Lone Ross

Mind and cancer: does psychosocial intervention improve survival and psychological well-being?

The aim of this review was to evaluate the scientific evidence for an effect of psychosocial intervention on survival from cancer and well-being and in particular on anxiety and depression. A literature search yielded 43 randomised studies of psychosocial intervention. Four of the eight studies in which survival was assessed showed a significant effect, and the effect on anxiety and depression was also inconsistent, indicating three possible explanations: (i) only some of the intervention strategies affect prognosis and/or well-being and in only certain patient groups; (ii) the effect was weak, so that inconsistent results were found in the generally small study populations; or (iii) the effect was diluted by the inclusion of unselected patient groups rather than being restricted to patients in need of psychosocial support. Thus, large-scale studies with sound methods are needed in which eligible patients are screened for distress. Meanwhile, the question of whether psychosocial intervention among cancer patients has a beneficial effect remains unresolved.

Mind and cancer: do psychological factors cause cancer?

Abstract We have reviewed the evidence for an association between major life events, depression and personality factors and the risk for cancer. We identified and included only those prospective or retrospective studies in which the psychological variable was collected independently of the outcome. The evidence failed to support the hypothesis that major life events are a risk factor for cancer. The evidence was inconsistent for both depression and personality factors. Chance, bias or confounding may explain this result, as many of the studies had methodological weaknesses. The generally weak associations found, the inconsistency of the results, the unresolved underlying biological mechanism and equivocal findings of dose–response relationships prevent a conclusion that psychological factors are established risk factors. However, certain intriguing findings warrant further studies, which must, however, be well conducted and large and include detailed information on confounders.

Risk for Hospitalization With Depression After a Cancer Diagnosis: A Nationwide, Population-Based Study of Cancer Patients in Denmark From 1973 to 2003

PURPOSE As more people survive cancer, it is necessary to understand the long-term impact of cancer. We investigated whether cancer survivors are at increased risk for hospitalization for depression. METHODS We linked data on all 5,703,754 persons living in Denmark on January 1, 1973, or born thereafter to the Danish Cancer Registry and identified 608,591 adults with a diagnosis of cancer. Follow-up for hospitalization for depression in the Danish Psychiatric Central Register from 1973 through 2003 yielded 121,227,396 person-years and 121,304 hospitalizations for depression. The relative risk (RR) for depression among cancer survivors relative to the cancer-free population was estimated by Poisson regression analysis with adjustment for age and period and stratified by sex, site of cancer, and extent of disease. RESULTS The risk for depression in the first year after a cancer diagnosis was increased, with RRs ranging from 1.16 (95% CI, 0.90 to 1.51) in women with colorectal cancer to 3.08 (95% CI, 1.88 to 5.02) in men with brain cancer. Decreasing but still significant excess risks during subsequent years were observed for most specific cancers. The risk remained increased throughout the study period for both men and women surviving hormone-related cancers, for women surviving smoking-related cancers, and for men surviving virus- and immune-related cancers. CONCLUSION This study confirms an increased risk for depression in patients facing a disruptive event like cancer. Early recognition and effective treatment are needed to prevent admission of cancer survivors for depression.

Psychoeducational intervention for patients with cutaneous malignant melanoma: a replication study.

PURPOSE In 1993, a randomized intervention study among patients with malignant melanoma showed a significant decrease in psychological distress and increased coping capacity 6 months after the intervention and enhanced survival 6 years later. We applied a similar intervention with a few modifications in a randomized controlled trial among Danish patients with malignant melanoma and evaluated results on immediate and long-term effects on psychological distress and coping capacity. PATIENTS AND METHODS A total of 262 patients with primary cutaneous malignant melanoma were randomly assigned to the control or intervention group. Patients in the intervention group were offered six weekly sessions of 2 hours of psychoeducation, consisting of health education, enhancement of problem-solving skills, stress management, and psychological support. The participants were assessed at baseline before random assignment and 6 and 12 months after surgery. The analyses of the main effects of the intervention were based on analyses of covariance. RESULTS The patients in the intervention group showed significantly less fatigue, greater vigor, and lower total mood disturbance compared with the controls, and they used significantly more active-behavioral and active-cognitive coping than the patients in the control group. The improvements were only significant at first follow-up. CONCLUSION The findings of this study support the results of an earlier intervention study among patients with malignant melanoma and indicate that a psychoeducational group intervention for such patients can decrease psychological distress and enhance effective coping. However, this effect is short term and the clinical relevance is not obvious.

The relation between socioeconomic and demographic factors and tumour stage in women diagnosed with breast cancer in Denmark, 1983–1999

The authors investigated the association between socioeconomic position and stage of breast cancer at the time of diagnosis in a nationwide Danish study. All 28 765 women with a primary invasive breast cancer diagnosed between 1983 and 1999 were identified in a nationwide clinical database and information on socioeconomic variables was obtained from Statistics Denmark. The risk of being diagnosed with a high-risk breast cancer, that is size >20 mm, lymph-node positive, ductal histology/high histologic grade and hormone receptor negative, was analysed by multivariate logistic regression. The adjusted odds ratio (OR) for high-risk breast cancer was reduced with longer education with a 12% reduced risk (95% confidence interval (CI), 0.80,0.96) in women with higher education and increased with reduced disposable income (low income group: OR, 1.22; 95% CI, 1.10,1.34). There was an urban–rural gradient, with higher risk among rural women (OR 1.10; 95 % CI, 1.02, 1.18) and lower risk among women in the capital suburbs (OR, 0.85; 95% CI, 0.78, 0.93) and capital area (OR, 0.93; 95% CI, 0.84–1.02). These factors were significant only for postmenopausal women, although similar patterns were observed among the premenopausal women, suggesting a subgroup of aggressive premenopausal breast cancers less influenced by socioeconomic factors.

ReviewMind and cancer: do psychological factors cause cancer?

Abstract We have reviewed the evidence for an association between major life events, depression and personality factors and the risk for cancer. We identified and included only those prospective or retrospective studies in which the psychological variable was collected independently of the outcome. The evidence failed to support the hypothesis that major life events are a risk factor for cancer. The evidence was inconsistent for both depression and personality factors. Chance, bias or confounding may explain this result, as many of the studies had methodological weaknesses. The generally weak associations found, the inconsistency of the results, the unresolved underlying biological mechanism and equivocal findings of dose–response relationships prevent a conclusion that psychological factors are established risk factors. However, certain intriguing findings warrant further studies, which must, however, be well conducted and large and include detailed information on confounders.

Influence of socioeconomic factors on survival after breast cancer—A nationwide cohort study of women diagnosed with breast cancer in Denmark 1983-1999

The reasons for social inequality in breast cancer survival are far from established. Our study aims to study the importance of a range of socioeconomic factors and comorbid disorders on survival after breast cancer surgery in Denmark where the health care system is tax‐funded and uniform. All 25,897 Danish women who underwent protocol‐based treatment for breast cancer in 1983–1999 were identified in a clinical database and information on socioeconomic variables and both somatic and psychiatric comorbid disorders was obtained from population‐based registries. We used Cox proportional hazards models to estimate the association between socioeconomic position and overall survival and further to analyse breast cancer specific deaths in a competing risk set‐up regarding all other causes of death as competing risks. The adjusted hazard ratio (HR) for death was reduced in women with higher education (HR, 0.91; 95% confidence interval (CI), 0.85–0.98), with higher income (HR, 0.93; 95% CI, 0.87–0.98) and with larger dwellings (HR, 0.90; 95% CI, 0.85–0.96 for women living in houses larger than 150 m2). Presence of comorbid disorders increased the HR. An interaction between income and comorbid disorders resulting in a 15% lower survival 10 year after primary surgery in poor women with low‐risk breast cancer having comorbid conditions (∼65%) compared to rich women with similar breast cancer prognosis and comorbid conditions (∼80%) suggests that part of the explanation for the social inequality in survival after breast cancer surgery in Denmark lies in the access to and/or compliance with management of comorbid conditions in poorer women.

Impact of symptom burden on health related quality of life of cancer survivors in a Danish cancer rehabilitation program: A longitudinal study

Abstract Introduction. Little research has been conducted on the effect of self-reported rating of symptom severity on quality of life (QoL) among cancer survivors. The aim of the study was to examine the prevalence of symptoms and whether information about self-reported symptom severity adds value to QoL measurements. Material and methods. A questionnaire including the EORTC QLQ-C30 and an empirically derived symptom check-list was completed by 2 486 cancer survivors participating in a rehabilitation program at baseline and at 1, 6 and 12 months’ follow-up. We used multivariate linear regression models to evaluate the association between QoL and the dichotomous variables for perceived symptom severity (high vs. low) and cancer stage (high vs. low), with adjustment for age, gender, education and time since diagnosis. Results. Of the 2 379 participants who reported having one or more symptoms, 1 479 (62%) considered the reported symptom to be severe. This subgroup had significantly poorer QoL at baseline for all sites, ranging from −15.9 to −10.2, compared to those who did not regard their symptom as severe. Significantly lower baseline levels on all functional subscales were seen for all sites in association with high perceived symptom severity (range from −9.9 to −3.0 (physical functioning), from −21.1 to −13.0 (social functioning), from −18.8 to −8.5 (emotional functioning), and from −18.4 to −9.6 (cognitive functioning). The impairment of physical, social, emotional, and cognitive functioning persisted through 12 months for participants with cancer of the breast, lung and those with lymphomas, although not all reached significance. Discussion. Cancer survivors, irrespective of cancer site, experience a high burden of symptoms. Thorough monitoring and assessment of symptoms and careful scrutiny of cancer survivors’ perceptions of how symptoms affect their lives is critical for clinical identification of patients who might benefit from enhanced medical attention and may be an important supplement to QoL measures.

Survival After a Psychoeducational Intervention for Patients With Cutaneous Malignant Melanoma: A Replication Study

PURPOSE The results of a randomized, intervention study done in 1993 of psychoeducation for patients with early-stage malignant melanoma showed a beneficial effect on recurrence and survival 6 years after the intervention. In the present study, we replicated the study with 258 Danish patients with malignant melanoma. We also compared recurrence and survival among the participants in the randomized study with 137 patients who refused to participate. PATIENTS AND METHODS We randomly assigned 262 patients with primary malignant melanoma to a control or an intervention group. Patients in the intervention group were offered six weekly 2-hour sessions of psychoeducation. Participants and nonparticipants were followed up for vital status and recurrence 4 to 6 years after surgical treatment. Prognostic factors (thickness of the tumor and lymph node status), sex, and age were adjusted for in a Cox regression model (proportional hazards regression) to derive an adjusted survival rate ratio and an adjusted relapse-free survival rate ratio, with 95% CIs. RESULTS The hazard ratio was 1.30 (95% CI, 0.5 to 3.5) for survival and 0.73 (95% CI, 0.3 to 1.9) for recurrence. Being a nonparticipant increased the risk for death by more than two-fold (hazard ratio, 2.26; 95% CI, 1.0 to 5.2) over that of participants. CONCLUSION Psychoeducation did not increase survival or the recurrence-free interval among patients with malignant melanoma; however, nonparticipants had a statistically significantly greater risk for death than participants.

Are different groups of cancer patients offered rehabilitation to the same extent? A report from the population-based study “The Cancer Patient’s World”

PurposeThe number of cancer survivors is growing and cancer is now viewed as a chronic disease. This has highlighted the importance of providing adequate rehabilitation to prevent physical, psychological, and social sequelae of cancer. However, it is unclear whether those in need of rehabilitation are offered this.MethodsUsing patient–observer agreement and cognitive interviews, we validated a seven-item questionnaire designed to assess cancer patients’ perception of the sufficiency of the offered rehabilitation. A cross-sectional study among 2,202 Danish cancer patients affiliated with hospitals was carried out.ResultsThe questionnaire was well understood, indicating good validity. In the cross-sectional study, 1,490 patients (68%) participated. Up to 39% of cancer patients did not receive the physical rehabilitation they felt they needed. About half of those who had felt a need to talk to a psychologist were offered this. Insufficiency of other rehabilitation offers was reported by 10–24%. Age most consistently predicted insufficient rehabilitation; higher age predicted insufficient information about support from other sources (than hospital staff) and younger age predicted lack of help to manage symptoms, return to everyday life, and deal with financial and especially work-related consequences. We found no consistent signs of traditional social inequality in the perception of rehabilitation, but we observed some signs of social inequality for unemployed or divorced/separated patients.ConclusionsAge predicted sufficiency of the rehabilitation in two directions, possibly reflecting different needs in younger and older patients. When tailoring rehabilitation programs, it should be ensured that the different needs are met.