Gender, age and surgery as a treatment modality leads to higher distress in patients with cancer

A Comprehensive Assessment of The Eight Vital Signs

The term “vital sign” has been assigned to various phenomena with the presumptive intent to emphasize their importance in health care resulting in the emergence of eight vital signs with multiple designations and overlapping terms. This review developed a case definition for vital signs and identified and described the fifth through eighth vital signs. PubMed/Medline, Google and biographical databases were searched using the individual Medical Subject Headings (MeSH) terms, vital sign and fifth, vital sign and sixth, vital sign and seventh, and vital sign eighth. The search was limited to human clinical studies written in English literature from 1957 up until November 30, 2021. Excluded were articles containing the term vital sign if used alone without the qualifier fifth, sixth, seventh, or eighth or about temperature, blood pressure, pulse, and respiratory rate. One hundred ninety-six articles (122 for the fifth vital sign, 71 for the sixth vital sign, two for the seventh vital sign, and one for the eighth vital sign) constituted the final dataset. The vital signs consisted of 35 terms, classified into 17 categories compromising 186 unique papers for each primary authored article with redundant numbered vital signs for glucose, weight, body mass index, and medication compliance. Eleven terms have been named the fifth vital sign, 25 the sixth vital sign, three the seventh, and one as the eighth vital sign. There are four time-honored vital signs based on the case definition, and they represent an objective bedside measurement obtained noninvasively that is essential for life. Based on this case definition, pulse oximetry qualifies as the fifth while end-tidal CO2 and cardiac output as the sixth. Thus, these terms have been misappropriated 31 times. Although important to emphasize in patient care, the remainder are not vital signs and should not be construed in this manner.

Age-related differences in self-report and objective measures of cognitive function in older patients prior to chemotherapy

Aim

Evaluate for differences in demographic and clinical characteristics and subjective and objective measures of cognitive function (CF) between younger older adults (YOA, 60–69 years) and older adults (OA, ≥70 years).

Design

Cross‐sectional.

Methods

Older oncology patients (n = 139) completed subjective (Attentional Function Index, European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire (EORTC) CF scale) and objective (Montreal Cognitive Assessment, Trail Making Test (TMT) A & B) measures of CF prior to chemotherapy. Data were analyzed using parametric and nonparametric tests.

Results

No differences were found between the two groups for any of the subjective or objective CF measures, except that OA patients had higher TMT B scores. Compared with the general population, OAs had significantly higher EORTC CF scores and YOAs had significantly worse scores for all of the objective tests. Clinically meaningful difference between group differences was found for the TMT B test.

Psychological Distress and Its Association with Unmet Needs and Symptom Burden in Outpatient Cancer Patients: A Cross-Sectional Study

OBJECTIVES

To evaluate the relationships of sociodemographic and clinical characteristics, symptom burden, and supportive care needs of patients with a prevalence of psychological distress in outpatients with cancer.

DATA SOURCES

The study was carried out with 298 outpatient cancer patients at an oncology center in Turkey, and a descriptive correlational design was used. The data were collected through Hospital Anxiety-Depression Scale (HADS), Nightingale Symptom Assessment Scale (N-SAS), and Supportive Care Needs Scale Short Form (SCNS-SF34). Descriptive statistics and hierarchical regression analyses were performed.

CONCLUSION

The study determined that the anxiety and depression scores of a significant portion of cancer patients receiving outpatient treatment were clinically significant. It was observed that the physical and psychological symptom burden of the patients and the increase in unmet care needs related to psychological, physical, and activities of daily life contributed to the development of anxiety and depression. Of the sociodemographic and disease-related characteristics of the patients, female sex was found to be an important factor for both anxiety and depression, and advanced age was found to be an important factor for depression. These results indicate that cancer patients receiving outpatient treatment need intensive supportive psychosocial care.

IMPLICATIONS FOR NURSING PRACTICE

It is recommended that patients' psychological distress levels and supportive care needs be included in the care process as a routine component of care, as in symptom assessment, and to develop a more sensitive and supportive care environment in meeting psychosocial care needs and accessing support.

Emotional Problems Prior to Adjuvant Radiation Therapy for Breast Cancer

BACKGROUND/AIM

Being scheduled for radiotherapy can cause emotional distress. This study aimed to identify risk factors in 338 patients assigned to radiotherapy for breast cancer.

PATIENTS AND METHODS

Nineteen potential risk factors including the COVID-19 pandemic were investigated for associations with the six emotional problems included in the National Comprehensive Cancer Network Distress Thermometer.

RESULTS

Worry and fears were significantly associated with age ≤60 years; sadness with age and Karnofsky performance score (KPS) <90; depression with KPS and Charlson Comorbidity Index ≥3; loss of interest with KPS. Trends were found for associations between sadness and additional breast cancer/DCIS, Charlson Index and chemotherapy; between depression and additional breast cancer/DCIS, treatment volume and nodal stage N1-3; between nervousness and additional breast cancer/DCIS, mastectomy and triple-negativity; between loss of interest and Charlson Index, family history of breast cancer/DCIS, invasive cancer, chemotherapy, and treatment volume. The COVID-19 pandemic did not increase emotional problems.

CONCLUSION

Several risk factors for emotional problems were identified. Patients with such factors should receive psychological support well before radiotherapy.

Predicting decisional conflict: Anxiety and depression in shared decision making

OBJECTIVES

Emotional distress can be a potential barrier to shared decision making (SDM), yet affect is typically not systematically assessed in medical consultation. We examined whether urological patients report anxiety or depression prior to a consultation and if emotional distress predicts decisional conflict thereafter.

METHODS

We recruited a large sample of urological outpatients (N = 397) with a range of different diagnoses (42 % oncological). Prior to a medical consultation, patients filled in questionnaires, including the Hospital Anxiety and Depression Scale. After the consultation, patients completed the Decisional Conflict Scale. We scored the rate of anxiety and depression in our sample and conducted multiple regression analysis to examine if emotional distress before the consultation predicts decisional conflict thereafter.

RESULTS

About a quarter of patients reported values at or above cut-off for clinically relevant emotional distress. Emotional distress significantly predicted a higher degree of decisional conflict. There were no differences in emotional distress between patients with and without uro-oncological diagnosis.

CONCLUSIONS

Emotional distress is common in urology patients - oncological as well as non-oncological. It predicts decisional conflict after physician consultation.

PRACTICE IMPLICATIONS

Emotional distress should be systematically assessed in clinical consultations. This may improve the process and outcome of SDM.

Moving closer to death: understanding psychosocial distress among older veterans with advanced cancers

BACKGROUND

Early identification of psychosocial distress is important to address the needs of vulnerable populations and influence symptom management. Older veterans diagnosed with life-limiting cancers are particularly vulnerable because they often have unmet needs, experiencing psychological or emotional problems and gaps in healthcare communication, which extends suffering. Lack of emotional support, ongoing physical pain, and unresolved symptom control can further increase distress among older veterans, contributing to complexity of decision-making for end of life (EOL) care.

OBJECTIVE

We explored older veterans' experiences and identification of psychosocial distress in cancer care to better understand how they describe distress while facing the end of life.

METHODS

Guiding this study is a conceptual framework from psychosocial oncology with the multifactorial experience of distress indicated by NCCN guidelines for distress screening. We use a phenomenological approach to explore the experience of psychosocial distress among older veterans diagnosed with advanced cancers at risk for dying within a year.

INCLUSION CRITERIA

Provider response of "no" to, "Would you be surprised if your patient died within a year?" and "yes", to the question, "Have you talked with your patient about the severity of their illness as being life-limiting, terminal?"

RESULTS

Five themes emerged: (1) the meaning of distress: "It's hard to explain"; (2) severity of advanced cancer: "There's no stage five"; (3) distressing thoughts about the possibility of dying: "Either way, it's life limiting"; (4) coping: "Deal with it and hope for a better day"; and (5) personal factors: "I don't want to be anything but a man who can handle adversity." Findings suggest older veterans may have unique cancer experiences different from other populations.

CONCLUSION

Older veterans in this study exhibited distressing symptoms which demonstrate they are at risk for declining health and in need of support for their distress. Healthcare providers are urged to understand the complexity of distress to provide the best possible treatment for older veterans.

Distinct Stress Profiles Among Oncology Patients Undergoing Chemotherapy

CONTEXT

Cancer and its treatment are inherently stressful and stress impacts important patient outcomes. Patients vary considerably in their response to stress. Understanding this variability requires a patient-centered multidimensional approach.

OBJECTIVES

The objectives of this study were to identify and characterize patient subgroups with distinct multidimensional stress profiles (stress appraisal, exposure, and adaptation) during cancer treatment.

METHODS

Among 957 patients undergoing chemotherapy for breast, gastrointestinal, gynecological, or lung cancer, latent profile analysis was performed to identify patient subgroups using concurrent evaluations of global (Perceived Stress Scale) and cancer-specific (Impact of Events Scale-Revised) stress, lifetime stress exposure (Life Stressor Checklist-Revised), and resilience (Connor-Davidson Resilience Scale-10).

RESULTS

Three latent classes were identified: "Normative" (54.3%; intermediate global stress and resilience, lower cancer-related stress, lowest life stress); "Stressed" (39.9%; highest global and cancer-specific stress scores, lowest resilience, most life stress); and "Resilient" (5.7%; lowest global stress, cancer-specific stress comparable to Normative class, highest resilience, intermediate life stress). Characteristics that distinguished the Stressed from the Normative class included the following: younger age, female gender, lower socioeconomic status, unmarried/partnered, living alone, poorer functional status, and higher comorbidity burden. Compared to Stressed patients, Resilient patients were more likely to be partnered, to not live alone, and had a higher functional status. No demographic or clinical characteristics differentiated Normative from Resilient patients. Exposure to specific life stressors differed significantly among the classes.

CONCLUSION

A subset of patients warrants intensive psychosocial intervention to reduce stress and improve adaptation to cancer. Intervention efforts may be informed by further study of Resilient patients.

The Distress Thermometer: Cutoff Points and Clinical Use

Purpose/Objectives

To establish an optimal cutoff point for the National Comprehensive Cancer Network’s Distress Thermometer (DT) as a screening measure to identify and address psychological distress in individuals with cancer, and to examine whether distress as measured by the DT significantly changes across the treatment trajectory.

Design

Secondary analyses of baseline data from a longitudinal parent study examining a computerized psychosocial assessment.

Setting

Three diverse comprehensive cancer centers across the United States.

Sample

836 patients with a current or past diagnosis of cancer.

Methods

Study participants were selected from a randomized clinical trial. Patients during any stage of the cancer treatment trajectory were recruited during a chemotherapy infusion or routine oncology appointment.

Main Research Variables

The Behavioral Health Status Index and the DT were administered and compared using receiver operating characteristic analyses.

Findings

Results support a cutoff score of 3 on the DT to indicate patients with clinically elevated levels of distress. In addition, patients who received a diagnosis within the 1–4 weeks prior to the assessment indicated the highest levels of distress.

Conclusions

Providers may wish to use a cutoff point of 3 to most efficiently identify distress in a large, diverse population of patients with cancer. In addition, results indicate that patients may experience a heightened state of distress within 1–4 weeks postdiagnosis compared to other stages of coping with cancer.

Implications for Nursing

Using a brief measure of distress can help streamline the process of screening for psychosocial distress.

The Influence of Pain Severity and Interference on Satisfaction with Pain Management among Middle-Aged and Older Adults

Background. Health outcomes are often contingent on how effective the individual is able to manage existent illness-related symptoms. This is all the more relevant among chronic pain patients. Objective. This study aimed to identify indicators of pain treatment satisfaction among middle-aged and older adults (N = 150) receiving outpatient treatment from a comprehensive cancer center. Methods. Patients were surveyed on questions assessing pain treatment satisfaction, pain severity, and additional social characteristics. Results. Descriptive data showed that middle-aged adults reported more pain locations, greater pain severity, and less satisfaction with pain treatment. A multivariate model was specified, showing older adults being more satisfied with their pain treatment. For the middle-aged adults, treatment satisfaction was generally lower with greater pain severity. This counters that for the older adults, where treatment satisfaction remained consistent despite increased levels of pain severity. Conclusion. These findings address an important issue regarding how pain is experienced across the life course. This suggests that general assumptions cannot be made about the health outcomes of older adults. Beyond the descriptive definitions of pain, there remains the need to develop models that account for determinants that may account for the pain experience among a diverse adult population.

Predictors of psychological distress and interest in mental health services in individuals with cancer

Identifying risk factors for psychological distress in patients with cancer may help providers more efficiently screen, identify, and manage distress. This article presents predictors of psychological distress in a large heterogeneous sample of cancer patients. In total, 836 patients were enrolled in a large randomized control trial and completed computerized psychosocial assessments Mental Health Assessment and Dynamic Referral for Oncology. Multivariate regressions examined predictors of distress and interest in mental health services. Final models suggest that psychological distress was related to six variables, and interest in mental health services was related to previous history of mental health counseling, total number of cancer-related symptoms, and race/ethnicity. Results may be used to identify high-risk patients who may benefit from proactive psychosocial interventions.

Co-occurrence of anxiety and depressive symptoms following breast cancer surgery and its impact on quality of life

PURPOSE

Little is known about the prevalence of combined anxiety and depressive symptoms (CADS) in breast cancer patients. Purpose was to evaluate for differences in demographic and clinical characteristics and quality of life (QOL) prior to breast cancer surgery among women classified into one of four distinct anxiety and/or depressive symptom groups.

METHODS

A total of 335 patients completed measures of anxiety and depressive symptoms and QOL prior to and for 6 months following breast cancer surgery. Growth Mixture Modelling (GMM) was used to identify subgroups of women with distinct trajectories of anxiety and depressive symptoms. These results were used to create four distinct anxiety and/or depressive symptom groups. Differences in demographic, clinical, and symptom characteristics, among these groups were evaluated using analyses of variance and Chi square analyses.

RESULTS

A total of 44.5% of patients were categorized with CADS. Women with CADS were younger, non-white, had lower performance status, received neoadjuvant or adjuvant chemotherapy, had greater difficulty dealing with their disease and treatment, and reported less support from others to meet their needs. These women had lower physical, psychological, social well-being, and total QOL scores. Higher levels of anxiety with or without subsyndromal depressive symptoms were associated with increased fears of recurrence, hopelessness, uncertainty, loss of control, and a decrease in life satisfaction.

CONCLUSIONS

Findings suggest that CADS occurs in a high percentage of women following breast cancer surgery and results in a poorer QOL. Assessments of anxiety and depressive symptoms are warranted prior to surgery for breast cancer.

"There won't' be anything else...it's over": perceptions of women referred to palliative care only

BACKGROUND

It is not well-known how women with advanced breast and gynecological cancers cope with the transition to palliative care (PC) only, but we anticipate that this is a challenging situation for them.

OBJECTIVE

To investigate women's understanding on the reasons of anticancer treatment withdrawal, their ideas about PC, and also perceptions of the communication of bad news.

METHOD

Twenty women were interviewed by a single researcher after being informed that their antineoplastic treatment would be discontinued and they would be exclusively monitored by PC staff. The interviews were audiotaped, transcribed verbatim, and analyzed according to content analysis.

RESULTS

Three categories were identified in the participants' narratives: (1) an understanding of the meaning of PC; (2) a lack of understanding of the shift in treatment and follow-up; (3) differing perspectives about hope. The PC Unit was stigmatized as a place to die, resulting in a "place to die" subcategory. The narratives of the participants who previously had experienced PC converged on a subcategory that reveals better recognition of the importance of the PC Unit as "a place that enhances the quality of life".

CONCLUSION

The participants manifested little knowledge about PC and the forthcoming strategies for their clinical follow-up. In addition, the PC Unit was patently stigmatized as a place to die. Early referral to PC seems to be associated with a less painful therapeutic transition, based on more accurate knowledge of the importance of PC.

Randomized controlled trial to test a computerized psychosocial cancer assessment and referral program: methods and research design

The National Cancer Coalition Network, National Cancer Institute, and American College of Surgeons all emphasize the need for oncology providers to identify, address, and monitor psychosocial needs of their patients. The Mental Health Assessment and Dynamic Referral for Oncology (MHADRO) is a patient-driven, computerized, psychosocial assessment that identifies, addresses, and monitors physical, psychological, and social issues faced by oncology patients. This paper presents the methodology of a randomized controlled trial (RCT) that tested the impact of the MHADRO on patient outcomes at 2, 6, and 12 months. Patient outcomes including overall psychological distress, depression, anxiety, functional disability, and use of psychosocial resources will be presented in future publications after all follow-up data is gathered. Eight hundred and thirty six cancer patients with heterogeneous diagnoses, across three comprehensive cancer centers in different parts of the United States, were randomized to the MHADRO (intervention) or an assessment-only control group. Patients in the intervention group were provided detailed, personalized reports and, when needed, referrals to mental health services; their oncology provider received detailed reports designed to foster clinical decision making. Those patients who demonstrated high levels of psychosocial problems were given the option to authorize that a copy of their report be sent electronically to a "best match" mental health professional. Demographic and patient cancer-related data as well as comparisons between patients who were enrolled and those who declined enrollment are presented. Challenges encountered during the RCT and strategies used to address them are discussed.

Anxiety and depression after cancer diagnosis: prevalence rates by cancer type, gender, and age

BACKGROUND

Reported prevalence of emotional distress in cancer patients varies widely across studies. The present study determined prevalence of anxiety and depression (separated for presence of symptoms versus clinical levels) in a large, representative sample of cancer patients after diagnosis.

METHOD

During the years 2004-2009, 10,153 consecutive patients were routinely screened with the Psychosocial Screen for Cancer questionnaire at two major cancer centers.

RESULTS

Patients' mean age was 59 years and 45% were men. Across cancer types, 19.0% of patients showed clinical levels of anxiety and another 22.6% had subclinical symptoms. Further, 12.9% of patients reported clinical symptoms of depression and an additional 16.5% described subclinical symptoms. Analyses by cancer type revealed significant differences such that patients with lung, gynecological, or hematological cancer reported the highest levels of distress at the time point of cancer diagnosis. As expected, women showed higher rates of anxiety and depression, and for some cancer types the prevalence was two to three times higher than that seen for men. In some cancer types emotional distress was inversely related to age. Patients younger than 50 and women across all cancer types revealed either subclinical or clinical levels of anxiety in over 50% of cases.

LIMITATIONS

Findings describe levels of emotional distress after diagnosis but cannot inform about trajectories of anxiety and depression over time.

CONCLUSION

Given that levels of anxiety and depression varied widely by cancer type, gender, and age, these results inform which cancer patients are most likely in need of psychosocial support.

Do cancer and treatment type affect distress?

OBJECTIVE

We examined differences in distress levels and Distress Thermometer (DT) cutoff scores between different cancer types. The effect of socio-demographic and illness-related variables on distress was also examined.

METHODS

One thousand three hundred fifty patients (response = 51%) completed questions on socio-demographic and illness-related variables, the Dutch version of the DT and Problem List, and the Hospital Anxiety and Depression Scale. Receiver operating characteristics analyses were performed to determine cancer specific cutoff scores. Univariate and multivariate effects of socio-demographic and illness-related variables (including cancer type) on distress were examined.

RESULTS

Prostate cancer patients reported significantly lower DT scores (M = 2.5 ± 2.5) and the cutoff score was lower (≥ 4) than in patients with most other cancer types (M varied between 3.4 and 5.1; cutoff ≥ 5). Multivariate analyses (F = 10.86, p < .001, R(2) = 0.08) showed an independent significant effect of four variables on distress: intensive treatment (β = .10, any (combination of) treatment but surgery only and 'wait and see'); a non-prostate cancer type (β = -.17); the interaction between gender and age (β = -.12, highest distress in younger women as compared with older women and younger and older men); and the interaction between cancer type and treatment intensity (β = .08, lowest scores in prostate cancer patients receiving non-intensive treatment as compared with their counterparts).

CONCLUSIONS

Distress and cutoff score in prostate cancer patients were lower than in patients with other cancer types. Additionally, younger women and patients receiving treatment other than surgery only or 'wait and see' are at risk for higher distress. These results can help identify patients possibly in need of referral to professional psychosocial and/or allied health care.

Duloxetine for the treatment of mood disorder in cancer patients: a 12-week case-control clinical trial

OBJECTIVE

The aim of this study was to investigate the efficacy and tolerability of duloxetine in cancer patients with mood disorder (MD) by means of a comparison with a matched control group of patients with MD without medical illness.

METHODS

Fifty-nine consecutive patients with MD were enrolled in this prospective case-control study and received duloxetine 60/120 mg per day for 12 weeks. Twenty-seven patients were affected by cancer, whereas 32 had an MD without cancer. All the patients were assessed by means of efficacy and effectiveness tolerability scales for depression (Montgomery-Asberg Depression Rating Scale and Hospital Anxiety and Depression Scale), anxiety (State-Trait Anxiety Inventory-Y1/Y2) and severity of symptoms (Clinical Global Impression (CGI)-Severity) at baseline (T0), after 4 weeks (T1) and 12 weeks (T2). The CGI-Improvement, CGI-Effectiveness Index and Dosage Record Treatment Emergent Symptom Scale were administered at T1 and T2.

RESULTS

A significant global improvement in all the efficacy measures was found. The results showed no significant interaction 'Time X Group', suggesting a similar improvement in efficacy scores for cancer-depressed patients and depressed patients without cancer. No difference was found between the two groups with regard to drop-out percentage, effectiveness and tolerability.

CONCLUSION

Although the results of this case-control study are preliminary, they suggest that duloxetine can be considered a good option for the treatment of MD in cancer patients.