I get tired for no reason: a single item screening for cancer-related fatigue.

This study examined the criterion validity and sensitivity and specificity of a single item to rapidly screen patients in ambulatory oncology clinics for cancer-related fatigue. In an effort to expand the utility of the Zung Self-Rating Depression Scale (ZSDS) as a screen for other symptoms, the utility of the single fatigue item was examined. The fatigue item reads "I get tired for no reason" and is rated on a four-point scale ranging from "none or a little of the time" to "most or all of the time." Fifty-two subjects were administered the Zung, the Functional Assessment of Cancer Therapy-Anemia (FACT-An) scale, and the Fatigue Symptom Inventory (FSI). The Zung item was highly correlated with the ZSDS (r= 0.63, p < 0.0001) and the FACT-An (r = -0.70, p < 0.0001), as well as to the individual items of the FSI, ranging from 0.41 (p < 0.003) to 0.71 (p < 0.0001). All 10 subjects considered to be depressed based on the ZSDS were also considered to fatigued on the FACT-An. Setting the ZSDS item cutoff point at level 3--"A good part of the time"--yielded a sensitivity of 78.95% and a specificity of 87.88%. It is concluded that a single item can be a fast and accurate way of screening cancer patients for fatigue to trigger additional follow-up, thus expanding the utility of a depression screening tool for problems other than the purely psychiatric.

An attempt to employ the Zung Self-Rating Depression Scale as a "lab test" to trigger follow-up in ambulatory oncology clinics: criterion validity and detection.

We examined issues of criterion validity and detection of depression employing the Zung Self-Rating Depression Scale (ZSDS) as a "lab test" to trigger follow-up interviews of ambulatory oncology patients by oncology staff and the possibility of subsequent algorithm-based antidepressant treatment. Sixty oncology patients were screened with the ZSDS and then interviewed using the Mini-International Neuropsychiatric Interview (MINI). We examined the sensitivity and specificity of various cutoffs on the ZSDS and a briefer version, the Brief Zung Self-Rating Depression Scale (BZSDS) as they predicted results of the MINI, which was used as the criterion. Mean age of patients was 58.3 years (SD = 11.9). Thirty-two were female (53.3%) and 28 were male (46.7%). The correlation of the ZSDS (r = -0.66, P <.0001) and BZSDS (r = -0.57, P <.0001) with the MINI overall suggested acceptable levels of criterion validity. Additionally, we examined various cutoff scores on the ZSDS and BZSDS to explore the false negative and false positive rates that are associated with each. For example, using the mild cutoff on the Zung (score > 48) to determine depression or adjustment disorder, 14 false negatives and 2 false positives were found. When the more stringent moderate cutoff (score > 56) was used, 25 false negatives and 0 false positives were found. Oncology staff can utilize such data to make decisions about where to set cut-offs that trigger follow-up based on the amount of error that is allowable in their attempts to identify depressive symptoms in their patients. We discuss that such decisions might be based on many factors including the resources available in a particular site for follow-up or the comfort of particular oncologists and nurses managing and prescribing psychotropic medications, or in providing supportive counseling.

The changeable nature of patients' fears regarding chemotherapy: implications for palliative care.

The side effects of chemotherapy are feared by cancer patients as they begin their treatment. In this study, we investigated patients' anticipatory fears about chemotherapy. We then re-assessed these fears three to six months after the initial interview for patients who received chemotherapy during that time. We also examined symptom distress at these intervals. Hair loss, vomiting, infection, nausea, and weight loss were ranked as the most feared side effects of cancer treatment for the group as they began treatment. Patients beginning chemotherapy endorsed frequent or intense levels of fatigue, worrying about the future, pain, and sleep problems. No differences were found in the reporting of symptoms based on gender, age, or educational level. While changes in symptom distress over the study period were unremarkable, changes in fears about chemotherapy were of interest. The most feared symptoms were re-ordered following the treatment experience. The endorsement of nausea and vomiting, alopecia, and loss of appetite decreased significantly. Thirty-five percent fewer chemotherapy patients reported vomiting as one of their most feared side effects; 45% fewer patients who received anti-emetics reported vomiting as one of their most feared side effects. Effective treatments, such as those that have been developed to treat acute chemotherapy-related emesis, can relieve the fears of patients on treatment. We conclude that patients' fears about treatment are fluid and malleable. Patients' fears of suffering related to chemotherapy treatment change in response to the provision of adequate management. We discuss the implications of these findings for palliative care education.

Managing chronic nonmalignant pain: overcoming obstacles to the use of opioids.

Physicians involved in cancer pain management treat thousands of patients with opioids, whose effective analgesia improves overall functioning. Side effects generally are tolerable, and treatment can be maintained with stable doses for long periods. Problems with addiction are infrequent. Many physicians, however, assume that opioids should be used only for chronic malignant pain. Research and clinical experience have demonstrated that opioids can safely and effectively relieve most chronic moderate to severe nonmalignant pain. Fears of addiction, disciplinary action, and adverse effects result in ineffective pain management. With current information on the use of opioids in chronic nonmalignant pain, primary care physicians can overcome these obstacles. Guidelines must clearly define the role of the primary care physician in the proper management of pain and the integration of opioid therapy. Used appropriately, opioids may represent the only source of relief for many patients.

The importance of quality-of-life endpoints in clinical trials to the practicing oncologist.

Quality-of-life research has helped describe and draw attention to the human side of cancer treatment. The field has made tremendous advances and has influenced the treatment of cancer. The practicing oncologist can benefit greatly by keeping abreast of developments in this field and applying them to the selection of treatment modalities based on both treatment efficacy and the patient's wishes. In the future, quality-of-life research will probably continue to be integrated into the practice of oncology.

Oncology staff recognition of depressive symptoms on videotaped interviews of depressed cancer patients: implications for designing a training program.

We examined oncologists' and nurses' ability to recognize depressive symptoms in two cancer patients who were interviewed on videotape. The study was conducted in a rural community, hospital-based outreach network. Staff were given a one-hour in-service on the use of the Mini International Neuropsychiatric Interview (MINI)-a brief diagnostic interview-to provide a differential diagnosis (no psychiatric diagnosis, major depressive disorder, or adjustment disorder with depressed mood). Next, the staff viewed a videotape of an investigator (S.P.) utilizing the MINI to interview two depressed breast cancer patients. Staff subsequently rated depressive symptoms on the MINI and made a diagnosis. Findings indicated a high concordance among staff regarding symptom ratings on a straightforward example of major depressive disorder. Concordance on diagnosis, severity level, and specific symptoms declined slightly on a more difficult case involving primarily cognitive symptoms and a diagnosis of adjustment disorder. Following brief didactic training on depressive disorders, oncologists and nurses were able to identify depressive symptoms in cancer patients on videotape. Learning to use a semistructured interview can increase oncologists' awareness of depressive symptoms and may be a good training model.

A pilot survey of aberrant drug-taking attitudes and behaviors in samples of cancer and AIDS patients.

The clinical assessment of drug-taking behaviors in medically ill patients with pain is complex and may be hindered by the lack of empirically derived information about such behaviors in particularly medically ill populations. To investigate issues surrounding the assessment of these behaviors, we piloted a questionnaire based on the observations of specialists in pain management and substance abuse. This preliminary questionnaire evaluated medication use, present and past drug abuse, patients' beliefs about the risk of addiction in the context of pain treatment, and aberrant drug-taking attitudes and behaviors. This instrument was piloted in a mixed group of cancer patients (N = 52) and a group of women with HIV/AIDS (N = 111). Reports of past drug use and abuse were more frequent than present reports in both groups. Current aberrant drug-related behaviors were seldom reported, but attitude items revealed that patients would consider engaging in aberrant behaviors, or would possibly excuse them in others, if pain or symptom management were inadequate. Aberrant behaviors and attitudes were endorsed more frequently by the women with HIV/AIDS than by the cancer patients. Patients greatly overestimated the risk of addiction in pain treatment. We discuss the significance of these findings and the need for cautious interpretation given the limitations of the methodology. This early experience suggests that both cancer and HIV/AIDS patients appear to respond in a forthcoming fashion to drug-taking behavior questions and describe attitudes and behaviors that may be highly relevant to the diagnosis and understanding management of substance use among patients with medical illness.

The cancer patient with borderline personality disorder: suggestions for symptom-focused management in the medical setting.

Medically ill cancer patients with borderline personality disorder (BPD) face formidable emotional challenges as they cope with cancer diagnosis and treatment. The anxiety and discomfort associated with medical treatment can lead them to have difficulties with medical caregivers, distort reality for emotional protection, or exhibit outright aggression and self-destructiveness. Co-morbid substance abuse or a history of physical or sexual trauma may further complicate cancer treatment. These patients may be in particular need of symptom-focused psychotherapeutic management, which must include comprehensive assessment and treatment of psychiatric symptoms, measures to limit aggression and self-destructiveness, and staff education and support. These interventions can reduce patients' distress and maximize cancer treatment outcomes.

Managing addiction in advanced cancer patients: why bother?

The management of addiction in patients with advanced cancer can be time-consuming, labor-intensive, and difficult. Some clinicians believe that it is not worth the effort, due in part to a failure to appreciate the deleterious impact of addiction on palliative care efforts and a view of addiction as intractable in any case. Indeed, it is possible that some clinicians perceive addiction not only fatalistically but, because of common misconceptions, believe that managing or attempting to decrease the patient's use of alcohol or illicit substances would be tantamount to depriving a dying patient of a source of pleasure. In this paper, we argue that managing addiction is an essential aspect of palliative care for chemically-dependent and alcoholic patients. The goal of such efforts is not complete abstinence, but exerting enough control over illicit drug and alcohol use to allow palliative care interventions to decrease suffering. To illustrate this view, we describe two patients with chemical-dependency. We highlight the impact of unchecked substance abuse on patients' perpetuation of their own suffering, the complication of symptom management, the diagnosis and treatment of mood/anxiety disorders, and the effect on the patients' family and caregivers.

Factor analysis of the Zung Self-Rating Depression Scale in a large ambulatory oncology sample.

Screening cancer patients for depression with self-report inventories presents clinical and methodological challenges. Many investigators separate "somatic" from "cognitive" symptoms when adapting such measures to oncology settings. However, this practice has rarely been empirically validated through factor-analytic studies. The following study describes a factor analysis of the Zung Self-Rating Depression Scale (ZSDS) from a large ambulatory sample of cancer patients (N = 1,109). A four-factor solution emerged, consisting of a cognitive symptom factor, a manifest depressed mood factor, and two somatic factors (eating and non-eating related). These factors accounted for 20% (cognitive), 13% (mood), 8% (non-eating), and 7% (eating) of the variance on the Zung, respectively. The authors discuss the implications of these results as they pertain to screening cancer patients for depression.

A chart review of the ordering and documentation of urine toxicology screens in a cancer center: do they influence patient management?

Urine toxicology screens (UTSs) may be useful in the diagnosis or monitoring of patients with established or suspected substance abuse. In the medically ill, including those with cancer, the test may help clinicians manage therapy with controlled prescription drugs. To describe the current use of UTSs in a cancer center, the medical records of 111 patients who underwent UTS were reviewed. These 111 patients were randomly selected from a group of 215 patients who underwent screening between January 1, 1990 and December 31, 1994 (a period during which over 80,000 admissions occurred). Fifty-six of the 111 patients had evidence of one or more illicit drugs, a prescription medication that had not been ordered, or alcohol; 50 patients had negative screens. The likelihood of a positive UTS was higher if the patient had human immunodeficiency virus (HIV) infection (100% versus 46.6%) or was undergoing treatment for chronic nonmalignant pain (100% versus 43.9%). Documentation of the UTS in the medical record was infrequent: 37.8% of the charts listed no reason for obtaining the test and the ordering physician could not be identified in 29% of the records. Eighty-nine percent of the records did not contain a subsequent mention of the result of the UTS. The result was more likely to lead to a documented outcome when it was positive rather than negative (14.3% versus 0%). These results suggest that UTSs are used infrequently in the tertiary care oncology center. The documentation surrounding the ordering and subsequent use of the test in patient management is unsystematic. The appropriate use and documentation of UTSs, like substance abuse issues in general, should be a focus of staff education and quality improvement efforts.

Symptom prevalence, characteristics, and distress in AIDS outpatients.

Symptom distress is an important but poorly characterized aspect of quality of life in AIDS patients. To assess and characterize the symptoms and symptom distress associated with AIDS, 504 ambulatory patients with AIDS were evaluated between December, 1992 and December, 1995. The assessment included measures of symptom distress, physical and psychosocial functioning, and demographic and disease-related factors. Patients described symptoms during the previous week using the Memorial Symptom Assessment Scale Short Form (MSAS-SF), a validated measure of physical and psychological symptom distress. The mean age was 38.6 years (range 18-69); 56% were male. African-Americans comprised 40% of the sample, Caucasians 35%, and Hispanics 23%. Ninety-three percent had CD4+ T-cell counts below 500, and 66% had counts below 200; 69% were classified in CDC category C (history of AIDS-defining conditions). Fifty-two percent reported intravenous drug use. Karnofsky performance status was > or = 70 in 80% of the patients. No patients were taking protease inhibitors. The mean (+/- SD) number of symptoms was 16.7 +/- 7.3. The most prevalent symptoms were worrying (86%), fatigue (85%), sadness (82%), and pain (76%). Patients with Karnofsky performance scores < 70 had more symptoms and higher symptom distress scores than patients with scores > or = 70 (21.2 +/- 6.5 vs. 15.6 +/- 7.1 symptoms/patient; 2.3 +/- 0.8 vs. 1.6 +/- 0.8 on the Global Distress Index [GDI] of the MSAS-SF; P < 0.0001 for both). Patients who reported intravenous drug use as an HIV transmission factor reported more symptoms and higher overall and physical symptom distress than those who reported homosexual or heterosexual contact as their transmission factor (17.8 +/- 7.5 vs. 15.4 +/- 6.9 symptoms/patient, P = 0.0002; 1.9 +/- 0.9 vs. 1.6 +/- 0.8 on the MSAS-GDI, P = 0.002). Both the number of symptoms and symptom distress were highly associated with psychological distress and poorer quality of life; for example, r = -0.69 (P < 0.0001) between GDI scores and scores on a validated measure of quality of life. Neither gender nor CD4+ T-cell count was associated with symptom number or distress. Responses from this self-referred sample of AIDS outpatients indicate that AIDS patients experience many distressing physical and psychological symptoms and a high level of distress. Both the number of symptoms and the distress associated with them are associated with a variety of disease-related factors and disturbances in other aspects of quality of life. Symptom assessment provides information that may be valuable in evaluating AIDS treatment regimens and defining strategies to improve quality of life.

Anxiety symptoms and panic attacks preceding pancreatic cancer diagnosis.

Cancer of the pancreas is a highly malignant disease with a very poor prognosis. Depression and anxiety occur more frequently in cancer of the pancreas than they do in other forms of intra-abdominal malignancies and other cancers in general. Yet, the etiology of psychiatric symptoms in patients with cancer of the pancreas may not be traced solely to poor prognosis, pain, or existential issues related to death and dying. In as many as half of patients that go on to be diagnosed with the disease, symptoms of depression and anxiety precede knowledge of the diagnosis. This observation has raised speculation that mood and anxiety syndromes are related to disruption in one of the physiologic functions of the pancreas. In this paper, we present a patient who had no prior psychiatric history and developed panic attacks just prior to diagnosis of her cancer. To our knowledge, this is the first report in the literature where panic attacks, not simply anxiety, presented prior to a pancreatic cancer diagnosis. Her symptoms resolved following resection of the tumor. Implications of such phenomena for the diagnosis and treatment of anxiety and depression in pancreas cancer are discussed.

The role of religious and spiritual beliefs in coping with malignant melanoma.

This study investigated the role of spiritual and religious beliefs in ambulatory patients coping with malignant melanoma. One-hundred and seventeen patients with melanoma being seen in an outpatient clinic completed a battery of measurements including the newly validated Systems of Belief Inventory (SBI-54). No correlation was found between SBI-54 scores and levels of distress. However, there was a correlation between greater reliance on spiritual and religious beliefs and use of an active-cognitive coping style (r = 0.46, p < 0.0001). Data suggest that use of religious and spiritual beliefs is associated with an active rather than passive form of coping. We suggest that such beliefs provide a helpful active-cognitive framework for many individuals from which to face the existential crises of life-threatening illness.

Nurses' recognition of depression in their patients with cancer.

PURPOSE/OBJECTIVES: To determine the degree to which nurses recognize levels of depressive symptoms in their patients with cancer and to describe patient characteristics that influence the accuracy of nurses' perceptions of depressive symptoms. DESIGN: Descriptive, prospective correlational design. SETTING: 25 community-based ambulatory oncology clinics affiliated with Community Cancer Care of Indiana. SAMPLE: 40 clinic nurses rated the depression levels of 1,109 patients. METHODS: Patients completed the Zung Self-Rating Depression Scale (ZSDS) prior to their medical oncology clinic appointment. Nurses rated their patients' level of depressive symptoms, anxiety, and pain on a 0-10 numerical scale along with determining a performance status score. MAIN RESEARCH VARIABLES: Patient-rated depression and the nurse depression rating. FINDINGS: The most frequent agreement between nurses and patients was observed when patients reported little or no depressive symptoms. They were only concordant 29% and 14% of the time in the mild and moderate/severe ranges, respectively. Nurses' ratings were influenced most by patients' endorsement of frequent and obvious mood symptoms and nurse ratings of patients' anxiety and pain. CONCLUSIONS: A marked tendency existed to underestimate the level of depressive symptoms in patients who were more severely depressed. Nurses' ratings were most influenced by symptoms such as crying, depressed mood, and medical factors that are useful but perhaps not the most reliable indicators of depression in this population. IMPLICATIONS FOR NURSING PRACTICE: Nurse assessment of depression might be improved if greater emphasis were placed on the more diagnostically reliable symptoms of depression and if screening tools for depression were incorporated into nursing practice.

Complicated delirium in a cancer patient successfully treated with olanzapine.

Delirium is common among cancer patients, especially those with advanced disease. Typical treatment involves addressing the underlying cause if possible; eliminating nonessential and/or other drugs that can worsen confusion, manipulating the environment; and administering antipsychotic drugs to control symptoms and agitated behavior, and attempt to clear the patient's sensorium. The newer atypical antipsychotics may have potential in the treatment of delirium and also have the added benefit of causing less akithisia and other extrapyramidal side effects. This is illustrated by the case of a 59-year-old woman with leukemia and pain of unclear etiology who developed a delirium and a moderate to severe extrapyramidal syndrome (EPS) in the setting of escalation of her pain medications and concomitant escalation of prochlorperazine. The patient presented with confusion and moderate to severe cogwheeling rigidity, masked facies, bradykinesia, and tremor. Additionally, the patient had a relatively recent history of subdural hematoma and one seizure. Conservative management including eliminating multiple nonessential medications (including the prochlorperazine); changing her opioid analgesic; providing a 24-hour companion: and administering low doses of haloperidol (0.5 mg-2.0 mg) were not effective in treating the patient's delirium. The patient's EPS was dramatically worse following haloperidol doses. After approximately I week without improvement, the patient was started on olanzapine 5 mg daily with initial improvement but with residual confusion in the evenings and overnight. The dose was titrated up to 10 mg nightly with 2.5 mg as needed during the day. After 3 days on this regimen, the patient's mental status exam was normal and she was discharged home. We discuss the potential utility of this atypical antipsychotic in the palliative care setting.

Surgeon-patient communication in the treatment of pancreatic cancer.

BACKGROUND: Effective physician-patient communication has been correlated with patient satisfaction and improved outcome. Pancreatic cancer (PC) is a disease with an overwhelmingly poor prognosis that requires a complex level of communication and emotional support. Since the treatment of PC is often surgical, surgeons play a central role in the care of these patients. OBJECTIVES: To assess the quality of long- and short-term surgeon-patient communication. To assess the role of the surgeon in the emotional support of patients with PC. DESIGN: Combined mail and telephone survey of a case series of patients who had undergone a pancreatic resection for PC. SETTING: Urban tertiary cancer referral center. PATIENTS: Forty-eight patients who underwent pancreatic resection for PC. INTERVENTION: Pancreatic resection. MAIN OUTCOME MEASURE: Patient satisfaction. RESULTS: Forty-eight patients completed surveys for a response rate of 70%. Patients were extremely satisfied with the information provided by their surgeon before surgery and while in the hospital. However, 21% of patients reported an unexpected outcome of their operation and 27% had questions about their disease at the time of the survey. Patients were largely satisfied with the emotional support they had received while in the hospital and after discharge. The attending surgeon was the most commonly desired source of additional emotional support. CONCLUSIONS: While surgeon-patient communication was extremely effective before surgery and during hospitalization, patients developed long-term questions and dissatisfaction after discharge from the hospital. Strategies to improve long-term support and communication would benefit a significant number of patients with operable PC. Surgeons play an important role in the emotional support of patients with operable PC.

Patient-related barriers to pain management in ambulatory AIDS patients.

A number of studies have demonstrated that pain is dramatically undertreated among patients with AIDS and that opioids in particular are rarely prescribed. To date, however, there has been no systematic attempt to examine patient-related barriers to the management of pain in AIDS. This study examines potential patient-related barriers to pain management in patients with AIDS using the Barriers Questionnaire (Ward et al., Pain, 52 (1993) 319-324), and assesses gender, racial, and other demographic differences in the endorsement of these barriers. We surveyed 199 ambulatory patients with AIDS, recruited from numerous sites in New York City, as part of an ongoing study of pain and quality of life in ambulatory AIDS patients. In addition to obtaining demographic and medical data, we administered a number of self-report questionnaires including the Brief Pain Inventory (BPI), the Brief Symptom Index (BSI), the Beck Depression Inventory (BDI), and the Memorial Symptom Assessment Scale (MSAS). Barriers to pain management were assessed using a modified version of the Barriers Questionnaire (BQ), including the original 27 questions from this self-report instrument along with an additional 12 items developed for an AIDS population. Results indicated that the most frequently endorsed BQ items were those concerning the addiction potential of pain medications and physical discomfort associated with opioid administration (e.g. injections) or side effects (e.g. nausea, constipation). There were no associations between age, gender, or HIV transmission risk factor and total scores on the BQ; however, Caucasian patients endorsed significantly fewer BQ items than did non-Caucasian patients and years of education was negatively correlated with BQ scores. Scores on the BQ were also significantly correlated with number of physical symptoms (MSAS) and scores on several self-report measures of psychological distress (the BSI Global Distress Index, BDI total scores). Patient-related barriers (i.e. BQ total scores) were significantly associated with undertreatment of pain (as measured by the Pain Management Index), and added significantly to the prediction of undertreatment in a logistic regression analysis, even after controlling for the impact of gender, education and IDU transmission risk factor. These data suggest that patient-related barriers to pain management may add to the already considerable likelihood of undertreatment of AIDS-related pain.