Thyroid nodules. The place of fine-needle aspiration biopsy in management.

Although the advent of fine-needle aspiration biopsy (FNAB) has revolutionized evaluation of thyroid nodules, the procedure remains an imperfect instrument when used alone. Careful consideration of factors in the patient's history and physical examination can signal an indication for biopsy; an abundance of high-risk factors should override even negative biopsy results. Suspicious (cellular) biopsy results require singular attention. Subsequent radioisotopic imaging revealing an autonomous (hot) nodule essentially excludes the possibility of carcinoma, but warm or cold nodules require surgical excision for definitive diagnosis. Low false-negative rates accompanying benign or indeterminate results on FNAB permit management with suppressive therapy and periodic examination to detect growth or changes in characteristics of the nodule, development of adenopathy, or vocal cord paralysis. Persistent nodules justify rebiopsy in 1 year, or sooner if new risk factors emerge.

Pre-diagnostic symptom recognition and help seeking among cancer patients.

Failure to recognize symptoms which signal cancer may delay contact with the medical care system, thus decreasing the chances of diagnosis at an early stage of disease. We investigated the determinants of cancer symptom recognition and delay in seeking medical care in a population-based sample of 625 newly diagnosed lung, breast and colorectal cancer patients. Although the majority (79.5%) of patients reported noticing symptoms prior to diagnosis, one quarter of these patients (24.7%) delayed longer than three months in seeking medical care. Contrary to the findings of research based on clinic samples, logistic regression analysis revealed that no demographic or social support factors were predictive of symptom recognition or delay, with the exception that older colorectal cancer patients were less likely to notice symptoms, but also less likely to delay. Lung and colorectal patients diagnosed with advanced disease were more likely to notice symptoms than patients with local disease. Results of a content analysis of patients' remarks indicate that breast cancer patients were significantly more likely than lung or colorectal cancer patients to attribute their symptoms to cancer (p less than .001). Symptoms common to lung and colorectal cancer appear to be attributed to other, less serious causes. Given the lack of demographic predictors of symptom recognition and delay in seeking care, we suggest that education programs address risk groups for specific cancers, rather than the general public as a whole, grouping together all cancers and cancer symptomatology.

Understanding depression in medical patients. Part I: Diagnostic considerations.

Little attention has been devoted to integrating theoretical conceptions of depression when considering patients with medical illness. This is more true of the social work literature than the psychiatric, in which medical formulations and treatment of depression gain primary focus. This paper presents an approach for understanding the phenomenon of depression in medical patients. It incorporates a theoretical perspective on the mechanism of depression relevant to social work intervention. Topics reviewed include diagnostic criteria for depression in the medically ill, organic factors in depression, and psychosocial theory of depression applied to medical patients. A second part of this paper will provide case examples and recommendations for social work intervention.

Understanding depression in medical patients. Part II: Clinical intervention.

This paper presents case examples to illustrate key aspects of social work intervention with medical patients. Principles of clinical technique are discussed in relation to diagnosing and treating depression in the medically ill. This paper is a follow-up companion to "Understanding Depression in Medical Patients Part I: Diagnostic Considerations" and emphasizes the unique contribution of social work in the complex treatment of the biopsychosocial needs of individuals and families coping with physical illness.

Negotiating concrete needs: short-term training for high-risk cancer patients.

Advances in the diagnosis and treatment of cancer and revisions in health care financing and reimbursement have changed the experience of living with cancer. The disease now is diagnosed earlier and patients are likely to live longer with the disease. Patients and their families, thus, will require more concrete service needs. The authors review the psychosocial oncology literature and the literature on case management theories. They present their findings of a survey of the concrete needs of 413 cancer patients who were undergoing chemotherapy. Based on this survey, they developed a short-term case management intervention model to improve patient problem-solving skills. The intervention is designed to increase patient and family autonomy and mastery, reduce unmet needs, and counteract common feelings of helplessness associated with serious illness.

Surgically incurable well-differentiated thyroid carcinoma. Prognostic factors and results of therapy.

A series of 97 consecutive patients with well-differentiated thyroid carcinoma treated between 1941 and 1970 presented with distant metastatic disease or extensive nonresectable local neck disease or had residual carcinoma after thyroid resection. Men 40 years of age or younger and women 50 years of age or younger were considered at low risk for dying of disease; older patients were considered at high risk for dying of disease. Of 17 patients with distant metastatic carcinoma, 40% of younger patients in the low-risk group and 92% of older patients in the high-risk group died. Of 80 patients with unresectable or residual local neck cancer, only 13% of younger patients but 71% of older patients died. Survival related better to risk group classification as defined by age and sex than to any details of disease presentation or management. Treatment was far more successful in patients in the low-risk group.

Extreme denial in breast cancer patients and capacity for object relations.

This study tested an assumption of the theoretical hierarchy of defenses: denial reflects primitive ego development. The study hypothesized a positive relationship between extreme denial and immature object relationship functioning. Twenty breast cancer patients who demonstrated extreme denial and delayed help-seeking were compared on a measure of object relations with a group of 30 similar patients who did not manifest denial or delay. The central hypothesis was not supported, although trends suggested possible validity. Further study may improve our understanding of the mechanisms which influence symptom recognition, help-seeking, and emotional adjustment to cancer.

Malignancies of the thyroid gland. The Lahey Clinic experience.

The management of patients with thyroid carcinoma remains controversial. Review of the Lahey Clinic's experience with 964 patients treated for thyroid malignancy and followed up for a period of 15 to 40 years assisted in the formulation of our current guidelines for management of this disease.

Psychotherapy for the spouses of lung cancer patients: assessment of an intervention.

This study was a randomized prospective clinical trial to test the effect of a professionally provided program of social support counselling on newly diagnosed lung cancer patients and their families. Over the 6 months of the intervention there was no differential change by experimental status for either the patients or their principal support in outcome measures of emotional, social, or physical function. This paper reviews methodological issues which must be considered before accepting these negative findings. Further, it discusses important design considerations relevant for any psychotherapy intervention study in medical patients.

Risk factor analysis in differentiated thyroid cancer.

Six hundred patients with primary differentiated thyroid carcinoma had follow-up studies for a minimum of 15 years and a maximum of 45 years. Recurrence rate and death rate were significantly different in defined high-risk and low-risk groups of patients. These basic risk groups were defined by age and sex alone; low risk consisted of men 40 years of age and younger and women 50 years of age and younger whereas the high-risk group were older patients. Recurrence and death rates in patients at high risk were 33% and 27% while respective figures for patients at low risk were 11% and 4%. In more recent years these results have shown significant improvement. Basic risk group definition outweighed the effect of pathologic type, local disease extension, type of treatment, and site of recurrence or metastasis. For instance, radioactive iodine cured 70% of patients at low risk with metastatic disease but only 10% of patients at high risk. Less aggressive biologic behavior of thyroid cancer before the age of menopause implies that an estrogen-rich milieu may alter the effects of initiating and promoting factors in carcinogenesis. It also suggests that therapeutic trials of estrogen be undertaken in progressive metastatic differentiated thyroid cancer.

Riedel's struma associated with subacute thyroiditis, hypothyroidism, and hypoparathyroidism.

Riedel's struma with dense fibrous invasion of surrounding muscle and fat was found in a patient who had clinical subacute thyroiditis superimposed on primary hypothyroidism. Riedel's struma may sometimes be an uncommon stage in the more common subacute form of thyroiditis, although in our patient an unusual coincidence of subacute thyroiditis and Riedel's struma is also possible. Of interest in our patient was the development of spontaneous primary hypoparathyroidism; parathyroid function returned to normal concomitant with the spontaneous resolution of the goiter after partial resection. This patient also represents another instance of hyperthyroidism developing in a previously hypothyroid patient.