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Articles/items published ahead of print or only online.
Wednesday, October 29, 2014
BY ROBERT H. CARLSON
Allogeneic transplantation has long been associated with a high risk of treatment-related mortality due to the use of myeloablative regimens, but new research shows that allogeneic transplantation can lead to sustained remission for patients with advanced multiple myeloma, even for those with relapsed/refractory disease.
The retrospective study (Biology of Blood and Marrow Transplant 2014:20:1211-1216) of 57 consecutive patients undergoing allogeneic transplantation at the John Theurer Cancer Center at Hackensack University Medical Center also showed that patients who had chronic graft-versus-host disease had a significant survival advantage, although acute graft-versus-host disease (occurring in the first 100 days) had a significant adverse effect on survival.
“This is proof of the concept that a graft-versus-tumor effect does exist in multiple myeloma, something that has been well established in leukemia,” the first author of the study, Michele Donato, MD, Medical Director of the Blood and Marrow Collection Facility, said in a telephone interview. “When donor cells have enough maturity to fight malignancy, which we have demonstrated specifically in multiple myeloma, we can improve survival very significantly.”
Other findings from the study:
· Allogeneic transplantation led to a prolonged overall survival both in patients with early disease and in those with late disease;
· Patients who had adverse cytogenetics did as well as those with more favorable profiles;
· Multivariate analysis showed that there was no significant difference in overall outcome whether patients had undergone a reduced intensity, non-myeloablative, or myeloablative conditioning regimen, although the small number of patients in each regimen may not have been enough to show a difference; and
· Transplants from unrelated donors produced overall survival rates as high as did transplants from sibling donors.
“There was no difference if the source of cells was related or unrelated,” Donato said. “Very often, allogeneic transplant has been reserved for patients who have siblings who are full match, but half of our patients did not; they received an unrelated donor and did just as well.”
She said the study period of 2004 to 2011 is in the modern era of transplant with current standards of supportive care such as proper screening for viral infections, antibiotic and antiviral therapy, and gene typing.
“In the past we did not have the typing specificity we have now, and we are now much better at finding better donors than we were 15 to 20 years ago. In the era of modern HLA typing we can find unrelated donors who are just as good as sibling donors.”
At five years, 49.2 percent of all patients were in complete response; and that was increased to 62.5 percent for the 16 patients who received either donor lymphocyte infusions or immune suppression withdrawal for disease progression.
The five-year overall survival rates were 59 percent for all patients, 82 percent for patients who underwent allogeneic transplantation for consolidation after their first autograft and 38 percent for those who received allogeneic transplant as salvage therapy.
Five-year overall survival for patients with chronic graft-versus-host disease was about 79 percent, versus about 43 percent for patients without chronic graft-versus-host disease.
Donato said a prospective study is now under way at Hackensack looking at the same parameters as in the retrospective study and is about to close, which should provide more answers about the feasibility of allogeneic transplant in multiple myeloma.
Writing in an accompanying commentary (Biol Blood Marrow Transplant 2014;8:1078-1079), Paul G. Richardson, MD, Clinical Director of the Jerome Lipper Myeloma Center at Dana-Farber Cancer Institute, said the favorable survival rate among patients who developed chronic graft-versus-host disease suggests an important role for a graft-versus-myeloma effect.
Richardson, who titled the article “Allogeneic Transplantation in Multiple Myeloma: A Potential Renaissance in the Era of Novel Therapies?” said that although it was encouraging that the overall five-year survival rate was 59 percent, it was much lower for patients who underwent transplantation as salvage. “Intriguingly, donor type (be it unrelated or related), as well as cytogenetics and age, were otherwise not significant predictors of outcome,” he wrote.
Although the numbers were small, the study did underscore the importance of an effective immunologic platform in disease control, Richardson said.
Clinical Implications Not Yet Clear
Also asked to comment for this article, Robert J. Soiffer, MD, Chief of the Division of Hematologic Malignancies at Brigham And Women's Hospital, said it was not clear yet how these data might be used clinically: “It's hard to know how best to engineer a low acute but moderate chronic GvHD process,” he said via e-mail. “In a recent controlled, randomized study, sirolimus helped prevent grade 3 to 4 acute GvHD without impacting chronic GvHD” (Cutler et al: Blood 2014;124:1372-1377).
He said he would be “hesitant to call on that as a strategy,” but the recent study could be used as an example.
Wednesday, October 29, 2014
BY MARK FUERST
Substantially more women in California diagnosed with early-stage breast cancer had bilateral mastectomy over the past several years, but the surgical procedure did not lower the risk of death compared with use of breast-conserving surgery plus radiation. That is the conclusion of the first side-by-side comparison of all three common surgical treatments for early-stage breast cancer.
“This is a very large, representation study of breast cancer patients in California that has high generalizability to other breast cancer patients,” the lead author, Allison W. Kurian, MD MSc, Assistant Professor of Medicine and of Health Research and Policy at Stanford University School of Medicine, said in an interview. “The study was well powered to show the survival benefit for bilateral mastectomy, but there is no evidence that a bilateral mastectomy improves survival for women with early-stage breast cancer.”
Randomized trials have shown similar survival rates for patients with early-stage breast cancer treated with breast-conserving surgery plus radiation or with mastectomy. Even so, there has been an increasing trend toward the use of mastectomy, particularly bilateral mastectomy, among U.S. women with breast cancer. “There have been hints in the literature comparing two treatments at once. By now, getting all three – i.e., including unilateral mastectomy -- in one study, we have a clear sense of what’s going on in terms of who is doing well,” she said.
The observational cohort study, published in the Journal of the American Medical Association (2014;312:902-914), used data from the California Cancer Registry from 1998 through 2011, comparing the use of and rate of death after bilateral mastectomy, breast-conserving therapy plus radiation, and unilateral mastectomy among more than 189,734 patients.
The researchers analyzed survival for patients with unilateral non-metastatic breast cancer managed with breast-conserving surgery in 55 percent of patients, bilateral mastectomy in six percent of patients, and unilateral mastectomy in 39 percent.
The study excluded women with bilateral mastectomy because “most women have one-sided breast cancer,” Kurian said. “We wanted to study the typical scenario of one breast cancer and what a woman should do.”
The results showed that the rate of bilateral mastectomy increased from two percent in 1998 to 12.3 percent in 2011, an annual increase of 14.3 percent. The increase in bilateral mastectomy rate was greatest among women younger than age 40, with the rate increasing from 3.6 percent in 1998 to 33 percent in 2011, a 17.6 percent annual increase. Use of unilateral mastectomy declined in all age groups.
There was no mortality benefit associated with bilateral mastectomy compared with breast-conserving surgery plus radiation, and higher mortality associated uniquely with unilateral mastectomy, the researchers reported.
Breast-conserving surgery with radiation had a 10-year mortality rate of about 17 percent, and bilateral mastectomy had a 10-year mortality rate of about 19 percent. Unilateral mastectomy was associated with a 10-year mortality rate of about 20 percent.
Kurian said that with increasing concerns about overtreatment of breast cancer, the risks and benefits of bilateral mastectomy warrant careful consideration, and raise the larger question of how physicians and society should respond to a patient's preference for breast cancer therapy.
Use of bilateral mastectomy increased the most among patients younger than 40 at diagnosis. “I see these young women in my oncology practice. They may have more aggressive disease, which is more traumatizing, and they just want to make it go away. Young women may also have young children. No matter how low the risk numbers oncologists cite, the risk is not low enough for them. They are risk intolerant, and want to be alive to see their children grow up,” Kurian said.
Socioeconomics also appears to be a factor, she said. Women who underwent bilateral mastectomy were more likely to be non-Hispanic white and privately insured, to live in high socioeconomic status neighborhoods, and to be treated in National Cancer Institute-designated cancer centers. This pattern of use suggests that affluent, non-Hispanic white women of high socioeconomic status seek more aggressive preventive care.
This is consistent with the reported association between greater use of expensive diagnostic tests, such as breast magnetic resonance imaging (MRI) and genetic testing, and bilateral mastectomy. In contrast, women who underwent unilateral mastectomy were more likely to be Asian, Hispanic, or non-Hispanic American Indian or categorized as “others”; to have public/Medicaid insurance; and to be treated in hospitals serving patients of lower socioeconomic status.
“Socioeconomics paint a clear picture of the demographic group who chooses bilateral mastectomy,” Kurian said. “Women who choose unilateral mastectomy may have the decision forced upon them by circumstance. Breast-conserving surgery plus radiation requires radiation treatments for four weekdays for four to six weeks. If a woman has little flexibility at work or no transportation, she may choose to have a unilateral mastectomy, even though that may not be what she wanted.”
One possibility for the increase in mastectomies may be the dissemination of sensitive diagnostic tests such as breast MRI and genetic testing of BRCA1 and BRCA2 mutations. Kurian points out the evidence for a survival benefit appears limited to rare patient subgroups, including women with BRCA1/2 mutations or strong family history of cancer.
Emerging Imaging Tests
She said she believes that emerging imaging tests play a more important role than genetics in the choice of therapy: “MRI may have some role since these more sensitive tests may lead to more biopsies. This experience may make some women anxious about breast cancer, and they choose to remove both breasts. I doubt genetics is driving bilateral mastectomy. BRCA mutations are rare; they are found in only five percent of women.”
The take-home message, Kurian said, is that “there is no evidence of benefit for women who received bilateral mastectomy versus breast-conserving surgery plus radiation. Many women with one-sided breast cancer think about having a lumpectomy to treat the cancer they have, while others choose a bilateral mastectomy with the goal of preventing involvement of the second breast.
“Our evidence shows if you have bilateral mastectomy, you will not necessarily live longer.”
In an accompanying editorial (JAMA 2014;312:895-897), Lisa A. Newman, MD, MPH, Professor of Surgery and Director of the University of Michigan Breast Care Center, discussed whether prophylactic mastectomy is a reasonable option. She said that although the unilateral mastectomy patients experienced a statistically significant survival disadvantage compared with those having breast-conserving surgery plus radiation, the absolute difference was less than four percent: “These findings support the rationale for encouraging breast-conserving surgery whenever possible,” she said.
“The need for patients to be accurately informed regarding safe and oncologically acceptable treatment options is indisputable. The dense fog of complex emotions that accompanies a new cancer diagnosis can impair the ability to process this information. Patients should be encouraged to allow the intensity of these immediate reactions to subside before committing to mastectomy prematurely.
“Physicians should not permit excessive treatment delays to compromise outcomes, but the initial few weeks surrounding the diagnosis are more effectively utilized by time invested in patient education and procedures that contribute to comprehensive treatment planning as opposed to hastily coordinating impulsive, irreversible surgical plans.”
Asked for her opinion for this article, Daleela Dodge, MD, Medical Director of the Breast Service at LG Health in Lancaster, Pennsylvania, noted that the study used diagnostic code identifiers only rather than individual chart reviews, and that in 1998, genetic testing was rarely performed, while today it is NCCN standard of care to test women diagnosed under age 50, especially those with triple-negative breast cancers.
The benchmark used as the endpoint of comparison – mortality – is “very crude,” she continued. “I have never seen a postoperative death in any patient of mine or of my partners who underwent mastectomy with or without reconstruction for breast cancer.”
Kurian said, though, when asked about that comment that “mortality is the bottom line -- Patients care about that endpoint, and want to know what may happen to them. They fear cancer because they fear dying.”
Dodge also said that there are now much better options for breast reconstruction than were available during the early study period. “Breast reconstruction leads many women to opt for bilateral mastectomy, especially if they elect to have an autologous reconstruction procedure using the abdominal pannus, which cannot be used again in the future, if they develop contralateral cancer,” she said.
Also, some women elect to have bilateral mastectomy to achieve a better cosmetic result -- especially breast symmetry. “This is, after all, becoming an era, especially in California, of many women seeking perfection and an eternally youthful appearance through plastic surgery. Women with breast cancer want to complete treatment perhaps looking even better than before,” Dodge said.
The increased prevalence of obesity also leads to more bilateral surgery because of asymmetry, whether patients chose to have reconstruction or not, she added.
Kurian said she agreed that better appearance, utilizing new reconstructive surgical techniques, is one reason why women choose bilateral mastectomy.
Dodge also said the study may reflect improved detection of contralateral cancers at the time of diagnosis through both the adoption of digital mammography and increased use of breast MRI. “There is also ample data supporting the choice of mastectomy for women under age 40, even those who are not gene-mutation carriers, because of a very high lifetime risk of both developing a new primary in the previously affected breast or a contralateral cancer,” she said.
“I agree that in-depth counseling is essential to avoid treatment decisions being made based on an initial desire to save a woman's life by having the most radical treatment, even when circumstances would allow treatment with breast-conserving surgery plus radiation with an equivalent chance of survival, and with less morbidity and risk of surgical complications.”
Tuesday, October 28, 2014
BY MARY MARCUS BROPHY
In the “old days,” you performed your research, wrote up your study, submitted it to a peer-reviewed journal, and felt a sense of accomplishment if the study was accepted and a printed copy landed in your mailbox some months later. If you were lucky, the media would catch wind of it and your findings would be shared with a broader audience.
But times have changed, studies published in medical journals now typically appear online first, and myriad social media platforms are opening up new opportunities to share research results. The conundrum, though, is how to best use those platforms?
Is a Tweet or a Facebook post about your newest journal-published study the equivalent of standing on a street corner, like the newspaper boys of days past, hawking your wares? Or is it just good common sense to trumpet research results and get the word out, share and stimulate conversation among colleagues, and provide patients and their families with trustworthy information?
The Word from Journals
While many scientist-authors say it's a no-brainer to promote research this way, well-respected medical journals say promoting scientific studies on social media needs to be done judiciously and some offer or are in the process of developing social media guidelines for their authors.
For example, earlier this fall, the American Society of Clinical Oncology (@ASCO) tweeted this message: "Promoting your JCO article on social media. Tips & Best Practices from the Journal of Clinical Oncology http://bit.ly/1mZBhVP ."
Those social media guidelines are simple and straightforward, stating, "We encourage authors to promote their article through social media posts and professional and academic communities to help reach the best and widest audience. Authors will find social media icons prominently displayed in the abstract, full text, and PDF views of JCO articles for easy dissemination through various platforms."
While it's against ASCO’s policy for the social media staff to be interviewed by the media, Don Dizon, MD (@drdonsdizon), a member of ASCO's Cancer Communications Committee, said, "There's been a core group of folks who've been working with the social media manager at ASCO in terms of broadening ASCO's social media spaces and creating more thoughtful ways to interact."
Dizon practices medical gynecologic oncology at the Massachusetts General Hospital Cancer Center where he also founded and directs the Oncology Sexual Health Clinic. A regular contributor to ASCO Connection, he recently wrote a post titled, "Why do Twitter? Because Twitter Counts" (http://bit.ly/ASCOConn-Dizon-Oct92014).
"Twitter has become a rich resource for collaboration—beyond the traditional walls of my own institutions,” he wrote. “I have collaborated on columns with people I have never met IRL (in real life) and met others in oncology who have gone on to become important colleagues. Indeed, in an era where the patient voice is becoming more important (finally), Twitter has provided a forum for me to engage on a much deeper level with people with cancer and those impacted by it."
And that includes sharing study findings directly with patients, Dizon said in an interview for this article.
"I do tweet out newly published study results that I find interesting, and I regularly link to journals that I follow and publish in. Sometimes I do it in response to something someone else has posted. There was just a tweet chat last night (using the hashtag #GYNCSM) and a couple of women on the chat said they were diagnosed with low-grade ovarian cancers and a couple of us tweeted out links on clinicaltrials.gov to relevant trials currently accruing.”
The key to tweeting out your research, and any other information for that matter, is maintaining a certain professional etiquette and clarity, Dizon said. He recommends ASCO University's course "Use of Social Media" (university.asco.org/use-social-media)—which he teaches along with David L. Graham, MD (@davidgrahammd), of Levine Cancer Institute--for oncology experts who have published studies and are interested in learning more about how to best utilize social media to share their findings, and to learn more about the research of others.
Individual Journal Policies
While some journals, such as JCO, offer social media guidelines for authors, others are still formulating them. Others are still in the process of creating their own internal social media strategies.
The New England Journal of Medicine (@NEJM), for example, does not have social media guidelines for authors, a spokesperson said. Currently, their guidelines surrounding social media pertain only to their own internal social media platforms and practices.
At BMJ (@bmj_latest), the editors and social media team are "currently putting together guidance on social media for authors across its portfolio of over 50 journals. This will be made available on journal websites."
And at the Journal of the American Medical Association (@JAMA_current), Michael Berkwits, MD, MSCE, Deputy Editor and Electronic Editor, said the journal's social media efforts began in earnest about a year ago: "We have developed ways to publish more systematically on social media channels, primarily on Facebook and Twitter. We also have a modest presence on Pinterest and LinkedIn.
“We have 10 journals and we've announced an eleventh--JAMA Oncology--so to systematize that across 10 titles and editorial offices is a challenge, but something we have every intention of doing."
He added, "We are pretty careful. Our editorial process is rigorous and turns many claims of success into more modest findings. Authors are, by human nature, inclined to promote their work and make claims for findings that are greater than the evidence actually demonstrates, so we've had some hesitation about encouraging authors to promote their own work through JAMA channels. But we are not disallowing anything through their own accounts, nor do we have the authority to do that."
Berkwits said they are considering ways to systemize a process by which authors would be invited to submit tweets and posts for their articles that would then undergo editorial review.
One of the challenges when tweeting about research is that some medical journal content, of course, can be viewed only by paid subscribers.
"The key thing for journals is to be generous about who they let see their stuff,” said Michael Fisch, MD (@fischmd), Chair of the Department of General Oncology, Division of Cancer Medicine, at the University of Texas MD Anderson Cancer Center. “For some of the articles, you have to have a subscription. It happens a lot. If you're going to tweet the article, let people have access. It burns me if I retweet journal studies and non-subscribers can't read it. There’s no sense in me sharing things that can't be shared."
Fisch uses his Twitter account for a variety of tweets, including retweeting those of journals and other oncologists, but he said some Tweeters do promote only their own studies. "Why would they do that? To get a physician audience to be aware of the work that they're doing,” he said. “And you may say that's a very narcissistic thing to do, but you could also say a lot of work and funding goes into those papers and a lot of patients donated their time, and if those papers sit unlooked at, then what good is it?"
‘Approachable Yet Professional’
While medical journals continue to form and update their social media guidelines, oncologists and experts who have been active on social media for a few years say that if you want to tweet out your research or studies by others, just use common sense and keep the tone approachable yet professional.
"The Mayo guideline is that the majority of tweets should be business-related if you are going to use your Mayo Clinic identity--primarily, but not exclusively," said S. Vincent Rajkumar, MD, Professor of Medicine and Chair of the Myeloma Group at the Mayo Clinic. He tweets from two accounts: @vincentRK and @MayoMyeloma.
"I tweet to get information out--to promote studies that I believe to be critically important. I do not use a disclaimer. My retweets are endorsements. I don’t retweet unless I believe that paper or feel it's something people should know about. Tweet what you believe is true," he said.
Tuesday, October 28, 2014
BY ROBERT H. CARLSON
A large percentage of consults for palliative surgery for patients at cancer centers involve malignant bowel obstruction. An experienced general surgeon could perform the operation indicated, but would a surgeon specializing in palliative care be a better choice for the consult?
Perhaps, says Lawrence D. Wagman, MD, Executive Medical Director of the Center for Cancer Prevention and Treatment at St. Joseph Hospital in Orange, California. A surgical oncologist doing palliative surgery for a cancer patient would have a different perspective on the operations and interventions compared with a general surgeon, he explained in a telephone interview.
Palliative surgery is considered to be any invasive procedure with the goal of relief of symptoms or to improve quality of life for patients with advanced illness, rather than surgery with a therapeutic goal. “A cancer surgeon compared with a general surgeon would be better able to choose the patient who will benefit from a palliative surgical intervention, although you don't need to be a board-certified palliative care specialist to be a cancer surgeon who understands the treatment of the cancer patient who needs a palliative intervention.”
Wagman, previously Chairman Emeritus of the Division of Surgery at City of Hope National Medical Center, said some surgeons might be reluctant to perform a procedure on a patient with cancer if it is not expected to be curative: “That is becoming less common with more training and emphasis on quality of life at the end of life, and more open discussions of the diagnosis and about realistic expectations with the patient. Some general surgeons have been at it a long time and have had experience with cancer patients, but experienced surgical oncologists know more about the diseases so they can better apply the tools of palliative surgery.”
For example, he said, with palliation in mind a surgeon might try a laparoscopic instead of an open procedure.
He noted that City of Hope conducted a survey at one time on physicians' knowledge about palliative care, and acceptance versus non-acceptance of palliative surgical approaches. The results showed that "there was always the concern among the surgeons about not taking away hope in that environment.”
‘Successful Palliation is a Very Successful Surgical Intervention’
Speaking in an interview during the Interdisciplinary Conference on Supportive Care, Hospice and Palliative Medicine, sponsored by the University of Texas MD Anderson Cancer Center, Eduardo Bruera, MD, Professor and Chair of the Department of Palliative Care and Rehabilitation Medicine there, said that in the past it has been difficult to find surgeons for palliative procedures because they considered them to be generally futile since the procedure was not going to resolve the underlying problem of cancer.
“But nowadays there are a few surgeons who see that successful palliation is a very successful surgical intervention,” Bruera said.
He called palliative surgery an “extraordinarily useful intervention” for patients who have a specific problem – relief of pain, odor, bleeding, gastrointestinal function, obstructions, or fungating lesions. “There are many problems where bringing a surgeon aboard who understands how you deliver surgical interventions in patients who are very frail, in a bad state of nutrition, and who need a rapid recovery because they do not have a lot of time to live, is extraordinarily effective.”
Few Are Board Certified
In a presentation at the conference, Brian Badgwell, MD, Associate Professor of Surgery, estimated that there are only about 60 board-certified palliative surgeons in the country.
The American Board of Surgery defines a subspecialist in hospice and palliative medicine as “a surgeon with special knowledge and skills to prevent and relieve the suffering experienced by patients with life-limiting illnesses. This specialist works with an interdisciplinary hospice or palliative care team to maximize quality of life while addressing the physical, psychological, social and spiritual needs of both patient and family.”
There are so few, Badgwell said in an interview, not only because certification requires an additional level of training but also because surgeons have not traditionally embraced palliative care. “But I do believe that is changing, and palliative care is becoming more important in surgery.”
He said that 20 to 25 percent of cancer surgery is palliative care, and estimated that of the approximately 1,000 surgical in-patient consultations a year at MD Anderson, almost half of those meet the criteria for palliative care.
A broad mix of patients meet the criteria for surgical consultation, with obstructive bowel at the top of the list, Badgwell noted. Others are ascites, gastrointestinal bleeding, wound problems, obstructive jaundice, placement of feeding tubes, and venting tubes for palliation, as well as treatment for the side effects of chemotherapy such as neutropoenic enterocolitis and bowel perforations.
In addition, many consults are for abdominal pain of unknown etiology, he said.
In a review published in 2009 in Supportive Care in Cancer (2009; 6:727-734), Badgwell and colleagues (including Bruera) found that of 1,102 surgical consultations requested for inpatients, 40 percent met the criteria for surgical palliative evaluation. Gastrointestinal obstruction was the most common problem (43%), along with wound problems such as bleeding or infected tumors (10%), gastrointestinal hemorrhage (8%), requests for feeding tubes, abdominal pain, and obstructive jaundice.
The surgeons performed palliative procedures in only 27 percent, and median survival was 2.9 months, the study found. “Given that overall survival in this population is short and surgery is associated with considerable morbidity and mortality, non-operative management is desirable,” the authors concluded.
At One Time Almost a Pejorative Term
Geoffrey Dunn, MD, Medical Director of the Palliative Care Consultation Service at the University of Pittsburgh's Hamot Medical Center, noted in an interview that “palliative surgery” at one time was considered almost a pejorative term, used to describe a non-curative operation.
“Surgeons would say 'the margins were positive and we left disease behind, so that was just a palliative operation,' even if did not necessarily do anything for symptom relief.
“Early on, I got a lot of rolling eyeballs and doors slamming when talking about palliative care. Even now, I can see the body language of surgeons when I talk about palliative care--they're uneasy with it, uneasy in dealing with situations where they don't have control.
“But I knew what mattered to the older surgeons, and worked to convince them that this is important and follows all the core principles of surgery.”
Dunn, who was Chairman of the Department of Surgery at Hamot before working full time in the field of palliative and hospice care, said, “I believe that many of the salient principles of palliative surgery have been with us since the beginning of surgery. It's nothing really new, it's a matter of rediscovering principles and attitudes.”
Palliative surgeries are in themselves really no different and can be done in any hospital, he said. What distinguishes them is the framework in which the decision is made – “what question is being asked for which the operation is the answer?
“That's where you need a good functioning palliative care service. Making the decision involves knowing the psychology of the family and patient, being aware of comorbid conditions, and understanding adjunctive therapies.”
These are the most complicated decisions there are in surgery, Dunn continued.
“If you get hit by a car and you have a ruptured spleen it's not hard to figure out what you're going to do and how to do it. But it's a completely different question if you have a recurrent cancer and a complete intestinal obstruction – we might relieve the bowel obstruction, but then the patient might lose their appetite and be so debilitated because of advanced cancer, so are they really gaining anything? And meanwhile they have taken on all the risks of the procedure, which are considerable.”
Dunn wrote in a journal article recently that “surgeons can more effectively meet the public's increased expectation of patient-centered care by directing attention to pain and to non-pain symptoms including depression and anxiety, in addition to the patient's personal preferences, resources, and support needs” (J Surg Oncol 2014;5:621-628).
“Patient navigation and palliative care, both pioneered by surgeons, provide complementary frameworks for the screening, assessment, and intervention needed to achieve enhanced patient outcomes including adherence to care, improved quality of life, and patient satisfaction,” he wrote along with his coauthor, Nina Miller, MSSW, OSW-C.
Monday, October 27, 2014
BY JANELLE WEAVER
Receiving a cancer diagnosis can produce a great deal of psychological distress, and patients often experience clinically significant levels of anxiety and depression. Among the most commonly diagnosed mental disorders in oncology are adjustment disorders, as cancer patients often face changes in social roles, an increased dependency on others, and impairments in the ability to function normally.
Despite convincing evidence of psychological problems among a range of cancer patients, the exact prevalence has not been clear, researchers noted, due to variability in the methods, size, and quality of past studies. Moreover, most studies in cancer populations have assessed only a few of the disorders as described by the diagnostic classification manuals for mental disorders.
To address the lack of reliable data on mental disorders in patients with cancer, Anja Mehnert, PhD, Professor of Psychosocial Oncology at University Medical Center Leipzig and colleagues conducted a large, multicenter, epidemiologic cross-sectional study to estimate the four-week prevalence of mental disorders in patients with cancer across major tumor types using a validated standardized clinical interview.
In the study, available online ahead of print in the Journal of Clinical Oncology (DOI: 10.1200/JCO.2014.56.0086), the researchers found that nearly one-third of cancer patients have been diagnosed with one or more mental disorders, with anxiety and adjustment disorders the most prevalent. Moreover, the prevalence estimates varied widely among patients with different tumor types, which shows the importance of providing targeted interventions, Mehnert said in an interview.
“The four-week prevalence rate of any mental disorder gives health care policymakers and hospital administrations a very good basis to calculate the resources necessary to provide adequate psychological support services,” she said. “Our study also provides data on which patients we should watch more closely. We want to reassure patients who are struggling that they are not alone or unique, and that mental and emotional challenges can be temporary, especially with effective psychological support or state-of-the-art mental health treatment.”
Mehnert and her team enrolled adult cancer patients from acute care hospitals, outpatient cancer care facilities, and cancer rehabilitation clinics in Germany. Patients across all major tumor types and disease stages were included and stratified by nationwide incidence of cancer diagnoses. Each stratum was represented in the sample in the same proportion as in the population.
A total of 5,889 eligible patients were identified at 30 institutions. The response rate for the survey was 68.3 percent, which led to 4,020 participants. These patients were screened with the depression module of the Patient Health Questionnaire (PHQ-9), and 903 patients who scored at least nine on the scale then completed the Composite International Diagnostic Interview for Oncology (CIDI-O). A random sample of patients with a PHQ-9 score lower than nine were also selected for the CIDI-O, and 1,238 of these individuals completed the interview.
Approximately 32 percent of patients with cancer were diagnosed with at least one mental disorder. Anxiety disorders were the most prevalent mental disorders, affecting 11.5 percent of patients, whereas mood disorders affected 6.5 percent. An additional 11 percent of patients met the criteria for adjustment disorders, a term assigned when neither anxiety nor depressive disorders were present.
Approximately six percent of patients were diagnosed with two disorders and about 1.5 percent of patients had three or more disorders. Surprisingly, the prevalence of alcohol abuse/dependence was negligible at only 0.3 percent--lower than the 2.5 percent prevalence found in the general population in Germany.
The total four-week prevalence rate for any mental disorder was similar to that reported in a previous study of cancer patients, but it was higher than the 20 percent prevalence among the general German population. “We believe that this is primarily due to a higher rate of adjustment disorders as a stress response to the cancer diagnosis and cancer treatments, as well as anxiety disorders,” Mehnert explained.
The prevalence rate for any anxiety disorder was slightly higher than the previously reported rate of about 10 percent in oncological, hematological, and palliative care settings. It was also higher than the nine percent prevalence among the general German population.
On the other hand, the prevalence estimate for any mood disorder was remarkably low, similar to the six percent prevalence among the general German population, and much lower than previous reports of clinically significant levels of depressive symptomatology in 11 to 37 percent of cancer patients, she noted.
Differences Between Different Types of Cancer
Notably, the prevalence for any mental disorder was roughly 40 percent in patients with breast cancer, head and neck cancer, and malignant melanoma, compared with only about 20 percent in patients with pancreatic cancer, stomach/esophagus cancers, and prostate cancer.
“The presence of a mental health disorder was not apparently tied to the relative prognosis of patients, with patients with breast cancer experiencing a higher incidence compared with those with a relatively worse prognosis, such as esophageal or pancreatic cancers,” said Don S. Dizon, MD, FACP, Assistant in Medicine, Medical Gynecologic Oncology, at Massachusetts General Hospital, who was asked for his perspective for this article. “This implies that patients with cancer are at risk for experiencing these issues, almost irrespective of what cancer they have.”
According to the authors, the wide range of prevalence rates across patients with different tumor types might be partially explained by different disease stages, treatment phases, and medical conditions, such as the presence of pain and functional impairments. They also noted the potential influence of such demographic characteristics as gender, age, and educational differences, as well as socioeconomic and psychosocial factors, including coping mechanisms.
Also asked to comment, William F. Pirl, MD, MPH, Associate Professor of Psychiatry at Massachusetts General Hospital, noted that the authors did not present any data adjusting for the various demographic factors collected in the study. “Some of those differences may have contributed to the reported differences in rates among different cancer types, especially the high rate in patients with breast cancer.”
Another limitation is that the study participants were younger, had more education, and were more likely treated in a rehabilitation clinic than during inpatient acute care, compared with those who refused to participate. Moreover, the CIDI-O completion rates varied across patients with different tumor types. As a result, it’s not clear how generalizable the prevalence estimates are.
Regarding limitations, Dizon also noted that since the study evaluated patients at only one point in time, it is not necessarily known how this might change during and after treatment—“or for those without a curable disease, how it might change as treatments continue or change, and as the patient’s physical condition changes.”
Still, despite these weaknesses, the study does have an important take-home message, Dizon said: “The study certainly tells me as a medical oncologist to be more sensitive to the psychological stress associated with a new cancer diagnosis. Even if I feel that a patient has a relatively good prognosis, this is not protection from distress or other mental health consequences. We need to be proactive about screening patients about their mental health, no matter what kind of cancer they have been diagnosed with.”
In the end, it is still not clear which interventions might help patients the most. “The next steps in research should focus on how best to treat, or even prevent, psychiatric disorders in patients with cancer,” Pirl said.