Framework for timing of the discussion about forgoing cancer-specific treatment based on a qualitative study with oncologists.

BACKGROUND: Many patients with advanced cancer receive aggressive chemotherapy close to death and are referred too late to palliative or hospice care. AIM: The aim of this study was to investigate oncologists' and oncology nurses' perceptions of the optimal timing for discussions about forgoing cancer-specific therapy at the End-of-Life (EOL) and the reasons that might hinder them. DESIGN: Qualitative in-depth interviews with oncologists and oncology nurses were carried out. The empirical data were evaluated from a normative perspective. SETTING/PARTICIPANTS: Twenty-nine physicians and nurses working at the Department of Hematology and Oncology of a German university hospital were interviewed. RESULTS: Health-care professionals differed considerably in their understanding of when to initiate discussions about forgoing cancer-specific therapy at the EOL. However, their views could be consolidated into three approaches: (1) preparing patients gradually throughout the course of disease (anticipatory approach) which is best suited to empower patient self-determination in decision-making, (2) waiting until the patient him/herself starts the discussion about forgoing cancer-specific treatment, and (3) waiting until all tumor-specific therapeutic options are exhausted. CONCLUSION: The empirically informed ethical analysis clearly favors an approach that prepares patients for forgoing cancer-specific therapy throughout the course of disease. Since the last two approaches often preclude advance care planning, these approaches may be less ethically acceptable. The proposed framework could serve as a starting point for the development of concrete recommendations on the optimal timing for EOL discussions.

Personality influences quality-of-life assessments in adult patients after allogeneic hematopoietic SCT: results from a joint evaluation of the prospective German Multicenter Validation Trial and the Fred Hutchinson Cancer Research Center.

The influence of personality on health related quality of life (QoL) and physical functioning in the setting of allogeneic hematopoietic SCT (alloHSCT) is unknown. We conducted a joint evaluation within two independent cohorts of alloHSCT recipients to investigate the impact of personality on reported QoL and physical functioning. Two-hundred-eight patients (median age 44 years, range 18-72) of cohort 1 and 93 patients (median age 55 years, range 19-79) of cohort 2 after alloHSCT were evaluated. Personality was assessed using the 24-adjective measure (AM), which measures the Big-Five personality domains and the Life Orientation Test-Revised (LOT-R), measuring optimism and pessimism. QoL was measured using the Functional Assessment of Cancer Therapy with bone marrow transplantation subscale (FACT-BMT), Short Form 36 (SF-36), the human activity profile (HAP), as well as the NIH criteria-based cGVHD activity assessment form and the Lee cGVHD symptom scale. Neuroticism was significantly associated with worse function measured by the HAP and FACT-BMT. Optimism significantly improved QoL captured by the FACT-BMT. Pessimism significantly impaired physical function captured by the HAP and SF-36. Extraversion was significantly associated with reduced depression and lower severity of cGVHD symptoms reported by the patient and the physician. The results suggest that personality traits and pre-treatment QoL assessments should be measured in clinical trials to facilitate the interpretation of QoL data.

[Psycho-oncology : the psyche and cancer]. / Psychoonkologie : Psyche und Krebs.

The relationships between the psyche and cancer are manifold. Psycho-oncology focuses on the psychological adjustment to life-threatening illnesses. Crises are not unusual in health care, but the perception of cancer is totally different because the diagnosis of cancer often results in an irrational shock reaction in all parties involved. A diagnosis of cancer is much more negatively perceived than any other incurable disease, such as cardiopathy or neuropathy with a comparable or worse prognosis. During the shock of having received a diagnosis of cancer, there is no awareness that cancer can be cured. Improvement of quality of life, identification of psychological distress and prevention of mental disorders are the main tasks of psycho-oncology. Psycho-oncological services are not longer regarded a luxury, but are recognized by health care politicians as being important. However, the financing of services remains unclear.

[Psychosocial distress as a concomitant symptom in cancer patients]. / Psycho-sozialer Distress als Begleitsymptom der Krebserkrankung.

According to the lay mind the psyche is somehow responsible for the cancer growth, at least to name one reason for the verdict of guilty. Scientifically this issue has no evidence, as well as there is no evidence that the psyche has an influence on neither survival time nor healing rates. Merely undisputed is the effect of the psychosocial stress of a life-threatening medical illness onto the quality of life of the patients and family members. This kind of stress is called "distress"in the American-speaking countries. The translation into German terms is still poorly defined and mainly concentrated to the psychiatric disorders (ICD-10) like depressions and anxiety disorders. Psycho-oncological research is currently interested besides others issues in the question of a suitable screening-method to identify patients in regard to their distress level, who would profit by a specific psycho-oncological intervention.

[Therapy of chronic myeloid leukemia with interferon-alpha. A decade of experiences]. / Therapie der chronischen myeloischen Leukämie mit Interferon alpha. Erfahrungen aus einem Jahrzehnt.

PATIENTS AND RESULTS: One hundred and fifty-nine patients with chronic myelogenous leukemia have been treated in six studies during 10 years at Hannover Medical School University Center. The prognosis of 111 patients without pretreatment has been improved compared to conventional therapy with a median survival of 5.7 years. Cytogenetic remissions have been induced in all studies followed for a longer time. The most pronounced improvement of prognosis has been observed in these patients. CONCLUSIONS: Several conclusions can be drawn on the basis of the results on the different treatment concepts: 1. Patients with pretreatment have an unfavourable response to interferon. 2. There is a likely effect of the dose of Interferon alpha on the frequency of cytogenetic remissions. 3. The combination of Interferon alpha and interferon gamma has been toxic and ineffective in a pilot study. 4. The combination of interferon and cytosine arabinoside has a positive impact on the frequency of cytogenetic remissions. A continuous parallel application of both drugs seems to be most effective in this respect. An ongoing trial has been initiated to compare a fixed combination of Interferon alpha and cytosine arabinoside and with hydroxyurea respectively. Additionally the feasibility of autologous peripheral blood stem cell transplantation will be studied in patients with insufficient response to the interferon treatment.

G-CSF in the long-term treatment of cyclic neutropenia and chronic idiopathic neutropenia in adult patients.

Eleven adult patients with chronic neutropenia have been treated with recombinant human granulocyte colony-stimulating factor (G-CSF). Seven patients had idiopathic sporadic neutropenia, 2 idiopathic congenital neutropenia and 2 cyclic neutropenia. Treatment was started with 3 micrograms/kg s.c. daily and was modified according to response. All patients had a rapid increase of neutrophils. The cycle length shortened from 21 to 14 days in patients with congenital cyclic neutropenia. Doses required for maintenance ranged from 0.1 to 8 micrograms/kg. One patient with idiopathic sporadic neutropenia recovered after 151 days with an absolute neutrophil count (ANC) of > 2000/microliters and had no need for further treatment. The overall efficacy of the treatment was good with abrogation of severe infections. Treatment has been continuously given to a maximum of 4.5 years. No loss of efficacy was observed during long-term treatment. There was no evidence for lineage drain or stem cell exhaustion with prolonged treatment. Cytogenetic analyses in seven of eleven patients did not reveal the development of abnormal cell-clones. G-CSF is safe and efficient in long-term treatment of adult patients with chronic neutropenias.

Granulocyte colony-stimulating factor enhances the expression of CD62 on platelets in vivo.

The expression of CD41, CD42 and CD62 on platelets was determined in ten patients with and without G-CSF treatment. CD41 and CD42 is expressed in nearly 100% of the platelets without change after G-CSF treatment. The expression of CD62 on the platelets' surface is significantly enhanced by G-CSF indicating a depletion of the alpha-granules. No platelet aggregation was observed. The enhanced secretion of thrombocyte-specific proteins does not induce aggregation but may promote ADP-induced aggregation. Furthermore, the surface-bound and soluble CD62 binds specifically to macrophages and endothelial cells and is involved in the regulation of inflammatory processes. Thus indirect mechanisms may supplement direct effects of G-CSF after chemotherapy.