Alfred S. Ketcham

How coping mediates the effect of optimism on distress: a study of women with early stage breast cancer.

At diagnosis, 59 breast cancer patients reported on their overall optimism about life; 1 day presurgery, 10 days postsurgery, and at 3-, 6-, and 12-month follow-ups, they reported their recent coping responses and distress levels. Optimism related inversely to distress at each point, even controlling for prior distress. Acceptance, positive reframing, and use of religion were the most common coping reactions; denial and behavioral disengagement were the least common reactions. Acceptance and the use of humor prospectively predicted lower distress; denial and disengagement predicted more distress. Path analyses suggested that several coping reactions played mediating roles in the effect of optimism on distress. Discussion centers on the role of various coping reactions in the process of adjustment, the mechanisms by which dispositional optimism versus pessimism appears to operate, third variable issues, and applied implications.

Optimism versus pessimism predicts the quality of women's adjustment to early stage breast cancer

Background. Recent studies indicate that breast cancer patients do not usually experience the devastating psychological consequences once viewed as inevitable. However, some adjust to the disease more poorly than others. This study examined the personality trait of optimism versus pessimism as a predictor of adjustment over the first year, postsurgery.

Postsurgical adjuvant chemotherapy with or without radiotherapy in women with breast cancer and positive axillary nodes : a South-Eastern cancer study group (SEG) trial

In a prospective study of 622 women with breast cancer, those with one to three histologically positive axillary lymph nodes were randomised after mastectomy to receive cyclophosphamide 100 mg/m2 orally on days 1-14, methotrexate 40 mg/m2 intravenously on days 1 and 8, and fluorouracil 600 mg/m2 intravenously on days 1 and 8 every 28 days for six cycles (CMF x six), or for twelve cycles of the same chemotherapy (CMF x 12). Those with > or = four positive nodes were randomised to one of these two groups or to 5000 cGy of postmastectomy regional radiotherapy (RT) followed by six cycles of the same chemotherapy (RT + CMF x six). With about 10 years median follow-up, there was no significant difference in survival or disease-free survival among the three groups. There was evidence of decreased locoregional recurrence in patients with > or = four nodes who received RT + CMF x six (relative risk 0.53, P = 0.067). Multivariate analysis indicated that the presence of > or = four positive nodes (negatively) and the percentage of ideal (full) dose of CMF received (positively) were the strongest factors predictive of survival. This study shows no advantage for 12 over six cycles of CMF chemotherapy in women with breast cancer and positive axillary nodes. There was a suggestion of decreased locoregional recurrence but no improvement in survival with radiotherapy for women with > or = four positive nodes.

Pelvic exenteration for advanced pelvic malignancy.

Pelvic exenteration is a demanding, yet potentially curative operation, for patients with advanced pelvic cancer. The majority will present with recurrence after prior surgery and radiotherapy. After exenteration, 5-year survival is 40% to 60% in patients with gynecologic cancer as compared to 25% to 40% for patients with colorectal cancer. Physiologic age and absence of co-morbidities appear to be more important when selecting patients for exenteration than chronological age. Careful pre-operative staging, including either computed tomography (CT) scan or magnetic resonance imaging (MRI), usually will identify patients with distant metastases, extrapelvic nodal disease, or disease involving the pelvic sidewall (which generally precludes surgery). The recent application of intra-operative radiotherapy or postoperative high-dose brachytherapy for patients with more advanced pelvic disease, which may include sidewall involvement, may expand the standard indications for exenteration. However, the intent of this procedure, with or without radiotherapy, should be resection of all tumor with the aim of cure since the place of palliative exenteration is controversial at best. The operative details of exenteration are presented, as are two surgical approaches to composite resection of pelvic structures in continuity with sacrectomy. Filling the pelvis with large tissue flaps, usually a rectus abdominus flap, has decreased morbidity rates, particularly with small bowel complications. Peri-operative mortality is usually 5% to 10%, and significant morbidity occurs in over 50% of patients. Restorative techniques for both urinary and gastrointestinal tracts can diminish the need for stomas and, along with vaginal reconstruction, can significantly improve quality of life for many patients after exenteration. These advances in surgery and radiotherapy help make the procedure a viable option for patients with otherwise incurable pelvic malignancy.

Sacral resection for control of pelvic tumors.

A surgical approach for treating patients with resected, recurrent, posterior pelvic visceral tumors involving the sacrum is detailed. Of 11 patients, 9 had rectal cancers, 1 had chordoma, and 1 had cancer of the cervix. Five total pelvic exenterations and five posterior exenterations were performed en bloc with involved sacrum. One patient had a sacral resection only. Surgical mortality was 9%, and the average hospital stay was 1 month. Mean disease-free survival was 1 year, and mean survival was 3 years. Absolute cure rate was 18% with a complete 5-year follow-up. This experience confirms the value of this procedure in selected patients.

Vexed surgeons, perplexed patients, and breast cancers which may not be cancer.

In situ cancer of the breast is being diagnosed with increasing frequency due to the widespread use of mammography and heightened awareness of these lesions among pathologists. Treatment of these preinvasive cancers is controversial in light of recent data supporting breast‐conserving therapy for small invasive cancers. Therapy for in situ breast cancer is discussed with attention to known risk factors for recurrence and breast cancer‐related mortality. The controversies surrounding treatment of ductal and lobular carcinoma in situ compel the conscientious oncologist to seek fully informed consent and to respect the individual patients feelings about cosmesis and breast cancer risk. Hopefully, prospective randomized studies such as the National Surgical Adjuvant Breast and Bowel Project (NSABP) B‐17 trial will relieve the oncology community of much of its confusion about the natural history and optimal therapy for these diseases.

Primary squamous carcinoma of the rectum: Report of a case and review of the literature

Squamous cell carcinoma of the colorectum is a rare pathologic curiosity. Since the first report by Schmidtman in 1919, only 69 cases have been reported in the English medical literature. The mean age at presentation is 52 years, and the disease presents itself equally in men and women. The rectum accounts for slightly less than one half of all cases. Survival appears to correlate with nodal status and findings of visceral metastases at presentation. Most tumors can be identified easily by physical examination and/or barium enema. Therapy is limited largely to surgical resection, although attempts at irradiation and chemotherapy have been made. At this time, the etiology of this disease process is unknown, but a likely explanation revolves around replacement of damaged epithelium by cells which undergo anaplasia due to repeated trauma. In addition to this review of the literature, the authors wish to add one additional report of a patient treated successfully by a multimodality approach.

Gluteus maximus myocutaneous flap for the treatment of recalcitrant pilonidal disease

The treatment of a patient for multiple recurrent pilonidal disease failed all forms of conventional therapy. After re-excision, a gluteus maximus myocutaneous flap, measuring 15×15 cm and based on the superior gluteal artery, was swung to cover the defect. Complete relief from severe pain was obtained immediately. No recurrence is noted after two and one-half years of follow-up.

The total thigh and rectus abdominis myocutaneous flap for closure of extensive hemipelvectomy defects

Hemipelvectomy is a lifesaving procedure when used appropriately and yields a 35%, five‐year survival in the cancer patient. However, the standard posterior flap for closure is not always available. Two flaps, the thigh flap and the rectus abdominis myocutaneous flap, are described in which any soft tissue defect resulting from hemipelvectomy can be safely closed primarily when the posterior flap is not available. The total rectus abdominis flap is previously undescribed and unique in its application. These techniques significantly contribute to the surgeons armamentarium for decreasing morbidity and mortality and resectability of unusual pelvic and thigh tumors.

Correlation of cell cycle analysis with Duke's staging in colon cancer patients

The biologic potential of a tumor for growth and metastasis is relatively inaccurately mirrored by the present staging system in colon cancers [29]. Except for Stage IV disease, traditional morphologic criteria approaches only 50-75% accuracy for predicting recurrent disease. Reliable staging, however, has become more critical in the light of the current thrust in adjuvant therapy research. First, the patients receive toxic and expensive therapy. Second, and of even greater importance, a central tenet of adjuvant therapy research is that treatment and control groups under study are comparable. Inadequate staging not only undermines analysis, especially when small improvements of lo-20% may be expected, but also demands very large study groups to offset this defect. A significant amount of research has attempted to quantitate the metastatic potential of a tumor. In the animal model some factors such as cell adhesiveness, tumor angiogenesis, detachability, thromboplasticity, and shedding of membrane antigen have been associated with an increased propensity of a tumor to spread [23]. In the clinical forum, analysis of factors such as tumor grade [4, 71, vascular invasion [7], host immune status [ 1, 8, 91 have not been established as having a clear-cut prognostic value. Hopefully prospective studies, objective criteria, and more sophisticated statistical analysis [6] may yield less disappointing results in the future. In this respect, accumulating evidence indicates that the analysis of tumor kinetics will be a major determinant of the metastatic potential of a tumor. It is well established that kinetic data of tumor doubling time and labeling index (LI) is associated with length of survival [ 11, 18, 21, 271, but the effect of tumor doubling time on ultimate survival was reported by Joseph et al. [12, 161. In his report, patients with resection of solitary pulmonary metastasis with doubling times less than 40 days subsequently died of metastasis whereas 60% of the patients with tumor doubling time over 40 days were cured. Other measures of tumor proliferative activity, i.e, mitotic index in sarcomas 1281 and labeling index in breast cancer patients 1151 have recently been implicated as important prognostic determinants, and in the former instance has been incorporated into the A.J.C. stating system [20] as a factor influencing tumor grading. Finally, the development of flow cytometry [24] has now made the rapid and objective analysis of cell cycle kinetics an exciting clinical reality. In this study, the predictive potential of cell cycle analysis by flow cytometry was examined by comparing the proliferative activity of colorectal adenocarcinoma with Duke’s staging and modified Broder’s grading.