Mechthild Neises

Adjuvant endocrine treatment with medroxyprogesterone acetate or tamoxifen in stage I and II endometrial cancer—a multicentre, open, controlled, prospectively randomised trial

Endometrial cancer is a hormone-dependent disease and therefore an adjuvant hormonal therapy might improve the outcome in the early stages of the disease. Between 1983 and 1989, we conducted a randomised trial of 388 patients who received either medroxyprogesterone acetate (MPA) (n=133) or tamoxifen (n=121) orally for 2 years, or were observed only (n=134) after surgical therapy. The aim was to evaluate whether an adjuvant treatment can improve disease-free and overall survival rates. After a median follow-up period of 56 months (range 3-199 months), we observed no differences in the disease-free and overall survival rates for the tamoxifen group compared with the control or the MPA group. Side-effects were more frequent and severe in the MPA-group than in the tamoxifen group. In patients with early endometrial cancer, adjuvant endocrine treatment did not significantly improve the outcome. However, tamoxifen did have some beneficial effects on coexisting morbidity.

Sexuality and Sexual Dysfunction in Gynecological Psychooncology

Introduction In gynecologic-oncological patients problems with their sexuality are latently or manifestly present. It is not only a matter of sexual experience within partnerships but also of dysfunction caused by gynecologic-oncological disease and treatment. As a matter of fact many women look upon their gynecologist as being their first contact person in the coping of sexual problems, which very often stands in contrast to minimal or even no competence on the doctors’ side. Patients very often feel shame and unease when talking directly and frankly about their sexual problems. During the conversation it is most important to find adequate answers to those questions that are merely hidden messages, i.e. to find the right balance between distance and intimacy. Patients’ interviews revealed that 80% definitely wished to be fully informed about possible consequences of the disease and its treatment on their sexuality [1]. In another study [2] it was shown that 41% of the interviewed oncological patients wished to have the possibility to talk about sexuality and 80% demanded written information about potential consequences of their disease and the respective treatment on their sexual life. Talking about sexuality becomes increasingly difficult if patients are severely ill, possibly leading to a situation where the sick body, and consequently also sexuality, is excluded from conversation. But also the contrary is possible, bringing sexuality into focus with the intention to make the patient healthy and vivid. This can be induced both by patients or doctors [3]. As Ringel [4] pointed out: ‘What makes human medicine human is the language, so we should make use of this possibility’. Special emphasis should be laid on sexuality at old age. As a matter of fact, elderly and old women increasingly are seeking gynecological consultation due to sexual difficulties in their partnerships. Such consultations, however, are hindered by feelings of shame and fear, especially the fear of being embarrassed or of embarrassing others. The necessity of talking about sexuality coincides with the incidence of the problem. Vermillion and Holmes [5] showed that 38% of all interviewed patients admitted to have sexual problems, including avoidance, fear, inactivity and orgasm dysfunction. 30% of these women, however, are generally satisfied in their sexual relationship. While inquiring the medical history, gynecologists who regularly ask their patients about sexual activities establish 50% satisfaction. These figures are even more substantiated by interviews with married couples. During these interviews, which were not made in the frame of patients’ contacts, 63% of all women and 40% of all men revealed to have had sexual dysfunction in the past [5].

Psychooncologic Aspects of Breast Cancer

Around one third of all patients reveal signs of stress disorder and adaptation difficulties following breast cancer or during the course of the illness, often manifested clinically as fear and depression. Supportive treatment should be made available to all patients in the form of psycho-educative group sessions introducing information and assistance to help overcome the illness. The indication for extensive treatment, e.g. psychotherapy, can be deduced from the somatopsychic disorders presented. Individual or group therapy will be offered to the patient corresponding to her diagnostics and motivation. The aim of therapy should be discussed openly with the patient, that is, an improvement in the quality of life and the possibility to overcome the situation. In general, the various intervention programmes have proved to be beneficial for patients with cancer. These include relaxation therapy and stress management as well as behavioural therapy and supportive psychotherapy. Patients have high expectations of the therapy offered and this should be taken into careful consideration by all physicians, psychologists and others responsible for administering treatment. The aim of this work is mainly to present the clinical experience gained in a breast centre.

Psychoonkologie – spezielle Aspekte bei Brustkrebspatientinnen

Keller: Zahlen zur Häufigkeit psychosozialer Belastungen bei Brustkrebspatientinnen und zur Inanspruchnahme von psychosozialer Beratung/Behandlung repräsentieren zwei ganz unterschiedliche Bereiche. Psychosoziale Belastungen werden an größeren Stichproben mit Hilfe standardisierter Fragebogeninstrumente erhoben und haben ganz unterschiedliche Schwellenwerte, so dass die Zahlen aufgrund ausgeprägter methodischer Unterschiede nur schwer vergleichbar sind. Zum anderen basieren die Daten auf einmaligen Querschnittserhebungen, die wenig Aufschluss über den weiteren Verlauf, z.B. spontane Verbesserungen bzw. ausreichende psychosoziale Basisbetreuung durch die behandelnden Ärzte nachweisen. Untersuchungen zeigen, dass die Inanspruchnahme von psychosozialen Beratungen zum kleineren Teil durch psychische Belastungen, viel stärker aber aufgrund der Motivation und des Veränderungswunsches von Patientinnen erfolgt. Idealerweise würden bei einem indikationsgeleiteten Versorgungskonzept Patientinnen hinsichtlich ihres aktuellen psychischen Befindens und Belastungen gescreent (mit kurzen Fragebögen oder Screening-Fragen des behandelnden Gynäkologen). Bei denjenigen mit aktuell hoher Belastung sollten in einem diagnostischen Interview aktuelle Probleme und der Bedarf an psychotherapeutischer Unterstützung geklärt werden. Voraussetzung hierfür ist die Integration der psychosozialen Dimension in die medizinische Behandlung von Brustkrebspatientinnen ab dem Zeitpunkt der Diagnosestellung, wie sie auch in der Verordnung DPM-Brustkrebs festgeschrieben sind. Aus klinischer Sicht ist die wichtigste Voraussetzung, dass die behandelnden Gynäkologen Patientinnen auch auf ihr psychisches Befinden ansprechen und dies zu einem integralen Teil einer patientenorientierten Versorgung machen. Andererseits kann die Inanspruchnahme durch mögFrage 1: In Studien zeigt sich immer wieder eine Diskrepanz zwischen Zahlen zur psychosozialen Belastung nach Brustkrebs und zur Inanspruchnahme von psychosozialer Beratung. Erstere werden mit bis zu 50% angegeben, letztere dagegen mit zirka 30%. Welche Faktoren begünstigen und welche hemmen nach Ihrer Ansicht das Aufsuchen von psychosozialer Beratung?