Hope, optimism and survival in a randomised trial of chemotherapy for metastatic colorectal cancer.

PURPOSE: Psychological responses to cancer are widely believed to affect survival. We investigated associations between hope, optimism, anxiety, depression, health utility and survival in patients starting first-line chemotherapy for metastatic colorectal cancer. METHODS: Four hundred twenty-nine subjects with metastatic colorectal cancer in a randomised controlled trial of chemotherapy completed baseline questionnaires assessing the following: hopefulness, optimism, anxiety and depression and health utility. Hazard ratios (HRs) and P values were calculated with Cox models for overall survival (OS) and progression-free survival (PFS) in univariable and multivariable analyses. RESULTS: Median follow-up was 31 months. Univariable analyses showed that OS was associated negatively with depression (HR 2.04, P < 0.001) and positively with health utility (HR 0.56, P < 0.001) and hopefulness (HR 0.75, P = 0.013). In multivariable analysis, OS was also associated negatively with depression (HR 1.72, P < 0.001) and positively with health utility (HR 0.73, P = 0.014), but not with optimism, anxiety or hopefulness. PFS was not associated with hope, optimism, anxiety or depression in any analyses. CONCLUSIONS: Depression and health utility, but not optimism, hope or anxiety, were associated with survival after controlling for known prognostic factors in patients with advanced colorectal cancer. Further research is required to understand the nature of the relationship between depression and survival. If a causal mechanism is identified, this may lead to interventional possibilities.

Developing an Evidence-Based, Nurse-Led Psychoeducational Intervention With Peer Support in Gynecologic Oncology.

BACKGROUND: The physical and psychosocial impact of radiotherapy for gynecologic cancer requires complex interventions to address treatment-related, psychosocial, and psychosexual and survivorship needs. A multidisciplinary approach is required to address these needs, but standard practice is varied and lacks a sound evidence base. OBJECTIVE: The aim of this study was to describe the process of development and pilot testing of a novel evidence-based, complex psychoeducational intervention aiming to improve psychosocial outcomes for gynecologic-oncology patients treated curatively with radiotherapy. METHODS: The intervention combines tailored nursing consultations with telephone peer support pretreatment, midtreatment, end of treatment, and posttreatment. The UK Medical Research Council framework for developing complex interventions was used to produce an evidence-based, feasible, and acceptable intervention. RESULTS: Intervention manuals and study materials were informed by literature reviews of best-available evidence, relevant theory, and iterative consumer and expert consultations. The nurse manual specified content for consultations providing self-care information, coaching tailored to individual needs, and multidisciplinary care coordination. The peer manual described phone consultations aimed at providing psychosocial support and encouraging adherence to self-care strategies. Three peers and 1 nurse underwent rigorous skills and knowledge-based intervention delivery training. The intervention was pilot tested with 6 patients. Qualitative feedback led to minor design and content changes. CONCLUSIONS: The intervention was found to be feasible, relevant, and acceptable to participants and clinicians and is currently being tested in a national randomized controlled trial (PeNTAGOn). IMPLICATIONS FOR PRACTICE: The Medical Research Council framework is useful in developing nursing interventions. The specific methods and strategies described are useful for designing future complex studies targeting patient supportive care.

Profile and predictors of long-term morbidity in breast cancer survivors.

BACKGROUND: A sound understanding of the benefits of different treatment options and their health-related quality of life (HRQoL) impacts is required for optimal breast cancer care. METHODS: A cross-sectional cohort study was conducted to determine the prevalence and severity of persistent functional decrements and symptoms and identify demographic, clinical and treatment variables associated with poorer outcomes. Four hundred English-speaking women treated for ductal carcinoma-in-situ or stage I to III breast cancer between 1999 and 2009, at least 12 months after surgery and currently disease free, were randomly selected and invited to complete (1) the Breast Cancer Treatment Outcome Scale and (2) the EORTC core Quality of Life Questionnaire, version 3. RESULTS: The response rate was 85.60 %. Many participants reported moderate to severe decrements in a number of HRQoL domains, including functional well-being (15 %), cosmetic status (32 %) and overall quality of life (21 %). There were significant associations (p < .05) between younger age and poorer HRQoL but none between time since surgery and morbidity (p > .05). Different treatments were associated with different HRQoL impacts. Poorer functional status was predicted by axillary dissection (p = .011), and adjuvant radiotherapy was a significant predictor of breast-specific pain (p < .05). CONCLUSIONS: Many breast cancer survivors report long-term morbidity that is unaffected by time since surgery. The significant associations between the extent of locoregional therapies and poorer HRQoL outcomes emphasize the importance of the safe tailoring of these treatments.

To tell or not to tell: the community wants to know about expensive anticancer drugs as a potential treatment option.

PURPOSE: Many new cancer treatments are available only at significant financial cost to the patient. We previously reported that Australian medical oncologists commonly do not discuss unsubsidized, expensive anticancer drugs (EACD) because of concern about causing distress. We argued that this position was not consistent with modern ethical principals but wanted to seek the community viewpoint. METHODS: A cross-sectional telephone survey of the Australian general public was performed. Respondents' views were sought about three hypothetical scenarios in which they were diagnosed with incurable cancer and an EACD treatment (out-of-pocket cost US$25,000) was available. RESULTS: Responses were obtained from 1,255 respondents (response rate, 43%). One hundred thirty-seven (11%) had a prior cancer diagnosis. Ninety-one percent of respondents wanted to be told by their doctor about an EACD that could improve survival by an additional 4 to 6 months, with 51% prepared to pay for it. People were more willing to pay if the drug could improve quality of life (71%) or if there was no effective standard treatment (76%). Sixty-eight percent believed the government should pay. Cost would be a significant financial burden for 31% of those willing to pay. Those more likely to want to be informed were younger, employed, better-educated, or had higher income levels (P < .05). Responses did not vary with the person's personal experience of cancer. Of the 9% who did not wish to be informed, half of these were concerned about the information causing distress. CONCLUSION: The Australian general public wants to be informed about EACD as potential treatment options, even if they are not willing or readily able to pay for them.

Is symptom burden a predictor of anxiety and depression in patients with cancer about to commence chemotherapy?

OBJECTIVES: To assess the prevalence, severity and distress from physical symptoms and the prevalence of anxiety and depression in patients about to undergo chemotherapy for potentially curable cancers; and to explore the presence of symptom clusters and investigate their relationships with anxiety and depression. DESIGN, PARTICIPANTS AND SETTING: Cross-sectional survey of 192 patients with breast or gastrointestinal cancers or lymphoma before first ever chemotherapy treatment with curative intent. MAIN OUTCOME MEASURES: Hospital Anxiety and Depression Scale to assess anxiety and depression and the Chemotherapy Symptom Assessment Scale to measure physical symptom prevalence, severity and distress ("bother"). RESULTS: Prevalence of anxiety was 45% and depression 25%. The most prevalent physical symptoms were pain (48%), feeling unusually tired (45%) and difficulty sleeping (45%). Physical symptoms rated as most severe were pain (28%), difficulty sleeping (26%) and feeling unusually tired (19%). Physical symptoms causing the most distress were pain (39%), constipation (18%) and nausea (16%). Factor analysis of symptom distress scores indicated that five factors explained 36.7% of the variance and included: gastrointestinal (nausea, vomiting, pain), general malaise (tiredness, feeling weak, headaches), emotional (feeling depressed, feeling anxious), nutritional (changes to appetite, weight loss or gain) and general physical (mouth/throat problems, shortness of breath). Regression analysis indicated that symptom distress for the malaise (beta = 1.46; P < 0.001), nutritional (beta = 0.70; P < 0.05) and gastrointestinal (beta = 0.73; P < 0.05) factors were independent predictors of depression. CONCLUSIONS: Before commencing chemotherapy, patients are already experiencing distressing symptoms and have high scores for anxiety and depression, partially explained by physical symptom distress. Patients should be routinely screened for both emotional and physical needs and appropriate interventions should be developed. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN012606000178549.

Towards better communication in cancer care: a framework for developing evidence-based interventions.

Increasing recognition of the complexity and difficulty of communication in patient care has led to a burgeoning but chaotic literature that tends to be incomplete on any one topic. A co-ordinated, planned approach is required to facilitate the rapid development and implementation of evidence-based interventions in this area. We propose a seven-stage model of communication research that is designed to provide clear directions to improve communication in cancer care. The stages are: (1) identification of communication difficulties; (2) documentation of patient and clinician views; (3) identification of practices associated with better outcomes; (4) the development of evidence-based guidelines and interventions; (5) testing the effectiveness of the intervention in changing current practice and improving patient outcomes; (6) dissemination of the effective interventions; and (7) broad adoption of the intervention. Examples are provided for each stage of research to elucidate the type of study proposed.

Youth culture and smoking: Integrating social group processes and individual cognitive processes in a model of health-related behaviours.

This article assesses four theoretical models proposed to predict future smoking. Young adults were surveyed at three six-month intervals, the first occurring three months after leaving school. Models 1 and 2 were versions of theory of triadic influence (TTI), which links a person's behavioural experience and cognitions to their future behaviour. Model 1 did not fit the data; the fit of model 2 was just adequate. Model 3 combined TTI and self-categorization theory (ST), by allowing norms of the individual's peer group to influence cognitions and future behaviour. It fitted the data well. Model 4, which extended model, provided the best fit. Strength of identification to the peer group was found to enhance the effect of the peer group norm.

How oncologists discuss complementary therapy use with their patients: an audio-tape audit.

Understanding the dynamics of oncologist-patient communication regarding complementary therapy (CT) use is essential for the development of much-needed clinical guidelines. Discussions of CT use in 314 audio-taped initial consultations between cancer patients and their oncologists were identified and coded. Patients' anxiety levels and coping styles were also assessed. Reference to CT use was found in 91 consultations (29%). Patients and kin initiated most CT discussions, commonly during discussions of patients' medical history, treatment options or prognosis. In half of these discussions, patients volunteered that they were currently using a CT or were considering its use. Discussion of CT use was more likely to occur in consultations with patients who were younger, were better educated, spoke poorer English, had metastatic disease or limited life expectancy and expressed higher levels of fighting spirit and anxious preoccupation and lower levels of fatalism. The most commonly discussed CTs were: changes in diet; use of multivitamins, vitamin C or antioxidants; and having a positive attitude or fighting spirit. The doctor's overall response to CTs was most frequently coded as "encouraging", although 35% of attempts to initiate discussion were ignored by the oncologist. Doctors were more likely to make encouraging statements about CTs typically perceived to be potentially helpful versus potentially harmful. The current findings point to a need for practical consensus on how to communicate with cancer patients on the subject of CT use so that patients can receive the support and guidance that they are seeking from their oncologists.