Symptoms in the lives of terminal cancer patients: which is the most important?

OBJECTIVES: Symptoms other than their primary disease can interfere in the lives of terminal cancer patients. We sought to identify which of these symptoms is most important. METHODS: We administered a questionnaire, including the M.D. Anderson Symptom Inventory (MDASI), to 142 terminal cancer patients at the National Cancer Center, Korea. The validity of the MDASI was tested by principal-axis factor analysis and Cronbach's alpha coefficient. Stepwise multiple regression analysis was used to determine the symptoms that interfered most in terminal cancer patients' lives. RESULTS: Factor analysis showed that it was composed of two factors (symptom and interference scales). Cronbach's alpha coefficients of symptom and interference scales were each >0.70. The patients had an average of 11 of 13 symptoms of the MDASI. Pain was the most common and severe, followed by feelings of distress and fatigue. Fatigue was the most highly correlated with interference sum. In stepwise multiple regression analysis, the most interfering symptom was fatigue. CONCLUSIONS: Although pain was the most common and severe symptom, fatigue was the most important symptom interfering in the lives of terminal cancer patients. In treating terminal cancer patients, healthcare providers should actively intervene to reduce both fatigue and pain.     

Long-term course of pain in breast cancer survivors: a 4-year longitudinal study

After successful treatment of early breast cancer, many women still report pain symptoms, and attribute them to the previous illness or its treatment. However, knowledge about the long-term course of pain in breast cancer is limited. Baseline assessment included 3,088 women who received a breast cancer diagnosis on average 2 years prior to enrollment, and who completed typical medical treatments. After 4 years, a subsample of 2,160 recurrence-free women (70%) was re-assessed. The major outcome variable was the composite index for general pain symptoms. Over the 4-year course, a slight but significant increase in pain was reported. If only medical variables were examined, a triple interaction between surgery type, breast cancer stage, and time indicated that pain scores increased in most subgroups, while they decreased in stage II women after mastectomy and stage III women after lumpectomy. Using a regression analytical approach, psychological and other variables added significantly to the prediction of pain persistence. Regression analysis revealed that pain symptoms increased in those women taking tamoxifen at baseline, in those reporting depression at baseline or stressful life events during the first 12 months after enrollment. Exercise at baseline had a beneficial effect on pain recovery. The persistence or increase of pain symptoms in women surviving breast cancer is associated with some medical factors (surgery type, tamoxifen use), but also with psychological factors. Pain should be a standard outcome variable in the evaluation of cancer treatment programs.     

A therapy impact questionnaire for quality-of-life assessment in advanced cancer research.

The first part of the validation procedure used for a Therapy Impact Questionnaire (TIQ) on quality-of-life assessment in advanced cancer patients is described. The TIQ is composed of 36 items which assess both disease and therapy impact according to four dimensions that operationally define quality of life: physical symptoms (24 items), functional status (3 items), concomitant emotional and cognitive factors (6 items) and social interaction (2 items). A global judgement expressed as "have you been feeling ill" further completes the TIQ. Patients answered each question using a 4-point verbal Likert scale: not at all, slight, a lot and very much. The TIQ was given to 1,000 consecutive patients who were no longer responsive to cancer treatment and presented symptoms due to disease progression. The compliance rate was quite high (87%). Results of confirmatory factor analysis were consistent with the operational dimensions identified during questionnaire construction. In particular, the dichotomized answers to 3 functional status items could be used as a Guttman scale. In a sub-sample of 50 patients, the reproducibility of functional status items was assessed using a 7-item parallel form. The intraclass correlation coefficient obtained indicated a reasonably high reproducibility. On the basis of the analyses conducted, the TIQ appears to be a reliable and concise instrument for studies aimed to assess the effectiveness of therapies in advanced cancer patients.     

Psychological aspects of ovarian cancer.

Ovarian cancer presents a range of physical and psychological symptoms during stages of diagnosis, treatment, and survival. Women at risk for ovarian cancer who attend screening programs are vulnerable to high levels of depression and anxiety, particularly young women with poor social support. Multiple physiological stressors of surgical menopause, steroid therapy, and pain present during active treatment that place women at high risk of depression and anxiety during this time. Symptoms of anxiety and depression are also prevalent immediately after chemotherapy and during palliative care. Screening for psychological distress may be useful to identify women who will benefit from psychological counseling. They should be referred to a mental health professional affiliated with the hospital at which they are receiving oncology services. Brief group or individual supportive psychotherapies are effective in relieving psychological distress. Face-to-face psychological intervention should be tailored to the patient's degree of physical mobility. Pain, discomfort, and severe mood symptoms should be addressed pharmacologically, when possible, by a psychiatric consultant knowledgeable in oncology psychiatry. Survivors experience chronic fear of recurrence, sexual dysfunction, and identity disturbance. Reports that ovarian cancer can result in positive life changes, such as closer interpersonal relationships, are encouraging and may provide hope to patients who become despairing about the future.     

Symptomatic local recurrence of prostate carcinoma after radiation therapy

BACKGROUND: Symptomatic local recurrence of prostate carcinoma (SLRPC) after radiation therapy (RT) is associated with morbidity and debilitating symptoms that have a substantial impact on the patient's quality of life. Most reports on the results of RT for localized prostate carcinoma (PC) do not address this endpoint. The objective of this study was to determine the incidence of SLRPC and to identify the risk factors for this endpoint. METHODS: The medical charts of 1006 patients who received RT for localized PC at the University of Texas M. D. Anderson Cancer Center between 1987 and 1997 were reviewed. Local symptoms were defined as hematuria, voiding symptoms, urinary obstruction, and pelvic pain. Progressive symptoms accompanied by either confirmatory histology or cystoscopic findings were attributed to PC. Univariate and multivariate analyses using Cox proportional hazards models were applied to identify risk predictors. RESULTS: Among 964 patients for whom follow-up data were available, 277 patients had prostate-specific antigen (PSA) progression, and 45 patients died of PC during a median follow-up of 9.4 years. In total, 33 patients (3.4%) developed SLRPC. In patients who experienced biochemical progression, the actuarial 5-year incidence of SLRPC was 8.3%. Among the patients who had developed SLRPC, 23 patients (69.7%) died of PC at a median of 25.3 months from the onset of local symptoms. Adverse histologic tumor subtypes (ductal, small cell, and sarcomatoid) were associated significantly with SLRPC (hazard ratio, 8.4; 95% confidence interval, 2.99-23.63). Clinical T classification at diagnosis, Gleason score, and initial PSA level showed a trend toward an increased hazard ratio. CONCLUSIONS: SLRPC after radiotherapy therapy was an uncommon but clinically significant event. Aggressive histologic subtypes were predictive of this endpoint. Clinical T classification, Gleason score, and initial prostate-specific antigen levels also may have predictive value.     

抗抑郁药物联合阿片类药物和心理干预治疗晚期癌痛伴抑郁的疗效观察

目的研究抗抑郁药物作为辅助性干预措施对伴有抑郁状态和癌痛晚期癌症患者的治疗效果。方法将68例患者随机分为两组,进行为期4周的临床观察。对照组联合使用阿片类药物以及心理干预,治疗组联合使用阿片类药物、心理干预以及抗抑郁药物度洛西汀,采用汉密尔顿抑郁量表(HAMD17)、视觉模拟评分法(VAS)于治疗前及治疗后第1、2、4周末进行疗效评估,观察辅助性抗抑郁药物对伴有抑郁状态的癌痛患者抑郁情绪及联合用药对疼痛改善、阿片类药物使用的情况。结果在治疗后第1、2、4周末,治疗组患者HAMD17评分显著降低,抑郁情绪明显改善(P<0.05),对照组患者治疗前后HAMD17评分无明显下降(P>0.05)。治疗组患者在治疗后第2、4周末HAMD17焦虑/躯体化、体重、认知障碍、睡眠障碍以及阻滞各因子分均有显著下降(P<0.05)。治疗组患者阿片类药物使用量在治疗前后无明显增加(P>0.05),而对照组患者阿片类药物使用量在第4周末有显著增加(P<0.05)。治疗组患者在用药期间未见明显的不良反应。结论对伴有抑郁状态的晚期癌痛患者,单纯的心理干预和止痛治疗不能明显改善患者抑郁情绪;在接受阿片类药物和心理干预的同时联合抗抑郁药物度洛西汀,其效果优于阿片类药物联合心理干预,能明显缓解患者抑郁情绪,并有益于疼痛的控制。     

Concomitant chemoradiotherapy for patients with nonmetastatic breast carcinoma: side effects, quality of life, and organization.

BACKGROUND: This study was designed to investigate the personal experience of patients with nonmetastatic breast carcinoma who were treated with the concurrent administration of radiotherapy and chemotherapy in terms of side effects and quality of life (QL). METHODS: One hundred nine patients with nonmetastatic breast carcinoma, recruited between May 1995 and February 1997, were included in a protocol combining chemotherapy with mitoxantrone and cyclophosphamide, administered intravenously in 4 cycles of 21 days, and concomitant radiotherapy. Side effects of treatment and its impact on patients' daily lives were measured using ad hoc questionnaires; QL was measured by the European Organization for Research and Treatment of Cancer QLQ-C30 QL questionnaire, and pain was measured by a visual analogue scale (VAS). RESULTS: All patients agreed to participate. The mean number of chemotherapy and radiotherapy symptoms per cycle were: 7.2+/-2.5 and 2.4+/-1.8, respectively. Chemotherapy symptoms generally were more frequent and distressing than those of radiotherapy. The average pain score reported on the VAS by patients during treatment was 3.0+/-2.0. Multidimensional QL assessment showed that treatment mainly affects physical functioning and global QL. Multivariate analysis showed that the main determinants of QL at the end of treatment were fatigue, pain, and loss of appetite experienced during treatment. Moreover, 62.8% of patients required specific help for transportation to the hospital and/or home upkeep. CONCLUSIONS: The concurrent administration of chemotherapy and radiotherapy deteriorates patients' QL but in a proportion similar to sequential administration while presenting the advantage of a shorter duration of treatment. However, increased fatigue, pain, and loss of appetite as well as difficulties in patients' daily lives have to be taken into account in therapeutic decision-making analysis.     

Greek brief pain inventory: validation and utility in cancer pain

OBJECTIVE: The Brief Pain Inventory (BPI) is a pain assessment tool. It has been translated into and validated in several languages. The purpose of this study was the translation into and validation of the BPI in Greek. Moreover, we wanted to detect cultural and social differences, if any, of pain interference in patients' lives. METHODS: The translation and validation of the inventory took place at the Areteion Hospital. The final validation sample consisted of 220 cancer patients (123 males, 97 females, age range 21-87 years, mean age 61.3). Primary cancer locations were lung 25.6%, gastrointestinal tract 25.6%, breast 11.5%, prostate 7.07%, gynecological cancers 9.6% and others 20.57%. The patients themselves completed the majority of the Greek BPI (G-BPI) papers. The pain management index (PMI) was also calculated in order to assess the adequacy of pain treatment. Assessing the reliability and the validity made the actual validation of the G-BPI. RESULTS: Pain severity and pain management: 147 patients reported severe pain, 48 patients moderate, and 25 patients mild pain (mean average pain 6.22). From these patients only 21 were found on strong and 33 on weak opioid treatment, while 166 patients were found on no opioid analgesic treatment. In agreement with these data is the PMI which was positive only for 9 patients, while 44 patients had PMI = 0 and all the others had negative PMI scores. Reliability and Validity of the G-BPI: Coefficient alphas were 0.849 for the interference items and 0.887 for the severity items. Additionally, the factor analysis of the G-BPI items results in a two-factor solution, that satisfies the criteria of reproducibility, interpretability and confirmatory setting. CONCLUSION: This study shows the efficacy of the G-BPI for the assessment of pain severity as well as the pain management in Greece, and therefore its utility in improving the analgesic treatment outcome in Greek patients.     

鼻咽癌复发患者的生存质量研究

目的研究鼻咽癌放疗后患者的生存质量。方法从2005年8月1日至2005年9月30日对广西医科大学一附院进行复查的307例鼻咽癌患者进行问卷调查,所用问卷是Washington大学的UW-QOL简体中文第四版,并增加了三项问题:耳部症状、视力、鼻部症状。结果不同年龄和性别的QOL总分差异无显著性(P>0.05)。QOL各项中,得分最低的是唾液、耳部症状、咀嚼及鼻部症状。复发组的总体生存质量显著低于无复发组(P<0.05),但单项只有疼痛、活动及娱乐三项差异有显著性(P<0.001)。结论年龄、性别不影响QOL,QOL得分最低的项目所对应的器官均为在放疗照射野覆盖范围。二程放疗加重了照射区域的正常组织器官功能损害,造成复发组生存质量较差。虽然大部分单项在两组间差异无显著性,但是其叠加结果造成了疼痛、活动及娱乐这三个综合项目显著恶化。     

Pain and other symptoms after different treatment modalities of breast cancer

Purpose: The aim of this study was to analyse the risk factorsthat predispose women to chronic symptoms related to the treatmentof breast cancer. Patients and methods: A questionnaire wassent to 569 women who had undergone modified radical mastectomieswith axillary evacuation (MRM) or breast resection with axillaryevacuation (BCT). Results: Pain, paraesthesias and strange sensationswere reported by half of the patients. The chronic pain slightlyaffected the daily lives of about 50% of the patients and moderatelyor more the daily lives of about 25% of the patients. Pain wasreported significantly more often after BCT than after MRM bothin the breast scar (BS) and in the ipsilateral arm (IA). Thepatients with chronic pain were significantly younger and hadlarger primary tumours. Postoperative complications increasedthe incidence of chronic pain in the LA. The highest incidenceof pain in the IA was reported by patients who had had bothradio- and chemotherapy. The fact that the incidence of pain(IA) had a significant correlation with the incidence of paraesthesias,oedema, strange sensations and muscle weakness may be an indicationof nerve injury. Conclusions: Chronic pain was more common afterbreast-conserving surgery than after radical surgery. Surgicalcomplications and postoperative radiotherapy and chemotherapyincreased the risk of chronic pain and other symptoms. Modificationsin the treatment protocol and preclusion of postoperative complicationsmay be necessary in order to minimize chronic treatment-relatedsymptoms. breast cancer, breast surgsery, chronic pain, quality of life, radiotherapy     

Amitriptyline in neuropathic cancer pain in patients on morphine therapy: a randomized placebo-controlled,double-blind crossover study

AIMS AND BACKGROUND: Amitriptyline is the most common analgesic adjuvant used in cancer patients with neuropathic pain, even though no specific studies have demonstrated a benefit. A randomized placebo-controlled, double-blind crossover study was designed to evidence the effects of amitriptyline in patients with neuropathic cancer pain. METHODS: Sixteen advanced cancer patients with neuropathic pain on systemic morphine therapy, no longer receiving oncologic treatment, presenting moderate pain (about 4 or more, but less than 7, on a numerical scale of 0-10) in the last week, and given a stable morphine dose in the last 2 days were admitted to the study. During the first week of study, patients were administered 25 mg of amitriptyline or equivalent drops of placebo at night for 3 days and 50 mg for the following 4 days. Doses for patients aged more than 65 years were 15 mg (first 3 days) and 30 mg (3 days after). After a week, a crossover took place for the second week, with the other treatment at an inverse sequence. Opioid consumption, pain intensity, symptoms and adverse effects, mood, sleep, patient's preference, quality of life before starting the study, the first week after and the second week after were recorded. RESULTS: No significant benefits in analgesia were found in the global pain intensity of the previous week of treatment, the least pain intensity or the pain evaluated just after a week of treatment, at the moment of the visit, when amitriptyline was compared with placebo. A significant difference was evidenced for the worst pain (P < 0.035). No differences in opioid doses during the period of study were found. Drowsiness, confusion and dry mouth were significantly more intense with amitriptyline than with placebo (P < 0.036, 0.003, and 0.034, respectively). There were no substantial differences between the two treatments in Spitzer's quality of life score and for each item. No differences in patients' preference for the two treatment periods were found. The analgesic effects of amitriptyline were slight and associated with adverse effects. CONCLUSIONS: In light of the results obtained in the study, the extensive use of the drug for cancer pain should be questioned.     

Informing advanced cancer patients of the terminal nature of their disease and how this influenced their mental state

From January, 1983 to July, 1987, advanced cancer patients, who have since died, were analysed as to the influence of their mental state after being told of the terminal nature of their disease. After obtaining family consent, 27 out of total of 65 patients were told the true nature of their disease, in contrast to the remaining 38 terminal patients who were kept unaware that they had cancer on the insistence of their families. The depression observed just before death was the marker used to determine the patients' mental distress during the terminal period, and it was noted that the incidence of this terminal depression was higher in the uniformed patients, and highest in those with pain who had not been told. Thus it was concluded that informing a patient that he or she has terminal cancer does not always induce mental distress, even in patients in an advanced cancer stage. Further, the pain that cancer causes must be effectively fought, since this was the major cause of mental distress during the terminal stage of the disease.     

Do cancer suicides differ from others?

Based on a nationwide psychological autopsy study comprising all suicides committed in Finland during one year (n = 1397), victims who had suffered from cancer (n = 60) were compared with other suicides. Cancer suicides were significantly older and more often male, which required adjusting the control group (n = 60) for age and sex. The cancer suicides had more pain and were more often physically disabled. The social network of cancer patients was stronger: 93% of them and 65% of the control cases had a significant other. Family histories of mental disorder were more common in the control group. Cancer was the main underlying factor in the suicide process in 62% of the cancer patients and a contributing factor in 23%. Background factors of the suicide process of the cancer patients with terminal illness (n = 18) were different from those with cancer in remission and from victims among the general population. The frequency of physical symptoms and of depression before suicide in cancer patients emphasizes the need for more competent palliative care and psychological support for cancer patients.     

Measuring social relational quality in colorectal cancer: the Social Relational Quality Scale (SRQS)

Objectives: Social relationships are central in Asian communities. Despite colorectal cancer (CRC) incidence increasing in Asian populations the roles of social activity in facilitating adjustment and optimizing coping resources in Asian peoples remains largely unknown. We derived and validated among Chinese CRC patients, an instrument assessing social relational quality to enable study of these social processes. Methods: Qualitative interviews (n=16) generated 22‐items subsequently administered to 166 Chinese CRC survivors. Principal components analyses identified underlying constructs. The draft instrument, plus measures of optimism, affect, physical symptoms, and perceived social support were administered to a second cohort of 234 newly diagnosed Chinese CRC patients. Results: Three factors were extracted (54.44% of the total variance): Family Intimacy(7 items, 33.08%), Family Commitment (5 items, 14.17%), and Friendships (5 items, 7.19%). All subscales were internally consistent (α=0.75–0.82), exhibiting concurrent validity in negative correlations with anxiety and depression and positive correlations with physical and psychological well‐being. Convergent validity was indicated by significant positive correlations with optimism, and divergent validity by insignificant inverse correlations with physical symptoms and moderate correlations with perceived social support. Hierarchical regressions revealed positive correlations of the three subscales with psychological well‐being, controlling for perceived social support (β=0.13–0.28). Good criterion validity was indicated. Conclusion: The Social Relational Quality Scale is a psychometrically sound self‐report measure of social relational quality among Chinese CRC patients and needs further validation among other Asian groups. Copyright © 2008 John Wiley & Sons, Ltd.     

Do patients with advanced breast cancer benefit from chemotherapy?

This study aimed to assess the proportion of patients with advanced breast cancer who report benefit from first-line palliative chemotherapy using a simple global measure of wellbeing and to identify factors predicting benefit. A consecutive series of women with advanced breast cancer undergoing first-line palliative chemotherapy was evaluated. The main outcome measure was patient report of overall wellbeing assessed at post-treatment interview. Physical, psychological and functional status were assessed using the Rotterdam Symptom Checklist (RSCL) on three occasions (pretreatment, at the start of the third cycle and post treatment). It was planned that treatment would be discontinued after six cycles (i.e. 18-24 weeks). One hundred and sixty patients started treatment, of whom 155 were assessable for quality of life. After treatment, 41 (26%) patients reported they felt better, 29 (19%) felt the same and 34 (22%) felt worse than they did before treatment. The other 51 (33%) patients either died or stopped attending the hospital before the post-treatment interview and were assigned as treatment ''failures''. Patients who reported feeling better after treatment had improvements in psychological distress (P < 0.0001), pain (P = 0.01), lack of energy (P = 0.02) and tiredness (P = 0.02), as well as improvement in functional status (P = 0.07). Feeling better was also correlated with disease response (P = 0.03). Feeling worse after treatment or treatment ''failure'' was predicted by the pretreatment presence of a dry mouth (P = 0.003) and high levels of psychological distress (P = 0.03). Pretreatment lack of energy (P = 0.01), dry mouth (P = 0.02), presence of liver metastases (P = 0.03) and breathlessness (P = 0.03) predicted treatment ''failures''. The results of this study suggest that first-line palliative chemotherapy for advanced breast cancer confers benefit on a substantial proportion of patients, with about one-quarter feeling better after treatment and nearly a half feeling better or the same some 4-6 months after the start of treatment. Factors identified in this study may assist clinicians in deciding which patients should not be offered treatment, because of high risk of feeling worse or treatment ''failure''. This work now needs to be validated on a further cohort of women receiving chemotherapy for advanced breast cancer.     

Fatigue and psychological distress--exploring the relationship in women treated for breast cancer

Disabling fatigue and psychological symptoms of depression or anxiety are commonly reported by women with treated breast cancer. However, most instruments designed to assess fatigue do not assess concurrent psychological symptoms. This study compared the characteristics of two conceptually different, self-report instruments assessing fatigue to determine the extent to which common psychological symptoms co-exist with the symptom of fatigue in women treated for breast cancer. Women attending an oncology day-care facility for adjuvant treatment of breast cancer or ongoing surveillance post-treatment, completed two self-report questionnaires. The Somatic and Psychological Health REport-34 items (SPHERE) and the Functional Assessment of Cancer Therapy-Fatigue (FACT-F subscale-13 items). One hundred and nine women (mean age 52.8 years) completed both questionnaires and total scores on both fatigue assessment scales, FACT-F and SOMA-6, were highly correlated (r = 0.72, P < 0.001). Using the SPHERE case criteria, prolonged fatigue (37% [40/109]) and psychological distress 31% (34/109) were common in women treated for breast cancer. However, those who reported fatigue were much more likely to also report psychological symptoms (22/40 vs. 12/69, X(2) = 16.7: degrees of freedom (df)=1; P < 0.001) and the levels of fatigue on the FACT-F were not significantly different between those who reported "fatigue only" and those who reported "psychological distress only" (18.8 vs. 17.8, P = 0.79). Thus the recent emphasis on recording fatigue during and following treatments for cancer needs to be accompanied by concurrent measurement of psychological symptoms.     

Evaluation of therapeutic effect of chemotherapy with reference to clinical benefit response

In chemotherapy (CHT) for solid tumors, improvement of symptoms may be clinically beneficial, even if objective tumor responses are not recognized. The vast majority of patients with advanced pancreatic cancer (PC) are symptomatic at diagnosis. In particular, severe pain and poor general condition can be major debilitating problems. In patients with such symptoms, optimal palliation of symptoms to maximization the quality of life is of primary importance. In recent years, such a clinical benefit response (CBR) has become a new treatment end-point being explored in clinical trials involving PC. The CBR is generally evaluated using two parameters in patients with PC: pain (intensity of pain and consumption of morphine) and Karnofsky performance status (KPS). A remarkable CBR was obtained in about 20-25% of patients treated with gemcitabine or combined CHT using fluorouracil and cisplatin (FP therapy). This new assessment method for CHT using CBR may be useful for evaluating chemotherapeutic response and may provide a strong rationale for continuing CHT in patients with stable disease according to imaging modalities.     

Impact of relaxation training according to Yoga In Daily Life® system on perceived stress after breast cancer surgery

The purpose of this pilot study was to gather information on the immediate and short-term effects of relaxation training according to Yoga In Daily Life(?) (YIDL) system on the psychological distress of breast cancer patients. 32 patients at the Institute for Oncology of Ljubljana were randomized to the experimental (N=16) and to the control group (N=16). Both groups received the same standard physiotherapy for 1 week, while the experimental group additionally received a group relaxation training sessions according to YIDL(?) system. At discharge the experimental group was issued with audiocassette recordings containing the similar instructions for relaxation training to be practiced individually at home (for further 3 weeks). An experimental repeated measures design was used to investigate the differences over 1 month period in stress levels, changes in mental health and psychological parameters. Measures were obtained at three time points during the study period: baseline, at 1 week, and at 4 weeks, by blinded investigators using standardized questionnaires General Health Questionnaire-12 (GHQ-12), Rotterdam Symptom Checklist (RSCL) psychological subscale, Perceived Stress Scale (PSS). Patients who received relaxation training reported feeling significantly less distressed during hospitalization and after discharge-period than did the controls that did not receive relaxation training. The results indicate that relaxation training according to Yoga in Daily Life(?) system could be useful clinical physiotherapy intervention for breast cancer patients experiencing psychological distress. Although this kind of relaxation training can be applied to clinical oncology in Slovenia, more studies need to be done.