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.

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.

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.

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.

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.

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.

Substance abuse issues in cancer patients. Part 2: Evaluation and treatment.

The relationship between the therapeutic use of potentially abusable drugs for symptom control and the multifaceted nature of abuse and addiction is extremely complex. Research is only beginning to elucidate the nature of this relationship and its clinical implications. At present, practical management is based primarily on clinical experience and anecdotal observations. In part I of this two-part series (published last month), the authors explored the epidemiology of substance abuse in the cancer population, provided definitions of addiction and abuse appropriate for the oncology setting, and offered guidelines for the assessment of aberrant drug-taking behavior. In this second part, the authors provide recommendations for the evaluation and treatment of patients with cancer who have a history of substance abuse. Suggested therapeutic goals are outlined, and plans for inpatient and outpatient management and detailed.

Substance abuse issues in cancer patients. Part 1: Prevalence and diagnosis.

Although rare, drug abuse problems present a complex set of physical and psychosocial issues that complicate cancer treatment and pain/ symptom management. Most oncologists are not be well versed in either the conceptual or practical issues related to addiction. As a result, they often struggle in their attempts to effectively treat patients who are or have been substance abusers, and they find it difficult to understand issues of addiction in patients with pain who have no history of substance abuse. In the first installment of a two-part series, the authors explore the epidemiology of substance abuse. An examination of the distinctions between abuse and dependence leads to definitions of these terms appropriate for the oncology setting. Guidelines for assessing aberrant drug-taking behavior are also offered. Part 2, which will appear in the next issue of ONCOLOGY, will discuss the clinical management of cancer patients with a history of substance abuse.

Oncologists' recognition of depression in their patients with cancer.

PURPOSE: This study was performed as part of a large depression screening project in cancer patients to determine the degree of physician recognition of levels of depressive symptoms in cancer patients and to describe patient characteristics that influence the accuracy of physician perception of depressive symptoms. METHODS: Twenty-five ambulatory oncology clinics affiliated with Community Cancer Care, Inc of Indiana enrolled and surveyed 1,109 subjects treated by 12 oncologists. Subjects completed the Zung Self-Rating Depression Scale (ZSDS) and physicians were asked to rate their patients' level of depressive symptoms, anxiety, and pain using numerical rating scales. Subjects' sex, age, primary tumor type, medications, primary caregiver, and disease stage at diagnosis were also recorded. RESULTS: Physician ratings of depression were significantly associated with their patients' levels of endorsement of depressive symptoms on the ZSDS. However, agreement between physicians and patients is most frequently clustered when patients report little or no depressive symptoms. While physician ratings are concordant with patient endorsement of no significant depressive symptomatology 79% of the time, they are only concordant 33% and 13% of the time in the mild-to-moderate/severe ranges, respectively. Physician ratings were most influenced by patient endorsement of frequent and obvious mood symptoms, ie, sadness, crying, and irritability. Physician ratings also appeared to be influenced by medical correlates of patients' level of depressive symptoms (functional status, stage of disease, and site of tumor). Additionally, patients whose depression was inaccurately classified reported significantly higher levels of pain and had higher levels of disability. Physicians' ratings of depression were most highly correlated with physicians' ratings of patients' anxiety and pain. CONCLUSION: Physicians' perceptions of depressive symptoms in their patients are correlated with patient's ratings, but there is a marked tendency to underestimate the level of depressive symptoms in patients who are more depressed. They are most influenced by symptoms such as crying and depressed mood, and medical factors that are useful, but not the most reliable, indicators of depression in this population. Physicians' ratings of their patients' distress symptoms seem to be global in nature--they are highly correlated with anxiety, pain, and global dysfunction. Physician assessment might be improved if they were instructed to assess and probe for the more reliable cognitive symptoms such as anhedonia, guilt, suicidal thinking, and hopelessness. Screening instruments and the use of brief follow-up interviews would help to identify patients who are depressed.

The Network Project: a multidisciplinary cancer education and training program in pain management, rehabilitation, and psychosocial issues.

Despite recent advances in cancer pain management and education, the undertreatment of cancer pain remains a national health problem. In response to the need for interdisciplinary education and training, we have developed "The Network Project" at Memorial Sloan-Kettering Cancer Center. This program includes a 2-week observership in cancer pain management, psychosocial oncology, and cancer rehabilitation. The efficacy of the Network Project Observership Program was evaluated with the use of a knowledge and attitude inventory which contains questions pertaining to cancer pain, psychosocial oncology, and cancer rehabilitation, and follow-up questionnaires completed one year after participation in the program. The knowledge and attitude inventory was completed by each participant both before and after the observership period. Analysis of the 152 observers who participated in the first 3 years of the Network Project's Observership Program demonstrated a significant improvement in knowledge of cancer pain, psychosocial issues, and rehabilitation issues (P < 0.0001). In addition, observers reported a significant increase in their local educational and training activities in the year following participation in the Network Project (P < 0.01). The Network Project, funded by the National Cancer Institute, is an interdisciplinary, multimodal training program which has been demonstrated to be an effective means for improving and disseminating knowledge regarding the multidisciplinary management of pain and psychological distress in cancer patients.

Psychosocial aspects of upper extremity lymphedema in women treated for breast carcinoma.

BACKGROUND: Lymphedema of the upper extremity following breast carcinoma is highly distressing and disabling. METHODS: A review is presented of the literature on psychosocial aspects of lymphedema. RESULTS: Studies have shown that women who develop lymphedema exhibit higher levels of psychological, social, sexual, and functional morbidity than women with breast carcinoma who do not develop this complication. Women who have poor social support, pain, lymphedema in the dominant hand, and/or a passive and avoidant coping style report the highest levels of disability. CONCLUSIONS: Due to the morbidity of lymphedema once it develops, prevention and information given early are extremely important. However, the recommendations made to women sometimes involve considerable changes in lifestyle but are not based on solid, prospective evidence. In addition, how to best impart and time information about lymphedema pre- and postoperatively require investigation. In this paper, the authors discuss the psychological and functional impact of lymphedema and strategies for intervention and research to help women prevent the condition or enhance coping with it once it develops.