Communication between patients with breast cancer and health care providers. Determinants and implications.

BACKGROUND: This study evaluated the perceptions of patients with breast cancer of their medical interactions with providers. The determinants and psychological consequences of communication problems also were examined. METHODS: Ninety-seven patients with Stage I or II breast cancer completed a set of validated questionnaires before initiating postoperative therapy. Data on psychological distress were collected at baseline and 3-month follow-up, and multivariate models were fit to explain the relationship between pretreatment communication problems and subsequent psychological distress. Data on clinical variables were abstracted from medical records. RESULTS: A substantial proportion of patients (84%) reported difficulties communicating with the medical team. Communication problems were more common among patients who were less optimistic about their disease and had less assertive coping styles. Patient-reported communication problems were associated with increased anxiety, depression anger, and confusion at the 3-month follow-up. The association between communication problems and mood disturbance remained significant, although small, after adjusting for baseline mood disturbance, demographic, clinical, and coping style variables. CONCLUSION: Interventions that enhance communication between patients with breast cancer and their providers may improve patients' psychological adjustment to treatment. Conversely, interventions that lower distress and modify coping style may enhance communication.

New opportunities for screening and early detection of bladder cancer.

In the United States, over 51,000 new cases of urinary bladder tumors are diagnosed annually. Approximately 75-85% of all newly diagnosed cases are superficial transitional cell carcinomas (TCCs). Incidence is highest (80% of the cases) in the 50-79 year age group. Recent studies have reported that 21-25% of risk for bladder cancer among United States white males is due to occupational exposure. The DuPont Chambers Works in Deepwater, New Jersey, was a major producer of two chemicals now known to be human bladder carcinogens (beta-naphthylamine and benzidine) as well as two suspected human bladder carcinogens [ortho-toluidine and 4,4'-methylene- bis,2-chloroaniline (MOCA)]. Between 1954 and 1982, DuPont screened 1723 exposed employees annually at the Chambers Works using the Papanicolaou test for urinary cytology and microscopic urinalysis. A review of the prior screening program found that employees who developed bladder cancer during this time period were approximately twice as likely to have had hematuria than those comparably exposed who did not develop bladder cancer. Building on this finding, a three-year screening study evaluated a home self-test for microscopic hematuria to aid early detection of treatable urologic conditions among exposed workers at this chemical plant. Every six months, subjects tested their urine at home for 14 consecutive days, for the presence of blood. A high degree of adherence to our protocol (over 92% completed and returned the self-testing record) as well as high compliance with repeat screening (85% returned for screening in subsequent quarters) demonstrated good acceptance and performance of the recommended schedule of self-testing. Through the first 7 periods of screening, two new cases and one recurrence of TCC of the bladder were detected.

Survival and quality of life among patients receiving unproven as compared with conventional cancer therapy.

BACKGROUND: Cancer treatments without proved efficacy have achieved new levels of popularity, particularly among well-educated patients. The value of these therapies is vigorously debated. METHODS: We compared the length of survival and quality of life in patients who received treatment at a prominent unorthodox cancer clinic in addition to conventional treatment and in matched control patients from an academic cancer center who received only conventional treatment. All the patients had documented extensive malignant disease associated with a predicted median survival time of less than one year. The study sample consisted of 78 pairs of patients matched according to sex, race, age, diagnosis, and time from the diagnosis of metastatic or recurrent disease, who were enrolled over a period of 3 1/2 years. Periodic follow-up (approximately every two months) continued until death. RESULTS: There was no difference between the two patient groups in length of survival. Median survival for both groups was 15 months (P = 0.22; relative risk, 1.23; 95 percent confidence interval, 0.88 to 1.72). Quality-of-life scores were consistently better among conventionally treated patients from enrollment on. CONCLUSIONS: For this sample of patients with extensive disease and for this particular unorthodox treatment regimen, conventional and unorthodox treatments produced similar results.

Psychosocial correlates of cancer survival: a subsequent report 3 to 8 years after cancer diagnosis.

Professional and public interest in possible relationships between psychosocial factors and disease outcome continues to increase. Published research in this area, however, is marked by contradictory results. Positive relationships between a variety of psychosocial factors and length of survival from cancer are reported, but other studies uncover no such associations. In a previously reported prospective investigation of 359 patients with newly diagnosed malignant diseases, we found no relationship between clinical outcome and any psychosocial factor studied. We have continued to observe these patients, who are now up to 8 years post-diagnosis, and report here additional data on their disease outcomes as they relate to psychosocial factors assessed at diagnosis. Two groups of patients were studied: 204 patients with advanced, prognostically poor malignant disease at diagnosis; and 155 patients with intermediate or high-risk melanoma or breast cancer. Shortly after diagnosis, patients completed a self-report questionnaire that assessed seven psychosocial factors previously reported to predict longevity in the general population. Factors included social ties and marital history, job satisfaction, use of psychotropic drugs, general life satisfaction, subjective view of adult health, hopelessness, and perception of amount of adjustment required to cope with the new diagnosis. Clinical factors--performance status and extent of disease at diagnosis--predicted clinical outcome. No psychosocial factor consistently was associated with length of survival or remission. Results of additional exploratory analyses also are reported.

Patient and physician delay in melanoma diagnosis.

The sequence of events leading ultimately to the diagnosis and treatment of malignant melanoma was investigated. We conducted interviews with 275 patients and the physicians whom they had consulted regarding their suspicious lesions before their eventual referral to a melanoma center. An average of 1 year elapsed from the time that patients first noticed a new or changed lesion and the date of diagnosis. Major components of delay were attributable to both patients and physicians. An average of 6 months elapsed between patients' recognition of a new or changed lesion and their realization that the lesion was suspicious. For 21% of cases, at least 2 months elapsed between physicians' observation of lesions and a definitive diagnosis of malignant melanoma, and 13% were diagnosed a minimum of 4 months following a visit to the physician. Patients routinely cannot distinguish between melanomas and moles. Physicians do not always diagnose melanoma accurately or act promptly in response to suspicious lesions. We have yet to take adequate advantage of the unique opportunity for early detection and cure in this readily visible, rapidly increasing malignancy.

How well do physicians recognize melanoma and other problem lesions?

The alarming increase in the incidence of cutaneous malignant melanoma in the United States emphasizes the importance of its early detection and treatment. Early detection requires accurate clinical recognition of both malignant and precancerous skin lesions (dysplastic nevi). This study presents data on dermatologists' and nondermatologists' ability to diagnose skin lesions. A total of 105 nondermatologist physicians, from first-year residents to practicing physicians, and forty-eight dermatologists were asked to identify color slides or photographs of eleven cutaneous lesions, including malignant melanomas, dysplastic nevi, and innocuous lesions such as seborrheic keratoses and common moles. Diagnosis of cutaneous lesions was generally inaccurate among nondermatologists. Only 38% correctly identified four or more of the six melanomas as melanoma of any type, and 58% were unable to diagnose dysplastic nevi. Only 17% categorized their relevant training as excellent or good. Improved training in the diagnosis of skin lesions for practicing physicians and house staff is required if mortality from malignant melanoma is to be decreased in the United States.

Factors associated with psychological distress in cancer patients.

We studied the mental health of 1,278 patients with cancer and 645 family members of patients with cancer to delineate clinical and demographic characteristics associated with poor psychological status. For both patients and their matched relatives, there was a direct relationship between poorer mental health scores and younger age. Highly significant age differences emerged as well for subscale scores of anxiety, depression, and general positive affect in patients, and for depression, emotional ties, and loss of control in relatives. Treatment status, performance status, and sex also contributed significantly to mental health scores. Patients at greatest risk for psychological problems are young, female, receiving palliative or active treatment as opposed to follow-up care, and symptomatic or not fully ambulatory. Clinicians should be alert to the potential for psychological problems among patients in these categories.

Absorbable versus nonabsorbable suture for microneurorrhaphy.

The results of epineural microneurorrhaphy with use of 10/0 monofilament absorbable (Vicryl and Dexon) and nonabsorbable ( Dermalon , Ethilon, and Prolene) microsuture were compared in 150 isogeneic male Sprague-Dawley rats. After sciatic nerve transection and epineural repair, the animals were observed clinically and reexplored before death at intervals from 2 days to 20 weeks. Half of the animals were randomly selected for electrodiagnostic studies at 6, 12, and 20 weeks before sacrificed. We found no significant clinical, electrodiagnostic, or histologic differences affecting axonal regeneration that were attributable to any of the suture types used. All sutures incited moderate zones of localized inflammation acutely. After dissolution, the absorbable group was essentially free of inflammation, whereas the nonabsorbable sutures persisted in small local granulomas. A possible advantage may be suggested in the use of monofilament absorbable sutures for microneural repairs in certain situations.