and 67 percent were postmenopausal at diagnosis.

One month after surgery these women complained of muscle stiffness, breast sensitivity, aches and pains, tendency to take naps, and difficulty concentrating. These symptoms were associated with poorer medical and emotional function. Sexual function was worse for those who had chemotherapy. Good emotional function was reported in all treatment groups. Aches and pains as well as difficulty concentrating were common complaints. Those who had not had chemotherapy also reported difficulty concentrating. Those who perceived that they had trouble concentrating also reported poorer emotional function. Those who had a mastectomy had poorer physical function one month after mastectomy than those who had a lumpectomy.

At the end of treatment, 61% of patients were not happy with their appearance, 60% had hot flashes, 56% had forgetfulness, about half had joint pains and muscle stiffness. The experience of chemotherapy was associated with a higher rate of pain with intercourse, vaginal dryness, hot flashes, difficulty concentrating, being easily distracted, and being more excitable.

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Can you evaluate the benefit of complex palliative care consultation?

Rabow M, Dibble S, Pantilat S, McPhee SJ. The comprehensive care team: a controlled trial of outpatient palliative medicine consultation. Arch Intern Med 2004;164:2004;83-91.

This paper reports a controlled trial of the effect of an outpatient palliative medicine consultation team. This is a creative study that took on the challenging task of assessing the benefit of complex consultation. The authors at the general medical practice of an urban, tertiary care, university medical center (University of California, San Francisco/Mount Zion) compared 50 patients with consultations to 40 control patients in a general medicine outpatient clinic. Patients with cancer, chronic obstructive pulmonary disease, or congestive heart failure with a prognosis of 1 to 5 years were referred by primary care physicians. Those from one practice module received an intervention while those from a second module did not.

The Comprehensive Care Team included a social worker, nurse, chaplain, pharmacist, psychologist, art therapist, volunteer coordinator, and three physicians who addressed physical, emotional and spiritual issues. All were trained in palliative care. The team developed recommendations for the patientís primary care physician via letter and email. These included recommendations for physical symptoms, psychological well-being, social support, spiritual well-being, and advance care planning. The physicians made recommendations based on patientís written surveys and social work assessment, but did not themselves examine or interview the patient. The social worker provided case management and psychological support in person and by telephone. A nurse offered caregiver training to family, formal classes, and informal individual consultation. A pharmacist assessed drug interactions from the drug list. A chaplain offered spiritual and psychological support. Patients and families were invited to monthly support groups with discussion about symptom management and advance care planning. Medical and pharmacy students added support and advocacy by telephone contacts with patients, monthly visits, and regular communication.

The comprehensive consultation was associated with less anxiety, better sleep, better reports of spiritual well-being, and less dyspnea in the intervention group. No differences in pain, depression, quality of life, or satisfaction with care were noted. Depression was measured by the Center for Epidemiologic Studies-Depression Scale (CES-D). Often the primary care physicians did not offer patients the analgesic or antidepressant medications that the comprehensive team physician had recommended. One barrier to care of pain and depression was that the primary care physicians were reluctant to treat pain and depression. There were no difference in charges but primary care visits and urgent visits decreased, and there was no increase in emergency department visits, specialty clinic visits, and overall charges did not differ. The team made the most difference when they offered direct service, education, and support.

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How can you simply assess the character and intensity of neuropathic pain?

Bouhassira D, Attal N, Fermanian J, Achaar H, Gautron M et al. Development and validation of the Neruopathic Pain Symptom Inventory. Pain 2004;108:248-257.

Here is a simple and easy-to-use instrument, developed and validated, to assess neuropathic pain both for clinical studies and practice. The authors hypothesized that neuropathic syndromes had four distinct dimensions: spontaneous ongoing pain, spontaneous paroxysmal pain, pain evoked by mechanical or thermal stimuli (allodynia/hyperalgeisa), and paresthesia or dysesthesia. In their model, ongoing pain may be either superficial and burning or deep, characterized by pressure and/or squeezing. In spite of the multiple dimensions, the total score correlated with global rating of pain intensity. The NPSI includes 10 descriptors and two temporal items, one judging how much the ongoing pain has been present in the past 24 hours, and how many times in the last 24 hours paroxysmal pain has occurred. Most of the 12 questions have a scale of severity from 0 to 10. The questionnaire was validated with 176 patients with neuropathic pain in France and Belgium. Both French and English versions are offered.

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Depression and comorbid medical illness: what is the view on cancer?

Croyle RT, Rowland JH. Mood disorders and cancer: a National Cancer Institute perspect. Biological Psychiatry. 2003;54:191-194.

Spiegel D, Giese-Davis J. Depression and cancer: mechanisms and disease progression. Biological Psychiatry 2003;269-282.

Raison CL, Miller AH. Depression in cancer: new developments regarding diagnosis and treatment. Biological Psychiatry 2003; 283-295.

A recent issue of Biological Psychiatry was devoted to mood disorders and medical illness. Cancer was the topic of three reviews. Croyle and Rowland present the National Cancer Institute perspective. They argue for continued support for research that improves quality of life for all cancer survivors, including those depressed. They review grants, conferences, and collaborations that have focused on depression and cancer. Spiegel and Giese-Davis review the literature on depression as a predictor of cancer incidence, progression, and mortality; randomized trials assessing whether psychosocial treatment affects cancer survival time; and studies showing no effect of depression on cancer. They highlight the interplay of depression, endocrine and immune function, adherence to medical treatment, and capacity to cope with cancer. Raison and Miller discuss sickness syndrome in cancer patients, analogous to the syndrome of laboratory animals exposed to inflammatory cytokines. The authors discuss the possibility of treating this syndrome in humans with cancer to prevent symptoms of malaise.

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What is the social contribution to the distress of survivors of childhood brain tumors?

Zebrack BJ, Gurney JG, Oeffinger K, Whitton J et al. Psychological outcomes in long-term survivors of childhood brain cancer: a report from the Childhood Cancer Survivor Study. J Clin Oncol 2004;999-1006.

Children who survive a brain tumor have a distinct psychological and cognitive burden, but this study highlights the role of social factors in survivorship. From a large, multi-institutional epidemiological study of long-term survivors of childhood cancer and their siblings, this study examines the prevalence of depression, somatization, anxiety, and psychological stress in about 1100 young adult survivors of a brain tumor. Survivors and their siblings filled out the Brief Symptom Inventory evaluating distress over the past week, as well as the Global Severity Index, and three six-item subscales on depression, somatization, and anxiety. The majority did not report psychological distress. The rates were comparable to the general population, but the rate in survivors of brain tumors (11%) was higher than the rate in siblings (5%). Low-income survivors who believed that they had fair or poor health had higher levels of distress than all others. More anxiety symptoms were noted in nonwhite survivors, and those nonwhite survivors living in households with income less than $20,00 reported greater anxiety than all others. Female gender and low socioeconomic status were risk factors for distress.

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What do we know about post-operative fatigue?

Rubin GJ; Hotpopf M. Systematic review and meta-analysis of interventions for postoperative fatigue. Brit J Surg 2002;89:971-984.

Postoperative fatigue is one aspect of cancer treatment. Post-operative fatigue is characterized by the need to sit or lay down and an increased need for sleep. These authors bring together for meta-analysis randomized controlled trials of interventions for postoperative fatigue. Four time points from operation were evaluated: the first day, days 2-7, 8-30, or more than 30 days after the operation.

Immediately following the operation, the first day, pain relief is the critical variable. After abdominal surgery, human growth hormone administered at operation can reduce fatigue between 8 and 30 days post-operatively.

The authors found no solid evidence in randomized controlled trials that psychosocial interventions affect the course of post-operative fatigue. The interventions varied from emotionally disclosive writing, psychiatric support, relaxation training, coping skills training, and education. Melanoma surgery and gynecological surgery provided clinical settings, but most studies were done in cardiac surgery populations.

The results comparing laparoscopic to open surgery were not grouped for meta-analysis, but two of five studies reported less fatigue in the laparoscopic group between days 8 and 30.

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Who is most upset in the mammography suite?

Gurevich M, Devins G, Wilson C, McCready D, Marmar CR, Rodin GM. Stress response syndromes in women undergoing mammography: a comparison of women with and without a history of breast cancer. Psychosomatic Medicine 2004;66:104-112.

The mammography suite is a place where the women are often anxious. Women taking a mammogram are more stressed if they had a previous diagnosis of breast cancer or if they had breast symptoms before mammography. Presumably, then women are more stressed when they do not feel that the examination is merely part of a screening routine. This data comes from a comparison of 66 women with breast cancer diagnosed more than one year before and 69 women there for routine screening. They filled out the Stanford Acute Stress Reaction Questionnaire, Somatosensory Amplification Scale, Trauma History Questionnaire, questions about psychiatric history, a Social Network and Support Assessment scale, and a measure of support from medical caregivers. Other variables associated with increased stress responses were those related to each womanís tendency to anxiety: greater somatization and previous psychiatric medication use. In women who did not have a history of breast cancer, those who had more distress reported less perception of physician support.

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Who are the most distressed women with ovarian cancer?

Norton TR, Manne SL, Rubin S, Carlson J, Hernandez E, et al. Prevalence and predictors of psychological distress among women with ovarian cancer. J Clin Oncol 2004;22:919-926.

Both anxiety and depressive symptoms have been noted to be high in patients with ovarian cancer. Distress was moderate to severe in 20 percent of patients in this study, a study of 143 patients with ovarian cancer, a Karnofsky score of better than 80%, half with Stage III or IV disease, most receiving anti-cancer treatment. These are the patients of an ambulatory oncology clinic. The greatest distress was among younger patients, those with advanced or recurrent disease, and those recently diagnosed. Most were not using mental health services or psychotropic medication. Patientsí distress was measured on the Beck Depression Inventory (BDI), the Mental Health Inventory, and the Impact of Events Scale. On the BDI, one fifth had scores of 19 or higher. Some medication for sleep, mood, or nerves was taken by one-third of patients, but the type of medication was not specified. Few were participating in any psychosocial intervention. The study was limited by a 49% rate of refusal to participate in the study; refusers were older and less likely to have recurrent disease.

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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