Depression and psychological distress in patients during the year after curative resection of non-small-cell lung cancer

Twenty-four-hour urinary cortisol levels before complete resection of non-small cell lung cancer and survival

Cortisol has been speculated to play a role in survival from cancer. The objective of this study was to investigate the association between 24-h urinary cortisol levels and survival from non-small cell lung cancer. From June 1996 to April 1999, a total of 226 patients with resectable non-small cell lung cancer were enrolled. Urine samples were collected over a 24-h period before the curative resections. A total of 14 650 person-months (median = 71 months, range = 1-97 months) were accrued. Over the follow-up period, 56 deaths from all causes were identified through January 2004. Cox proportional hazards regression analyses were used to estimate the relative risk (RR) of death from all causes according to three categories of 24-h urinary cortisol levels. Multivariable RRs of death from all causes for individuals in the highest and intermediate categories, compared with the lowest category, were 1.09 (95% confidence interval = 0.54-2.21) and 1.17 (0.55-2.46), respectively (p for trend = 0.17). The present data do not support the hypothesis that 24-h urinary cortisol levels are associated with survival from non-small cell lung cancer.

Survey of the current status of cancer rehabilitation in Japan

PURPOSE

To elucidate the current status of cancer rehabilitation in institutions nationwide.

METHOD

A questionnaire survey regarding the current status of cancer rehabilitation in 1693 healthcare institutions was conducted by mail. The survey first asked whether rehabilitation was being conducted for cancer patients and, in facilities in which it was being conducted, it then asked about the content of the rehabilitation, the stage of the cancer patients, etc. Facilities in which cancer rehabilitation was not being conducted were surveyed in regard to whether there was a need for cancer rehabilitation.

RESULTS

Valid replies were obtained from 1045 (62.0%) institutions and 864 (82.7%) of them conducted rehabilitation for cancer patients. A high proportion of the content of the rehabilitation was found to be related to physical function. Activities of daily living guidance and training were also found to be conducted in a high proportion. Low proportions of the facilities conducted content that was specialized for cancer. Of the 181 facilities in which rehabilitation was not being conducted for cancer patients, 171 (94.5%) replied that they felt that rehabilitation was needed for cancer patients.

CONCLUSIONS

Based on the results of this fact-finding survey it will be necessary to consider strategies for popularizing and developing rehabilitation programmes for cancer patients in Japan.

Clinical experience of the modified nurse-assisted screening and psychiatric referral program

Objective:

We previously reported that the nurse-assisted screening and psychiatric referral program (NASPRP) facilitated the psychiatric treatment of depressive patients, but the high refusal rate was a problem even though referral was recommended by the nurse to all positively screened patients. We modified the program so that the nurses could judge the final eligibility of referral using the result of the screening. This study assessed if the modified NASPRP led to more psychiatric referral of depressive patients.

Method:

We retrospectively evaluated the annual change of the psychiatric referral proportion and compared the findings among the usual care term, the NASPRP term, and the modified NASPRP terms.

Results:

The referral proportions of the modified NASPRP terms were 4.4% and 3.9%. These were not significantly higher than the usual care term (2.5%), and significantly lower than the NASPRP term (11.5%).

Significant of results:

The modified NASPRP did not facilitate psychiatric treatment of depressive patients and another approach is needed.

Psychosocial factors in lung cancer: quality of life, economic impact, and survivorship implications

Lung cancer is the leading cause of cancer mortality in men and women. Lung cancer accounts for approximately 30% of all cancer deaths in the United States. In addition, it is the most often diagnosed cancer in men, and the second most often diagnosed cancer in women. Five-year survival rates in lung cancer remain very low, around 15%. Approximately 45% of patients present with stage III disease. The majority of these patients are considered non-resectable, leading to the poor survival statistics seen in this disease. Unfortunately, survival rates have not improved in the past 30 years despite much research in diagnostics and therapeutics. Patients with advanced disease often experience multiple symptoms, including fatigue, pain, dyspnea, cough, hemoptysis, and anorexia. This paper will review the enormous toll that lung cancer takes on society, as well as individuals and families affected. In addition, we will examine psychosocial factors pertinent to lung cancer. Specifically, the article briefly discusses treatment approaches to lung cancer, as they relate to quality of life (QOL). QOL as a construct within lung cancer is then reviewed. Comment is made on the evaluation and prognostic importance of QOL. Next, economic and survivorship aspects of lung cancer are discussed. Finally, a summary of relevant psychosocial interventions for patients diagnosed with lung cancer is given.

Cancer Care Ontario and American Society of Clinical Oncology adjuvant chemotherapy and adjuvant radiation therapy for stages I-IIIA resectable non small-cell lung cancer guideline

PURPOSE

To determine the role of adjuvant chemotherapy and radiation therapy in patients with completely resected stage IA-IIIA non-small-cell lung cancer (NSCLC).

METHODS

The Cancer Care Ontario Program in Evidence-Based Care and the American Society of Clinical Oncology convened a Joint Expert Panel in August 2006 to review the evidence and draft recommendations for these therapies.

RESULTS

Available data support the use of adjuvant cisplatin-based chemotherapy in completely resected NSCLC; however, the strength of the data and consequent recommendations vary by disease stage. Adjuvant radiation therapy appears detrimental to survival in stages IB and II, with a possible modest benefit in stage IIIA.

CONCLUSION

Adjuvant cisplatin-based chemotherapy is recommended for routine use in patients with stages IIA, IIB, and IIIA disease. Although there has been a statistically significant overall survival benefit seen in several randomized clinical trials (RCTs) enrolling a range of people with completely resected NSCLC, results of subset analyses for patient populations with stage IB disease were not significant, and adjuvant chemotherapy in stage IB disease is not currently recommended for routine use. To date, very few patients with stage IA NSCLC have been enrolled onto RCTs of adjuvant therapy; adjuvant chemotherapy is not recommended in these cases. Evidence from RCTs demonstrates a survival detriment for adjuvant radiotherapy with limited evidence for a reduction in local recurrence. Adjuvant radiation therapy appears detrimental to survival in stage IB and II, and may possibly confer a modest benefit in stage IIIA.

Negative psychological aspects and survival in lung cancer patients

We conducted a prospective cohort study in Japan to investigate associations between negative psychological aspects and cancer survival. Between July 1999 and July 2004, a total of 1178 lung cancer patients were enrolled. The questionnaire asked about socioeconomic variables, smoking status, clinical symptoms, and psychological aspects after diagnosis. Negative psychological aspects were assessed for the subscales of helplessness/hopelessness and depression. Clinical stage, performance status (PS), and histologic type were obtained from medical charts. The subjects were followed up until December 2004, and 686 had died. A Cox regression model was used to estimate the hazards ratio (HR) of all-cause mortality. After adjustment for socioeconomic variables and smoking status in addition to sex, age, and histologic type, both helplessness/hopelessness and depression subscales showed significant linear positive associations with the risk of mortality (p for trend<0.001 for both). However, after adjustment for clinical state variables in addition to sex, age, and histologic type, these significant linear positive associations were no longer observed (p for trend=0.41 and 0.26, respectively). Our data supported the hypothesis that the association between helplessness/hopelessness and depression and the risk of mortality among lung cancer patients was largely confounded by clinical state variables including clinical stage, PS, and clinical symptoms.

Quality of life before and after major lung resection for lung cancer: a prospective follow-up analysis

BACKGROUND

The objective of this study was to assess the preoperative and postoperative quality of life of candidates for major lung resection with lung cancer.

METHODS

In all, 156 consecutive patients (144 lobectomies, 12 pneumonectomies) were prospectively assessed by means of the Short Form-36 Health Survey, version 2, preoperatively and 1 month and 3 months after operation. Serial quality of life scales were compared by repeated measures analysis of variance.

RESULTS

In our series, most quality of life values were reduced compared with the general population. Compared with preoperative values, the physical composite scale was significantly reduced at 1 month (51 versus 45.1, p < 0.0001), and completely recovered at 3 months (51 versus 52.4, p = 0.2), whereas the mental composite scale remained unchanged. All correlation coefficients between these values and forced expiratory volume in 1 second, carbon monoxide lung diffusion capacity, and height reached at stair-climbing test at each evaluation period were below 0.2. With the exception of pneumonectomy patients (who had a significantly lower physical composite scale [p = 0.04]), no significant differences in both physical and mental values were noted in other high-risk subgroups of patients (elderly, coronary artery disease, poor pulmonary function) compared with lower-risk counterparts.

CONCLUSIONS

Candidates for lung resection with lung cancer had a worse preoperative quality of life compared with the general population. Quality-of-life measures had poor correlation with forced expiratory volume in 1 second, carbon monoxide lung diffusion capacity, and exercise test performance. Therefore, these functional variables cannot substitute for specific evaluation instruments. Finally, patients traditionally considered at higher risk for lung resection had postoperative physical and emotional quality of life scores similar to those observed in younger and fitter patients.

Using Q-methodology to understand perceived fatigue reported by adolescents with cancer

Although fatigue is an unpleasant symptom commonly experienced by pediatric oncology patients, it also tends to be under-recognized and under-treated. A conceptual understanding of how patients perceive fatigue is beneficial for better identification and treatment planning. The purpose of this study was to understand how adolescents with cancer perceive their fatigue and to explore potential factors influencing their perceptions by using Q-methodology. The sample included 15 patients (ages 12-18 years) from the Chicago metropolitan area who were receiving cancer treatment. All participants completed a 37-statement Q-sort task. Data were analyzed by using PQMethod computer software. Results identified three descriptors of perceived fatigues reported by adolescents: energy and related capacity for physical functioning, psychosocial effects, and anemia-specific concerns. Appropriate referral for patients with the latter two descriptors of fatigue was recommended.

Morphine glucuronosyltransferase activity in human liver microsomes is inhibited by a variety of drugs that are co-administered with morphine

Morphine is an analgesic drug used for the treatment of acute and chronic pain syndromes for cancer patients. Glucuronidation is a major pathway of the elimination of morphine in humans. Morphine is metabolized to 3-glucuronide (no analgesic effect) and 6-glucuronide (more potently analgesic than morphine) mainly by UGT2B7. In the present study, we investigated the inhibitory effects of a variety of drugs on the morphine glucuronosyltransferase activities in human liver microsomes. Twenty-one drugs including anticancer drugs, immunosuppressants, analgesics, anticonvulsants, antidepressants, antipsychotic drugs were selected in this study, because they are frequently co-administered with morphine. We found that 10 out of 21 drugs, tamoxifen, tacrolimus, diclofenac, carbamazepine, imipramine, clomipramine, amitriptyline, diazepam, lorazepam and oxazepam extensively inhibited the morphine 3- and 6-glucuronosyltransferase activities. Although some of the drugs are not substrates of UGT2B7, they would be potent inhibitors of UGT2B7. If patients receive morphine and these drugs simultaneously, the drug-drug interaction may change the levels of morphine and these glucuronides, resulting in altered analgesic efficacy and the risk of side effects. The results presented here will assist clinicians in choosing the proper drugs and/or dosages, and enable them to anticipate potential drug-drug interactions.

Prospective analysis of depression and psychological distress before and after surgical resection of lung cancer

OBJECTIVES

The psychological effects of surgery have received little attention in patients with lung cancer, so it is unclear how much psychological support is required by these patients. This study was done to assess the mental state of patients with lung cancer before and after surgery and to determine their need for psychological care.

METHODS

A group of 165 patients with lung cancer scheduled for surgical treatment were included in this study. They were asked to complete the Profile of Mood States questionnaire before surgery and on discharge after completion of treatment. The data on mood from the questionnaires were analyzed.

RESULTS

Tension-anxiety improved significantly after surgery, whereas the fatigue score increased significantly. The scores for depression-dejection and confusion were elevated before surgery and were unchanged afterward.

CONCLUSIONS

Patients with lung cancer were depressed before surgery and remained depressed after their operations, although postoperative tension-anxiety diminished. These results indicate that lung cancer patients need psychological support to alleviate depression during the perioperative period.

Experiences and expectations of patients after oesophageal cancer surgery: an explorative study

We investigated which problems patients experience after resection for oesophageal cancer and what care they expect, in order to devise a better-tailored follow-up policy. Thirty patients, all within 1 year after surgery, filled in a one-time questionnaire on experienced physical, psychological and social problems and on expected care for these problems. Additionally, a semi-structured interview was performed. Frequencies of experienced problems and expected care over time were analysed. The majority of patients experienced physical problems such as 'early satiety' (97%) and 'fatigue' (84%) after oesophagectomy. In addition, patients often felt depressed (64%), were afraid of metastases (80%) and death (47%). Over time, the frequency of problems such as 'fatigue' (P = 0.035) and 'being dependent' (P = 0.012) decreased. Patients particularly expected professional care for physical issues related to their disease, whereas they often managed psychosocial problems in their own social network. Patients indicated that nurses' involvement during follow-up might improve their possibility to satisfactorily deal with problems. Patients frequently experience physical problems after oesophagectomy, and professional care is expected for these issues. Psychosocial problems are also present, but care is less commonly expected. Nurses' involvement during follow-up could be a way to optimize patients' management after oesophageal cancer surgery.

Multifaceted psychosocial intervention program for breast cancer patients after first recurrence: feasibility study

We developed a novel multifaceted psychosocial intervention program which involves screening for psychological distress and comprehensive support including individually tailored psychotherapy and pharmacotherapy provided by mental health professionals. The purpose of the present study was to investigate the feasibility of the intervention program and its preliminary usefulness for reducing clinical psychological distress experienced by patients with recurrent breast cancer. The subjects who participated in the 3 months intervention program completed psychiatric diagnostic interview and several self-reported measures regarding psychological distress, traumatic stress, and quality of life. The assessments were conducted before the intervention (T1), after the intervention (T2), and 3 months after the intervention (T3). A total of 50 patients participated in the study. The rates of participation in and adherence to the intervention program were 85 and 86%, respectively. While the proportion of psychiatric disorders at T2 (11.6%) was not significantly different from that at T1 (22.0%) (p = 0.15), the proportion of that at T3 (7.7%) had significantly decreased compared with that at T1 (p = 0.005). The novel intervention program is feasible, is a promising strategy for reducing clinically manifested psychological distress and further controlled studies are warranted.

Treatment decision difficulties and post-operative distress predict persistence of psychological morbidity in Chinese women following breast cancer surgery

BACKGROUND

The patterns and determinants of longer-term psychological morbidity in women following breast cancer surgery have not been described for Chinese populations.

METHODS

Chinese women were assessed at 3-days, 4-months and 8-months following breast surgery, on treatment decision-making difficulty (TDMD), satisfaction with treatment outcome (E-OI), self efficacy (GSeS), optimism (C-LOT-R), consultation satisfaction (C-MISS-R), physical symptom distress (PSD) and psychological morbidity (CHQ-12) and compared using polynomial logistic models.

RESULTS

Of 303/405 women providing complete data, 33% received chemotherapy and 26% radiotherapy. GSeS, CLOTR and TDMD scores were moderate. Though the proportion of women meeting psychological morbidity case-criteria declined from 78% (95% Confidence Interval 73-83%) at Baseline to 64% (59-69%) at 8-months, almost 50% (44-54%) of women remained distressed over the 8-month period. After adjustment for demographic and clinical factors, severity of psychological morbidity at 4-months was predicted by PSD, disappointment and higher Baseline CHQ12, and among moderate/severe cases only, greater TDMD and pessimistic outlook. At 8-months, CHQ12 scores were predicted by PSD, Baseline CHQ-12, and difficulties with TDM.

CONCLUSION

TDM difficulties, early post-surgical psychological and physical symptom distress indicate risk for prolonged distress in Chinese women following breast cancer surgery.

Distress screening in a multidisciplinary lung cancer clinic: prevalence and predictors of clinically significant distress

Screening for distress in cancer patients is recommended by the National Comprehensive Cancer Network, and a Distress Thermometer has previously been developed and empirically validated for this purpose. The present study sought to determine the rates and predictors of distress in a sample of patients being seen in a multidisciplinary lung cancer clinic. Consecutive patients (N=333) were recruited from an outpatient multidisciplinary lung cancer clinic to complete the Distress Thermometer, an associated Problem Symptom List, and two questions about interest in receiving help for symptoms. Over half (61.6%) of patients reported distress at a clinically significant level, and 22.5% of patients indicated interest in receiving help with their distress and/or symptoms. Problems in the areas of family relationships, emotional functioning, lack of information about diagnosis/treatment, physical functioning, and cognitive functioning were associated with higher reports of distress. Specific symptoms of depression, anxiety, pain and fatigue were most predictive of distress. Younger age was also associated with higher levels of distress. Distress was not associated with other clinical variables, including stage of illness or medical treatment approach. Similar results were obtained when individuals who had not yet received a definitive diagnosis of lung cancer (n=134) were excluded from analyses; however, family problems and anxiety were no longer predictive of distress. Screening for distress in a multidisciplinary lung cancer clinic is feasible and a significant number of patients can be expected to meet clinical criteria for distress. Results also highlight younger age and specific physical and psychosocial symptoms as predictive of clinically significant distress. Identification of the presence and predictors of distress are the first steps toward appropriate referral and treatment of symptoms and problems that contribute to cancer patients' distress.

Prefrontal cortex and amygdala volume in first minor or major depressive episode after cancer diagnosis

BACKGROUND

Major and minor depressive episodes in cancer patients are frequent and are frequently seen as the first depressive episode in a patient's life. However, the neurological basis of these depressive episodes remains largely unknown.

METHODS

Subjects were 51 breast cancer survivors (BCS) who had no history of any depressive episode before the cancer diagnosis (11 BCS with a history of a first minor depressive episode after cancer diagnosis, 11 BCS with a history of a first major depressive episode after cancer diagnosis, and 29 BCS with no history of any depressive episode after cancer diagnosis). We analyzed the prefrontal cortex (PFC) and amygdala volumes in a 1.5-Tesla Magnetic Resonance Imaging scanner. We characterized the structural correlates of depression using two complementary approaches. The first was voxel-based morphometry (VBM) that allowed us to scan the entire brain for reactive gray matter deficit. The second was classical volumetry focusing on the amygdala.

RESULTS

Voxel-based morphometry revealed no brain region, including PFC, for which volume was significantly different among the three groups. There were trend-level differences in the left amygdala volume in the manual tracing method among the three groups. The left amygdala volumes in the subjects with a first minor and/or major depressive episode were significantly smaller than in those with no history of any depressive episode.

CONCLUSIONS

It might be suggested that amygdala volume was associated with a first minor and/or major depressive episode after cancer diagnosis.

Factors related to depressive symptoms among long-term survivors of cervical cancer

In this article we describe depressive symptoms among survivors of cervical cancer. Study participants were previously diagnosed and treated with cervical cancer 5 to 25 years prior to the completion of a telephone survey. Through a population-based survey of women identified via a state tumor registry in southern New England, the investigators learned that depressive symptoms are prevalent among a subgroup of long-term survivors long after diagnosis and treatment. The at-risk participants included those who were at a lower economic status and whose marital status and ability to work had changed, and who continued to experience pain and diarrhea caused by radiotherapy. Findings from this study warrant additional research with this potentially vulnerable group of women.

Marital status, social support and survival after curative resection in non-small-cell lung cancer

It has been suggested that marital status and social support are associated with survival in cases of lung cancer, and that such an association may be mediated by several factors. In this prospective cohort study, we investigated the effect of marital status and social support on survival after curative resection for non-small cell lung carcinoma (NSCLC) in Japan. From June 1996 to April 1999, a total of 238 patients with resectable NSCLC were enrolled. Marital status and social support were assessed. The presence and absence of confidants and the satisfaction level with the confidants were used as factors reflecting social support. During the follow-up period, 57 deaths from all causes were identified through January 2004. For the statistical analysis, Cox proportional hazards regression analyses were used. With regard to marital status, the multivariable adjusted hazard ratio (HR) of unmarried patients versus married patients was 0.8 (95% confidence interval, 0.3-1.8) (P-value=0.53) after controlling for potential confounding factors, including age, sex, occasion of cancer diagnosis, pathological stage, smoking status, smoking status after surgery and serum albumin level. Similarly, the multivariable adjusted HR of patients without confidants versus those with confidants was 1.0 (0.5-2.2) (P-value=0.90), whereas the multivariable adjusted HR of the dissatisfied-with-confidants group versus the satisfied-with-confidants group was 0.7 (0.4-1.3) (P-value=0.28). The present data do not support the hypothesis that marital status and social support are associated with survival in NSCLC.

Depression and survival in patients with non-small cell lung cancer after curative resection: a preliminary study

Psychological depression is thought to be a predictor of poor survival among cancer patients. The objective of the present study was to investigate the association between depression and survival in surgically treated Japanese patients with non-small cell lung cancer (NSCLC). From June 1996 through April 1999, a total of 229 patients with postoperative lung cancer were enrolled. Three months after the patients' surgery, the Structured Clinical Interview for DSM-III-R (SCID) and the Profile of Mood States (POMS) were used to assess the patient for depression, based on the interviewers' rating and a self-report, respectively. The follow-up period consisted of a total of 14 342 person-months (median=69 months). As of January 2004, 55 deaths had occurred within the follow-up period. A Cox regression was used to estimate the hazard ratio (HR) of mortality adjusting for age, sex, smoking status, occasion of diagnosis, pathological stage and preoperative percentage forced expiratory volume in 1 s. The depression-dejection subscale on the POMS was divided into three score levels. The multivariate HR of survival for individuals with depression, as diagnosed by the SCID, was 2.2 (95% confidence interval 0.8-6.0) (P-value=0.14), compared with individuals without depression. The multivariate HR of survival for subjects in the highest level of the POMS Depression-Dejection subscale was 1.4 (0.7-2.6), compared with in the lowest level (trend P-value=0.0502). This prospective cohort study in Japan does not support the hypothesis that depression is associated with survival among NSCLC patients after curative resection, but further analysis involving a long-term follow-up period is needed.

Depressive symptoms after lung cancer surgery: their relation to coping style and social support

Lung cancer patients may experience greater emotional distress than patients with other cancers. Studies have shown social support to predict adjustment in other cancers, but findings among lung cancer patients have been equivocal. Coping style has been shown to predict distress among lung cancer patients, but has not been examined in the context of social support. We examined coping style and social support as predictors of depressive symptoms one week after surgery among 119 patients with non-small cell lung cancer. The Beck Depression Inventory was the primary outcome measure. Predictors included age, ECOG performance status, stage of disease, and measures of adaptive coping, less adaptive coping, Directive instrumental social support and Nondirective instrumental social support. Results indicated that 29% of lung cancer patients had scores above a standard cutoff for clinically significant depression. Results also showed that depressive symptoms were directly related to use of less adaptive coping methods and Directive instrumental social support, inversely related to age and use of adaptive coping methods, and unrelated to nondirective social support, stage of disease and performance status. Results extend previous findings by showing that adaptive coping methods are related to severity of distress, and that the benefits of social support may depend on the characteristics of that support.

Course of psychological distress and its predictors in advanced non-small cell lung cancer patients

This study investigated longitudinal changes and predictive factors for psychological distress among 85 newly diagnosed advanced non-small cell lung cancer (NSCLC) patients. Whereas tension-anxiety after diagnosis (T1) was significantly reduced at two months (T2) and six months (T3) after diagnosis and depression-dejection at T1 was significantly reduced at T2, other forms of psychological distress, including anger-hostility, vigor, fatigue, and confusion, did not show significant changes. Total mood disturbance did not show significant change. Only a higher total mood disturbance at T1 was a significant predictor of total mood disturbance at T3. These findings demonstrate that most types of psychological distress experienced by advanced NSCLC patients is likely to persist during the subsequent clinical course. The findings also suggest that initial psychological distress itself after cancer diagnosis is the most important predictor for subsequent psychological distress and that early intervention beginning immediately after the disclosure of a diagnosis of cancer is one way to prevent and/or reduce subsequent psychological distress in advanced NSCLC patients.

Inhibitory effects of psychotropic drugs on mexiletine metabolism in human liver microsomes: prediction of in vivo drug interactions

Mexiletine, an anti-arrhythmic agent, is used for the control of ventricular arrhythmias and for neuropathic pain from cancer or diabetes mellitus. It is sometimes used together with psychotropic drugs in patients with depression, schizophrenia or sleep disorder. It is metabolized mainly by cytochrome P450 (CYP) 2 D 6 and, to a minor extent, by CYP1A2. To predict possible drug interactions between mexiletine and psychotropic drugs, the inhibitory effects of 14 psychotropic drugs (phenytoin, carbamazepine, fluvoxamine, paroxetine, fluoxetine, citalopram, sertraline, imipramine, desipramine, haloperidol, thioridazine, olanzapine, etizolam, and quazepam) on mexiletine metabolism in human liver microsomes were determined. Fluoxetine (Ki=0.6+/- 0.1 microM), sertraline (Ki=7.6+/- 0.8 microM) and desipramine (Ki=3.2+/- 0.5 microM) competitively inhibited the mexiletine p-hydroxylation in human liver microsomes. Thioridazine (Kis=0.5+/- 0.2 microM; Kii =3.6+/-1.6 microM) and paroxetine (Kis=1.7+/- 0.7 microM; Kii=3.6+/- 0.9 microM) exhibited a mixed-type inhibition (competitive and non-competitive) toward mexiletine p-hydroxylation in human liver microsomes. The changes of the in vivo clearance of mexiletine by the psychotropic drugs were predicted by 1+(I/Ki) using the in vitro Ki and unbound inhibitor concentrations in liver. The values were calculated as 2.4 for paroxetine, 5.5 for fluoxetine, 1.1 for sertraline, 2.8 for desipramine and 2.2 for thioridazine. In addition, paroxetine exhibited a mechanism-based inactivation with Ki=0.7 microM and Kinact=0.15 min(-1). The present study predicted the possibility of drug interactions between mexiletine and paroxetine, fluoxetine, desipramine, and thioridazine in clinical use.

The association between oral health and general health and quality of life in older male cancer patients

OBJECTIVES

To describe the long-term effects of oral health problems on quality of life (QoL), functional status, pain, and general health in older male cancer patients.

DESIGN

Secondary analysis of a prospective observational study.

SETTING

Community dwelling cancer patients served by a Department of Veterans Affairs hospital.

PARTICIPANTS

One hundred fifty male cancer patients responded to the question "Do you have tooth or mouth problems making it hard to eat?" The relationship between patients answering "yes" and the following parameters was assessed: demographics, comorbid conditions, habits, activities of daily living, pain, anxiety, depression, social support, spirituality, QoL, and overall health ratings.

MEASUREMENTS

Chi-square contingency tables for dichotomous variables, Cochran-Mantel-Haenszel for ordered categorical variables, and t tests for associations with continuous variables.

RESULTS

The median age of respondents was 67. Those reporting tooth or mouth problems had had their cancer diagnosed on average 2.9 years before, and 83.3% were found clinically to be cancer free. Patients with these problems had significantly lower global (P=.003) and subscale scores on QoL analysis and higher levels of anxiety (P<.001) and depression (P=.01) than those without tooth or mouth problems; they also had significantly more pain (P<.001) and lower physical functioning (P<.001) and were more impaired in activities of daily living (P<.001). Those with tooth or mouth problems were more likely to describe their overall health as fair or poor (P=.01). Having cancer located in the head and neck region related significantly to having mouth or tooth problems (P=.005), but these problems were not associated with race, education, income, insurance coverage, age, comorbid conditions, alcohol consumption, tobacco or medication usage, type of cancer treatment, tumor stage at diagnosis or follow-up, perceived social support, or spirituality.

CONCLUSION

Older male cancer patients with mouth or tooth problems making it hard to eat are more likely to have a lower QoL, poorer emotional health, lower levels of physical functioning, and greater pain than patients without these problems.

Severely diseased lung cancer patients narrate the importance of being included in a helping relationship

Because patients with advanced lung cancer have a poor prognosis, healthcare staff should treat and support them with sensitivity without placing them under necessary strain. A common way of revealing patients' psychological needs is to rely on questionnaires where predefined potential problem areas are examined. Another and less common way of detecting their needs is to focus on the patients' concrete everyday-experiences in their contacts with health care. In this study, 23 consecutive patients with advanced non-small cell lung cancer were asked to describe their experiences in dealing with their healthcare providers. Data were analysed qualitatively by categorising the incidents according to content. It emerged that 'being connected to health care' and being 'acknowledged as a person' were by far the most prominent dimensions. Very few incidents were directly related to 'information'. The results suggest that in oncology it is important to call attention to the fact that the patient-physician relationship cannot be reduced to the communication of information. Other dimensions are worth considering.

Preoperative assessment for lung cancer surgery

PURPOSE OF REVIEW

Pulmonary resection remains the only curative treatment option for lung cancer surgery. This review summarizes recent advances in the preoperative functional evaluation of the patient with lung cancer.

RECENT FINDINGS

The workup of patients with bronchogenic carcinoma covers three areas: tumor type, tumor extent, and patient cardiopulmonary reserves. Significant advances have been made in the latter two areas. Traditionally lobectomy was regarded as the minimum resection for lung cancer; new studies are challenging this view and suggesting that segmentectomy is acceptable for stage Ia cancers < or =20 mm. An important change relating to cardiopulmonary reserves of the patient is the shift in emphasis toward early exercise testing and, in particular, the use of stair climbing as a surrogate marker of maximal oxygen consumption. New studies confirm the benefit of combined lung volume reduction surgery and lung cancer surgery in certain patients who might otherwise be excluded from surgery because of poor lung function.

SUMMARY

Advances in the preoperative workup of lung cancer patients and in surgical techniques are permitting resections in previously inoperable patients. A new, simplified algorithm for the preoperative workup of lung cancer patients assessing the value of stair climbing as a surrogate marker of maximal oxygen consumption is proposed.

Usefulness of the nurse-assisted screening and psychiatric referral program

BACKGROUND

Major depression and adjustment disorders are common psychiatric disorders in patients with cancer, but they are often overlooked in clinical oncology settings. The nurse-assisted screening and psychiatric referral program (NASPRP) has been introduced in clinical practice to facilitate psychiatric treatment for major depression and adjustment disorders. This study assessed the usefulness of the NASPRP and compared it with usual practice.

METHODS

The program consists of two stages. In the first stage, consecutive patients newly admitted to the Oncology/Hematology Unit are administered the Distress and Impact Thermometer (DIT) by nurses as a brief screening tool for major depression and adjustment disorders. In the second stage, the nurses recommend psychiatric referral to patients with scores above the cutoff point. Patients' records were reviewed for a 3-month period before the start of the program and during the 3-month period after the start of the program. These records were then compared.

RESULTS

Of 157 patients newly admitted during the program period, 86.0% (135/157) completed the DIT and results were positive in 49.6% (67/135), but only 28.2% (19/67) accepted psychiatric referral. Ultimately, 11.5% (18/157) of patients newly admitted were diagnosed with major depression or adjustment disorders and treated by psychiatric service, a significantly higher proportion than during the preceding 3-month period, before the program was begun (2.5%; P = 0.001).

CONCLUSION

The NASPRP enabled identification of major depression and adjustment disorders in patients with cancer and introduced them to psychiatric treatment. Nevertheless, there is room for improvement in the program.

Psychosocial aspects of lung cancer

BACKGROUND

Lung cancer is one of the commonest cancers in the industrialised world, and persons with this grave disease must deal not only with the physical effects but also with the psychosocial aspects.

METHODS

This review is based on an examination of intervention, prospective and case-control studies with more than 50 participants published between 1966 and 2003.

RESULTS

The studies show that on average one out of four persons with lung cancer experience periods of depression or other psychosocial problems during their illness. Persons who are not offered treatment for their cancer and persons with small-cell lung cancer have a higher risk compared to other groups of lung cancer patients. The degree of depression can be reduced by psychosocial interventions.

CONCLUSIONS

We suggest that psychosocial screening of persons with lung cancer could prevent depression and might result in improved quality of care.

Development of an Impact Thermometer for use in combination with the Distress Thermometer as a brief screening tool for adjustment disorders and/or major depression in cancer patients

Screening cancer patients for adjustment disorders and major depression is important, because both are prevalent and often underrecognized. The purpose of this study was to validate the Distress and Impact Thermometer, a 2-item questionnaire, which we newly developed as a brief screening tool for detection of adjustment disorders and/or major depression. Two hundred ninety-five cancer patients completed the Distress and Impact Thermometer and the Hospital Anxiety and Depression Scale (HADS), and were examined by psychiatrists based on DSM-IV criteria. Using cutoff points for detection of adjustment disorders and major depression of "3/4" on "distress" score and "2/3" on "impact," the sensitivity and specificity were 0.82 and 0.82, respectively. Screening performance of the Distress and Impact Thermometer was comparable to that of the Hospital Anxiety and Depression Scale. Its brevity and good performance suggest that the Distress and Impact Thermometer is an effective tool for routine screening in clinical oncology settings.

Prospective assessment of emotional distress, cognitive function, and quality of life in patients with cancer treated with chemotherapy

BACKGROUND

The current study sought to delineate prospectively the rates and clinical course of emotional distress, cognitive impairment, and quality of life (QOL) in chemotherapy-naive patients with cancer and to consider the determinants of global QOL.

METHODS

Patients who consented to participate were administered the European Organization for Research and Treatment of Cancer QLQ-C30 questionnaire, the Mini-Mental State Examination (MMSE), and the Hospital Anxiety and Depression Scale before and at the end of treatment (EOT).

RESULTS

Of the 102 patients initially assessed, 80 (78.4%) completed the study. Most aspects of QOL did not change considerably over time. At EOT, patients reported only significant increases in fatigue and significant decreases in sleep disturbance. Although no significant changes emerged in the rates of anxiety or depression throughout chemotherapy, nearly one-third of the patients experienced severe emotional distress at both points in time. In addition, the authors observed neither significant alteration in the cognitive performance over time nor reliable associations between scores on the MMSE and subjective cognitive function, emotional distress, or QOL. Finally, depression proved to be the leading predictor of global QOL at baseline and at EOT.

CONCLUSIONS

The results indicated that a significant proportion of Greek patients with cancer experienced intense anxiety and depression throughout chemotherapy and confirmed the importance of depression as a strong predictor of global QOL. Routine screening of emotional distress across all phases of cancer is mandatory because it will contribute to the identification of patients who are in need of pharmaceutical and/or psychologic intervention.

Psychiatric disorders in oncology: recent therapeutic advances and new conceptual frameworks

PURPOSE OF REVIEW

Major advances achieved in anticancer treatment have resulted in significant increases in cancer patients' survival periods. At the same time, growing awareness of the psychologic impact of the diagnosis and treatment of cancer on quality of life has created the need for deeper insights into the adjustment process, its disorders, and effective strategies for the treatment of psychiatric morbidity. The wider availability of brain imaging techniques and other neurobiologic tools is creating major opportunities for a scientific understanding of psychodynamic processes.

RECENT FINDINGS

Several elements indicate a stress-system activation in response to cancer. The existence of traumatic stress-like syndromes has received increasing support. Structural brain imagery has revealed volumetric alterations of the amygdala, a major participant in emotional and fear responses. Hypotheses about functional modifications at the hypothalamic-pituitary-adrenal axis level may have significant implications for the identification, treatment, and even prevention of psychopathology. Finally, longitudinal studies assessing psychologic adjustment confirm the need for psychosocial and pharmacologic interventions.

SUMMARY

Our understanding of the cancer experience at the emotional and cognitive levels remains insufficient, leading to weakly positive results of psychosocial intervention models. The use of antidepressant medication has received substantial empiric and scientific support, but a risk of antidepressant-induced carcinogenesis has not been excluded, which should keep clinicians from overprescribing attitudes. Finally, improving the quality of doctor-patient communication and the psychologic impact of carrying a genetic marker of cancer risk should be the focus of further attention.

Psychological distress: concept analysis

BACKGROUND

The term 'distress' is frequently used in nursing literature to describe patient discomfort related to signs and symptoms of acute or chronic illness, pre- or post-treatment anxiety or compromised status of fetuses or the respiratory system. 'Psychological distress' may more accurately describe the patient condition to which nurses respond than does the term 'distress'. Psychological distress is seldom defined as a distinct concept and is often embedded in the context of strain, stress and distress. This creates confusion for nurses attempting to manage the care of people experiencing psychological distress.

AIMS

This paper is a concept analysis of psychological distress based on Walker and Avant's (1995) criteria that identifies the attributes, antecedents, and consequences of psychological distress based upon the findings of the literature review. In addition, empirical references are identified and constructed cases presented.

METHODS

A literature search was conducted using MEDLINE, CINAHL, Ovid, PsychINFO, and Cancer Lit databases over the last 50 years. The purposes of this concept analysis were: (1) to establish the concept of psychological distress as a clear and distinct concept, separate from strain, stress and distress, and (2) to provide nurses with a base of knowledge from which to plan effective clinical interventions.

FINDINGS

Content analysis of the literature revealed that, although used frequently in health care literature, the origin of the concept of psychological distress has not been clearly articulated and is ill-defined.

CONCLUSIONS

Psychological distress is a serious problem faced by many of the people whom nurses encounter on a daily basis. An understanding of the concept of psychological distress will help nurses ameliorate this problem in patients. Nursing research related to the exploration of psychological distress is also needed.

Does a symptom management intervention affect depression among cancer patients: Results from a clinical trial

Cancer patients diagnosed with solid tumors and undergoing a first course of chemotherapy were randomized to either conventional care or a 10 contact 20 week cognitive behavioral intervention designed to reduce emotional distress. Three hypotheses were tested. First, a test for a group effect found that patients in the intervention who entered the trial with higher symptom severity reported significantly lower depression at 10 but not 20 weeks. Patients in the experimental group who entered with higher depression were more depressed at 10 weeks than patients in the control group. The second hypothesis compared the intervention in two sub-indices of symptom severity; one comprised of symptoms with a depressive component, the other of symptoms not associated with depression. The intervention was more effective in lowering depression at 10 weeks through an interaction with the non-depressive symptom sub-index. At 20 weeks, a significant main effect for the intervention on depression was observed. No interaction with either sub-index was observed. The third hypothesis found no main or interaction effect between psychotropic drugs and the intervention. In conclusion, behavioral interventions may influence depression differently over time. Initially, the intervention lowered depression through certain symptoms and only later did it effect depression directly. Symptoms with an affective component are relatively unaffected by the intervention which was independent of the presence of psychotropic medications.