IMPARTER, Phase 1 of an intervention to improve patients' understanding of gene expression profiling tests in breast cancer

PURPOSE

To compare participants' knowledge about gene expression profiling (GEP) tests and recurrence risks after reading an information leaflet with that following viewing of an information film.

METHODS

Using a randomised cross-over design, at time-point one (T1), women aged 45-75 years without breast cancer either read leaflets or watched information films about Oncotype DX or Prosigna tests. Participants answered nine questions assessing knowledge (maximum score 18). Next-day information in the opposite modality was provided and knowledge re-assessed. Additional questions probed which format was easiest to understand, participants' preferences for film or leaflet and their reasons for these.

RESULTS

120 women participated (60 received OncotypeDX films and leaflets; 60 received the Prosigna versions). T1 mean knowledge scores were higher following film viewing (13.37) compared with that after reading leaflets (9.25) (mean difference 4.1; p < 0.0001; 95% CI 3.2, 5.0). When participants read leaflets first and subsequently viewed films, all increased their scores (mean + 6.08, from T1 of 9.25, p < 0.0001; 95% CI 5.44, 6.72). When films were viewed first, followed by leaflets, (36/60, 60%), participants' scores declined (mean-1.55 from T1 of 13.37, p < 0.001; 95% CI -2.32, -0.78). A majority of participants expressed preferences for the films (88/120, 73.3%) irrespective as to whether they described OncotypeDX or Prosigna. Reasons included the clarity, ease of understanding, visual material and reassuring voice-over.

CONCLUSION

Discussions between oncologists and patients about recurrence risk results can be challenging. Information leaflets may aid understanding but often employ complex language. Information films significantly improved knowledge and were preferred by participants.

What are the Psychological Factors Influencing Attendance, Non-Attendance and Re-Attendance at a Breast Screening Centre?

We describe some preliminary findings from a pilot study using three recently developed questionnaires which assessed items such as the health beliefs, knowledge about cancer and attitudes to breast cancer screening in 242 women invited to attend for mammographic screening in South East London. We suggest that these questionnaires should be used in all regional centres both to monitor psychological variables and to identify local problems within the service which may be influencing the up-take of invitations to come for screening.

Abstract OT3-08-01: Interview data from women contemplating LORIS trial entry during the feasibility study

Background: LORIS is a multi-centre, randomised (1:1) controlled trial of Surgery v Active Monitoring with annual mammography in patients with low risk ductal carcinoma in situ (DCIS). During a 2 year Feasibility Study potential patients were invited to complete the Clinical Trials Questionnaire (CTQ)1 and participate in a semi structured telephone interview about the verbal, written and DVD based trial information. The DVD was produced to complement the patient information sheet (PIS) and incorporates simple graphics and a Q&A session with women asking the Chief Investigator questions about the trial.

Aims:To examine the reasons for trial participation/rejection and obtain feedback about the clarity, timing and usefulness of the PIS and DVD in order to identify potential communication drivers and barriers to trial recruitment.

Methods: Participants completed the CTQ1 prior to randomisation and with their consent were contacted following randomisation for an interview. Women declining the trial were issued with an optional pack containing the CTQ1 and the researchers' contact details if they wanted an interview. The CTQ1 comprises16 reasons that might influence a decision to either accept or decline a trial. For each statement participants register their agreement or disagreement on a scale of 1 (strongly agree) to 5 (strongly disagree) and indicate the most important reason for their decision. Interviews explored factors such as, attitudes about randomisation, and usefulness of the trial information provided.

Results: 41 patients were randomised during feasibility; 20 surgery, 21 active monitoring, 16 patients declined the trial. 40/41(98%) acceptors and 9/16 (56%) decliners completed the CTQ1. The main reason for joining LORIS was:- “I thought the trial offered the best treatment available” 13/40 (32%) and for decling the trial was “The idea of randomisation worried me” (4/9; 44%).

35 interviews were conducted (31/41 (76%) accepted and 4/16 (25%) declined LORIS). At interview acceptors commented that the PIS was very useful and clear (84%; 26/31 & 90%; 28/31, respectively). 74% (23/31) of women who joined LORIS watched the DVD and the majority (19/23; 83%) found it “very useful” and 22 (22/23; 96%) “very easy to understand”. A third of women (10/31) said the PIS and the DVD helped them decide to participate in LORIS. Women who declined the trial had clear treatment preferences; 2/4 did not watch the DVD. Three quarters of women interviewed (19/25) watched the DVD with family members/friends and found it reassuring. One commented it was “Put in words you can understand and not be baffled by”. The most popular aspect was the Q&A session (13/25; 52%).

Conclusions:The LORIS DVD was a useful, easy to understand recruitment tool, complementing the PIS. Many women felt reassured that the content was consistent with, and added to that provided by healthcare professionals. Opinions of family and friends, worries about randomisation and personal preferences exert an influence of those declining these types of trial.

Fallowfield LJ, Jenkins V, et al. (1998) Attitudes of patients to randomised clinical trials of cancer therapy. Eur J Cancer 34(10):1554–1559.

Citation Format: Fallowfield LJ, Matthews L, Jenkins VA, May SF, Francis A, Rae D, Wallis M. Interview data from women contemplating LORIS trial entry during the feasibility study [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr OT3-08-01.

Abstract P4-11-04: Talking about risk in the context of GEomic profiling tests (TARGET)

Background: Risk of recurrence scores from genomic profiling tests such as OncotypeDX® and EndoPredict® are being used increasingly with other clinico-pathologic features to help determine the likely benefit of adjuvant chemotherapy in early stage breast cancer. Decision-making requires the balancing of likely absolute benefits in terms of preventing recurrence versus the treatment related side effects. Health literacy and numeracy skills in the general population are often poor thus explaining risk and uncertainty can be confusing especially when set against a backdrop of fear and anxiety. As clinicians are facing more of these types of conversations with their patients we developed an educational program to help when discussing genomic test results.

Methods: The development of the educational package followed discussions with key clinicians who routinely used genomic profiling tests, clinician-scientists and a review of the risk literature. We mapped out the difficulties they encountered when explaining high, intermediate and low risk test results together with the added challenges faced when communicating with patients with different personality and socio-educational characteristics. As clinicians and their patients may both have a measurable intolerance to uncertainty this may contribute irrespective of the recurrence score (RS) to seemingly irrational decisions about treatment. We rehearsed simulated patients (actors) experienced in improvisation to create different characters and filmed unscripted genomic test result consultations with cancer clinicians. This process proved successful in previous educational initiatives aimed at improving communication about clinical trials. (Jenkins et al 2006; Fallowfield et al 2012).

Results: The educational package comprises an interview with Professor Mitch Dowsett explaining the science behind gene expression profiling tests, a lecture on the psychology of risk with group exercises and strategies on how to communicate together with 5 filmed scenarios with a timecoded facilitator handbook. The scenarios depicted are based on real clinical situations and demonstrate some of the issues discussing RS with low risk patients who nevertheless wish to have chemotherapy as well as high risk patients who are averse to chemotherapy.

Conclusion: Discussions about the logic and rationale behind different treatment recommendations for breast cancer have become increasingly complex. Clinicians need an increased repertoire of communication skills to explain risks and benefits. We are now evaluating the efficacy of TARGET prior to training facilitators to roll the program out.

Citation Format: Fallowfield LJ, Jenkins VA. Talking about risk in the context of GEomic profiling tests (TARGET) [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-11-04.

No man's land: information needs and resources of men with metastatic castrate resistant prostate cancer

The majority of men treated for prostate cancer will eventually develop castrate-resistant disease (CRPC) with metastases (mCRPC). There are several options for further treatment: chemotherapy, third-line hormone therapy, radium, immunotherapy, and palliation. Current ASCO guidelines for survivors of prostate cancer recommend that an individual's information needs at all stages of disease are assessed and that patients are provided with or referred to the appropriate sources for information and support. Earlier reviews have highlighted the dearth of such services and we wished to see if the situation had improved more recently. Unfortunately, we conclude that there is still a lack of good-quality congruent information easily accessible specifically for men with mCRPC and insufficient data regarding the risks, harms, and benefits of different management plans. More research providing a clear evidence base about treatment consequences using patient reported outcome measures is required.

Abstract P1-11-03: Breast cancer trial design may influence recruitment to RCTs

Appreciation of the barriers and drivers affecting enrolment in RCTs is important for future trial design, communication and information provision. Although trials may address pertinent scientific questions, not all RCTs are equally attractive to patients. Many factors influence likely participation and include patients’ perceptions that novel treatments, or more treatment given for longer, must, in the context of life-threat, be better. Lack of awareness of such issues can lead to overly optimistic predictions of likely enrolment numbers and slow recruitment. Speedy completion of RCTs is required for drug approvals and timely introduction of efficacious therapies into clinics. We examined the barriers and drivers affecting recruitment to breast cancer trials in UK women.

Method: As part of an intervention to facilitate effective multidisciplinary team communication about RCTs, patients who had discussed a trial with a doctor and/or research nurse completed study-specific questionnaires. Reasons for either accepting or declining trial entry were explored and patients indicated how strongly 16 separate statements had influenced their decision-making.

Results: 152 women, median age 60, completed questionnaires about their reasons for participation or not in one of 16 different RCTs; 12 of these were chemoprevention, perioperative and adjuvant systemic or radiotherapy trials, 4 were for patients with advanced/metastatic disease. 113/152 (74%) patients consented to enrolment. Overall the primary reason 58/108 (54%) for trial acceptance was altruism- “I feel that others with my illness will benefit from the results of the trial”. Acceptors’ and decliners’ responses to 9/16 statements concerning decisions about trial participation differed significantly (p&lt;0.02). In particular, ‘wanting to help with the doctor's research’ influenced 100% acceptors compared to 61% of decliners (p&lt;0.001). Decliners were more likely to be ‘worried about randomisation’ (38% v 20%; p&lt;0.016) and to ‘want the doctor to choose treatment rather than be randomised’ (49% v 30%; p&lt;0.20). Irrespective of adjuvant or metastatic setting, trial design appeared to influence recruitment.

Table 1: acceptance rates for different trial designsTrial designExampleAcceptanceperioperativePOETIC - 2 weeks perioperative endocrine therapy pre and post-surgery15/18 (83%)standard therapy versus standard + novel drugBETH - chemotherapy and trastuzumab +/- bevacizumab15/19 (79%)standard versus new therapy or regimenPERSPHONE - 12 versus 6 months trastuzumab43/57 (75%)placebo controlledREACT - double blind RCT celecoxib versus placebo29/42 (69%)

Conclusion: A majority of respondents accepted RCT entry citing altruistic motivations as primary drivers for participation. Randomisation is a barrier and needs careful, reassuring justification. Trial design did seem to deter some, especially if one arm appeared to be offering less or no treatment. Explanations that longer treatment durations or regimens that include additional novel drugs may not necessarily enhance outcomes are especially important. Our findings may have implications for trial design, communication and the information provided during trial recruitment.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-11-03.

Abstract PL03: Psychosocial, survivorship issues: Are we doing better?

Extraordinary advances have been made in the past 3 decades in breast cancer treatment. More women have greater prospects of cure or lengthier, good quality survival. Advances include:- improved diagnostic and staging procedures, sophisticated onco-plastic surgery, enhanced radiotherapy techniques and targeted systemic therapies. Much more attention has also been paid to cancer care delivery and access to specialist nurses, counsellors, support groups and services provided by breast cancer charities. It is questionable whether or not these considerable improvements in treatment delivery and outcomes have led to comparable, measurable changes in patients’ psychosocial, functional and sexual well-being. Data are mixed – some reports suggest that psychological morbidity remains high and unremitting whilst others have found a decline over time and little difference from that of age-matched controls without breast cancer. Other research has explored the pre-existing psychosocial factors associated with poor adjustment such as a history of psychological problems and social isolation. Determining healthy long-term adjustment is more than just assessment of psychological morbidity; the impact that non-life threatening, iatrogenic harms of otherwise efficacious anti-cancer treatments has is often over-looked. A concentration on clinician reported safety data in trials rather than patient reported outcomes has hampered research into ameliorative interventions. Systematic monitoring of quality of life-threatening side-effects would permit early implementation of effective interventions and enhance long-term survivorship.

We have known for some time that inadequate communication by health-carers affects adjustment. Communication has arguably become even more difficult given the increasing complexity of modern breast cancer treatment, and the number of therapeutic options available. Just as gross disparities exist in outcomes such as survival between patients in different socio-economic groups, those in lower groups have less time with healthcare professionals, are not confident asking for explanations about care plans and are unlikely to access on-line informational sources or support services.

Nevertheless women's reactions to breast cancer and its treatment vary enormously irrespective of culture or class divides. For some the diagnosis is a catastrophe, irreparably threatening their physical, functional, social, psychological, sexual and occupational well-being. For others it represents yet one more of life's hurdles to overcome together with other social, educational and financial iniquities they face. Consequently, just as with the exciting advent of personalised and targeted medicine, we need similar endeavours producing more individualised psychosocial care; communication should be flexible, adapted to the varying needs of individuals, appropriate screening should enable resources, be that counselling, relaxation therapy, yoga, exercise or mindfulness training to be focussed on those at most risk of the unremitting psychosocial dysfunction that compromises healthy survivorship. Spreading scarce supportive services thinly for all irrespective of their risk of poor adjustment, makes as much sense as administering hormone treatment or trastuzumab without information about receptor status.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr PL03.

Adjuvant chemotherapy in elderly women with breast cancer (AChEW): an observational study identifying MDT perceptions and barriers to decision making

BACKGROUND

As few older women with breast cancer receive adjuvant chemotherapy, we examined the barriers and perceptions of 24 UK NHS multidisciplinary breast cancer teams to offering this treatment to women ≥70 years.

PATIENTS AND METHODS

Questionnaires regarding 803 patients with newly diagnosed breast cancer were completed by specialist teams following discussion or outpatient consultation.

RESULTS

Of 803 patients, 116 (14%), all <85 years, were offered chemotherapy and 66 (8%) received it. Only 94 of 309 (30%) of women with high-risk disease were offered chemotherapy, and 53 (17%) received it. The most common reasons for not offering chemotherapy were 'other treatments more appropriate' (usually patients with ER-positive tumours) or 'benefits too small' (63% and 54% of patients, respectively). Co-morbidities and frailty were less common reasons but became more frequent with increasing age. Recommendations regarding chemotherapy were made in the absence of documented HER2 and performance status in 29% and 33%, respectively. Treatment offered varied considerably between cancer centres.

CONCLUSIONS

National guidelines need development describing the minimally acceptable data for decision making, incorporating objective fitness measures and specific treatment recommendations. Such guidelines will require educational support for implementation but should standardise care and improve chemotherapy uptake in this increasing population of older patients.

Clinical benefit in patients with metastatic bone disease: results of a phase 3 study of denosumab versus zoledronic acid

BACKGROUND

Patients with metastatic bone disease are living longer in the metastatic stage due to improvements in cancer therapy, making strategies to prevent the aggravation of bone disease and its complications, such as skeletal-related events (SREs) and pain, increasingly important.

PATIENTS AND RESULTS

In this phase 3 trial in patients with advanced cancer (excluding breast and prostate cancer) or multiple myeloma, denosumab reduced the risk of radiation to bone by 22% relative to zoledronic acid (P = 0.026), prevented worsening of pain and pain interference (2-point increase in Brief Pain Inventory score; P < 0.05 versus zoledronic acid), and reduced the frequency of a shift from no/weak opioid analgesic use to strong opioids (P < 0.05 versus zoledronic acid at months 3-5). Denosumab delayed the time to moderate-to-severe pain compared with zoledronic acid in patients with mild or no pain at the baseline (P = 0.04), supporting early treatment. Health-related quality-of-life scores were similar in both groups. The number needed to treat to avoid one SRE for denosumab was 3 patient-years versus placebo and 10 patient-years versus zoledronic acid.

CONCLUSION

The use of denosumab was associated with better prevention of the complications of metastatic bone disease secondary to solid tumors or multiple myeloma versus zoledronic acid.

Long-term assessment of quality of life in the Intergroup Exemestane Study: 5 years post-randomisation

BACKGROUND

The Intergroup Exemestane Study (IES) (ISRCTN11883920) demonstrated improved survival for postmenopausal women with ER-positive/unknown primary breast cancer who switched to exemestane after 2-3 years tamoxifen, compared with those continuing on tamoxifen to complete 5 years therapy. This was achieved without detriment to on-treatment quality-of-life (QoL). We report on- and post-treatment QoL impact in IES.

METHODS

A total of 582 patients from 8 countries participated in the QoL substudy. Functional Assessment of Cancer Therapy-Breast (FACT-B) and endocrine symptom subscale (ES) were completed at baseline, 3, 6, 9, 12, 18, 24, 30, 36, 48 and 60 months. The primary endpoint was FACT-B Trial Outcome Index (TOI); secondary endpoints included severity of individual endocrine symptoms.

RESULTS

Both the groups showed gradual improvement in overall QoL and lessening of total endocrine symptoms post treatment compared with baseline (P<0.002). There was no evidence of any between-group differences in TOI. Vasomotor complaints remained high on treatment. Vaginal discharge was more frequent (P<0.01) with tamoxifen up to 24 months from baseline. In both the groups, post-treatment libido did not recover to baseline levels.

CONCLUSION

Clinical benefits of switching to exemestane are accompanied by good overall QoL. Although some symptoms persist, the majority of endocrine symptoms improve after treatment completion.

Quality of life and patient-reported outcomes in the older breast cancer patient

As the world population ages, the incidence of cancer will probably also increase as it is a disease predominantly affecting older people. However, those aged 70 years or more have largely been excluded from clinical trials. This review focuses on breast cancer. Increasingly there is recognition that many older breast cancer patients are being undertreated and could and should be offered the same treatments as younger patients. Comprehensive assessment of the quality of any survival benefit from treatments is also needed to ensure that in the future older patients can make fully informed decisions about their treatment options. The aim of this overview is two-fold: first to describe methods by which to assess quality of life; and second to review the recent surgical, radiotherapy, chemotherapy and other studies that include such assessment with older breast cancer patients. Current studies are also outlined, including quality of life assessments, and recommendations are made for future research in this area.

WITHDRAWN: A qualitative study looking at the psychosocial implications of bilateral prophylactic mastectomy

The publisher regrets that this is an accidental duplication of an article that has already been published in The Breast, 12 (2003) 1-9, doi:10.1016/S0960-9776(02)00135-2. The duplicate article has therefore been withdrawn.

Survival and safety of exemestane versus tamoxifen after 2-3 years' tamoxifen treatment (Intergroup Exemestane Study): a randomised controlled trial

BACKGROUND

Early improvements in disease-free survival have been noted when an aromatase inhibitor is given either instead of or sequentially after tamoxifen in postmenopausal women with oestrogen-receptor-positive early breast cancer. However, little information exists on the long-term effects of aromatase inhibitors after treatment, and whether these early improvements lead to real gains in survival.

METHODS

4724 postmenopausal patients with unilateral invasive, oestrogen-receptor-positive or oestrogen-receptor-unknown breast cancer who were disease-free on 2-3 years of tamoxifen, were randomly assigned to switch to exemestane (n=2352) or to continue tamoxifen (n=2372) for the remainder of a 5-year endocrine treatment period. The primary endpoint was disease-free survival; overall survival was a secondary endpoint. Efficacy analyses were intention-to-treat. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN11883920.

RESULTS

After a median follow-up of 55.7 months (range 0-89.7), 809 events contributing to the analysis of disease-free survival had been reported (354 exemestane, 455 tamoxifen); unadjusted hazard ratio 0.76 (95% CI 0.66-0.88, p=0.0001) in favour of exemestane, absolute benefit 3.3% (95% CI 1.6-4.9) by end of treatment (ie, 2.5 years after randomisation). 222 deaths occurred in the exemestane group compared with 261 deaths in the tamoxifen group; unadjusted hazard ratio 0.85 (95% CI 0.71-1.02, p=0.08), 0.83 (0.69-1.00, p=0.05) when 122 patients with oestrogen-receptor-negative disease were excluded.

CONCLUSIONS

Our results suggest that early improvements in disease-free survival noted in patients who switch to exemestane after 2-3 years on tamoxifen persist after treatment, and translate into a modest improvement in overall survival.

Postmenopausal women undergoing transvaginal ultrasound screening prefer not to have chaperones

The Royal College of Radiologists has recommended chaperones of the appropriate gender for those undergoing intimate scans. This has significant implications for clinical and research programmes. Two hundred and fifty women undergoing scanning in a screening trial were sent postal questionnaires to determine their views as to the presence of chaperones and the gender of ultrasonographers. Ninety-five percent of 198 women stated that they would not like another person to be present during transvaginal scanning. Of greater consequence to women was the gender of the ultrasonographer, with 83.3% expressing a preference for a female ultrasonographer. This needs to be considered in making decisions about allocation of scarce resources.

Communication and informed consent in phase 1 trials: a review of the literature

Phase 1 (P1) trials are vital to the development of cancer treatments; however, the patients involved in these trials are unlikely to receive any therapeutic benefit, and there are significant possibilities that they will experience serious side effects. Ethical requirements stipulate that patients must be adequately informed before they consent to participate in P1 trials. This review focuses on studies that have measured patient comprehension of information given during the informed consent process of P1 cancer trials. Patients consenting to participate in P1 trials currently have a limited understanding of trial purpose, an unrealistic expectation of the benefits and risks associated with trial participation and a questionable appreciation of their right to abstain or withdraw. Health care professionals recruiting to P1 trials need clear and practical guidelines and training packages designed to ensure that all details of P1 trials are communicated effectively to eligible patients.

Patients' preferences for adjuvant endocrine therapy in early breast cancer: what makes it worthwhile?

Adjuvant endocrine therapy improves recurrence and survival rates, but has side effects and is inconvenient. The aim of this study was to determine the preferences of premenopausal women who had adjuvant endocrine therapy in a randomised trial. In all, 85 (or eighty-five) women completed semistructured interviews 6–30 months after finishing adjuvant endocrine therapy. Hypothetical scenarios based on known potential survival times (5 or 15 years) and rates (60% or 80% at 5 years) without adjuvant endocrine therapy were used to determine the smallest gains women judged necessary to make their adjuvant endocrine therapy worthwhile. Although a third of the women considered gains of 1% in survival rates or 6 months in survival times sufficient to make their adjuvant endocrine therapy worthwhile, more than half the women required gains of at least 5% in survival rates or 3 years in survival time as necessary to make adjuvant endocrine therapy worthwhile. Larger benefits were required by women who had longer treatment, worse side effects, and by those who were treated with goserelin alone. The route of administration (tablet vs injection) did not affect preferences and some women judged small benefits sufficient to make their adjuvant endocrine therapy worthwhile, but many women required larger benefits than their counterparts in similar studies of preferences for adjuvant chemotherapy.

A qualitative study looking at the psychosocial implications of bilateral prophylactic mastectomy

The study objective was to explore the attitudes and beliefs of women at high risk of developing breast cancer who accepted or declined bilateral prophylactic mastectomy (BPM). This qualitative study employed semi-structured interviews of 60 women who opted for BPM and 20 women who declined. Interviews took place in the women's own homes. Qualitative analysis led to the generation of a number of categories that provided conceptualisation of the women's primary experiences. These categories included: anxiety; surgery; sexual impact; information; gene testing; reconstruction and support. The study revealed that there is a clear need for information to be written specifically for this patient group and that emotional support for high-risk women offered BPM should be provided.

Truth may hurt but deceit hurts more: communication in palliative care

Healthcare professionals often censor their information giving to patients in an attempt to protect them from potentially hurtful, sad or bad news. There is a commonly expressed belief that what people do not know does not harm them. Analysis of doctor and nurse/patient interactions reveals that this well-intentioned but misguided assumption about human behaviour is present at all stages of cancer care. Less than honest disclosure is seen from the moment that a patient reports symptoms, to the confirmation of diagnosis, during discussions about the therapeutic benefits of treatment, at relapse and terminal illness. This desire to shield patients from the reality of their situation usually creates even greater difficulties for patients, their relatives and friends and other members of the healthcare team. Although the motivation behind economy with the truth is often well meant, a conspiracy of silence usually results in a heightened state of fear, anxiety and confusion--not one of calm and equanimity. Ambiguous or deliberately misleading information may afford short-term benefits while things continue to go well, but denies individuals and their families opportunities to reorganize and adapt their lives towards the attainment of more achievable goals, realistic hopes and aspirations. In this paper, some examples and consequences of accidental, deliberate, if well-meaning, attempts to disguise the truth from patients, taken verbatim from interviews, are given, together with cases of unintentional deception or misunderstandings created by the use of ambiguous language. We also provide evidence from research studies showing that although truth hurts, deceit may well hurt more. 'I think the best physician is the one who has the providence to tell to the patients according to his knowledge the present situation, what has happened before, and what is going to happen in the future' (Hippocrates).

The impact of endocrine therapy on patients with breast cancer: a review of the literature

This paper reviews studies which have examined the impact of endocrine therapy on the quality of life (QOL) of patients with breast cancer. In patients with primary disease, published studies suggest that endocrine therapies, such as tamoxifen, significantly increase both gynaecological and vasomotor symptoms. However, few studies have been able to demonstrate the impact which these symptoms have on patients' QOL. This failure can be partially attributed to a range of methodological problems. Psychosocial research in advanced disease has largely consisted of randomized controlled studies with QOL as one of several study endpoints. Second generation treatments, such as aromatase inhibitors, have frequently been compared with older treatments, such as progestin therapies. Unfortunately, QOL data reported in these studies have tended to be fairly limited. Problems with existing QOL research in endocrine treatment are discussed and recommendations are made for further work.

The psychological impact of post-operative arm morbidity following axillary surgery for breast cancer: a critical review

In this paper we review the published research that has investigated the psychological impact of arm morbidity associated with axillary dissection for early breast cancer. This critique is particularly timely given the drive towards minimally invasive techniques, such as sentinel node biopsy, which aim to reduce the incidence and severity of post-operative arm problems. Reported symptoms are multifactorial and include numbness, pain, swelling, weakness/stiffness, and restricted shoulder mobility of the affected arm. Conclusions from the few studies that have investigated the severity, incidence, duration and psychological impact of such disability are often limited by methodological problems. We identify these limitations and examine assessment tools used to determine the psychological impact of lymphoedema. The paper highlights the need for methodological rigor in study design, and the careful selection of appropriate, sensitive, reliable and clinically meaningful outcome measures to evaluate the impact of post-operative arm morbidity.

Tolerability of hormone therapies for breast cancer: how informative are documented symptom profiles in medical notes for 'well-tolerated' treatments?

Hormonal therapies for cancer are often viewed as a gentler option than many other cancer treatments, but is low toxicity an accurate perception of patients' experiences? Side effects tend to be described as minimal or well tolerated, yet published symptoms from hormonal therapy vary considerably in their descriptions and frequencies. Previous research has highlighted under-reporting of side effects by clinical staff so as part of a wider study examining tamoxifen and goserelin treatment as adjuvant therapy for breast cancer, treatment-related symptoms documented in medical notes were compared with those that patients reported during a research interview. There was a significant difference in the frequency of many side effects reported by the two methods in this study. Sixty four out of 72 (89%) women who had received adjuvant tamoxifen or goserelin had side effects recorded in their medical notes, compared with 74/75 (99%) reporting side effects at interview. We compared the published frequencies of commonly reported symptoms with those found ourselves. The discrepancies between patient-reported and clinician-recorded (usually from clinical trial data) symptom profiles were similar to those found in our study. Without accurate comprehensive side effect profiles for hormone therapies, prospective patients cannot make informed judgements on proposed treatments.

The validation of a quality of life scale to assess the impact of arm morbidity in breast cancer patients post-operatively

This paper documents the validation of a quality of life scale (QOL) designed to assess the impact of arm morbidity on patients following breast cancer surgery. A four item arm subscale was developed to supplement a multi-dimensional, validated breast cancer QOL tool, the functional assessment of cancer therapy (FACT-B.) The new questionnaire, the FACT-B + 4, was validated on 279 women participating in a trial of sentinel node guided axillary therapy and 29 women attending a lymphoedema clinic. The subscale demonstrated good internal consistency (alpha co-efficient = 0.62 to 0.88) and stability (test-retest reliability = 0.97). Lymphoedema patients reported significantly greater arm problems than a matched sample of pre-operative trial participants. The lymphoedema group also scored lower than trial patients on the FACT-B + 4 indicating a poorer quality of life (p < 0.05). A subset of 66 trial patients who had completed three consecutive assessments was used to evaluate the sensitivity of the questionnaire to change over time. Scores on the FACT-B + 4 were found to decline significantly between the pre-operative assessment and post-operative assessment at 1 month. Arm problems significantly increased during this period. FACT-B + 4 score increased again from 1 month to 12 weeks post-surgery and symptoms reduced, as the extent of arm morbidity resolved. The FACT-B + 4 appears to be psychometrically robust and sensitive to patient rehabilitation, making it suitable for use in longitudinal surgical trials. Given the dearth of existing scales available to measure arm morbidity, we hope this new tool will prove useful to researchers.

Are members of multidisciplinary teams in breast cancer aware of each other's informational roles?

AIM

To conduct a commissioned survey of multidisciplinary breast team members' expectations of their own and each other's roles in providing different kinds of information to women with breast cancer.

DESIGN

Questionnaire based survey.

SETTING AND PARTICIPANTS

Health professionals from five multidisciplinary breast care centres within a Sussex health authority.

MAIN OUTCOME MEASURES

Interdisciplinary awareness of informational roles played by different team members.

RESULTS AND CONCLUSIONS

The results of the team survey suggest that, in most cases, health professionals fulfilled the roles expected of them by the team, with two or three individuals identified as the main providers of information for each topic. However, many more professionals were involved in major discussions without the team's knowledge. The professional consistently playing a major "unseen" role was the breast nurse specialist.

How do doctors explain randomised clinical trials to their patients?

As part of a larger study designed to improve doctor-patient communication in randomised clinical trials (RCT), we audiotaped the discussions between doctor and patient in which consent was being obtained for a RCT. This paper reports on 82 discussions conducted by 5 clinical oncologists in both District General and University Hospital outpatient departments. When introducing the subject of trials, uncertainty about treatment decisions was expressed by the doctors in the majority of cases (79, 96.3%). This was most often stated in a general sense (78, 95.1%), but some mentioned personal uncertainty (12, 14.6%), an approach which helps to maintain a trusting doctor-patient relationship. The word randomization was mentioned in 51 (62.2%) consultations, although the process itself was usually described implicitly (78, 95.1%), e.g. by telling the patient that they would be allocated either one or other treatment. Analogies were used in 28 (34.1%) cases to describe the randomisation process. In addition, although treatments and side-effects were described frequently, (68, 82.9%) and (72, 87.8%) respectively, information leaflets about the trials were not given to 23 (28%) patients. The study shows that U.K. clinicians adopt individual methods when providing information and eliciting consent to trials.

Assessment of quality of life in women undergoing hormonal therapy for breast cancer: validation of an endocrine symptom subscale for the FACT-B

Existing quality of life instruments do not include adequate items to measure the side effects and putative benefits of hormonal treatments given in breast cancer. We report the development and validation of an 18 item endocrine subscale (ES) to accompany a standardised breast cancer quality of life measure, the Functional Assessment of Cancer Therapy (FACT-B). The FACT-ES (FACT-B plus ES) was tested initially on 268 women with breast cancer receiving endocrine treatments. Alpha coefficients for all subscales demonstrated good internal consistency (range alpha = 0.65-0.87). Test-retest reliability of the ES indicated good stability (r = 0.93, p < 0.001). Advanced breast cancer patients' quality of life was high, showing the efficacy of endocrine therapy, but women with primary disease reported better physical, social, and functional well-being and fewer breast cancer concerns. Most frequently reported symptoms were loss of sexual interest (31%), weight gain (25%), and hot flushes (24%). Significant differences were found between treatment groups for hot flushes and vaginal dryness. Two assessments of the instrument's responsiveness to change were made; 32 women in a clinical trial of endocrine therapy and 18 women without breast cancer taking HRT completed the FACT-ES at baseline, 4, 8, and 12 weeks. Trial patients reported significantly more symptoms at 8 and 12 weeks than at baseline. Women taking HRT reported significantly fewer or less severe symptoms than at baseline. In conclusion the FACT-ES has acceptable validity and reliability and is sensitive to clinically significant change, making it suitable for clinical trials of endocrine therapy.

Sexual activity questionnaires in clinical trials: acceptability to patients with gynaecological disorders

OBJECTIVE

To assess the feasibility and acceptability of including sexual activity questionnaires in gynaecological clinical trials.

DESIGN

A longitudinal quality of life study during the Maintenance Interferon Trial and the EVALUATE Hysterectomy Trial.

SETTING

Gynaecology clinics and women's homes.

SAMPLE

Ninety-six women with advanced ovarian cancer participating in the Maintenance Interferon Trial and 542 women undergoing a hysterectomy in the EVALUATE Hysterectomy Trial.

METHODS

Quality of life questionnaires, including the sexual activity questionnaire, were completed by women prior to randomisation and periodically after randomisation.

MAIN OUTCOME MEASURES

Compliance rates of the sexual activity questionnaire, both overall and with respect to the level of sexual functioning and age of the women. Attitudes of the women towards completing the questionnaire, and suitability of using the sexual activity questionnaire in clinical trials.

RESULTS

Compliance rates of over 80% were achieved in both trials, both overall and for each questionnaire completed. The age of the woman did not appear to influence the completion of the questionnaire, nor did her level of sexual functioning. Women were supportive of the research and did not find the questionnaire intrusive.

CONCLUSIONS

It is feasible to include sexual activity questionnaires in gynaecological clinical trials requiring repeated assessment of quality of life over a long period of time. The sexual activity questionnaire is an appropriate tool to carry out investigations of sexual functioning and is worth considering for use in future clinical trials.

Attitudes of patients to randomised clinical trials of cancer therapy

The aim of this study was to test an instrument which might be useful for doctors in explaining the randomisation procedure to an individual patient. The sample comprised 323 patients with cancer attending for out-patient appointments and/or chemotherapy treatment in two major cancer centres in the U.K. 315 patients completed a self-report questionnaire--The Attitudes to Randomised Trials Questionnaire (ARTQ). The results show that the majority of subjects 287 (91.1%) believe that patients should be asked to take part in medical research, but only 242 (76.8%) would be prepared to take part in a study comparing two treatments. If treatment was randomised, only 141 (44.8%) would agree to participate. When given further information about the randomisation procedure, 119 (68.4%) of the 174 (55.2%) who initially said 'no' to randomisation or who were unsure, would change their minds and take part in a trial. The ARTQ discriminated between three categories of patient with the following prevailing attitudes: (a) those who seem comfortable with the concept of randomisation; (b) those with some concerns, who with fuller explanation are prepared to consider randomisation; and (c) those firmly against randomisation and participation in trials whatever information is provided. Prior knowledge of patients' attitudes might assist communication about trials and encourage more doctors to approach eligible patients.

Assessment of quality of life in breast cancer

Effective treatment for breast cancer can produce a reasonably good ten-year survival rate in comparison to many other cancer sites. Nevertheless, the potential psychological, sexual and physical dysfunction caused by both the diagnosis and treatments can have a deleterious impact on the quality of a woman's life. The range of possible treatments may have similar outcomes in terms of response and survival, but can produce very different effects on emotional well-being. Therefore, monitoring quality of life in breast cancer should be a mandatory part of follow-up in clinical trials. Data derived from various studies of quality of life can also be used to assist the doctor and patient in decision-making about treatment options. Furthermore, assessment of quality of life can help identify those patients who might profit from psychosocial interventions. In this paper some of the instruments used to assess quality of life in breast cancer will be discussed.

A daily diary for quality of life measurement in advanced breast cancer trials

The Qualitator is a daily diary card to measure Quality of Life, developed for use in chemotherapy trials for patients with advanced breast cancer. In a trial at King's College Hospital, 29 patients completed the Qualitator and their scores were compared with scores in the Linear Analogue Self-Assessment and Nottingham Health Profile taken four-weekly. In a separate study at Guy's Hospital, 31 patients completed the diary. The Qualitator offers accurate prognostic data regarding subsequent UICC response and survival and is simple to use.

Combination or mild single agent chemotherapy for advanced breast cancer? CMF vs epirubicin measuring quality of life

Forty patients with advanced breast cancer, randomised to receive CMF or weekly low dose Epirubicin, were evaluated by UICC criteria of response and WHO toxicity criteria, in addition to three QoL instruments: the 'Qualitator' daily diary card, 4 weekly Nottingham Health Profile (NHP) and Linear Analogue Self-Assessment (LASA). Response rates were 58% for CMF and 29% for epirubicin (chi 2 = 3.51, 1 d.f., P > 0.05). Median time to treatment failure was 24 weeks for CMF, 7 weeks for epirubicin (P < 0.05) but survival was similar in both groups. Survival was better for responders than for non-responders (medians 87 and 30 weeks, P = 0.02). CMF caused more objective alopecia (P < 0.001), nausea and vomiting (P < 0.001) and haematological toxicity (P < 0.02). However, QoL measures only recorded a significant difference in energy and pain, influenced primarily by the non-responders in each treatment group but with no difference in overall global scores. Scores for responders, irrespective of treatment, were better to start with (LASA P = 0.001); at 12 weeks, scores had improved (Qualitator P < 0.05; NHP P < 0.05). Scores in non-responders showed no change. In this small study aggressive chemotherapy gave better response and similar survival without impairing Quality of life overall. Detailed QoL measurement should be integral to all cancer chemotherapy trials.

Quality of life measurement in breast cancer

Appropriate assessment of quality of life parameters should be a mandatory requirement when determining the outcome of different treatments for breast cancer. Such measures provide useful, sometimes counterintuitive information concerning treatment costs and benefits and can help guide the clinician with management decisions. It is important to choose well-validated measures of quality of life to enable comparison between studies assessing the impact of different therapeutic modalities and psychosocial interventions.

Behavioural interventions and psychological aspects of care during chemotherapy

Numerous studies have reported the deleterious impact that the side effects of cytotoxic chemotherapy can exert on the quality of life in patients with cancer. Nausea and vomiting consistently feature as the most distressing aspects of cancer therapy. Uncontrolled emesis can cause patients to abandon treatment and the poor public image of chemotherapy may lead others to refuse treatment altogether. Anticipatory nausea and vomiting can also develop in patients and this may persist for many years after successful completion of treatment. There are several behavioural interventions that are effective in ameliorating or preventing these unpleasant side effects. Consequently, psychological support should be provided as an integral part of good patient management, alongside appropriate antiemetic and anxiolytic drugs. As we can identify the characteristics of those patients more at risk from severe emesis and the development of anticipatory problems, there are good arguments for the most effective drug therapy (rather than the cheapest) being given to them prophylactically, together with relaxation techniques.

Psychosocial and sexual impact of diagnosis and treatment of breast cancer

Psychosocial and sexual disturbances are common sequelae to a diagnosis of breast cancer and its treatment. The intuitively plausible hope that the advent of breast conserving techniques would prevent the psychological distress experienced following mastectomy has not been realised. Studies comparing psychosocial outcome of mastectomy with lumpectomy and radiotherapy reveal some advantage to women treated with breast conserving procedures in terms of body image, but very little difference in terms of psychiatric morbidity or sexual dysfunction. Whatever the primary therapy, women must still confront the fact that they have had cancer, a life-threatening disease which may recur. In this chapter the research comparing psychological outcome between mastectomy and lumpectomy is critically reviewed and the implications that these data have for clinical practice are discussed.

Psychological outcomes of different treatment policies in women with early breast cancer outside a clinical trial

OBJECTIVES

To assess outside a clinical trial the psychological outcome of different treatment policies in women with early breast cancer who underwent either mastectomy or breast conservation surgery depending on the surgeon's opinion or the patient's choice. To determine whether the extent of psychiatric morbidity reported in women who underwent breast conservation surgery was associated with their participation in a randomised clinical trial.

DESIGN

Prospective, multicentre study capitalising on individual and motivational differences among patients and the different management policies among surgeons for treating patients with early breast cancer.

SETTING

12 District general hospitals, three London teaching hospitals, and four private hospitals.

PATIENTS

269 Women under 75 with a probable diagnosis of stage I or II breast cancer who were referred to 22 different surgeons.

INTERVENTIONS

Surgery and radiotherapy or adjuvant chemotherapy, or both, depending on the individual surgeon's stated preferences for managing early breast cancer.

MAIN OUTCOME MEASURES

Anxiety and depression as assessed by standard methods two weeks, three months, and 12 months after surgery.

RESULTS

Of the 269 women, 31 were treated by surgeons who favoured mastectomy, 120 by surgeons who favoured breast conservation, and 118 by surgeons who offered a choice of treatment. Sixty two of the women treated by surgeons who offered a choice were eligible to choose their surgery, and 43 of these chose breast conserving surgery. The incidences of anxiety, depression, and sexual dysfunction were high in all treatment groups. There were no significant differences in the incidences of anxiety and depression between women who underwent mastectomy and those who underwent lumpectomy. A significant effect of surgeon type on the incidence of depression was observed, with patients treated by surgeons who offered a choice showing less depression than those treated by other surgeons (p = 0.06). There was no significant difference in psychiatric morbidity between women treated by surgeons who offered a choice who were eligible to choose their treatment and those in the same group who were not able to choose. Most of the women (159/244) gave fear of cancer as their primary fear rather than fear of losing a breast. The overall incidences of psychiatric morbidity in women who underwent mastectomy and those who underwent lumpectomy were similar to those found in the Cancer Research Campaign breast conservation study. At 12 months 28% of women who underwent mastectomy in the present study were anxious compared with 26% in the earlier study, and 27% of women in the present study who underwent lumpectomy were anxious compared with 31% in the earlier study. In both the present and earlier study 21% of women who underwent mastectomy were depressed, and 19% of women who underwent lumpectomy in the present study were depressed compared with 27% in the earlier study.)

CONCLUSIONS

There is still no evidence that women with early breast cancer who undergo breast conservation surgery have less psychiatric morbidity after treatment than those who undergo mastectomy. Women who surrender autonomy for decision making by agreeing to participate in randomised clinical trials do not experience any different psychological, sexual, or social problems from those women who are treated for breast cancer outside a clinical trial.

Psychosocial adjustment after treatment for early breast cancer

Psychosocial and sexual disturbances are common sequelae to a diagnosis of breast cancer and its treatment. The hope that the development of breast-conserving techniques would protect women from the psychological distress experienced after mastectomy has not been realized. Studies comparing the psychosocial outcome of mastectomy with lumpectomy and radiotherapy reveal an advantage of the breast-conservation groups in terms of body image, but little difference in terms of psychiatric morbidity. Whatever the primary therapy, women still have to confront the fact that they have had cancer, a life-threatening disease which may recur. It is therefore most important that, irrespective of the treatment offered, we improve our understanding of the premorbid personality characteristics and sociodemographic factors that may predispose certain women to failure of adjustment following a diagnosis of breast cancer.