Paul Craft

Self-Rated Health as a Predictor of Survival Among Patients With Advanced Cancer

PURPOSEnEvidence is emerging about the strong predictive relationship between self-rated health (SRH) and survival, although there is little evidence on palliative populations where an accurate prediction of survival is valuable. Thus, the relative importance of SRH in predicting the survival of ambulatory patients with advanced cancer was examined. SRH was compared to clinical assessments of performance status, as well as to quality-of-life measures.nnnPATIENTS AND METHODSnBy use of a prospective cohort design, 181 patients (76% response rate) with advanced cancer were recruited into the study, resurveyed at 18 weeks, and observed to record deaths.nnnRESULTSnThe average age of patients was 62 years (SD = 12). The median survival time was 10 months. SRH was the strongest predictor of survival from baseline. Also, a Cox regression comparing changes in SRH over time yielded hazard ratios suggesting the relative risk (RR) of dying was greater for fair ratings at 18 weeks (approximately 3 times) compared with consistent good or better ratings; the RR was even greater (4.2 and 6.2 times) for poor ratings, especially when ratings were poor at baseline and 18 weeks (31 times). Improvement in SRH over time yielded the lowest RR.nnnCONCLUSIONnSRH is valid, reliable, and responsive to change as a predictor of survival of advanced cancer. These qualities suggest that SRH should be considered as an additional tool by oncologists to assess patients. Similarly, health managers could use SRH as an indicator of disease severity in palliative care case mix. Finally, SRH could provide a key to help us understand the human side of disease and its relationship with medicine.

Concurrent validity of the modified Edmonton Symptom Assessment System with the Rotterdam Symptom Checklist and the Brief Pain Inventory

Abstract As part of a longitudinal prospective study we sought a self-completed instrument of symptom assessment suitable for a population of cancer patients who were receiving palliative therapy. The modified Edmonton Symptom Assessment System (ESAS) is such an instrument, but it required validation for this population. This study represents a validation of the modified ESAS with the Rotterdam Symptom Checklist and the Brief Pain Inventory – two instruments widely used in patients receiving palliative therapy for cancer. We conclude that the modified ESAS is a valid, self-administered instrument to assess symptoms for patients from differing palliative care settings.

Fluctuating awareness of treatment goals among patients and their caregivers: a longitudinal study of a dynamic process

BackgroundBecause increasing numbers of people now survive for months or years with advanced cancer, communication between patients, service providers, and family caregivers often continues over long periods. Hence, understanding of the goals of medical treatment may develop and change as time elapses and disease progresses. This understanding is closely related to the “awareness of dying,” which has been studied in both qualitative and quantitative research. However, when both a patient and family caregiver are involved, the question of “awareness” becomes more complex. A recent longitudinal study reported on patient and caregiver knowledge of treatment goals, but no comparison of such knowledge using matched interview schedules and paired data analysis has been provided. This report examines patterns of awareness and factors associated with these patterns.Materials and methodsOne hundred sixty-three patients with incurable cancer and their nominated principal family caregivers (136) were recruited from The Canberra Hospital Oncology Services. Participants’ understanding of the treatment goals were measured by interview questions at weeksxa01 and 12.ResultsOne-third of both patients and caregivers understood that the treatment goal was not curative; however, not all patient and caregiver pairs had the same understanding. In 15% of pairs, both patient and caregiver believed that the goal of treatment was curative, while another 13% said that they did not know the aim of the treatment. Thirty-nine percent of pairs registered incongruent responses in which only one member of the pair understood that the treatment was not intended to cure the disease. Over time, a few respondents changed their perception of the treatment goals toward accurate clarification. Bivariate analysis using an awareness variable, constructed for the purpose, showed that in 6xa0months before death, at least one person in 89% of pairs understood that the treatment was noncurative. Time-to-death, gender, and place of residence were also important predictors of knowledge.ConclusionsDiscrepancies between patients and their caregivers may complicate the delivery of effective care when patients are seriously ill. Misunderstanding or uncertainty about treatment goals will obstruct proper informed consent. Health professionals providing care for families dealing with advanced cancer must recognize that the discussion of treatment goals is a dynamic process, which may require them to extend their communication skills.

Family caregiver knowledge of treatment intent in a longitudinal study of patients with advanced cancer

Goals of workCaregivers have become part of a triad of care and frequently attend patient consultations in the ambulatory cancer setting. Effective caregiving and decision making require that they understand the course of the disease and the changing treatment goals. This study sought to evaluate caregiver perception of treatment intent.Patients and methodsA cohort of 317 subjects (181 patients and 136 caregivers) from The Canberra Hospitals Cancer Services were followed for 6xa0months. Caregiver understanding of patient treatment intent was measured over time together with sources of information.Main resultsMost caregivers understood that the illness was life-threatening (92% at weekxa012) and that treatment goals were to control illness and improve quality of life. Only half understood that treatment was noncurative (48% at weekxa012); 27% were unsure and 25% believed that treatment would cure. A high proportion of caregivers identified the specialist as the source of information (77%) and almost half also included the general practitioner (47%). These figures remained fairly constant over time. There were significant gender and age differences in understanding. At baseline, more women than men had an accurate perception of treatment intent and these numbers increased over time. Mens perception did not change.ConclusionsCaregivers ability to fully engage in the task of caring for those with a terminal illness may be hampered by their lack of understanding of the treatment patients receive.

Clinical characteristics and outcomes of bilateral breast cancer in an Australian cohort

PURPOSEnUncertainty remains about the impact of bilateral breast cancer. Characteristics and outcomes of unilateral and bilateral breast cancer were compared within an Australian multi-institutional cohort.nnnMETHODSnDemographic, tumour and treatment characteristics were compared among unilateral (n = 2336) and bilateral cases (52 synchronous, 35 metachronous) using descriptive analyses. Disease-specific outcomes were investigated using Cox regression modelling to adjust for prognostic and treatment factors.nnnRESULTSnFactors associated with increased risk of bilateral breast cancer included lobular histology (p = 0.046), family history (p = 0.025) and metropolitan residence (p = 0.006). Mastectomy was more common for bilateral cases (p = 0.001) while radiotherapy was less common (p = 0.015). Index metachronous cases were less likely to receive hormonal therapy (p = 0.001). Five-year survivals for metachronous, synchronous and unilateral cases were 79%, 88% and 94%, respectively. Poorer outcomes remained after adjusting for prognostic factors [HR = 2.26, 1.21-4.21].nnnCONCLUSIONnOur results confirm international findings indicating worse outcomes from bilateral compared with unilateral breast cancer.

Variation in the management of early breast cancer in rural and metropolitan centres: Implications for the organisation of rural cancer services

The study examines the management and outcomes of women with early invasive breast cancer treated in rural and metropolitan centres over a nine-year observation period. A prospective audit of the treatment and outcomes of 2081 women with early breast cancer who underwent potentially curative surgery between 1997 and 2006 in metropolitan Canberra or in the surrounding rural region was completed. Overall, there was good agreement between published guidelines and the treatment received by the women in the study. However, women treated in rural centres were less likely to receive postoperative radiotherapy after breast-conserving surgery, or to undergo axillary lymph node surgery or sentinel lymph node biopsy compared with women treated in metropolitan centres. Surgery in a rural centre was associated with increased breast cancer recurrence (HRxa0=xa01.54, pxa0<xa00.001) and increased breast cancer mortality (HRxa0=xa01.84, pxa0<xa00.001), after adjustment for age and tumour characteristics. Non-cancer related mortality was increased in women treated in rural centres compared with women travelling to a metropolitan centre for surgery (HRxa0=xa02.08; pxa0=xa00.005). There were differences in both the care provided and treatment outcomes between women treated in rural centres and women treated in metropolitan centres. However, the increased non-cancer related mortality in women treated in rural centres suggests an increased medical comorbidity in this group. Initiatives supporting rural-based surgeons to adopt new procedures such as sentinel node biopsy may help to optimise rural breast cancer treatment.

Surgical margins and risk of locoregional recurrence in invasive breast cancer: An analysis of 10-year data from the breast cancer treatment quality assurance project

AIMnThere is debate as to what constitutes an adequate excision margin to reduce the risk of locoregional recurrence (LRR) after breast cancer surgery. We have investigated the relationship between surgical margin distance and LRR in women with invasive breast cancer (IBC).nnnMETHODSnTumour free margin distances were extracted from histopathology reports for women with IBC, treated by either breast conserving surgery or mastectomy, enrolled in the Breast Cancer Treatment Group Quality Assurance Project from July 1997 to June 2007. Cox proportional hazards regression analyses were conducted to compare the risk of LRR for involved margins compared with negative margins, measured in increments rounded to the nearest mm.nnnRESULTSn88 of 2300 patients (3.8%) experienced an LRR after a mean follow-up of 7.9 years. An involved margin, or a margin of 1 mm was associated with an increased risk of LRR (HR 2.72, 95% CI 1.30-5.69), whilst margin distances of 2 mm or greater were not. Risk of LRR with margin distances <2 mm was particularly high amongst those not receiving radiotherapy (RT).nnnCONCLUSIONnBased on our findings, we recommend that a tumour free margin distance of 2 mm be adopted as an adequate margin of excision for IBC, in the setting of patients receiving standard adjuvant RT and adjuvant drug therapies as dictated by the current clinical treatment paradigms.

Phase III, randomized, double-blind, placebo-controlled study of modafinil for fatigue in patients treated with docetaxel-based chemotherapy

PurposeModafinil has been reported to benefit a subgroup of patients suffering severe fatigue while undergoing chemotherapy. Docetaxel is associated with fatigue that may lead to premature therapy withdrawal. We investigated whether modafinil could reduce fatigue during docetaxel chemotherapy.MethodsThis multicenter, randomized, double-blind, placebo-controlled study evaluated the efficacy of modafinil in patients with metastatic prostate or breast cancer undergoing docetaxel chemotherapy (every 21xa0days; minimum dose 50xa0mg/m2). At the start of their third or subsequent chemotherapy cycle, patients with significant docetaxel-associated fatigue were randomized to receive concurrent modafinil 200xa0mg/day or placebo for 15xa0days (“treatment periods” (TP)). Docetaxel was continued for up to four further cycles. Fatigue was evaluated with the fatigue component of the MD Anderson Symptom Inventory (MDASI). The primary endpoint was cumulative MDASI area under the curve (AUC) during the first 7xa0days of study medication during TP1 and TP2.ResultsEvaluable data were available from 83 patients (65 with prostate cancer). There was no statistically significant difference between the two treatment arms for the primary endpoint (MSADI AUC3–10 35.9 vs 39.6; 95xa0% confidence interval −8.9, 1.4; Pu2009=u20090.15). Overall toxicity was comparable between treatment groups; however, the incidence of grade ≤2 nausea and vomiting was higher in the modafinil arm (45.4 vs 25xa0%).ConclusionsAssessing and managing chemotherapy-related fatigue remains a major challenge. There was a lack of difference between the two arms in the planned primary endpoint. However, there was a modest but consistent trend towards improvement of docetaxel-related fatigue in those treated with modafinil. Based on the study findings, modafinil for the treatment of fatigue associated with docetaxel chemotherapy elicits modest improvements. Larger, longer term, randomized, controlled studies are required to clarify the exact role of modafinil in the treatment of docetaxel-related fatigue.

Surgical management of invasive breast cancer: a 5-year prospective study of treatment in the Australian Capital Territory and South-Eastern New South Wales

Background:u2003 Breast cancer is a major health problem in Australia. The aim of the present report is to evaluate the surgical management of invasive breast cancers in our region.

Does emotional support influence survival? Findings from a longitudinal study of patients with advanced cancer

A total of 163 patients with advanced cancer at an Australian teaching hospital were interviewed to investigate whether emotional support was predictive of survival duration. Survival was analysed using the Kaplan-Meier product-limit estimate, and multivariable Cox proportional hazards regression, from entry to the study in 1996 to date of death, or 31 March 2003, whichever came first. The number of confidants with whom feelings were being shared at the time of study entry was predictive of survival duration. The regression analysis indicated that compared with patients reporting two or three confidants, the relative risk of a shorter survival (95% confidence limits) was 0.44 (0.25, 0.79) for those with no or one confidant and 0.60 (0.40, 0.89) for those with four or more confidants. Shorter survivors shared their feelings more with family members than longer survivors. Conversely, longer survivors shared their feelings more with friends than shorter survivors. These relationships did not hold at 12xa0weeks from study entry. At that time, longer survivors were more likely to be sharing their feelings with a doctor than shorter survivors. The relationship between emotional support and survival duration was not linear and appeared to be more complex than reported previously for people with heart disease and newly diagnosed breast cancer.