Tomer T. Levin

Mixed Anxiety/Depression Symptoms in a Large Cancer Cohort: Prevalence by Cancer Type

BACKGROUND Mixed anxiety/depression is associated with poorer psychosocial and treatment outcomes, worse quality of life, pooreradherence to treatment, slower recovery, greater suicide risk, and highercost-utilization. OBJECTIVE This study aimed to examine the cancer-specific prevalence of these symptoms. METHOD Cross-sectional anxiety and depression symptom data were collected with the Brief Symptom Inventory from adult outpatients presenting to a tertiary cancer center (N=8,265). RESULTS Mixed anxiety/depression symptoms were seen in 12.4% of patients; overall depression symptoms in 18.3%, overall anxiety symptoms in 24.0%, pure anxiety symptoms in 11.7%, and pure depression symptoms in 6.0%; 70% had neither. Higher rates of mixed anxiety/depression symptoms were seen with stomach, pancreatic, head and neck, and lung cancers, but lower rates were seen in those with breast cancers. The mixed anxiety/depression phenotype occurs in two-thirds of depressed cancer patients. DISCUSSION The fact that 70% of patients did not meet thresholds for depression or anxiety symptoms can be interpreted as a reflection of the resistance to developing a significant level of these symptoms. However, because stomach, pancreatic, head and neck, and lung cancers have higher levels of mixed anxiety/depression symptoms, the question can be raised as to whether these are associated with a more biological type of anxiety/depression (e.g., due to cytokine release) and whether this phenotype should be actively targeted because of its frequent occurrence in these cancers.

Communication Skills Training for Oncology Professionals

PURPOSE To provide a state-of-the-art review of communication skills training (CST) that will guide the establishment of a universal curriculum for fellows of all cancer specialties undertaking training as oncology professionals today. METHODS Extensive literature review including meta-analyses of trials, conceptual models, techniques, and potential curricula provides evidence for the development of an appropriate curriculum and CST approach. Examples from the Memorial Sloan-Kettering Cancer Center CST program are incorporated. RESULTS A core curriculum embraces CST modules in breaking bad news and discussing unanticipated adverse events, discussing prognosis, reaching a shared treatment decision, responding to difficult emotions, coping with survivorship, running a family meeting, and transitioning to palliative care and end of life. Achievable outcomes are growth in clinicians self-efficacy, uptake of new communication strategies and skills, and transfer of these strategies and skills into the clinic. Outcomes impacting patient satisfaction, improved adaptation, and enhanced quality of life are still lacking. CONCLUSION Future communication challenges include genetic risk communication, concepts like watchful waiting, cumulative radiation risk, late effects of treatment, discussing Internet information and unproven therapies, phase I trial enrollment, and working as a multidisciplinary team. Patient benefits, such as increased treatment adherence and enhanced adaptation, need to be demonstrated from CST.

How do-not-resuscitate orders are utilized in cancer patients: timing relative to death and communication-training implications.

OBJECTIVES End-of-life communication is crucial because most U.S. hospitals implement cardiopulmonary resuscitation (CPR) in the absence of do-not-resuscitate directives (DNRs). Despite this, there is little DNR utilization data to guide the design of communication-training programs. The objective of this study was to determine DNR utilization patterns and whether their use is increasing. METHODS A retrospective database analysis (2000-2005) of DNR data for 206,437 patients, the entire patient population at Memorial Sloan-Kettering Cancer Center (MSKCC), was performed. RESULTS The hospital recorded, on average, 4,167 deaths/year. In 2005, 86% of inpatient deaths had a DNR, a 3% increase since 2000 (p < .01). For patients who died outside the institution (e.g., hospice), 52% had a DNR, a 24% increase over 6 years (p < .00001). Adult inpatients signed 53% of DNRs but 34% were signed by surrogates. The median time between signing and death was 0 days, that is, the day of death. Only 5.5% of inpatient deaths had previously signed an outpatient DNR. Here, the median time between signing and death was 30 days. SIGNIFICANCE OF RESULTS Although DNR directives are commonly utilized and their use has increased significantly over the past 6 years, most cancer patients/surrogates sign the directives on the day of death. The proximity between signing and death may be a marker of delayed end-of-life palliative care and suboptimal doctor-patient communication. These data underscore the importance of communication-training research tailored to improve end-of-life decision making.

End-of-life communication in the intensive care unit☆

OBJECTIVE Because one in five Americans die in the intensive care unit (ICU), the potential role of palliative care is considerable. End-of-life (EOL) communication is essential for the implementation of ICU palliative care. The objective of this review was to summarize current research and recommendations for ICU EOL communication. DESIGN For this qualitative, critical review, we searched PubMed, Embase, Cochrane, Ovid Medline, Cinahl and Psychinfo databases for ICU EOL communication clinical trials, systematic reviews, consensus statements and expert opinions. We also hand searched pertinent bibliographies and cross-referenced known EOL ICU communication researchers. RESULTS Family-centered communication is a key component of implementing EOL ICU palliative care. The main forum for this is the family meeting, which is an essential platform for implementing shared decision making, e.g., transitioning from curative to EOL palliative goals of care. Better communication can improve patient outcomes such as reducing psychological trauma symptoms, depression and anxiety; shortening ICU length of stay; and improving the quality of death and dying. Communication strategies for EOL discussions focus on addressing family emotions empathically and discussing death and dying in an open and meaningful way. Central to this is viewing ICU EOL palliative care and withdrawal of life-extending treatment as predictable and not an unexpected emergency. CONCLUSIONS Because the ICU is now a well-established site for death, ICU physicians should be trained with EOL communication skills so as to facilitate palliative care more hospitably in this challenging setting. Patient/family outcomes are important ways of measuring the quality of ICU palliative care and EOL communication.

A Randomized Controlled Trial of a Cardiopulmonary Resuscitation Video in Advance Care Planning for Progressive Pancreas and Hepatobiliary Cancer Patients

BACKGROUND Cardiopulmonary resuscitation (CPR) is an important advance directive (AD) topic in patients with progressive cancer; however such discussions are challenging. OBJECTIVE This study investigates whether video educational information about CPR engenders broader advance care planning (ACP) discourse. METHODS Patients with progressive pancreas or hepatobiliary cancer were randomized to an educational CPR video or a similar CPR narrative. The primary end-point was the difference in ACP documentation one month posttest between arms. Secondary end-points included study impressions; pre- and post-intervention knowledge of and preferences for CPR and mechanical ventilation; and longitudinal patient outcomes. RESULTS Fifty-six subjects were consented and analyzed. Rates of ACP documentation (either formal ADs or documented discussions) were 40% in the video arm (12/30) compared to 15% in the narrative arm (4/26), OR=3.6 [95% CI: 0.9-18.0], p=0.07. Post-intervention knowledge was higher in both arms. Posttest, preferences for CPR had changed in the video arm but not in the narrative arm. Preferences regarding mechanical ventilation did not change in either arm. The majority of subjects in both arms reported the information as helpful and comfortable to discuss, and they recommended it to others. More deaths occurred in the video arm compared to the narrative arm, and more subjects died in hospice settings in the video arm. CONCLUSIONS This pilot randomized trial addressing downstream ACP effects of video versus narrative decision tools demonstrated a trend towards more ACP documentation in video subjects. This trend, as well as other video effects, is the subject of ongoing study.

Augmenting advance care planning in poor prognosis cancer with a video decision aid: a preintervention-postintervention study.

The authors tested whether an educational video on the goals of care in advanced cancer (life‐prolonging care, basic care, or comfort care) helped patients understand these goals and had an impact on their preferences for resuscitation.

Conducting family meetings in palliative care: Themes, techniques, and preliminary evaluation of a communication skills module

OBJECTIVE To develop a communication skills training module for health care professionals about how to conduct a family meeting in palliative care and to evaluate the module in terms of participant self-efficacy and satisfaction. METHODS Forty multispecialty health care professionals from the New York metropolitan area attended a communication skills training module at a Comprehensive Cancer Center about how to conduct a family meeting in oncology. The modular content was based on the Comskil model and current literature in the field. RESULTS Based on a retrospective pre-post measure, participants reported a significant increase in self-efficacy about their ability to conduct a family meeting. Furthermore, at least 93% of participants expressed their satisfaction with various aspects of the module by agreeing or strongly agreeing with statements on the course evaluation form. SIGNIFICANCE OF RESULTS Family meetings play a significant role in the palliative care setting, where family support for planning and continuing care is vital to optimize patient care. Although these meetings can be challenging, this communication skills module is effective in increasing the confidence of participants in conducting a family meeting.

Brain SPECT study of common ground between hypothyroidism and depression.

Hypothyroidism and major depressive disorder (MDD) share neuropsychiatric features. Cerebral perfusion deficits are found in both disorders. We compared regional cerebral blood flow (rCBF) in hypothyroidism and MDD to determine if clinical similarities are mediated by common neurocircuitry. Ten hypothyroid and 10 depressed patients underwent 99mTc-HMPAO-SPECT and clinical evaluation before and after response to respective treatments. Ten healthy controls underwent a similar, single, evaluation. Before treatment, rCBF in hypothyroid and depressed patients was lower than in controls, in posterior and anterior aspects of the brain respectively. rCBF in hypothyroidism was lower than in MDD in right posterior cingulate and parieto/occipital regions, and higher in frontal, prefrontal and sub-genual regions. Reduced rCBF in pre- and post-central gyri was found in both groups. Following treatment, rCBF in depressed patients increased and normalized, but remained unchanged in hypothyroidism. Affective symptoms in hypothyroidism may be mediated by neurocircuitry different from that of major depression.

Augmenting advance care planning in poor prognosis cancer with a video decision aid

The authors tested whether an educational video on the goals of care in advanced cancer (life‐prolonging care, basic care, or comfort care) helped patients understand these goals and had an impact on their preferences for resuscitation.

Schizophrenia should be renamed to help educate patients and the public.

Background: A new name for schizophrenia, reflecting a biopsychosocial conceptualization, may have utility in educating patients and the public. If readily translatable, it would be of great value in transcultural psychiatry. It may be clinically beneficial to psychoeducation in evidence-based treatment modalities such as medication management, multifamily group psycho-education and cognitive therapy. Discussion: Neuro-Emotional Integration Disorder (NEID) is proposed as the biopsychosocial candidate term to replace schizophrenia. The following subtypes are proposed: defensive type replacing paranoid, motoric type replacing catatonic, Brief Neuro-Emotional-Integration Breakdown (B-NEIB) replacing brief psychotic episode, NEID-Time Limited replacing schizophreniform disorder. Schizoaffective disorder might be termed NEID-Bipolar type. Anti-psychotic medication would be termed NEI-Enhancing medication. Conclusions: By emphasizing the neuropsychiatric basis of this ‘highly treatable brain disorder’ through its labeling, stigma may ultimately be reduced. Even if the term NEID is not ultimately adopted, the principles outlined here should be helpful in choosing a replacement term for ‘schizophrenia’.