Caregiver symptom burden: the risk of caring for an underserved patient with advanced cancer

BACKGROUND:

The growing diversity of the population of the United States and the high burden of cancer‐related symptoms reflect the need for caregiver research within underserved groups. In this longitudinal study, the authors assessed changes in symptom severity in caregivers and underserved minority patients diagnosed with advanced solid tumors who were being treated at public hospitals.

METHODS:

A total of 85 matched patient‐caregiver dyads completed the M. D. Anderson Symptom Inventory 3 times during 20 weeks of chemotherapy. At each time point, symptom severity and interference with daily activities were assessed. Group‐based trajectory modeling was used to classify caregivers into high‐symptom or low‐symptom burden groups.

RESULTS:

Sadness and distress were more prevalent among caregivers (P = .005). Symptom burden remained stable among caregivers in the high‐symptom group (40%), whereas the low‐symptom group (60%) demonstrated a statistically significant decrease over time. Multivariate analysis found being a family‐member caregiver (adjusted odds ratio [ADJ‐OR], 4.1; 95% confidence interval [95% CI], 1.4‐11.6) and caring for a highly symptomatic patient (ADJ‐OR, 8.0; 95% CI, 1.5‐41.4), rather than race, ethnicity, or sociodemographic characteristics, were significant predictors of the caregiver's membership in the high‐symptom burden group.

CONCLUSIONS:

Approximately 40% of the caregivers in the current study were found to be at an increased risk for moderate to severe sadness and distress, which remained severe throughout the patient's treatment course at public hospitals. To the authors' knowledge, this study marks the first time that the concept of symptom burden has been used to measure caregiver burden, and the first time that symptom burden has been measured and documented in dyads of caregivers and underserved minority patients. Cancer 2011. © 2010 American Cancer Society.     

Randomized controlled trials of the efficacy of lung cancer screening by sputum cytology revisited

BACKGROUND:

Two randomized controlled trials of lung cancer screening initiated in the 1970s, the Johns Hopkins Lung Project and the Memorial Sloan‐Kettering Lung Study, compared 1 arm that received annual chest X‐ray and 4‐monthly sputum cytology (dual‐screen) to a second arm that received annual chest X‐ray only. Previous publications from these trials reported similar lung cancer mortality between the 2 groups. However, these findings were based on incomplete follow‐up, and each trial on its own was underpowered to detect a modest mortality benefit.

METHODS:

The authors estimated the efficacy of lung cancer screening with sputum cytology in an intention‐to‐screen analysis of lung cancer mortality, using combined data from these trials (n = 20,426).

RESULTS:

Over ½ of squamous cell lung cancers diagnosed in the dual‐screen group were identified by cytology; these cancers tended to be more localized than squamous cancers diagnosed in the X‐ray only arm. After 9 years of follow‐up, lung cancer mortality was slightly lower in the dual‐screen than in the X‐ray only arm (rate ratio [RR], 0.88; 95% confidence interval [CI], 0.74‐1.05). Reductions were seen for squamous cell cancer deaths (RR, 0.79; 95% CI, 0.54‐1.14) and in the heaviest smokers (RR, 0.81; 95% CI, 0.67‐1.00). There were also fewer deaths from large cell carcinoma in the dual‐screen group, although the reason for this is unclear.

CONCLUSIONS:

These data are suggestive of a modest benefit of sputum cytology screening, although we cannot rule out chance as an explanation for these findings. Cancer 2009. © 2009 American Cancer Society.     

Improved survival is associated with treatment at high‐volume teaching facilities for patients with advanced stage laryngeal cancer

BACKGROUND:

Because of the multidisciplinary nature of treatment for advanced laryngeal cancer, the authors hypothesized that treatment at high‐volume teaching/research facilities is associated with improved survival.

METHODS:

After exclusions, 19,326 patients who were diagnosed with advanced laryngeal cancer (stage III and IV) between 1996 and 2002 and who received treatment (chemoradiotherapy [CRT], total laryngectomy [TL], or radiotherapy [RT]) were analyzed from the National Cancer Database (NCDB). Facilities were classified into 6 groups (low‐volume and high‐volume teaching/research facilities, low‐volume and high‐volume community cancer centers, and low‐volume and high‐volume community facilities). Multivariate proportional hazards regression modeling was used to determine 90‐day, 365‐day, and 4‐year hazard ratio (HR) estimates.

RESULTS:

Treatment included TL (37.6%), CRT (29.4%), and RT alone (33%). Overall, 36.2% of patients were treated at high‐volume teaching/research centers (average, 17.1 cases per year). Among all patients, 20% died within the first year. In multivariate models that were controlled for covariates, 90‐day, 365‐day, and 4 year HR estimates for death were lowest for high‐volume teaching/research centers.

CONCLUSIONS:

Receiving treatment at high‐volume teaching/research facilities was associated with improved survival. Undergoing total laryngectomy also was associated with improved survival. The current results suggested that the regionalization of care for patients with advanced‐stage laryngeal cancer has occurred, because most patients were treated either at high‐volume teaching/research facilities or at high‐volume community cancer centers. Future studies should investigate the factors associated with better survival at high‐volume teaching/research facilities, such as quality of care, processes of care, and referral patterns. Cancer 2010. © 2010 American Cancer Society.     

Safety and feasibility of aerobic training on cardiopulmonary function and quality of life in postsurgical nonsmall cell lung cancer patients: a pilot study

BACKGROUND.

A feasibility study examining the effects of supervised aerobic exercise training on cardiopulmonary and quality of life (QOL) endpoints among postsurgical nonsmall cell lung cancer (NSCLC) patients was conducted.

METHODS.

Using a single‐group design, 20 patients with stage I‐IIIB NSCLC performed 3 aerobic cycle ergometry sessions per week at 60% to 100% of peak workload for 14 weeks. Peak oxygen consumption (VO_2peak) was assessed using an incremental exercise test. QOL and fatigue were assessed using the Functional Assessment of Cancer Therapy–Lung (FACT‐L) scale.

RESULTS.

Nineteen patients completed the study. Intention‐to‐treat analysis indicated that VO_2peak increased 1.1 mL/kg^?1/min^?1 (95% confidence interval [CI], ?0.3‐2.5; P = .109) and peak workload increased 9 W (95% CI, 3‐14; P = .003), whereas FACT‐L increased 10 points (95% CI, ?1‐22; P = .071) and fatigue decreased 7 points (95% CI; ?1 to ?17; P = .029) from baseline to postintervention. Per protocol analyses indicated greater improvements in cardiopulmonary and QOL endpoints among patients not receiving adjuvant chemotherapy.

CONCLUSIONS.

This pilot study provided proof of principle that supervised aerobic training is safe and feasible for postsurgical NSCLC patients. Aerobic exercise training is also associated with significant improvements in QOL and select cardiopulmonary endpoints, particularly among patients not receiving chemotherapy. Larger randomized trials are warranted. Cancer 2008. © 2008 American Cancer Society.     

Differences in survival among women with stage III inflammatory and noninflammatory locally advanced breast cancer appear early: a large population-based study

BACKGROUND:

Significant improvements in the survival of women with breast cancer have been observed and are attributed to a multidisciplinary approach and the introduction of polychemotherapy and endocrine regimens. The objective of this population‐based study was to determine whether women with inflammatory breast cancer (IBC) who received treatment in a modern era had a poorer survival compared those with non‐IBC locally advanced breast cancer (LABC).

METHODS:

The Surveillance, Epidemiology, and End Results program registry was searched to identify women with stage IIIB/C breast cancer diagnosed between 2004 and 2007 who had undergone surgery and radiotherapy. Patients were categorized as either having IBC or non‐IBC LABC according the sixth edition of the American Joint Committee on Cancer (AJCC) criteria. Breast cancer‐specific survival (BCS) was estimated using the Kaplan‐Meier product limit method and compared across groups using the log‐rank statistic. Cox models were then fitted to compare the association between breast cancer type and BCS after adjusting for patient and tumor characteristics.

RESULTS:

A total of 828 (19.2%) women and 3476 (80.8%) women had stage IIIB/C IBC and non‐IBC LABC, respectively. The median follow‐up was 19 months. The 2‐year BCS rate was 90% (95% confidence interval [95% CI], 88%‐91%) for the entire cohort and 84% (95%CI, 80%‐87%) and 91% (95%CI, 90%‐91%) among women with IBC and non‐IBC LABC, respectively. In the multivariable model, patients with IBC were found to have a 43% increased risk of death from breast cancer compared with patients with non‐IBC LABC (hazard ratio, 1.43; 95%CI, 1.10‐1.86 [P = .008]).

CONCLUSIONS:

In the era of multidisciplinary management and anthracycline‐based and taxane‐based polychemotherapy regimens, women with IBC continue to have worse survival outcomes compared with those with non‐IBC LABC. Cancer 2011. © 2010 American Cancer Society.     

Alcohol consumption,finasteride, and prostate cancer risk

BACKGROUND:

Current research is inconclusive regarding the relation between alcohol consumption and prostate cancer risk. In this study, the authors examined the associations of total alcohol, type of alcoholic beverage, and drinking pattern with the risk of total, low‐grade, and high‐grade prostate cancer.

METHODS:

Data for this study came from the 2129 participants in the Prostate Cancer Prevention Trial (PCPT) who had cancer detected during the 7‐year trial and 8791 men who were determined by biopsy to be free of cancer at the trial end. Poisson regression was used to calculate relative risks (RRs) and 95% confidence intervals (95% CIs) for associations of alcohol intake with prostate cancer risk.

RESULTS:

Associations of drinking with high‐grade disease did not differ by treatment arm. In combined arms, heavy alcohol consumption (≥50 g of alcohol daily) and regular heavy drinking (≥4 drinks daily on ≥5 days per week) were associated with increased risks of high‐grade prostate cancer (RR, 2.01 [95% CI, 1.33‐3.05] and 2.17 [95% CI, 1.42‐3.30], respectively); less heavy drinking was not associated with risk. Associations of drinking with low‐grade cancer differed by treatment arm. In the placebo arm, there was no association of drinking with risk of low‐grade cancer. In the finasteride arm, drinking ≥50 g of alcohol daily was associated with an increased risk of low‐grade disease (RR, 1.89; 95% CI, 1.39‐2.56); this finding was because of a 43% reduction in the risk of low‐grade cancer attributable to finasteride treatment in men who drank <50g of alcohol daily and the lack of an effect of finasteride in men who drank ≥50 g of alcohol daily (P_interaction = .03).

CONCLUSIONS:

Heavy, daily drinking increased the risk of high‐grade prostate cancer. Heavy drinking made finasteride ineffective for reducing prostate cancer risk. Cancer 2009. © 2009 American Cancer Society.     

A Multimedia Self-management Intervention to Prepare Cancer Patients and Family Caregivers for Lung Surgery and Postoperative Recovery

Background

The purpose of this study was to evaluate the feasibility and acceptability of a multimedia self-management (MSM) intervention to prepare patients and family caregivers for lung surgery.

Procalcitonin levels predict clinical course and progression‐free survival in patients with medullary thyroid cancer

BACKGROUND:

Procalcitonin has been well established as an important marker of sepsis and systemic infection. The authors evaluated the diagnostic and predictive value of calcitonin and its prohormone procalcitonin in medullary thyroid cancer.

METHODS:

The authors systematically explored the ability of calcitonin and procalcitonin to identify medullary thyroid cancer and predict the endpoints local recurrence and distant metastases, as well as the progression‐free survival. Patients with C‐cell hyperplasia; patients after thyroidectomy for differentiated thyroid cancer, goiter, or Graves disease; and healthy subjects served as controls. The study was performed in accordance with the Reporting Recommendations for Tumor Marker Prognostic Studies of the National Cancer Institute.

RESULTS:

Sixty‐nine medullary thyroid cancer patients and 96 controls were included (median observed interval: 10.9 years [range, 1.4‐47.5 years]; 981.8 patient‐years). The 1‐year, 5‐year, 10‐year, and 20‐year recurrence rates were 9%, 34%, 45%, and 56%, respectively. Calcitonin had a higher diagnostic accuracy for detecting medullary thyroid cancer than procalcitonin (area under the curve [AUC], 0.94; 95% confidence interval [95% CI], 0.90‐0.99 vs AUC, 0.89; 95% CI, 0.83‐0.95 [P = .038]). The procalcitonin:calcitonin ratio predicted disease progression (AUC, 0.63; 95% CI, 0.51‐0.75 [P = .036]) and progression‐free survival (hazards ratio, 1.49; 95% CI, 1.09‐2.04 [P = .013]).

CONCLUSIONS:

The results of the current study indicate a superior diagnostic accuracy of calcitonin and an independent predictive value of the procalcitonin:calcitonin ratio. These findings may lead to improved diagnostic and therapeutic strategies for medullary thyroid cancer patients. Cancer 2010. © 2010 American Cancer Society.     

The association of nonalcoholic steatohepatitis and tamoxifen in patients with breast cancer

BACKGROUND:

Nonalcoholic steatohepatitis (NASH) is a form of liver damage that can progress to cirrhosis. NASH is associated with obesity and diabetes. The condition also may be associated with some medications, including tamoxifen. Early case reports and small series have documented NASH in patients who received tamoxifen.

METHODS:

The records of patients registered in the St. Vincent Hospital Cancer Registry of Green Bay Wisconsin from January 1, 1992 to December 31, 2000 were reviewed.

RESULTS:

In total, 1105 patients with breast cancer were evaluated for NASH, and 24 cases of NASH were documented (2.2%). Seven patients had NASH before their diagnosis of breast cancer, and 17 patients developed NASH after their diagnosis of breast cancer. In multivariate analysis, the factors associated with NASH were tamoxifen use (odds ratio [OR], 8.2; 95% confidence interval [CI], 1.06‐63.72), body mass index (BMI) (OR, 1.13; 95% CI, 1.06‐1.20), and age (OR, 95% CI, 0.91‐0.99). NASH improved after tamoxifen was stopped. After discontinuation of tamoxifen, transaminase levels returned to normal in 14 of 16 patients.

CONCLUSIONS:

NASH was present in 24 of 1105 patients with breast cancer (2.2%). Seven patients had NASH before they were diagnosed with breast cancer, and 17 patients developed NASH after their diagnosis. NASH was associated with the use of tamoxifen and improved when tamoxifen was stopped. Cancer 2009. © 2009 American Cancer Society.     

Qigong improves quality of life in women undergoing radiotherapy for breast cancer

BACKGROUND:

Radiotherapy may lead to side effects that undermine patients' quality of life (QOL). Although mind‐body practices like qigong appear to improve QOL in cancer survivors, little is known about their benefits for patients who are receiving radiotherapy. Thus, in the current randomized controlled trial, the authors examined the efficacy of a qigong intervention on QOL in women with breast cancer during and after treatment.

METHODS:

Ninety‐six women with breast cancer were recruited from a cancer center in Shanghai, China, and were randomized to a qigong group (N = 49) or a waitlist control group (N = 47). Women in the qigong group attended 5 weekly classes over 5 or 6 weeks of radiotherapy. QOL outcomes (ie, depressive symptoms, fatigue, sleep disturbance, and overall QOL) and cortisol slopes were assessed at baseline, during treatment, at the end of treatment, 1 month later, and 3 months later.

RESULTS:

The mean age of the women was 46 years (range, 25‐64 years). Seven percent of women had stage 0 disease, 25% had stage I disease, 40% had stage II disease, and 28% had stage III disease. Fifty‐four percent of women underwent mastectomy. Multilevel analyses revealed that women in the qigong group reported less depressive symptoms over time than women in the control group (P = .05). Women who had elevated depressive symptoms at the start of radiotherapy reported less fatigue (P < .01) and better overall QOL (P < .05) in the qigong group compared with the control group, and these findings were clinically significant. No significant differences were observed for sleep disturbance or cortisol slopes.

CONCLUSIONS:

The current results indicated that qigong may have therapeutic effects in the management of QOL among women who are receiving radiotherapy for breast cancer. Benefits were particularly evident for patients who had preintervention elevated levels of depressive symptoms. Cancer 2013. © 2013 American Cancer Society.     

Quality of life,self‐esteem,fatigue, and sexual function in young men after cancer

BACKGROUND:

Androgen deficiency is increasingly recognized in young male cancer survivors; however, its impact on quality of life (QOL) is not established. The authors investigated the relationship between androgen levels, QOL, self‐esteem, fatigue, and sexual function in young male cancer survivors compared with control subjects.

METHODS:

A cross‐sectional, observational study of 176 male cancer survivors and 213 male controls aged 25 to 45 years was performed. Subjects completed 3 QOL scales (Medical Outcomes Study 36‐Item Short‐Form Health Survey version 2, the 12‐item General Health Questionnaire [GHQ‐12], and Aging Male Scale), and measures of self‐esteem (Rosenberg Self‐Esteem Scale), fatigue (Functional Assessment of Chronic Illness Therapy‐Fatigue), and sexual function (Derogatis Interview for Sexual Functioning‐II Self‐Report‐Male).

RESULTS:

Cancer survivors had lower scores for all components of the Short‐Form Health Survey, Aging Male Scale, and Functional Assessment of Chronic Illness Therapy‐Fatigue, and for 4 of 5 subsections of the Derogatis Interview for Sexual Functioning than controls. The majority of these differences remained after adjusting by linear regression analysis. Levels of psychiatric disorder or self‐esteem did not differ between the 2 groups. In cancer survivors, those with androgen deficiency (serum testosterone ≤10 nmol/L) had lower scores than those without for all components of the Short‐Form Health Survey, the General Health Questionnaire, Functional Assessment of Chronic Illness Therapy‐Fatigue, and the Derogatis Interview for Sexual Functioning. Serum testosterone only weakly correlated with health measures.

CONCLUSIONS:

Young male cancer survivors self‐report a marked impairment in QOL, energy levels, and quality of sexual functioning, and this was exacerbated in those with androgen deficiency. However, psychological distress was not elevated, self‐esteem was normal, and sexual relationships were not impaired. The relationship with testosterone is complex, and appears dependent on a threshold level rather than direct correlation. Interventional trials are needed to determine whether testosterone replacement would improve QOL in young male cancer survivors. Cancer 2010. © 2010 American Cancer Society.     

Pulmonary tuberculosis increases the risk of lung cancer: a population-based cohort study

BACKGROUND:

The possible effect of pulmonary tuberculosis (TB) on subsequent lung cancer development has been suspected, but the evidence remains inconsistent. The purpose of this study was to perform a nationwide population‐based cohort study to investigate the risk of lung cancer after pulmonary TB infection.

METHODS:

This nationwide population‐based cohort study was based on data obtained from the Taiwan National Health Insurance Database. In total, 5657 TB patients and 23,984 controls matched for age and sex were recruited for the study from 1997 to 2008.

RESULTS:

The incidence rate of lung cancer (269 of 100,000 person‐years) was significantly higher in the pulmonary TB patients than that in controls (153 of 100,000 person‐years) (incidence rate ratio [IRR], 1.76; 95% confidence interval [CI], 1.33‐2.32; P < .001). Compared with the controls, the IRRs of lung cancer in the TB cohort were 1.98 at 2 to 4 years, 1.42 at 5 to 7 years, and 1.59 at 8 to 12 years after TB infections. The multivariate Cox proportional hazards model revealed pulmonary TB infections (hazard ratio [HR], 1.64; 95% CI, 1.24‐2.15; P < .001) and chronic obstructive pulmonary disease (HR, 1.09; 95% CI, 1.03‐1.14; P = .002) to be independent risk factors for lung cancer.

CONCLUSIONS:

Pulmonary infection with TB is associated with an increased risk of lung cancer. Cancer 2011. © 2010 American Cancer Society.     

Psychologic intervention improves survival for breast cancer patients

BACKGROUND.

The question of whether stress poses a risk for cancer progression has been difficult to answer. A randomized clinical trial tested the hypothesis that cancer patients coping with their recent diagnosis but receiving a psychologic intervention would have improved survival compared with patients who were only assessed.

METHODS.

A total of 227 patients who were surgically treated for regional breast cancer participated. Before beginning adjuvant cancer therapies, patients were assessed with psychologic and behavioral measures and had a health evaluation, and a 60‐mL blood sample was drawn. Patients were randomized to Psychologic Intervention plus assessment or Assessment only study arms. The intervention was psychologist led; conducted in small groups; and included strategies to reduce stress, improve mood, alter health behaviors, and maintain adherence to cancer treatment and care. Earlier articles demonstrated that, compared with the Assessment arm, the Intervention arm improved across all of the latter secondary outcomes. Immunity was also enhanced.

RESULTS.

After a median of 11 years of follow‐up, disease recurrence was reported to occur in 62 of 212 (29%) women and death was reported for 54 of 227 (24%) women. Using Cox proportional hazards analysis, multivariate comparison of survival was conducted. As predicted, patients in the Intervention arm were found to have a reduced risk of breast cancer recurrence (hazards ratio [HR] of 0.55; P = .034) and death from breast cancer (HR of 0.44; P = .016) compared with patients in the Assessment only arm. Follow‐up analyses also demonstrated that Intervention patients had a reduced risk of death from all causes (HR of 0.51; P = .028).

CONCLUSIONS.

Psychologic interventions as delivered and studied here can improve survival. Cancer 2008. © 2008 American Cancer Society.     

Effect of metabolic syndrome and its components on recurrence and survival in colon cancer patients

BACKGROUND:

Although epidemiologic studies suggest that metabolic syndrome (MetS) increases the risk of colorectal cancer, its effect on cancer mortality remains controversial.

METHODS:

The authors used the Surveillance, Epidemiology, and End Results (SEER)‐Medicare linked database (1998‐2006) to conduct a retrospective cohort study of 36,079 patients with colon cancer to determine the independent effect of MetS and its components on overall survival (OS) and recurrence‐free rates (RFRs). Data on MetS and its components were ascertained from Medicare claims. OS and RFRs in patients with and without MetS and its components were compared using multivariate Cox models.

RESULTS:

MetS had no apparent effect on OS or RFR. Both elevated glucose/diabetes mellitus (DM) and elevated hypertension were associated with worse OS (adjusted hazard ratio [aHR], 1.17 [95% confidence interval, 1.13‐1.21] and 1.08 [95% confidence interval, 1.03‐1.12], respectively) and worse RFRs (aHR, 1.25 [95% confidence interval, 1.16‐1.34] and 1.22 [95% confidence interval, 1.12‐1.33], respectively). In contrast, dyslipidemia was associated with improved survival (aHR, 0.77; 95% confidence interval, 0.75‐0.80) and reduced recurrence (aHR, 0.71; 95% confidence interval, 0.66‐0.75). These effects were consistent for both men and women and were more pronounced in patients with early stage disease.

CONCLUSIONS:

MetS had no apparent effect on colon cancer outcomes, probably because of the combined adverse effects of elevated glucose/DM and hypertension and the protective effect of dyslipidemia in patients with nonmetastatic disease. The authors concluded that patients who have early stage colon cancer with elevated glucose/DM and/or hypertension may benefit from more intensive surveillance and/or broader use of adjuvant therapy and that trials to define the benefits of low‐fat diets, insulin‐lowering agents, and statins on recurrence/survival in patients with nonmetastatic colon cancer are warranted. Cancer 2013. © 2012 American Cancer Society.     

Delays in diagnosis and bladder cancer mortality

BACKGROUND:

Mortality from invasive bladder cancer is common, even with high‐quality care. Thus, the best opportunities to improve outcomes may precede the diagnosis. Although screening currently is not recommended, better medical care of patients who are at risk (ie, those with hematuria) has the potential to improve outcomes.

METHODS:

The authors used the Surveillance, Epidemiology, and End Results‐Medicare linked database for the years 1992 through 2002 to identify 29,740 patients who had hematuria in the year before a bladder cancer diagnosis and grouped them according to the interval between their first claim for hematuria and their bladder cancer diagnosis. Cox proportional hazards models were fitted to assess relations between these intervals and bladder cancer mortality, adjusting first for patient demographics and then for disease severity. Adjusted logistic models were used to estimate the patient's probability of receiving a major intervention.

RESULTS:

Patients (n = 2084) who had a delay of 9 months were more likely to die from bladder cancer compared with patients who were diagnosed within 3 months (adjusted hazard ratio [HR], 1.34; 95% confidence interval [CI], 1.20‐1.50). This risk was not markedly attenuated after adjusting for disease stage and tumor grade (adjusted HR, 1.29; 95% CI, 1.14‐1.45). In fact, the effect was strongest among patients who had low‐grade tumors (adjusted HR, 2.11; 95% CI, 1.69‐2.64) and low‐stage disease (ie, a tumor [T] classification of Ta or tumor in situ; adjusted HR, 2.02; 95% CI, 1.54‐2.64).

CONCLUSIONS:

A delay in the diagnosis of bladder cancer increased the risk of death from disease independent of tumor grade and or disease stage. Understanding the mechanisms that underlie these delays may improve outcomes among patients with bladder cancer. Cancer 2010. © 2010 American Cancer Society.     

Influence of patients' preferences and treatment site on cancer patients' end‐of‐life care

BACKGROUND:

Research suggests that patients' end‐of‐life (EOL) care is determined primarily by the medical resources available, and not by patient preferences. The authors examined whether patients' desire for life‐extending therapy was associated with their EOL care.

METHODS:

Coping with Cancer is a multisite, prospective, longitudinal study of patients with advanced cancer. Three hundred one patients were interviewed at baseline and followed until death, a median of 4.5 months later. Multivariate analyses examined the influence of patients' preferences and treatment site on whether patients received intensive care or hospice services in the final week of life.

RESULTS:

Eighty‐three of 301 patients (27.6%) with advanced cancer wanted life‐extending therapy at baseline. Patients who understood that their disease was terminal or who reported having EOL discussions with their physicians were less likely to want life‐extending care compared with others (23.4% vs 42.6% and 20.7% vs 44.4%, respectively; P ≤ .003). Patients who were treated at Yale Cancer Center received more intensive care (odds ratio [OR], 3.14; 95% confidence interval [CI], 1.16‐8.47) and less hospice services (OR, 0.52; 95% CI, 0.29‐0.92) compared with patients who were treated at Parkland Hospital. However, in multivariate analyses that controlled for confounding influences, patients who preferred life‐extending care were more likely to receive intensive care (adjusted OR [AOR], 2.91; 95% CI, 1.09‐7.72) and were less likely to receive hospice services (AOR, 0.45; 95% CI, 0.26‐0.78). Treatment site was not identified as a significant predictor of EOL care.

CONCLUSIONS:

The treatment preferences of patients with advanced cancer may play a more important role in determining the intensity of medical care received at the EOL than previously recognized. Future research is needed to determine the mechanisms by which patients' preferences for care and treatment site interact to influence EOL care. Cancer 2010. © 2010 American Cancer Society.     

Relationship between cytokine gene single nucleotide polymorphisms and symptom burden and quality of life in lung cancer survivors

BACKGROUND:

Previous research has demonstrated that many lung cancer survivors report difficulties with symptom control and experience a poor quality of life (QOL). Although recent studies have suggested a relationship of single nucleotide polymorphisms (SNPs) in several cytokine genes with cancer susceptibility and prognosis, associations with symptom burden and QOL have not been examined. The current study was conducted to identify SNPs related to symptom burden and QOL outcomes in lung cancer survivors.

METHODS:

All participants were enrolled in the Mayo Clinic Lung Cancer Cohort following diagnosis of lung cancer. A total of 1149 Caucasian lung cancer survivors completed questionnaires and had genetic samples available. The main outcome measures were symptom burden as measured by the Lung Cancer Symptom Scale and health‐related QOL as measured by the Short‐Form General Health Survey.

RESULTS:

Twenty‐one SNPs in cytokine genes were associated with symptom burden and QOL outcomes. Our results suggested both specificity and consistency of cytokine gene SNPs in predicting outcomes.

CONCLUSIONS:

These results provide support for genetic predisposition to QOL and symptom burden and may aid in identification of lung cancer survivors at high risk for symptom management and QOL difficulties. Cancer 2010. © 2010 American Cancer Society.     

Impact of axillary lymph node dissection on breast cancer outcome in clinically node negative patients

BACKGROUND:

The regional lymph node control and survival impact of axillary dissection in breast cancer has been the subject of multiple randomized trials, with various results. This study reviews and conducts a meta‐analysis of contemporary trials of axillary dissection in patients with early stage breast cancer.

METHODS:

A systematic MEDLINE review identified 3 randomized trials published between January 2000 and January 2007 of axillary dissection versus no dissection in clinically lymph node negative early stage breast cancer patients. A fourth trial of axillary radiotherapy versus no axillary treatment was also identified and included in this review. Meta‐analyses were performed for survival, axillary recurrence, metastatic disease, and ipsilateral breast recurrence.

RESULTS:

All trials reported a higher rate of axillary recurrence (1.5%‐3%, median follow‐up 5‐15 years) in the absence of axillary dissection or radiotherapy. Overall survival was similar with and without definitive axillary treatment in 3 of the 4 trials, with an increased rate of nonbreast cancer‐related death in the observation arm of the fourth trial. Meta‐analyses found no significant difference in overall survival (odds ratio [OR] 1.55; 95% confidence interval [CI], 0.74‐3.24), metastases (OR 0.91; 95% CI, 0.65‐1.29), or ipsilateral breast recurrence (OR 1.11; 95% CI, 0.68‐1.83) associated with axillary treatment. A significantly lower rate of axillary recurrence was seen after lymphadenectomy (OR 0.28; 95% CI, 0.11‐0.73, P<.01).

CONCLUSIONS:

Axillary dissection does not confer a survival benefit in the setting of early stage clinically lymph node negative breast cancer. Although the rate of axillary failure was increased in the absence of dissection, the absolute risk was found to be extremely low. Cancer 2009. © 2009 American Cancer Society.     

An eHealth system supporting palliative care for patients with non–small cell lung cancer

BACKGROUND:

In this study, the authors examined the effectiveness of an online support system (Comprehensive Health Enhancement Support System [CHESS]) versus the Internet in relieving physical symptom distress in patients with non–small cell lung cancer (NSCLC).

METHODS:

In total, 285 informal caregiver‐patient dyads were assigned randomly to receive, for up to 25 months, standard care plus training on and access to either use of the Internet and a list of Internet sites about lung cancer (the Internet arm) or CHESS (the CHESS arm). Caregivers agreed to use CHESS or the Internet and to complete bimonthly surveys; for patients, these tasks were optional. The primary endpoint—patient symptom distress—was measured by caregiver reports using a modified Edmonton Symptom Assessment Scale.

RESULTS:

Caregivers in the CHESS arm consistently reported lower patient physical symptom distress than caregivers in the Internet arm. Significant differences were observed at 4 months (P = .031; Cohen d = .42) and at 6 months (P = .004; d = .61). Similar but marginally significant effects were observed at 2 months (P = .051; d = .39) and at 8 months (P = .061; d = .43). Exploratory analyses indicated that survival curves did not differ significantly between the arms (log‐rank P = .172), although a survival difference in an exploratory subgroup analysis suggested an avenue for further study.

CONCLUSIONS:

The current results indicated that an online support system may reduce patient symptom distress. The effect on survival bears further investigation. Cancer 2013. © 2013 American Cancer Society.