1 Describe key psychosocial problems found among cancer survivors in multiple settings during the past 25 years: distress, depression, fatigue, cognitive changes, body image, sexual
Trang 1Pat Fobair, LCSW, MPH Supportive Care Program Cancer Center, Stanford University Hospital
Trang 2 1 ) Describe key psychosocial problems
found among cancer survivors in multiple settings during the past 25 years: distress, depression, fatigue, cognitive changes,
body image, sexual dysfunction.
2) Discuss four effective interventions for improving mood and returning survivors to
a sense of inner control: physical exercise, group support, journal writing, yoga,
meditation, and imagery.
Trang 3 Literature search of English language abstracts and databases,
Trang 7 20% (77) Faller et al 2003
Psychother Psychosom Med
Psychol (Brca) Germany
25% (46) Flatten et al 2003
Psychother Psychosom Med
Psychol (Surgical tumors) Germany
38% (2776) Carlson et al
2004 Br J Cancer (All ca) Canada
40% t1(127) Mehnert & Koch
2006, 33% at t2, oncology (Brca) Germany
Psycho- 47% (135) Cliff & MacDonagh BJU Int 2000 (Prostate) Britain
62% (136) Tagay et al 2006 Qual Life Res May;15(4) 695- (Thyroid) Germany
Trang 8 In, Spiegel, D and J Giese-Davis (2003)
"Depression and cancer: mechanisms and
disease progression." Biol Psychiatry 54(3):
269-282,
rates among cancer populations to be between
a fourth (25%) and a third (33%) of each group.
Trang 9 16% (127) Mehnert & Koch
37% (303) Kissane et al
2004 Aust NZJ Psychiatry (Brca)
38% (60) Pelletier et al 2002
J Neurooncol.(Brain) Canada
Trang 10 In study w/5,736 Lymphoma and leukemia pts vs 2565 sibling controls found that survivors were signif more likely than controls to report symptoms of
depression and somatic distress Zebrack et al 2002, Pediatrics USA
In study w/1,101 adult survivors of
childhood brain cancer and 2,817 controls
found that survivors reported signifi higher global distress and
depression scores than siblings Zebrack et al 2004, JCO USA
Trang 11 Clinically depressed Hodgkin’s patients were less likely (38%) to achieve a return of energy by the fifth year following treatment Fobair et al 1986, JCO
Among 161 survivors of childhood leukemia,
fatigue and depression were highly correlated
Meeske et al 2005, JCO.
Fatigue and depression were highly correlated in
a study of 1,933 Korean breast cancer patients
Kim et al 2006, ASCO Abstract.
Trang 12 66% of 1,933 Korean br.ca survivors w/fatigue Kim et al
2006 ASCO abstract
76% of 379 pts 2 yrs + tx W/ fatigue 3+days each mo
(30% w/daily fatigue.) Curt et al
2000, The Oncologist US
Trang 14 511 w/HD’s vs 224 siblings Ng et al 2005, AnnOncol “HD’s
were signif more likely to report lower mean fatigue scores.” USA
818 w/HD’s vs 935 controls Ruffer et al 2003, Eur J
Cancer.”Fatigue levels of HD pts are signif higher than control groups Germany
93 w/HD’s vs 186 controls Joly et al 1996, JCO “Compared with controls, HD patients reported more chronic fatigue.” France
791 w/testicular ca vs HD’s & GenPop Fossa et al 2003
“Fatigue 24% w/HD’s, 16% w/TCS, 10% GenPop.” Norway
110 w/BrCa pts vs 100 controls Tchen et al 2003 JCO Patients were more fatigued than controls (P<0001) Canada
Trang 16 1000 patients, in 28 studies: 44% chemotherapy, 44% radiation
patients,and 64.5% of patients w/ adj treatments had cognitive
deficits in meta-analysis. Welzel et al 2005 Strahlenther Onkol Germany
110 Brca pts vs 100 controls (16 % vs 4%, P = 008) A higher
incidence of moderate or severe cognitive impairment among patients versus controls. Tchen et al 2003 JCO Canada
53 Brca pts performed worse in verbal learning, spatial functioning, and visual memory than BCS treated with surgery only No difference with between matched pts w/& w/0 breast cancer No relationship between survivors complaints and scores Castellon et al 2004 J Clin Exp
Neuropsychol USA
104 Brca pts compared with 102 control over two years found
cognitive dysfunction improved in most patients over time Fan et al
2005 JCO Canada
Trang 17 25% of 187 Brca pts treated for benign tumors felt problems
w/body image Bukovic et al 2004 Coll Antropol.Croatia
45% of 98 Brca pts felt differences in body image, 1-5yrs after
breast conservation surgery Bukovic et al 2005, Onkologie Croatia
46 % of 185 Brca pts 5 yrs later were embarrassed w/ their body Bloom et al 2004, Psychooncology USA
55% of 549 Brca pts,embarrassed w/ their body 0-7 months after diagnosis Fobair et al 2006, Psychooncology USA.
58% of 108 Brca pts felt differences in body image 1-5 yrs after modified radical surgery for advanced stage Brca Bukovic et al 2005, Onkologie Croatia.
70 % of 202 Brca pts were unhappy w/appearance, 4-42 mos Avis
et al 2005, J Clin Oncol USA
Trang 19 36% of 187 Brca pts w/benign tumors = deterioration in
sexual life. Bukovic et al 2004, Coll Antropol Croatia.
w/sex life after treatment vs 27% before Bukovic et al 2005,
Onkologie Croatia
diagnosis, w/sex problems Fobair et al 2006, Psychooncology USA
sexual desire Bloom et al 2004, Psychooncology USA
dissatisfied w/sex life after treatment vs 30% before Bukovic et al
2005, Onkologie, Croatia
Trang 20 19% or 6/39 pts w/rectal ca recovered normal
Rectum Japan
Surg.Canada
surgery vs 91% before Hendren et al 2005, Ann Surg.Canada
Trang 21 45% of 96 men w/prostate ca & brachytherapy
w/ED 2.5 yrs later Finney et al 2005, Urology Australia
w/ED (0) % before) Merrick et al 2005, Int J Radiat Oncol Biol Phys USA
radiotherapy, w/ED. Potosky et al 2000, JNCI USA
w/ED (40% before) Korfage et al 2005, Int J Cancer The
Netherlands
Trang 22 79.6% of 1156 men w/prostate ca, 55-74 &
rad’s or surgery w/ED (36% before) Schover et al 2002, Cancer USA
(31% before) Korfage et al 2005, Int J Cancer The Netherlands.
Trang 23 Physical exercise improved mortality risk, physical energy, mood, vigor, and sexual functioning.
Group Support, helped survivors decrease stress, anxiety and depression, and loneliness while
improving emotional well-being and vigor.
Journal writing was effective in decreasing
survivor’s pain, self blame, and physical
symptoms, and improved emotional affect and
CD4+ lymphocyte count.
Trang 24 2,987 Nurses w/Brca followed from 1984-2002 3-5 miles p/wk vs less active Results: the unadjusted mortality risk reduction was 6% at 10 years for those who walked 3 –5 mls per week Holmes et al 2005, JAMA USA.
36% w/ED prior to treatment Schover et al 2002, Cancer USA
Increases in exercise resulted in higher scores of SF physical health, (p = 005) Kendall et al 2005, Qual Life Res USA
exercise, or supervised exercise Physical functioning
increased by 5.7 pts in self directed group, 2.2 in
supervised, decreased 4.1 pts in control group, Segal et al 2001, JCO Canada
Trang 25 111 ca pts randomized to 14 week training or to controls The fatigue score decreased x 17 pts in control group and 5.8 in active group Thorsen et al 2005 JCO Norway
higher level physical activity = better sexual functioning Dahn et al
2005, Urology USA
in fitness were correlated w/improvements in depression but not w.anxiety Midtgaard et al 2005, Palliat Support Care Denmark.
physical fitness, activity levels, treatment related symptoms, physical & role functioning Adamsen et al 2006 Support Care Cancer Denmark
Trang 26 66 men w/Prostate ca randomized to walking (33) or control (33) Control pts Exercise group increased their distance walked (13.2%, P = 0.0003) Controls improved their fatigue scores,
exercisers did not Windsor et al 2004, Cancer Scotland, UK
treatment Women who walked 90 minutes 3x’s week had less
fatigue, emotional.distress and better QOL than those who
were less active Mock et al 2001 Cancer Practice USA
brca pts Regular exercisers reported more positive attitudes re:
physical condition, vigor, sexual attractiveness, less
confusion, fatigue, depression and better mood Pinto & Trunzo
2004 Mayo Clin Proc USA
Trang 27 Meta-Analysis of 116 studies found benefits for adults w/ cancer in relation to anxiety, depression mood, nausea, vomiting pain and knowledge Devine & Westlake 1995, Oncol Nurs Forum USA.
303 Brca pts, in 3 yr study found trend (p=0.05) w/
intervention group having reduced anxiety vs.controls Kissane et al
2003, Psychooncology Australia
complementary/alternative interventions (CAM) 91% SG & 80% CAM improved symptoms of PTSD; only support group had significantdecreases in overall stress. Levine et al 2005, Psychooncology USA
Trang 29 154 Brca pts assessed for emotion regulation and
adjustment over 4 pts time 12 week Interv 54 group, 56 decliners,
44 control At 4 mo’s Interv.pts.+ better emotional well-being &
at 12 mo’s + decrease in emotional suppression = showing
delayed impact Cameron et al 2006, Psychooncology, New Zealand
fewer problems with mood and +higher scores vigor vs
controls Fukui et al 2000, Cancer Japan
151 Brca pts, 6 week interv 46 participants, Interv group
confidants vs controls Fukui et al 2003, Oncol Nurs Forum, Japan
Trang 31 134 Ca pts offered 10 weekly 2 hour groups in 10 cities
in Switzerland QL assessed x 3 QL improved in
et al 2000 Schweiz Med Wochenschr Switzerland.
interv.vs 61 controls 102 completed Group members
2001, Arch Gen Psychiatry USA.
partners reported less POMS and greater marital
satisfaction Bultz et al 2000, Psychooncology Canada
Trang 33 104 Ca pts rand to write about emotions or a nonemotional topic, 20
min/day for 3 days Eval.@ 0 & 6 mos Written disclosure buffered the effects
of social constraints on stress at 6-month follow-up Zakowski et al 2004, Health Psychol USA.
92 Fibromyalgia pts rand to trauma writing group, a control writing
group or control 20 minutes 3 days (1) week Eval @ 0, & 4, & 10 mo follow-up Trauma group = reduction in pain, fatigue & psychological well-being
at 4 mo follow-up, but not at 10 month Broderick et al 2005, Psychosom Med USA.
60 Brca pts rand to 4 sessions 1) EMO=deepest thoughts and feelings; 2) POS= positive thoughts and feelings; 3) CTL= facts about their breast cancer experience EMO most useful for women low in avoidance POS most useful for women high in avoidance EMO group decreased physical symptoms Both EMO and POS had fewer medical appointments for cancer related morbidities Stanton et al 2002, JCO, USA
Trang 35 50 adolescents with asthma, randomized to write
for 3 days at home about stressful events (disclosure) or control
topics 0 & 2 months after writing Disclosure writing led to improved emotional affect and self blame Warner et al 2006, J Pediatr Psychol USA
48 women with chronic pelvic pain wrote 3 days
about stressful consequences of pain (disclosure) or positive writing (control) Disclosure writing resulted in less pain intensity and less disability among women with greater difficulty in writing disclosure Norman et al 2004, Psychosom Med, USA.
37 HIV infected pts randomized to emotional or
lymphocyte count over controls Petrie et al 2004, Psychosom Med, New Zealand
Trang 36 9 studies found improvements in sleep quality, mood, stress, related symptoms, and overall quality of life Bower et al, 2005, Cancer Control USA.
cancer- 38 cancer survivors randomly assigned (20/18) to a 7-week yoga
program had better quality of life, better emotional function, and fewer physical symptoms Culos-Reed et al, 2006, PsychoOncology Canada.
20 studies on meditation (397 intervention/561controls) found benefit for cancer patients in better mood, less anxiety, better autoimmune
function, and less emotional disturbance Arias et al 2006, J Altern Complement Med USA
154 breast cancer patients w/12 week intervention with relaxation,
guided imagery, meditation, emotional expression, behavior
modification reported increase in relaxation techniques, sense of
control, emotional well-being, coping, and less cancer worry Cameron et al
2006, PsychoOncology, NZ.
Trang 37 Using mixed methods of artistic therapy, this pilot study evaluated the effects of a creative arts therapy o the quality life of childrn receiving chemotherapy.
Using a 2-group, repeated measures, randomized controlled design, they compared creative arts therapy with a volunteer’s attention (n=16)
Statistical analysis suggested an improvement in: 1) parents report of child’s hurt (P=.03); 2) parents report of child’s nausea (P=.0061)
After using a nonrandomized phase with the children, they found there was improved mood (P=.01); children were more excited (<.05);
happier (P <.02) and less nervous (P<.02)
Madden JR, Mowry P, Gao D, Cullen PM, Foreman NK J
Pediatr Oncol Nurs 2010 May-Jun (30 133-45)
Trang 40 Physical exercise improved mortality risk, physical
energy, mood, vigor, and sexual functioning.
and depression, and loneliness while improving
emotional well-being and vigor.
Journal writing was effective in decreasing survivor’s
pain, self-blame, and physical symptoms, and improved emotional affect.
well-being, coping and reduce worry Yoga helped with sleep, mood, & quality of life
Trang 42 Psychosocial Problems range from 25% to over 50% of
survivors for distress, fatigue and sexual problems
yoga and imagery have demonstrated effectiveness in
helping patients improve physical, emotional health and sexual health.
These interventions are relatively easy to initiate in
medical or community settings.
help them recover.