Coyne JC, Palmer SC, Shapiro PJ, Thompson R, DeMichele A.Distress, psychiatric morbidity, and prescriptions for psychotropic medication in a breast cancer waiting room sample. Gen Hosp Psychiatry. 2004 Mar-Apr;26(2):121-8.

We examined relationships among psychiatric screening, the prevalence of psychiatric morbidity, and prescription rates for psychotropic medication in a waiting room sample of breast cancer patients (N=113). Rates of distress (29%), major depressive disorder (MDD; 9%), and generalized anxiety disorder (GAD; 6%) were low and similar to those found in primary care settings. A substantial proportion of patients (52%) had received psychotropic medication during treatment, including almost half (48%) of those without a current psychiatric diagnosis. Most individuals with MDD received pharmacotherapy during cancer treatment (80%), although only half of those with GAD were treated. Overall high rates psychotropic medication negatively impacted the efficiency of screening, and individuals with elevated distress were about 6 times less likely to represent a case of untreated psychiatric morbidity than to be a new case. We conclude that the risk of psychiatric morbidity attributable to breast cancer may be lower and treatment rates for psychiatric morbidity higher than previously believed and that screening is unlikely to provide efficient identification of untreated psychiatric morbidity. Adequacy of follow-up care is unclear and medication may be prescribed non specifically. The low rate of untreated psychiatric morbidity may signal a need for multisite collaborations to generate adequate numbers of participants in clinical trials.

Owen JE, Klapow JC, Roth DL, Nabell L, Tucker DC.Improving the effectiveness of adjuvant psychological treatment for women with breast cancer: the feasibility of providing online support. Psychooncology. 2004 Apr;13(4):281-92

Many well-designed studies have shown psychosocial treatments for cancer to be efficacious for improving patients' quality of life, but the actual impact of these treatments may be limited by low rates of participation. Web-based treatment formats could improve effectiveness by increasing availability and accessibility. Two phases of a feasibility study are reported in this article. In the first phase, we sought to assess internet access and perceived interest in online support among 136 women with breast cancer (June-October, 1999). Levels of interest in participating in an online psychosocial treatment were associated with age, outcome expectancy, and barriers to using the internet but not stage or time since diagnosis. In the second phase, we document accrual rates among several methods of recruitment during a randomized trial (February-December, 2001) and report changes over time in internet access. Recruitment rates were substantially higher when a study representative was available in clinic to provide information about the treatment than for all other methods of recruitment. Access to the internet increased between 1999 (63%) and 2001 (70%) and varied across age groups. These results suggest that internet-based psychosocial treatments, with notable limitations, are feasible for increasing the impact of psychosocial care. Copyright 2003 John Wiley & Sons, Ltd.

McGregor BA, Antoni MH, Boyers A, Alferi SM, Blomberg BB, Carver CS.Cognitive-behavioral stress management increases benefit finding and immune function among women with early-stage breast cancer. J Psychosom Res. 2004 Jan;56(1):1-8.

OBJECTIVE: This study examined the effect of a cognitive-behavioral stress management (CBSM) intervention on emotional well-being and immune function among women in the months following surgery for early-stage breast cancer. METHOD: Twenty-nine women were randomly assigned to receive either a 10-week CBSM intervention (n=18) or a comparison experience (n=11). The primary psychological outcome measure was benefit finding. The primary immune function outcome measure was in vitro lymphocyte proliferative response to anti CD3. RESULTS: Women in the CBSM intervention reported greater perceptions of benefit from having breast cancer compared to the women in the comparison group. At 3-month follow-up, women in the CBSM group also had improved lymphocyte proliferation. Finally, increases in benefit finding after the 10-week intervention predicted increases in lymphocyte proliferation at the 3-month follow-up. CONCLUSION: A CBSM intervention for women with early-stage breast cancer facilitated positive emotional responses to their breast cancer experience in parallel with later improvement in cellular immune function.

Hack TF, Degner LF. Coping responses following breast cancer diagnosis predict psychological adjustment three years later. Psychooncology. 2004 Apr;13(4):235-47.

The relationship between coping responses and psychological adjustment to a breast cancer diagnosis is well documented for time periods close to diagnosis. The purpose of the present study was to assess the long term association between these two variables. Fifty-five women completed measures of coping response, decisional control, frustration expression, and psychological adjustment within six months of receiving their breast cancer diagnosis. These women were contacted three years later and their psychological adjustment-as measured by the profile of mood states (POMS)-was reassessed. Univariate and multivariate analyses were performed. The results showed that women who were depressed at time of treatment planning, and who responded to their cancer diagnosis with cognitive avoidance, i.e. acceptance/resignation, had significantly worse psychological adjustment three years later. Poor adjustment was significantly associated with cognitive avoidance and minimal use of approach-based coping responses. The findings suggest that women who respond to their breast cancer diagnosis with passive acceptance and resignation are at significant risk for poor long term psychological adjustment. Psychological interventions for these women should address cognitive avoidance, with the aim of fostering approach-based coping and positive well-being. Copyright 2003 John Wiley & Sons, Ltd.

Bordeleau L, Szalai JP, Ennis M, Leszcz M, Speca M, Sela R, Doll R, Chochinov HM, Navarro M, Arnold A, Pritchard KI, Bezjak A, Llewellyn-Thomas HA, Sawka CA, Goodwin PJ. Quality of life in a randomized trial of group psychosocial support in metastatic breast cancer: overall effects of the intervention and an exploration of missing data. J Clin Oncol. 2003 May 15;21(10):1944-51.

PURPOSE: To evaluate the effect of a standardized group psychosocial intervention on health-related quality of life (HrQOL) in women with metastatic breast cancer and to explore the effect of missing data in HrQOL analyses. PATIENTS AND METHODS: Between 1993 and 1998, seven Canadian centers randomly assigned 235 eligible women to participate in a weekly, 90-minute, therapist-led support group that adhered to principles of supportive-expressive (SE) therapy or to a control arm (no SE). All women received educational material and any type of medical or psychosocial care deemed necessary. HrQOL data were prospectively collected using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30 (EORTC QLQ-C30) at baseline, 4, 8, and 12 months. The primary HrQOL analyses compared scores in the two study arms. Analyses were limited to women with appropriate baseline HrQOL information (n = 215). RESULTS: Baseline EORTC QLQ-C30 scores were not different between the two study arms (all P >.05). Primary analysis of all subscales failed to show a significant influence of the intervention on HrQOL (all P >.05). There was a significant deterioration over time in several functional scales of the EORTC QLQ-C30: global (P =.03), physical (P =.0002), role (P =.01), and cognitive functioning (P =.04); and in symptom scales: dyspnea (P =.007), appetite loss (P =.04), and fatigue (P =.003); these changes were independent of randomization allocation. Results were similar in additional analyses of overall HrQOL using a variety of approaches to handling missing data. CONCLUSION: Supportive-expressive group therapy in patients with metastatic breast cancer does not appear to influence HrQOL, as measured by the EORTC QLQ-C30.

Osborne RH, Sali A, Aaronson NK, Elsworth GR, Mdzewski B, Sinclair AJ Immune function and adjustment style: do they predict survival in breast cancer? Psychooncology. 2004 Mar;13(3):199-210.

The aim of this study was to investigate the role of immune status and psychosocial factors in survival from early breast cancer (N=61). Baseline assessments included lymphocyte number and function, natural killer cell activity (NKA), plasma cortisol and prolactin level. Psychosocial measures included anxiety, depression and mental adjustment to cancer and social support. Length of follow-up was 6.1-7.9 years with 14 (23%) breast cancer deaths. In Cox proportional hazards models adjusting for lymph node status two parameters predicted longer survival, low NKA (HR 29 per LLU, p=0.003) and minimizing the illness adjustment (HR 0.64 per scale point, p=0.012). These data provide little evidence for a psychoneuroimmunological mechanism in the survival from breast cancer. While this study is limited due to small sample size, and therefore the possibility of inflated estimates, longer survival in those minimizing the illness is a finding consistent with recent studies; however, the counter-intuitive finding that high NKA predicts shorter survival may be a marker for current disease or response to treatments. Copyright 2003 John Wiley & Sons, Ltd

Chochinov HM, Hack T, Hassard T, Kristjanson LJ, McClement S, Harlos M.Dignity in the terminally ill: a cross-sectional, cohort study. Lancet. 2002 Dec 21-28;360(9350):2026-30.

BACKGROUND: Considerations of dignity are often raised in reference to the care of dying patients. However, little research that addresses this issue has been done. Our aim was to identify the extent to which dying patients perceive they are able to maintain a sense of dignity, and to ascertain how demographic and disease-specific variables relate to the issue of dignity in these individuals. METHODS: We did a cross-sectional study of a cohort of terminally ill patients with cancer, who had a life expectancy of less than 6 months. We enrolled 213 patients from two palliative care units in Winnipeg, Canada, and asked them to rate their sense of dignity. Our main outcome measures included: a 7-point sense of dignity item; the symptom distress scale; the McGill pain questionnaire; the index of independence in activities of daily living (IADL); a quality of life scale; a brief battery of self-report measures, including screening for desire for death, anxiety, hopelessness, and will to live; burden to others; and requirement for social support. FINDINGS: 16 of 213 patients (7.5%; 95% CI 4-11) indicated that loss of dignity was a great concern. These patients were far more than likely than the rest of the cohort to report psychological distress and symptom distress, heightened dependency needs, and loss of will to live. INTERPRETATION: Loss of dignity is closely associated with certain types of distress often seen among the terminally ill. Preservation of dignity should be an overall aim of treatment and care in patients who are nearing death.

Harcourt D, Rumsey N.Mastectomy patients' decision-making for or against immediate breast reconstruction. Psychooncology. 2004 Feb;13(2):106-15.

This multi-centred study examined how 93 women due to undergo mastectomy had elected for (n=37) or against (n=56) immediate breast reconstruction. Initial semi-structured interviews were conducted prior to undergoing surgery whilst follow-up interviews 6 and 12 months later examined particpants' experiences of surgery and their views on their decision.Three decision-making styles were identified. Most women (76) reported making quick, 'instant' decisions, whilst 14 sought further information before making their choice. Three women deliberated over their options and found decision-making particularly difficult. Decision-making was influenced by the perceived salience of alternatives, prevailing 'norms' regarding surgical practice within each hospital system and interactions with health professionals. Experiences of surgery often failed to match patients' pre-surgical expectations and the process of adjusting to the impact of surgery continued throughout the following year, during which women contended with a range of problems including pain, scarring and adjusting to a reconstructed breast. However, most women reported themselves satisfied with their decision and justified their choices by focussing on positive aspects of their surgery.Whilst many women make a quick decision about breast reconstruction, research needs to explore ways of facilitating decision-making amongst those who find this decision particularly difficult. Copyright 2003 John Wiley & Sons, Ltd.

Jones JM, Huggins MA, Rydall AC, Rodin GM.Symptomatic distress, hopelessness, and the desire for hastened death in hospitalized cancer patients. J Psychosom Res. 2003 Nov;55(5):411-8.

OBJECTIVE: This study evaluated the desire for hastened death (DHD) in cancer patients at varying stages of disease to determine its frequency and relationship to physical and psychological distress. METHODS: Two hundred twenty-four inpatients at Princess Margaret Hospital completed questionnaires assessing pain, physical symptoms, depression, hopelessness, and DHD. RESULTS: There was significant physical and psychological distress in this sample with a mean of nine physical symptoms reported by each subject. Seven percent reported moderate DHD on the Schedule of Attitudes Towards Hastened Death (SAHD) and 2% reported high DHD. Hopelessness and stage of disease were the only significant independent predictors of DHD and their interaction was associated with increased DHD. Hopelessness and, less so, depression both mediated the pathways between illness-related factors and DHD. CONCLUSIONS: Findings suggest that DHD is significantly related to hopelessness and advancing disease. Assessment of this phenomenon prior to the end of life may provide opportunities for intervention.

Ljubisavljevic V, Kelly B. Risk factors for development of delirium among oncology patients. Gen Hosp Psychiatry. 2003 Sep-Oct;25(5):345-52

To determine the occurrence of delirium in oncology inpatients and to identify and evaluate admission characteristics associated with the development of delirium during inpatient admission, a prospective observational study was conducted of 113 patients with a total of 145 admissions with histological diagnosis of cancer admitted to the oncology unit over a period of ten weeks. At the point of inpatient admission, all patients were assessed for the presence of potential risk factors for development of delirium. During the index admission patients were assessed daily for the presence of delirium using the Confusion Assessment Method. Delirium was confirmed by clinician assessment. Delirium developed in 26 of 145 admissions (18%) and 32 episodes of delirium were recorded with 6 patients having 2 episodes of delirium during the index admission. Delirium occurred on average 3.3 days into the admission. The average duration of an episode of delirium was 2.1 day. Four patients with delirium (15%) died. All other cases of delirium were reversed. Factors significantly associated with development of delirium on multivariate analysis were: advanced age, cognitive impairment, low albumin level, bone metastases, and the presence of hematological malignancy. Hospital inpatient admission was significantly longer in delirium group (mean: 8.8 days vs 4.5 days in nondelirium group, P<.01). Delirium among hospitalized oncology patients is a common condition. Identification of risk factors to delirium at the time of inpatient admission can be used to recognize those patients at the greatest risk and may aid prevention, early detection and treatment.