Quality of life among patients with primary, metastatic and recurrent cancer.

Diagnosis of cancer is an emotionally traumatic event that significantly impacts the quality of life (QoL) of the patients. Progression to metastasis or recurrence of cancer after first diagnosis poses a greater threat to life that further increases this emotional trauma and can worsen the QoL. In this research we sought to explore the differences in QoL (symptom severity and physical functioning) experienced by primary non-metastatic (PNM), primary metastatic (PM) and recurrent (RC) cancer patients. Cancer patients recruited in two cognitive intervention trials formed the sample for this analysis. Data were analysed using longitudinal mixed models, with two interaction terms. Least square means were calculated and compared. Over the period of study RC patients reported the worst symptom severity and physical function followed by PM and PNM patients. Primary non-metastatic patients showed a steady decline in severity whereas PM and RC showed slight gains after the first follow-up. Primary non-metastatic patients displayed best physical functioning followed by PM and RC patients, and remained stable over time. Breast cancer patients displayed most variation in symptom severity among the three progression groups, whereas significant variation in physical function among the three groups was observed within all cancer sites.

Predictors of use of health care services among elderly lung cancer patients: the first year after diagnosis.

In this study, we investigated predictors of utilization of physician, hospital, and emergency room services in a sample of 277 elderly patients during the first year following a diagnosis of lung cancer. Data were obtained by a combination of patient interview and patient self-administered questionnaire at four intervals: baseline (wave 1), 3 months (wave 2), 6 months (wave 3), and 12 months (wave 4). Of the 277 patients, 242 provided data at wave 1, 209 at wave 2, 157 at wave 3, and 115 at wave 4. Symptomatology was assessed with the Symptom Experience Scale (simple count of symptoms present, chosen from a list of 37 cancer-related symptoms), and physical functioning was assessed with the Medical Outcomes Study 36-Item Short Form Health Survey. Analysis of covariance models were implemented separately for the active treatment period (0-6 months) and the continuing care period (6-12 months) to determine how age, gender, comorbidity, length of survival, treatment status, stage of disease, cancer site, physical functioning, and symptom count were related to physician visits, nights in hospital, and emergency room visits. During the active treatment period, patients with worse physical functioning reported more hospital nights (p=0.002) and more emergency room visits (p=0.013), while men reported more frequent emergency room visits (p=0.032) and more nights in hospital (p=0.006) than women. Patients reporting more symptoms also reported more physician visits (p=0.020). During the continuing care period, physical functioning had a similar relation to hospital nights (p=0.005) and emergency room visits (p=0.003), and patients with late-stage disease reported more physician visits than patients with early-stage disease (p=0.003).

Primary malignant brain tumor incidence and Medicaid enrollment.

BACKGROUND: The relationship between socioeconomic status and health care disparities in the incidence of brain tumors is unclear. OBJECTIVE: To identify the associations between age, sex, and Medicaid enrollment and the incidence of primary malignant brain tumors in Michigan in 1996 and 1997. METHODS: Records were obtained from the Michigan Cancer Surveillance Program on the 1,006 incident cases during this period and cross-checked with Medicaid enrollment files. RESULTS: Persons enrolled in Medicaid were more likely than non-enrolled persons to develop a malignant brain tumor of any type, a glioblastoma multiforme, and an astrocytoma for certain subgroups. In addition, incidence rates for malignant brain tumors in persons enrolled in Medicaid peaked at a younger age. CONCLUSION: Sociodemographic status may be associated with cerebral malignancy and should be considered when targeting treatment and educational interventions at persons at risk.

Predictors of depressive symptomatology of geriatric patients with colorectal cancer: a longitudinal view.

Colorectal cancer constitutes a major health problem for elderly patients. The disease and its stage, treatment, and attendant symptoms can have significant negative impact on the mental functioning of these patients. As part of a larger longitudinal study, 158 patients 65 years of age or older with an incident diagnosis of colorectal cancer were recruited from 23 sites within a Midwestern state. Random effects regression analysis techniques were used to analyze how age, gender, race, presence of a family caregiver, co-morbid conditions, stage of disease at diagnosis, and the time-dependent variables marital status, employment status, symptoms, physical functioning, social functioning, and treatment predict depressive symptomatology at four assessments over the 1st year following diagnosis. Gender, race, co-morbid conditions, physical functioning, social functioning, and symptoms were significant predictors of depressive symptomatology over the four waves of the study. Female patients, African Americans, and patients with two or more co-morbid conditions exhibited more depressive symptomatology. Both more symptoms and more restricted physical and social functioning corresponded to higher levels of depressive symptomatology. At a clinical level of patient care, these findings mandate early identification of psychosocial difficulties experienced, an individualized symptom management plan and the application of other interventions, such as information giving, reassurance and referral to other resources, with particular attention to African American and female patients.

Predictors of depressive symptomatology of geriatric patients with lung cancer-a longitudinal analysis.

BACKGROUND: Lung cancer is a major health problem throughout the world. It is the leading cause of cancer-related death in men and women in the USA, with a 5-year survival rate of only 14%. It has been hypothesized that variables such as physical and social functioning, cancer-related symptomatology, comorbid conditions, cell type, and treatment are valid predictors of the psychological response to a diagnosis of lung cancer. METHODS: As part of a larger longitudinal study, 211 patients, 65 years of age or older, with an incident diagnosis of lung cancer, were recruited from 23 sites within a midwestern state. Repeated measures analysis of variance techniques were used to analyse how age, gender, comorbid conditions, stage of disease, cell type, as well as the time-dependent variables symptoms, physical functioning, social functioning, and treatment predict depressive symptomatology at four assessments over the first year following diagnosis. RESULTS: Social functioning (p<0.0001), symptoms severity (p<0.0001) and radiation treatment (p=0.017) were significant predictors of depressive symptomatology, with more symptoms and more restricted social functioning generally corresponding to higher levels of depressive symptomatology. Patients who had not received radiation treatment were more depressed than those who had received treatment at least 40 days prior to the interview. CONCLUSIONS: At a clinical level of patient care, these findings mandate early identification of psychosocial difficulties experienced, an individualized symptom management plan and the application of other interventions, such as information giving, reassurance and referral to other resources.

Research design and subject characteristics predicting nonparticipation in a panel survey of older families with cancer.

BACKGROUND: While recognized that loss of subjects over time may introduce bias and complicate statistical analysis in panel studies, it is seldom acknowledged that sampling bias starts with subjects who are eligible but do not participate. OBJECTIVES: Community-based recruiters identified 1,948 subjects as eligible to participate in a descriptive panel survey of older families with cancer. Focusing on the time between identification of eligible subjects until contact for the first interview for consenting subjects, the purpose of this study was to determine if subject or research design factors predicted who was more prone to nonparticipation. METHOD: A multivariate model explored the simultaneous effects of subject and research design characteristics on nonparticipation. Demographic and cancer characteristics, as well as features of the study protocol, were used as predictors in a multinomial logit regression model to enable a three-way comparison between nonconsenters (n = 748), consenters who dropped out prior to data collection (n = 208), and consenters who participated in the intake interview (n = 992). RESULTS: Age and cancer diagnosis played roles in whether consent was obtained, whereas race did not affect consent but raised odds of drop out after consent. Powerful evidence emerged that design features, such as if a caregiver participated, recruitment staff roles, and payment to recruiters, affected the probability of subjects not participating or dropping out before being interviewed. CONCLUSIONS: Findings suggest that both subject and research design characteristics affect the likelihood of nonparticipation in a panel study of older cancer patients and family caregivers. Future research involving testing of strategies addressing access and accrual issues, research staff roles, reimbursements, and responsiveness to the needs of research personnel, ill participants, and family members is warranted.

Family support in advanced cancer.

Changes in the health care system have resulted in a shift of cancer care from the in-patient arena to ambulatory and home settings. This shift has likewise translated into increased family involvement in the day-to-day care of the person with cancer. Cancer patients have multifaceted needs, including disease and treatment monitoring, symptom management, medication administration, emotional support, assistance with personal care, and assistance with instrument care. Family caregivers may be ill prepared to assume these tasks, requiring information on the disease and treatment, as well as instruction in technical and care skills. Moreover, caregiving must be balanced against already established roles and role responsibilities. In addition, family caregivers have their own emotional responses to the patients' diagnosis and prognosis, and may require coaching and emotional support themselves. The health care system can facilitate positive outcomes by embracing the family caregiver as a partner in the health care team, providing instruction and guidance to the caregiver as he/she assumes this role, and evaluating the home care situation. Research to date has only scratched the surface of testing interventions that meet the needs of the cancer caregiver. A research agenda is proposed to more fully elucidate the cancer caregiver's experience throughout the illness and treatment trajectory, and identify the means to effecting positive outcomes for the person with cancer, their family caregiver, and the health care system.

Screening for high utilizing somatizing patients using a prediction rule derived from the management information system of an HMO: a preliminary study.

BACKGROUND: Somatization is a common, costly problem with great morbidity, but there has been no effective screening method to identify these patients and target them for treatment. OBJECTIVES: We tested a hypothesis that we could identify high utilizing somatizing patients from a management information system (MIS) by total number of visits and what we termed "somatization potential," the percentage of visits for which ICD-9 primary diagnosis codes represented disorders in the musculoskeletal, nervous, or gastrointestinal systems or ill-defined complaints. METHODS: We identified 883 high users from the MIS of a large staff model HMO as those having six or more visits during the year studied (65th percentile). A physician rater, without knowledge of hypotheses and predictors, then reviewed the medical records of these patients and identified somatizing patients (n = 122) and nonsomatizing patients (n = 761). In two-thirds of the population (the derivation set), we used logistic regression to refine our hypothesis and identify predictors of somatization available from the MIS: demographic data, all medical encounters, and primary diagnoses made by usual care physicians (ICD-9 codes). We then tested our prediction model in the remaining one-third of the population (the validation set) to validate its usefulness. RESULTS: The derivation set contained the following significant correlates of somatization: gender, total number of visits, and percent of visits with somatization potential. The c-statistic, equivalent to the area under the ROC curve, was 0.90. In the validation set, the explanatory power was less with a still impressive c-statistic of 0.78. A predicted probability of 0.04 identified almost all somatizers, whereas a predicted probability of 0.40 identified about half of all somatizers but produced few false positives. CONCLUSIONS: We have developed and validated a prediction model from the MIS that helps to distinguish chronic somatizing patients from other high utilizing patients. Our method requires corroboration but carries the promise of providing clinicians and health plan directors with an inexpensive, simple approach for identifying the common somatizing patient and, in turn, targeting them for treatment. The screener does not require clinicians' time.

Improving depressive symptoms among caregivers of patients with cancer: results of a randomized clinical trial.

PURPOSE/OBJECTIVES: Determine the impact of a 16-week supportive nursing intervention on caregivers of patients with newly diagnosed cancer. DESIGN: Randomized clinical trial. SETTING: Two midwestern cancer treatment sites. SAMPLE: Caregivers of newly diagnosed patients. Patients' mean age was 55.73 years; 55% had breast cancer, and 76% were female. Caregivers' mean age was 52.44 years, and 50% were female. 125 dyads consented to participate; 89 dyads completed the study. METHODS: A nursing intervention was delivered to the experimental group that emphasized symptom monitoring/management, education, emotional support, coordination of services, and caregiver preparation to care. Nurses made a total of nine contacts, five in person and four by telephone, over 16 weeks. Centers for Epidemiological Studies-Depression (CES-D) and a symptom inventory were used. Medical record audits were conducted retrospectively. MAIN RESEARCH VARIABLES: Patient and caregiver depression scores and patient symptom experience. FINDINGS: Baseline caregiver depression and the number of patient symptoms at baseline, 9, and 24 weeks were significant predictors of caregiver depression at 9 and 24 weeks. However, no main effect of the experimental condition existed on caregiver depression. At the final observation, a nonsignificant inverse relationship was found between the number of interventions and depression scores for caregivers. CONCLUSIONS: The intervention appeared to be more effective in slowing the rate of deterioration of depressive symptoms than in decreasing levels of depression in this sample of caregivers. Determining the effectiveness of this intervention in decreasing caregiver depression was difficult because caregivers with higher levels of depression were more likely to withdraw from the study. IMPLICATIONS FOR NURSING PRACTICE: Nurses must be vigilant in monitoring caregivers for signs of depression and must intervene to provide emotional support and make appropriate referrals for follow-up care to promote positive outcomes for patients and caregivers.

Predictors of pain and fatigue in the year following diagnosis among elderly cancer patients.

Using data obtained from an inception cohort of 841 patients aged 65 or older newly diagnosed with breast, colon, lung, or prostate cancer, and observed at 6-8, 12-16, 24-30, and 52 weeks, three questions related to patients' experiences with pain and fatigue were posed. First, how do numbers of patients reporting neither pain nor fatigue, either symptom, or both change during the observation year? Second, did number of comorbid conditions, site and stage of cancer, treatment modalities, symptom management medication, and time affect the presence of these two symptoms? Third, do pain and fatigue predict the numbers of co-occurring other symptoms? Findings indicate that during the year patients improved with respect to their reports of pain and/or fatigue. Stage, more comorbidity, and lung cancer were related to both pain and fatigue. Chemotherapy was related to reports of fatigue, but did not have an extended effect on fatigue.

Disparities in cancer diagnosis and survival.

BACKGROUND: Concern has been raised over the disproportionate cancer mortality among minority and low-income persons. The current study examined differences in disease stage at the time of diagnosis and subsequent survival for patients who are medically indigent compared with the rest of the population of cancer patients in Michigan. METHODS: The authors linked three Michigan statewide data bases: the Cancer Registry, Medicaid enrollment files, and death certificates. The analysis focused on female breast, cervix, lung, prostate, and colon carcinoma, and differences were analyzed in the incidence, disease stage at the time of diagnosis, and survival between younger women and older women who were either insured or not insured by Medicaid. To estimate the risk of late stage diagnosis and death, the authors used logistic regression, controlling for age, race, and Medicaid enrollment. Ordered logit models also were used as a refinement of disease stage prediction. RESULTS: Medically indigent persons had a disproportionately larger share of cancer. Persons age < 65 years who were insured by Medicaid had the greatest risk of late stage diagnosis and death across all five disease sites analyzed. African-American women had a greater risk of death from breast carcinoma compared with other women independent of Medicaid status. No interaction effects were found between age, race, and/or gender and Medicaid enrollment. CONCLUSIONS: The results of this study showed that the disparities in cancer outcomes may be greater than previously thought and are consistent across disease sites. If advancements made in cancer control are to be shared by the low-income population, then improvements clearly are needed in cancer prevention, early detection, and treatment for the poor.

Physical functioning and depression among older persons with cancer.

PURPOSE: The purpose of this study was to help identify factors to assess which elderly patients are likely to experience problems with physical and psychological functioning in association with cancer or its treatment. DESCRIPTION OF STUDY: A study was undertaken with a sample of 420 patients with cancer who were between the ages of 65 and 98 years and had received an incident diagnosis of breast, colon, lung, or prostate cancer. An analysis of covariance technique was used to determine how cancer site, treatment type, stage of disease, gender, age, comorbidity, symptom severity, and pre-diagnosis levels of physical functioning were related to physical functioning deficit, and how all of these in turn influenced patient depressive symptomatology. RESULTS: Pre-diagnosis physical functioning, symptom severity, and days since surgery were significant predictors of physical functioning deficit. Patients who had been treated only with surgery experienced greater physical functioning deficits than did patients who had received both surgery and adjuvant therapy. This apparent anomaly was partly explained by the time interval from surgery to interview. Higher levels of symptom severity, lower levels of prior physical functioning, and greater physical functioning deficits all predicted higher levels of depressive symptomatology. CLINICAL IMPLICATIONS: In the care of elderly patients with cancer, it is important for healthcare providers to consider the pre-diagnosis levels of physical functioning of patients with cancer to understand and anticipate the physical and psychological consequences of cancer and its treatment. Equally important is the proper management of patient symptoms in maximizing both the physical and psychological quality of life.

Symptomatology and loss of physical functioning among geriatric patients with lung cancer.

In this study of 129 geriatric patients with lung cancer, we investigated how symptom severity varied according to treatment type, stage of disease, and gender; how change in physical functioning (prediagnosis versus post-hospital discharge) was predicted by symptomatology, prior physical functioning, comorbidity, and age; and whether differences exist according to stage of disease, treatment status, or gender. Data were gathered through patient interviews and audits of patient records. Analysis of variance (ANOVA) techniques revealed that there were no significant differences in average symptom severity scores by gender, treatment categories, or stages of disease. Significant predictors of loss of physical functioning were symptom severity, prior physical functioning and patient age. Characteristics of a profile for elderly lung cancer patients at high risk of suffering substantial losses in physical functioning include higher prior levels of physical functioning, higher levels of current symptomatology, and lower age.

Comparison of changes in physical functioning of elderly patients with new diagnoses of cancer.

BACKGROUND: Controversy surrounds the impact of site of cancer and treatments on functioning of elderly cancer patients. OBJECTIVES: This research determines (1) whether age, gender, comorbid conditions, site and stage of cancer, and treatments are related to losses in physical functioning at 4 observations during the year after diagnosis; (2) whether symptoms are a mediating variable between treatment and function; and (3) which indicators account for true change in functioning in the year after diagnosis. METHODS: An inception cohort of 907 patients aged > or =65 years and newly diagnosed with breast, colon, lung, or prostate cancer were accrued from 24 community oncology programs. Stage and treatment data were obtained from medical records. Physical functioning was measured with the SF-36 subscale. Interviews were conducted at 6 to 8, 12 to 16, 26 to 30, and 52 weeks after diagnosis. RESULTS: Men scored 10 points higher on physical function than women at all observation points. Patients with > or =3 comorbid conditions scored lower in functioning. Interactions between site of cancer and treatment modalities were observed. Pain, fatigue, and numbers of symptoms were independent predictors of loss of function. Surgery, female gender, and number of symptoms predicted reliable change in function. CONCLUSIONS: Elderly patients with cancer report levels of function similar to other chronic conditions. Scores on physical function varied by site of cancer; the pattern of change was similar among sites. Age, comorbidity, treatment modalities, and symptom reports each had an independent effect on loss of functioning. Untreated breast cancer patients had lower functioning, suggesting a possible treatment bias.

Predictors of physical functioning among geriatric patients with small cell or non-small cell lung cancer 3 months after diagnosis.

This study investigated how treatment options, symptom severity, prediagnosis levels of physical functioning, comorbidity, gender, and age predicted current physical functioning in geriatric patients with small-cell or non-small-cell lung cancer, 12 weeks after their diagnosis. The study involved 146 patients aged 65 years and over with an incident diagnosis of lung cancer. Analysis of covariance revealed no significant differences in physical functioning according to treatment type, small-cell versus non-small-cell classification or gender. Significant predictors of current physical functioning were symptom severity and prior physical functioning. The characteristics of a high-risk profile for disruption in physical functioning of elderly lung cancer patients 12 weeks after their diagnosis would include preexisting physical impairment and high levels of symptomatology.

The influence of symptoms, age, comorbidity and cancer site on physical functioning and mental health of geriatric women patients.

This article focuses on how cancer site, age and comorbid conditions of elderly women cancer patients influence their reporting of symptoms; how these variables in turn impact their physical functioning and mental health; and whether there are differences according to the site of the cancer. For the study, a sample of 299 women, age 65 and above, was selected from an on-going longitudinal study of cancer patients recruited from six cancer treatment centers in Michigan and who were recently diagnosed with breast, colon or lung cancer. Age, comorbidity and cancer site were predictors of symptom severity. Age, comorbidity, symptom severity and cancer site were significant predictors of physical functioning, while mental health scores were only predicted by symptom severity. Lung cancer patients reported greater losses in physical functioning than either breast or colon cancer patients, however there were no significant differences in average mental health scores among the three cancer sites. A systematic and comprehensive approach to self-care management of symptom distress provided by oncologists and other health care professionals may enable patients, especially elderly patients with comorbid conditions, to successfully alleviate or reduce the impact of symptoms on their lives.

Complementary therapy use among older cancer patients.

PURPOSE: The purpose of this study was to assess the use of complementary therapies among older cancer patients, to report patterns of use, and to understand who is more likely to use complementary therapies. DESCRIPTION OF STUDY: A survey was conducted of 699 older cancer patients at 4 weeks and 6 weeks into cancer treatment. All participants were 64 years of age or older, had received a diagnosis of breast, colorectal, prostate, or lung cancer, and were recruited from community cancer treatment centers throughout Michigan. Measures of interest included self-reported physical symptoms, depressive symptomatology, optimism, spirituality, and use of conventional and complementary health services. RESULTS: Approximately 33% of older cancer patients reported using complementary therapies. These individuals were more likely to be women, to be breast cancer patients, and to have a higher level of education. The three most frequently used therapies were exercise, herbal therapy, and spiritual healing. Complementary therapy users were significantly more optimistic than nonusers. Also, there were significant differences between users and nonusers on types of physical symptoms experienced, but no differences on reported depressive symptomatology or spirituality. CLINICAL IMPLICATIONS: Oncology providers need to be aware that one third of their older patients are likely to supplement conventional care with complementary therapies. Therefore, providers should be knowledgeable about the safety and efficacy, in particular, of various exercise programs, herbal and vitamin therapies, and spiritual healing. It would be beneficial to develop a system within cancer centers by which patients could easily report on their use of complementary therapies, allowing providers to work in partnership with their patients.

A profile of bereaved caregivers following provision of terminal care.

Caregivers are often overwhelmed by the strain of terminal caregiving. We wished to better understand the needs of terminal caregivers and to supply a basis for tailoring interventions to them during caregiving and early bereavement. This report provides a profile of 124 bereaved caregivers interviewed within three months of their patient's death. Three quarters were female and married to the patient. Four major areas were assessed: psycho-spiritual, personal-social, health status, and financial status. Caregivers reported higher than average depressive symptomatology (mean CES-D = 17.6), moderate levels of positive outlook, low negative reactions to caring, and relatively high levels of spirituality. Caregivers were highly involved in their patient's activities of daily living, providing an average of 10.8 hours/day of direct care and 8.9 hours/day of companionship. Caregivers reported low utilization of health services and relatively high personal health status. 45% of the sample reported lower income since the patient's death and 44% reported out-of-pocket expenses not covered by insurance. Suggestions for interventions that target emotional, physical, and financial concerns are discussed.

The impact of new demands for assistance on caregiver depression: tests using an inception cohort.

Family caregivers of patients facing high numbers of new demands for assistance following hospital discharge were more likely to experience increased levels of depression in the following six months compared with caregivers facing similar overall demands but few new demands for assistance following hospital discharge. New demands for assistance had a significant independent effect upon the levels of depression and were independent of family relationship (spouse vs nonspouse) and caregiver gender. These findings provide insight into theories of caregiver stress, begin to specify the interaction of time following the onset of a stressful event and caregivers' subsequent reactions, and suggest which caregivers may require some assistance following discharge of their patients.

Longitudinal employment decisions of daughters and daughters-in-law after assuming parent care.

Employment decisions of full-time, part-time and not employed daughters and daughters-in-law (n = 157) are described over the first 18 months of parent care at two points in time: three months after assuming care and 15 months later. Employment decisions were also examined when caregiving continued (n = 55), when it was discontinued (n = 55) and when a parent died (n = 47). Findings indicate that part-time employed daughters make more changes and adjustments in their employment than do full-time or not employed daughters. When a parent died, more changes in employment occurred prior to the death than when a parent remained in care.