The Effects of Adding Reassurance Statements: Cancer Patients' Preferences for Phrases in End-of-Life Discussions.

CONTEXT: When discussing end-of-life issues with cancer patients, the addition of reassurance statements is considered helpful. However, patients' preferences for such statements have not been systematically demonstrated. OBJECTIVES: The objectives of this study were to clarify if phrases with additional reassurance statements would be more preferable to phrases without them and explore variables associated with patients' preferences. METHODS: In a cross-sectional survey, 412 cancer patients assessed their own preferences for phrases with/without additional statements using a six-point scale (1 = not at all preferable; 6 = very preferable). These included the statements of "hope for the best and prepare for the worst" ("hope/prepare") when discussing prognosis; symptom palliation when discussing code status; and specific goals, continuity of care, and nonabandonment when discussing hospice referral. We evaluated demographic data and the coping style and conducted multivariate regression analysis. RESULTS: Compared with the phrase of life expectancy (i.e., median + typical range) alone [mean (SD), 3.5 (1.2); 95% CI, 3.4-3.6], the phrase with the additional "hope/prepare" statement was more preferable [3.8 (1.4); 3.7-3.9]. Compared with the phrase of do-not-resuscitate alone (3.1(1.3); 3.0-3.3), the phrase with the additional statement of symptom palliation was more preferable [3.9 (1.3); 3.7-4.0]. Compared with the phrase of hospice referral alone [3.4 (1.2); 3.3-3.5], phrases with the addition of a specific goal [3.9 (1.0); 3.8-4.0], specific goal and continuity (4.4(1.0); 4.3-4.5), and specific goal, continuity, and nonabandonment [4.8 (1.2); 4.7-4.9] were more preferable. In multivariate analyses, task-oriented coping was significantly correlated with preferences for phrases including additional reassurance statements. CONCLUSION: Cancer patients systematically preferred reassurance statements. In end-of-life discussions, especially with patients with task-oriented coping, clinicians may provide additional reassurance statements.

Adding a Wider Range and "Hope for the Best, and Prepare for the Worst" Statement: Preferences of Patients with Cancer for Prognostic Communication.

INTRODUCTION: Although various phrases to communicate prognoses based on a certain concept have been proposed, no study has systematically investigated preferences of patients with cancer for actual phrases. We investigated whether phrases with a wider range and additional "hope for the best, and prepare for the worst" (hope/prepare) statement would be more preferable and explored variables associated with patients' preferences. MATERIALS AND METHODS: In a cross-sectional survey, 412 outpatients with cancer self-assessed their preferences for 13 phrases conveying prognostic information (e.g., phrases with or without median, typical range, and/or best/worst cases, and those with or without a hope/prepare statement) on a 6-point scale (1 = not at all preferable; 6 = very preferable). We evaluated demographic data and the Coping Inventory for Stressful Situations and conducted multivariate regression analysis. RESULTS: Regarding phrases with various ranges, the one including the median, typical range, and best/worst cases was more preferable (mean ± SD, 3.8 ± 1.3; 95% confidence interval [CI], 3.6-3.9) than the one with the median and typical range (3.4 ± 1.2; 3.3-3.6) or the one with only the median (3.2 ± 1.3; 3.1-3.3). Concerning the hope/prepare statement, the phrase including the median, typical range, uncertainty, and hope/prepare statement was more preferable (3.8 ± 1.4; 3.7-3.9) than the one without the statement (3.5 ± 1.2; 3.4-3.6). In multivariate analyses, task-oriented coping was significantly correlated with preferences for phrases with explicit information. CONCLUSION: Overall, phrases with a wider range and the hope/prepare statement were preferable to those without them. When patients with cancer ask about prognoses, especially those with task-oriented coping, clinicians may provide explicit information with a wider range and the hope/prepare statement. IMPLICATIONS FOR PRACTICE: Discussing prognoses with patients with advanced cancer is among the most important conversations for clinicians. In this cross-sectional survey to systematically investigate preferences of 412 patients with cancer for phrases conveying prognostic information, phrases with the median, typical range, and best/worst cases and those with the "hope for the best and prepare for the worst" (hope/prepare) statement were the most preferred. When patients with cancer ask about prognoses, clinicians may provide explicit information with a wider range and include the hope/prepare statement.

Psychological distress in men with prostate cancer and their partners before and after cancer diagnosis: a longitudinal study.

OBJECTIVE: To examine the relative risk of psychological distress of men with prostate cancer and their partners during the period before and after prostate cancer diagnosis compared with men without prostate cancer and their partners. METHODS: The participants reported questionnaires on psychological distress at four time points: before prostate cancer biopsy, and at 1, 3 and 6 months following prostate cancer diagnosis. We performed multiple logistic regression analyses to examine the relative risk of psychological distress. RESULTS: A total of 115 couples answered the questionnaires at all four time points. Men with prostate cancer showed a significantly higher risk of psychological distress compared to men without prostate cancer at 1 (odds ratio [OR] = 4.8, 95% confidence interval [CI] = 1.9-13.1), 3 (OR = 3.2, 95% CI = 1.1-10.2) and 6 months following prostate cancer diagnosis (OR = 6.9, 95% CI = 2.3-25.7). Their partners showed a significantly higher risk of psychological distress compared to the partners of men without prostate cancer at 1 month following prostate cancer diagnosis (OR = 2.6, 95% CI = 1.1-6.6). CONCLUSIONS: Men with prostate cancer showed psychological distress during the 6 months following the cancer diagnosis. Their partners also showed psychological distress at 1 month following the cancer diagnosis. Inviting both men with prostate cancer and their partners to speak to their concerns, empathizing with them, finding the solutions together and monitoring of their psychological status regularly should be regarded as important following prostate cancer diagnosis.

Psychologists involved in cancer palliative care in Japan: A nationwide survey.

OBJECTIVE: The aim of this study was to clarify, using a nationwide survey, what is perceived as necessary knowledge and skills for psychologists involved in cancer palliative care in Japan, the expectations of medical staff members, and the degree to which these expectations are met. METHOD: We conducted a questionnaire survey of psychologists involved in cancer palliative care. A total of 419 psychologists from 403 facilities were asked to fill out the questionnaire and return it anonymously. Some 401 psychologists (89 males, 310 females, and 2 unspecified; mean age, 37.2 ± 9.5 years) responded about necessary knowledge and skills for psychologists working in cancer palliative care, the necessity for training, expectations at their current workplace, and the degree to which expectations are met. RESULTS: More than 90% of participants responded that many kinds of knowledge and skills related to the field of cancer palliative care are necessary. Over 80% of participants indicated a necessity for training related to these knowledge and skills. Although more than 50% (range, 50.1-85.8%) of participants responded that such services as "cooperation with medical staff within a hospital," "handling patients for whom psychological support would be beneficial," and "assessment of patients' mental state" were expected at their workplace, fewer than 60% (31.4-56.9%) responded that they actually performed these roles. SIGNIFICANCE OF RESULTS: Our results show that many psychologists in cancer palliative care feel unable to respond to the expectations at their current workplace and that they require more adequate knowledge and skills related to cancer palliative care to work effectively. No other nationwide surveys have generated this type of information in Japan, so we believe that the results of our study are uniquely important.

Psychosocial longitudinal study profile and distress of couples in relation to the conduct of prostate biopsy.

OBJECTIVE: Partners of prostate cancer patients have been reported to suffer from high levels of psychological distress, although there are few reports of the changes in their distress levels observed before and after the diagnosis and the factors influencing them. This study constructed a longitudinal psychosocial database of prostate cancer biopsy subjects and their partners. This paper describes a summary of the database and the nature and severity of the psychological distress and cancer-related worry. METHODS: We distributed self-administered questionnaires to subjects scheduled for a prostate cancer biopsy and their partners on four occasions: prior to the biopsy, and 1, 3 and 6 months after being informed whether the diagnosis was cancer or not. The questionnaires included questions pertaining to the psychological distress, cancer-related worry and correlational factors. RESULTS: Of the 240 couples who agreed to participate in the database project, 184 couples completed the first and second surveys; thus, the database consists of them. While no significant differences in the levels of psychological distress were found among the participants before the biopsy, the prostate cancer patients and their partners had significantly higher levels of psychological distress as compared with the non-prostate cancer patients at 1 month after being informed whether the diagnosis was cancer or not. CONCLUSIONS: This study constructed a longitudinal psychosocial database of prostate cancer biopsy subjects and their partners. Our findings suggest that partners of prostate cancer patients might experience a similar psychological impact to the prostate cancer patients before and after the diagnosis.

Troubles and hardships faced by psychologists in cancer care.

OBJECTIVE: The aim of this study was to identify problems experienced by psychologists involved in cancer and palliative care and consider an education system for psychologists. METHODS: We conducted a questionnaire survey of psychologists involved in cancer care and palliative care. At the 403 facilities, 419 psychologists who received the questionnaire were asked to fill it out anonymously. A total of 294 people (61 male, 233 female, average age ± SD = 36.3 ± 9.4) responded about troubles and hardships actually faced by psychologists working in cancer care. We performed qualitative content analysis of free responses. RESULTS: We obtained the following five categories: 'Hospital system', 'Psychologist role and specialization (ambiguity of the role expected of psychologists and problems arising because psychologists are not nationally licensed)', 'Collaboration with other medical professionals (problems with the method of requesting psychologist cooperation and problems of consultation and liaison work within the hospital)', 'Specialized support provided by psychologists (difficulty of interaction with patients and their families, inadequate provision of psychological support in cancer care, problems related to death care and lack of psychiatric knowledge)', 'Stress faced by psychologists (psychologist's isolation and anxiety, psychologist's internal conflicts, psychologist burnout and helplessness and psychologist self-improvement)'. CONCLUSIONS: Psychologists must acquire at least a minimal level of medical knowledge and understanding of cancer treatment. Furthermore, they require training through specific case studies in order to facilitate collaboration with other medical professionals and concrete training in aspects of psychological support that are specifically tailored to cancer treatment through case studies.

Chronic fluvoxamine treatment changes 5-HT(2A/2C) receptor-mediated behavior in olfactory bulbectomized mice.

AIMS: Olfactory bulbectomy (OBX) in rodents represents a valuable experimental model of depression. This study was designed to shed further light on the impact of putative serotonergic neuronal degeneration in OBX mice and to assess the effect of a widely used antidepressant on serotonergic related behavioral changes induced by OBX. MAIN METHODS: Adult male ddY mice were subject to bilateral OBX or sham surgery. The serotonin (5-HT)(2A/2C) receptor agonist 2,5-dimethoxy-4-iodoamphetamine (DOI) enhanced a head-twitch response (HTR) in OBX mice. Effects of 5-HT(2A), 5-HT(2C) antagonists and fluvoxamine were observed in OBX mice following DOI administration. KEY FINDINGS: The HTR elicited by the administration of DOI (0.5 mg/kg and 1 mg/kg, i.p.) was increased about twofold in OBX mice when compared with controls on the 14th day after the surgery. The injection of ketanserin (0.025 mg/kg, i.p.), a 5-HT(2A) receptor antagonist, inhibited the enhancement of the DOI-induced HTR after OBX. Likewise, the administration of SB 242084 (1 mg/kg, s.c.), a 5-HT(2C) receptor antagonist, also inhibited the DOI-induced HTR in OBX mice. Chronic but not acute treatment with the antidepressant fluvoxamine, a selective serotonin reuptake inhibitor (SSRI), suppressed the enhancement of DOI-induced HTR after OBX. SIGNIFICANCE: These findings indicate that OBX, and the subsequent degeneration of neurons projecting from the olfactory bulb, caused a supersensitivity of 5-HT(2A/2C) receptors which may be involved in symptoms of depression.

Subchronic stress-induced depressive behavior in ovariectomized mice.

AIMS: Mood disorders including depression are more common in women than men, particularly in times of lower estradiol levels. In this study, we investigated the effect of estrogen on emotional behavior in mice in a stress environment. MAIN METHODS: Female mice were divided into four groups: two groups were ovariectomized (OVX) and two were sham-operated. One group each of OVX and sham mice was kept in a normal environment and the other groups were assigned to a daily stress (1 h/day) for 7 days from 5 days after operation. On the 14th day after operation, subjects were measured to assess behavioral specificity, locomotor activity, elevated plus-maze (EPM) behavior, passive avoidance (PA) behavior and forced swimming behavior. KEY FINDINGS: The OVX plus stress (OVX+S) group showed a significant prolongation of immobility compared with the other groups. In all the groups there were no changes in locomotor activity, EPM behavior or PA behavior. We further examined the effect of estrogen against depressive behavior in the OVX+S group. The vehicle or 17beta-estradiol (E2) was administered s.c. to OVX+S mice for 4 days beginning on post-operative day 11. Subchronic E2 treatment decreased the stress response and improved depressive behavior relative to the vehicle group. SIGNIFICANCE: These data have important implications regarding the prevention of depression in postmenopausal women undergoing estrogen therapy.

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

OBJECTIVE: We previously reported that the nurse-assisted screening and psychiatric referral program (NASPRP) facilitated the psychiatric treatment of depressive patients, but the high refusal rate was a problem even though referral was recommended by the nurse to all positively screened patients. We modified the program so that the nurses could judge the final eligibility of referral using the result of the screening. This study assessed if the modified NASPRP led to more psychiatric referral of depressive patients. METHOD: We retrospectively evaluated the annual change of the psychiatric referral proportion and compared the findings among the usual care term, the NASPRP term, and the modified NASPRP terms. RESULTS: The referral proportions of the modified NASPRP terms were 4.4% and 3.9%. These were not significantly higher than the usual care term (2.5%), and significantly lower than the NASPRP term (11.5%). SIGNIFICANT OF RESULTS: The modified NASPRP did not facilitate psychiatric treatment of depressive patients and another approach is needed.

Can psychiatric intervention improve major depression in very near end-of-life cancer patients?

OBJECTIVE: Although depression is a prevalent and burdensome psychiatric problem in end-of-life cancer patients, little is known about its susceptibility to treatment, especially when patients reach very close to the end of life. This study was conducted to evaluate response rate of that end-of-life depression to psychiatric intervention and to assess the feasibility of conventional evidence-based pharmacological therapy for depression. METHODS: The medical records of 20 patients who were referred to the psychiatry division for major depressive disorder and died within 3 months after the referral were reviewed. The Clinical Global Impression-Improvement (CGI-I) Scale was used for each case, and responders were defined as patients whose scores were much or very much improved. All pharmacological treatments were extracted, and the doses of the antidepressant prescribed were compared to their evidence-based-defined therapeutic doses. RESULTS: Of the 20 patients, seven were responders, but no response was achieved when the survival time was less than 3 weeks. Most patients were treated with antidepressants, but the doses prescribed were far less than the defined doses, especially the doses of the tricyclic antidepreSsants (TCAs). SIGNIFICANCE OF RESULTS: These results suggested that patients' survival time largely determines susceptibility to psychiatric treatment, and it is hard to achieve response in patients whose survival time was less than about 1 month. Implementation of conventional evidence-based pharmacological treatment is difficult, especially with TCAs, and various antidepressants, which can be administrated by other routes, are needed when oral intake is impossible.

[Practice of psychotherapy for cancer patients].

Cancer is a threat to life and to the psychological well-being of patients. Previous studies have demonstrated that several patients with cancer have suffered from psychological distress. Psychotherapy for cancer patients is effective against psychological distress. There are several kinds of psychotherapy for these patients, such as supportive psychotherapy, cognitive behavioral psychotherapy including relaxation techniques and cognitive restructuring, and supportive-expressive group psychotherapy. Supportive psychotherapy is feasible for many clinicians. Psychotherapists develop a trustful relationship with patients, provide an empathic posture, and use various types of psychotherapeutic treatments. It is important for psychotherapists to understand the psychological background of such patients from various viewpoints.

Psychological distress experienced by families of cancer patients: preliminary findings from psychiatric consultation of a Cancer Center Hospital.

OBJECTIVE: The purpose of the present study was to obtain preliminary findings regarding psychiatric disorders and background characteristics among Japanese family members of cancer patients. METHODS: We investigated the psychiatric diagnosis and background factors of family members of cancer patients by analyzing the consultation data of patients referred to the Psychiatry Division, National Cancer Centre Hospital East, Japan. RESULTS: Of a total of 1469 psychiatric consultation, 47 (3.2%) family members were referred, and 85% of them were spouses. The most common patient cancer site was the lung. Approximately one-half of the referred family encountered patients' end-of-life issues. The most common psychiatric diagnoses were adjustment disorders, followed by major depression. CONCLUSIONS: These preliminary findings suggest that psychosocial support for family members is not fully delivered and development of a comprehensive support system for caregivers of cancer patients is an urgent issue in the clinical oncology setting in Japan.

Good communication with patients receiving bad news about cancer in Japan.

PURPOSE: Despite a recent increase in the attention given to improving communication when disclosing bad news to cancer patients, understanding of good patient-physician communication is still lacking in Japan. The aim of the present study is to describe attributes of good communication with patients receiving bad news about cancer in Japan. METHODS: Forty-nine participants, including 42 cancer patients and seven oncologists, were requested to undergo an in-depth interview, and the data obtained were qualitatively analyzed. RESULTS: Seventy-one attributes of good communication with patients receiving bad news about cancer were obtained from 619 opinions, and classified into four domains. (1) SETTING: a private room and sufficient time. (2) Information given: impact on daily activities and alternative therapy. (3) Method of disclosure: facilitation of patient understanding. (4) Emotional support: encouragement and allowing expression of emotions. CONCLUSIONS: The four domains of good patient-physician communication in Japan are apparently similar to those in Western countries. The domain involving information given and method of disclosure in previous Western studies was further divided into two domains in the present study. Japanese physicians should perhaps pay careful attention to these issues when disclosing bad news about cancer. There are some cultural differences related to the details of communication attributes (e.g. using euphemisms and showing consideration for the patient's family).

Usefulness of the nurse-assisted screening and psychiatric referral program.

BACKGROUND: Major depression and adjustment disorders are common psychiatric disorders in patients with cancer, but they are often overlooked in clinical oncology settings. The nurse-assisted screening and psychiatric referral program (NASPRP) has been introduced in clinical practice to facilitate psychiatric treatment for major depression and adjustment disorders. This study assessed the usefulness of the NASPRP and compared it with usual practice. METHODS: The program consists of two stages. In the first stage, consecutive patients newly admitted to the Oncology/Hematology Unit are administered the Distress and Impact Thermometer (DIT) by nurses as a brief screening tool for major depression and adjustment disorders. In the second stage, the nurses recommend psychiatric referral to patients with scores above the cutoff point. Patients' records were reviewed for a 3-month period before the start of the program and during the 3-month period after the start of the program. These records were then compared. RESULTS: Of 157 patients newly admitted during the program period, 86.0% (135/157) completed the DIT and results were positive in 49.6% (67/135), but only 28.2% (19/67) accepted psychiatric referral. Ultimately, 11.5% (18/157) of patients newly admitted were diagnosed with major depression or adjustment disorders and treated by psychiatric service, a significantly higher proportion than during the preceding 3-month period, before the program was begun (2.5%; P = 0.001). CONCLUSION: The NASPRP enabled identification of major depression and adjustment disorders in patients with cancer and introduced them to psychiatric treatment. Nevertheless, there is room for improvement in the program.

[Dysfunction of serotonergic systems in thiamine-deficient diet fed mice: effects of SSRI on abnormality induced by thiamine deficiency].

Mice fed a thiamine deficient (TD) diet, showed some abnormal behaviors such as amnesia and mood abnormality. It is known that several neurons, especially marked in serotonergic neuron, are damaged in humans and rodents in the earlier phase of TD. The symptoms derived from dysfunction of serotonergic neurons are observed in Wernicke-Korsakoff patients (WKS)-derived TD, and it is known that fluvoxamine is effective for WKS. However, the mechanism of this dysfunction is still unclear. For that reason, we studied the relative mechanism between abnormal behaviors and selective dysfunction of serotonergic neurons in TD animals. As a result, this dysfunction by TD is much affected by the brainstem region. But the effect of fluvoxamine on depressive symptoms in WKS patients is not reported; therefore we also studied the effects of fluvoxamine on the depressive behaviors in TD mice as a model of WKS. The increase of immobility time in a forced swimming test as depressive behavior in TD mice was significantly inhibited by fluvoxamine, suggesting an improvable effect on depressive symptoms. With those results of ours, the possible mechanisms between the abnormal behaviors derived from the dysfunction of serotonergic neurons and the role of serotonin in TD and WKS are reviewed here.

Communication skills training for Japanese oncologists on how to break bad news.

BACKGROUND: Despite significant communication gaps between patients and physicians, there has been little effort to initiate and evaluate teaching programs. We investigated whether a communication skills training (CST) could be effectively conducted for Japanese oncologists. METHODS: Fifty-eight oncologists participated in the CST. We evaluated the program by measuring participant-rated confidence for communication with patients, burnout, and satisfaction of participants. RESULTS: Immediately and at 3 months after CST, confidence in communication increased significantly compared with before. The providers' emotional-exhaustion 3 months after the workshop, however, worsened. The participants' satisfaction level with the program was high. CONCLUSIONS: The CST is feasible for Japanese oncologists, but it needs to be modified to reduce emotional-exhaustion.