Vittorio Mattioli

Quality of life, fatigue and depression in Italian long-term breast cancer survivors

Data from the European Cancer Registries show an increase in survival in the last decade: the 5-year age-standardised relative survival rate for breast cancer has reached 79 % for women diagnosed in 1995–1999 [1], which is higher from the 76 % for those diagnosed in 1990–1994 [2]. Nevertheless, most survivors experience adverse effects that can negatively affect their quality of life [3–5]. Risk factors for long-term cancer and treatment-related sequelae may differ by time from completion and type of treatment, age at diagnosis, comorbid conditions and biological factors as well as psychosocial or behavioural factors such as healthy or unhealthy lifestyle. All these aspects may affect both physical and psychological functioning [5]. Among physical late effects in breast cancer survivors (BCS), arm/shoulder complaints, cardiovascular disease, gonadal dysfunction and fatigue are the most common [6]. Fatigue is a distressing symptom in breast cancer patients both during treatments and during the survivorship phase. Long-term BCS tend on average to be more fatigued than the general population, but, until now, evidence of greater fatigue severity compared to healthy controls is mixed [7]. Incidence and prevalence rates for fatigue in long-term BCS range from 24 to 62 %, with most studies reporting rates of approximately 40 % [8–10]. In reality, both the diverse definitions of survivorship and the various fatigue measurement tools implied complicate the ability to make adequate data comparison and to draw clear conclusions on fatigue incidence and prevalence. Regarding psychological sequelae, it was found that in long-term BCS, depression is one of the most distressing and disabling symptoms, even more than anxiety and posttraumatic stress disorder [11]. In a recent US populationbased study [12], including 4,636 adult long-term survivors diagnosed five or more years earlier, the prevalence of significant psychological distress was found to be significantly higher compared to the healthy peers and similar data were also found in European studies [13, 14]. Fatigue and depression have been found to be closely related both in cancer patients and in cancer survivors [e.g. 15, 16]. The concept of health-related quality of life (HRQOL) includes aspects of physical and mental health as a subjective perception and is usually considered a valid indicator of the impact of health on peoples quality of life. In some previous studies on long-term BCS, it was surprisingly found that BCS reported better health compared to the general female population [17] even if reporting more frequent use of health care facilities [18]. When studying cancer late effects in cancer survivors, the intercultural variations across countries should also be mentioned: different cultures and health systems may contribute to diverse adaptation in the survivorship phase. For example, many European countries, such as France, Italy and the F. Romito (*) : C. Cormio :V. Mattioli Experimental Unit of Psychological Oncology, Department of Critical Area and Surgery, National Cancer Center “Giovanni Paolo II”, Via O. Flacco 65, 70126 Bari, Italy e-mail: francescaromito@yahoo.com

The Italian response to cancer survivorship research and practice: developing an evidence base for reform

IntroductionImprovement in cancer survival rates have increased longevity but have also revealed physical and psycho-social sequelae of long-term survivorship and raised many questions regarding how to assess, treat, and prevent these survival-related problems. The United States, Australia, and some northern European Union countries have already started to address these issues. Italy still needs to take up this challenge, taking into account its specific social and cultural background that shapes a different survivorship scenario.MethodsThis brief report summarizes the concept of cancer survivorship and the response to this emerging public health issue in Italy. Two current nationwide research programs on long-term cancer survivorship and post-cancer pain are described to provide readers with a perspective of how Italy is seeking to increase the understanding of the needs and problems of cancer survivors.Implications for cancer survivorsThe results of these nationwide research programs will provide an evidence base for reforming the national care plans to address the needs of the growing number of Italian people with a history of cancer. It is hoped that this description of Italy’s response to this public health challenge will offer some insight into how Italy is responding to the health and psychosocial needs of cancer survivors.

Psychological well-being and posttraumatic growth in caregivers of cancer patients

Introduction: Although research has shown that many cancer patients report positive life changes following cancer diagnosis, there are few data in the literature related to PTG in caregivers of cancer patients. However, the few studies available have shown that this kind of positive changes can also be experienced by family members. The aims of this study were to explore PTG in caregivers of cancer patients and to investigate correlations between the Posttraumatic growth, psychological status and QoL of caregivers and those of patients, taking into account also clinical and socio-demographic aspects. Methods: We enrolled 60 patient/caregiver pairs in the Department of Medical Oncology of the National Research Center “Giovanni Paolo II” in Bari. Both patients and caregivers were assessed using the following scales: Posttraumatic growth Inventory (PTGI); Hospital anxiety and depression scale; Short Form (36) Health Survey (SF-36); ECOG Performance Status. Clinical and socio-demographic data were collected. Results: Caregivers showed significantly higher scores than patients in the dimension of “personal strength.” Furthermore, we found a significantly close association between anxiety and depression of caregivers with those of patients. Younger caregivers were better than older ones in terms of physical activity, vitality, mental health, and social activities. Although the degree of relationship with the patient has no significant effect on the dependent variables of the study, it was found that caregivers with a degree of kinship more distant to the patient have less physical pain than the closest relatives. Conclusion: Results of the present study show that caregivers of cancer patients may experience post-traumatic growth as the result of their caregiver role. It would be interesting to investigate in future research which factor may mediate the presence of post-traumatic growth.

Clinical and prognostic role of circulating MMP-2 and its inhibitor TIMP-2 in HCC patients prior to and after trans-hepatic arterial chemo-embolization

BACKGROUND AND AIMS Trans-hepatic arterial chemo-embolization is the most commonly used treatment for unresectable hepatocellular carcinoma. The prognostic impact of tumor biomarkers has not therefore been evaluated in this treatment. Imbalance between matrix metalloproteinase-2 and tissue inhibitor metalloproteinase-2 is considered to play an important role in extracellular matrix remodeling and degradation. Higher serum levels of MMP-2 have been shown to predict a poor prognosis and shorter overall survival in HCC after TACE. The objective of this study was to evaluate the serum levels of MMP-2 and TIMP-2 in HCC patients before and after TACE to evaluate their clinical significance and usefulness as prognostic biomarkers. METHODS MMP-2 and TIMP-2 levels were measured by ELISA in 75 HCC patients and 30 healthy controls. Sera MMP-2 and TIMP-2 were correlated with clinico-pathological features. RESULTS The mean serum MMP-2 and TIMP-2 levels of HCC patients before TACE were 1700±71ng/mL and 89±45ng/mL respectively, significantly higher than that of the control group: 771±60ng/mL (p<0.0001, t-test) and 25.7±20ng/mL respectively (p<0.0001, t-test). A significant decrease of MMP-2 levels after 1 and 3months compared to baseline time was observed (p<0.0001), while with TIMP-2 a gradual increase in serum before and after TACE (p<0.01) was detected. No significant correlation between serum MMP-2 levels and other clinico-pathological features was observed. Patients with serum MMP-2 >1500ng/mL (median value) had worse overall and recurrence-free survival compared with those with serum MMP-2 levels <1500ng/mL before treatment. CONCLUSION Higher serum MMP-2 levels and MMP-2/TIMP-2 ratio could predict poor prognosis after TACE, suggesting prognostic role of these biomarkers in HCC.

Targeting Tumour Vascularization from Bench to Bedside: Suggestions for Combination with Hyperthermia

Angiogenesis is an important pathway in tumour growth and progression. Overexpression of pro-angiogenic factor or down regulation of physiologic angiogenic inhibitors are the stimuli that induce new blood vessel formation from a pre-existing vascular bed. On the other hand tumour vasculature is a major important factor influencing the therapeutic application of hyperthermia used as anticancer therapy. Both endothelial cells and microvessels can be lethally damaged by the hyperthermia. Because tumour vasculature is a target of hyperthermia combined treatments with angiogenesis inhibiting agents or vascular disrupting agents and hyperthermia may lead to synergetic effects or potentiation of the combined therapy over each modality alone. In this chapter we summarize the state of the art regarding the combination between drugs that targeting tumour vasculature and hyperthermia, furthermore the pre-clinical rationale for future clinical trials is suggested.

The European Accreditation of Istituto Tumori Giovanni Paolo II of Bari

The National Cancer Institute of Bari (Istituto di Ricovero e Cura a Carattere Scientifico, IRCCS) has been involved since the conception of the project of the Italian Ministry for Health aimed to validate the applicability of the Organisation of European Cancer Institutes (OECI) accreditation and designation (A&D) model to the Network of Italian Cancer Centers, IRCCS, of Alleanza Contro il Cancro. The self-assessment phase of the Institute started in September 2013 and ended in June 2014. All documents and tools were transferred to the OECI A&D Board in June 2014 and a 2-day peer review visit was conducted in October 2014 by an international qualified audit team. The Institute received its final designation and certification in June 2015. The OECI A&D Board, in its final report, came to the conclusion that Istituto Tumori “Giovanni Paolo II” of Bari has a strong research component with some essential elements of comprehensive cancer care still under development; the lack of a system for using outcome data for the strategic management approach to decision-making and missing a regular internal audit system eventually helping further quality improvement were reported as examples of areas with opportunities for improvement. The OECI A&D process represented a great opportunity for the cancer center to benchmark the quality of its performance according to standard parameters in comparison with other international centers and to further develop a participatory group identity. The common goal of accreditation was real and participatory with long-lasting positive effects. We agree with the OECI comments about the next areas of work in which the Institute could produce future further efforts: the use of its powerful IT system as a means for outcome analysis and empowerment projects for its cancer patients.

Musica, canto ed espressione emozionale durante la chemioterapia. Fanno stare meglio?

Le pazienti oncologiche vivono elevati livelli di distress psicologico, in particolar modo durante le prime fasi di diagnosi e trattamento. Lo studio valuta l’efficacia di un intervento di terapie complementari, nel contenimento di ansia, depressione, rabbia e stress in pazienti oncologiche. 62 pazienti sono state randomizzate in gruppo sperimentale e di controllo. Il gruppo sperimentale ha partecipato ad una singola sessione di musicoterapia nella globalita dei linguaggi e holding psicologico in gruppo, durante l’infusione di chemioterapia ambulatoriale. Lo strumento di valutazione pre e post intervento e stato l’Emotional Thermometers Tool. Nel gruppo sperimentale i livelli di stress, ansia, depressione e rabbia, risultano ridotti in maniera significativa dopo l’intervento. Nel gruppo di controllo si riducono stress e ansia. La richiesta di aiuto risulta maggiormente soddisfatta nel gruppo sperimentale. L’intervento di gruppo di musicoterapia e holding psicologico si e dimostrato utile nel ridurre il distress emozionale durante l’infusione di chemioterapia. Andrebbe valutato l’impiego delle terapie complementari nei percorsi di umanizzazione.