Pär Salander

How do patients and spouses deal with the serious facts of malignant glioma

Malignant glioma is a severe disease with little chance for recovery. Due to its effect on cerebral function, it is also a disease with an obvious social impact on family life. Brain tumours, therefore, produce much of the anguish associated with cancer diseases. There is a lack of prospective studies concerning how patients and spouses together deal with the serious facts of cancer. In this study, a series of 25 consecutive patients with malignant gliomas and their spouses was followed during the whole course of the disease process by repeated thematic interviews. The spouses were also subjected to a summarizing interview after the patients death. The interviews were analyzed qualitatively in order to detect the various ways the patient spouse couples dealt with this severe situation and how they discussed it with each other. Four different social processes were detected: 1) the patient does not seem to be aware, the spouse is aware but pretends not to be; 2) both are aware, but the patient does not want to share; they drift apart; 3) both are aware, they do/do not talk openly about the gravity of the situation; nevertheless, there is a joint platform; and 4) neither patient nor spouse seems to be aware; they carry on living as before. The patients, compared to the spouses, seemed content with received information. A few of the couples openly discussed death and dying. More common, and apparently sufficient, was a mutual acknowledgement of the serious facts, without using the words ‘death’ and ‘dying’. In a sense, the present findings challenge the awareness categories suggested by Glaser and Strauss.

Long-term memory deficits in patients with malignant gliomas

Knowledge about the neuropsychological performance of adult patients with brain tumors, and especially with malignant gliomas, is limited. In this study 30 patients were consecutively included at time of diagnosis. Five months after completion of radiotherapy eleven of the patients showed no signs of focal neurology or tumor recurrence. These eleven patients, and their partners, were interviewed independently. Using each partner as control the patients were assessed neuropsychologically with special emphasis on memory abilities. The selective reminding technique was used with nouns of different visual imagery. A consistent pattern was found: there was no clear impairment in global intellectual abilities, but there was a pronounced deficit in long-term memory. However, the patients had a preserved capacity to use visual imagery to boost performance. It is important that medical staff acknowledge or confirm this problem. The sparing of imaginai coding makes it possible for the staff to assist with advice facilitating memory. Memory is a vital cognitive ability and the selective reminding technique was a sensitive method capable of detecting subtle impairments. The technique is recommended in future examinations of conditions and evaluations of treatments affecting the CNS.

Differences between women who have and have not undergone breast reconstruction after mastectomy due to breast cancer

Abstract Aim. This study compares potential differences between women with breast cancer who after mastectomy had undergone breast reconstruction with those who had not. Material and methods. All women (N=149) in the northern medical region of Sweden who had undergone mastectomy in 2003 received a self-reported questionnaire entitled “Life After Mastectomy (LAM)” that included standardized measures of sociodemographic, decision-making process, breast reconstruction (BR) yes or no, sexuality, and body image. SPSS was used for data processing. Results. In total 85% of the women returned the questionnaire and of these 25% had undergone BR. In accordance with previous studies, we found that the mean age of the women in the BR group was significantly lower (52 vs. 64 years), they had a higher education, and a higher proportion were employed, influenced by the physicians opinion regarding BR, sexually active, and rated a negative impact concerning the factors attractiveness and body disclosure. A multiple regression analysis, however, showed that the choice to undergo breast reconstruction or not was only independently associated with age, feeling of attractiveness and sexual interest. Discussion. Age explained most differences found between the two groups. When researchers try to identify what differentiates the groups of women who undergo reconstruction between those who do not undergo reconstruction after mastectomy, it is thus necessary to take into consideration that the meanings of mastectomy, body image, attractiveness and similar variables may vary due to the phase of a womans life. In conclusion, considering the impact of age is of paramount importance in future studies for our understanding of womens experiences.

‘Admission into a helping plan’: a watershed between positive and negative experiences in breast cancer

Cancer patients are in an exposed situation that raises certain psychosocial needs in contact with health care. Previous studies have mainly investigated these needs by assessments on pre‐defined categories.

Using beliefs and magical thinking to fight cancer distress-a case study.

This case relates to the way in which a young patient developed serious difficulties in coping with her life in the years following a successful bone‐marrow transplant. By means of an illustrative metaphor, she revealed her existential position and the way in which she attempted to deal with her anxiety. Being diseased implied that lifes order was replaced by disorder and a loss of basic trust. She tried to re‐establish order by establishing beliefs that attributed specific regularities to life, and to influence the risk of recurrence by living according to these beliefs. Unfortunately, this meant that she had to tread a very thin line over a course mined with anxiety and eventually, she became a prisoner of her own creation. The author claims that we can learn from this case, as it clearly illustrates psychological dimensions commonly seen in cancer patients: the way anxiety is related to disorder and the way patients try to regain control of their lives through constructing belief‐systems. The case also features a discussion of how we, as clinicians, may be able to help these patients. Copyright

High-grade astrocytoma treated concomitantly with estramustine and radiotherapy

SummaryExperimental and early clinical investigations have demonstrated encouraging results for estramustine in the treatment of malignant glioma. The present study is an open randomized clinical trial comparing estramustine phosphate (Estracyt®) in addition to radiotherapy with radiotherapy alone as first line treatment of astrocytoma grade III and IV. The 140 patients included were in a good clinical condition with a median age of 55 years (range 22–87). Estramustine was given orally, 280 mg twice daily, as soon as the diagnosis was established, during and after the radiotherapy for a period of in total 3 months. Radiotherapy was delivered on weekdays 2 Gy daily up to 56 Gy. Eighteen patients were excluded due to misclassification, leaving 122 patients eligible for evaluation. Overall the treatment was well tolerated. Mild or moderate nausea was the most common side effect of estramustine. The minimum follow-up time was 5.2 years for the surviving patients. For astrocytoma grade III the median survival time was 10.6 (1.3–92.7) months for the radiotherapy only group and 17.3 (0.4–96.9+) months for the estramustine  + radiotherapy group. In grade IV the corresponding median survival time was 12.3 (2.1–89.2) and 10.3 (0.3–91.7+) months, respectively. Median time to progress for radiotherapy only and radiotherapy and estramustin group in grade III tumours was 6.5 and 10.1 months, respectively. In grade IV tumours the corresponding figures were 5.1 and 3.3 months, respectively. Although there was a tendency for improved survival in grade III, no statistical significant differences were found between the treatment groups. No differences between the two treatment groups were evident with respect to quality of life according to the EORTC QLQ-protocol. In conclusion, this first randomized study did not demonstrate any significant improvement of using estramustine in addition to conventional radiotherapy, however, a trend for a positive response for the estramustine group was found in patients with grade III glioma.

The impact of breast cancer on living an everyday life 4.5 - 5 years post-diagnosis - a qualitative prospective study of 39 women

Abstract Background. The survival of women with breast cancer has improved. There are many studies available describing different aspects of how the illness and its treatment affect the women. Usually these studies are cross-sectional and focus on assessments of a sample of women at a single point in time during post-treatment. These studies are important but of limited value if we are interested in understanding more about breast cancer in a life context. The present study is a contribution. Methods. A consecutive sample of 39 women was followed up by means of repeated thematic interviews about how they lived their lives, from the end of radiation therapy to a point four years later, i.e. 4.5–5 years post diagnosis. Results. Four different groups of women emerged. Largely, the first group evaluated the cancer initiated transformation of their lives in a positive way. The breast cancer helped them depart from a career treadmill or to positive interpersonal experiences. In the second group the cancer and its treatment seemed to pass without marked traces. The cancer made a difference for the third group, but both in positive and negative ways. A different life perspective or improved relationships were weighted against troublesome side effects from treatment. Finally, in the fourth group a bodily decline due to side effects and other health problems was predominant and this obstructed their chances of living a good life. Discussion. The narratives showed that being diseased by breast cancer has different impacts depending on how the woman lives her life – it is very much a matter of transition in a life context. The results are furthermore discussed in relation to adaptation and coping theory.

Cancer and ‘playing’ with reality : clinical guidance with the help of the intermediate area and disavowal

Cancer and ‘playing’ with reality : clinical guidance with the help of the intermediate area and disavowal

Facilitating interventions and/or relationships in malignant brain tumors

Brain tumors have special oncological significance. The prognosis of brain tumors is mostly poor, and they are also connected to functional and cognitive deficiencies, as well as possible personality changes. Therefore, the social impact of the disease has special significance as it also affects family and friends of patients with brain tumors. This review focuses on different professional arenas that can psychologically facilitate for the patient and/or for their next of kin. The different arenas discussed are: the patient-physician relationship, the specialist nurse function, functional and cognitive rehabilitative efforts, and support groups. The patient-physician relationship is important, but there is a lack of knowledge of its psychological impact outside of information giving. The few studies conducted on the specialist nurse function are quite unanimous about its facilitating value and this mainly seems to pertain to the next of kin. Functional rehabilitative efforts seem to be worthy, but even if there are promising results, there is still lack of knowledge of the potential of cognitive rehabilitation. Although there is a long history of peer support groups for patients with brain tumors, we do not know enough about the potential in professionally initiated supportive groups or different Internet forums. When initiating further studies within the different arenas for the purpose of understanding how to facilitate for patients with brain tumors and their families, we should also consider the psychological meaning of the activity/intervention.

From "no big deal" to "losing oneself" : different meanings of mastectomy

Background: Because of early detection and advanced treatment options, more women with breast cancer survive after mastectomy and thus have to face the choice of living with or without a reconstructed breast for many years to come. Objective: This article investigates these women’s narratives about the impact of mastectomy on their lives, as well as their reflections on breast reconstruction. Methods: Fifteen women were strategically chosen from a previous population-based study on mastectomy. They were contacted for further exploration in thematic narrative-inspired interviews 4.5 years after mastectomy. Results: Three types of storylines were identified. In the first storyline, the mastectomy was described as “no big deal”; losing a breast did not disturb the women’s view of themselves as women, and breast reconstruction was not even worth consideration. In the second storyline, the women described the mastectomy as shattering their identity. Losing a breast implied losing oneself as a sexual being, a woman, and a person. The third storyline fell in between the other two; the sense of femininity was wounded, but not to the extent that they felt lost as women. Conclusion: Our findings suggest that the experience of mastectomy due to breast cancer is very much individual and contextual. Losing a breast may be of minor or major importance. Implications for Practice: Healthcare practitioners should be attentive to how the women themselves experience the personal meaning of losing a breast and guard against vague preconceptions based on the breast-sexuality-femininity discourse and its connection to what the patient needs.