Psychological distress among male patients and male spouses: what do oncologists need to know?

BACKGROUND: The aim of the current study was to strengthen the knowledge of oncologists concerning psychological distress and social support among married and unmarried male cancer patients and healthy male spouses of female cancer patients. PATIENTS AND METHODS: Three groups of men were recruited from three major cancer centers in Israel: 185 married colon and rectal cancer patients, 54 single (unmarried) colon and rectal cancer patients, and 153 male spouses of female cancer patients. Participants were evaluated on four standardized instruments measuring psychological distress, coping, and social support. RESULTS: About 42.6% of the participants reported on a clinical level of psychological distress, with the highest rates (61.1%) among the single (unmarried) patients. Distress was negatively correlated to Karnofsky score and coping variables among all study groups. Distress was significantly and negatively correlated to social support variables among the spouses and married patients but not among the single patient groups. CONCLUSIONS: Social support received by male cancer patients from friends and family may be mediated by spouse support. As a result, single male patients are at higher risk for psychological distress. Male spouses were also found to have high rates of distress. These two groups need special attention by oncologists.

Skilled nursing facilities as a setting for comprehensive care of older people with advanced cancer: a model of care in the post oncologic stage.

METHODS: We surveyed the elderly cancer patients admitted to the Skilled Nursing Wards of Shmuel Harofe Hospital, Geriatric Medical Center, during a 5-year period. RESULTS: The 304 elderly patients admitted with advanced cancer represented 16% of the skilled nursing patients admitted during this period. Their average time of survival was 4.2 months, ranging from 9.1 for breast cancer to 1.8 months for gastric cancer. Ninety-five percent were severely dysfunctional, and all had a high rate of medical complications. CONCLUSIONS: Our study reveals the benefits of a skilled nursing system that provides comprehensive care, flexibility, and continuity of care at a difficult and demanding stage of this illness. This model functions at reasonable cost, and we recommend it for the care of elderly patients with advanced cancer in the post oncologic stage.

Cancer in married couples: higher or lower distress?

This study focuses on the question of what occurs when both spouses become seriously ill. Our hypothesis was that psychological distress in married couples involving two ill partners is far higher than when only one partner is ill. The study group comprised 20 married couples, in which both spouses were diagnosed with cancer. Two comparison groups were also studied: 20 married couples with the husband diagnosed with cancer, and 20 couples with the wife diagnosed with cancer. All patients in the three groups completed four self-report scales: the Brief Symptom Inventory (BSI); the Perceived Family Support (PFS); the Impact of Events Scale (IES); and the Mental Adjustment to Cancer (MAC). The healthy spouses completed only the first three scales. Our findings supported the null hypothesis--that is, that the psychological distress in married couples with both partners diagnosed with cancer was not significantly different than when only one partner had cancer. Our findings also showed that neither sociodemographic background, medical condition, nor family support affect patient distress. Gender differences were found with Intrusiveness contributing to the distress of male, but not female, patients. This study confirms and augments earlier work, and shows that partners of cancer patients report a high degree of distress, with this level of distress not being much different from that of the patients.

Leukocyte alkaline phosphatase, CA15-3, CA125, and CEA in cancer patients.

Peripheral blood leukocyte alkaline phosphatase (LAP) scores and CA15-3, CA125, and CEA levels in plasma were measured in 57 patients with metastatic breast, ovarian, and colorectal cancer, respectively, and in 79 patients with the same types of nonmetastatic cancer. The mean LAP scores of the metastatic cancer patients (261, 272 and 275 for breast, ovary and colon, respectively) were significantly higher than those of the nonmetastatic cancer group (70, 68 and 57, respectively). There was no overlap between the 95% confidence intervals of the two groups (i.e., metastatic versus nonmetastatic), and no patient known to be metastatic had a LAP score within the normal range. The mean levels of other markers in the metastatic patients (CA15-3, 63.4 mu/ml; CA125, 104.8 mu/ml; and CEA, 51.8 ng/ml for metastatic breast, ovarian, and colon cancer, respectively) were also higher than in the nonmetastatic patients (CA15-3, 24 mu/ml; CA125, 25.3 mu/ml; and CEA, 5.8 ng/ml for nonmetastatic breast, ovarian, and colon cancer, respectively). However, the 95% confidence intervals of the nonmetastatic and the metastatic patients overlapped so that there were false-negatives and/or false-positives when the other markers were used. We therefore conclude that the addition of the LAP score to conventional cancer markers could be helpful for the diagnosis of recurrence and follow-up of cancer patients and suggest that our results be confirmed by further studies on a larger series of patients.

Meningiomas after radiotherapy for tinea capitis--still no history.

AIMS AND BACKGROUND: To review the clinical, radiological and histological findings of 19 patients with radiation-induced intracranial meningiomas treated at our neurosurgical department between 1981 and 1996. METHOD: The records of 18 patients with intracranial meningiomas who underwent low-dose radiation for tinea capitis in childhood, and of one patient irradiated for pituitary adenoma, were analyzed in respect of the previously reported features of postradiation meningiomas. RESULTS: The mean age of the patients with low-dose radiation-induced meningiomas was 58 years and the mean shortest onset latency was 48 years. The male to female ratio was 1.1:1. Forty-seven percent of patients presented with mental changes and/or focal neurological signs, 21% with signs of increased intracranial pressure and 26% with seizures. Calvarial location of the meningiomas was found in 54% of patients and in one patient the tumor arose from the skull base. Multiple tumors were present in 15% of patients and 29% of the meningiomas displayed malignant features on histological examination. A significantly lower meningioma recurrence rate was found in our series compared to the recurrence rate in the reported series of postradiation meningiomas. Five patients had a history of a second neoplasm other than meningioma. CONCLUSION: Our series of low-dose radiation-induced meningiomas represents one of the largest of its kind in the English literature. The patients did not differ substantially in sex ratio, tumor localization, multiplicity and histological features from the previously reported postradiation meningioma patients, except for the significantly lower tumor recurrence rate. It would seem that over the next years we will be further witnessing the deleterious effects of low-dose radiation administered in childhood.

Effect of very high single dose of cisplatinum and of radiation on the brain of the rabbit.

The importance of chemotherapy and radiotherapy for treating brain tumors, is well established. In a previous study, a rabbit's brain was treated with doses of up to 12 mg kg-1 of cisplatinum and 4000 cGy, without any morphological or pathological changes. The purpose of this study is to establish the effect of very high single doses of cisplatinum and radiation on the rabbit's brain, applied in 12, 16 and 18 mg kg-1, and 5000, 7500 and 8000 cGy, respectively. The general clinical and neurological condition of the rabbits was unaffected, but areas of alopecia and scalp ulcers appeared. Although these are very high doses of chemotherapy and radiotherapy, the histopathological and morphological examination of the rabbit's brain remained normal.

Cancer among spouses: review of 195 couples.

BACKGROUND: The study of cancer in spouses may play an important role in the assessment of cancer etiology. METHODS: Patterns of occurrence of cancer in 195 couples related by marriage only and treated in a regional hospital are reported. The distribution of tumors by site was compared with national data. RESULTS: Seven sites of cancer were found to be more frequent in married couples than in the general population, in particular carcinoma of the colon (37 observed vs. 19.5 expected in husbands [relative risk (RR) = 1.89 (95% confidence intervals [CI], 1.5-2.4); P < 0.001] and 32 vs. 16.7 in wives [RR = 1.92 (95% CI, 1.4-2.5); P < 0.001]), carcinoma of the prostate (32 vs. 20 in husbands [RR = 1.6 (95% CI, 1.19-2.09); P < 0.01]), and carcinoma of the female breast (84 vs. 55 in wives [RR = 1.53 (95% CI, 1.3-1.8); P < 0.001]). Same site tumors were observed in 13 couples versus 6.21 expected in the general population (RR = 2.09 [95% CI, 1.25-3.26]; P < 0.01). A combination of carcinoma of the prostate and female breast sites was found in 18 couples versus 5.4 expected in the general population (RR = 3.34 [95% CI, 2.19-4.84]; P < 0.001). CONCLUSIONS: The distribution of cancer sites among spouses in those families in which both spouses have developed a cancer differs from that of the general population. These differences may be caused by shared risk factors. Increased awareness can explain only part of the excess.

Effect of high simple dose of cisplatinum and of radiation on the brain of rabbit.

In former studies of intracarotid and intravenous administration of cisplatinum, separate and combined with brain irradiation, we found no cerebral damage. In this study, gradually increasing high doses (above the therapeutic ones) of cisplatinum were administered intravenously to one series of rabbits and increasing high amounts of irradiation (above the therapeutic amounts) were given to another series. Although the rabbits that received highest doses of irradiation developed areas of alopecia and skin ulcers on the head, the general clinical and histopathologic examination of the rabbits' brains in both series was normal. The purpose of this study was to establish the effects of high doses of intravenous cisplatinum and irradiation on the rabbits brains.

Clinical determinants of long-term survival in patients with glioblastoma multiforme.

Repeated reports of more than ten years postoperative survival in patients with glioblastoma multiforme (GM) have appeared in the literature over the last decades. Authors have tried to identify the clinical, therapeutic and histological features determining long-term survival. We present two patients in whom, after radical removal of the tumor followed by conventional radiation, there has been no recurrence for at least ten years. The young age of the patients and the radical surgical approach were in accordance with previous reports of long-term survival. Nevertheless, one tumor originated from the thalamus, a location considered to be of unfavorable prognosis. We therefore further discuss the value of clinical signs as determinants in the prognosis of GM.

Effect of the combination of cisplatinum and radiation in the rabbit's brain.

The effect of cisplatinum as a potential radiosensitizer in brain tumors is controversial. We examined the effect of the combination of cisplatinum with radiation compared to radiation alone in rabbits' brain. All rabbits were irradiated and cisplatinum was injected intravenously into part of them. Therapeutic doses of cisplatinum and irradiation were given. The rabbits were euthanised at different intervals according to protocol. The general clinical and neurological condition of the rabbits was unaffected, and histopathological examination of the rabbit's brain was normal. The purpose of this study was to establish the effect of cisplatinum followed by cranial irradiation in therapeutic doses to the normal rabbit's brain.

[Elderly cancer patients requiring skilled nursing care].

Cancer is an age-associated disease, and 55% of newly diagnosed cases and 67% of cancer deaths are in those above 65 years. There has recently been increasing interest in geriatric oncology, and more of the elderly are being screened for early cancer detection. Elderly cancer patients present problems not only because of their primary disease, but also because of comorbidity, reduced functional reserve, and diminished social support. Because of this combination of factors many of them need the specially skilled nursing care available in special units. 304 elderly cancer patients were admitted to our "skilled nursing division" of 156 beds during the 6 years 1987-1992. They represented 16% of all admissions and their average age was 78 +/- 0.4 (SD). Mean survival after admission was 4.1 +/- 0.4 months. In the 143 men it was 3.1 +/- 0.4 months and in the 161 women, significantly longer, 4.9 +/- 0.5. The most common location in men was colorectal (22.6%), followed by prostate (16%), while in women it was breast (25.4%), followed by colorectal (16.0%). The longest survival was for women with breast cancer (9.1 +/- 1.3 months) and the shortest for women with gastric cancer (1.9 +/- 0.6). On admission 81% had more than 1 comorbid condition: 91% had restricted mobility, 215 urinary incontinence and 12% various kinds of stomas. Serious conditions were urinary tract infections in 40%, sepsis 20%, pneumonia 12%, gastrointestinal bleeding 10% and bedsores in 7%. 77% needed intravenous fluids and/or drugs for infections, 50% narcotics for analgesia, 27% nasogastric tubes, 20% blood transfusions, 6% debridement, and 5% paracentesis. The elderly with cancer are the most difficult long term patients to treat, since their conditions are dynamic, continuously deteriorating, and they require intensive medical, nursing and psychological care.

Brain effect of intracarotid administration of cisplatinum.

The antitumoral effect of Cisplatinum is well known, including its effect on brain tumors. With the purpose of establishing the effect of intraarterial cis-dichlorodiammine platinum (CDDP) on the brain, Cisplatinum was injected in rabbits that were sacrificed at different intervals. The general clinical and neurological condition of the rabbits was unaffected, and histopathological examination of the rabbit's brain was normal.

Leukocyte alkaline phosphatase and serum alkaline phosphatase in patients with metastatic breast and colon cancer.

Peripheral blood leukocyte alkaline phosphatase (LAP) scores and serum alkaline phosphatase (SAP) levels in 70 patients with metastatic breast and colorectal cancer (metastases to the liver, lung, bone and abdomen) and in 18 healthy controls were measured. The mean LAP score in the metastatic cancer patients was significantly higher than in the control group (244 vs. 61) and there was no overlap between the 95% confidence level intervals of the two groups. The mean (SAP) level in the metastatic patients was also higher than in the controls (249 u/l vs. 162 u/l) but the 95% confidence level interval of the controls was inside the 95% interval of the metastatic patients meaning that considerable percentage of the metastatic patients will have a SAP level within the normal range. We conclude that of the two markers, the LAP is the better one for detection of metastatic tumors.

Long-term follow-up of patients with superficial transitional cell carcinoma of the urinary bladder treated by intravesical mitomycin C.

Prophylactic intravesical chemotherapy (IVC) reduces recurrence rates of superficial transitional cell carcinoma (TCC) of the urinary bladder. The patient cohort existed of 86 individuals (stage TaN0M0 or T1N0M0) superficial carcinoma of various grades of malignancy. Following initial transuretheral resection or diagnostic cystoscopy, mitomycin C (MMC), 20 mg dissolved in 50 ml saline, was instilled intravesically by catheter over 1 hr at 2-week intervals, initially and then four more times followed by diagnostic cystoscopy (one course = 12 weeks). Two similar courses were administered thereafter for a total period of 36 weeks. For patients in remission, installations continued in monthly fractionations for 9 more months (cystoscopy every 3 months) and then at 2-month intervals for 12 more months (cystoscopy every 6 months). When cystoscopy revealed recurrence, IVC was repeated from the beginning. No symptoms of MMC-related toxicity were observed. Cystoscopic follow-up evaluations showed a complete response rate of 84% at 3 years and 81% at 5 years after initial therapy. Twenty-seven patients who had not responded to previous treatment with other drugs responded to MMC.

Leukocyte alkaline phosphatase as a probable predictor of the metastatic state in breast and colon cancer patients.

Leukocyte alkaline phosphatase (LAP) score in peripheral blood was determined in 45 new cancer patients, 30 with breast cancer and 15 with colorectal cancer, with nonmetastatic disease. The LAP scores were performed immediately after diagnosis or surgery, and later at intervals of 1-3 months, until clinical detection of metastases. The preliminary data presented here show that there may be some utility in measuring LAP score in patients with solid tumors on a serial basis to detect evidence of metastatic disease prior to its clinical recognition. In 22 out of 30 breast cancer patients and 11 out of 15 colon cancer patients, there were 'alarming signals' of metastases (defined in this study) in the data taken before the checkup in which metastases were diagnosed by other methods. We conclude that LAP scores should be introduced into routine checkup of breast and colon cancer patients and could be a helpful nonspecific additional element in detecting earlier metastatic disease during the follow-up of a patient. As an extrapolation from this study we suggest that work should be undertaken to explore the possibility that a sudden rise of LAP score in an otherwise healthy person, who has no known reason for an elevated LAP score, might be the very first measurable sign of cancer.

Randomized study comparing chemotherapy with and without estrogen priming in advanced breast-cancer.

A randomized trial was performed to determine if combination chemotherapy (CT) with estrogen (E) priming (E+ study arm) was superior to CT alone (E- study arm) in patients with advanced breast cancer. CT for both arms included adriamycin + vincristine (AV) starting on day 7 alternating with cytoxan + methotrexate + fluorouracil (CMF) starting on day 28, the entire cycle repeated every 6 weeks. Estrogen priming consisting of 2 mg estradiol + 1 mg estriol (E+ arm) was given orally twice daily beginning on day 1 and continuously through CT until disease progression or unacceptable toxicity. Performance status (KPS) for all patients (n=19, E+ arm; n=22, E- arm) ranged between 70-100%. Mean age (53 y, E+ arm; 56 y, E- arm), menopausal and estrogen receptor status and treatment duration (approximately 38 weeks) were similar for both groups. Estrogen priming did not alter or enhance CT toxicity. Objective responses (CR,PR) were noted in 79% on the E+ arm (CR=11%, PR=68%) and in 73% on the E- arm (CR=9%, PR=64%). Thus, estrogen priming in this cohort of patients with advanced breast cancer did not appear to add to the toxicity or palliative benefit of CT.

Leukocyte alkaline phosphatase and carcinoembryonic antigen in lung cancer patients.

Leukocyte alkaline phosphatase (LAP) scores in peripheral blood and plasma carcinoembryonic antigen (CEA) levels were determined in 58 lung cancer patients and compared with those of 22 healthy persons, who served as controls. In the control group we found LAP scores of 54 +/- 28 and CEA levels of 4 +/- 3 ng/ml. The 97.7% confidence intervals are: LAP score < 110 and CEA level < 10. In the patients with limited lung cancer we found LAP scores of 152.4 +/- 36.7 and CEA levels of 22.7 +/- 48 ng/ml. The 97.7% confidence intervals are: LAP score > 78.6 and CEA level > 0. In the patients with extensive lung cancer we found LAP scores of 272 +/- 49 and CEA levels of 47.5 +/- 80.4 ng/ml. The 97.7% confidence intervals are: LAP score > 174 and CEA level > 0. The sensitivity of each marker is discussed, here as percent of false-negative results, denoted PFN, and meaning that with a chosen threshold for the marker level, only PFN% of the patients with a given condition (e.g. extensive lung cancer) might have a marker level less than the chosen threshold and could therefore be assumed healthy. The sensitivity of the LAP score is 0.05% PFN for the group of patients with extensive lung cancer, and we conclude that indeed LAP score < 110 indicates a very low probability of having extensive malignancy. The sensitivity of the CEA level is 32% PFN. The sensitivity of the LAP score to limited lung cancer is 12% PFN for the group of patients with that condition compared with 40% of CEA. The specificities of both LAP score and CEA levels, expressed as percent of false-positive results in the control group, are fair (2.3%), provided that the common conditions, other than cancer, that elevate LAP score and/or CEA levels are well known and can be eliminated by the physician. It is concluded that the LAP score is considerably more useful than the CEA level as a marker for extensive lung cancer.

Leukocyte alkaline phosphatase and carcinoembryonic antigen in metastatic colorectal cancer patients.

Peripheral blood leukocyte alkaline phosphatase scores and plasma carcinoembryonic antigen levels in 26 patients with metastatic colorectal cancer were compared to those in 30 healthy controls. Patients had metastases to the liver and abdomen. The mean leukocyte alkaline phosphatase score in the metastatic colorectal cancer patients was significantly higher than in the control group (246 +/- 65 vs, 52 +/- 26, p less than 0.001); and the mean carcinoembryonic antigen level in the patients was also significantly higher than in the controls (110 +/- 100 vs, 4.9 +/- 3 ng/ml, p less than 0.001). One hundred percent of the metastatic cancer patients had elevated LAP scores and 73% of these patients had elevated CEA levels. There was a difference between the mean CEA levels in the patients with liver metastases and those with abdominal metastases (162 +/- 135 vs, 39 +/- 53 ng/ml, p less than 0.04). The results suggest that although both markers were elevated in metastatic colorectal cancer, the LAP score seems to be more useful in detecting metastatic disease, since we found 11% false negatives with the CEA level and 0% false negatives with the LAP score.