WHEELING, W.Va., July 27 — Cancer patients surviving at least five years are substantially more likely to show signs of serious psychological distress than other people, researchers found.

• Explain to interested patients that cancer survivors are subject to many stresses and would be likely to experience significant distress.
• Explain that it was not known how the prevalence of distress would compare to that among other people after controlling for measurable stress-related factors such as insurance or marital status.

Serious distress was seen 40% more frequently among long-term cancer survivors compared with people who had never been diagnosed with cancer, reported Karen E. Hoffman, MD, MHSc, of Brigham and Women’s Hospital in Boston, and colleagues.

“Prompt diagnosis and treatment of mental distress can have a positive impact on the functioning, quality of life, and overall well-being of survivors,” they wrote in the July 27 issue of Archives of Internal Medicine.

“The increased risk of serious psychosocial distress and the need to screen for [it] should be communicated to primary care physicians and other care providers,” they added.

The findings emerged from an analysis of responses from nearly 127,000 participants in the National Health Interview Survey, conducted from 2002 to 2006 by the U.S. Census Bureau.

Dr. Hoffman and colleagues compared signs of serious distress apparent in the survey responses from 4,636 participants who had been diagnosed with cancer at least five years previously and in 122,220 other respondents who had been cancer-free.

The questionnaire used in the survey included all items contained in the validated K6 screening test for psychosocial distress. For example, respondents were asked how frequently they had experienced such feelings as nervousness, restlessness, hopelessness, or extreme sadness.

A score of 13 on the 24-point K6 scale was the threshold for a determination of serious distress in the study.

The raw data indicated that 5.6% of the cancer survivors versus 3.0% of the cancer-free respondents were suffering serious distress.

After adjusting for a variety of known or potential confounding factors — age, sex, race, relationship status, educational attainment, insurance status, comorbidities, smoking history, and ability to perform instrumental activities of daily living — Dr. Hoffman and colleagues calculated an odds ratio of 1.4 (95% CI 1.2 to 1.7) for serious distress among the cancer survivors.

The risk for serious distress was slightly higher (OR 1.5, 95% CI 1.1 to 2.0) among cancer survivors who reported not seeing a medical specialist in the previous six months.

Factors that appeared to predict serious psychosocial distress in the cancer survivors included the following, given as adjusted odds ratios:

• Age less than 45: 5.6 (95% CI 3.3 to 9.5) relative to those 65 and older
• No spouse or live-in partner: 1.7 (95% CI 1.2 to 2.4) relative to those married or living with partner
• Less than high school education: 2.1 (95% CI 1.5 to 3.0) relative to at least high school education
• Uninsured: 2.4 (95% CI 1.6 to 3.7) relative to insured
• At least two comorbid conditions: 3.5 (95% CI 2.2 to 5.6) relative to no comorbidities
• Current or former smoker: 1.7 (95% CI 1.2 to 2.5) relative to never having smoked
• Difficulty with activities of daily living: 3.6 (95% CI 2.5 to 5.3) relative to no difficulty

A higher proportion of all cancer survivors in the survey reported having seen a mental health professional in the previous year, compared with the cancer-free respondents (9% versus 6%).

But only one-third of the cancer survivors with serious distress said they had been in contact with a mental health professional. Some 18% said they could not afford it. Those figures were virtually identical to those found in the cancer-free comparison group.

Dr. Hoffman and colleagues said it wasn’t surprising to find higher rates of distress among cancer survivors. The disease and its treatment may produce long-term physical and neurological problems.

Moreover, they said, “a cancer history can also affect social adaptation, employment opportunities, and insurance coverage.”

The finding that rates of distress are higher among survivors even after adjusting for some of these factors “suggests that survivors have increased vulnerability to psychological distress through additional mechanisms that were not captured by the survey.”

These could include treatment-related fatigue, regret over lost opportunities, or fear of recurrence and death, Dr. Hoffman and colleagues suggested.

The researchers said clinicians could use the distress predictors they found to identify patients most at risk.

“Studies have demonstrated that routine psychological screening can be successfully integrated into the cancer survivor clinic and that several quick, low-cost screening methods are available,” they pointed out.

“Cancer survivorship clinics may benefit from having mental health providers on staff for a multidisciplinary approach to the care of these patients,” the researchers concluded.

Amy Abernethy, MD, an oncologist at Duke University, said it was an important study “because it highlights that the psychological distress persists long after the treatment ends.”

She said in an e-mail that clinicians and patients may hope that survivors resume normal lives, “but the truth is that they might not. People are plagued by the threat of recurrence, by recurrent memories of the cancer experiences, and can even suffer from post-traumatic stress disorder.”

She said cancer survivors who show signs of continuing distress should have access to counselors familiar with cancer-related effects.

“Would psychosocial care during the cancer care phase reduce the risk of long-term problems? I don’t know, but I suspect that it is the right place to start,” Dr. Abernethy said.

The researchers noted limitations to the study that included its cross-sectional design, lack of information on previous mental health history or cancer treatment or outcome details, and reliance on participants’ self-reports of cancer diagnoses.

The National Health Interview Survey was conducted by the U.S. Census Bureau. No external funding for the analysis was reported. The authors declared no potential conflicts of interest.

This article was developed in collaboration with ABC News.

Primary source: Archives of Internal Medicine

Source reference:

Hoffman K, et al “Psychological distress in long-term survivors of adult-onset cancer results from a national survey,” Arch Intern Med 2009; 169: 1274-81.

HOUSTON, July 27 — Concurrent chemoradiation followed by surgery improves progression-free but not overall survival in patients with stage III non-small cell lung cancer (NSCLC) compared with chemotherapy and definitive radiation, a cooperative group clinical trial showed.

• Explain to patients that surgery after chemoradiation improved progression-free survival but not overall survival in stage III non-small cell lung cancer.
• An unplanned analysis showed that less extensive surgery (lobectomy versus pneumonectomy) improved overall survival.

Subgroup analysis showed that surgery did improve overall survival when lobectomy was performed, as opposed to pneumonectomy, Kathy Albain, MD, of Loyola University Chicago in Mayfield, Ill., and colleagues reported online in The Lancet.

Taken together, the results indicate that either therapeutic strategy is an option for patients with stage III NSCLC and ipsilateral mediastinal nodal metastases (N2).

“A prospective trial is unlikely to be done to validate the hypothesis generated as a result of our exploratory analysis [of lobectomy],” the authors concluded. “Thus, medically healthy patients with stage IIIA(N2) non-small cell lung cancer should be assessed by a team skilled in multimodality treatment, and treatment options can be considered during assessment.

“On the basis of the findings of our study, patients should be counseled about the risks and potential benefits of definitive chemotherapy plus radiotherapy with and without a surgical resection (preferably by lobectomy).”

Progressive clinical-trial evaluation showed that concurrent chemoradiation improved survival in stage IIIA(N2) NSCLC compared with surgery or radiotherapy alone.

Several pilot studies suggested that surgery after chemoradiation optimized local control. However, the results sparked controversy because long-term survival was higher than expected, the authors said.

Moreover, the studies of trimodal therapy demonstrated substantial toxicity, postoperative morbidity, and mortality.

The studies also were criticized because of patients’ clinical heterogeneity and because the patients seemed unusually healthy compared with the general population of stage III NSCLC.

Two additional phase II studies showed favorable outcomes in stage III NSCLC patients: one employing trimodal therapy and the other chemotherapy, definitive radiation therapy, followed by more chemotherapy (J Clin Oncol 1995; 13(8): 1880-92, J Clin Oncol 2002; 20(16): 3454-60).

On the basis of those two trials, Dr. Albain and colleagues designed a study to compare the two strategies.

Patients with T1-3pN2M0 NSCLC received cisplatin-etoposide chemotherapy plus 45 Gy radiotherapy. In the absence of disease progression, patients were randomized to surgical resection or to continue radiotherapy to a maximum dose of 61 Gy, followed by additional chemotherapy.

The primary endpoint was overall survival.

The authors reported findings on 396 patients. The surgery group had a median overall survival of 23.6 months compared with 22.2 months in the nonsurgical group.

Five-year survival was 27% with surgery and 20% without, a nonsignificant difference. Among patients who had N0 status at thoracotomy, median overall survival was 34.4 months.

Surgical resection was associated with significant improvement in progression-free survival (12.8 months versus 10.5 months, P=0.017). Five-year PFS was 22% with surgery and 11% without.

The most common grade 3-4 toxicities associated with chemotherapy and radiation therapy were neutropenia and esophagitis, which occurred in 38% and 10% of the surgical group and 41% and 23% of the nonsurgical group, respectively.

The surgery group had an 8% treatment-related mortality, compared with 2% in the nonsurgery group. The mortality disparity led the authors to perform an unplanned, exploratory analysis of overall survival by type of surgical procedure.

Overall survival matching analysis was feasible for 90 of 98 lobectomies and 51 of 54 pneumonectomies. Median overall and five-year survival with lobectomy was 33.6 months and 36% versus 21.7 months and 18% without surgery (P=0.002).

Median overall survival did not differ significantly between groups in the comparison of pneumonectomy versus no surgery.

However, the trend was toward better survival without surgery: median overall survival of 29.4 months versus 18.9 months with pneumonectomy. Five-year survival was 22% with pneumonectomy and 24% without surgery.

The results provide “clear arguments in favor of surgery in well-selected subsets of patients,” according to authors of an invited commentary.

“Can we undertake surgery in patients with stage IIIA(N2) NSCLC after induction chemoradiotherapy for now on? Yes, we can — selectively in patients with less extensive resection . . . than pneumonectomy,” Wilfried Eberhardt, MD, Georgios Stamatis, MD, and Martin Stuschke, MD, of University Hospital Essen in Germany, wrote.

“Further data from randomized trials are urgently needed to define the best selection criteria for bimodal or trimodal treatment,” they added.

The authors and the editorialists declared no conflicts of interest.

Primary source: The Lancet

Source reference:

Albain KS, et al “Radiotherapy plus chemotherapy with or without surgical resection for stage III non-small cell lung cancer: a phase III randomized controlled trial” Lancet 2009; DOI:10.1016/S0140-6736(09)60737-6.

Additional source: The Lancet

Source reference:

Eberhardt WEE, et al “Surgery in stage III non-small cell lung cancer” Lancet 2009; DOI:10.1016/S0140-6736(09)61026-6.

Long-term survivors of cancer that developed in adulthood are at increased risk of experiencing serious psychological distress, according to a report in the July 27 issue of Archives of Internal Medicine, one of the JAMA/Archives journals.

The estimated 12 million cancer survivors in the United States represent approximately 4 percent of the population, according to background information in the article. “The number of cancer survivors has steadily increased over the last three decades and is expected to continue to increase with the implementation of improved cancer screening, the adoption of more efficacious cancer treatment and the aging of the population,” the authors write. “As more individuals survive cancer, it is important to understand how cancer and cancer therapies affect long-term quality of life and psychological adjustment.”

Karen E. Hoffman, M.D., M.H.Sc., of Brigham and Women’s Hospital and Dana-Farber Cancer Institute, Boston, and colleagues studied participants in the National Health Interview Survey, a cross-sectional in-person survey conducted annually by the U.S. Census Bureau. Participants in the 2002 to 2006 surveys were asked questions about their history of cancer and assessed using a scale of serious psychological distress. The researchers compared the responses of 4,636 individuals who had survived five years or longer following the diagnosis of an adult-onset cancer with those of 122,220 individuals who had never had cancer.

A total of 5.6 percent of cancer survivors screened positive for severe psychological distress within the previous 30 days, compared with 3 percent of those without cancer. “After adjustment for other clinical and sociodemographic variables, long-term survivors who were younger, were unmarried, had less than a high school education, were uninsured, had more comorbidities or had difficulty performing instrumental activities of daily living were more likely to experience serious psychological distress,” the authors write.

A history of cancer may affect current mental health in several ways, the authors note. “Cancer diagnosis and treatment can produce delayed detrimental effects on physical health and functioning such as secondary cancers, cardiac dysfunction, lung dysfunction, infertility, neurological complications and neurocognitive dysfunction,” they write. “A cancer history can also affect social adaptation, employment opportunities and insurance coverage. Adjusting to these functional and life limitations may create long-term psychological stress.”

A total of 9 percent of long-term cancer survivors and 6 percent of individuals without cancer reported seeing or talking to a mental health professional within the previous 12 months. One-third of survivors with serious psychological distress reported using mental health services, whereas 18 percent said they could not afford mental health care during the previous year.

“Because long-term survivors may not be seen by oncologists as frequently as they were during treatment, or at all, the increased risk of serious psychological distress and the need to screen for serious psychological distress should be communicated to primary care physicians and other care providers,” the authors conclude. “Given that cancer survivors with more chronic medical conditions tended to be those most at risk for psychological distress in this study, the findings also underscore the need to integrate medical and behavioral health care for survivors. Specifically, cancer survivorship clinics may benefit from having mental health providers on staff for a multidisciplinary approach to the care of these patients.”

Arch Intern Med. 2009;169[14]:1274-1281.

Source
Archives of Internal Medicine