Leslie G. Walker

Breast screening: the psychological sequelae of false-positive recall in women with and without a family history of breast cancer.

The psychological effects of false-positive mammography were evaluated in 124 women who had taken part in the U.K. National Health Service Breast Screening Programme. In addition, the effects of recall on women with and without a family history were compared. These women were asked to complete the Hospital Anxiety and Depression Scale (HADS) before being invited to attend for screening, at recall and 5 weeks and 4 months after recall. At screening and at recall, the women were asked to complete the Health Questionnaire (HQ) which measures stress-related behaviour changes in the previous week. In the week before screening, compared with women who did not have a family history of breast cancer, women with a family history had lower scores on HADS depression and reported fewer stress-related behaviour changes. At recall, regardless of family history, the women were more likely to have borderline or clinically significant anxiety than at baseline or screening. Nevertheless, for most women, recall-induced anxiety was relatively transient (less than 5 weeks). Compared with women without a family history, women with a family history were more anxious 4 months after recall, although their anxiety scores tended to be lower (P < 0.06) than at baseline. A strength of the present study is that the initial baseline measure was uncontaminated by the screening process. Women who did not complete questionnaires at one or more of the subsequent time points scored higher on HADS depression at baseline, indicating that the results are likely to have underestimated the effects of recall. Screening appears to be less stressful for women with a family history than for those without a history. However, for both groups recall causes short term distress. Breast screening programmes should ensure that steps are taken to minimise the number of women who are recalled for unnecessary investigations.

Treatment of large and locally advanced breast cancers using neoadjuvant chemotherapy

BACKGROUNDnNeoadjuvant (primary) chemotherapy is being used increasingly in the treatment of patients with large and locally advanced breast cancer with the aim of reducing the size of the primary tumor and eliminating micrometastatic disease. Response rates to, compliance with, and survival of patients following neoadjuvant chemotherapy have been variable. We report the results of a consecutive series of 77 patients with breast cancer who received neoadjuvant chemotherapy.nnnMETHODSnSeventy-seven patients with locally advanced breast cancers were treated with multimodality therapy comprising up to six cycles of chemotherapy (cyclophosphamide, vincristine, doxorubicin, and prednisolone), radiotherapy, and then surgery. The median follow-up was 54 months. Clinical response rates to therapy and overall survival have been documented. In addition, prognostic factors for survival were identified using the Cox proportional hazards model.nnnRESULTSnThe overall objective response rate of the primary tumor to chemotherapy alone was 87% (25% complete and 62% partial responses, UICC criteria). Following radiotherapy the response rate was 90% (52% complete and 38% partial responses). The overall 5-year survival for all patients was 0.48. However, the probability of survival at 5 years was 0.74 in those with a complete response, and 0.36 if there was a partial clinical response, but no patients who had either stasis of disease or progression survived for 5 years. Independent predictors of better survival that were identified were a complete histopathological response after chemotherapy and radiotherapy, a complete clinical response to chemotherapy, and five or six cycles of chemotherapy versus four or less.nnnCONCLUSIONSnNeoadjuvant chemotherapy in patients with large and locally advanced breast cancers can result in satisfactory local control and overall survival rates, especially in patients with a complete clinical or histopathological response after treatment.

The psychological and psychiatric effects of rIL-2 therapy: a controlled clinical trial

It has been suggested that recombinant interleukin‐2 (rIL‐2) may cause pyschological and psychiatric problems, although the effects of rIL‐2 on its own have not been well documented. To evaluate these effects, 17 patients with advanced colorectal cancer took part in a randomised, parallel group study of rIL‐2 with chemotherapy (5‐fluorouracil and leucovorin) versus chemotherapy alone.

The effects of the participation of patients with cancer in teaching communication skills to medical undergraduates : A randomised study with follow-up after 2 years

The importance of good doctor-patient communication is widely recognised. The aims of this study were to evaluate the immediate effects of the participation of patients with cancer on the attitudes and skills of undergraduate medical students receiving an interview skills training programme, and to assess the effects of the participation of patients with cancer on the attitudes and interview performance of students 2 years later. It was hypothesised that the participation of cancer patients would have specific beneficial effects on attitudes and interview performance. Before participating in a 6-session interview methods course in third year, students were randomised to be taught with patients who had cancer (experimental group) or with patients with other diagnoses (control group). Before and after participating in the course, 233 students (94% response rate) completed an Attitudes Questionnaire. When they reached their fifth year, 54 students again completed the Attitudes Questionnaire and, in addition, made a video recording of an interview with a patient who had gynaecological cancer. These recordings were rated independently by two researchers using the Interview Rating Instrument. Immediately after the course, a number of differences were found between the two groups. For example, students in the experimental group were more likely to consider the ability to listen an extremely important characteristic of hospital doctors and to consider more strongly that trust is an essential part of the doctor-patient relationship. 2 years after the course, the ability of hospital doctors to communicate with patients, and the need for clinical decisions to reflect patients wishes, were considered to be more important by students in the experimental group, although even 96% of controls felt both these issues were very or extremely important. As hypothesised, the experimental group had better ratings in terms of responding empathically, showing regard and concern for the patient, and assessing the impact of the symptoms on the patients life. The participation of patients with cancer has beneficial and enduring effects on the attitudes and interview performance of medical undergraduates. Medical schools should consider how best patients with cancer can make an important contribution to communication skills training.

Predicting a second hip fracture

In an attempt to identify a high-risk cohort of patients, who could be offered preventive therapy, we assessed patients who had suffered one hip fracture. A total of 394 patients were prospectively followed to determine those who had suffered a second fracture. Entry bone mass of the unfractured hip and total body was examined by dual X-ray absorptiometry (DXA) and of the os calcis, by quantitative ultrasound (QUS), along with various clinical parameters. The relative risks in the QUS parameters did not reach significance, except for broadband ultrasound attentuation as measured by the McCue CUBA Clinical, whereas femoral neck and total body bone mineral density also reached significance. Lowest quartile body weight was also a significant risk factor as were occurrence of a new fall and poor mobility score. Using Receiver Operator Characteristic curves, we found no significant differences between DXA trochanter or for the Mini Mental State Examination score in predicting those who sustained a second hip fracture. In this elderly group risk factors are almost as good as bone mass at predicting those who will sustain a second hip fracture. Low body weight and poor mobility could be used as triggers for the use of preventive therapy without the use of bone mass measurements and to target expensive preventive therapy to reduce fracture risk.

The cognitive effects of recombinant interleukin-2 (rIL-2) therapy: a controlled clinical trial using computerised assessments.

It has been suggested that patients undergoing treatment with recombinant interleukin-2 (rIL-2) may develop cognitive impairment. To evaluate these effects, 17 patients with advanced colorectal cancer took part in a randomised, parallel group study of rIL-2 with chemotherapy (5-fluorouracil and leucovorin) and chemotherapy alone. Assessments were carried out daily whilst patients were in hospital and regularly between cycles of treatment using state-of-the-art computerised cognitive assessment, as well as traditional psychometric tests. Rigorous discontinuation criteria were applied to ensure that the effect of time-related variables did not influence the results. One patient developed repeated transient psychotic episodes associated with rIL-2 infusions and another regularly became confused. Computerised cognitive assessments revealed that immunochemotherapy produced significant impairment in various tasks, especially reaction time, picture recognition and vigilance. These effects were not due to sleep deprivation or pyrexia. For most patients, cognitive functioning was restored to the baseline level within 10 days following the cessation of rIL-2. In conclusion, during infusions of rIL-2, some patients experience severe confusion and amnesia which resembles some of the major cognitive impairments associated with dementias such as Alzheimers disease. Computerised cognitive assessment using the Cognitive Drug Research system provides a feasible, sensitive and reliable method of evaluating cognitive changes in patients with cancer. It could usefully be included in quality of life assessments in clinical trials where treatment-related cognitive changes need to be evaluated.

PSYCHOLOGICAL ASSESSMENT AND INTERVENTION : FUTURE PROSPECTS FOR WOMEN WITH BREAST CANCER

During the last decade, there has been a growing interest in the psychosocial aspects of breast cancer. Studies have addressed multifarious aspects, including the possible importance of personality factors and stress in the onset and progression of malignancy, the psychological impact of diagnosis and treatment, the incidence and nature of psychological and psychiatric problems, the development and evaluation of psychological interventions to ameliorate treatment side effects and to enhance quality of life, the psychological effects of screening for breast cancer and of counselling women at high risk, the organization of services, training, and psychoneuroimmunology. These and other studies are reviewed and possible directions for future research are indicated. It is clear that psychosocial factors are becoming increasingly important components of the assessment and management of patients with breast cancer.

THE PERCEIVED IMPACT OF POLICE WORK ON POLICE OFFICERS' SPOUSES AND FAMILIES

Over 400 spouses of police officers were surveyed by questionnaire to assess the impact of police work on the welfare and functioning of these spouses and their families. The results suggest that police work has an adverse impact, particularly in terms of spouses social life. The main culprits are long hours, shiftwork and cancelled leave. Dangerous duties and working with the opposite sex did not usually have an injurious effect on those at home. The methods used by the officers to combat work-induced stress may create additional difficulties for their spouses and families.

Psychosocial aspects of cancer in the elderly

A number of studies have shown that older people are less distressed by the diagnosis of cancer than their younger counterparts. This may be because older people have fewer dependants and they are less likely to suffer financial difficulties and to experience disruption to their daily routine following the diagnosis. It is surprising, therefore, that many elderly patients do not receive the biologically optimal treatment of their disease, even when comorbid medical conditions are taken into account. This appears to reflect an age bias amongst professionals involved in the management of cancer. There is a paucity of studies examining the perspective of elderly patients themselves regarding factors they consider important in their management. Elderly patients with cancer are not an homogeneous group in terms of their views about management. The vast majority of elderly patients, in common with younger patients, consider that giving the most effective treatment for breast cancer is just as important for older patients as it is for younger patients and that, in making a decision about the best treatment for them, the surgeon should only take account of the biological aspects of the disease. Clinicians, therefore, should avoid making assumptions about what patients wish simply on the basis of the age of the patient. Although there is a recent trend towards more elderly patients participating in oncology treatment trials, there is a great dearth of information about the acceptability and effectiveness of psychosocial interventions in elderly patients.

Psychoneuroimmunology: A new fad or the fifth cancer treatment modality?

T he concept that psychological factors may be important to the onset and course of malignant disease is not new. As long ago as the second century AD, the Greek physician Galen suggested that cancer was associated with melancholia and not with sanguinity. Moreover, it is not just Woody Ailen who, in the film “Manhattan,” expressed his belief that suppressing anger was the reason for his developing a growth. Some patients with cancer also attribute their illness to personality factors and, more commonly, to stressful life events. Even among women who do not have cancer, of the 157 Scottish women we surveyed, as many as 94% “agreed” (41% “strongly agreed”) with the proposition that “the attitude of patients with cancer to their disease can significantly affect the course of their illness” (C. Smith, H. Kitchener, L.G. Walker, unpublished data, 1991).