Palliative care. Clinical practice guidelines in oncology.
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Medical Oncology↗
Biomedical subjects
David Spiegel
Publications and source records attributed to David Spiegel.
Mood disorders in the medically ill: scientific review and recommendations.
OBJECTIVE: The purpose of this review is to assess the relationship between mood disorders and development, course, and associated morbidity and mortality of selected medical illnesses, review evidence for treatment, and determine needs in clinical practice and research. DATA SOURCES: Data were culled from the 2002 Depression and Bipolar Support Alliance Conference proceedings and a literature review addressing prevalence, risk factors, diagnosis, and treatment. This review also considered the experience of primary and specialty care providers, policy analysts, and patient advocates. The review and recommendations reflect the expert opinion of the authors. STUDY SELECTION/DATA EXTRACTION: Reviews of epidemiology and mechanistic studies were included, as were open-label and randomized, controlled trials on treatment of depression in patients with medical comorbidities. Data on study design, population, and results were extracted for review of evidence that includes tables of prevalence and pharmacological treatment. The effect of depression and bipolar disorder on selected medical comorbidities was assessed, and recommendations for practice, research, and policy were developed. CONCLUSIONS: A growing body of evidence suggests that biological mechanisms underlie a bidirectional link between mood disorders and many medical illnesses. In addition, there is evidence to suggest that mood disorders affect the course of medical illnesses. Further prospective studies are warranted.
Acquired Immunodeficiency Syndrome↗
Breast cancer and problems with medical interactions: relationships with traumatic stress, emotional self-efficacy, and social support.
This investigation examined relationships between breast cancer patients' psychosocial characteristics (impact of the illness, traumatic stress symptoms, emotional self-efficacy, and social support) and problems they perceived in their medical interactions and their satisfaction with their physicians. Participants were 352 women enrolled in a multicenter trial of the effects of group therapy for women with recently diagnosed primary breast cancer. The findings reported here are from a cross-sectional analysis of baseline data gathered prior to randomization. Problems interacting with physicians and nurses were associated with greater levels of cancer-related traumatic stress (p < 0.01), less emotional self-efficacy for cancer (p < 0.05), less satisfaction with informational support from family, friends, and spouse, and a tendency to perceive those sources of support as more aversive (p < 0.05). Women who were less satisfied with emotional support from their family, friends and spouse were less likely to feel satisfied with their physicians (p < 0.05). These patient characteristics identify women with primary breast cancer who are likely to experience difficulty in their interactions with nurses and physicians and to be less satisfied with their physicians.
Adaptation, Psychological↗
Anticipating loss and other temporal stressors predict traumatic stress symptoms among partners of metastatic/recurrent breast cancer patients.
This study examined pre- and post-loss levels of posttraumatic stress symptoms (intrusion and avoidance) in partners of metastatic/recurrent breast cancer patients, and the relationship of these symptoms to past, current, and anticipatory stressors. The results indicate that 34% (17/50) of the partners experienced clinically significant symptom levels prior to the patients' deaths. Prior to loss, partners' symptoms were positively associated with their current level of perceived stress and anticipated impact of the loss; whereas following loss, partners' symptoms were predicted by higher pre-loss levels of symptoms, past family deaths, and anticipated impact of the loss. Limitations and treatment implications of the present research and directions for future research are discussed.
Adult↗
Social support and maladaptive coping as predictors of the change in physical health symptoms among persons living with HIV/AIDS.
This study examined social support and maladaptive coping as predictors of HIV-related health symptoms. Sixty-five men and women living with HIV/AIDS completed baseline measures assessing coping strategies, social support, and HIV-related health symptoms. The sample was primarily low-income and diverse with respect to gender, ethnicity, and sexual orientation. Three, 6, and 12 months after completing baseline assessments, physical health symptoms associated with HIV disease were assessed. After controlling for demographic characteristics, CD4 T-cell count, and baseline HIV-related health symptoms, individuals reporting lower increase in HIV-related health symptoms used less venting (expressing emotional distress) as a strategy for coping with HIV. However, when satisfaction with social support was added to the model, the use of this coping strategy was no longer significant, and individuals reporting more satisfying social support were more likely to report lower increase in their HIV-related health symptoms, suggesting that social support is a robust predictor of health outcomes over time independent of coping style and baseline medical status. These findings provide further evidence that social support can buffer deleterious health outcomes among individuals with a chronic illness. Future research needs to examine mediating pathways that can explain this relationship.
Adaptation, Psychological↗
Treatment of acute traumatic stress reactions.
This paper calls for a broadening of the context within which we study responses to traumatic stress, the course of recovery, components of effective interventions, and assessments of outcome. Acute stress reactions to trauma as a spectrum include anxiety, dissociative, and depressive symptoms. The course of these symptoms may vary, with fluctuations between intrusion (positive) and avoidance/numbing/dissociative (negative) symptoms that may complicate assessment, treatment-seeking, and course of recovery. Components of effective treatments including affect management, cognitive restructuring, and social integration are discussed. Finally, a broader view of outcome assessment in such research is called for, including not just reduction in psychopathological symptoms but attention to coping styles, affect management, resilience, social reorganization, and sensitivity to subsequent trauma.
Crisis Intervention↗
Hypnosis reduces distress and duration of an invasive medical procedure for children.
OBJECTIVE: Voiding cystourethrography (VCUG) is a commonly performed radiologic procedure in children that can be both painful and frightening. Given the distress that some children experience during the VCUG and the need for children to be alert and cooperative during the procedure, finding a psychological intervention that helps children to manage anxiety, distress, and pain is clearly desirable. This study was designed to examine whether relaxation and analgesia facilitated with hypnosis could reduce distress and procedure time for children who undergo this procedure. METHODS: Forty-four children who were scheduled for an upcoming VCUG were randomized to receive hypnosis (n = 21) or routine care (n = 23) while undergoing the procedure. The sample consisted of 29 (66%) girls and 15 (34%) boys with a mean age of 7.6 years (SD: 2.5; range: 4-15 years). Ethnic/racial backgrounds were 72.7% white, 18.2% Asian, 4.5% Latino, 2.3% black, and 2.3% Filipino. The mean number of previous VCUGs was 2.95 (SD: 2.51; mode: 2; range: 1-15). Potential participants were identified through computerized hospital records of upcoming VCUGs. Parents were contacted by telephone and invited to participate if their child was eligible. To be eligible for the study, the child must have undergone at least 1 previous VCUG, been at least 4 years of age at that time, and experienced distress during that procedure, and both the child and the participating parent had to be English speaking. Each eligible child and parent met with the research assistant (RA) before the day of the scheduled procedure for an initial assessment. Children were queried regarding the degree of crying, fear, and pain that they had experienced during their most recent VCUG. Parents completed a series of parallel questions. Immediately after this assessment, those who were randomized to the hypnosis condition were given a 1-hour training session in self-hypnotic visual imagery by a trained therapist. Parents and children were instructed to practice using the imaginative self-hypnosis procedure several times a day in preparation for the upcoming procedure. The therapist was also present during the procedure to conduct similar exercises with the child. The majority (83%) of those who were randomized to the routine care control group chose to participate in a hospital-provided recreation therapy program (offered as part of routine care). The program includes demonstration of the procedure with dolls, relaxation and breath work training, and assistance during the procedure. On the day of the VCUG, the RA met the family at the clinic before the procedure, and both the child and the parent rated the child's present level of fearfulness. During the procedure, the RA recorded observational ratings of the child's emotional tone and behavior and timed the overall procedure and its phases. Immediately after the VCUG, the child was asked how much crying, fear, and pain he or she had experienced during the procedure; the parent rated the child's experience on the same dimensions and also how traumatic the procedure had been (both generally and compared with their previous one), and the medical staff rated the degree of procedural difficulty. Outcomes included child reports of distress during the procedure, parent reports of how traumatic the present VCUG was compared with the previous one, observer ratings of distress during the procedure, medical staff reports of the difficulty of the procedure overall, and total procedural time. RESULTS: Results indicate significant benefits for the hypnosis group compared with the routine care group in the following 4 areas: (1) parents of children in the hypnosis group compared with those in the routine care group reported that the procedure was significantly less traumatic for their children compared with their previous VCUG procedure; (2) observational ratings of typical distress levels during the procedure were significantly lower for children in the hypnosis condition compared with those in the routine care condition; (3) medical staff reported a significant difference between groups in the overall difficulty of conducting the procedure, with less difficulty reported for the hypnosis group; and (4) total procedural time was significantly shorter-by almost 14 minutes-for the hypnosis group compared with the routine care group. Moderate to large effect sizes were obtained on each of these 4 outcomes. CONCLUSIONS: Hypnotic relaxation may provide a systematic method for improving the overall medical care of children with urinary tract abnormalities and may be beneficial for children who undergo other invasive medical procedures. Because the VCUG is an essential part of the evaluation of urinary tract infections and vesicoureteral reflux in children, lower distress during the procedure may improve patient and family compliance with initial as well as follow-up evaluations. These findings augment the accumulating literature demonstrating the benefits of using hypnosis to reduce distress in the pediatric setting. The present findings are noteworthy in that this study was a controlled, randomized trial conducted in a naturalistic medical setting. In this context, we achieved a convergence of subjective and objective outcomes with moderate to large effect sizes, including those that may have an impact on patient care and procedure cost, that were consistently supportive of the beneficial effects of hypnosis-a noninvasive intervention with minimal risk. The findings, therefore, have immediate implications for pediatric care. Limitations of this study include the lack of participant and staff blindness to the child's condition assignment, which could have introduced bias into reports. However, the objective procedural time differences between groups were consistent with the other, more subjective outcome findings. The sample was also small and primarily white in ethnic/racial makeup, which may have restricted our ability to detect some differences and may limit the generalizability of findings to more representative samples. In addition, the sample comprised children who had already undergone at least 1 VCUG during which they had had difficulty. Consequently, additional research is needed to determine whether hypnosis would be helpful to those who are undergoing their first VCUG. Additional limitations, clinical observations, and directions for future research are also discussed.
Child↗
A randomized trial of the efficacy of group therapy in changing viral load and CD4 counts in individuals living with HIV infection.
OBJECTIVE: This randomized pilot study evaluates whether seropositive patients who are randomly assigned to receive a supportive-expressive group therapy plus education intervention show greater improvements in increased immune function and decreased viral load compared to those randomly assigned to an education-only intervention. METHOD: Fifty-nine individuals who had been HIV-seropositive for at least 6 months prior to inclusion in the study and had been receiving standard pharmacologic treatment were entered in a prospective randomized trial of the effects of weekly supportive-expressive group therapy on changes in immune status. Participants were matched for AIDS status and sex and randomized to receive weekly sessions of group psychotherapy plus educational materials on HIV/AIDS, or to receive the educational materials alone. Participants were assessed before treatment and then 12 weeks later. RESULTS: Individuals who were randomized to group therapy showed a statistically significant increase in CD4 count and decrease in HIV viral load. Among individuals randomized to the education only condition, no significant change occurred in CD4 count or viral load. CONCLUSIONS: These results provide preliminary data suggesting that HIV-seropositive individuals who receive supportive-expressive group psychotherapy may experience concomitant improvements in CD4 cell count and viral load. Further research with a larger sample should examine the possible underlying mechanisms of such benefits.
Adult↗
The assessment of intraobserver and interobserver error in the measurement of noncongenital scoliosis in children < or = 10 years of age.
STUDY DESIGN: Retrospective review of scoliosis radiographs. OBJECTIVES: To determine measurement variability in children < or = 10 years of age with noncongenital scoliosis. SUMMARY OF BACKGROUND DATA: Measurement variability in congenital and adolescent idiopathic scoliosis has been studied. There is no study of measurement variability in young children with noncongenital scoliosis. METHODS: A retrospective review of children < or = 10 years of age followed for noncongenital scoliosis was performed. End vertebrae were identified on radiographs, and the curves were measured (Cobb method) twice by each of six observers. The same soft lead pencil and goniometer was used. Intraobserver and interobserver variability for continuous data was determined. RESULTS: There were 64 children. The diagnosis was infantile/juvenile idiopathic scoliosis in 42, neuromuscular scoliosis in 7, scoliosis associated with mesenchymal disorders or other syndromes in 12, and unknown in 3 children. The curve was thoracic in 54, thoracolumbar in 8, and lumbar in 2. There were 19 left and 45 right curves. The average age was 6.6 +/- 2.6 years. There were a total of 768 Cobb angle measurements with an average Cobb angle of 38 +/- 22 degrees (range, 10 degrees -115 degrees ). Intraobserver variability was +/- 6 degrees; interobserver variability was +/- 7 degrees. CONCLUSION: In children < or =10 years of age with noncongenital scoliosis, intraobserver measurement variability in Cobb angle measurement is +/- 6 degrees and interobserver variability is +/-7 degrees. To be certain that there is a significant difference between Cobb angle measurements in children with noncongenital scoliosis and < or = 10 years of age there must be a change of at least +/-7 degrees.
Age Factors↗
Placebos in practice.
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Evidence-Based Medicine↗
Cancer supportive care, improving the quality of life for cancer patients. A program evaluation report.
GOALS OF WORK: As medical care for cancer has become more specialized in diagnosis, treatment has become more technical and fragmented. In order to help cancer patients and their families, we developed a coordinated program called the Stanford Cancer Supportive Care Program (SCSCP) at the Center for Integrative Medicine at Stanford Hospital and Clinics. The Stanford Cancer Supportive Care Program was initiated in 1999 to provide support for cancer patients, addressing the need for improved physical and emotional well-being and quality of life. This paper is a program evaluation report. PATIENTS AND METHODS: The number of patient visits grew from 421 in 1999 to 6319 in 2002. This paper describes the utilization of the SCSCP program as assessed by 398 patient visit evaluations during a 9-week period, January 2002 to March 2002. During this time we collected attendance records with demographic data and anonymous questionnaires evaluating each program. Patients were asked to evaluate how the program helped them regarding increase of energy, reduction in stress, restful sleep, pain reduction, sense of hopefulness, and empowerment. MAIN RESULTS: Over 90% of the patients using the SCSCP felt there was benefit to the program. Programs were chosen based on a needs assessment by oncologists, nurse managers, social workers, and patients. Massage, yoga, and qigong classes had the highest number of participants. Qualitative data showed benefit for each program offered. CONCLUSIONS: This evaluation of a free cancer supportive care program initiated in a hospital outpatient setting provides initial evidence of patient satisfaction and improvement in quality of life.
Adaptation, Psychological↗
The interaction of social network size and stressful life events predict delayed-type hypersensitivity among women with metastatic breast cancer.
This study examined relationships between social support, stressful life events and antigen-specific cell-mediated immunity. Participants were 72 women with documented metastatic breast carcinoma, who completed self-report measures of social support and life stress. Immune response was assessed using the delayed type hypersensitivity (DTH) skin test. Number of positive antigens was significantly related to the interaction of social network size and stressful life events (p<0.05). Number of positive antigens was greater for women who had experienced a high frequency of stressful life events but who reported a larger network of support. However, social network size was inversely related to DTH response among women who had experienced fewer stressful life events. Average induration size was not significantly related to the quality of social support, life stress per se, or their interactions. The relationship between social network size and immune response in women with metastatic breast cancer depends on prior stressful life experience.
Antibody Formation↗
Sleep disturbances among HIV-positive adults: the role of pain, stress, and social support.
OBJECTIVE: Investigate the relationships between pain, stress, social support, and sleep disturbance among a diverse sample of HIV-positive adults. METHOD: Participants (N = 146) completed self-report measures on pain, stress, social support, and sleep disturbance. CD4 T-cell count was obtained from medical records. RESULTS: Greater pain and stress were associated with greater sleep disturbance. Greater assistance from friends was associated with greater sleep disturbance, whereas greater understanding from friends regarding participants' HIV-related stress was associated with less sleep disturbance. CONCLUSION: As expected, pain was significantly associated with sleep disturbance. Additionally, psychosocial variables were strongly associated with sleep. The type of support from friends differentiated whether the support was positively or negatively associated with sleep problems. Social support, depending on the type, may not always be helpful for adults living with HIV/AIDS. Future studies need to examine factors that may mediate the relationship between psychosocial constructs and healthy sleep.
Adult↗
Flattened cortisol rhythms in metastatic breast cancer patients.
Allostatic load, the physiological accumulation of the effects of chronic stressors, has been associated with multiple adverse health outcomes. Flattened diurnal cortisol rhythmicity is one of the prototypes of allostatic load, and has been shown to predict shorter survival among women with metastatic breast cancer. The current study compared diurnal cortisol slope in 17 breast cancer patients and 31 controls, and tested associations with variables previously found to be related to cortisol regulation, i.e, abdominal adiposity, perceived stress, social support, and explicit memory. Women with metastatic breast cancer had significantly flatter diurnal cortisol rhythms than did healthy controls. Patients with greater disease severity showed higher mean cortisol levels, smaller waist circumference, and a tendency toward flatter diurnal cortisol rhythms. There were no relations between cortisol slope and psychological or cognitive functioning among patients. In contrast, controls with flatter rhythms showed the expected allostatic load profile of larger waist circumference, poorer performance on explicit memory tasks, lower perceived social support, and a tendency toward higher perceived stress. These findings suggest that the cortisol diurnal slope may have important but different correlates in healthy women versus those with breast cancer.
Body Composition↗
Repression and high anxiety are associated with aberrant diurnal cortisol rhythms in women with metastatic breast cancer.
Previous research has provided evidence of autonomic, endocrine, and immunological dysregulation in repressers and a possible association with cancer incidence and progression. Recently published data from the authors' laboratory demonstrated that flatter diurnal cortisol slopes were a risk factor for early mortality in women with metastatic breast cancer. In the current analysis of this same sample (N=91), the authors tested differences at baseline between groups scored using the Weinberger Adjustment Inventory on diurnal cortisol slope and mean cortisol levels. When compared with self-assured and nonextreme groups, the represser and high-anxious groups had a significantly flatter diurnal slope. Diurnal slope was similar for repressers and high-anxious groups. Groups did not differ on mean cortisol levels, nor did they differ on intercept (morning) values.
Adaptation, Psychological↗
Depression and cancer: mechanisms and disease progression.
Depression and cancer commonly co-occur. The prevalence of depression among cancer patients increases with disease severity and symptoms such as pain and fatigue. The literature on depression as a predictor of cancer incidence is mixed, although chronic and severe depression may be associated with elevated cancer risk. There is divided but stronger evidence that depression predicts cancer progression and mortality, although disentangling the deleterious effects of disease progression on mood complicates this research, as does the fact that some symptoms of cancer and its treatment mimic depression. There is evidence that providing psychosocial support reduces depression, anxiety, and pain, and may increase survival time with cancer, although studies in this latter area are also divided. Psychophysiological mechanisms linking depression and cancer progression include dysregulation of the hypothalamic-pituitary-adrenal axis, especially diurnal variation in cortisol and melatonin. Depression also affects components of immune function that may affect cancer surveillance. Thus, there is evidence of a bidirectional relationship between cancer and depression, offering new opportunities for therapeutic intervention.
Adrenal Glands↗
Electronic support groups for breast carcinoma: a clinical trial of effectiveness.
BACKGROUND: A recent Pew Charitable Trust study found that 52,000,000 individuals used the Internet to obtain health/medical information. Clinical trials of face-to-face breast carcinoma support groups show evidence of 1) improvement in quality of life, 2) reduction of psychologic symptoms, 3) improvement in coping responses, and 4) a reduction in pain. To the authors' knowledge, a few studies published to date have investigated Internet-delivered electronic support groups (ESGs) for cancer. The most sophisticated is the Comprehensive Health Enhancement Support System (CHESS) program, which provides integrated information, referral, and a newsgroup-based social support program. However, to the authors' knowledge, no studies published to date have examined the impact of a breast carcinoma ESG in a clinical trial. METHODS: Sixty-seven women completed the initial baseline questionnaires, 32 of whom accepted the authors' invitation and began the groups. With regard to geographic location, 49% lived in rural/small towns, 41% lived in medium-sized cities, and 10% lived in large cities. Diagnostic stages of disease were: Stage I, 22%; Stage II, 56%; Stage III, 12%; and other forms, 10%. There were 4 intervention groups, of which 8 participants led by trained Wellness Community (TWC) (a national agency) leaders met for 1.5 hours once a week for 16 weeks. Student t tests for paired outcome data were computed using baseline and postgroup scores. RESULTS: The results of the current study indicated that breast carcinoma patients significantly reduced depression (Center for Epidemiologic Studies-Depression [CES-D] scale) and Reactions to Pain. They also demonstrated a trend toward increases on The Posttraumatic Growth Inventory (PTGI) in two subscales: New Possibilities and Spirituality. Counterintuitively, breast carcinoma patients appeared to demonstrate an increase in emotional suppression. Postinterview results indicated that approximately 67% of patients found the group to be beneficial. Those who withdrew from the groups (20%) demonstrated low scores in their ability to contain anxiety and appeared to be more likely to suppress their thoughts and feelings regarding their illness. CONCLUSIONS: The findings of the current study are encouraging, particularly because it was conducted through TWC, a national agency willing to make this type of intervention readily available at no cost. A limitation of the current study was the lack of randomization and a control group comparison. Although the authors were not able to demonstrate effectiveness without the addition of a control condition, the analysis of pregroup and postgroup outcomes suggests that a randomized trial is worthwhile. Women with a devastating disease will join and commit themselves to an online support group. In addition, because a large percentage of these women were from rural locations, this type of intervention may hold promise for those who have limited access to support groups.
Breast Neoplasms↗
Mood disturbance in community cancer support groups. The role of emotional suppression and fighting spirit.
OBJECTIVE: In this cross-sectional study, we tested whether the coping styles of emotional suppression and fighting spirit were associated with mood disturbance in cancer patients participating in professionally led community-based support groups even when demographic, medical, and group support variables were taken into account. METHODS: A heterogeneous sample of 121 cancer patients (71% female, 29% male) completed the Courtauld Emotional Control Scale (CECS), the Mini-Mental Adjustment to Cancer Scale (Mini-MAC), a measure of perceived group support, and the Profile of Mood States (POMS). RESULTS: Consistent with hypotheses, lower emotional suppression and greater adoption of a fighting spirit, in addition to older age and higher income, were associated with lower mood disturbance. Gender, time since diagnosis, presence of metastatic disease, time in the support group, perceived group support, cognitive avoidance, and fatalism were unrelated to mood disturbance. CONCLUSION: Expression of negative affect and an attitude of realistic optimism may enhance adjustment and reduce distress for cancer patients in support groups.
Adaptation, Psychological↗