Eleni Tsilika

Cancer information disclosure in different cultural contexts.

The relationship between truth telling and culture has been the subject of increasing attention in the literature. The issue of whether, how and how much to tell cancer patients concerning diagnosis is still approached differently depending on country and culture. The majority of physicians tell the truth more often today than in the past, in both developed and developing countries, but most of them prefer to disclose the truth to the next of kin. Nurses in Anglo-Saxon countries are considered to be the most suitable health-care professionals for the patients to share their thoughts and feelings with. Nevertheless, in most other cultures the final decision on information disclosure lies with the treating physician. Regardless of cultural origin, the diagnosis of cancer affects both family structure and family dynamics. In most cases patients’ families, in an effort to protect them from despair and a feeling of hopelessness, exclude the patient from the process of information exchange. The health-care team–patient relationship is a triangle consisting of the health-care professional, the patient and the family. Each part supports the other two and is affected by the cultural background of each of the others as well as the changes that occur within the triangle.

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.

The Hospital Anxiety and Depression Scale in Greek cancer patients: psychometric analyses and applicability

Goals of workThe aim of the present study was to validate the Greek version of the Hospital Anxiety and Depression Scale (HAD) in a palliative care unit.Patients and methodsThe scale was translated with the “forward-backward” procedure to Greek. It was administered twice, with a 1-week interval, to 120 patients with advanced cancer. Together with the HAD scale, the patients also completed the Spielberger State-Anxiety Scale (STAI-S).Main resultsFactor analyses identified a two-factor solution corresponding to the original two subscales of the HAD, which were found to be correlated. The Greek version of the HAD had Cronbach’s alphas for the anxiety and depression scales of 0.887 and 0.703, respectively. Validity as performed using known-group analysis showed good results. Both anxiety and depression subscales discriminated well between subgroups of patients differing in disease severity as defined by ECOG performance status. Correlations between the HAD scale and the STAI-S was 0.681 for the anxiety subscale and 0.485 for the depression subscale.ConclusionsThese psychometric properties of the Greek version of the HAD scale confirm it as a valid and reliable measure when administered to patients with advanced cancer.

Long-Term Management of Noncancer Pain With Transdermal Therapeutic System-Fentanyl

Transdermal therapeutic system-fentanyl (TTS-F) has been extensively studied in cancer pain management. However, few studies have addressed the long-term management of noncancer pain, especially when it relates to neuropathic pain. A total of 529 patients were recruited into this prospective open-label study to determine the safety and effectiveness of TTS-F in relation to quality-of-life (QOL) stratified according to pain type and etiology. TTS-F significantly improves QOL within 28 days, and pain management within 48 hours. The frequency of side effects rapidly decreases over time, and patients not experiencing adequate pain management are identified within 28 days. The median duration of therapy for effective pain management was 10 months, and 90% of patients sustained such efficacy. TTS-F offers statistically significant increases in QOL-Short Form 12 (including the Physical Component Scale and Mental Component Scale measures) and pain control (Greek Brief Pain Inventory) from one time point to the next (P <.0001). These improvements are not influenced by pain type or etiology. TTS-F is a safe and effective pain management system independent of patient characteristics and demographic factors. What is of most importance is that in those patients with neuropathic pain, for whom opioids have long been thought to be ineffective, similar effectiveness is demonstrated when compared to patients with nociceptive pain.

Greek M.D. Anderson Symptom Inventory: Validation and utility in cancer patients

Objective: The M.D. Anderson Symptom Inventory (MDASI) is a brief assessment of the severity and impact of cancer-related symptoms. The purpose of this study was the translation and validation of the questionnaire in Greek (G-MDASI). Methods: The translation and validation of the assessment took place at a Pain Relief and Palliative Care Unit. The final validation sample included 150 cancer patients (61 males, 89 females, age range 31–88 years, mean age 63.32). The patients completed the questionnaires at the outpatient clinic. Assessing the validity and reliability constituted the actual validation of the G-MDASI. Results: The item ‘diarrhea’ had a score of 0 in 139 patients and, thus was omitted from the ‘core’ list. Consequently, the core questionnaire consisted of 14 items. Factor analysis resulted in a 3-factor model, in both validation and cross-validation samples. The examination of the sensitivity of the MDASI revealed that there were differences between patients with poor-to-good performance status but no differences were found between patients in different treatment groups. Conclusions: The results showed that the G-MDASI is a reliable and valid measure in Greek cancer patients. It has proved to be a comprehensive symptom assessment tool.

How is sleep quality affected by the psychological and symptom distress of advanced cancer patients

The aim of this study was to assess the relationship between sleep quality, pain, psychological distress, cognitive status and post-traumatic experience in advanced cancer patients. Participants were 82 advanced cancer patients referred to a palliative care unit for control of pain and other symptoms. A variety of assessment tools were used to examine the prevalence of sleep disturbance, the severity of pain and depression, hopelessness, cognitive function and quality of life. Using the Pittsburgh Sleep Quality Index (PSQI) 96% of patients were ‘poor sleepers’. Statistically significant associations were found between PSQI and the SF-12 (Short Form-12) Quality of Life Instrument (MCS, P < 0.0005, PCS, P < 0.0005), depression (Greek Depression Inventory) (P < 0.0005) and hopelessness (Beck Hopelessness Scale) (P = 0.003). Strong associations were also found between PSQI and IES-R (Impact of Event Scale-Revised) (P = 0.004). The strongest predictors of poor sleep quality in this model were MCS (P < 0.0005), PCS (P < 0.0005) and IES-R (P = 0.010). Post-traumatic experience and quality of life seemed to be the strongest predictors of sleep quality in a sample of advanced cancer patients referred for palliative care.

Use of TTS Fentanyl as a Single Opioid for Cancer Pain Relief: A Safety and Efficacy Clinical Trial in Patients Naive to Mild or Strong Opioids

Background: Up to now, a transdermal therapeutic system (TTS) of fentanyl has been applied to cancer patients on opioid analgesics previously treated with mild opioids or morphine. The aim of this study was to investigate the efficacy and safety of TTS fentanyl (patch) administration as an analgesic to patients treated with opioid analgesics for moderate-to-severe cancer pain, with immediate-release oral morphine only as rescue medication. The prior analgesic medication of the patients did not include mild or strong opioids. Methods: The study group consisted of 113 patients (54 men and 59 women; age range: 21–87 years, mean ± SD 61.3 ± 14.84 years) with undertreated chronic cancer pain. The study period was 42 days. The patients were hospitalized for the first 3 days of the study; thereafter they were transferred to their home for the rest of the study. Daily cards were completed, noting their pain score (0–10 VAS), nausea, vomiting, constipation, skin reactions, dizziness or any other complaints. Vital signs were also recorded. Data assessments were made at baseline, on days 1, 2 and 3 (during hospitalization) and thereafter on days 7, 14, 21, 28, 35, and 42 after hospital discharge. The initial TTS fentanyl delivery rate was chosen depending on the patient’s analgesic requirements. All patients were given an oral morphine solution (5–10 mg), every 4–6 h, for the first 12 h, as rescue medication. Results: Baseline pain score was between 6 and 10 (mean ± SD 7.1 ± 1.7). The initial TTS fentanyl delivery rate was between 25 and 50 µg/h (mean ± SD 36.5 ± 15.7). On day 3, 95 patients (84%) reported a pain score ≤3 (mean ± SD 0.5 ± 0.8), 14 patients (12.4%) a pain score of 4 and 4 patients (3.5%) of 5–8. No adverse effects suggesting the discontinuation of the study were reported. From day 7 until the completion of the study, the mean pain score was between 1.3 and 0.16 while the TTS fentanyl delivery rate on day 42 was between 25 and 400 µg/h (mean ± SD 122.1 ± 81.2 µg/h). Conclusion: Analgesic treatment with TTS fentanyl used as a single opioid is effective and safe for cancer pain relief, given that is cautiously applied, in patients requiring strong opioid analgesics even if they were naive to strong or mild opioids.

Depression, hopelessness, and sleep in cancer patients' desire for death

Objective: The aim of this study was to evaluate the prevalence of clinical characteristics and risk factors for hastened death in advanced cancer patients. Methods: Patients completed the Greek version of Schedule of Attitudes toward Hastened Death (G-SAHD), a sleep quality measure, the Pittsburgh Sleep Quality Index (PSQI), a Greek version of a depression inventory, the Beck Depression Inventory (BDI), a hopelessness scale, the Beck Hopelessness Scale (BHS), and a Visual Analogue Scale (VAS) for the assessment of pain. Patients: The final sample consisted of 102 terminally ill cancer patients attending a Palliative Care Unit. Results: Statistically significant associations were found between G-SAHD and patients performance status (ECOG) (χ2 = 8.62, p = 0.003). Strongest associations were observed between desire for death, depression, and hopelessness (r = 0.468, p < 0.0005, r = 0.678, p < 0.0005, respectively). In the prediction of G-SHAD the contribution of “hopelessness” (p < 0.0005), “depression” (p < 0.0005), “use of sleeping medication” (p < 0.0005), and “sleep quality” (p=0.001) was high (59% of variance). Conclusion: Depression, hopelessness, and sleep quality appeared to have a statistically significant relationship with desire for hastened death. Health care professionals finding desire for death in advanced cancer patients should not only consider depression and hopelessness, but also other factors such as poor sleep quality in their diagnostic formulations in order to provide the appropriate treatment.

LONG-TERM CANCER PAIN MANAGEMENT IN MORPHINE PRE-TREATED AND OPIOID NAIVE PATIENTS WITH TRANSDERMAL FENTANYL

There is emerging data supporting the use of TTS‐F (transdermal therapeutic system‐fentanyl) in opioid naive patients. Our study examines the safety and efficacy of TTS‐F in the long‐term control of cancer pain in opioid naive patients and those transferring from oral morphine. Pain was assessed in 589 patients (Group A: 268 opioid naive, Group B: 321 transferring from morphine) using a Visual Analogue Scale (VAS; 0–10), based on selected questions from the Greek Brief Pain Inventory (GBPI). Overall treatment satisfaction was assessed on a 4‐point scale. Quality of Life (QOL) and ECOG (0–4) status were also recorded. These were assessed in relation to TTS‐F dose, pain type (neuropathic, combined, nociceptive), concomitant use of anti‐inflammatory drugs and other demographic data. Of 589 patients, 59 (10%) withdrew as a result of inadequate pain satisfaction or for other reasons. There were no discontinuations due to side effects; no Grade 3–4 events occurred. A total of 530 continued on‐study, 211 patients died during study period and 295 departed; all (506; 89%) were satisfied with their pain relief. Analysis of patients at baseline, 28 days, 6 and 12 month time points (n = 153 Group A; n = 214 Group B) with respect to QOL and pain measures indicated a statistically significant (p < 0.001) improvement in all measures across time independent of pain type, or any other patient characteristic(s). In patients with intolerable pain, transfer to TTS‐F offers an efficient and safe long‐term analgesic option. TTS‐F offers durable long‐term maintenance of pain relief with acceptable side effects in opioid naive patients. In general, TTS‐F as a first line analgesic approach for carefully selected and monitored patients experiencing moderate to severe cancer pain should be considered.

Self-Efficacy, Depression, and Physical Distress in Males and Females With Cancer

Aims: To examine the relationship between self-efficacy with depression and physical distressing symptoms in males and females with cancer. Methods: A total of 41 males and 49 females with cancer completed the General Perceived Self-Efficacy Scale (GSE), depression scale, from the Hospital Anxiety and Depression Scale (HAD-D), and the MD Anderson Symptom Inventory (MDASI). Results: Correlations were found between depression and self-efficacy in males (r = -.501, P = .001) and females (r = -.588, P < .0005). The multivariate regression analysis revealed that education and depression could influence self-efficacy in male population. Urogenital versus breast cancer as well as depression seemed to influence females’ self-efficacy. Conclusions: Patients who had higher self-efficacy had lower depressive symptoms. Men with depressive symptoms and women with breast cancer and depression are more likely to have low self-efficacy than patients with other cancer types.