Abstracts of the 7th World Congress of Psycho

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PSYCHO-ONCOLOGY

Psycho-Oncology 13: S1–S233 (2004)

PAPER ABSTRACTS

ABSTRACTS OF THE 7TH WORLD CONGRESS OF PSYCHO-ONCOLOGY

Advocacy 1 Knowledges and Believes about Prevention and Cure of Cancer Estap!e T1, Estap!e J2, Martin D3 1 Psychooncology, FEFOC Barcelona, Spain; 2Medical Director, FEFOC, Barcelona, Spain; 3Graphic Designer, FEFOC, Barcelona, Spain PURPOSE: To ascertain knowledge on the European Code Against Cancer (ECA) and believes on cancer cure. METHODS: 1200 individuals were randomly selected equally distributed by sex among our database. It contains 3200 subscribed persons interested on receiving information about our non-profit foundation devoted to cancer education and support. They were approached by mail by a questionnaire on the ECA. We also provide an envelop and free post to send it back. RESULTS: 601 individuals answered our questionnaire. Among them, only 9.6% (55) know the ECA. 160 have or have had cancer. They do know the ECA in a superior percentage (11.61%) than among those who have not had the illness (8.92%), but these differences are not significant. Women are better informed than men (p50.009). Mean age of those who know ECA is 49 years old not statistically significant (over mean of those who do not know the ECA (52). Among the 55 who do know the ECA the three recommendations more cited were ‘maintain a healthy diet’ (78.2%) ‘do not smoke’ (76.5%), ‘do not abuse of alcohol consumption’ (60%). The three recommendations of the ECA more followed were Copyright # 2004 John Wiley & Sons, Ltd.

‘taking fruit and vegetables’ (67.3%), ‘not smoking’ (67.3%) and ‘take alcohol in a moderate level’ (50.9%). About factors that facilitate cure of cancer the more frequently answered by the 601 individuals were an early diagnosis (92.7%), a positive attitude towards cancer (54.5%) stage at the diagnosis (49.1%). Treatment was the fourth factor more cited.

2 WHO Policy Goals & Psycho-Oncology}Role of Community Based Organisations Pramod S, Narayanan R Health Alert Organisation of India, Dhule, India ISSUES: Use of psycho-oncology is rate-limiting step for intervention in Tobacco-Induced cancers. Policy planners need to increase awareness about WHO Policy Goals in Tobacco Free World? Especially to NGO community. POLICY ISSUES: We need internationally agreed-upon benchmarks agreed to by leaders. There are eight central goals that cover wide-ranging objectives which address health, poverty, environment, education, gender equality and development. Each goal has specific targets and indicated benchmarks. Overall goal is to achieve vast majority of these objectives by 2015. WHO approved projects seeking to devise and recommend best globally coordinated but locally specific operational strategies for achieving objectives. Strategies will focus on how to implement policy, scientific, and financial priorities. DEVELOPING NEW METHODOLOGIES: Evaluators need to focus on How does

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WHO/UN Projects relate to country specific objectives/strategies? We should begin public process of making available preliminary international reports for comments by policymakers, economists, and others interested in project. NGO workers constantly face questions like What are most promising trends in addressing issue of tobacco use? INTERNATIONAL WILL: New political commitment and leadership to fight the epidemic in many nations combating HIV/AIDS presents great hope. This will present enormous opportunities for tobacco addiction to be seriously curtailed in future. We need to standardise policy matters in developmental stages. How it applies differently to developed & developing nations. Our module will be very useful to the Helsinki Conference participants back in their home country. RECOMMENDATIONS: NGO community needs to be united to combat powerful tobacco lobby.

Aetiology 3 Vital Exhaustion and Risk of Cancer}A Prospective Study Bergelt C1, Prescott E2, Grnbæk M3, Koch U4, Johansen C1 1 Department of Psychosocial Cancer Research, Danish Cancer Society, Copenhagen, Denmark; 2 Department of Cardiology, Rigshospitalet Copenhagen, Denmark; 3Centre for Alcohol Research, National Institute of Public Health, Copenhagen Denmark; 4Institute of Medical Psychology, University Clinic Hamburg, Hamburg, Germany BACKGROUND: Stress and depression have been associated with the subsequent onset of cancer in both the scientific community and the lay public. Vital exhaustion is defined by feelings of depression and fatigue and was so far mainly investigated as a risk factors for cardiovascular disease. METHODS: The sample consists of 8527 subjects (55% female, 45% male) aged 21–94, examined in 1991–1994 in the Copenhagen City Heart Study. For the analysis the sample was divided into quartiles with regard to vital exhaustion scores (measured by a 17-item questionnaire). Cancer cases were ascertained through linkage to

Copyright # 2004 John Wiley & Sons, Ltd.

the Danish Cancer Registry, cases before date of entry were excluded. A total of 976 subjects (11.45%) were diagnosed with cancer during follow-up. RESULTS: Study participants have a significantly decreased risk of developing cancer compared to the population (SIR 0.79, 95% CI 0.75–0.83). Regression analyses (Cox model) showed that subjects with the highest exhaustion scores have a significantly decreased risk of developing cancer compared to other categories of exhaustion (HR 0.80; 95% CI 0.67–0.97), but also have a higher all cause mortality (HR 1.47, 95% CI 1.28–1.68). DISCUSSION: The results clearly do not support the hypothesis, that vital exhaustion is a risk factor for developing cancer. Differences between study sample and population may be one explanation for the results.

4 Major Life Event}A Diagnosis of Schizophrenia in Offspring and Risk for Cancer Dalton SO1, Laursen TM2, Mortensen PB3, Johansen C4 1 Institute of Cancer Epidemiology, Danish Cancer Society Copenhagen, Denmark; 2National Centre for Register-based Research, Aarhus University, Aarhus, Denmark; 3National Center for Registerbased Research, Aarhus University, Aarhus Denmark; 4Institute of Cancer Epidemiology, Danish Cancer Society, Copenhagen, Denmark PURPOSE: To investigate the effect of the diagnosis of schizophrenia in a son or daughter as an indicator of psychological stress on subsequent cancer risk. METHODS: Using data from the Danish Central Population Registry we identified all 1,999,072 parents to offspring born after 1935. By linking this nation-wide populationbased parent cohort to the Danish Psychiatric Central Register we identified 19,856 parents to offspring with schizophrenia. Follow-up for cancer began on April 1 1969 or the day the offspring turned 15 years and ended on the date of a cancer diagnosis, death or December 31, 1997, yielding a total of 48,343,429 person-years and 105,347 cancer cases. Parents were classified as exposed from the date of schizophrenia in the offspring. The relative risk for cancer among parents who experienced a schizophrenia diagnosis in offspring

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relative to parents with non-schizophrenic offspring was estimated by Poisson regression, separate by sex and adjusted for age, calendar period, and number of children. RESULTS: The risk for overall cancer among parents whose offspring were diagnosed with schizophrenia was not increased; however a 30% increased risk for lung cancer was observed in mothers (95% confidence interval, 1.03–1.61). There was no excess risk for any other cancer form a priori hypothesized to be associated with psychological stress in either mothers or fathers. CONCLUSION: This analysis provides no support for a direct effect of psychological stress in cancer causation, but indicates an effect mediated by life style factors, i.e. smoking.

interval, 1.03–1.07). The risk of cancer was increased for the first year after hospital admission, with brain cancer especially occurring more frequently than expected. When cancers diagnosed in the first year after admission were excluded the increase was mainly attributable to an increase in risk for smoking-related cancers: Standardized incidence ratios for non-smoking-related cancers were 1.00 (95% CI, 0.97–1.03) after 1–9 years of follow-up and 0.99 (95% CI, 0.95–1.02) after 10 or more years of follow-up. CONCLUSION: This study provides no support to the hypothesis that depression independently increases the risk for cancer but underlines the unfortunate effect that depression can have on lifestyle factors.

6 5 Depression and Cancer Risk: A Register-Based Study of Patients Hospitalized with Affective Disorders in Denmark, 1969–1993 Dalton SO1, Mellemkjær L2, Olsen JH3, Mortensen PB4, Johansen C5 1 Institute of Cancer Epidemiology, Danish Cancer Society, Copenhagen, Denmark; 2Institute of Cancer Epidemiology, Danish Cancer Society, Copen3 Institute of Cancer hagen, Denmark; Epidemiology, Danish Cancer Society, Copenhagen, Denmark; 4National Center for Register-based Research, Aarhus University, Aarhus, Denmark; 5 Institute of Cancer Epidemiology, Danish Cancer Society, Copenhagen, Denmark PURPOSE: Depression is widely believed to cause cancer, but the epidemiological evidence is inconsistent. We investigated the cancer risk in patients hospitalised with depression in a nationwide Danish cohort study. METHODS: All 89,491 adults in Denmark admitted to hospital for depression, as defined by ICD-8, between 1969 and 1993 were identified, accruing a total of 1,117,006 person-years of follow-up. Incidence rates of all cancers and of site-specific cancers were compared with national incidence rates for first primary cancers, with data being adjusted for sex, age, and calendar-time. RESULTS: A total of 9922 cases of cancer were diagnosed in the cohort, with 9434.6 expected, yielding a standardized incidence rate ratio of 1.05 (95% confidence

Copyright # 2004 John Wiley & Sons, Ltd.

Personality Traits, Health Behavior, and Risk for Cancer: A Prospective Study of a Swedish Twin Cohort Hansen PE1, Johansen C1, Floderus B2 1 Department of Psychosocial Cancer Research, Institute of Cancer Epidemiology, Danish Cancer Society, Copenhagen, Denmark; 2Institute of Environmental Medicine, Karolinska Institutet Stockholm, Sweden BACKGROUND: Many people believe that certain personality traits may involve an increased risk for cancer. We prospectively investigated the relationship between personality traits and risk for cancer. METHOD: Our study cohort consisted of 29,595 Swedish twins from the national Swedish Twin Registry who at time of entry were between 15 and 48 years old. In 1973, the twins completed a questionnaire including information on personality traits and health behavior. Personality traits were assessed using the short version of the Eysenck Personality Inventory (EPI-Q), which involves neuroticism and extroversion as two personality dimensions. Proportional hazard models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI) for extroversion and neuroticism separately and for their joint effect while adjusting for several health behavior factors. Analyses were conducted within five aetiology-based cancer groups (hormone related organs, virus and immune related malignancies, digestive organs (excluding liver), respiratory

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organs, other sites, and all sites). We furthermore used a conditional logistic regression analysis to estimate the relationship between personality traits and risk for cancer within twin pairs discordant for cancer. RESULTS: Through follow-up in the Swedish Cancer Registry between 1974 and 1999, we identified a total of 1,898 cancer incidents. We did not find any significant associations between neuroticism or extroversion and risk for any cancer group. CONCLUSION: The results from our study do not support the hypothesis that personality traits are associated with cancer risk.

7 Effects of Widowhood and Divorce on Risk of Cancer: A Populational Cohort Study Jacobsen R, Johansen C Psychosocial Cancer Research, Danish Cancer Society Copenhagen, Denmark BACKGROUND: Increased divorce rates have been reported in many Western countries during the last decades and divorce and widowhood have been suggested as possible stressful life events. These two stressful life events have previously been related to an increased or decreased risk of cancer. Here we examine the risk for developing cancer among divorced and widowers for the total population of Denmark, to approach the hypothesis that divorce or widowhood are stressful life events which may led to coping strategies of unhealthy life style and thereby increased risk of cancer. METHODS: The study population comprised all married persons in Denmark in 1968– 1969. Covariates in the analysis were marital status, deaths, immigration and emigration. Outcome measures were total cancer rates and cause specific cancer rates. RESULTS: There was a significant higher risk of developing a cancer among divorced persons (adjusted rate ratio: 1.3, CI 95%: 1.28–1.33), when compared to a married person, not previously divorced. Widowers had no statistically robust increased or decreased risk for developing cancer compared to the reference group (adjusted rate ratio: 0.99, CI 95%: 0.98– 1.00). The increased adjusted relative risk for divorced persons on developing all cancers, were mostly due to cancers associated with certain life

Copyright # 2004 John Wiley & Sons, Ltd.

style factors. CONCLUSION: In this cohort study based on the total Danish population, we showed that increased cancer rates and a previous divorce were associated and suggest that this have to do with a change in life style as a coping strategy on this possible stressful life event.

8 Personality and the Risk of Cancer Nakaya N1, Tsubono Y1, Hosokawa T2, Fukudo S3, Tsuji I1 et al. 1 Public Health and Forensic Medicine, Tohoku University, Sendai, Japan; 2Human Development Disability, Tohoku University, Sendai, Japan; 3 Behavioral Medicine, Tohoku University, Sendai, Japan PURPOSE: The role of personality in the causation of cancer has been controversial. METHODS: From June through August 1990, 30,277 residents of Miyagi Prefecture in northern Japan completed the Japanese version of the short-form Eysenck Personality Questionnaire-Revised and another questionnaire on various health habits. During 7 years of follow-up until December 1997, we identified 986 incident cases of cancer. We used Cox regression to estimate the relative risk of total cancer according to the four levels of four personality subscales (extraversion, neuroticism, psychoticism, and lie), with adjustment for sex, age, education, smoking, drinking, body mass index, and family history of cancer. RESULTS: Multivariate relative risks for the highest versus the lowest level of personality subscales were 0.9 for extraversion (95 percent confidence interval, 0.7–1.1; trend P=0.32), 1.1 for psychoticism (95 percent confidence interval, 0.9–1.3; trend P=0.96), 0.9 for lie (95 percent confidence interval, 0.7–1.0; trend P=0.19), and 1.2 for neuroticism (95 percent confidence interval, 1.0–1.4; trend P=0.06). Although neuroticism showed significant, positive, linear associations with 671 cancer cases prevalent at baseline (trend P50.001) and with 320 cases diagnosed within the first three years of follow-up (trend P=0.03), it showed no association with 666 cases diagnosed during the fourth through the seventh years of follow-up (trend P=0.43). CONCLUSIONS: This prospective study does not support hypothesis that

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personality is a risk factor for cancer incidence. The association between neuroticism and prevalent cases of cancer seems to be a consequence, rather than a cause, of the diagnosis or symptoms of cancer.

factors may be determined by personality, which, in turn may, determine the risk for cancer.

10 9 Personality Traits and Cancer}Theories, Results And Discussion Schapiro IR1, Nielsen LF2, Jrgensen T2, Boesen EH1, Johansen C1 1 Institute of Cancer Epidemiology, The Danish Cancer Society, Copenhagen, Denmark; 2Centre for Preventive Medicine, Glostrup University Hospital, Glostrup, Denmark PURPOSE: The definition of a cancer-prone personality as defined by Kissen and Eysenck in 1962 was not confirmed in a recent prospectively designed investigation. This study was designed to estimate the incidence of cancer in a random sample of persons in the general Danish population in relation to a personality characteristic measured by the Test of Psychic Vulnerability given that Psychic vulnerability has been associated with a number of physical symptoms and diseases. METHODS: We examined the cancer incidence in a cohort of 5136 randomly sampled persons living in Copenhagen County, Denmark. The responses to questionnaires and the results of examinations including the Test of Psychic Vulnerability were collected in 1982–1984 and 1991– 1992. The observed numbers of cancers were compared with those expected had the cohort members experienced the same risk of cancer as the population of Copenhagen County. Regression analyses were performed with the Cox proportional hazards model to adjust for wellknown risk factors for cancer. RESULTS: A total of 403 cancers were observed and 412.02 were expected, yielding a standardized incidence ratio (SIR) of 0.98 (95% confidence interval [CI]=0.88, 1.19). The risk for cancer was not influenced by type of vulnerability in a multivariate analysis (hazards ratio=1.16; 95% CI=0.85, 1.57). CONCLUSION: We found no increased risk for cancer among psychically vulnerable persons when compared with non-vulnerable persons; however, our results indicate that behavior and certain life-style

Copyright # 2004 John Wiley & Sons, Ltd.

Negative Life Events and Breast Cancer Diagnosis }A Semiprospective Study Zachariae R1, Jensen AB1, Lehbrink M2, Christensen S1, Lassesen B1 1 Oncology Aarhus University Hospital, Aarhus Denmark; 2Radiology, Aarhus University Hospital, Aarhus, Denmark PURPOSE: to investigate the association between reported negative life events and breast cancer diagnosis. METHODS: A total of 804 women referred to mammography and classified as belonging to a high (N=288), medium (N=358), and low risk group (N=158) completed the List of Recent Events (LRE) 1–2 weeks before the mammography. Other measures included demographic and psychosocial variables. RESULTS: A total of 71 women were later diagnosed with primary breast cancer. Prior to diagnosis, women with cancer reported significantly fewer life-events during the previous 12 months (Mean=3.2; SD=3.0) compared to healthy women (4.5;4.2) (p50.01). When comparing negative and neutral/positive events, only negative life-events differed significantly (1.3;1.8 and 2.1;2.6; p50.01). When controlling for age, marital status, children, education, risk group, perceived risk, family history of breast cancer and other cancers, number of neutral or positive life events, defensiveness, intrusion, avoidance, and distress with a multiple, logistic regression, having breast cancer continued to be significantly associated with fewer reported negative life events (B= 0.23; p50.05; Odds Ratio: 0.79; CI (95%): 0.63–0.99). Older age and belonging to the highrisk group were the only other factors significantly (p50.05) associated with cancer diagnosis. CONCLUSIONS: Contrary to the results of previous retrospective studies, showing that cancer patients report more negative life-events than controls, and prospective studies, which have found no association, cancer patients in our study reported fewer negative life events than healthy women, further questioning the hypothesis that life-events are associated with cancer.

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Art/Creative Therapy 11 Dealing with Death in Art Therapy with Cancer Patients Luzzatto P Psychiatry MSKCC New York, NY, USA In this paper I am reporting on how cancer patients at Memorial Sloan-Kettering Cancer Centre have been able to express freely their state of mind about death and dying during a variety of art therapy interventions. Through a content analysis of the images made by about sixty patients, between 1996 and 2002, seven categories have emerged. We have defined the seven categories in the following ways: (1) The Unthinkable; (2) Dreams; (3) Fantasies; (4) Memories: death of a loved one; (5) Awareness of one’s mortality; (6) Death and Spirituality; Death and Negativity. Images were made during three types of interventions: (a) The Open Studio, where patients work on their own, supported by the group environment; (b) The Art Therapy Workshop, where patients join and leave the group at the same time, and relate to each other, adding verbal explanations and reflections to their image-making; (c) The Individual Art Therapy Session, which is more similar to Individual Psychotherapy. Images about death were always made freely and spontaneously, and not in response to a theme about Death, which in fact was never given to the patients, following the art therapist’s awareness that not all patients wish to move into that area.

12 ‘‘Playing with Colour for Cancer Patients’’}A Project Regarding Health and Art Hauken MAa1, Meland GT2, Heradstveit S3 1 Freelancer, The Norwegian Cancer Society, Bergen, Norway; 2Freelancer - painter, The Norwegian Cancer Society, Bergen, Norway,3 BACKGROUND: People can communicate through and be inspired by using different types of art. We initiated the project: ‘‘Playing with colour for cancer patients’’. It is a co-operation between The Norwegian Cancer Society and the

Copyright # 2004 John Wiley & Sons, Ltd.

society of art and artists in Bergen, Norway. AIMS: – Participants, through art and specifically painting, will be stimulated to use their own resources in a difficult phase. – Participants can meet others living in similar circumstances. – To give a break from the focus on disease and treatment, and offer a positive experience associated with coping. METHOD: Courses are arranged once a week over a period of 8 weeks with 9–15 participants. Sessions lasts for two hours. A professional artist teaches. PARTICIPANTS: People living with cancer. Since the autumn 1999 we have arranged ten courses for approximately 130 participants. RESULTS: Participants evaluated the practical arrangement, the content and the presentation of the topics in each session from very good to excellent. They found painting as highly relevant and useful during this difficult period of their lives. They learned new skills, experienced coping and positive feelings. They emphasised the importance of meeting others living in similar circumstances. CONCLUSION: Aims fulfilled. Use of art regarding people living with a serious disease is effective. The project will now be extended using different types of art regarding cancer patients.

13 Creative Activity in Palliative Care: Ways of Creating Connections to Everyday Life la Cour K1,2,3, Josephsson S1,2, Luborsky M4 1 Occupational Therapy, CVU-South, School of Occupational and Physical Therapy, Næstved, Denmark; 2Occupational Therapy, Karolinska Institute, Stockholm, Sweden; 3Research & Development, Palliative Care Stockholms Hospital & Nursing Home Foundation, Stockholm, Sweden; 4Gerontology, Wayne State University Detroit, MI, USA OBJECTIVE: The purpose of this study was to characterise experiences of engaging in creative activity in palliative occupational therapy from the perspective of therapist and elderly people. METHOD: Qualitative interviews were conducted with 15 participants. 8 clients and 7 therapists were recruited over a six-month period from a nursing home with palliative care in Sweden that follows an explicit philosophy to support the use of cultural and creative therapy modalities in their

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ABSTRACTS OF THE 7TH WORLD CONGRESS OF PSYCHO-ONCOLOGY ART/CREATIVE THERAPY

services. Seven of the clients had incurable cancer and one was a survivor of stroke. The activities included woodworking, pottery, painting, soap casting, knitting and gardening. They were offered both in-group and on an individual basis. Analysis of the interviews was conducted using a constant comparative method. RESULTS: The results suggest that engagement in creative activity can enable clients in creating connections to daily life out side the nursing home and extend the experience of self as an active person, while dealing with uncertain features of life-threatening illness. Creating connections to life was depicted as the core category, carried out in reference to three subcategories. 1. A generous receptive environment identified as the foundation for engaging in creative activity, 2. Unfolding creations as an evolving process, 3. Reaching beyond for possible future and alternative meaning horizons. Positive benefits were expressed as experiences of joy, forgetting illness, gaining energy and experiences of competence and hope among others. CONCLUSION: The results support the importance of having access to creative therapy modalities as part of good palliative care.

14 Transformations in Science and Art: White work}a Gentle Path Wyllie D, Hagan OC Cancer Research, UK Drug DNA Interactions Group, University College London, London, UK INTRODUCTION: This one day creative arts workshop is designed to introduce artists Denise Wyllie and Clare O Hagan and their work ‘‘Transformations in Science and Art’’. This monumental cross media artwork, an outcome of their collaboration with Professor John Hartley, Director of Cancer Studies, UCL, London, marked the beginnings of a creative journey through the cancer process: encompassing research, care and psychosocial issues. Whitework }A gentle path. This work accompanies the highly embellished artwork Transformations in Science and Art. Whitework}a technique using only white on white materials, is designed to focus attention and intention on a small tangible quiet space. It is designed to give people who are

Copyright # 2004 John Wiley & Sons, Ltd.

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touched by cancer an opportunity to experience the making of a place of calm, in the middle of intense activity. AIMS OF THE WORKSHOP: Whitework}a gentle path. The workshop aims to provide attendees the opportunity to describe an experience of cancer, nonverbally. METHODS: A 20 min documentary film on the making of the work, starts the workshop, followed by visual presentation of sample whitework. A description of creative art processes and techniques will be followed by practical work. The philosophy of the work will be described throughout the workshop, and participants will learn of the response to work to date. A discussion involving workshop participants will follow. OUTCOMES: Workshop participants will make a small two dimensional artwork, illustrating an innovative response to an experience of the cancer.

15 Drawings, the Universal Language of Children. The Experience within a Pediatric Hematology and Oncology Unit Zarri DA1, Massimo LM2 1 Pediatric Hematology and Oncology, G. Gaslini Children’s Hospital, Genova, Italy; 2Pediatric Hematology and Oncology, G. Gaslini, Children’s Hospital, Genova, Italy Inside a Hospital a child in troublesome situations is always a foreigner with regards to the uneasiness that accompanies his/her experience, and does not receive suitable answers from verbal and body language. Children have easier access to drawings since it is a habit they cultivate, and because this activity satisfies their natural need to communicate with themselves and with others. When in hospital, the child is afraid, embarrassed in front of strangers and of parents, especially when they are in touch with physicians. His/her need for truth and for communication unfolds through artistic expression, basis of art therapy. The opportunity to express themselves through their drawings is what makes the ill child his/her own therapeutic agent through a self healing mechanism. We have studied the analogies grasped through the drawings of Italian and foreign patients, analogies that overcome linguistic barriers. Drawings by both Italian and immigrant

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children allowed them to depict their present and future relationship with the disease, with the Hospital, and with the environment in general. Their pictures reflected not only their current state of mind, but also past experiences and future prospects. Art therapy proved to be a vitally important means of communication. The collection and evaluation of drawings, in an attempt to establish the intellectual, cultural, and emotional status of each child, thus becomes of paramount importance. To this end, play-workers have been trained to carefully observe immigrant children while they draw. Such extremely important collaboration prevents the loss of relevant and vital details.

Children 16 Assessing a Booklet for 10–16 Year Old Cancer Survivors: Comparing the Views of Survivors and Parents Absolom K1, Eiser C1, Griffiths A2 1 Psychology University of Sheffield, Sheffield, UK; 2 Oncology/Haematology, Birmingham Children’s Hospital, Birmingham, UK PURPOSE: To compare the views of survivors and parents toward a booklet designed to improve cancer related knowledge and health care behaviours. METHODS: At a routine follow-up clinic 36 survivors and 33 parents completed a questionnaire after reading a sample page from the booklet (Time 1). Ratings of importance, ‘scariness’ and usefulness of the information, the need for further cancer related information and the importance of health behaviours relevant to cancer survivors were measured. The participants were given the booklet and a second similar questionnaire to complete at home (Time 2). Fifteen survivor and 17 parents completed the Time 2 questionnaire. RESULTS: Survivors reported learning more from the booklet than their parents thought they would (p50.05). Parents of sons reported encouraging their child to see the doctor alone more and also rated the importance of the booklet more highly than those of daughters (p50.05). Female survivors rated the booklet as significantly more ‘scary’ for themselves than the

Copyright # 2004 John Wiley & Sons, Ltd.

males (p50.05). CONCLUSIONS: Parents expected their child to have learnt less from the booklet than they did. This may be because the booklet contains simple information that parents expected their children to already know. This finding along with the gender differences are discussed in relation to recommendations for medical teams dealing with the long term followup care of these young patients.

17 When Cancer Becomes Psychic Trauma in Child Patients Albasi C2,4, Gelli P3,4, Clerici CA1,4, Ferrari A1, Odero S4 1 Unita" Operativa Pediatria Istituto Nazionele per lo Studio e la Cura dei Tumori Milan, Italy; 2Department of Psychology, University of Turin, Turin, Italy; 3Unita" Operativa Neuropsichiatria Infantile Ospedale Niguarda Milan, Italy; 4Gruppo di Ricerca in Psicologia Clinica dello Sviluppo nelle Patologie Pediatriche Milan, Italy Survival of patients treated for cancer in the age of development has significantly grown in the last few years thanks to advances in medical treatment. In the treatment process this fact must be carefully considered and it is necessary to define models, theories and intervention techniques on these patients’ psychic discomfort. Since a few years the concept of psychic trauma has undergone an important re-examination and represents a field of common interest for both empirical research and clinical practice, in the psychiatric, psychological and psychoanalytical domains. The aim of this contribution is to suggest an understanding of the oncologic disease in terms of psychic trauma, through a revision of the literature and by the light of clinical experience; specific psychological interventional techniques that can be enacted during and after treatment are described. An objective event holding an enormous impact on patients’ life, such as cancer, acquires subjective meanings within the child’s relationship system. Cancer disease implies a real trauma (in the descriptive and objective sense of the event) and concerns a complex set of factors that acquire a

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sense in the organisation of psychic life: integrity (representation of one’s own body limited by boundaries), pain (modulation of somatic suffering), identity (conceived as social role), changes in the relations with caregivers. Real trauma becomes psychic, depending on how these variables are organised in the child’s subjectivity, as psychic functions are articulated in the involved relational contexts. The implication of this model opens important possibilities of psychological intervention in oncology.

18 Peculiarities of Sexual Identity of Teenagers with Oncopathology Aralova MP1, Aslanyan KS2, Yershova MP3, Tseytlin GY4 1 Clinical Psychology, Rostov State University Rostov-on-Don Russia; 2Head of Ambulance of Oncohaematological Centre, Regional Child Hospital, Rostov-on-Don, Russia; 3Psychology Don Pedagogical College Rostov-on-Don, Russia; 4Head of rehabilitation Department Research Institute of Children’s Oncology and Haematology of Russian oncological Scientific Centre of Russian Medical Academy, Moscow, Russia PURPOSE: The study of sexual identity of teenagers having oncopathologies with various remission periods in comparison with their healthy coevals: traits of sexual stereotypes (cognitive level of sexual identity) and peculiarities of their attitude to images of femininity and masculinity (emotional level). PROBATIONERS: 144 teenagers, 15–17 years old: two groups of 72 people} Main group (which was subdivided according to remission period) and Test group. METHODS: Modified system ‘‘Semantic Differential’’ by Ch. Osgood: 7-grades scale evaluation of notions ‘‘majority of men’’, ‘‘majority of women’’; Relationship Colour Test: ranging of 8 coloured cards from standard Lusher test set according to the degree of proximity to categories ‘‘majority of men’’ (MM), ‘‘majority of women’’ (MW); factor analysis. RESULTS/CONCLUSIONS: Probationers with oncopathology have somewhat onesided structure of femininity-masculinity stereotypes: femininity stereotype is presented only by

Copyright # 2004 John Wiley & Sons, Ltd.

emotional-communicative traits while masculinity stereotype by instrumental–professional qualities. Structure of the major factors of sexual identity of healthy probationers tends to sexual-role democratization (androgenization) and cooperation psychology arising from it. In Main group emotional preferences related to sexual affiliation (emotional level of sexual identity) are less different than those in Test group. The longer remission period is (in the group with remission period over 10 years) the more sexual preferences coincide with those of healthy coevals. In the test group the other sex is considered to be emotionally attractive. Research results testified that teenagers with oncopathology (in comparison with their healthy coevals) lack ability of integral perception and of emotional attitude toward people according to their sex.

19 The Study of ‘‘Self-Image’’ of Teenagers with Oncological Diseases Aralova MP1, Aslanyan KS2, Yershova MP3, Tseytlin GY4 1 Clinical Psychology, Rostov State University, Rostov-on-Don Russia; 2Head of Ambulance Onco-hematological Center of Rostov Regional children?s Hospital, Rostov-on-Don, Russia; 3Psychology Don Pedagogical College Rostov-on-Don, Russia; 4Head of the rehabilitation Department Research institute of children?s oncology and Hematology of Russian Oncological Scientific Centre of Russian Academy of Medical Science, Moscow, Russia PURPOSE: Study of ‘‘Self-image’’ of teenagers having oncopathologies with various remission periods in comparison with their healthy coevals. PROBATIONERS: 144 teenagers, 15–17 years old: two groups of 72 people}Main group (which was subdivided according to remission period}2– 15 years) and Test group. METHODS: Modified system ‘‘Semantic Differential’’ by Ch.Osgood: 7grades scale evaluation of notions ‘‘Self’’, ‘‘Ideal Self’’; factor analysis. RESULTS AND CONCLUSIONS: Probationers with oncopathology have Self image presented by emotional traits while their healthy coevals}by business-communicational ones. Conscious Self-image of teenagers

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with oncopathology is exclusively positive; whereas their healthy coevals have age-related negation of Self-image, striving for self-affirmation. Self-images of girls with oncopathology and healthy ones are more alike than of boys. Young men with oncopathology have sharp discrepancy of Self and Ideal Self, which indicates a rather high degree of their inner self-dissatisfaction. The longer remission period is, the less is inner tension as well as the discrepancy between Self and Ideal Self, though even if remission is long, young men still consider themselves to be less sociable and relaxed than their healthy coevals. Probationers with oncopathology in a 2–5 year remission have deficiently developed volitional personality qualities (judging from self-appraisal); so, they lack selfcontrol and self-dependence. Probationers with oncopathology in a 5–10 year remission have a more contradictory Self-image, it’s displayed in negation of self image and is natural for maturation process. In this period communicative qualities are actively formed. Self-dependence becomes apparent only if the remission period is over 5–10 years.

20 Study of Teenagers with Oncopathology in Remission and their Reactions in Frustrating Situations Aralova MP1, Aslanyan KS2, Yershova MP3, Tseytlin GY4 1 Clinical Psychology, Rostov State University, Rostov-on-Don Russia; 2head of Ambulance Oncohematological Center of Rostov Regional children’s Hospital, Rostov-on-Don Russia; 3Psychology Don Pedagogical College, Rostov-on-Don, Russia; 4 Head of the Rehabilitation Department Research institute of children’s Oncology and Hematology of RussianOncological Scientific Centre of Russian Academy of Medical Science, Moscow, Russia PURPOSE: To study peculiarities of emotional and behavioral reactions for frustrating situations of teenagers with oncopathology. PROBATIONERS: 144 teenagers, 15–17 years old: two groups of 72 people}the main group (which was subdivided according to remission period) and the test group. METHODS: Rosenzweig Picture Frustration Study, methods of mathematical statistics. RESULTS AND CONCLUSIONS:

Copyright # 2004 John Wiley & Sons, Ltd.

Teenagers with oncopathology in remission in comparison with their healthy coevals demonstrate fewer impunitive reactions (the differences are statistically significant) indicating that difficulties of the frustrating situation are either ignored of reduced to minimum; they more often display extrapunitive reactions of obstacle-dominating type (the differences are statistically significant) which point at tendency to excessive fixation on unpleasant feelings, embarrassment, perplexity as an appeal to their associates to notice their problems. Probationers with oncopathology have more intropunitive reactions of self-defensive type (the differences are statistically significant)– i.e. self-accusation reactions and more often such reactions are displayed by boys. Teenagers with oncopathology with 5–10 year remission period have stronger tendency to view the frustrating situation as an unimportant one. So, the probationers with oncopathology in comparison with their healthy coevals feel stronger impact of other people onto their behaviour; are more concentrated on their ‘‘self’’ protection; more often they show tendency to fix on negative feelings. In frustrating situations teenagers with oncopathology in comparison with their healthy coevals have greater obstacle idea and less ability to adequately solve difficult situations.

21 Social Skills in Survivors of Pediatric Brain Tumours: Cognitive Functioning, Physical Appearance, and Depression as Contributing Factors Barrera ME, Fleming CF, Spiegler BJ Haematology/Oncology Program, Department of Psychology, The Hospital for Sick Children Toronto, Canada PURPOSE: Survivors of childhood brain tumours are at risk for several adverse late effects including social isolation. This study examined factors contributing to the development of social skills in these survivors. Socio-economic status (SES), treatment (radiation/no radiation), time since diagnosis, cognitive functioning (IQ), self-perception of physical appearance, and depressive symptoms were investigated as potential predictors. METHODS: Fifty-eight survivors of childhood brain tumours (two years post diagnosis and

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in stable condition), aged 8 to 19 years (M=13.7 years) participated. Children completed standardized measures of social skills, depressive symptoms, self-perception, and IQ. Parents completed a standardized measure of social skills and provided demographic information. Teachers completed the teacher form of the social skills measure. Hierarchical multiple regression analyses were used to test for predictors of social skills. RESULTS: SES, Verbal IQ, perception of physical appearance, and depressive symptoms were significant predictors of social skills as reported by the child (R2=0.452, p=0.000) and the parent (R2=0.329, p=0.002), but not the teacher (R2=0.133, p=0.068). Social skills (M (child report)=102.84; M (parent report)=98.70; M (teacher report) =98.68), depression scores (M=49.59), perception of physical appearance (M=2.71), and Verbal IQ (M=100.97) did not differ significantly from population norms (p50.05). CONCLUSIONS: These results suggest that adequate SES and cognitive functioning, few depressive symptoms, and high self-perception of physical appearance play an important role in the social skills of survivors of childhood brain tumors.

22 Stranger in the Community: Life After Cancer in Childhood Drew S Centre for the Study of Health and Society, University of Melbourne, Melbourne, Australia While disease onset and curative treatment occurs early in life for survivors of childhood malignancy, individuals may experience consequences of disease and treatment that extend well into adulthood. Serious consideration must therefore be given to long-term effects of cancer on survivors’ lives. In spite of the developing influence of psycho-oncology, a continued focus on issues of treatment and physical cure means biomedicine fails to recognise adequately the transformative potential of cancer as a social experience. This paper explores lived experiences of survivorship, in order to develop a broader answer to the question ‘How does a history of cancer in childhood influence social and personal well-being in young adulthood?’ A multidisciplinary, social

Copyright # 2004 John Wiley & Sons, Ltd.

science approach is employed. Data consists of 55 qualitative questionnaires and 32 in-depth interviews with young adults, analysed through a combination of grounded theory and narrative analysis. Instead of bringing return and restoration to a former way of being-in-the-world, cancer survival is better understood as foreshadowing the beginning of almost a whole new life. While good health and many regular aspects of social interactions might characterise that life, survivors nevertheless occupy a fundamentally changed personal and social identity which will, to varying degrees, have a life-long effect on their personal well-being and the nature of their participation in social living, particularly in the areas of education, employment and intimate relationships. The social and personal legacy of cancer experienced in childhood must be acknowledged more fully, before service provision can adequately supply the resources and support required by adult survivors.

23 Theory and Technique of the Clinical Psychological Consultation in Hospital with Parents whose Children are Affected by Chronic Illness; Literature Review and Clinical Experiences Gelli P4,5, Albasi C3,4, Clerici CA1,2,4, Ferrari A1, Fossati Bellani F1 et al. 1 Unita" Operativa Pediatria Istituto Nazionale per lo Studio e la Cura dei Tumoi, Milan, Italy; 2Department of Psychology University of Milan-Bicocca, Milan, Italy; 3Department of Psychology, University of Turin, Turin, Italy; 4Gruppo di Ricerca in Psicologia Clinica dello Sviluppo nelle Patologie Pediatriche, Milan, Italy; 5Dipartimento di Neuropsichiatria Infantile Ospedale Niguarda, Milan, Italy In the last few years, psychological interventions on children affected by chronic illness and their parents gradually spread out in paediatric hospitals; these have been performed by members of hospital staff with different training, backgrounds and theoretical models. Orientation towards evidence based interventions and the need of using defined protocols, took us to revise models, theories and techniques of the above-mentioned interventions.

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Up to now psychological interventions in paediatric hospitals are different both in forms and cultural traditions. The literature review on psychological consultation in children affected by chronic illness and their parents has been developed in this study using databases. The aim was to identify the efficacy of these interventions starting from the analysis of common factors reported in different theoretical models, techniques and traditions and taking into consideration the clinical experience too.

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joining a group and 12-weeks after joining. RESULTS: Teens reported high levels of comfort with use of the Internet and expressed strong enthusiasm for online support resources. Important themes associated with return to school, fatigue, and desire to develop peer groups among fellow survivors emerged. Preliminary results regarding use of the web site, qualitative themes of group discussion, therapists’ perceptions of group functioning, and change over time in quality of life will be presented. IMPLICATIONS: Results suggest that extending available face-to-face resources through the use of online peer communities may significantly increase the impact of psychosocial care and improve QOL in childhood cancer survivors. Limitations and future directions will be discussed.

Group Loop: Teens. Talk. Cancer. Online: An Innovative Online Support Program for Teens with Cancer and their Parents Golant M1, Owen J2, Katz E3, Kuperberg A3, Winzelberg A4 1 Research & Development, The Wellness Community, Santa Monica, USA; 2Division of Cancer Prevention and Control Research, University of California, Los Angeles, USA; 3Behavioral Sciences Section, Childrens Hospital Los Angeles, Los Angeles, USA; 4Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, USA

Children’s Self-Report of Symptoms and Anticipation for Symptom Change: A Pilot Comparative Study of Oncology and Surgical Patients Goodenough B1,2, Craft T1 1 Centre for Children’s Cancer & Blood Disorders, Sydney Children’s Hospital, Randwick, Australia; 2 School of Psychology, University of New South Wales, Sydney, Australia

BACKGROUND: Psychosocial concerns, including loneliness, social isolation and anxiety, and body image concerns, are common among childhood cancer survivors and take place in the challenging context of adolescent social development and long term late effects of the illness. Despite the significant social, emotional, and informational needs of many teen cancer survivors, few efforts to address these needs have been reported. METHODS: A series of focus groups were conducted with 18 teen survivors of childhood cancer to identify the psychosocial needs of this population. This information was then used to develop a new web site, GroupLoop (www.grouploop.org), to provide free professionally-facilitated online support groups, bulletin boards, information, and resources to teens with cancer. Between February and August, 2004, participants will be asked to complete standardized questionnaires to assess quality of life, social anxiety, traumatic symptoms, and coping efforts prior to

PURPOSE: The Memorial Symptom Assessment Scale (MSAS 7-12) is a multidimensional selfreport measure for children aged 7 to 12 years targeting eight symptoms: tiredness, sadness, itch, pain, worry, anorexia, nausea, and insomnia. The MSAS 7-12 format was used to investigate whether children’s symptom self-reports related to retrospective symptom expectations and anticipations for change in the next 24 hours. METHODS: Paediatric hospital inpatients (mean age 11.2 years) were sampled from two groups: receiving treatment for cancer or recovering after elective surgery. There were 16 children in each group, with equal numbers of boys and girls. All children completed the MSAS 7-12, and a short symptom appraisal scale to measure: (1) Expectancy for symptom over the previous 48 hours (Did you expect to feel 5symptom>? ‘‘Yes/no/ maybe/not sure’’) (2) Anticipated change for the next 24 hours (How do you think your 5symptom> will feel tomorrow? ‘‘Same/less[better]/

Copyright # 2004 John Wiley & Sons, Ltd.

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more[worse]/not sure’’). RESULTS: Compared with surgical patients, oncology patients reported fewer symptoms but had higher prior expectations. Most children did not anticipate symptom worsening over the next 24 hours, with half anticipating improvement. Regression analysis showed that predictors of anticipated change differed across symptoms. Variance was largely explained by prior symptom expectations and the MSAS 7–12 dimensions of duration, severity and distress, rather than demographic factors. CONCLUSIONS: The MSAS 7–12 may be a useful symptom self-report scale for both oncology and nononcology patients of school-age, with anticipated symptom change adding a useful dimension to retrospective estimates.

26 The Course of Life of Survivors of Childhood Cancer is Hampered Grootenhuis MA, Stam H, Last BF Psychosocial Department Emma Kinderziekenhuis, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands INTRODUCTION: The developmental consequences in adulthood of growing up with childhood cancer are not well understood. The aim of this study was to assess the course of life and socio-demographic outcomes in young adult survivors of childhood cancer. Knowledge about possible gaps in the course of life could enable health care providers to aim at the most favourable course of life. METHODS: A total of 353 Dutch survivors and 508 peers without a history of cancer, aged 18–30 years, completed the course of life questionnaire, which assesses the achievement of developmental milestones retrospectively and socio-demographic outcomes in young adulthood. Differences between survivors and comparison group were tested. RESULTS: The young adult survivors of childhood cancer in the Netherlands proved to have achieved fewer milestones, or at older age, than their peers, with respect to autonomy development, social development, and psycho-sexual development. In addition, survivors have displayed less risk behaviour. The survivors and peers differed also at some socio-demographic issues. A considerably lower percentage survivors

Copyright # 2004 John Wiley & Sons, Ltd.

than peers was married or living together, and/or employed. Their educational level, on the other hand, was as high as the level of their peers. CONCLUSIONS: The current study has demonstrated the impact of childhood cancer on the development; the course of life of the survivors seemed to be hampered. The next step would be to investigate (1) which survivors are at risk for a hampered course of life, and (2) whether the course of life of survivors is correlated with their adjustment in adult life.

27 Leaving Home after Cancer in Childhood: A Measure of Functional Independence in Early Adulthood Koch SV1, Kejs AMT2, Engholm G3, Moller H4, Johansen C1 et al. 1 Department of Psychosocial Cancer Research, Danish Cancer Society, Copenhagen, Denmark; 2 National Institute of Public Health, Copenhagen, Denmark; 3Department of Cancer Prevention & Documentation Danish Cancer Society, Copenhagen Denmark; 4Thames Cancer Register, Guy’s, King’s and St Thomas’ School of Medicine King’s College London, London, UK PURPOSE: As a measure of functional independence after childhood and adolescent cancer, we investigated whether cancer survivors displayed the same patterns of leaving their parental home as a population-based control cohort. METHODS: We identified 1597 patients in the Danish Cancer Register, born in 1965–1980, in whom a primary cancer was diagnosed before they reached the age of 20 in the period 1965–1995. The patients were compared with a random sample of the general population (n=43,905) frequency matched on sex and date of birth. By linking the two cohorts to registers in Statistics Denmark, we obtained socioeconomic data for the period 1980–1997. The relative risk for leaving home was estimated with discrete-time Cox regression models. RESULTS: The risk for leaving home of survivors of haematological malignancies and solid tumors did not differ significantly from that of the control cohort. Adjustments for possible socioeconomic confounders did not change this pattern. In contrast, survivors of central nervous system

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tumors had a significantly reduced risk for leaving home, which was most pronounced for men (relative risk, men: 0.66; 95% confidence interval, 0.55–0.80; women: 0.88, 95% confidence interval, 0.80–0.97). DISCUSSION: Overall, the psychosocial effects of cancer in childhood or adolescence and its treatment on the survivor and family did not appear to impede functional independence in early adulthood. The significant deficit of leaving the parental home among survivors of childhood brain tumors may be due to other factors, such as late neurological and neurocognitive effects.

28 Educational Achievements of Childhood Cancer Survivors}A Danish Nationwide Population Based Cohort Study Koch SV1, Kejs AMT2, Engholm G3, Johansen C1, Schmiegelow K4 1 Department of Psychosocial Cancer Research, Danish Cancer Society, Copenhagen, Denmark; 2 National Institute of Public Health, Copenhagen, Denmark; 3Department of Cancer Prevention & Documentation, Danish Cancer Society, Copenhagen, Denmark; 4Section of Paediatric Haematology and Oncology, Juliane Marie Centre, University Hospital, Copenhagen, Denmark BACKGROUND: Previous studies of childhood cancer survivors have demonstrated deficits in educational achievements; however, generalisations of results have been hampered by methodological limitations. METHODS: To avoid selection and recall bias, we identified a cohort of 2384 cancer patients in the Danish Cancer Register, diagnosed before the age of 20 in the period 1960–1996. This cohort was compared to a cohort of 53,143 sex and age-matched population-based controls identified in the Register of Population Statistics. These two cohorts were linked to Statistics Denmark to obtain socio-economic information covering the years 1980–2000. Using Cox-regression analyses, we estimated the relative chance of achieving education at different levels. RESULTS: Overall childhood cancer survivors showed reduced levels of education, however, this was largely due to deficits among brain tumour survivors,

Copyright # 2004 John Wiley & Sons, Ltd.

who had relative chances of 0.85 (confidence interval: 0.61–1.19) and 0.58 (confidence interval: 0.39–0.86) for achieving higher education for men and women, respectively. Furthermore, they more often completed vocational}than theoretical educations. Results pointed towards cranial radiation therapy, female gender, and young age at diagnosis, as risk factors for reduced educational outcome. Socio-economic factors had no synergistic effect on cancer survivors, but reduction in educational attainment was seen among both cancer patients and control persons with many siblings, unemployed fathers, or low parental income and education. CONCLUSION: Deficits in educational achievement after childhood cancer was primarily seen in brain tumour survivors. Psychosocial follow-up of childhood cancer patient’s should offer special attention to survivors treated with cranial radiation therapy, with mental problems, or adverse socio-economic backgrounds.

29 ‘‘The Fear of ALL is a Constant Companion.’’ Adjustment Problems in Children Treated for Acute Lymphoblastic Leukemia from their Parents’ Point of View. Langer Th, Plattig B, Beck JD Pediatric Immunology and Oncology, University of Erlangen-Nuremberg Erlangen Germany PURPOSE: About 75% of children suffering from acute lymphoblastic leukemia (ALL) are expected to survive their disease. Patients and their parents, however, may be confronted with physical and psychosocial adjustment problems during and after treatment, which probably aggravate the re-entry in family, school, and social life. METHODS: 107 children newly diagnosed with ALL have been enrolled in our multicentre, longitudinal study to investigate the impact of disease and antileukemic and prophylactic CNS chemotherapy on their psychosocial functioning. RESULTS: Our sample of ALL patients, taken as a group, showed CBCL problem behavior scores in the normal range comparable to normative data. The parents, however, reported a broad range of problems and fears. They are concerned about heightened aggressive behavior, agitation,

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anxieties and limited endurance at the ending of the reinduction therapy when compared to post-diagnosis. The predominant fears refer to the possibility of a relapse and of adverse long-term effects on their children’s future lives (i.e., school, employment, marriage, fertility). Moreover, the parents are afflicted by doubts whether their children can cope their cancer experience. CONCLUSIONS: ALL patients who are seriously affected by their disease and the antileukemic and prophylactic CNS chemotherapy are at risk for psychosocial long-term effects. Therefore, risk-specific support should be offered by psychosocial services to the patients and their families in order to help them to competently manage the challenges of a cancer diagnosis and its treatment.

30 From Informed Consent to Shared Consent: A Developing Process in Pediatric Oncology Massimo LM1, Wiley TJ2 1 Department of Pediatric Hematology and Oncology, Giannina Gaslini Children’s Teaching Hospital, Genova, Italy; 2Scientific Direction Giannina Gaslini Children’s Teaching Hospital, Genova, Italy The informed consent process for pediatric oncology research and treatment protocols is replete with bioethical, psychological and social pitfalls, all the more so if randomization (Rm) is entailed. Parents asked to give their written consent to a Rm protocol are, however, often unprepared to grasp, let alone accept, the implications of this scientifically crucial but seemingly unfair mechanism whereby a computer selects the treatment, or even why additional consent is requested; ultimately, their unwillingness to accept the Rm process may jeopardize recruitment and validation of trials. Because the relations that ensue among the health care team, parents and children patients can be trying and emotionally taxing, with parents’ ability to cope and adapt often becoming a balancing act influenced by risk and resistance factors, continuous and open communication from the outset is pivotal. We suggest that informed consent be requested only at enrollment in the trial – even if it includes Rm – and that the dialogue leading to consent among the attending physician, the family

Copyright # 2004 John Wiley & Sons, Ltd.

and (to the extent possible) the under-aged patient be managed as a shared cognitive process using the Problem-based learning method as a guide. Our model provides proper and honest information to both families and children through easy to understand dialogues with the physician. Because the attending medical staff must be versed in approaches to effectively handle and negotiate the encounters leading to comprehensive shared consent, we propose that medical students and physicians-in-training receive specific instruction in communication, behavioral and relational skills.

31 Causality Reasoning for Symptoms of Pain, Fatigue and Nausea in Children Diagnosed with Cancer Mathews K1, Goodenough B1,2, Washuta A2, Tay K2 1 School of Psychology, University of New South Wales, Randwick, Australia; 2Causality Reasoning for Symptoms of Pain, Fatigue and Nausea in Children Diagnosed with Cancer, Sydney Children’s Hospital Randwick Australia PURPOSE: Studies of children’s beliefs about the causes of illness and symptom experience are equivocal with respect to the Piagetian concept of immanent justice reasoning (e.g. the result of moral wrong-doing). Despite the lack of direct evidence using clinical samples, clinicians are often cautioned in guidelines for symptom management that younger children may be susceptible to immanent justice style thinking. METHODS: Two studies used vignette methods explored the confidence with which children (5–12 years) attributed symptoms of pain, fatigue and nausea to one or more of four types of reasons: ‘plausible’ (Physiological and Behavioural) and ‘implausible’ (Immanent Justice or Irrelevant). Study 1 recruited healthy asymptomatic children (n=66). Study 2 (n=29; in progress) recruited children receiving treatment for cancer with contemporaneous experience of pain, fatigue and nausea. RESULTS: The majority of children (healthy or cancer) endorsed behavioural and physiological (‘plausible’) explanations for symptoms, although younger children endorsed immanent justice and irrelevant explanations more frequently.

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There were also some differences as a function of symptom type. For example, behavioural explanations were endorsed more often for nausea, and all children endorsed irrelevant explanations more frequently than immanent justice explanations for pain. CONCLUSIONS: While no general significant differences were found between the healthy and cancer groups, symptom causality beliefs were influenced by age and the particular symptom under consideration. Findings underscore the role of cognitive developmental factors in symptom causality beliefs (including immanent justice), with implications for practitioner guidelines for symptom management in paediatric oncology.

32 Evaluation of Coping Strategies by Children with Cancer Moura MJ Psycho-Onchology, IPO Lisboa, Portugal PURPOSE: This project’s goal is the study of coping strategies used by children with cancer. METHODS: An exploratory study in which a cognitive control strategy scale has been used as described by Grootenhuis & Last, to access cognitive control strategies, created according to Rothbaum et al. (1982). This scale is divided into four control sub-scales: predictive, vicarious, illusory and interpretative. The scale has been adapted for the portuguese population, with authorization from the author. A 60 children sample has been used, aged between 8 and 16 years. Demographic data include the child’s age and school year. Clinical data include the remission phase and the relapse phase. Treatment period is divided between less than two years and over two years. Type of disease: Leukemia/ Lymphoma and Solid Tumors. RESULTS: Highlights of end results: When comparing age groups of 8 to 12 and 12–16 years, 78% of children aged 12–16 use interpretative control strategies; 85% of children in relapse phase use illusory control; 67% of children with Leukemia also use illusory control. 75% of children use predictive control. CONCLUSIONS: Teenagers want to know more about the disease, which is probably related to the young person’s cognitive development phase.

Copyright # 2004 John Wiley & Sons, Ltd.

Illusory control is essentially related with external factors, like ‘‘chance’’. This strategy is probably more used in high adversity, either in long treatment phases or in particular relapse phases. In general, children have positive expectations over the period of the disease, showing evidence of predictive control.

33 How do Adolescents Perceive their Physical and Psychological Status Five Years after the Completion of their Treatment. Oppenheim D, Brugi"eres L, Antoni G, Hartmann O Department of Pediatrics, Unit of Psycho-oncology, Institut Gustave Roussy Villejuif, France OBJECTIVE: To gain a better understanding of the future of adolescents treated for a cancer. METHODS: A questionnaire was sent to all adolescents (13–18 years old) treated in our hospital 5 years ago. Questions concerned their physical and psychological status, sequels sustained, what bothers them, whether they or their parents felt fragile, whether they wanted psychological support or medical information or an interview. RESULTS: 93 subjects; 61% answered. 3 items were significant: they have no health problems (74%) but physical sequels (69%), they wish to receive medical information (90%) concerning their illness, their present status, having children in the future. Eight requested an interview. The major points addressed were: treatment was a trying experience, they felt lonely (they could not explain their feelings and could not be understood) and ambivalent about psychological support; the first year following treatment was hard, they felt different from before and from others; sexuality was difficult (they were ashamed of their body, feared being rejected or loved for pity); fatigue and visible sequels which attract the attention of and questions from others bothered them. They would appreciate group discussions and psychological support during treatment and during the first year following therapy. CONCLUSION: As the majority of adolescents are cured without major sequels, greater attention should be directed at ‘minor’ sequels which can markedly impair the quality of life of adolescents: fatigue,

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solitude, visible sequels, sexuality, feeling different from before and from others.Study supported by a grant 2002-11 IGR.

CONCLUSIONS: Understanding physician’s attitudes, behaviors, and approaches will provide insight into truth telling issues. The implications for children and their families will be discussed.

34 35 Physician Communication with Children with Cancer: Cross Cultural Approaches Acress the Illness Continuum Parsons SK1, Saiki-Craighill S2, Mayer DK1, Terrin N1, Nakagawa K2 et al. 1 Center on Child and Family Outcomes, Tufts-New England Medical Center, Boston, USA; 2Tokyo Metropolitan University of Health Sciences, Tokyo, Japan PURPOSE: To describe direct communication attitudes and practices of pediatric oncologists with children ages 10–17 in the US and Japan. METHODS: A four-part survey developed and translated into both languages, elicited responses on factors and attitudes influencing actual and hypothetical communication practices. The 2003 survey was mailed to members of the American Society of Pediatric Hematology/Oncology and the Japanese Societies of Pediatric Hematology and Oncology. The response rate among eligible responders was 72% in the US and 44% in Japan. In addition to descriptive statistics, logistic regressions were performed. RESULTS: Differences across cultures were evident. US physicians were influenced by their sense of responsibility in truth telling and by disease factors. Japanese physicians were influenced by the impact of truth telling and the communication preferences of the parent-child dyad. Work culture was significantly linked to truth telling in Japan, but not in the US. Logistic regression results will be presented. Table 1: Respondent reports of always telling the child about their cancer

Told initial diagnosis Meaning of relapse Terminal stage

US (N=350) 227 (65%)

Japan (N=362) 34 (9.5%)

225 (65%)

116 (33.5%)

165 (48%)

12 (4%)

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Psychiatric Hospitalizations among Survivors of cancer in Childhood or Adolescence Ross L, Johansen C, Dalton SO, Mellemkjær L, Thomassen LH et al. Institute of Cancer Epidemiology Danish Cancer Society Copenhagen Denmark PURPOSE: The improved survival of children and adolescents with cancer has stimulated interest in possible psychosocial after-effects. Our aim was to study whether such survivors are at increased risk for psychiatric hospitalization. METHODS: In a nation-wide, population-based cohort study, 3710 three-year survivors from cancer in childhood or adolescents, diagnosed during 1943 to 1990 and alive 1 January 1970 or born thereafter, were identified in the Danish Cancer Register. This study population was followed up for psychiatric hospitalizations from 1 January 1970–1993 by linkage with the Danish national Psychiatric Central Register. Expected figures were based on the appropriate national hospitalization rates for psychiatric disease. RESULTS: An overall 30% increase in the risk for hospitalization for any psychiatric disease was found, but the excess was confined to survivors of tumours of the central nervous system (standardized hospitalization ratio, SHR 1.8; 95% CI, 1.5–2.2) on the basis of 88 hospitalizations. An increased risk for psychoses of somatic, cerebral causes (SHR 7.7; 95% CI, 4.1–13.2), psychiatric disorders in somatic disease (SHR 5.1; 95% CI, 2.5–9.1), and schizophrenia and related disorders (SHR 2.4; 95% CI 1.2–4.4) was observed for survivors of these tumours. The risk for diagnoses in the schizophrenia spectrum was significantly increased only among patients treated with radiotherapy (SHR 3.8; 95% CI, 1.4–8.2). CONCLUSION: There is no evidence of a significantly increased risk for major depression. Furthermore, no excess risk for any other psychiatric diagnoses was observed except for survivors of CNS tumours.

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36 Physician Communication with Children with Cancer and Parent at the End of Life: A Us-Japanese Comparison Saiki-Craighill S1, Mayer DK2, Parsons SK2, Terrin N2, Nakagawa K1 et al. 1 Nursing, Tokyo Metropolitan University of Health Sciences, Tokyo, Japan; 2Center on Child and Family Outcomes, Tufts-New England Medical Center, Boston, USA; 3Center on Child and Family Outcomes, Tufts-New England Medical Center Boston, US; 4Institute for Clinical Research and Health Policy Studies, Tufts-New England Medical Center, Boston, USA; 5Tokyo Metropolitan University of Health Sciences, Tokyo, Japan PURPOSE: To describe end-of-life experiences, communication attitudes and practices of pediatric oncologists with children ages 10–17 in the US and Japan. METHODS: A four-part survey, developed and translated into both languages, elicited responses to factors and attitudes influencing communication at the end of life with a focus on actual experiences with a recent child’s death. The 2003 survey was mailed to members of the American Society of Pediatric Hematology/Oncology and the Japanese Societies of Pediatric Hematology and Oncology. The response rate among eligible responders was 72% (US) 44% (Japan). RESULTS: While physicians in both countries universally talk with parents about a child’s impending death, this is not the case for the child. Similarly, US physicians are more likely always to discuss the child’s wishes and values for care at the end of life (66%) than are Japanese physicians (12%). Adjusting for physician age, gender, years in and size of practice, work culture factors most influenced communication practices. Table 1. Respondent reports of telling the child and family that the child was dying (in the last few days of life...) US (n=350)/Japan (n=362) The child was told that he/she was dying The child’s family was told he/she was dying Talk with the parents about the child’s wishes

147 (59%)/21 (9%) 274 (95%)/271 (94%) 265 (93%)/214 (74%)

Copyright # 2004 John Wiley & Sons, Ltd.

CONCLUSIONS: Communication with children and their families at the end of life is both complex and challenging. The implications of physicians’ attitudes and practices on all parties will be discussed.

37 Quality of Life and Coping in Young Adult Survivors of Childhood Cancer Stam H, Grootenhuis MA, Last BF Psychosocial Department Emma Kinderziekenhuis, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands OBJECTIVES: More insight is needed into the long-term adjustment of young adult survivors of childhood cancer. The purpose of this study was to (1) assess HRQoL, and (2) to explore the role of cognitive coping in relation to HRQoL. METHODS: HRQoL of 353 Dutch young adult survivors of childhood cancer and 507 age-matched and sexmatched peers was assessed with the RAND-36. Survivors also filled in the Cognitive Control Strategies Scale. Differences on HRQoL between survivors and peers were tested by MANOVA. HRQol of the survivors was predicted by linear regression analyses of: (1) demographics, (2) variables related to disease and treatment, (3) health status, and (4) cognitive coping. RESULTS: The results of MANOVA showed that the survivors had worse HRQoL than their peers on the RAND-scales Physical Functioning, Social Functioning, Role limitations due to Physical problems, and on the Physical Component Scale. Health status was the best predictor of the Physical Component Scale of the RAND-36; health status and cognitive coping contributed almost equally well to the Mental Component Scale. The explanatory value of cognitive coping could mainly be attributed to the use of predictive control strategies. CONCLUSIONS: Survivors reported a lower HRQoL than peers. Because current coping seemed to be an important predictor of HRQoL, interventions directed at the coping strategies of survivors should be useful. The strong association between predictive coping and HRQoL stresses the importance of focusing at having positive expectations about the further course of the disease.

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38 Course of Life Predictor of Quality of Life and Socio-Demographic Outcomes in Young Adult Survivors of Childhood Cancer Stam H, Grootenhuis MA, Last BF Psychosocial Department Emma Kinderziekenhuis, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands

Suneson JK1,2, Goodenough B1,2, Cohn R2,3, Johnston K2 1 School of Psychology, University of NSW, Randwick, NSW, Australia; 2Centre for Children’s Cancer and Blood Disorders, Sydney Children’s Hospital Randwick, NSW, Australia; 3School of Women’s and Children’s Health, University of NSW, Randwick, NSW, Australia

INTRODUCTION: Growing up with childhood cancer may have developmental consequences. Recently it was found that the course of life of young adult survivors of childhood cancer in the Netherlands was hampered. The aims of current study were to investigate (1) the impact of variables related to disease and treatment, on the course of life, and (2) the effect of the course of life on QoL and on socio-demographic outcomes in young adulthood. METHODS: A total of 353 Dutch survivors, aged 18–30 years, completed in the RAND-36, and the course of life questionnaire, which assesses the achievement of developmental milestones retrospectively and socio-demographic outcomes in young adulthood. Medical data were obtained from the long-term follow-up clinic. Multiple linear and logistic regression analyses were performed to investigate the antecedents and consequences of the course of life. RESULTS AND CONCLUSIONS: Firstly, survivors of brain tumours and survivors having been treated with radiotherapy were found to be at risk for a hampered course of life. Secondly, a more favourable course of life proved to be correlated with better adjustment in young adulthood: survivors who had a hampered social development, were at risk. These findings show that a favourable social development during childhood is important for children with cancer. Therefore, parents and health-care providers should encourage children with cancer to make friends and to participate in peer activities.

The inclusion of ‘Life-threatening illness’ in the diagnostic criteria of the DSM-IV for Posttraumatic stress disorder (PTSD) acknowledges, for the first time, that diagnosis of serious illness can generate feelings of overwhelming fear, horror or helplessness precipitating a stress response comparable to that associated with other types of trauma (e.g. assault, accident). This acknowledgement, at a clinical diagnostic level, has facilitated PTSD-related research in the illness context, including cancer. Studies of long-term psychosocial outcomes in childhood cancer survivors suggest that a significant proportion of past childhood cancer patients exhibit persistent and pervasive posttraumatic stress symptoms as a result of the cancer experience. However, whilst prevalence data on stress symptoms is informative, this research currently lacks a solid treatment-focused theoretical orientation where symptom onset and maintenance can be explored, and interventions can be adequately evaluated. Recently, Ehlers and Clark (2000) proposed a cognitive model for treatment of posttraumatic stress disorder, which explores in depth many of the cognitive processes that may lead to the development of persistent PTSD. While the framework was originally developed outside the ‘lifethreatening illness’ context, it is argued that the model may be applied to the childhood cancer survivor context. It is suggested that this model may prove valuable for identifying predictive factors for persistent psychosocial adjustment difficulty in subsets of survivors of childhood cancer (and other family members), as well as be informative for developing interventions in the short and long-term.

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Posttraumatic Stress Disorder and Childhood Cancer Survivorship: An Overview of a Cognitive Model

Preliminary Investigation into the Co-occurrence of Posttraumatic Stress and Posttraumatic Growth

Copyright # 2004 John Wiley & Sons, Ltd.

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Outcomes in an Australian Sample of Adult Childhood Cancer Survivors Suneson J1,2, Goodenough B1,2, Cohn R1,3, Johnston K1 1 Centre for Children’s Cancer & Blood Disorders, Sydney Children’s Hospital Randwick, 2 School of Psychology NSW, Australia; University of New South Wales, Sydney, Australia; 3 School of Women’s and Children’s Health University of New South Wales, Sydney, Australia PURPOSE: To investigate prevalence and co-occurrence of posttraumatic stress and posttraumatic growth outcomes in an Australian sample of childhood cancer survivors. Relationships with psychological functioning, quality of life, and appraisal of life threat were also assessed. METHODS: 95 childhood cancer survivors (aged 16 to 40; 34 male, 61 female) registered with the Long-term Follow-up Clinic at the Sydney Children’s Hospital, Randwick, Australia, completed self-report measures of Posttraumatic Stress Symptoms (PTSS), Posttraumatic Growth responses (PTG), Psychological functioning, Quality of Life (QoL), and Assessment of life threat and treatment Intensity. RESULTS: Prevalence of moderate to high PTSS as endorsed by the patient sample are reported: Intrusion (9.9%), Avoidance (6.5%), and Arousal (3.3%). Prevalence of moderate to great PTG were: Relating to others (28.3%), New Possibilities (22.6%), Personal Strength (29.3%), Spiritual Change (18.5%), and Appreciation of Life (46.7%). Correlational analyses report significant positive relationships between PTSS and PTG, and PTSS and Psychological functioning. Assessment of Life Threat and Treatment Intensity is positively correlated to both PTSS and PTG, while a significant but negative relationship was found between PTSS and QoL, No significant relationship was found between PTG and QoL. CONCLUSIONS: These findings offer evidence that Posttraumatic Stress Symptoms and Posttraumatic Growth are not dichotomous but may co-exist. This suggests that traditional stress-deficit approaches used to investigating long-term psychosocial adjustment in the survivor population may be limited with associated implications to prediction and intervention. Research is continu-

Copyright # 2004 John Wiley & Sons, Ltd.

ing into the nature of this relationship and which factors (esp. cognitive) may best predict these outcomes.

41 An Adventure Jeep Trip with Young Adult Childhood Cancer Survivors: Lessons to Learn Yagil Y2, Cohen L3, Elad P1,2, Meller I1 1 The National Unit of Orthopedic Oncology, TelAviv Sourasky Medical Center, Tel-Aviv, Israel; 2 Social Services Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel; 3The Israeli Cancer Association Givatayim, Israel BACKGROUND: An 8-days adventure jeep trip in Greece was conducted with 17 young childhood cancer survivors. Participants were videotaped and interviewed during and following the trip. This data was studied in order to describe their major areas of concerns and preferred coping mechanisms. The analysis also dealt with the various aspects of ‘‘adventure therapeutic activity’’, in order to learn some lessons as to the therapeutic efficacy of such an activity with young adult cancer survivors. METHOD: Videotapes and interview materials were analyzed through a process of Content analysis. RESULTS: Survivors main areas of concern included: fear of dependency, social isolation, body image, sexuality, recurrence of disease and occupation. Preferred coping styles included use of humor, religious beliefs, cognitive reframing and use of imagination. The trip provided the young adults with an opportunity for physical challenges, and they reported improvements in self-confidence, independence and social contacts. In addition, the trip served as a catalyst for further group activities and group support. CONCLUSIONS: An adventure trip seems to be a suitable therapeutic milieu for young adult cancer survivors where they can profit from a nurturing setting in which rehabilitation promoting resources are available. We still need to learn which components in such an activity are more health promoting, what (if at all) are the counter-indications for recommending the participation in such a trip, and what is the role of health care professionals in this kind of activity?

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42 Cognitive function A Longitudinal Study of the Effects of Anastrozole on Cognition in Post-Menopausal Women at Risk of Developing Breast Cancer Atkins L1, Jenkins V1, Fallowfield LJ1, Howell A2 1 Cancer Research, UK Psychosocial Oncology Group Brighton and Sussex Medical School, University of Sussex, Brighton UK; 2Department of Medical Oncology, Christie Hospital, Manchester, UK Anastrozole is an aromatase inhibitor}a class of compounds that inhibit oestrogen synthesis in tissues and thus reduces serum oestrogen concentration to low levels. The effect that reduced oestrogen levels has on cognition is unclear but there is growing evidence from hormone replacement and dementia studies that oestrogen has a very important role in memory and cognition. The IBIS-II trial of anastrozole vs. placebo in post-menopausal women at increased risk of breast cancer provides an invaluable opportunity to examine the effects of aromatase inhibitors on cognitive functioning. Women recruited to the study will be at an age where normal age-related cognitive decline begins to be apparent, and therefore they may be particularly vulnerable to the effects of anti-oestrogens. 700 women eligible from the main study will be recruited to the cognitive substudy over a period of 3 years. Assessments of memory, mood and cognition will be performed at baseline (prior to receiving treatment), 6 months, two years and five years. The assessment comprises four tests of verbal memory and attention, IQ measurement, self-report evaluation on mood state, cognitive failures and endocrine symptoms. The selection of measures is based on previous findings of cognitive impairment in a small sample of women with breast cancer participating in the ATAC study (anastrozole, tamoxifen, alone or combined). Participating centres include Manchester, Bristol and Cardiff, with interest from London (Guy’s) and Southampton. The study has also received international interest from Australia and Italy.

43 Do Lowered Oestradiol Levels following Treatment for Breast Cancer Result in Hearing Loss?

Copyright # 2004 John Wiley & Sons, Ltd.

Beveridge HA1, Jenkins VA1, Low RDG2 1 Cancer Research UK, Psychosocial Oncology Group Brighton and Sussex Medical School, Brighton, UK; 2Department of Audiology, Royal Sussex County Hospital, NHS Trust Brighton, UK AIM: This pilot study will examine whether a decrease in serum oestradiol following treatment for breast cancer results in a significant hearing loss compared with age-matched population norms. BACKGROUND: Several regions of the brain, important in memory and cognition, are rich in oestrogen receptors. The degree to which oestrogen mediates our ability to learn and remember is however unclear. Several studies have shown that chemotherapy has a detrimental effect on memory and attention. In addition the results from our own cross-sectional work on 103 women receiving adjuvant endocrine therapy for early stage breast cancer showed a deficit in the recall of verbal memory, together with a decrease in processing speed (Jenkins, 2003). Previous animal and human studies have shown that oestrogen plays a significant role in the activity in both peripheral and central auditory structures. Evidence suggests that oestrogen has favourable effects on the human auditory system}younger women have shorter auditory brain stem response latencies and larger amplitudes than young males (Wharton and Church 1990). Also Kim et al. (2002) reported a significant loss of hearing sensitivity in menopausal women that was associated with lowered oestradiol levels. It may be therefore that the deficits found in memory for verbal information in women following treatment for breast cancer is compounded by a hearing loss. METHOD: Hearing sensitivity of 30 women, 40–60 years, who have completed treatment for breast cancer within the last year, will be examined using pure tone audiometry and tympanometry. Results will be available by August 2004.

44 An Investigative Longitudinal Pilot Study of the Cognitive Effects of Reversible Hormone Therapy for Prostate Cancer Edginton TL1, Jenkins V1, Shilling V1, Bloomfield DJ2

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Psychosocial Oncology Group, University of Sussex, Brighton, UK; 2Sussex, Cancer Centre, Brighton and Sussex University Hospitals Trust, Brighton, UK PURPOSE: Spatial and verbal memory improvements observed with testosterone supplementation (O’Connor et al., 2001) and similar impairments associated with the natural decline in testosterone levels (Wolf and Kirschbaum 2002) suggest that testosterone plays a modulatory role in cognition. Reversible testosterone suppression caused by the administration of anti-androgen hormone therapy for prostate cancer may therefore also impair spatial and/or verbal memory. METHODS: 34 patients receiving temporary reversible medical castration with an LHRH agonist as neo-adjuvant hormone therapy prior to radical radiotherapy for localised prostate cancer were tested at baseline (T1), three months (T2), and following the end of therapy at one year (T3). 18 healthy men, matched for age and intelligence were also assessed to calculate the reliable change index. Neuropsychological assessments included spatial, verbal and working memory tasks. At the same time QoL and anxiety were measured together with total and free testosterone and oestradiol levels. RESULTS: There were no overall group differences on the neuropsychological tasks at T2 although changes were occurring for some patients. 8/16 patients declined on one task, 6/ 16 declined on two tasks and 2/16 on three tasks. 7 patients remained above threshold on the GHQ12 at T2. Blood chemistry analysis showed a significant decline in testosterone and oestradiol levels (all p50.0001). T3 results and final interview data will provide a complete overview of any cognitive effects throughout treatment. CONCLUSIONS: Appraisal of cognitive effects will assist treatment selection for patients and doctors.

45 Brief Cognitive-Behavioral Treatment of Chemotherapy/Associated Cognitive Change Among Breast Cancer Survivors: Pilot Outcomes Ferguson RJ1, Ahles TA2 1 Behavioral Medicine Section, Dartmouth Medical School, Lebanon, NH, USA; 2Behavioral Medicine Section, Dartmouth Medical School Lebanon, NH, USA

Copyright # 2004 John Wiley & Sons, Ltd.

PURPOSE: To pilot-test a brief cognitive-behavioral treatment (CBT) aimed at remediation of chemotherapy-associated cognitive change following breast cancer treatment. METHODS: Thirty women (rural; mean age 56.77 years, sd=8.64) completed treatment. All were cancer free and enrolled an average of 8.44 years (sd=4.20) post-chemotherapy and screened for neurological and/or psychiatric disorder. The CBT program is brief (4 visits) and utilizes a participant manual for home self-instruction in compensatory strategies for memory problems. Phone contact for problem-solving is used between visits. Main dependent measures included a brief neuropsychological test battery at baseline, posttreatment (4 months after baseline) and 2-month follow-up. Self-report of cognitive function (Multiple Ability Self-report Questionnaire; MASQ), quality of life (QOL-CS; Quality of Life- Cancer Survivors) and post-treatment satisfaction were also assessed. RESULTS: Significant improvement at post-treatment and follow-up was observed in tests of: (1) Verbal memory (p50.01); and (2) Psycho-motor processing speed (p50.01). Selfreport of cognitive function also improved as assessed by MASQ total score, attention-concentration, language, visual-perceptual and visual motor subscales (p50.01). Total QOL-CS score also improved (p50.05) and satisfaction with the treatment was highly rated. CONCLUSIONS: These pilot results suggest chemotherapy-associated cognitive change may be compensated for with this CBT program, which is highly rated by participants and appears feasible. Six-month follow-up analyses are on-going. However, neuropsychological results reported could be due to practice effects. A second-phase, randomised, wait-list control trial is currently underway to control for practice effects that occur with repeat neuropsychological testing.

46 Delirium: A 2 Year Prospective Cohort Study of Outcome Kumar TM1, Lewis S2, Shergill N2, House AOH2 1 Liaison Psychiatry Becklin Centre, Leeds Mental Health NHS, Trust Leeds, UK; 2 Academic Unit of Psychiatry, University of Leeds, Leeds, UK

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BACKGROUND: Delirium, despite varying prevalence estimates, is well recognised as a significant problem complicating the management of cancer. It is either assumed to be a transient syndrome reflecting disease severity or a harbinger of death. Outcomes are commonly thought of in terms of cognitive states, with little attention paid to other psychological consequences and to effects on quality of life for patients and carers. PURPOSE: We set out to study the outcomes of delirium in an inception cohort of patients receiving cancer treatment, further focussing on the psychological risk factors for poor outcome. METHODS: An inception cohort of patients developing delirium during admission to 2 cancer wards was established, by screening consecutive admissions using standardised instruments. Outcomes of delirium in this cohort and psychological and other factors affecting outcome were studied prospectively and compared with controls. The study recruited patients over two-years. RESULTS: Of the nearly 900 patients who met the criteria for inclusion into the study, nearly half took part. Of these, more than 25% developed an episode of delirium. Mortality rate at follow up was high, more than half the patients being dead at 3 months. Mortality rate was significantly lower in control groups and follow up rate higher. Quality of life at 6 months was worse in the delirium group. CONCLUSIONS: Prospective cohort studies in delirium are rare. Our results indicate a high incidence of delirium and throws light on factors affecting poor outcome. Delirium independently seems to predict higher mortality and lower quality of life.

47 Long-term Effects of Standard Adjuvant vs. Highdose Chemotherapy Plus Stem-Cell Transplantation on Neuropsychological Functioning and HealthRelated Quality of Life in Patients with Breast Cancer Mehnert A1, Scherwath A1, Schleimer B1, Zander A2, Schulz-Kindermann F2 et al. 1 Institute of Medical Psychology, Hamburg University Clinic, Hamburg, Germany; 2Center for Bone Marrow Transplantation, Hamburg University Clinic, Hamburg, Germany

Copyright # 2004 John Wiley & Sons, Ltd.

PURPOSE: Adjuvant chemotherapy is the gold standard for the treatment of breast cancer patients with advanced disease. To improve survival, high-dose chemotherapy has been applied with several studies that have shown conflicting results. Beyond, neuropsychological effects of dose-intense chemotherapy have not been studied extensively so far. Nevertheless a growing body of research shows chemotherapy-induced cognitive dysfunction even years after treatment. Diffuse neurotoxic changes are supposed to be mainly evident as attention and memory dysfunctions and might lead to considerable implications for the quality of life of patients as they are highly relevant to daily living tasks. METHODS: The aim of this cross-sectional multicentre study is to assess neuropsychological longterm effects of standard vs. high-dose chemotherapy plus stemcell transplantation. The study follows a randomised clinical trial with high-risk breast cancer patients. Patients are assessed several years after treatment completion. A control group of stage I breast cancer patients only treated with radiotherapy is also assessed. Standardized evaluation includes a validated neuropsychological assessment and computerised tests focussing on attention and memory function as well as psychological questionnaires (HADS, MFI, EORTC-QLQ-C30, among others). RESULTS: Up to now, we assessed n=20 patients in the high-dose chemotherapy group, n=19 patients in the standard group as well as n=24 patients in the control group. First results indicate moderate to severe neuropsychological dysfunction in a subgroup of patients in specific cognitive performances such as selective attention or visual memory function. Prevalence of neuropsychological dysfunction will be presented as well as associations between objective and subjective cognitive impairment.

48 A Literature Review of Cognitive Dysfunction in Women Treated with Chemotherapy and/or Hormonal Therapy for Breast Cancer Mulrooney TJ1,2 1 Medical Oncology, Norris Cotton Cancer Center, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA; 2College of Nursing, University of Utah, Salt Lake City, UT, USA

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An estimated 212,600 new cases of breast cancer will be diagnosed in the United States this year (ACS, 2003). More than 100,000 women may receive chemotherapy as part of their treatment regimen (National Institutes of Health, 2000). Hormonal therapy may be used in about 60% of all breast cancer patients, either alone or in combination with chemotherapy (Elledge and Fuqua, 2000). Cognitive dysfunction is a problem that may occur as a result of these treatments for breast cancer. METHOD: A review of the literature was conducted using Medline, CINAHL and PsychINFO to identify studies assessing cognitive function in women who have received chemotherapy and/or hormonal therapy for breast cancer. RESULTS: The studies identified have shown deficits in domains of cognition, such as memory, concentration, attention and word recall. The deficits are often subtle, but are reported to be noticeable and bothersome to the breast cancer patient. They are more profound in high dose chemotherapy and less evident in hormonal therapy. CONCLUSIONS: This is an important issue that has an impact on many areas of day to day function. Future areas of research should concentrate on further assessment of the extent and level of permanence of dysfunction, impact on day to day functioning, identifying the relationship of this problem with other variables, predicting those at high risk and evaluating treatments for cognitive dysfunction.

with cognitive assessments at baseline, 6 and 18 months. The study will recruit 100 women who have had surgery for early breast cancer and who will begin adjuvant chemotherapy. A group of 50 healthy controls will also be recruited to examine practice effects. The assessment package incorporates standardised tests of verbal, semantic and visual memory as well as intelligence, processing speed, attention and concentration, providing a broad assessment of cognitive function. Preliminary analyses of data from 36 chemotherapy patients and 40 healthy controls found no significant group differences at baseline or 4 weeks post-chemotherapy. Using a reliable change index with the healthy control group as a reference, participants were classified as having declined meaningfully if they showed reliable decline on two or more measures. Chemotherapy patients were not significantly more likely to be classified as impaired than the healthy controls. Those patients who were impaired were not significantly less intelligent than patients who did not show impairment nor did they report more memory problems however they were significantly older (p=0.033). These results provide the first longitudinal data with a pre-treatment baseline and indicate that chemotherapy may not necessarily result in cognitive impairment and raise questions regarding dose and type of treatment given.

50 49 The Effects of Adjuvant Chemotherapy on Cognition in Women with Breast Cancer}an Observational Longitudinal Study Shilling V1, Jenkins V1, Morris R1, Deutsch G2, Bloomfield D2 1 Psychosocial Oncology Group, University of Sussex, Falmer, UK; 2Sussex Cancer Centre, Royal Sussex County Hospital, Brighton, UK Several studies have demonstrated that patients who have received chemotherapy have impaired cognition relative to a control group yet no published study has included a baseline assessment prior to the start of chemotherapy. To properly assess cognitive impairment as a result of chemotherapy we are conducting a longitudinal study

Copyright # 2004 John Wiley & Sons, Ltd.

FACT-Cog for use in German Clinical Oncology Trials: Linguistic Validation and Examination of Psychometric Properties of the Fact-Cog German Translation Wagner LI1, Eremenco S1, Herzberg T1, Du H1, Schuett G2 et al. 1 Center on Outcomes, Research and Education, Northwestern University, Medical School, Chicago, USA; 2Westgerman Study Group, University of Duesseldorf, Duesseldorf, Germany PURPOSE: Cancer patients undergoing chemotherapy have demonstrated cognitive impairments. The FACT-Cog is a self-report questionnaire developed as part of the Functional Assessment of Chronic Illness Therapy (FACIT) system to assess cognitive deficits among cancer

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patients and their impact on quality of life. METHODS: A 50-item version of the FACTCog (Version 2) was translated into German using a rigorous methodology involving two forward translations, reconciliation of the two translations by a third translator, back translation of the reconciled version to English, and three independent reviews by experts. The German FACT-Cog was administered to 20 women attending an outpatient oncology clinic in Germany for treatment of breast (95%) or ovarian (5%) cancer. Participants were a mean of 53.6 (+10.9) years of age. All participants were actively receiving chemotherapy when they completed the FACTCog and most participants had an ECOG PSR of 1 (65%; PSR 0, 2=15%). RESULTS: Reliability estimates for the FACT-Cog Sum score of cognitive domains and Impact on quality of life subscale were in the excellent range (Cronbach’s alpha=0.85, 0.84, respectively). Twelve patients made general comments on 14 items; however there were no direct criticisms of language. Therefore, no items were changed. CONCLUSIONS: Psychometric properties of the German FACTCog were established through administering this instrument to a sample of German oncology patients actively receiving treatment. The German FACT-Cog is linguistically acceptable, shows good psychometric performance, and is now ready for inclusion in clinical trials and research studies to evaluate the QOL of patients with cognitive impairment.

51 Evaluation of Neuropsychological Training Programmes Following Intensified Oncological Therapy: A Controlled-Randomised Study Weis JB, Poppelreuter M, Mumm A, Bartsch HH Psychooncology Tumor Biology Center, Freiburg, Germany; BACKGROUND: Although the neurotoxicity of many antineoplastic substances has been known for long, only little empirical investigation was carried out regarding neuropsychologic deficits following oncological therapies. While initially research was concentrated mainly on patients having undergone high-dose chemotherapies, recent studies now also reveal neuropsychological

Copyright # 2004 John Wiley & Sons, Ltd.

impairments arising with ‘‘conventional’’ chemotherapies. OBJECTIVES AND TOPICS: This study is designed to investigate the effects of two specific neuropsychological interventions compared with a control group. In addition, neuropsychological functions are evaluated with respect to the correlations with various psychosocial parameters. DESIGN OF THE STUDY: Breast cancer patients after adjuvant chemotherapy and patients with hematological malignancies after hematopoetic stem cell therapy are examined for neuropsychologic impairment by means of a special screening; according to the screening they are randomized to one of the two intervention groups (group training vs. computer-based training) or to the control group without any specific treatment (N=210). The points of measurement are at admission (t1), at the end of the rehabilitation programme (t2) and 6 months after rehabilitation (t3). RESULTS: Evaluation is carried out using neuropsychological parameters focussing on processes of attention and memory as well as the patients’ subjective assessment of their cognitive performance, psychological state, quality of life, fatigue and coping with the disease. The results show that there are only small differences between the two treatment groups.

Communication 52 The Quality of the Physician–Patient Relationship Predicts Prostate Cancer Patients’ Self-efficacy Baile WF1, Parker P2, Devine D2, Fortier A2, Cohen L2 1 Psychiatry Univeristy of Texas, M.D. Anderson Cancer Center, Houston, Texas, USA; 2Behavioral Science University of Texas, M.D. Anderson Cancer Center, Houston, Texas, USA PURPOSE: Using the Cancer Diagnostic Interview Scale (CDIS), an 18-item instrument measuring patients’ perceptions of the quality of the physician-patient relationship, we have previously shown that ratings of physician behaviours were associated with breast cancer patients’ long-term psychological adjustment. METHODS: In this study we used the CDIS to examine whether prostate cancer patients’ perception of the

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physician–patient relationship predicted their self efficacy [a 10-item scale assessing patients’ confidence in managing the physical (e.g. catheter care) and psychosocial (e.g. eliciting family support) tasks related to cancer surgery and recovery]. Patients also completed a demographic questionnaire and a measure of their fears and concerns about the upcoming surgery (e.g. complications during surgery, postoperative pain, loss of erectile function). 163 men (avg. age 61, 79% Caucasian, 85% married, 30% college degree or higher) with early stage prostate cancer scheduled for radical prostatectomy participated. They were assessed at 2 time points (baseline}2–3 weeks prior to surgery and then again 1–5 days prior to their operation). RESULTS: Findings showed that after controlling for demographic variables (age, education and marital status), surgery concerns, and baseline self-efficacy, the quality of the physician–patient relationship positively predictive of patients’ self-efficacy shortly before surgery (b=0.158, p=0.015). CONCLUSION: The findings suggest that even after controlling for surgery concerns, the quality of the physician– patients relationship predicted a change in self-efficacy leading up to surgery. This suggests that the quality of the physician–patient relationship can be a factor in promoting confidence in self-care after radical prostatectomy for prostate cancer.

53 Follow-up in Breast Cancer Clinics: Reassuring for Patients Rather than Detecting Recurrence Beaver K, Luker KA Nursing University of Manchester, Manchester, UK Despite research that questions the value of routine hospital follow-up after treatment for breast cancer, there is little evidence to indicate what actually takes place during follow-up consultations and whether patients benefit from the experience. This study aimed to investigate the nature and content of hospital follow-up visits following treatment for breast cancer using a mixed methods approach. Methods included direct observation and audio-recording of 104 consultations, semistructured interviews with 14 health care profes-

Copyright # 2004 John Wiley & Sons, Ltd.

sionals (HCP) involved in follow-up service provision and a patient survey (n=92). Our study found that consultations were focused on detection of recurrent disease by clinical examination, despite this being a rare event. Indeed, no recurrences were detected by clinical examinations in asymptomatic women in this study. HCPs’ style of interaction could foster the illusion that follow-up visits were intended to detect recurrence. Consultations were generally of brief duration (a mean of 6 min, the shortest consultation observed was one minute and 23 s) and were overwhelmingly optimistic, although patients gained reassurance from minimal interaction. Few opportunities were created (available) to meet information and psychosocial needs. The costly system of follow-up currently in operation is historically rather than evidence based, and subject to increasing demands and limited resources. Alternative approaches are needed that address the diversity of patients’ needs rather than searching for recurrent disease. However, when formulating policy and evaluating new approaches, patients’ expectations of what constitutes followup care need to be clearly addressed.

54 Factors Predicting Correct Knowledge of Treatment Intent Amongst Patients with Advanced Cancer and their Family Caregivers. A Report from a Longitudinal Study Burns CM1, Craft PS2, Lange K3, Smith WT4, Broom D5 1 Social Work Department, The Canberra Hospital Canberra Australia; 2Medical Oncology, The Canberra Hospital, Canberra, Australia; 3 Information Services Division, Flinders University, Adelaide, Australia; 4Centre for Clinical Epidemiology and Biostatistics, Newcastle, University, Newcastle, Australia; 5National Centre for Epidemiology and Population Health, Australian National University, Canberra, Australia PURPOSE: To examine factors predicting correct patient and caregiver understanding that treatment goals were non-curative. METHODS: A cohort of 317 Australian subjects, (181 patients and 136 caregivers) from The Canberra Hospital was followed for six months. Patients with

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advanced cancer were observed to death and censored March 31, 2003 (9 patients remained alive). Patients and their family caregivers’ understanding of treatment intent was measured and compared over time together with sources of information. A number of logistic regression models were used, with correct perception of treatment goals as the dependant variable. RESULTS: Patients who were married and lived in the city were more likely to correctly understand treatment goals when controlling for education and occupation levels, illness course catalogued as crisis, chronic or terminal, ambulatory status and time to death. Caregiver predictors were different and included: those aged under 40, those caring for patients with higher education levels, diagnosed with lung cancer, recruited from medical oncology, non-ambulatory, and with less than six months to live. At week 12, the only variable identified as significant was those caregivers who had stopped work to care. Caregivers who used education materials were more likely to have a correct perception. But those who relied on other health professionals than medical practitioners as an information source were significantly more likely to have an incorrect understanding of treatment goals. CONCLUSIONS: Knowledge of family caregivers’ social characteristics and consistent communication with the health-team is critical for effective oncology care planning.

55 Simply Calling Something a Team is not Enough:Improving Multidisciplinary Team Working in Cancer Catt SL, Fallowfield LJ, Jenkins VA, Langridge CI, Cox AC Cancer Research, UK Psychosocial Oncology Group, Brighton and Sussex Medical School, University of Sussex, Brighton, UK The multidisciplinary team approach promises benefits for patients through clear pathways of treatment and care decided by a team of experts and is also promoted as being beneficial for team members’ mental health. One report shows improved clinical outcomes for cancer patients through access to and use of protocol and up-to-

Copyright # 2004 John Wiley & Sons, Ltd.

date therapy. Another suggests that team composition, working methods and workload relate to the quality of clinical care delivered. We report on a Cancer Research UK funded study assessing satisfaction with team working, communication within and between the team and their patients, and the impact these factors had on team members’ psychological well-being. Six teams in breast and colorectal cancer participated. Findings were fed back to team members at a workshop to reinforce effective team working and to assist in the development of pragmatic strategies for improvement. Results showed a lack of interdisciplinary awareness about each others’ information giving roles and high levels of burnout in terms of emotional exhaustion and reduced levels of personal accomplishment. Psychiatric morbidity in teams ranged from general population levels of 12–27% previously reported in hospital consultants. Teams were committed provide an excellent service for their patients, but reported being frustrated by inadequate facilities for team meetings and a lack of protected time and administrative support for team working. We conclude that substantial resources need to be invested in team training and the provision of an environment that permits effective teamwork for the benefit of patients and healthcare professionals.

56 The Importance of Doctor–Patient Communication in Psycho-Oncology Cort!es-Funes F1, Abi!an L1, Go! ngora B2, Narva!ez A3, Rubin* os C4 et al. 1 Psycho-Oncology Unit Hospital, 12 de Octubre, Madrid, Spain; 2Psycho-Oncology Unit Hospital, Torreca!rdenas, Almeria, Spain; 3Psycho-Oncology Master Universidad Complutense, Madrid, Spain; 4 Psycho-Oncology Unit Asociacion Espan*ola Contra el Ca!ncer Ourense, Spain The relation between the doctor and the patients begins with the diagnosis. This moment will influence the kind of relation between them. A lot of studies have demonstrated that the different aspects of information influence the patients’ psychological adjustment. One of the objectives of this study is to measure the satisfaction of patients and their doctors in

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relation with their informational needs. We also search for the influence of several sociocultural and clinical characteristics of the patient when they ask for information. These characteristics are: age, sex, location of patient, cultural level, diagnosis, prognosis and performance status. The sample is composed by 45 patients with cancer and their oncologist. We elaborated a questionnaire that measures the needs of information about the diagnosis, treatment, prognosis of their disease and the degree of general satisfaction with the information received.

via health care professionals in cancer centres throughout the UK. This survey aims to identify the optimal way to communicate the process of randomisation in terms of clarity and patient preference in order to eradicate poor communication as a causal factor for poor accrual rates to clinical trials.

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Communicating the Concept of Randomisation: A Survey of Patient Preference Cox A, Jenkins V, Fallowfield L, Langridge C, Johnson L Cancer Research (UK), Psychosocial Oncology Group, University of Sussex, Brighton, UK

Physicians’ Communication with a Cancer Patient and a Relative: A Randomized Study Assessing the Efficacy of Consolidation Workshops Delvaux N1, Merckaert I1, Marchal S2, Libert Y1,2,3, Conradt S4 et al. 1 Unite! de Recherche en Psychosomatique et Psychooncologie, Universite! Libre de Bruxelles, Brussels, Belgium; 2C.A.M. (training and research group), Brussels, Belgium; 3Universite! Catholique de Louvain, Louvain-la-neuve, Belgium; 4Universite! de Lie"ge, Lie!ge, Belgium

As practice becomes more evidence based, the medical profession and governmental agencies recognise that the most accurate way to evaluate new treatments is within a randomised clinical trial (RCT). Health care professionals often have difficulty communicating the concept of randomisation to patients in the context of cancer treatment, as a result patients are often left confused and unable to make an informed decision regarding trial entry. Our initial work examined the preferences of patients and the general public to different descriptions of randomisation taken from Corbett’s study (1996) and compared them with clinicians’ current practice. Results showed that patients and members of the public preferred statements that did not reflect the current practice of the majority of clinicians. In contrast, the analogy ‘‘tossing a coin’’ used by 26% of clinicians was most disliked by over a third of patients (Jenkins et al. 2002). We wish to build on this research by reporting the preliminary results of a Cancer Research UK questionnaire based survey examining 700 cancer patients’ preferences for actual descriptions of randomisation. The descriptions were taken from current UK patient information sheets, the CancerBACUP website, the Cancer Research UK website and other organisations. Questionnaires were distributed

This study aims to assess the efficacy of participating to six 3-hour consolidation workshops after a 2.5-day basic training program on physicians’ communication skills in three-person interviews. Physicians, after attending the basic training program, were randomly assigned to consolidation workshops or to a waiting list. Training efficacy was assessed through simulated and actual interviews audiotaped at baseline and after consolidation workshops for the consolidation-workshops group, and 5 months after the end of basic training for the basic-training group. Physicians’ communication skills addressed to patients, to relatives and simultaneously to patients and relatives were assessed according to the Cancer Research Campaign Workshop Evaluation Manual. Patients’ and relatives’ satisfaction with physicians’ communication performance were assessed using a 15item questionnaire. Sixty-three physicians completed the training program. When they addressed patients, physicians in the consolidation-workshop group, compared to physicians in the basic-training group, used more open, open directive and screening questions (P=0.011 in simulated; P=0.005 in actual interviews) and elicited and clarified psychological concerns more often (P=0.006 in simulated; P50.001 in actual

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interviews). When they addressed relatives, they gave less premature information (P=0.032 in simulated; P50.001 in actual interviews). When they addressed simultaneously the patient and the relative, they used more supportive skills (P=0.003 in simulated; P=0.024 in actual interviews). Patients, but not relatives, who interacted with physicians in the consolidation-workshop group were more satisfied with physicians’ performance (P=0.022). Six three-hour consolidation workshops allow to improve communication skills addressed to patients and initiate the use of more effective skills addressed to relatives.

59 Medical Students Attitudes Towards Diagnosis Disclosure in Spain: Twelve Years Later Estap!e T1, Estap!e J2, Grau JJ3 1 Psycho-oncology, FEFOC, Barcelona, Spain; 2 Medical Director FEFOC, Barcelona, Spain; 3 Oncology, Barcelona University, Barcelona, Spain PURPOSE: In 1992 we published a survey on attitudes towards cancer diagnosis disclosure in a spanish sample, which included medical students. Now we want to ascertain if attitudes towards this crucial matter have changed and how. METHODS: A self-administered questionnaire about what they should want to know in case of being cancer patients and what to disclose to others was given to 49 medical students (4th year). This survey was conducted before receiving lessons on Oncology. RESULTS: Mean age of the sample is 22 years old. Most of them would prefer to be fully informed in case of having cancer in the future about diagnosis (91.89%), prognosis (83.7%) and consequences of treatment (95.9%). However in case of cancer would occur in other (relatives or friends) percentages were higher in ‘‘Depending on circumstances option (Diagnosis: 57.1%, Prognosis: 59.2%), except about ‘‘Treatment consequences’’ where most of the sample preferred to give fully information (49%). These percentages were statistically different from those obtained in 1992. CONCLUSIONS: Although more percentage of medical students in Spain prefer to be informed on diagnosis disclosure, it is not clear that they prefer the same for

Copyright # 2004 John Wiley & Sons, Ltd.

their loved ones. This is a pilot study, which needs widing the sample.

60 Good Communication when Disclosing Bad News: Patients’ Perspectives in Japan. Fujimori M1, 2, Akechi T2, Sakano Y1, Uchitomi Y2 1 Graduate School of Human Science, Waseda University, Tokorozawa, Japan; 2Psycho-Oncology Division, National Cancer Center Research Institute, East Kashiwa, Japan PURPOSE: Despite a recent increase in the attention given to improving communication when disclosing bad news, understanding of good patient-physician communication is still lacking in Japan. This study aimed to describe Japanese attributes of good communication when disclosing bad news regarding cancer. METHODS: Fiftynine participants, including 42 cancer patients, 10 family members, and seven oncologists, were invited to undergo an in-depth interview at the National Cancer Centre Hospital East in Japan. The data obtained were classified by qualitative analysis. Since there were no differences between patients, family members, and oncologists, all opinions were classified without dividing them according to source. RESULTS: Six-hundred seventy opinions on the attributes of good communication when disclosing bad news regarding cancer were obtained, and they were classified into four domains: (1) Setting: privacy and quiet room, face to face, being with family, trustworthy physician, sufficient time, (2) Content: disease, treatment, impact on daily activities and work, and alternative therapy, (3) Facilitation of patient’s understanding: speaking straightforwardly and honestly, avoiding medical jargon, written form, at the patient’s pace, and allowing questions, (4) Emotional support: warning signs, euphemisms, encouraging, telling in a spirit of hope, and allowing expression of emotions. CONCLUSIONS: These four domains of attributes of good patient-physician communication in Japan were identified. This basic information may help Japanese oncologists to improve communication with cancer patients and provide information that will assist in the development of intervention programs

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to facilitate good patient–physician communication from a Japanese perspective.

These points encourage more detailed exploration of Japanese patients’ preferences of communication when receiving bad news.

61 Japanese Cancer Patients’ Preferences of Communication when Receiving Bad News Fujimori M1,2, Akechi T2, Sakano Y1, Uchitomi Y2 1 Graduate School of Human Science, Waseda University, Tokorozawa, Japan; 2Psycho-Oncology Division, National Cancer Center Research Institute, East Kashiwa, Japan PURPOSE: In the U.S., it is reported that patients’ preferences of communication consist of content (what and how much information is told), support (emotional support during the interaction), and facilitation (setting and context variables) factors (Parker et al., 2001). The purpose of this study was to explore the components of the Japanese cancer patients’ preferences of communication when receiving bad news. METHODS: Randomly selected 529 cancer patients completed Japanese version of the Measure of Patients’ Preferences (MPP-J), that is a 46-item self-rating questionnaire, which was developed to assess cancer patients’ preferences of communication when receiving bad news in the U.S. They also completed the Mental Adjustment to Cancer (MAC) scale, and their characteristics. RESULTS: From 31-items of MPP-J, factor analysis extracted the following 5 factors (Cronbach’s alpha coefficients ranged from 0.86 to 0.91): Emotional Support; Facilitation and Answer to Questions; Clear Explanation; Medical Information; and Setting. Higher education and outhome-work were significantly associated with lower score on Emotional Support. Younger age, higher education, and outhome-work were significantly associated with higher score on Facilitation and Answer to Questions, Clear Explanation, and Medical Information. Younger age, higher education, and no outhome-work were significantly associated with higher score on Setting. CONCLUSION: There may be different component between Japan and the U.S., regarding cancer patients’ preferences. In Japan, emotional support component make the highest contribution to cancer patients’ preferences, in comparison with content in the U.S.

Copyright # 2004 John Wiley & Sons, Ltd.

62 Overview talks for Patients and their Families in an Oncology day Hospital Service: A Bridge Model Between Diagnosis and Therapy by Psycologist– Nurse Integration Gasparini GI, Ferretti FG, Carnevali CN, Bagnulo BA, Zoboli ZA Oncology San Sebastian Hospital, Correggio, Italy In our day hospital division we have experimented a global care approach consisting in programming, for every new case, an overview talk for our patients and families, performed by a nurse and the psychologist, after the diagnosis communication and before starting chemotherapy. OBJECTIVES: – patient’s compliance facility – better communication skills – lowering anxiety levels associated with lack of mental representations for the future – confirm the patient’s rights for a global care and a good Quality of Life. The overwrote talk is oriented to pick-up, by the psychologist, the major anamnesis information (social–cultural, family structure and ‘‘genogramma’’, life-cycle, past traumas, coping-styles, etc.), to verify diagnosis perception and to avoid lost or misunderstood information. The nurse shall have an active role in the explanation and discovery of all the items related to the specific characteristics of the cancer division and the assistance as well as chemo delivery modality, therapy time and hypothetic adverse reactions. We also have decided that the nurse participating in the talk with the patient was the same in service the starting day of the chemoschedule, so that, taking advantage from the imprinting process, we have continuative caring with good patient’compliance. RESULTS: – a family member always with patient – no drop-outs – low anxiety levels

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– better confidence producing beneficial compliance and coping styles.

63 The Journey: A Resource Guide for Patients and their Families in an Oncology Day Hospital Division Gasparini GI, Incerti IV, Brazzi BS, Zoboli ZA, Bagnulo BA Oncology San Sebastian Hospital, Correggio, Italy This informative booklet was produced by the oncologist, nurses and the psychologist of our division with the help of a professional graphic artist. It was supported by the Hospital Administration which intend to engage in the distribution to other oncology divisions. The booklet will be given to patients on their first admission, including the talk performed by the nurse and psychologist with the patients and their families. The booklet is addressed to patients candidate to chemo/radiotherapy and developed from the value information sharing during all the steps of the patient care program. Graphic issue was inspired from the symbolic message generated by the metaphor of the journey. The five imagines, done in aquarelle painting technique, show the phases of a hypothetic journey, then the filling of a travel bag, the start and the overviews you meet, the weakness you feel, the possibility to receive help and the arrival to final destination. With this booklet we want to facilitate transmission of medical and health issues through messages that came from emotional and relationship point of views. The booklet is easily consultable and doesn’t substitute the patient/health workers dialogue, but it’s an integration and supporting means to the development of a strong interaction between the care team and the patient. We also underline the support intervention of the family and friendly network to reduce the sense of loneliness so often referred.

64 Training Southern European Oncologists to Recognize Psychosocial Morbidity in their Cancer Patients

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Grassi L1, Travado L2, Gil F3, Baile W4 1 Dept. Medical Sciences Communication and Behavior, Section of Psychiatry University of Ferrara Ferrara, Italy; 2Psychotherapy Service, Hosptial S.Jos’ and Faculty of Psychology and Educational Sciences Indpendent University, Lisbon, Portugal; 3 Psycho-Oncology Unit; Hspital Duran i Reynals, Catalan Institute of Oncology, Barcelona, Spain; 4 Department of Neuro-Oncology, Psychiatry Section, MD Anderson Cancer Center, University of Texas, Houston, USA Communication and detection of psychosocial morbidity in cancer patients by oncologists have not been explored in Southern Europe. Within a specific project sponsored by the European Community (Southern European Psycho-Oncology Study) conducted in Italy, Portugal and Spain we developed a 12-h training course with aims of improving doctors’ ability in detecting psychological disorders in their patients. The workshop was standardized after a ‘‘train the trainers’’ course and consisted in provision of articles on communication skills, didactic presentations, scenarios of clinical interactions, large group discussions, exercises in small groups and role-play. The workshops were then applied to 30 oncologists in the three participating countries (Ferrara, Italy; Barcelona, Spain; Lisbon, Portugal). At the end of the workshops the oncologists-learners completed a scale assessing their satisfaction with the workshop. Most doctors considered that the workshop had much/very much reached its goals (86.6%), that the structure was much/very much adequate to the objectives (84.4%), that the methods were helpful/very helpful (96.7%), and that the workshop was relevant/ very relevant for their clinical practice (96.7%). The duration of the workshop was considered short by 56.7% of the doctors and adequate by 43.4%. Regarding the single ingredients of the workshop, the didactic presentations were evaluated as useful/very useful by 96.6% of doctors, the video-clips by 93.3%, the exercises in small groups by 93.3%, role-play by 93.3%, discussion in large group by 90% and the papers on communication by 76.7%. These preliminary data indicate the feasibility and importance of training Southern European oncologists in detecting psychosocial morbidity in. . . [truncated].

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‘‘How do you Assess your Chances of Getting Cured?’’ Grulke N1, Bailer H1, Larbig W2, Kaechele H1 1 Psychosomatic Medicine and Psychotherapy, University Hospital of Ulm, Ulm, Germany; 2Medical Psychology, University of Tuebingen, Tuebingen, Germany

An Audiotape Intervention to Enhance Informed Consent to Clinical Trials in Breast Oncology Hack T1, Whelan T2, Bultz B3, Magwood B4, Pritchard K5 et al. 1 Nursing and Clinical Health Psychology, University of Manitoba, Winnipeg, Canada; 2Radiation Oncology, Hamilton Regional Cancer Centre, Hamilton, Canada; 3Psychosocial Resources, Tom Baker Cancer Centre Calgary, Canada; 4Medicine University of Manitoba, Winnipeg, Canada; 5Medical Oncology, Toronto-Sunnybrook Regional Cancer Centre, Toronto, Canada

PURPOSE: It is assumed that during the informed consent before allogeneic BMT patients are fully educated about their prognosis. Does this mean that patients share the physicians’ estimates? We hypothesize: (1) Patients with poor prognosis rate their prognosis more favourable. (2) Correlations between depression/anxiety and prognosis are higher for the self ratings. (3) Survival time after BMT shows stronger associations to the expert ratings. METHODS: After informed consent patients and their transplanting physicians were asked for the prognosis on a 6-point Likert - scale (1=very good, 6=very bad). HADS was used to assess anxiety and depression. RESULTS: 142 patients were recruited from 10/1999 to 12/2001 at Ulm and Tu. bingen (Germany). In a first evaluation of 70 patients, we found that (1) Patients assessed their prognosis more favourable than the physicians (mean ratings 1.9 vs. 3.2, p50.01). Self ratings and physicians’ ratings do not correlate (r= 0.02, p>0.80). (2) Poorer prognoses in the self ratings are correlated with higher scores for anxiety (r=0.58, p50.01) and depression (r=0.62, p50.01). No correlation was found for the physicians’ ratings with HADS scores. (3) Survival time is highly associated with physicians’ but not with patients’ estimates. We will report on the total sample. CONCLUSION: Signing the ‘‘informed consent’’ does not mean there is consent about the prognosis. At this point, patients’ overoptimistic estimates may be psychologically necessary to go through the life threatening therapy.

Copyright # 2004 John Wiley & Sons, Ltd.

PURPOSE: To compare audiotape formats for conveying clinical trial information to women with breast cancer. METHODS: A subset of 69 patients solicited for participation in a large radiation therapy clinical trial (MA-20) were randomly assigned to receive an audiotape of their clinical trial consultation (n=20), a pre-made, standardized audiotape that included pertinent information regarding the MA-20 clinical trial (n=23), or both tapes (n=26). Follow-up measures, administered after the patients indicated whether or not they would participate in the clinical trial, included: Perception of extent of being informed about the trial; Knowledge of information relevant to having informed consent; Satisfaction with communication about clinical trial involvement; Value of the audiotape intervention; Preference for the consultation vs. standardized tape. RESULTS: The audiotape intervention was considered helpful by 70.5% of patients. Overall, patients felt well informed, were knowledgeable about the trial, and were satisfied with communication. Among all patients, 49.1% expressed a preference for having both tapes, 37.3% said they preferred the consultation tape, 11.9% indicated a preference for the standardized tape, and 1.7% stated no preference. Findings for those patients who received both tapes showed that 50% preferred the consultation tape, 15% preferred the standardized tape, and 35% had no preference. The study protocol was considered acceptable to most oncologists (90.9%) and clinical trial nurses (80.0%). CONCLUSIONS: Audiotapes of clinical trial consultations are highly regarded by women with breast cancer, and are generally favoured over standardized tapes. A sizeable minority prefer

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standardized tapes and a significant proportion appreciate having both tapes.

67 Physician–Patient Relationship and Euthanasia Hem E, Loge JH, Ekeberg Ø Department of Behavioural Sciences in Medicine, University of Oslo, Oslo, Norway In recent decades there has been a call for greater patient autonomy or self-determination in the physician–patient relationship. In fact, the principle of autonomy has become a cornerstone in modern medical ethics. Similarly, one of the main arguments in favour of euthanasia and physicianassisted suicide is the principle of patients’ autonomy. Thus, recent developments in the physician–patient relationship coincide with the ‘‘right to die’’ debate. In the Netherlands, the largest group of patients who die by euthanasia suffer from cancer. Will the request of euthanasiaor physician-assisted suicide influence the physician–patient relationship}and if it does, in what ways? The literature published 1966–2003 was reviewed via a computer search accessing Medline. Three main categories of papers were identified. First, theoretical papers claim that legalisation of euthanasia and/or physician-assisted suicide may have deleterious impacts on the physician–patient relationship, particularly the lack of trust. Others claim the opposite. However, no empirical studies were identified confirming or refuting these assumptions. It is also claimed that autonomy in the physician–patient relationship is limited to codetermination (dialogue), contrasted by self-determination (dictation). Second, two kinds of empirical studies have assessed the physician–patient interactions. A few papers have explored the hypothetical impact on patients if their physicians were conducting euthanasia. Moreover, a limited number of qualitative studies have been conducted in clinical settings. A core factor for a therapeutic relationship is the physicians’ ability to communicate adequately. Conclusively, there is a lack of empirical studies exploring the physician–patient relationship and euthanasia. Qualitative methods may be fruitful.

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68 Short Communication Training and Quality of Informed Consent in the Context of a Clinical Trial Hietanen P1, Aro AR2, Holli K3, Schreck M2, Joensuu H1 1 Department of Oncology University Hosp. of Helsinki Helsinki Finland; 2Department of Epidemiology, National Public Health Institute, Helsinki, Finland; 3Department of Oncology, University Hosp. of Tampere, Tampere, Finland AIM/METHODS: The aim was to evaluate the impact of communication training for clinical investigators on the quality of informed consent given to patients. The patients participated in a randomised clinical trial (RCT). The intervention group of investigators (n=6) had one day of training in how to interview patients that included role-play; the control group (n=8) had no training. Four months after randomisation the patients evaluated the quality of information received, and the communication skills of the investigators, using a questionnaire (QuIC+single items used previously). RESULTS: 90% (289) of the 320 questionnaires were returned. The patients seen by the intervention group doctors were more satisfied with doctor–patient communication (p=0.003), and they found more often that the time given to decision making was adequate than the control group (p=0.037). Ten months after the training the patients seen by the intervention group doctors understood better the aspects of informed consent (p=0.008), but this effect was no longer present at 18 months (p=0.15). Nearly all patients understood the method of treatment allocation. CONCLUSION: Training of investigators to communicate effectively increases patient understanding of the fundamental aspects of a clinical trial. However, the effect of investigator training may decrease with time, and repeat training during a RCT may be necessary.

69 Preliminary Lay Medical Decision Produces Risk Averseness Huber OW Psychology University of Fribourg, Fribourg, Switzerland

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The objective of the study was to demonstrate that the process of risky lay medical decision-making itself may result in risk-averseness. To that purpose, a quasi-naturalistic risky decision experiment was designed to investigate the effect of preliminary decisions}based on incomplete information}on a final decision based on complete information in the same task. It was expected that preliminary decisions would lead to a more intense processing of the negative outcomes and thus would make these more salient. In effect, a safe alternative with a moderate negative outcome would become more attractive compared to a risky alternative with two possible outcomes: A more negative outcome than that of the safe alternative and a neutral one. 100 subjects performed the task: a basic description depicted a decision situation with two alternatives, structured as described above. Subsequentially, subjects were given 10 additional pieces of information. In the preliminary decision condition subjects decided preliminary after each new piece of information, while control subjects only had to decide finally after having inspected all information. The results confirmed the hypothesis. 64% of the subjects chose the risky alternative in the control group, but only 44% chose it in the preliminary decision condition.

tion. Subjective and objective assessments were made pre (T1) and post (T2) workshop. Participants rated their self-confidence about different aspects of trial discussion and were videotaped discussing a trial of their choice with a simulated patient. An experienced rater, blinded to time point, checked for the presence/absence of essential points of key information. Simulated patients also assessed the interviews at each time point. RESULTS: 33 clinicians and 68 research nurses participated in the evaluation. Significant improvements were found on both subjective and objective measures of their communication behaviours. Selfconfidence increased significantly across all areas (P50.0001). Objective analysis of the video assessments demonstrated a positive shift with odds ratios showing significant changes for 10/15 items. Analysis of patient simulator ratings revealed a global improvement in participants’ discussions about trials (P50.0001). CONCLUSIONS: An intensive one-day programme significantly improved the confidence and competence of communication about RCTs. More of these interventions are needed to promote better understanding about trials and to encourage healthcare professionals to approach more eligible patients.

71 70 Efficacy of an Intervention to Improve Communication about Randomised Clinical Trials (RCTS) in Cancer Jenkins VA, Fallowfield LJ et al. CRUK Psychosocial Oncology Group, Brighton & Sussex, Medical School Brighton, UK PURPOSE: To assist communication between healthcare professionals (HCP) and patients about RCTs we designed and evaluated a comprehensive training programme. It comprises 4 modules with videotaped scenarios, interactive exercises and a comprehensive handbook. The first video deals with general issues surrounding the discussion and implementation of RCTs. The other 3 videos each contain 2 scenarios dealing with adjuvant trials, those with palliation as the goal and trials where patients have a preference for one treatment arm. METHODS: 101 HCPs participated in the evalua-

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Physicians are Different when they Learn Communication Skills: Influence of the Locus of Control Libert Y1,2,3,4, Merckaert I2, Delvaux N2, Marchal S3, Boniver SJ5 et al. 1 Institut Jules Bordet Brussels, Belgium; 2Universite! Libre de Bruxelles Brussels, Belgium; 3C.A.M. (training and research group) Brussels, Belgium; 4 Universite! Catholique de Louvain, Louvain-laneuve, Belgium; 5Universite! de Lie"ge, Lie"ge, Belgium PURPOSE: To test the hypothesis that physicians with an ‘‘internal’’ Locus of Control (LOC) (who believe that life outcomes are controlled by their own actions) would demonstrate communication skills acquisition to a greater degree than those with an ‘‘external’’ LOC (who believe that life outcomes are controlled by external forces such as luck, fate or others) following a communication skills training program. METHODS: Communication skills acquisition was assessed in two

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standardised simulated interviews before and after training (one two-person and one three-person interview). Communication skills were assessed using the Cancer Research Campaign Workshop Evaluation Manual. Physicians’ LOC was assessed using the Rotter I-E scale. Communication skills changes of the upper and lower quartiles of physicians in respect of their scores on this scale were compared using group by time repeated measures of variance. RESULTS: Sixty-seven medical specialists completed the training program. In the two-person and three-person interviews, the increase in open directive questions was greater among physicians with an ‘‘internal’’ LOC compared to physicians with an ‘‘external’’ LOC (P=0.066 and P=0.004 respectively). In the threeperson interview, the increase in directive questions (P=0.001), in assessing functions (P=0.002) and in the use of moderate feelings stated explicitly (P=0.011) was greater among physicians with an ‘‘internal’’ LOC compared to physicians with an ‘‘external’’ LOC. CONCLUSIONS: Physicians’ LOC could influence the efficacy of a communication skills training program. A psychological characteristic may facilitate communication skills acquisition through physicians’ belief that physicians themselves may control communication with patients.

72 Breaking Bad News with an Interdisciplinary Reception Protocol: Can we Reduce Anxiety Levels in Haematooncology Patients? Lo! pez-Fando T1, Arranz P1, Ulla S2, Rinco! n C1, Hern!andez-Navarro F1 1 Haematology and Haemotherapy Service, University Hospital, La Paz Madrid, Spain; 2Psycology University of Castilla La Mancha, Cuenca, Spain PURPOSE: (a) To evaluate the anxiety of patients recently admitted at the Haematology ward in the University Hospital La Paz; (b) To evaluate the anxiety of patients after interdisciplinary breaking bad news protocol, when they are informed about hemato-oncological diagnose; (c) To estimate the difference between these two moments. METHOD: A longitudinal study has been carried out to evaluate the anxiety of 13 patients when the interdisciplinary team welcomes a new patient,

Copyright # 2004 John Wiley & Sons, Ltd.

and after breaking bad news. We evaluated anxiety through a Likert scale (0–10), which was inserted in a semi-structured interview. Patients were asked: ‘‘How nervous, do you feel at this moment?’’ The 33% of the sample were men and 66% were women. The mean of age was 57 years (SD 14.48). RESULTS: The anxiety levels of patients when they were admitted to the ward reached a mean of 5.23 (SD 2.20), meanwhile after breaking bad news the mean decreased to 1.69 (SD 1.88). Considering these two moments statistically significant differences were found in the variable anxiety (Wilcoxon test: Z= 3.097; p=0.002). CONCLUSION: Patients who are welcomed with our interdisciplinary protocol feel relief; they feel less anxious after knowing their diagnoses than before. By using this protocol we can reduce the impact of breaking bad news and we suppose that it will facilitate the adaptation process (evaluation of this variable is taking place). Therefore, we suggest the use of an interdisciplinary breaking bad news protocol within the Counselling framework.

73 Can Communication Skills Training Improve Physicians’ Assessment of Psychological Distress in Cancer Patients ?}Results of a Randomised Study Merckaert I1, Libert Y1,2,3, Delvaux N1, Marchal S2, Boniver SJ4 et al. 1 Unite! de Recherche en Psychosomatique et Psychooncologie, Universite! Libre de Bruxelles, Brussels, Belgium; 2C.A.M. (training and research group) Brussels, Belgium; 3Universite! Catholique de Louvain, Louvain-la-neuve, Belgium; 4Universite! de Lie"ge, Lie"ge, Belgium PURPOSE: The purpose of this study was to assess the impact on physicians’ assessment of patients’ distress of participation to six 3-h consolidation workshops following a 2.5-day communication skills basic training program. METHODS: Physicians, after attending the basic training program, were randomly assigned to consolidation workshops or to a waiting list. Interviews with a cancer patient were audio-taped before training, after consolidation workshops and about 5 months after the end of basic training for

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the waiting-list group (T2). Patients’ distress was measured with the HADS. Physicians rated patients’ distress on a visual analogue scale (VAS). Communication skills were analysed according to the Cancer Research Campaign Workshop Evaluation Manual. RESULTS: At T1, physicians’ ratings of patients’ distress (VAS) were not correlated with patients’ distress (HADS). Moreover, physicians’ communication skills were not correlated with patients’ distress either. At T2, physicians’ ratings of distress were correlated with their patients’ distress in both groups (r=0.565; P50.001). This correlation improved significantly over time only in the consolidation-workshops group (r=0.166 at T1 and r=0.636 at T2, P50.05 for the consolidation-workshops group and r=0.291 at T1 and r=0.491 at T2, P>0.05 for the waiting-list group). Moreover, after training, physicians’ communication skills were correlated with patients’ distress in the consolidation-workshops group (r=0.444; P=0.018 for eliciting and clarifying psychological information) but not in the waiting-list group (r=0.284; P=0.129 for eliciting and clarifying psychological information). CONCLUSIONS. A 2.5-day basic training program initiates improvements in physicians’ ability to assess their patients’ distress that are further improved by six 3-h consolidation workshops.

74 How Accurately do Nurses and Oncologists Estimate Breast Cancer Patients’ Burden of Chemotherapy and Cancer? Mulders MCMA, Vingerhoets A, Nouws B, Van Aalst E, Breed W Psychology and Health, Tilburg University, Tilburg, Netherlands PURPOSE: It is unclear whether oncologists and nurses accurately estimate patients’ experienced burden of chemotherapy and cancer. The aim of the present study was to obtain insight into the degree of accuracy using a sample of 41 nurses, 49 oncologists and 80 former breast cancer patients. METHODS: A psychophysical questionnaire consisting of 19 items that described side-effects of chemotherapy and consequences of cancer was used. Hair loss served as reference point with a set score of 100; scores on other items reflected the

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burden relative to hair loss. The average ranking of the items was calculated for each group; all groups were compared to each other using Spearman’s rho. RESULTS: For all three groups the fear of metastases ranked first as most burdensome. Fatigue appeared second in the ranking of patients and oncologists, third in that of nurses. The most striking mismatch was found for hair-loss, which was rated fourth by patients, ninth by nurses and twelfth by oncologists. Rankings correlated +0.66 between patients and nurses, +0.62 between patients and oncologists and +0.90 between nurses and oncologists. CONCLUSIONS: Oncologists and nurses agreed to a greater extent with each other than with patients about what exactly are burdensome consequences of cancer and chemotherapy. It is concluded that both professional groups, potentially having a positive influence on the well-being of patients, should be more sensitive to the worries of their patients.

75 Measurment of the Impact of Cancer Diagnosis through the Thermometer Test and a Semi Structured Interview in a General Hospital Population Petit I2,3, Puig Me1,2,3, Ramos L1,2,3,, Iusin S1.2, Cesarco R1,2,3 et al. 1 Medical Psychology, Montevideo School of Medicine, Montevideo Uruguay; 2Psychosocial Medicine Unit Hospital Maciel, Montevideo, Uruguay; 3 Paliative Care Unit Hospital, Maciel Montevideo, Uruguay The authors investigate the impact of disease in patients admitted for a suspected cancer. Each patient went through the Clock test, the Distress Thermometer, the question ‘‘are you down or blue’’, and ‘‘what is your diagnosis’’, at the first day of staying and afterwards when the diagnosis is given. Two groups of patients were therefore discriminated, those who were explicited informed of the diagnosis of cancer, and those who were not informed. Each patient was compared with himself in the two moments and also the two groups were compared. First thing it striked was that patients referred to a symptom and not to a diagnosis.

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Very few were informed by his or her physician. The percentage of ‘‘nervous’’ (41%) was much higher than the depressed (37%). In the thermometer scale most of the patients rated high, (58%) and most of those who did rate low were confused. We were surprised of the results of the clock test since the percentage of low rating (cognitive impairment) was high (53%). Cultural difficulties that can be implicated in results and conclusions are discussed.

were related to counselees’ needs as measured prior to the counselee’s visit, and to outcome measures of the consultation in terms of counselees’ cognitions and anxiety. RESULTS: Preliminary results suggest that after feedback, counsellors provide more medical information and advice, and ask less medical questions. Counselees seen by a counsellor who received feedback perceived a lower risk of carrying a cancer gene. Feedback did not affect the extent to which psycho-social issues were discussed, nor counselees’ anxiety.

76 77 Genetic Counselling for Hereditary Cancer: Providing Counsellors with Feedback on their Communicative Behaviour Pieterse A1, Van Dulmen S1, Ausems M2, Beemer F2, Bensing J1,3 1 Communication research NIVEL, Utrecht, The Netherlands; 2Department of Medical Genetics, University Medical Centre Utrecht, Utrecht, The Netherlands; 3Health Psychology Utrecht, University Utrecht, The Netherlands BACKGROUND: The uncovering of cancer susceptibility genes has allowed personalized risk assessment through genetic counselling and genetic testing. Testing, however, has a number of limitations and genetic counselling may not provide counselees with the certainty they expected. A correct estimation of counselees’ prior needs may be critical for effective counselling, yet it is a difficult task. More attention is needed in finding ways how to improve this. PURPOSE: Assessing the influence of providing counsellors with feedback on their communicative behaviour on counsellor’s capacity to better tune in to counselees’ needs. METHODS: Counsellors (N=6) at the Department of Medical Genetics in Utrecht were randomly assigned to an experimental and a control condition. Counsellors in the experimental condition received a feedback training halfway the study period. All initial consultations counsellors conducted with new counselees (N=128) were videotaped, both before (all counsellors, N consultations=94) and after (experimental condition only, N consultations=34) feedback. Videotaped consultations were analyzed using an adaptation of the RIAS and these data

Copyright # 2004 John Wiley & Sons, Ltd.

Perspectives of Patients and Health Care Professionals (HCP) Regarding Communication about Chemotherapy Induced Infertility: A Qualitative Analysis Rosberger Z1,2,3, Achille M3, Chan P4, Lebel S3, Di Dio L1,2 et al. 1 Psychology Division, SMBD-Jewish General Hospital, Montreal, Canada; 2Psychosocial Oncology, Program McGill University, Montreal, Canada; 3 De!partement de psychologie, Universite! de Montre!al, Montreal, Canada; 4Department of Obstetrics and Gynecology, McGill University Health Centre, Montreal, Canada; 5Montreal, Canada BACKGROUND: Temporary or permanent infertility associated with chemotherapy treatment of testicular or lymphatic cancers in young men can result in increased psychological distress, lower self-esteem and often, interpersonal conflicts. HCP not only often lack clear information and guidelines about these potential difficulties, they also lack the skills necessary to communicate effectively with newly diagnosed patients about these issues. PURPOSE: The present study sought to identify factors that facilitated or impeded communication about chemotherapy induced infertility from both patients and HCP. METHOD: 20 HCP (e.g. oncologists, hematologists, urologists, nurses) and 15 testicular and lymphatic cancer patient survivors (between 2–10 years post diagnosis) were interviewed using a semi-structured protocol. Interviews were transcribed and analyzed for essential themes, using a grounded theory approach. RESULTS: HCP consistently expressed general ease in initiating discussion

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around infertility and sexual dysfunction, though this differed by gender and type of professional. Patients’ perception about their own or the HCP comfort and knowledge level in communication was more variable. Patients tended to focus on illness impact, treatment and survival issues, while fertility issues and sperm-banking decisions tended to create additional anxiety in the initial phase just after diagnosis. IMPLICATIONS: Patients had different expectations from HCP of what information was valuable to them and what role the HCP should take in the communication process. More (and repeated) time for discussion, clearer and more accurate information were among the most important. Recommendations for guidelines and training for communication around these important issues will be discussed.

78 Personality and Preferences for Communication in Spanish Cancer Patients. A Multicentric Study. Catalan-Balearic Psycho-Oncology Group (PSOCAB) S!anchez N1, Sirgo A2, Leo! n C3, Hollenstein MF4, Lacorte-Pi TM5 et al. 1 Clinical Institute of Psychiatry and Psychology, Hospital Cl!ınic Barcelona, Spain; 2Psycho-Oncology Unit. Oncology Department, University Hospital, Sant Joan Reus, Spain; 3Clinical Haematology Department, University Hospital, Sant Pau Barcelona, Spain; 4Psycho-Oncology Unit, Catalan Institute of Oncology, Barcelona, Spain; 5IMOR Foundation, Barcelona, Spain PURPOSE: (1) To study preferences for communication in a Spanish sample of cancer patients, and (2) to describe the relationship between preferences for communication and socio-demographic, tumor related and personality variables. METHODS: A sample of 71 Spanish cancer patients completed a set of questionnaires: (1) the Spanish adapted version of ‘‘Measure of patient’s preferences for communication’’ which includes three variables: content (what and how much information is told), facilitation (setting and context variables) and support (emotional support during the interaction), (2) the Extraversion and Neuroticism scales from the short form of ‘‘Eysenck Personality Questionnaire-Revised’’,

Copyright # 2004 John Wiley & Sons, Ltd.

EPQ-RS, (3) the EORTC QLQ-3.0 Quality of Life questionnaire and (4) the ‘‘Hospital Anxiety and Depression Scale’’, HADS. RESULTS: EPQ’s Extraversion factor shows a significant correlation with higher needs for information (content variables) (p=0.001) and emotional support (support variables) (p=0.014) in the doctor-patient communication setting. Women show higher scores in content variables (p=0.001), support variables (p=0.004) and facilitation variables (p50.001) than men. Younger patients show higher scores in content variables (p=0.013) than older patients. Patients with a recurrence of the disease show a higher interest on facilitation variables than first diagnosis patients (p=0.008). Quality of life and emotional distress do not show a correlation with preferences for communication. CONCLUSIONS: Personality, age, gender and cancer recurrence diagnosis are very important variables to take into account when studies on doctor–cancer patients communication are made.

79 Not Only Bad News Scaffidi E1, Lucchini D2, Crotti N3, Fasser N4, Zaninetta G5 et al. 1 Psychoncology Unit and WHO Collaborating Center for Cancer Control and Palliative Care, European Institute of Oncology, Milan, Italy; 2 Service of Psychology, Casa di Cura S. Anna Brescia, Italy; 3Service of Psychology, Istituto Nazionale per la Ricerca sul Cancro Genova, Italy; 4 Palliative Care Service Hospice Domus Salutis Brescia, Italy; 5Palliative Care Service Hospice Domus Salutis Brescia, Italy INTRODUCTION: Often doctors believe patients do not want to know their health situation and truth cannot give positive effects. But many people with cancer want to receive honest information to face the disease with energy and hope. PURPOSE: To observe doctors’ fears to tell the truth to patients and cultural and psychological obstacles to an empathic therapeutic relationship. Cinema and theatre can serve more than a frontal lecture to this aim. METHODS: Cinema and theatre are contaminated to emotionally experience how difficult is both giving and receiving bad news.

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Representation put on the stage the patient’s painful itinerary to accept bad news and to build up a respectful dialogue with doctors. Theme is narrated through images exerted from films, patients’ letters, doctors’ evidences and passages from scientific literature, underlined by musical accompaniment. Lecture will feedback the audience on how some of the members of the Italian Psycho Oncology Society worked using the group brainstorming. RESULTS: Audience could reconsider how difficult is for physicians to communicate bad news, while re-visiting misconceptions and false beliefs. Patients’ feelings were investigated to make clear the rational and emotional process needed to know their actual and future clinical status. CONCLUSIONS: Audience awareness about the importance to share cancer disease inside the family, and not to hide the truth to kids as well, was importantly increased. Individuals realized how relevant is for cancer patients to be gradually accompanied to face difficulties. The theatre show has been requested by voluntary associations, hospitals and medical institutions throughout Italy.

80 Optimism, Hope and Survival: What Message are Appropriate? Schofield PE1, Ball D2, Smith J3, Borland R4 1 Haematology & Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia; 2 Radation Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia; 3Statistics Department, Peter MacCallum Cancer Centre, Melbourne, Australia; 4VicHealth Centre for Tobacco Cancer, Council of Victoria, Melbourne, Australia PURPOSE: A person’s psychological response to cancer, particularly optimism or ‘a positive attitude’ is popularly believed to influence survival, however research has produced contradictory results. METHODS: 204 patients, who were participating in a randomised trial that compared accelerated and conventional radiotherapy with and without carboplatin chemotherapy, were asked to complete a Life Orientation Test which assesses optimism just prior to commencing treatment and the second after completing treatment. Survival was measured from the date of

Copyright # 2004 John Wiley & Sons, Ltd.

randomisation to date of death. Patients were followed for up to 10 years. RESULTS: There was no association between pre-treatment optimism and progression-free survival nor was there an association between pre-treatment optimism and overall survival. CONCLUSIONS: There was no evidence that a high level of optimism prior to treatment enhanced survival in people with NSCLC. We should question whether it is valuable to encourage optimism if it results in the patient concealing his or her distress in the misguided belief that this will afford him or her survival benefits. However, hope should be conveyed in an environment that supports the expression of fears and uncertainty for the future, so that the patient does not feel emotionally stymied. Discussion will focus on the distinction between hope and optimism and what messages are appropriate.

81 Courage to be}and what do we need to Develop Communication Skills Further? Svarre HM, Brandrup S, Holmstrup U, Boege P Patients Support, Couseling Centre Lyngby, The Danish Cancer Society, Lyngby, Denmark In the year 2000, the Danish Cancer Society launched an educational concept. The idea was to learn doctors and other professionals in health care to communicate better with cancer patients and their relatives. The Teaching concept is different from most of the literature on communication with cancer patients. The intention is to make the professionals reflect on the way they have these serious dialogues, rather than to teach them a specific way to communicate. The teaching concept is based on an existential psychological frame of reference. The material consists of a textbook and a video. The textbook deals with the following themes: Anxiety, The Family, Hope and The Interview. Furthermore, it contains a ‘‘how to do it’’ instruction to the teacher. The video consists of a number of sequences from three television documentaries, Courage to be. It shows unique shootings from a group therapy with cancer patients. The video scenes reflect the abovementioned four themes. The learning method

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encourages reflection, discussion, experience, situation games and exercises. The material has appeared to be a very useful tool in the learning process of communication skills. Here, a large number of doctors and nurses share their good experiences from their dialogue with cancer patients. The next step is to gather these positive stories from both cancer patients and professionals and use their examples to develop a new narrative approach to a better communication.

workshop. In relation to attitude, participants put more importance on the need to address sexual complications during cancer treatments and indicated less embarrassment to talk about sexually related matters with patients after participating in the workshop. The participants also noted the extreme importance in establishing a sustainable network for participants to exchange information on cancer and sexuality and to share experiences in the clinical setting.

83 82 Development and Evaluation of a ‘‘Cancer and Sexuality’’ Education Program for Medical HealthCare Providers Takahashi M1, Ohkawa R2, Kaneko K3, Watanabe C1, Kai I1 et al. 1 Social Gerontology, School of Health Science and Nursing, University of Tokyo, Tokyo, Japan; 2 Obstetrics and Gynecology, National Chiba, Hospital Chiba, Japan; 3Counseling Service Japan Red Cross Medical Center, Tokyo, Japan To develop, implement and evaluate an educational workshop to improve health-care providers’ information and skills to deal with female cancer patients’ sexual health needs arising from their cancer treatment. The one-day workshop developed by the authors included lectures on the female sexual response, sexual complications arising from various cancer treatments, special issues regarding gynaecological and breast cancers, a role playing exercise based on scenarios found in clinical settings, and a group discussion on the practicalities involved in creating clinical settings that support patients’ sexuality related treatment needs. 33 health-care providers (10 medical doctors and 23 nurses) participated in the workshop which took place in April, 2003. A two-panel questionnaire survey was conducted 1 week before and 3 weeks after the workshop in order to evaluate changes in participants’ knowledge and attitudes towards sexuality and cancer, and self-efficacy in dealing with patients’ sexual issues. The evaluation found that participants’ knowledge as well as their self efficacy were significantly improved after the

Copyright # 2004 John Wiley & Sons, Ltd.

What Survival Benefits do Pre-Menopausal Early Breast Cancer Patients Consider Necessary to make Endocrine Therapy Worthwhile? Thewes B1, Meiser B1, Duric V2, Stockler M2, Friedlander M1 et al. 1 Department of Medical Oncology, Prince of Wales Hospital, Sydney, Australia; 2NHMRC Clinical Trials, Centre University of Sydney, Sydney, Australia Endocrine therapies such as tamoxifen, goserelin and oophorectomy provide modest survival benefits for pre-menopausal women diagnosed with early breast cancer. However, these treatments may result in menopausal symptoms, sexual dysfunction, permanent infertility or the need to delay pregnancy. PURPOSE: This study aims to quantify the survival gains that pre-menopausal early breast patients cancer require to justify the side effects and inconvenience of adjuvant endocrine therapies. SUBJECTS: Data gathered from 103 early-stage (Stage I or II) breast cancer patients, who were treated for a minimum of 3 months with endocrine therapy (tamoxifen, goserelin and/or oophorectomy) and who were between 6–60 months post-diagnosis at interview will be presented. METHODS: Participants are asked to complete a face-to-face patient preferences interview that presents patients with four hypothetical clinical scenarios. The scenarios aim to quantify (a) survival rate benefit and (b) time benefit required to justify endocrine therapy. RESULTS: Preliminary results suggest that the majority of participants would consider adjuvant endocrine therapy worthwhile for 3% or less absolute gain in survival (56% of women) and 3 months or less gain in life expectancy (52% of women).

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CONCLUSIONS: Pre-menopausal breast cancer patients consider adjuvant endocrine therapies worthwhile for modest survival gains. A better understanding of pre-menopausal patients’ preferences for endocrine therapy should help premenopausal breast cancer patients to make more informed decisions about adjuvant endocrine therapy. The results can also be used to complement data currently emerging from clinical trials of endocrine therapy in pre-menopausal early breast cancer.

that many younger women have unmet needs for fertility- and menopause-related information. Data on predictors of participant’s satisfaction with and preferences for timing and format of fertility- and menopause-related information delivery will be presented. CONCLUSIONS: The results of this study provide preliminary empirical data to guide the development of better fertilityand menopause-related patient education materials for younger women with diagnosis of early breast cancer.

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The Fertility and Menopause Related Information needs of Younger Women with a Diagnosis of Breast Cancer Thewes B1, Meiser B1, Stuart-Harris R2, Links M3, Wilcken N4 et al. 1 Department of Medical Oncology, Prince of Wales Hospital, Sydney, Australia; 2Department of Medical Oncology, The Canberra Hospital, Canberra, Australia; 3Department of Medical Oncology St. George Hospital, Sydney, Australia; 4Department of Medical Oncology, Westmead Hospital, Sydney, Australia

Cancer Staff Communication Skills Training in the Context of a Clinical Psycho-Social Cancer Service Tolosa I1,2,3, Horne D1,2,3, Coombes L1 1 University Hospital of Birmingham, Psycho-Social Cancer Service, Birmingham, UK; 2Birmingham and Solihull Mental Health NHS Trust Psychology Services, Birmingham, UK; 3School of Psychology, University of Birmingham, Birmingham, UK

The use of chemotherapy and endocrine therapies in the treatment of pre-menopausal women carries with it reproductive and gynaecological implications which younger women may find both unpleasant and discordant with plans for childbearing. PURPOSE: This multi-centre study aims to investigate the fertility- and menopause-related information needs amongst pre-menopausal women with a diagnosis of early breast cancer. SUBJECTS: This study aims to recruit 250 women with a diagnosis of early breast cancer who are aged 40 years or younger at diagnosis and who are from 6–60 months post-diagnosis. To date approximately 210 women have been recruited to the study. Data collection will be completed by August 2004 and final results on the entire sample will be presented. METHODS: Participants completed a mailed self-report questionnaire that included a purposely designed fertility- and menopause-related information needs survey, as well as standardised measures of distress, anxiety, quality-oflife, optimism, menopausal symptoms and information seeking style. RESULTS: Results suggest

Copyright # 2004 John Wiley & Sons, Ltd.

The Psycho-Social Service at the Cancer Centre, University of Birmingham, UK is a ten year old regional service, employing four qualified psychologists and two trainee psychologists. It provides to 5000 patients yearly. In addition to offering support and therapy to patients and families, the Service has recently commenced training in psychological screening and communication skills (CS) to medical and nursing staff. The model used is based on that developed by Maguire (1996) and the Service aims to provide initial training and ongoing staff support via tutorials. Completed training modules to date include: Half-day communication skills session with role play for 16 Dermatology and Plastic Surgery Registrars in groups of four, each facilitated by two trainers. Five months pilot with 3 docutros and 2 trainers: 90 min monthly. Six months pilot with four groups of four Clinical Nurse Specialists for an hour-and-a-half monthly. This pilot was deemed highly successful and has become permanent. RESULTS: Feedback from this training has been very positive. Participants acknowledge the benefits of space and time to explore the difficulties of talking to people with cancer, including breaking bad news at diagnosis, etc. Increasing awareness and training in the importance of effective

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communication has obvious benefits for patient care. Similar communication skills workshops are planned over the next few months for cancer staff from neighbouring regional cancer services.

86 Shared Decision making in Primary Breast Cancer}Preliminary Results of a Randomised Controlled Trial Vodermaier A, Caspari C, Bauerfeind I, Kahlert S, Koehm J et al. Department of Obstretrics and Gynecology, Grosshadern University of Munich, Munich, Germany Therapies for breast cancer are straining, especially chemotherapy. Many patients are unsure about their optimal therapy and there is a considerable proportion of women who want to be more involved in treatment decisions. Taking an active role in cancer therapy may furthermore induce favourable locus of control perceptions and a higher quality of life. Several decision aids have been developed to support involvement of patients in therapy planning. Whelan et al. (1999) introduced decision boards to investigate shared decision making in breast cancer patients and found a high acceptance of the method both on the doctor’s and on the patient’s side. To investigate several options in treatment of primary breast cancer decision aids (decision boards and information brochures for the patients to take home) for three therapeutic and one diagnostic option were developed. Decision making under study were the following: 1. breast conserving therapy and irradiation vs. radical mastectomy 2. sentinellymphnode biopsy vs. axillary dissection 3. chemotherapy and endocrine therapy vs. pure endocrine therapy 4. preoperative chemotherapy vs. postoperative chemotherapy Shared decision making was operationalized by additionally applying decision aids and information brochures on the specific treatment

Copyright # 2004 John Wiley & Sons, Ltd.

options in question for the intervention group. Research questions under study are the extent of breast cancer patients’ wishes to be involved in therapy planning, whether there are differences between the intervention and control group concerning perceived involvement in their therapy, in terms of the therapy chosen and decisional conflict. Preliminary results will be presented and discussed.

Community-Based Support 87 35 Year History of Pschosocial Oncology}Implications for the Future Bolund C Unit of Psychosocial Oncology and Rehabilitation, Department of Oncology, Karolinska University Hospital, Stockholm/Solna, Sweden PURPOSE: Some units of psychosocial oncology do have years of experience}is it not time for looking at the history and for drawing conclusions of gains and costs, strengths and weaknesses of different models? METHODS: By describing our unit with its successes and shortcomings, it is the aim to put up a mirror or a check list with which to compare and describe relevant elements in the structure of psycho-social work in cancer. RESULTS: We will look closer at some of the elements of development: Clinical service, developmental work and routine praxis, integration in the community health care and in the university hospital, multiprofessional and interdisciplinary possibilities and problems, division between research and clinical work, team formation between psycho-socials and paramedics, training of specialists, generation shift coming on. CONCLUSIONS: The future of psychosocial oncology will depend on the way we manage to organise in or out of community, health-care or charity, how we will train professionals within our own field, how we manage integration without drowning in routine and administration. How will we be able to continue to move at the frontier of cancer care development?

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88 Community Cancer Care: Model and Implementation Bosserman LD, Carter SE Cancer Care WOMG La Verne, Californai, USA PURPOSE: We report on the initial outcome data collected on cancer patient characteristics, demographics and treatment utilization at an on site psycho-oncology counselling model in a community cancer care centre. We report on our current use of this on site counselling model in conjunction with the development and implementation of a computerized tablet for patient self reporting and monitoring. METHODS: We provided psycho-oncology counselling on site in a community cancer centre. From 1997 to 2000 data was analyzed from chart reviews of treated patients including demographics of patients and family members, issues addressed in counselling, marital status, and type of cancer and disease stage at diagnosis. Beginning January 2004, a computerized tablet was introduced at each patient visit to assess and track physical, social, spiritual, and psychological patient distress levels and symptom needs. A summary is immediately available to the treatment team at time of visit, with special indicators for areas of significant change and requests for help. RESULTS: The addition of the computerized assessment tool to the established on site counselling model allows a more formalized and immediate assessment of patient distress, which can trigger immediate interventions as well as providing quantified measures of distress, referrals and treatment outcomes. CONCLUSION: For the first time, clinicians can immediately collect and analyze data as well as provide concurrent interventions for patient’s psychological distress with the goal of improving comprehensive cancer care.

89 ARC Cancer Support Centre}Holistic Care in Cancer Courtney UM Director of Services, ARC Cancer Support Centre, Dublin, Ireland

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ARC Cancer Support Centre, a voluntary organisation and registered charity, was officially opened in 1996 to provide professional and holistic support to adults affected by all types of cancer. Patients react to a cancer diagnosis with a variety of emotions including shock, anger, guilt, denial, anxiety and depression. Psychosocial oncology focuses on how the physical manifestations of cancer impact upon the cognitive, behavioural, social and spiritual components of the lives of patients with cancer. Psychosocial interventions aim to alleviate the emotional and social impact of cancer on patients and their families. The support offered by ARC Cancer Support Centre includes counselling, psycho-educative group courses and research based complementary therapies. Information is a basic form of support and having adequate information is essential to the patient and family in adapting to a diagnosis of cancer. Studies suggest that patients who receive good information are more satisfied with their care and demonstrate lowered levels of anxiety and depression. Psycho-educative group support helps people who have similar problems to act as role models to one another, especially in the use of adaptive coping responses. Complementary therapies are not a replacement for conventional forms of cancer treatment but they are considered helpful in enhancing symptomatic relief and well-being when used as an adjuvant to traditional medical care. This paper describes the perceived benefits of a cancer support centre in an Irish context as ARC Cancer Support Centre helps people affected by cancer to develop coping mechanisms.

90 How Community-Initiated Research Collaborations make a Difference: Real Science for Real People Golant M1, Lieberman M2, Giese-Davis J3, Winzelberg A3 1 Research & Development, The Wellness Community, Santa Monica, USA; 2Department of Psychiatry, University of California, San Francisco, San Francisco USA; 3Department of Psychiatry, Stanford University, Stanford, USA Increasingly, the NCI and the NIH are emphasizing the significance of translating research findings

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into practice. Community-Initiated Research Collaborations (CIRC) is one model designed to bridge the gap between the lab bench and the park bench. In 1996, The Wellness Community (TWC) joined with academic research partners at Stanford University and the University of California San Francisco to answer questions not only important to TWC, but also the psychosocial oncology world. Key components of a successful CIRC will be discussed based upon a pilot study entitled, ‘‘The Effectiveness of Electronic Support Groups for Women with Breast Cancer’’ that led to the launch of The Virtual Wellness Community (www.thewellnesscommunity.org). Essential elements include understanding that researchers and the community operate from differing cultures}researchers focus on innovative science and bring scientific clarity to an issue valued by real people. The community organization tests innovation and needs to market and promote these results in order to serve more people. Conflicts may emerge in communicating scientific findings accurately to the public. Bridging this cultural gap requires: sharing power equally; understanding that the goal is to further science not evaluate programs; and, working together to disseminate findings in venues appropriate to both parties. We will outline a model of successful collaborations; share lessons learned and identify barriers to effective translational research.

naires at baseline and 6 month follow-up. Participants who indicated they had ceased group attendance at 6 months were administered a brief questionnaire, including qualitative questions, exploring their reasons for leaving their support group. Second, patients of 4 oncologists were invited to participate in semi-structured focus groups or telephone interviews, aiming to examine their perception of support groups, current support, and barriers to group attendance. RESULTS: Comparisons of those who had left their support group (n=28) and those who continued to attend (n=159) found that the former reported lower baseline levels of anxiety (p50.016) and satisfaction with their support group (p50.004). Three focus groups with 15 people and 14 individual interviews were also conducted. Analysis of qualitative responses of all participants indicated that the main barriers to attending a cancer support group included practical issues, difficulties related to their illness, concerns about the support group being a reminder of their cancer and the sense that their support needs were currently satisfied. CONCLUSION: The data obtained provides some insight into the experience of people who do not attend cancer support groups as well as the barriers to support group attendance.

92 91 Cancer Patients who don’t attend Support Groups: Barriers and Perceptions Kirsten LT1,2, Ussher JM1, Butow P2, Wain G3, Smith K3 et al. 1 School of Psychology, University of Western Sydney, Sydney, Australia; 2Medical Psychology Research Unit, University of Sydney, Sydney, Australia; 3Department of Gynaecological Oncology, Westmead Hospital, Sydney, Australia PURPOSE: To investigate the barriers to cancer support group attendance and consider the perceptions of support groups held by cancer patients who do not attend them. METHOD: Participants were recruited in two ways. First, 187 attendees recruited from a random sample of 50 cancer support groups in NSW were mailed question-

Copyright # 2004 John Wiley & Sons, Ltd.

Prospective Investigation of the Relationship between group Characteristics and Patient Outcomes in Cancer Support Groups Kirsten LT1,2, Butow P1, Ussher J2, Wain G3, Hobbs K3 et al. 1 Medical Psychology Research Unit, University of Sydney, Sydney, Australia; 2School of Psychology, University of Western Sydney, Sydney, Australia; 3 Department of Gynaecological Oncology, Westmead Hospital, Sydney, Australia PURPOSE: Despite the increasing popularity of cancer support groups little is known about their characteristics and impact. This study examined the relationship between group characteristics and patient outcomes over time. METHODS: Group leaders participated in an audit of 184 cancer support groups in NSW, Australia. Following this, a set of outcome measures and key group

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characteristics (locality, heterogeneity, setting, facilitator training, cancer experience of group leader) were developed and reviewed by an advisory group that included consumer representatives. Random sampling within the strata of the group characteristics was used to select 50 cancer support groups. Group members were sent questionnaires assessing quality of life, psychological well-being, cancer-related self-efficacy and satisfaction with the group. Participants included 333 people with cancer and 80 people who were carers. People with breast cancer (40%) and prostate cancer (36%) constituted the majority of the sample. Questionnaires were sent to participants at 3 time points, baseline (study entry), 6 months and 12 months. RESULTS: This presentation will discuss results of the 6 and 12 months follow-up results. Analyses will explore the impact of group process variables on patient outcomes over time.

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and time II (r=0.29), and between support and psychological states at time II (r= 0.41). Significant differences were found in physical states (t= 8.12; df=56; p=0.001) between time I (M=1.30; SD=1.19) and time II (M=3.60; SD=1.95), in support (t=3.87; df=54; p=0.001) between time I (M=4.00; SD=0.47) and time II (M=3.77; SD=0.52), and in conflict (t= 2.65; df=54; p=0.01) between time I (M=2.35; SD=0.47) and time II (M=2.50; SD=0.44). However, no significant differences were found in psychological states between time I and time II. CONCLUSIONS: Healthcare professionals need to consider social support as an important factor to help Japanese women’s adjustment to breast cancer. Further studies are needed to investigate the relationship of social support, psychological and physical states as a process of breast cancer experiences.

94 93 Social Support, Psychological and Physical States Among Japanese Women with Breast Cancer Makabe Reiko1, Nomizu Tadashi2, Sato Mie3, Komiyama Yoko3, Kikuchi Junko3 1 School of Nursing, Fukushima Medical University, Fukushima-shi, Japan; 2Department of Surgery, Hoshi General Hospital, Kooriyama-shi, Japan; 3 Depatment of Nursing, Hoshi General Hospital, Kooriyama-shi, Japan PURPOSE: The purpose of this study was to explore the relationship of social support, psychological and physical states among Japanese women with breast cancer, and to compare the variables before and after breast surgery. METHODS: Fifty-seven Japanese women with breast cancer participated in this study. Two instruments with established reliability and validity were used: the Japanese versions of the Interpersonal Relationship Inventory to measure support and conflict and the General Health Questionnaire to measure psychological states. Data were collected twice: before (time I) and three months after breast surgery (time II). Data analysis included Peason’s correlations and paired t-tests. RESULTS: Significant correlations were found between physical states and psychological states at time I (r=0.35)

Copyright # 2004 John Wiley & Sons, Ltd.

Analysing Socio-Economic-Cultural Diversity in Developing world to Modify Education Policy of Tobacco-Induced Cancer Pramod S, Narayanan R Health Alert Organisation of India, Dhule, India INTRODUCTION: Health education is crucial in motivating adolescents against tobacco use. Health policy matters depend on sociocultural and economic factors. We studied six educational methodologies on tobacco control. METHODOLOGY: Since October 2002, six conventional health educational methods analysed. TARGET: Rural/ tribal community divided in 11 groups based on economic/social/cultural and ethnic background. Our NGO modified conventional health education methods to study impact of newer methods in tobacco control. Followed by series of lectures, symposia and seminars in four subgroups. Each included school peers [60%], factory workers [12%], farmers [23%], others [5%]. After exposure of above population to modified health education/ teaching methods over 20 sessions revaluation was done. Objective was change in tobacco use habits. RESULT: 83% of population showed perceptive change in reduction/abstinence from tobacco use. 11% did not show this change. 3% population non-respondent [follow-up-failure], 3%

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population of targeted adolescents were hooked back to tobacco use after completion of study. Social factors changed revaluation in 28%, cultural factors in 27%, economic criteria in 40%, religious factors in 5%. DISCUSSION/CONCLUSION: We need to focus on cultural economical and social perceptions in education. For developing nations this approach will certainly have positive impact on exploring and problematizing socio-cultural diversity and difference with special significance to reduce tobacco use to statistically significant level of reduction. RECOMMENDATIONS: Community of educators and evaluator’s need to devise and practise specific conditions for tobacco withdrawal policy on sociopolitical level, so that reforms towards organisational and institutional development are contributing towards betterment of the society.

95 Voluntary Service and Oncological Pole}A Coordination, Formation and Supervision Proposal Tempia Valenta P1, Rossi R2, Forzan F1 1 Polo Oncologico ASL 12 Piedmont Region, Biella, Italy; 2Fondo e tempia Non-Profit Organization, Biella, Italy The volunteers are often motivated by a sheltering, returning or elaborating desire, and ask to occupy themselves and to become useful to sick persons. The P. O. offers, thanks to the organized Voluntary service, an activity of acceptance near the Day}Hospital, a relief activity near the stay in hospital unit called ‘‘let’s take tea together’’, and an activity of assistance at the patient domicile with the Palliative Cares. The task consists in keeping ‘‘sufficiently good company’’ to the sick person. The intervention is substantially a presence, defined from the same volunteers like a ‘‘transparent volunteer’’. Such presence mitigates, with its availability and attention, the threatening, persecutory or exclusively refusing perception of the external world. It seems important to describe the characteristics of the aid relation volunteer/ sick person, specific qualities resumed in some points, surely not exhaustive of its complexity: 1. Inexpert volunteer of professional aid relations.

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2. Volunteer lacking in acquaintances and experiences with sick persons. 3. Volunteer who attends indications on procedures, techniques and method to get professional, not remaining knot and alone in front of his sick interlocutor who attends a concrete and often material aid. We’ll describe in this job: 1. Coordination of the voluntary service. 2. Understanding Action between Oncological Pole and Associations. 3. Guide lines of formation. 4. Briefing with the Voluntary service Coordinators. 5. Volunteers’ Supervision. 6. Permanent and basic formation. 7. Support groups.

Distress 96 Major Depression, Adjustment Disorders, and PostTraumatic Stress Disorder in Terminally ill Cancer Patients: Associated and Predictive Factors Akechi T1,2, Okuyama T1, Sugawara Y1, Nakano T3, Shima Y4 et al. 1 Psycho-Oncology Division, National Cancer Center Research Institute, East Kashiwa, Japan; 2 Psychiatry Division, National Cancer Center Hospital, East Kashiwa, Japan; 3Psychiatry Division, National Cancer Center Hospital, Tokyo, Japan; 4Palliative Care Unit, National Cancer Center Hospital, East Kahiwa, Japan PURPOSE: Few studies have been conducted to elucidate the psychological distress of terminally ill cancer patients. This study attempted to determine the prevalence of adjustment disorders (AD), major depression (MD), and post-traumatic stress disorder (PTSD) among terminally ill cancer patients, to identify factors that contribute to them, and to determine how they change longitudinally. PATIENTS AND METHODS: Consecutive terminally ill cancer patients were recruited. Patients were assessed for psychiatric

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disorders by structured clinical interview twice, once at the time of their registration with a palliative care unit (PCU) (baseline) and again at the time of their PCU admission (follow-up), and possible contributed biomedical and psychosocial factors were evaluated. RESULTS: The proportions of patients diagnosed with AD, MD, and PTSD at baseline (N=209) were 16.3%, 6.7%, and 0%, respectively, whereas at follow-up (N=85) 10.6% were diagnosed with AD and 11.8% with MD. Lower performance status, concern about being a burden to others, and lower satisfaction with social support were significantly associated with AD/MD at baseline. There were changes in the diagnosis of AD and MD in 30.6% of the patients. Only HADS at the baseline was significantly predictive of AD/MD at follow-up. CONCLUSION: The factors underlying psychological distress are multi-factorial. Early intervention to treat subclinical anxiety and depression may prevent subsequent psychological distress.

with cancer completed the Distress and Impact Thermometer and the HADS and psychiatric examination based on DSM-IV criteria by psychiatrist. The sensitivity and specificity of the Distress and Impact Thermometer in detecting adjustment disorders and/or major depression were calculated by receiver operator characteristic (ROC) analysis. RESULTS: The cut-off points to detect adjustment disorders and major depression were determined ‘‘3/4’’ in the Distress Thermometer and ‘‘2/3’’ in the Impact Thermometer, and the sensitivity and specificity were 0.82 and 0.82. The cut-off to detect major depression was ‘‘4/5’’ and ‘‘3/4’’, and the sensitivity and specificity were 0.89 and 0.70. CONCLUSIONS: Screening performance the Distress and Impact Thermometer was comparable to that of the HADS. Brevity and good performance suggest that the Distress and Impact Thermometer is an effective tool in routine screening in the clinical oncology setting.

98 97 Development of the Impact Thermometer added to the Distress Thermometer as a Brief Screening Tool for Adjustment Disorders and/or Major Depression in Patients with Cancer Akizuki N1, Nakano T1, Okamura M2, Shimizu K2, Akechi T2,3 et al. 1 Psychiatry Division, National Cancer Center Hospital, Tokyo, Japan; 2Psychiatry Division, National Cancer Center Hospital, East Chiba, Japan; 3Psycho-Oncology Division, National Cancer Center Research Institute, East Chiba, Japan PURPOSE: Screening adjustment disorders and major depression in patients with cancer are important because they are prevalent and often underrecognized. The purpose of this study was to develop a new brief screening tool and to compare the performance to detect adjustment disorders and/or major depression with the Hospital Anxiety and Depression Scale (HADS). METHODS: We developed an Impact Thermometer added to the Distress Thermometer (Distress and Impact Thermometer; 2 item questionnaire). If both Thermometers are above cut-off point, the screening is positive. Two hundred ninety five patients

Copyright # 2004 John Wiley & Sons, Ltd.

Screening for Psychological Distress in Japan Akizuki N Psycho-Oncology, Division National Cancer Center Research Institute, East Kashiwa, Japan Psychiatric epidemiological studies using structured clinical interview for cancer patients in Japan revealed that major depression and adjustment disorders are the most prevalent psychiatric disorders. Routine screening by oncology staff is necessary for early detection and intervention for psychologically distressed cancer patients. We first developed a brief and easy screening tool; One Question Interview (OQI; ‘‘How distressed have you been during a previous week?’’). The OQI, the Distress Thermometer (1-item), and the Hospital Anxiety and Depression Scale (HADS; 14-item) were completed by 275 cancer patients, and given the DSM-IV diagnosis by psychiatrists. The sensitivity and specificity for detection of adjustment disorders and major depression at the cut-off points were 80% and 61% for the One Question Interview, 84% and 61% for the Distress Thermometer, and 92% and 57% for the HADS, respectively. Although the sensitivity of the two brief screening tools were inferior to the HADS, their performance was useful for routine screening.

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To improve screening performance further, we developed the Distress and Impact Thermometer (2-item questionnaire). Now we put the Distress and Impact Thermometer into the practical routine screening in the Oncology/Hematology ward, and include in the screening and intervention coordination program for patients after disclosure of their recurrent breast cancer.

99 Prevalence of Psychological Disorders and Quality of Life in Head and Neck Cancer Patients Bellver P!erez A1, Segura Huerta A2, Lo! pez Tendero P2, Palomar Abad L2, Molina Saera J2 1 Psycho-Oncology Unit, Junta Provincial A.E.C.C. Valencia, Spain; 2Medical Oncology Unit, University Hospital, La Fe, Valencia, Spain PURPOSE: We analysed the prevalence of psychological disorders in patients with head and neck cancer and its impact in quality of life. Furthermore we studied the relationship between psychological variables and quality of life during diagnosis and medical treatment. METHOD: We included 34 patients with histological diagnosis of head and neck cancer. Median age of 58,5 yr (+ 10.3), 91% were males. A 80% of patients were included in IVA stage. The treatment was chemotherapy and concurrent radiotherapy in 58% of patients. Psychological distress and quality of life were evaluated with Hospital Anxiety and Depression Scale (H.A.D.S) and the EORTC QLQ-C30/ HN-35. Both tests were performed previous to treatment and during chemotherapy. We made descriptive statistic and Pearson Correlation. RESULTS: A total of 60% of patients were evaluated at the moment of initial diagnostic and 40% in recurrence after local treatment. About a 43% of patients showed psychological distress based on D.S.M-IV: 15% had adjustment disorder with anxious mood, a total of 12% had adjustment disorder with depressed mood and a 15% shown with mixed emotional features. Negative and significant correlations were observed between anxiety and quality of life (p50.05) and between pain and quality of life (p50.001). CONCLUSIONS: At the moment of diagnosis half of patients with head and neck cancer showed adjustment disorders. Anxiety and pain have a

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negative impact in quality of life of patients. It must be included an evaluation of quality of life in the initial management and in the follow-up.

100 Prevalence and Predictors of Psychological Distress in Men with Breast Cancer Brain KE1, Williams B1, Iredale R1, France E2, Gray J2 et al. 1 Institute of Medical Genetics, University of Wales, College of Medicine, Cardiff, UK; 2Institute of Medical Genetics, University Hospital of Wales, Cardiff, UK BACKGROUND: Approximately 300 cases of male breast cancer are diagnosed every year in the UK, although the psychological impact of the condition is unknown. It is estimated that around one quarter of female breast cancer patients exhibit significant psychological distress in the first year after diagnosis. AIMS: To examine the prevalence of psychological morbidity and factors associated with general distress, cancer-related distress, and body image in a sample of men with breast cancer. METHODS: Data are reported from a cross-sectional questionnaire survey of 162 men with breast cancer recruited from breast clinics across the UK. RESULTS: Average age of the sample was 67 years (SD 11.91, range 27–88) and mean time since diagnosis was 38 months (SD 33.54, range 2–132). Prevalence of HADS caseness was 6% for anxiety and 2% for depression, while 40% of men reported moderate to high Impact of Event Scale scores. Factors associated with increased distress included younger age (p50.01) and current side effects of treatment (p50.05). Altered body image was also reported by younger men (p50.01) and those experiencing side effects (p50.05). There was a non-significant trend towards increased distress in men who had been diagnosed more recently. CONCLUSION: Prevalence of psychological morbidity appears to be low in male breast cancer patients, although cancer-specific measures may be more sensitive to men’s concerns. These results suggest that younger men and those experiencing treatment side effects may be at greatest risk of traumatic stress symptoms and may benefit from increased psychological support.

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101 Implementing a New Psychosocial Screening Tool to Better Understand Breast Cancer Patient Needs Caldwell MSWTC, Mortimer MDJM, Chantler MDMC Internal Medicine/Oncology Easter Virginia Medical School, Norfolk, Virginia, USA PURPOSE: The need to provide psychosocial supports for cancer patients is well established. Tools to determine patient needs are in use at many cancer centres. Momentum to address distress in patients with cancer gained further effort with the passage in 1996 of Standards of Care for Management of Distress in Patients with Cancer put forth by the NCCN (National Comprehensive Cancer Network). Visionaries in the field of screening for problems, James R. Zabora, MSW, and Matthew Loscalzo, MSW have created the framework from which the next step is possible. METHODS: This poster demonstrates the development of a carefully planned approach to psychosocial care at our new cancer institute. Integral to the approach is the creation of a carefully crafted screening tool. Development of a unique strengths based psychosocial screening tool that thoughtfully integrates a problem list comprised of practical, emotional, psychological and social barriers to maximize coping is routinely given to all new patients. A scoring system to rank the severity of the problem is added to the Screening Tool. The creation of interventions based on the reported needs of patients is in progress. The Screening Tool is IRB approved. It takes less than 5 min to complete. RESULTS: Early analysis of responses from patients with breast cancer is surprising. 26% of breast cancer patients report problems with sleep as their primary problem. Respondents in all age categories report problems with sleep. The second most common problem reported by women with breast cancer is with finances, 16%. The number of. . . [truncated].

1

Department of Psychosocial Cancer Research, Danish Cancer Society, Copenhagen, Denmark; 2 Department of Thoracic Surgery, Odense University Hospital, Odense, Denmark; 3Department of Oncology, Aarhus University Hospital, Aarhus, Denmark; 4Department of Thoracic and Cardiovascular Surgery, Gentofte University Hospital, Hellerup, Denmark BACKGROUND: Lung cancer is one of the most common cancers in the industrialised world, and patients diagnosed with this very often fatal disease must relate not only to the physical effect of lung cancer but also to the psychosocial aspects of this fatal cancer disease. METHODS: This review is based on an examination of scientific studies published between 1966–2003 and identified through a systematic search in Medline. The identified studies were examined and only intervention studies, prospective studies and casecontrol studies with more than 50 participants and with lung cancer as the primary outcome were included. RESULTS: The included studies show, that some 50% of patients with lung cancer may experience periods with depression during their illness. This is especially true for patients who are not offered treatment for their cancer disease and for patients diagnosed with small-cell lung cancer. The amount of depression may be reduced through psychosocial interventions. Interventions involving specially trained nurses teaching control of breathlessness and providing information about physical and psychological consequences of the disease have been found particularly effective. CONCLUSIONS: We suggest that a psychosocial screening of lung cancer patients in order to prevent depression may result in an improved quality of care offered to this group of patients. Furthermore, there is a need for well-designed studies in order to further document the quality and quantity of psychosocial problems faced by lung cancer patients during their illness.

103 102 Psychosocial Aspects of Lung Cancer}A Review Carlsen K1, Johansen C1, Jacobsen E2, Jensen AB3, Krasnik M4

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High Levels of Untreated Distress and Fatigue in Cancer Patients Carlson L Psychosocial Resources, Tom Baker Cancer Centre/ University of Calgary, Calgary, Alberta, Canada

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PURPOSE: Distress is common in cancer patients across the disease continuum, and can impact outcomes such as treatment compliance and overall quality of life. However, a large-scale assessment of distress in a representative cross-section of patients with concomitant information on help-seeking behavior related to common problems has never been published. PATIENTS AND METHODS: 3095 patients were assessed over a four-week period with the Brief Symptom Inventory-18 (BSI-18), a common problems checklist, and on awareness and use of psychosocial resources. Full data was available on 2776 patients. On average, patients were 60 years old, Caucasian (78.3%), and middle class. Approximately half were attending for follow-up care. Types of cancer varied, with the largest groups being breast (23.5%), prostrate (16.9%), colorectal (7.5%) and lung (5.8%) patients. RESULTS: Overall, 37.8% of all patients met criteria for general distress in the clinical range. A higher proportion of men met case criteria for somatization, and more women for depression. Minority patients were more likely to be distressed, as were those with lower income, cancers other than prostate, and those currently on active treatment. Lung, pancreatic, head and neck, Hodgkin’s disease and brain cancer patients were the most distressed. Almost half of all patients who met distress criteria had not sought professional psychosocial support nor did they intend to in the future. CONCLUSIONS: Distress is very common in cancer patients across diagnoses and across the disease trajectory. Many patients who report high levels of distress are not taking advantage of available supportive resources.

104 ‘‘Big Boys Don’t Cry’’: An Examination of Gender Bias in Psycho-oncology Research and Clinical Practice Collier SM, O’Dwyer AM Psycho-Oncology/Psychological Medicine Service, St. James’s Hospital, Dublin, Ireland PURPOSE: Exploration of whether the societal and cultural assumption that ‘‘big boys don’t cry’’ creates a gender based attitudinal barrier to the

Copyright # 2004 John Wiley & Sons, Ltd.

appropriate diagnosis and treatment of distress in male cancer patients. METHODS: In order to examine the effect of gender on referral and subsequent intervention, a retrospective review of 130 consecutive oncology patients referred to a Psychological Medicine Service was conducted. A comprehensive review of 10 years of psychooncology research (1993–2003) in peer-reviewed journals was also undertaken to explore the possibility of gender bias in existing research. RESULTS: Female patients were found to be three times more likely than male patients to be referred to a psychological medicine service. Females were significantly more likely to be referred for mood assessments and significantly less likely to be referred for ‘‘confusion’’ or ‘‘bizarre behaviour’’ than men. Clinical assessment revealed that referred females were significantly more likely to receive a diagnosis of adjustment disorder or subsyndromal anxiety/depressive symptomatology than men. While more men than women received diagnoses of clinical depression and anxiety disorders, there was no difference between the sexes for diagnosis of delirium, mood disorder related to medication or alcohol dependence/abuse. Of the 33 patients treated with cognitive behavioural therapy, 88% were female. The literature review revealed a significant bias in favour of women and women’s cancers. CONCLUSIONS: Strong gender biases exist which have significant implications for clinical practice, health promotion and future psychosocial research.

105 Mental Disorders in Long-Term Survivors of Testicular Cancer Dahl AA1, Haaland CF2, Mykletun A3, Foss(a S11 1 Department of Clinical Cancer Research, The Norwegian Radium Hospital, Ullernchausseen 70, 0310 Oslo, Norway Oslo, Norway; 2Department of Security Psychiatry, Ulleva(l University Hospital, Oslo, Norway; 3Department of Health Promotion, University of Bergen, Bergen, Norway PURPOSE: Former studies have found raised prevalence of anxiety disorders in testicular cancer survivors (TCSs), and identified various risk factors, but the samples have been small and

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biased without adequate controls. The aim of this study was to examine the prevalence of mental disorders in a large, national follow-up study of TCSs with population norms as controls. METHODS: All 1814 TCSs treated between 1980 and 1994 in Norway were addressed, and 1.408 (78%) delivered valid questionnaires. The filled in SF-36, IES, and HADS. 195 TCSs with highest HADS and IES scores, were invited to a structured psychiatric examination. TCSs findings were compared to national norms on SF-36, HADS, and prevalence of mental disorders. RESULTS: 25.1% of TCSs had a mental disorder which was significantly lower than the norm (28.8%). TCSs had significantly more anxiety disorders, depressions, and drug abuse/dependence, but significantly less alcohol abuse/dependence. Odds ratio for caseness was significantly raised by sexual problems, infertility worry, somatric illness, low education, and unemployment, but not by treatment strategies. CONCLUSION: Approximately one-quarter of TCSs have mental disorders at long-term. We have identified and confirmed risk factors that should help the clinician’s case-finding at follow-up examinations.

106 Increased Hospitalization Rate of Depression after Cancer Diagnosis: A Nationwide Cohort Study in Denmark Dalton SO1, Thomassen L1, Mortensen PB2, Johansen C1 1 Institute of Cancer Epidemiology, Danish Cancer Society, Copenhagen, Denmark; 2The National Centre for Register Based Research, Aarhus, Denmark PURPOSE: We investigated whether adult cancer patients subsequently are at increased risk for hospitalization for depressive disorders. METHODS: In a nationwide, population-based, retrospective cohort study, we identified 397 755 persons who were diagnosed with first primary cancers from 1970 to 1999, in the Danish Cancer Registry. The cohort was followed up for hospitalization for depression from 1 January 1970 or date of cancer diagnosis; whichever came last, through 1999 by linkage with the Danish national Psychiatric Central Register. The number of

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expected cases was based on national rates for hospitalization for depression. RESULTS: The risk of hospitalization for depression was increased in the cohort in the first year after cancer diagnosis with standard hospitalization rates (SHR) of 1.98 (95% CI, 1.7–2.3) in men and of 1.85 (95% CI, 1.7–2.0) in women. The SHR remained significantly increased until 5–9 years after diagnosis. For survivors of hormone related cancers the SHR was significantly increased throughout the followup period in both sexes. In men, significantly increased SHRs were also observed up to 5–9 years after diagnosis for lung cancer (SHR, 1.22) and up to 4 years after a diagnosis of alcohol related (SHR, 1.74) and virus and hormone related cancers (SHR, 1.46). In women, the SHR was increased up to 4 years after a diagnosis of a virus and immune related cancer (SHR; 1.28). CONCLUSION: Survivors of many cancer types have a significantly increased risk for hospitalization with depression persisting over substantial periods of time after diagnosis.

107 Sense of Coherence and Side Effects of Adjuvant Chemotherapy for Breast Cancer Debess JE, Ewertz M Department of Oncology, Aalborg Hospital, Aarhus University, Denmark BACKGROUND: Sense of Coherence (SOC) is a concept developed by Aron Antonowsky in the early 1970s. Studies have shown that low SOC correlate with a poor ability to cope with distress. A diagnosis of breast cancer can cause distress among women. When treated with chemotherapy, the women experience different degrees of side effects. Investigations of patients with other types of cancer have demonstrated that the coping ability may influence the degree of side effects and the immune system. PURPOSE: To examine the relationship between SOC and side effects, included leukocyte count, among women who receive adjuvant chemotherapy after operation for breast cancer. METHODS: The study is designed as a hypothesis generating descriptive cross-sectional study. It includes 165 women operated for primary breast cancer who received 7 cycles of adjuvant chemotherapy with

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cyclophosphamide, epirubicin and 5-fluouracil during the period 1st January 2002 to 31st December 2003. Data on breast cancer, chemotherapy, anti-emetic treatment, side effects and leukocyte counts were abstracted from the hospital records. Information on SOC is collected by Antonowsky’s questionnaire with 13 questions, mailed to the patients. The data collection is performed in February and March 2004 and the analysis will be carried out over the summer. The results will be presented at the conference.

108 Coping with Breast Cancer}What did Help Patients and Partners Most? A Pilot Study Dietmaier G, Samonigg H, Andritsch E Division of Clinical Oncology, University of Medicine, Graz, Austria Breast cancer is still the most common cause of death in women between 35 and 60 years of age. A possibly life-threatening disease is an extreme physical and psychological burden for the patients and their families. An immense amount of effort in adapting to this new situation in life is needed. Besides medical treatment, improvement in the quality of life and the satisfaction of patients and their families has gained more importance in the last few years. The presented study deals with the subjective experience of dealing with the disease in 206 breast cancer patients with adjuvant chemotherapy and 70 spouses at the Division of Oncology at the University Clinic Graz. Besides collecting the socio-demographic and medical basic data, the most important supporting mechanisms and the greatest obstacles in handling the disease were asked with questions with open response format. The subjective experience of the follow-up visits were asked and evaluated as well as the satisfaction with the attending team’s communication as to information, understanding and co-operation with a 10-point Lickert-scale. In addition, a global question to survey the subjective experience of the quality of the patient’s handling the disease was posed. The results show the integration of psychosocial support should be a necessary part in the follow-up care of breast cancer patients.

Copyright # 2004 John Wiley & Sons, Ltd.

109 Prevalence of Depressive and Anxiety Disorders Among Patients With Pancreatic Carcinoma: Preliminary Results of a Prospective Controlled Study Dominguez S1, Reich M2, Fournier C3, Clisant S4, Adenis A1 1 Gastrointestinal and Genitourinary Oncology Centre, Oscar Lambret, Lille, France; 2Psycho-oncology Centre, Oscar Lambret, Lille, France; 3Biostatistics Centre, Oscar Lambret, Lille, France; 4Clinical Research Centre, Oscar Lambret, Lille, France BACKGROUND: Pancreatic carcinoma (PCa) is a leading cause of death (5-year survival: 5%) among digestive cancer. PCa is associated with high prevalence of depression and anxiety (50%), albeit it is not known whether this psychological profile is linked to prognosis, pain, both of these or to some other factor (1, 2). OBJECTIVE: The aim of that study was to prospectively evaluate and characterize depressive and anxiety disorders in consecutive patients with PCa. METHOD: We have used 3 different questionnaires: the Hospital Anxiety and Depression Scale (HADS), the Beck Depression Inventory (BDI) and the 12-item General Health Questionnaire (GHQ-12). Our findings were controlled by the use of 2 control groups, one with patients presenting with advanced gastric or renal cancer (similar prognosis as PCa), the other with patients suffering from intensive pain in relation to other types of cancers. For all patients but the latter, depression and anxiety were investigated at the onset of the therapeutic management. A second evaluation was planned 3 months later. This study will run for 3 years, with a planned intermediary analysis at one year (5/2004). RESULTS: Up to now, 33 patients have been included over a period of 9 months. There are 14 PCa, 10 gastric cancers, 3 renal cancers and 6 patients with intensive pain. We will be able to present at the meeting detailed results on a series of about 50 patients with comparative data between the different cohorts of patients and the different questionnaires.

110 Screening of Distress in Oncology Patients. A Latin American Sample

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Ferro NF1, Piriz I2, Di Pretoro M3, Cesarco R4 et al. 1 Psycho-Oncology, Alexander Fleming Institute, Buenos Aires, Argentina; 2Mental Health Hospital, Interzonagl General de Agudos ‘‘Eva Peron’’ Provincia de, Buenos Aires, Argentina; 3 Psycho-Oncology, Instituto de Oncolog!ıa ‘‘Angel Roffo’’, Buenos Aires, Argentina, 4Mental Health Hospital, Maciel Montevideo, Uruguay The impact of distress on the oncology patients population has been known and studied for a long time. In the past 5 years many papers have been published using a Distress Thermometer as a valid instrument for screening and follow up distress. Unfortunately, in Latin America this kind of investigation has not been done yet. PURPOSE: This study is concentrated on: (a) The measure of distress in oncology patients. (b) To gather a cooperative group in Latin America. (c) To try the thermometer of distress as an instrument of screening in Rio de la Plata (Latin America). METHODS: We decided to use a Distress Thermometer according to guidelines of National Cancer Centre Networks (NCCN) to explore this brief screening tool. The patient indicates his/her level of distress on the ‘‘thermometer’’. Scores above five have been shown to indicate significant distress. It is accompanied by a Problem List which people can indicate their major sources of distress: physical, psychological, social, practical or spiritual problems. The sample studied is composed by 400 oncology out-patients who assisted to four Centres that treat different type of population. Three Oncology Hospitals of Argentina and one of Uruguay took part. The data has been studied specifying age, educational level, employment, marital status, social level, religion, family background, diagnosis, stage of illness, current and previous treatment modality for each centre and the whole sample. The analysis of data as well as the psychometrical results will be presented in detail.

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Fielding R1, Lam WWT2. Ho E1 1 Community Medicine, The University of Hong Kong, Hong Kong, Hong Kong, SAR; 2Nursing studies, The University of Hong Kong, Hong Kong, Hong Kong, SAR PURPOSE: To explore the prevalence of psychosocial morbidity among Chinese women following breast cancer surgery, and to identify factors predicting this morbidity. METHODS: Of 430/529 eligible Chinese female recipients of recent breast cancer surgery in one of six Hong Kong government hospitals, 405 (94%) agreed to participate and completed an interview within 1 week after surgery (baseline). Participants were retrospectively assessed regarding treatment decision making (TDM) difficulties, and satisfaction with TDM involvement and with consultation, expectations for treatment outcome and current measures of self-efficacy and psychological morbidity (Chinese Health Questionnaire-12 (CHQ12)). One month later 367 (91%) completed the CHQ12, measures of physical symptom distress Optimism/Pessimism (C-LOT-R) and ongoing treatment. Multivariate regression adjusted analysis of Baseline predictors of 1 month CHQ12 scores. RESULTS: In all, 29% of women had mild, and 32% moderate/severe psychological morbidity. Following adjustment, three Baseline variables remained that predicted higher Outcome CHQ12 scores: physical symptom distress, pessimism, and perceived expectations of poor outcome. (Adjusted R2=0.50). Physical symptom distress was predicted by concurrent chemotherapy, Baseline CHQ12 score and radiotherapy (Adjusted R2=0.18). Inclusion of Baseline CHQ12 displaced Expectations of outcome from the final model (Adjusted R2=0.572). CONCLUSION: Psychological morbidity following breast cancer surgery is enhanced by women’s experience of physical symptoms, pessimistic outlook, and inability to accurately anticipate treatment effects. Attention should be given to helping women accurately determine the resulting outcomes in terms of symptoms and appearance. Anticipatory symptom management is key in minimizing women’s psychological distress following breast cancer surgery.

Factors Predicting Psychological Morbidity in Chinese Women following Breast Cancer Surgery

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112 Lower Marital Satisfaction in Recently Diagnosed Breast Cancer Patients Forjaz MJ1, Monreal E2, Garrido-Landivar E1 1 Psychology and Education Universidad, Publica de Navarra, Pamplona, Spain; 2Ordinary Emergency Service Health Center of Estella, Estella, Navarra, Spain

Hospital, S. Jose!, Lisbon, Portugal; 3Psychiatric Service, Cantonal Socio-Psychiatric Organization, Lugano, Switzerland

PURPOSE: Breast cancer has been considered as a family diagnosis in the sense that it impacts not only the patient itself, but also the relationships with her spouse and children. This study aims at comparing the marital satisfaction and family dynamics of recently diagnosed breast cancer women with a control group. METHODS: The study group was formed by 158 women at the time of their surgery for recently diagnosed breast cancer (less than 2 months). The control group was 490 women who attended a screening mammography centre. All women were Spanish, aged 40–71 years old. Both groups were asked to complete the following questionnaires: GHQ-12 (a psychopathology screening); FACES-III (measure of family dynamics); and DAS (marital satisfaction). RESULTS: The breast cancer group showed a higher degree of psychopathology than healthy controls, t(183)=9.84, p50.001. Significant differences were also found for 3 DAS subscales, even when using the GHQ-12 as a covariate [MANCOVA: F(4)=57.4, p50.001, effect size=0.24], with beast cancer patients showing a lower marital satisfaction than healthy controls. CONCLUSIONS: Results suggest that breast cancer has a negative impact, resulting in more psychopathology symptoms and less marital satisfaction. Data collected with the same women, 2 and 6 months after surgery, will provide longitudinal information about the impact of breast cancer.

PURPOSE: Clinical depression is one of the psychiatric disorders more important in cancer patients. Few data is available about which are the risk factors for depression among cancer patients in Southern European countries. As part of a more general investigation (Southern European PsychoOncology Study}SEPOS), the aim of this study was to find the variables or factors associated with ‘‘depression’’ in our sample of southern European cancer patients. METHODS: A convenience sample of 323 outpatients with a diagnosis of cancer between 6 and 18 months, a good performance status (Karnofsky Performance Status >80), no cognitive deficits or CNS involvement by disease were approached in university and affiliated cancer centres in Italy, Portugal, Switzerland and Spain. Each patient was evaluated for depression symptoms (HADS), concerns about illness (CWI), sociodemographic characteristics, clinical data, coping strategies (Mini-MAC) and other psychosocial dimensions of cancer (mood, well-being, physical symptoms, difficulty in coping, leisure, social support, spirituality and global emotional distress). RESULTS: The variables related with ‘‘cases’’ of depression (HADS-Depression 311) were worries about illness (t=2,33, p=0.45), fighting spirit (t= 3,07, p=0.00), hopelessness (t=2,27, p=0.02), anxious preoccupation (t=2,74, p=0.00) and age (t=2,14, p=0.03). CONCLUSION: Older age, worries about illness and negative coping strategies have been observed as predictors for ‘‘depression’’ in southern European cancer patients. Further studies should evaluate other variables related with ‘‘depression’’ and the benefits of psychological and psychiatric interventions.

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Risk Factors for Depression in Cancer Patients: Report from the Southern European Psycho-Oncology Study (SEPOS) Gil F1, Travado L2, Tomamichel M3, Hollenstein MF1, Mate J1 et al. 1 Psycho-Oncology Unit, Oncology Catalan Institute, Barcelona, Spain; 2Psychotherapy Service

Psychosocial Implications of Cancer: A Study by Using the Diagnostic Criteria for Psychosomatic Research (DCPR) Grassi L, Sabato S, Rossi E, Gatti M et al. Department of Medical Sciences of Communication and Behavior, Section of Psychiatry University of Ferrara, Ferrara, Italy

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Psycho-oncology literature has shown that 30– 50% of cancer patients met the criteria for a psychiatric diagnosis, according to the usual nosographic classification (e.g. DSM). The Diagnostic Criteria for Psychosomatic Research (DCPR) have been shown to be useful in identifying psychological constellations in patients with medical illness. The aims of the study were to compare the DSM-IV and the DCPR in their application to cancer patients. One hundred and forty-six patients with cancer underwent semistructured interviews to assess psychiatric morbidity and psychosocial syndromes according to the DSM-IV and the DCPR, respectively. The Brief Symptom Inventory (BSI) was also used to assess psychological stress symptoms. Sixty-five subjects (44.5%) met the criteria for a DSM-IV diagnosis (DSM-cases), while 104 patients (71.2%) presented symptoms meeting the criteria for at least one DCPR syndrome. Three DCPR dimensions were more frequent than others, specifically Health Anxiety (37.7%), Demoralization (28.8%) and Alexithymia (26%). Among the subjects with no formal DSM-IV diagnosis (n=81), 58% had at least one DCPR syndrome. DSM-IV cases had higher scores on several BSI subscales in comparison with patients with only one DCPR syndrome, while no difference was found with patients with more than one DCPR diagnosis. The DCPR system was found to be useful in oncology in investigating psychological conditions which are not identified by the DSM-IV alone. Assessment of more specific constructs, other than intensity of general stress symptoms, may give more specific information on which tailoring psychological intervention in cancer patients.

115 Does Intensified conditioning Regimen with Radioimmunotherapy (RIT) Intensify the Distress of High-Risk Patients Undergoing Allogeneic SCT? Grulke N, Bailer H, Kaechele H Psychosomatic Medicine and Psychotherapy, University Hospital of Ulm, Ulm, Germany PURPOSE: Eradication of malignant cells before SCT is still a problem. Conventional conditioning for SCT is limited by organ toxicity. RIT directly

Copyright # 2004 John Wiley & Sons, Ltd.

targets on bone marrow and spleen. Higher doses of irradiation can be applied, with limited toxicity to non-target organs. There is no investigation about patients’ distress undergoing this experimental intensified conditioning regimen. We compare RIT with conventional conditioning. METHODS: Patients scheduled for BMT at Ulm (Germany) were administered the POMS, HADS and, EORTCQLQ at admission and discharge. During inpatient time, they were daily asked to assess their situation on 13 items. RESULTS: 72 patients were recruited from 10/1999 to 12/2001. 30 received RIT, 42 conventional conditioning. Although having a significant poorer prognosis, RIT-patients have the same distress as patients with conventional conditioning at admission and at discharge (HADS, POMS, EORTC-QLQ). During inpatient time, RIT-patients described themselves as slightly more distressed. CONCLUSION: The experimental intensified conditioning with RIT seems not to intensify distress.

116 Psychosocial Distress: The 6th Vital Sign: Discussant Holland J Department of Psychiatry & Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, New York, USA It is clear that for patients’ psychosocial care to be integrated into routine care, we must find a rapid, simple method that busy oncologists and nurses can use in the ambulatory clinics to identify those who are distressed. An algorithm for referral for supportive services also simplifies the action to be taken. Following the successful use of a 0–10 scale to ask patients about pain, a similar way has been found effective to ask about distress: ‘‘How distressed have you been today and over the past few days?’’ which can be done verbally or with a pencil and paper to mark the level on the Distress Thermometer which has a Problem List accompanying it to indicate the source of the distress. Similar to scores for pain, 5 or above triggers further evaluation of pain or distress. Since medical care dictates taking the patient’s vital signs (pulse, temperature, respiration and blood

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pressure), pain has been added as the 5th Vital Sign to assure that staff remembers to ask about it. We propose that Distress be added as the 6th Vital Sign to assure that staff asks about it. This offers a simple method that assures distress is assessed and its management integrated into total care.

Screening For Psychosocial Distress: (1) (2) (3) (4)

Jamal Katib-Amman, Jordan Linda Carlson-Calgary, Canada Nobuya Akizuki, Kashiwa, Japan Luigi Grassi, Ferrara, Italy

From Screening to Intervention Strategies:

117 Psychosocial Distress}the 6th Vital Sign: From Identification to Intervention Holland J1, Sepulveda C2, Zabora J3, Katib Jamal4, Grassi Luigi5 et al. 1 Psychiatry MSKCC, NYC, USA; 2Cancer WHO, Geneva, Switzerland; 3Social Service, CUA, Washington, USA; 4Oncology, KHCC, Amman, Jordan; 5Psychiatry University of Ferrara, Ferrara, Italy The emotional sequelae accompanying the diagnosis and treatment of cancer is both well researched and noted in the cancer community. Despite the evidence, administrators and the medical community have been reluctant to address the needs of cancer patients and their families. What do we, as psychosocial professionals and advocates, need to achieve to have the emotional issues addressed as a vital sign in the assessment and treatment of cancer? Ignoring psychosocial issues represents a clear failure to meet the moral imperative of compassionate and comprehensive cancer care. Goals of the workshop: (1) This workshop will review patient screening, looking at the prevalence of psychosocial distress in Jordan, Canada, Italy and Japan. (2) We will then discuss two intervention programs in the United States developed as a result of screening for psychosocial distress. (3) Finally, we will look to practice guidelines and global strategies for the dissemination and uptake of screening and interventions for psychosocial distress as a routine component of evidencebased cancer control. (4) Finally, we will attempt to raise the profile of Psychosocial distress in the cancer population by identifying Psychosocial Distress as the 6th Vital sign, following: Blood Pressure, Temperature, Respiration, Pulse, Pain and now, Psychosocial Distress.

Copyright # 2004 John Wiley & Sons, Ltd.

(1) James Zabora, Washington, USA Comments on directions: (1) Jimmie Holland-National Comprehensive Cancer Network, New York, USA (2) Cecilia Sepulveda-World Health Organization, Geneva, Switzerland

118 The FORPSYCH Project (Fears of Recurrence & Psychological Distress): Preliminary Findings Humphris GM1, Hodges LJ2, Macfarlane G3, Lowry R4, McKinney T5 1 Bute Medical School, The University of St. Andrews, St. Andrews, England; 2Academic Division of Clinical Psychology, University of Manchester, Manchester, England; 3Unit of Chronic Disease Epidemiology, University of Manchester, Manchester, England; 4Dental School, University of Newcastle, Newcastle, England; 5Information and Statistics, Division NHS Scotland, Edinburgh, Scotland Following treatment for cancer, patients live with the fear that the disease could recur and possibly become unmanageable and life threatening. This is often a central and lingering concern for many cancer patients yet there has been little empirical investigation to relate these specific fears to psychological morbidity. The FORPSYCH Project is a prospective study with 2 principle aims: (i) to assess the levels of fears of recurrence (FOR) over a 6-month period following a diagnosis of head and neck cancer, and (ii) evaluate the role of these fears in the development of anxiety and depression. Patients were recruited from 3 UK centres}Manchester, Edinburgh and Newcastle. Baseline data from a sample of 220 patients have so far been collected (female patients, 35.2% mean age=57.94 years).

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Results have shown that the subgroup of patients completing all 3 assessment points (baseline, 3- and 6-months, n=86) were not significantly more or less depressed or anxious than those patients who completed only the baseline interview (n=38). Anxiety scores and FOR were fairly stable over time, but depression levels significantly increased between the baseline and 6-month interviews (p=0.019). The FOR items were significantly positively correlated with patient anxiety and depression scores at all 3 time points (p50.02). Data collection is still ongoing and should provide an illuminating description of how a major patient health concern can influence psychological distress.

cancer diagnosis and the 51 with no history of major depressive episode at any time during their life were measured by magnetic resonance imaging and the Wechsler Memory Scale-Revised, respectively. RESULTS: The mean (SD) duration of the major depressive episode after cancer diagnosis was 11.9 (14.2) weeks. There were no significant differences in left or right hippocampal volume or in delayed recall function between the cancer survivors with and without a major depressive episode after cancer diagnosis. CONCLUSIONS: First major depressive episodes after cancer diagnosis in female cancer survivors do not appear to be associated with hippocampal volume. However, a longitudinal study with healthy control subjects is needed to draw a definite conclusion.

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Lack of Association between Hippocampal Volume and a First Major Depressive Episode after Cancer Diagnosis in Breast Cancer Survivors Inagaki M1, Yoshikawa E1 Matsuoka Y1,3, Akechi T1,2, Uchitomi Y1,2 et al. 1 Psycho-Oncology Division, National Cancer Center Research Institute, East Kashiwa, Japan; 2 Psychiatry Division, National Cancer Center Hospital, East Kashiwa, Japan; 3Adult Mental Health Division, National Center of Neurology and Psychiatry, Ichikawa, Japan

Assessment of Control of Negative Emotions in Portuguese Women with Breast Cancer Ivone Patr*ao IP, Isabel Leal IL Psychology ISPA, Lisbon, Portugal

OBJECTIVES: Patients experiencing their first major depressive episode after receiving a diagnosis of cancer are frequently seen in clinical oncology settings, however, little is known about the neurobiological basis of the first episode. In previous studies, a smaller hippocampus than in healthy controls has been observed in patients with a history of recurrent and prolonged major depressive episodes. The purpose of the present study was to investigate whether there is an association between hippocampal volume and a first major depressive episode after cancer diagnosis in cancer survivors. METHOD: The subjects were 68 female cancer survivors who had undergone breast cancer surgery 3 or more years earlier (mean interval: 4.3 years; SD: 0.9 years). The hippocampal volume and delayed recall function of the 17 cancer survivors who had their first major depressive episode after receiving their

Copyright # 2004 John Wiley & Sons, Ltd.

In Psycho-Oncology investigation the concept ‘‘Type C Personality’’ is used as a behavioural pattern present in individuals with cancer. The main characteristic of the Type C individuals is the control of negative emotions (anger, anxiety and depression) in interpersonal relationships and when facing conflict situations. Some research in this field shows evidence of emotional control in women with breast cancer. However, in Portugal, the control of negative emotions has not been studied in this population. This study (descriptive, exploratory and transversal) aims to evaluate the degree to which breast cancer suspicious (Portuguese) women control their negative emotions (anger, anxiety and depression). In order to assess the control of negative emotions we applied the CECS (Courtauld Emotional Control Scale}M. Watson and S. Greer, 1983) to 61 women before the surgery, at the Dr Alfredo Costa Maternity (Lisbon). The results show different degrees of control of negative emotions (60.7% have a medium control of their negative emotions, while 27.8% control them highly). These results suggest the need for further research, namely to study this variable in a large

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sample, in comparison with other variables and in other stages of the disease.

121 Distress in Cancer In-Patients in King Hussein Cancer Center (KHCC); A Study Using the Arabic Modified Version of the Distress Thermometer Khatib J1,2, Salhi R2, Awad G2 1 Psychiatry, KHCC, Amman, Jordan; 2Psychosocialonchology, KHCC, Amman, Jordan PURPOSE: This pilot study aims at exploring and examining the quality and quantity of distress associated with in-patients at our centre. Because our psycho-oncology department was newly formed in March 03 and is the 1st of its kind in Jordan we wanted to test the hypothesis of association between cancer and distress in our patients. METHOD: We used the distress thermometer developed by the NCCN, first, we translated it into Arabic, second, we validated it to suit jordanian culture and social norms, third we added the following criteria to the thermometer to extend the data gathered to help to form a comprehensive profile of the patients; age, gender, date of diagnosis, treatment, type of cancer, and marital status. We considered 5 as a cut off mark for distress; patients with scores below 5 were not. Finally, we interviewed every patient admitted to KHCC (new or re-admission) and studied the first 100 patients. RESULTS: 70% of those 100 patients recorded above 5 on the thermometer. Major components of distress were, anxiety, fear, pain, sadness and fatigue. CONCLUSION: Our study confirms the association between distress and cancer in jordanian patients, and the results obtained by the distress thermometer were consistent with direct clinical interview. Based on this data, we will be proactive to insure that all patients will be screened for quality and quantity of distress using the modified thermometer, and each patient shall be managed accordingly.

PsychOncology Program, King Hussein Cancer Center, KHCC, Amman, Jordan PURPOSE: This presentation presents the findings of a pilot study aimed at exploring and examining psychosocial distress associated with oncology inpatients at King Hussein Cancer Centre. Because our Psycho-Oncology Department was newly formed in March 2003, and is the first of its kind in Jordan. Accordingly, we wanted to determine the prevalence of psychosocial distress in our patient population. METHOD: Using the distress thermometer developed by the NCCN. We screened and interviewed 100 patients (new or readmission) admitted to the King Hussein Cancer Centre}KHCC. 1. First, we translated it into Arabic, 2. Second, we validated it to suit Jordanian culture and social norms, 3. Third, we added the following demographic questions (a) (b) (c) (d) (e) (f)

Age, gender, date of diagnosis, treatment, type of cancer, and marital status.

RESULTS: We considered 5 as a cut off mark for distress; patients with scores below 5 were not seen as experiencing significant distress. Of the 100 patients screened, 70% recorded scores above 5 on the thermometer. Major components of distress were, anxiety, fear, pain, sadness and fatigue CONCLUSION: Our study confirms the association between distress and cancer in Jordanian patients, and the results obtained by the distress thermometer were consistent with direct clinical interview. Based on this data, we will be pro-active to ensure that all patients will be screened for quality and quantity of distress using the modified thermometer, and each patient shall be managed accordingly.

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Psychological Distress Among Adult Bone Marrow Transplant Receipients and Mental Support for them

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Koyama A, Nishida S, Yasuda K, Iwagami K, Tochihara K et al. The Department of Psychosomatic Medicine, Sakai Hospital, Kinki University, School of Medicine, Osaka, Japan PURPOSE: Bone marrow transplantation (BMT) offers a therapeutic chance for a number of hematologic disorders but is associated with a lot of stressful situations and environments. The major purpose of this study was to evaluate the psychological status and emotional function of patients undergoing BMT and to investigate into the effective ways in supporting them. METHODS: 71 patients undergoing BMT participated in the study. Five standardized psychological tests were used in pre-BMT: Self-rating Depression Scale (SDS), State-Trait Anxiety Inventory (STAI), Yatabe-Guilford characteristic test (Y-G test), Tokyo University method Egogram (TEG) and the Rosenzweig Picture-Frustration study (PF study). The results were compared with those of patients with psychosomatic diseases and healthy controls. We also investigated each individual patient physical condition, Performance Status (P.S.) and their coping style. RESULTS: Approximately 20% of the patients undergoing BMT showed a moderately high score of depression on the SDS. Their State anxiety score was significantly high before BMT. The P.S. was significantly correlated with their behavioral adjustment (p50.05). The personality characteristics of the patients were the same with healthy controls. We gave some advice and support through the transactional analysis (TA) theory based on their test results. CONCLUSIONS: Our findings suggest that psychosocial adjustment factors of patients with hematological malignancies are quite variable. But psychological tests were useful to know the personality and mental status of patients in order to share the patient’s psychological status among doctors, nurses, dieticians and pharmacists and to give them proper advice.

1

Research Group for Psychosocial Oncology, University of Leipzig, Leipzig, Germany; 2Department of Social Medicine, University of Leipzig, Leipzig, Germany BACKGROUND: Mental disorders are often an indication for psycho-oncological support. The identification of cancer patients with need of psycho-oncological support should be based on sensitive psycho-oncological screening instruments and an attentive monitoring by doctors and nurses. METHODS: Between 2002 and 2003 cancer patients in primary treatment in four Leipzig clinics were interviewed using the Standardized Clinical Interview for DSM IV (SCID) by trained interviewers. The need of psycho-oncological treatment for these patients was estimated by the patients for themselves, doctors and nurses. The sensitivity of the Hamilton Anxiety and Depression Scale (HADS) was described for several mental disorders (assessed by the SCID). RESULTS: 507 cancer patients were eligible. 36% of the tumour patients had a co-morbid mental disorder. The sensitivity of the scale HADS-anxiety is remarkably higher than that of the HADSdepression, it varies (low cut-off 7) from 37% for specific phobia to 80% for major depressive episode and for generalized anxiety disorder. Doctors’ and nurses’ identification rates of mental problems in need of psycho-oncological treatment were between 0% (alcohol addiction) and 50% (PTSD). 30% of the tumour patients with a co-morbid mental disorder wished to get support by a psychologist. CONCLUSION: Mental co-morbidities are not the only, but an important indication for psycho-oncological counselling. The HADS’ sensitivity for mental disorders is acceptable only for depressive disorders and generalized anxiety disorder. Sensitive screening instruments for other, especially stress disorders, are necessary. Doctors’ and nurses’ rates of identification of mental problems in cancer patients are to improve.

124 125 Identification of Comorbid Mental Disorders in Cancer Patients Krau O1, Kauschke M1, Slesazeck H1, Singer S2, Schwarz R2

Copyright # 2004 John Wiley & Sons, Ltd.

Self-Efficacy and Short-Term Post-Surgical Adjustment Among Chinese Women with Breast Cancer Lam WWT1, Fielding R2, Ho E2

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Nursing studies, The University of Hong Kong, Hong Kong, Hong Kong, SAR; 2Community Medicine, The University of Hong Kong, Hong Kong, Hong Kong, SAR PURPOSE: To explore if women with higher selfefficacy (SE) who face treatment outcome expectancy disconfirmation have lower levels of psychosocial distress than women with lower SE as SE is hypothesized to have a buffering effect against the distress associated with unsatisfactory surgical outcome, protecting women against psychosocial distress. METHODS: Of all eligible Chinese women receiving breast cancer surgery in six Hong Kong government hospitals (529), 443 were sampled and 405 were recruited and interviewed within 1 week of surgery. After assessing SE, expectancy-outcome incongruence (E-OI), and psychological morbidity (Chinese Health Questionnaire, CHQ12), women were followed for 1month when 91% had psychological morbidity and social adjustment were assessed. Path analysis examined impact of high and low baseline SE scores on outcome. RESULTS: After adjustment, psychological morbidity was predicted by E-OI (b=0.19, p50.000). Women with high SE had better relationships with friends (b=0.16, p=0.003), while women with lower E-OI were more accepting of appearance (b= 0.20, p50.000), and better sexuality scores (b= 0.17, p50.000). Women with high SE tended to underestimate the negative consequence of surgery (t=6.04, p50.000), causing higher E-OI (b=0.18, p=0.001) and thereby more psychological morbidity. CONCLUSIONS: High post-surgical SE is associated with enhanced social adaptation 1 month following breast cancer surgery. However, women with high SE tend to under-estimate the negative impacts of surgery, impairing psychological adjustment. Through this mechanism, high SE can contribute indirectly and significantly to psychological morbidity. Therefore, interventions to enhance SE should ensure recipients have accurately estimated surgical consequences to avoid harmful disappointment.

126 Distress, Information and Communication in Prostate Cancer Patients

Copyright # 2004 John Wiley & Sons, Ltd.

Leo! n-Pizarro C1, Guix-Melcior B2, Broome B3, Casas F4 1 Psycho-Oncology Hospital de Terrasa, Terrasa, Spain; 2Radiotherapy IMOR Foundation, Barcelona, Spain; 3Psycho-Oncology, University South Alabama, Alabama, USA; 4Oncology Hospital Cl!ınic, Universitari Barcelona, Spain PURPOSE: This is a preliminary study that tries to know the Prostate Cancer Patients Distress as well as the kind of communication and information about the disease the patients use. PATIENTS AND METHOD: Twenty-one Prostate Cancer Patients referred to the IMOR Foundation and The Hospital Cl!ınic Universitari de Barcelona were recruited. We used: *

*

*

FACT-P to measure Health Related Quality of Life (HRQOL); HAD to determine anxiety and depression; and CCCP. This is a questionnaires designed to get information about the way the patients use to find information, with whom they speak about the illness, how their lives are affected and how they found it out.

RESULTS: The preliminary data show that 38.1% of patients speak about their illness with his partner. 66.7% of patients get information from the doctor and Health Services. 66.7% of patients practice some sport and 85.7% believe in God or someone superior. CONCLUSION: There is a specific profile of prostate cancer patients information and communication. More detailed results will be presented.

127 Insomnia and Depression in the Context of Cancer Loehr G, Graci G Oncology Northwestern University, Chicago, USA Quality of life in cancer patients has grown increasingly important in a clinical and research setting, since millions of new cancer diagnoses are made each year. Insomnia, depression and cancerrelated fatigue affect many domains of quality of life and are present in cancer patients at higher

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rates than in the general population. However, there is a paucity of literature on insomnia, depression, and cancer-related fatigue as they relate to cancer and to each other. Our overarching goal of this presentation is to provide a better understanding of what these symptom clusters are and how to incorporate the appropriate treatments to enhance and preserve quality of life in cancer patients. Sleep is a burgeoning field that is important to health and it is the health care professionals who should be able to discern if a patient’s sleep disturbance (i.e., insomnia) is either primary or secondary to a mood disorder. For instance, antidepressants are commonly prescribed for treatment of mood disturbance or hot flashes; however, these medications can often induce insomnia or promote sleep fragmentation. Behavioral and pharmacological treatment regimes will be discussed so that the practitioner has greater insight into the etiology and treatment of depression, cancer-related fatigue, and insomnia.

distress for women compared to their partners and higher rates of DSM-IV depression and anxiety in female partners than in the general female population in Australia. Men were no different from their counterparts in the general population. CONCLUSIONS: The results have important implications for the content and conduct of psychosocial interventions for men with prostate cancer.

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PURPOSE: The purpose of this study was to explore alexithymia and its possible relationship to anxiety in women with breast cancer and in their husbands. METHODS: A cross-sectional study was undertaken in 46 post-surgical ambulatory women with breast cancer and their husbands. Documented informed consent for the study was obtained from each subject. All subjects completed the Zung self-rating anxiety scale (SAS), the 20-item Toronto Alexithymia Scale (TAS-20), and the Family Assessment Device (FAD). RESULTS: Single variable analysis revealed a significant relationship between the SAS score and the TAS-20 score among the patients, and between the SAS score and the TAS-20 score and the level of education among the husbands. Moreover, multiple regression analysis revealed that the TAS-20 score was significantly related to the SAS score among the husbands (p=0.016). CONCLUSION: The present results suggest that alexithymia might be related to anxiety in women with breast cancer and their husbands. In order to reduce anxiety, it might be beneficial to detect and intervene alexithymic people among women with breast cancer and their husbands.

Comparing the Psychosocial Adjustment of Men with Prostate Cancer and their Partners Love AW1, Couper JW2, Bloch S2, Macvean M2, Kissane DW3 1 Psychological Science, La Trobe University, Bundoora, Australia; 2Psychiatry University of Melbourne, Melbourne, Australia; 3Psychiatry and Behavioral Science Memorial, Sloan-Kettering Cancer Center, New York, USA PURPOSE: To describe and measure over time the psychosocial adjustment of a cohort of women and their partners diagnosed with prostate cancer; to determine factors that might contribute to the nature of their psychosocial adjustment; and, to determine how the women’s adjustment compares to that of their partners. METHODS: Questionnaires regarding psychiatric morbidity, quality of life, coping styles and couple and family function have been administered to 78 men diagnosed with prostate cancer and to their female partners. We employ a longitudinal design but baseline data only will be presented. RESULTS: We found significantly greater global psychosocial

Copyright # 2004 John Wiley & Sons, Ltd.

129 Factors Related to Anxiety in Women with Breast Cancer and their Husbands: Relationship Between Anxiety and Alexithymia Mantani T1, Saeki T1, Ozono S1, Yamawaki S1, Okamura H2 et al. 1 Department of Psychiatry and Neurosciences, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan; 2Institute of Health Sciences, Faculty of Medicine, Hiroshima University, Hiroshima, Japan

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130 Prevalence of Post-traumatic Stress Disorder, Anxiety and Depression in a Representative Sample of Breast Cancer Patients Mehnert A Institute of Medical Psychology, Hamburg University Clinic, Hamburg, Germany PURPOSE: Prevalence rates of psychiatric disorders in adult cancer patients differ a lot ranging from 0% to 35% for post-traumatic stress disorder (PTSD) and to approximately 50% for affective and anxiety disorders. Prevalence rates closely depend on cancer type, disease stage, treatment, time and methods of assessment as well as applied diagnostic categories. Furthermore, evidence is lacking whether psychiatric co-morbidity in cancer patients significantly differs compared to the general population. METHODS: The aims of this cross-sectional study was to assess psychiatric comorbidity and risk factors in women with breast cancer at all stages of the disease. N=1083 patients randomly selected by the local cancer registry (response rate 67%) filled out a questionnaire including the following instruments: IES-R, PCL-C and HADS, among others. Mean time since cancer diagnosis was 47 months (range 18–77). 13% had a diagnosis of recurrent cancer. RESULTS: Between 8% and 15% of patients met criteria for cancerrelated PTSD, and significant levels of intrusive (38%), avoidant (22%) and arousal (34%) symptoms were reported. 19% of the patients were anxious, 10% were depressed and 7% were both (scores more than 11 on the HADS). 71% did not meet criteria for any of these psychiatric disorders. Patients with PTSD-diagnosis showed higher levels of anxiety, depression as well as fear of progression (each p50.001, effect sizes from d=1.6 to 1.8). CONCLUSIONS: Results indicate that slightly less than one third of breast cancer patients are likely to meet criteria for a co-morbid psychiatric disorder depending on particular cut-off-scores.

131 Factors Predicting Psychological Distress in Cancer Patients Montazeri A, Sajadian A, Fateh A, Haji-Mahmoodi M, Ebrahimi M

Copyright # 2004 John Wiley & Sons, Ltd.

Quality of Life Study Group, Iranian Centre for Breast Cancer (ICBC), Tehran, Iran PURPOSE: To investigate about psychological symptoms and its predicting factors in cancer patients in Tehran, Iran. METHODS: A consecutive sample of heterogeneous cancer patients was required. Anxiety and depression was measured using the HAD Scale. In addition Global QOL was measured and information on patients’ clinical and demographic status also were collected. RESULTS: In all 625 cancer patients were interviewed. Of these the most had either breast (28%) or gastrointestinal (25%) cancers. The mean age of patients was 47.6 (SD=15.2) years, and mostly were females (68%). Severe symptoms of anxiety and depression were reported by 29%. Performing logistic regression it was found that for anxiety time since diagnosis (odds ratio=2.2, 95% CI 1.5–3.4, P50.0001) and QOL (odds ratio=0.95, 95% CI 0.94–0.96, P50.0001) and for depression age (odds ratio=1.02, 95% CI=1.0– 1.04, P=0.01), knowledge of cancer diagnosis (odds ratio=1.7, 95% CI 1.1–2.6, P=0.02) and QOL (odds ratio=0.94, 95% CI 0.92–0.95, P50.0001) were significant independent predicting factors. Other variables studied did not show any significant results. CONCLUSIONS: The findings suggest that overall one-third of cancer patients experience severe symptoms of anxiety and depression. Although global quality of life score could predict anxiety and depression, at the same time these psychological symptoms are outcomes of different variables.

132 Screening of Emotional Distress in Cancer Patients Moscoso MS, Reheiser EC Psychology University of South Florida, Tampa, Florida, USA The purpose of this study was to replicate the preliminary findings for the Hospital Emotional Distress Inventory (HEDI) and provide evidence of construct validity for this brief measure. We report its reliability, internal consistency, and construct validity. Sixteen items were developed and tested for appropriateness in cancer patients. The items were administered to 238 cancer patients

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at Morton Plant Hospital Cancer Centre in Clearwater, Florida. Responses to the items were examined by Factor Analyses of Principal Components with promax rotations, which yielded three initial factors. The first factor accounted for 82% of the variance and was comprised of items reflecting feelings of anxiety and depression. The second factor accounted for 10% of the variance and included items relating to the loss of hope and was labelled Demoralization. The third factor accounted for 8% of the variance, and was comprised of items that indicate Anger Expression. The first factor was determined to be a higher order factor and its items were subjected to further factor analysis with promax rotation. Separate factors of Depression and Anxiety with an interfactor correlation of 0.71 were identified. The HEDI had an alpha coefficient of 0.91 and itemremainder correlations >0.39. The HEDI, comprised of four distinct first-order factors, has subscales that assess Anxiety, Depression, Demoralization, and Anger Expression with alpha coefficients of 0.83, 0.80, 0.72 and 0.78, respectively.

also are collected. METHODS: Data collection from five regional oncology centres in Hungary resulted over 800 patients who completed the Hospital Anxiety and Depression Scale (HADS; a 14-item, self-report questionnaire), the Distress Thermometer (a 1-item, self-report tool), and the Symptom List. RESULTS: Reliability analyses of the translated tools showed high internal consistency, and validity (using known groups comparison analysis) showed satisfactory results as well. Scores on the Distress Thermometer were significantly correlated with both anxiety and depression scales of the HADS. Previous findings of the optimal cut-off points (5 for the distress thermometer and 7 for both HADS scales) were reconfirmed. CONCLUSIONS: We describe the psychological state of Hungarian cancer patients as severe, since over 40% of the patients expressed an advanced level of distress, anxiety and depression resulting mostly from emotional and physical problems related with their illness. We conclude that the Distress Thermometer can, and should be used for rapid screening of the patients with advanced distress and related problems in Hungary.

133 134 Screening for Distress of Hungarian Cancer Patients, Validation Study of Hungarian Version of HADS ! M2, Moln!ar M3, Muszbek K1, Balogh E 4 5 Roh!anszky M , Varga K et al. 1 Hungarian Hospice Foundation, Budapest, Hungary; 2Department of Oncology, Debrecen University, Debrecen, Hungary; 3Oncoradiology Centre, Kecskeme!t County Hospital, Kecskeme!t, Hungary; 4 Department of Oncology St. La!szlo! Hospital, Budapest, Hungary; 5Oncotherapy Clinic, Szeged University, Szeged, Hungary PURPOSE: Whereas cancer treatment is developing fast in Hungary, psycho-oncology is still very much behind. There is no data about the psychological state of cancer patients and the importance of psychosocial support is unrecognized. As a first step we initiate a general screening procedure for distress of Hungarian cancer patients to establish empirical basis for the development of a novel psycho-oncology program. Some interesting data for the perception of illness

Copyright # 2004 John Wiley & Sons, Ltd.

Psychosocial Distress in Cancer Patients During Outpatient Treatment}Preliminary Results Ortner M, Niedermayer R, Schmidinger M, Marosi Ch, Zielinski Ch et al. Internal Medicine I, Medical University, Vienna, Austria; Psychoanalysis and Psychotherapy, Medical University, Vienna, Austria PURPOSE: The goal of this study is to identify psychosocial distress in cancer patients during outpatient treatment for malignancies and to find out if the key position of the attending oncologists can be used to address psychosocial support according to the needs of the patients at an early stage of treatment. METHODS: Cancer patients attending the outpatient ward of the clinic for the first time were asked to complete the Hospital Anxiety and Depression Scale (HADS), the Hornheider Questionnaire and to give demographic and clinical information. Attending oncologists estimated the psychosocial distress of their patients globally (yes/no). RESULTS: The rate of

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returned questionnaires was 81.5%. 71 patients completed the questionnaire (32 female, 39 male), 26 refused participation. 25.7% of the sample showed clinical relevant values of anxiety (HADSA) and 10.0% of depression (HADS-D). Regarding these scales the physicians estimation of the patients need of psychosocial support was very good (74.4% HADS-A, 77.4% HADS-D). Results of the Hornheider Questionnaire show that 35.7% of the patients need psychosocial support, physicians detected them in 58%. CONCLUSIONS: The first results reveal the important role of oncologists, who have a very good ability to identify psychosocial distress in their patients and therefore can refer them to psychosocial services at a very early stage of cancer treatment. It seems that especially depression is a good indicator for the oncologists estimation of psychosocial distress in cancer patients.

with greater distress (r=0.58, p50.001). The interaction between surgery concerns and intrusive thoughts was significantly associated with distress (beta=0.50, p50.02) suggesting that surgery concerns moderated the association between intrusive thoughts and distress. Graphical representation of the interaction revealed that the association between intrusive thoughts and distress was diminished for patients reporting low surgery concerns. Thus, it may be important to identify ways to reduce men’s surgery-related concerns leading up to prostate cancer surgery. For example, educational interventions could be designed to increase knowledge about the surgery process and ways to manage side effects. This may reduce the negative effects that intrusive thoughts have on patients’ level of distress prior to surgery.

136 135 Surgery Concerns Moderates the Association Between Intrusive Thoughts and Distress Parker PA1, Devine D1, Fortier A1, Pettaway C2, Cohen L1 et al. 1 Behavioral Science, The University of Texas, M. D. Anderson Cancer Center, Houston, USA; 2 Urology, The University of Texas, M. D. Anderson Cancer Center, Houston, USA We examined the association between surgery concerns, intrusive thoughts/avoidance behaviors (intrusive thoughts), and distress in men with early stage prostate cancer. One hundred fifty men who were 1–5 days before radical prostatectomy surgery completed measures of surgery concerns (11 items assessing the extent of men’s concerns about their upcoming surgery (e.g., surgery complications, postoperative pain, erectile dysfunction)), intrusive thoughts (Impact of Events Scale) and distress (Profile of Mood States). Participants were mostly Caucasian (79%), married (87%), an average of 60.8 years old (SD= 6.6 years), and 76% had at least some college education. Correlation analyses revealed that men with more surgery concerns had significantly more intrusive thoughts (r=0.37, p50.001) and greater distress (r=0.49, p50.001). Having more intrusive thoughts was also significantly associated

Copyright # 2004 John Wiley & Sons, Ltd.

Screening for Psychosocial Distress Among Ambulatory Oncology Patients: Evaluation of the Distress Thermometer Patrick-Miller LJ1, Broccoli TL2, Levine E3, Much JK4 1 Behavioral Sciences, The Cancer Institute of New Jersey (UMDNJ/Robert Wood Johnson Medical School), New Brunswick, NJ, USA; 2Psychology Rutgers University, New Brunswick, NJ, USA; 3 Social Work, The Cancer Institute of New Jersey (UMDNJ/Robert Wood Johnson Medical School), New Brunswick, NJ, USA; 4Nursing, The Cancer Institute of New Jersey (UMDNJ/Robert Wood Johnson Medical School), New Brunswick, NJ, USA PURPOSE: Distress among ambulatory oncology patients (AOP) is common and deleterious to treatment decisions, symptoms, adherence and outcomes, but treatable. Recent NCCN guidelines recommend screening AOP for distress at initial patient visit (IPV) using single-item self-report Distress Thermometer (DT) and 33-item Problem List (PL). This study establishes operating characteristics of DT and PL. METHODS: AOP (n=1272; 15–97 YO, mean=54.7; 31% male) completed DT, PL, health history and Hospital Anxiety and Depression Scale (HADS) at IPV. Receiver operating characteristics (ROC) analysis established DT’s sensitivity/specificity and optimal

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cut-offs. Stepwise discriminant analysis evaluated added contribution of PL and health history. RESULTS: DT correlates more strongly and produces greater Area under ROC Curve for HADS-Total scale (HADS-T: r=0.70; AROC=87.6%) than Anxiety (HADS-A: r=0.68; AROC=84.9%) and Depression (HADS-D, r=0.54; AROC=80.2%). DT cut-offs (>4; >5) have sensitivity (84%; 67%), specificity (73%; 84%), positive predictive value (46.57%; 59.71%) and negative predictive value (82.57; 69.86) to detect caseness (criteria: HADS-T=15). PL and ADL, but not gender, age, pain or tangible support, significantly reduced variance unaccounted for by DT (p=0.00). Only PL’s Emotional (PL-EMOT) and Physical (PL-PHYS) subscales improved classification (AROC= 93.7%; sensitivity=71%; accuracy=90%). CONCLUSIONS: DT better predicts caseness for global distress and anxiety than depression in AOP. Sensitivity is adequate at both cut-offs. Adding PL-EMOT and PL-PHYS to DT most improves classification. Screening AOP with DT, PL-EMOT and PL-PHYS maximizes sensitivity, accuracy and efficiency.

137 The Emotional Distress in Advanced Cancer Patients Treated with Chronomodulated Chemotherapy Perrone M1, Pugliese P1, Garufi C2, Falcicchio C1, Terzoli E2 et al. 1 Psychology National Cancer Institute, ‘‘Regina Elena’’, Rome, Italy; 2Oncology National Cancer Institute, ‘‘Regina Elena’’, Rome, Italy PURPOSE: The aims of the study was to describe the course of distress and Quality of Life (QoL) in 2 groups of patients with advanced cancer; to assess the distress as prognostic factor of QoL. METHOD: 44 advanced colorectal cancer patients during chronomodulated therapy were evaluated. Group1 consisted of 22 patients with high level of anxiety and depression symptoms (HADs 38; 10 male/12 female; median age: 61); Group 2 consisted of 22 patients with low level of anxiety and depression symptoms (HADs £8; 10 male/12 female; median age: 62). The evaluation instruments were a semistructured interview to evaluate

Copyright # 2004 John Wiley & Sons, Ltd.

the adaptation and the awareness, the EORTC QLQ C30 (QLQ C30) for QoL evaluation, the HADs for anxiety and depression evaluation. The evaluation was performed before and after 3 and 6 months of treatment. The whole population were followed by an integrated e! quipe (psychologists and oncologists) with a supportive function during the therapy. The psychological intervention was a brief crisis intervention. RESULTS: Before treatment the Group1 showed a worse QoL in four QLQ C30 variables: Emotional functioning (mean: 57 vs 79); Social functioning (mean: 67 vs 90); Global Health (58 vs 76) and Global QoL (mean: 55 vs 79). After 6 months Group1 showed an improvement in the same QoL variables. The same trend was showed for anxiety and depression. In Group2 the QoL and the anxiety and depression symptoms showed stable scores during whole treatment. Patients with more distress at diagnosis showed a worse Social Functioning and Global QoL.

138 The Relationship Between Personal Cancer History, Family Cancer History, and Distress Rabin C1,2, Pinto B1,2, Frierson G1,2, Trask P1,2, Nash J1,2 1 Behavioral Medicine, Miriam Hospital, Providence, RI, USA; 2Psychiatry & Human Behavior, Brown University Medical School, Providence, RI, USA A personal or family history of cancer may increase risk for distress, but it has not yet been established whether having both exerts a synergistic effect. It is also unclear whether distress associated with family history of cancer depends on the family member affected. This study used data from National Health Interview Survey 2000 (N=32,374). A series of 2  2 ANOVAs were performed to examine the main effects and interactions of personal cancer history and family cancer history. Likert ratings on mood items}sad, nervous, restless, hopeless, everything was an effort, and worthless}were used as outcomes. Personal cancer history consistently exerted a main effect on all mood items (F-values= 4.47–26.53, p50.05 or 0.01). Analyses also revealed that, while ‘‘mother with cancer’’ had a main effect on all

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mood items (F-values=9.88–22.34, p50.05 or 0.01), ‘‘father with cancer’’ was significantly associated with only two. Similarly, ‘‘sister with cancer’’ had a main effect on four mood outcomes, but ‘‘brother with cancer’’ only one. Finally, ‘‘personal cancer history’’ and ‘‘mother with cancer’’ exerted an interaction effect on two mood items. These findings suggest that having a female relative with a cancer history is particularly distressing and that those with both personal cancer history and mother with cancer may be most distressed. Data on gender effects interacting with personal and family cancer history will also be presented. Findings have implications for identifying patients who may be at elevated risk for distress following their own or a family member’s cancer diagnosis.

139 Attachment and Cancer Rodin G, Jones J, Walsh A, Rydall A, Gagliese L Psychosocial Oncology and Palliative Care, Princess Margaret Hospital, Toronto, Canada BACKGROUND: Attachment style is a personality characteristic which affects psychological well-being and the capacity to form and maintain relationships important for felt security. This characteristic has not been explored in patients with advanced or terminal disease, although it has been shown in chronic medical conditions to predict adjustment and positive relationships with health care providers. We explored its relationship to psychological well-being in patients with metastatic cancer as part of a longitudinal study to identify predictors of well-being and distress in this population. METHODS: 115 subjects with stage IV metastatic gastrointestinal cancer completed measures which included: Memorial Symptom Assessment Scale, Rosenberg Self Esteem Scale, Beck Depression Inventory-II, Beck Hopelessness Scale, Experiences in Close Relationships, and the Schedule of Attitudes Towards Hastened Death. RESULTS: Moderate to severe symptoms of depression were reported by 20.9% (BDI>15), hopelessness by 26.1% (BHS>8) and the desire for hastened death by 11.3% (SAHD>11). Insecure (anxious) attachment style was positively correlated with depression (r=0.47, p50.001), the

Copyright # 2004 John Wiley & Sons, Ltd.

desire for hastened death (r=0.32, p50.006) and negatively correlated with self-esteem (r=0.42, (p50.001). Subjects reported a mean of 5.7 (+3.7) physical symptoms. CONCLUSIONS: Findings from this study confirm that an insecure attachment style is associated with lower self regard and impaired psychological well-being in patients with metastatic cancer. Further research is needed to determine the stability of this characteristic and its clinical significance.

140 A Comparison between First Occurrence and Recurrence of Breast Cancer: Anxiety, Depression, PTSD Sadeh-Tassa D1,2, Yagil Y2,3, Stadler J1 1 The Breast Health Center, Tel Aviv Sourasky Medical Center, Tel-Aviv, Israel; 2Social Services, Tel Aviv Sourasky Medical Center, Tel-Aviv, Israel; 3Shappel School of Social Work, Tel-Aviv University, Tel-Aviv, Israel RATIONAL: Breast cancer is the most prevalent malignant disease afflicting women in Israel (1:8). Research has examined various aspects in adaptation to breast cancer. However, there is hardly any research comparing the emotional distress of women facing the disease for the first time and women undergoing a recurrent event. In addition, little has been written about comparing the frequency and the extent of post-traumatic symptoms in women at first occurrence and those experiencing a recurrence (Cella, Mahon and Donovan, 1990). STUDY HYPOTHESIS: Women who experience a recurrence will suffer severe post-traumatic symptoms. PARTICIPANTS: 70 breast cancer women patients, 40 experiencing 1st occurrence and 30 undergoing a recurrence. MEASURES: SCL-90, PCL, and IES. FINDINGS: Women who experience a recurrence suffer from more anxiety and depression than women experiencing occurrence of disease. Women suffering a recurrent show higher rates of PTSD (30%) compared to women facing 1st occurrence (20%). Women facing recurrent disease suffer less intrusive symptoms, though more frequently. CONCLUSIONS: In face of the cumulative effect of distress symptoms along the recurrence of disease, there is a major importance in preparing

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women during the remission period, and finding ways to cope better with anxiety, especially with the knowledge that the disease might recur. In this sense, preventive intervention has a valuable meaning with women who are facing the disease for the first time, in addition to the importance of the psychosocial evaluation which should be done shortly following the diagnosis of the disease.

Symptoms such as avoidance tend to decrease in time.

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There is evidence that the diagnosis and treatment of cancer produce considerable distress in patients and their families. Regardless of prognosis, the initial diagnosis is still perceived by many patients as a life-threatening event. Even in cases where the chance of survival is very good, there may be threats to physical functioning, changes in personal appearance, and frequently, significant disruptions of normal daily routines. WHO’s cancer prevention and control policy (National cancer control programmes: policies and managerial guidelines, 2nd ed. Geneva, WHO 2002) establishes the need for providing routine psychosocial services for cancer patients, family members and health care providers when necessary. Psychosocial support is seen as a key component of palliative care and of rehabilitation as well. These services include:

Symptoms of Post-traumatic Stress Disorder in Patients with Malignant Hematologic Disease Santos FRM et al. Psicobiologia UNIFESP, Sa*o Paulo, Brazil Many cancer patients survive longer than in the past. However, occasionally, cancer diagnosis and treatment may set off a traumatic experience, giving rise to the development of Post Traumatic Stress Disorder (PTSD). According to DSM-IV, PTSD may occur after a traumatic event, as the diagnosis of diseases that threaten life, when the patient keeps intrusive memories and feelings and avoids situations and thoughts about it. PURPOSE: To investigate the incidence of PTSD symptoms (avoidance and intrusion), in patients with malign hematological disease, and their anxiety and depression. To evaluate the relationship of these factors with social support and diagnosis time. METHODS: A study with 58 patients, ranging from 21 to 84 years old, out of which 22 had Lymphoma and 36 had Leukemia was performed. Demographic and social support data were collected in interviews, followed by application of the instruments: HADS (Anxiety and Depression); IES (Intrusion and Avoidance Symptoms) and EORTC QLQ-C30. RESULTS: 15.5% of the patients presented high level for intrusion and 29.3% for avoidance. Social support correlates negatively with IES and HADS scores (p=0.000, p=0.044). Diagnosis time correlates negatively with avoidance symptoms (p=0.043). There is no meaningful difference between leukemia and lymphomas, related to IES and HADS rates. There is a positive correlation between IES and HADS rates. CONCLUSION: Patients who have little social support present higher PTSD symptoms than those who have social support.

Copyright # 2004 John Wiley & Sons, Ltd.

142 WHO Cancer Control Programme Sepulveda C Coordinator Cancer Control Programme, World Health Organization (WHO), Geneva, Switzerland

– Assessment of patients for the presence of anxiety and depression and appropriate care to ameliorate the symptoms. – Support to help patients adhere to treatment plans. – Skill building for coping with cancer. – Information and basic emotional support. – Support for families of cancer patients during the course of the disease and bereavement period. – Continuous training and support for health care providers and family care givers. WHO gives great importance to self-care and home-care provided by trained family care givers, properly supervised by primary health-care workers, as a means to ensure wide coverage of supportive care and end-of-life care including psychosocial support. This is especially relevant in low-resource settings where health professionals are very scarce.

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143 Mirtazapine Treatment of Depression and Weight Loss in Pancreatic Cancer Patients Sherman LK1, Clarke MJ2 1 Neuro-oncology, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA; 2Psychiatry, Washington University, St. Louis, MO, USA Pancreatic cancer carries a poor prognosis, with a 1-year survival rate under 5%. Numerous case reports, series and studies have appeared in the literature demonstrating the common comorbidity of pancreatic cancer and depression. A comprehensive reanalysis of case reports revealed depression symptoms in 71% of patients, and that in up to 50% of these patients depressive symptoms may predate the diagnosis of pancreatic cancer. Only two case reports discuss attempts at treating depression in pancreatic cancer patients, both unsuccessful. Another symptom associated with pancreatic cancer that often precedes the diagnosis and continues thereafter is weight loss and cachexia (decline in lean muscle mass associated with decreased performance status). Weight loss occurs in 85% of pancreatic cancer patients, and cachexia is considered to be a major cause of death in this population. Some research suggests that eicosapentaenoic acid may attenuate cachexia, but no agent has been shown to definitively improve cachexia in this population. In our clinical experience we have found that mirtazapine (Remeron) can both effectively treat depression and promote weight gain in pancreatic cancer patients. A retrospective chart review was conducted on pancreatic cancer patients referred for evaluation and treatment of depression. Fifteen of eighteen patients treated with mirtazapine (dose range 15– 60 mg) showed remission of depression and weight gain (range 1–11 kg). Mirtazapine was well-tolerated. Since improvement of cachexia could potentially prolong survival, it is evident that further prospective, controlled study of mirtazapine for weight loss/cachexia and depression in the pancreatic cancer population is warranted.

1

Psychology University of Missouri-Kansas City, Kansas City, Missouri, USA; 2Psycho-Oncology, The Cancer Institute, Kansas City, Missouri, USA; 3 Vanderbilt University, Nashville, Tennessee, USA Research has demonstrated optimism is related to better psychological adjustment in those dealing with stressful events, such as a cancer diagnosis and treatment. Less is known about the mechanism(s) by which optimism enhances adjustment. One path may be through coping. Prior studies examining coping as mediator in the relationship of optimism and adjustment among individuals with cancer have delineated several coping strategies playing a negative role in adjustment. Fewer helpful cognitive and behavioral strategies explaining the association between optimism and psychological outcomes have been identified. Additionally, methods of coping have commonly been analyzed in isolation rather than in the context of other coping strategies in which the individual engages. This study examined the relationship of optimism with symptoms of depression and anxiety in 105 women diagnosed with early-stage breast cancer, and tested a mediational model incorporating our theoretical framework of coping (Primary Control Coping, Secondary Control Coping, and Disengagement Coping). Path analysis indicated excellent fit of our model for the prediction of Beck Anxiety Inventory scores (Chisquare=0.017, ns; GFI=1.0; CFI=1.0; RMSEA= 0.00), with Secondary Control Coping exerting the strongest mediational role in the context of other coping methods. While Primary Control Coping mediated the relationship of optimism and Beck Depression Inventory scores, the overall path model did not demonstrate acceptable fit (Chisquare=4.582, p50.05; GFI=0.98, CFI=0.95; RMSEA=0.19). Thus, results provide partial support for our models of adjustment and emphasize the role of positive coping methods (i.e., Primary and Secondary Control Coping) in the relationship of optimism and emotional outcomes.

145 144 Optimism and Psychological Adjustment in Women with Breast Cancer: Coping as Mediator Sherman ML1,2, Compas BE3

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Feasibility and Usefulness of the Distress and Impact Thermometer as a Brief Screening Tool to Detect Psychological Distress in Clinical Oncology Practice

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Shimizu K1, Akechi T1,2, Okamura M1, Akizuki N3, Uchitomi Y1,2 1 Psychiatry, National Cancer Center Hospital East Kashiwa, Japan; 2Psycho-Oncology, National Cancer Center Research Institute, East Kashiwa, Japan; 3 Psychiatry, National Cancer Center Hospital, Tokyo, Japan PURPOSE: Despite high screening ability for psychological distress in patients with cancer, few distressed patients have been adequately treated. This study addresses following two questions concerning the feasibility and usefulness of the Distress and Impact Thermometer (DIT) to detect major depression and adjustment disorders in clinical oncology practice. First, what percentages of patients with cancer are administered DIT? Second, does the DIT in combination with nurses’ recommendations based on the screening results contribute to increasing psychiatric referral of major depression and adjustment disorders? METHOD: From July to October 2003, the Nurse-Assisted Screening and Psychiatric Referral Program was introduced on the Oncology/Haematology unit of National Cancer Centre Hospital East, Japan. In this program, nurses used the DIT to routine screen and recommended psychiatric referral to positive patients. Patients who accepted referral were seen by the psychiatric service and diagnosed according to the DSM-IV. RESULT: The DIT could be adequately administered to 86.0% (135/157) of all inpatients during the study period and 42.7% (67/157) were positive. Among the positive patients, 28.4% (19/67) accepted referral, and the other 71.6% (48/67) refused. Ultimately, 18 patients were diagnosed as major depression or adjustment disorders. The referral rate concerning these disorders was 11.5% (18/ 157) and significantly higher (p50.001) than that of historical control data (1.5%, 2/134). CONCLUSION: The fare screened rate and increase in psychiatric referral suggested that the DIT with nurse-assisted intervention is feasible and useful in clinical oncology practice. Meanwhile the high refusal rate requires future barrier studies for psychiatric referral.

146 Recognition of Distress in Cancer Patients

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Sommerfeldt S, Brechtel A, Fischer C, Knight L, Keller M Department of Surgery, University Hospital, Heidelberg, Germany PURPOSE: Timely and valid identification of psychosocially distressed patients gains increasing importance. This study aimed to determine the prevalence of psychological morbidity among cancer patients treated in a university surgical setting as well as the doctors’ and nurses’ ability of reliably diagnose patients’ distress and need for psychosocial intervention. METHODS: In a crosssectional design 189 consecutively recruited patients were included and preoperatively assessed. Based on a multi-level approach distress was measured by patients’ self-report (HADS) and rated by surgical residents and nursing staff. The Structured Clinical Interview (SCID-I for DSMIV, gold standard) was administered to a randomised subsample of 78 patients. Referrals to a psychosocial liaison service initiated by the medical staff were analysed. RESULTS: We found 24 current psychiatric DSM-IV diagnoses in 22 of the patients (28%). According to HADS (cut-off =16) 26% of the patients were highly distressed. Surgeons and nurses judged about 50% of the patients as distressed and/or in need of psychosocial support. Surgeons correctly recognised marked distress in 77% of patients, nurses reached 75% sensitivity. Because of low specificity, the positive predictive value was only 39% in surgeons and 40% in nurses. Forty percent of the patients were referred to the psychosocial liaison service. CONCLUSIONS: Distressed cancer in-patients are underdiagnosed and undertreated. This indicates the necessity for testing systematic screening procedures upon admission by patient-reported questionnaires at customised cut-off values. Data of the first 300 patients of a current screening project we are establishing as a transcription of the study results will be also presented.

147 Assessing Shame and Stigma in Lung Cancer Street AF1, Love A2, Kissane DW3 1 La Trobe/Austin Health Clinical School of Nursing, La Trobe University, Heidelberg, West Australia; 2School of Psychological Sciences,

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La Trobe University, Bendigo, Australia; 3 Department of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, New York, USA International studies have demonstrated that lung cancer, with its poor prognosis, can produce a heavy burden of symptom distress. It has been argued that the meanings that illness hold for the person includes both physical and mental anguish. Thus symptom distress has primarily been defined in terms of physical symptoms and quality of life measures. Drawing upon preliminary research we argue that symptom distress also involves social anguish such as guilt, stigma or shame. It is important that the interrelationship of physical, psychological and social distress be captured in any study on symptom distress. This paper describes the development of a Shame and Stigma Scale in lung cancer (SSS- LC) for inclusion in a larger questionnaire on symptom distress. There has been little work done on shame or stigma in relation to medical illness, with the exception of sexually transmitted diseases. Yet people with lung cancer may experience guilt and shame associated with a history of smoking and feelings of stigma that relate to societal views on smoking behaviors. Conceptual analysis around distress related to shame and stigma in the literature was followed up with the development of an empirical study. This 24-item Shame and Stigma Scale has been designed with a 4-point (0–3) scale to gather information that measures individual difference in feelings of stigma, shame and guilt. This paper will report on the conceptual analysis, development and testing of the Shame and Stigma Scale and provide some preliminary data from the study on symptom distress in lung cancer.

148 Daily Omega-3 Fatty Acid Intake and Depression in Japanese Patients with Newly Diagnosed Lung Cancer Suzuki S1,2, Akechi T1, Taniguchi K1, Miyaoka H2, Uchitomi Y1 et al. 1 Psycho-Oncology Division, National Cancer Center Research Institute, East Kashiwa, Japan; 2 Department of Psychiatry, Kitasato University, Sagamihara, Japan

Copyright # 2004 John Wiley & Sons, Ltd.

The aim of the present study was to examine the association between daily omega-3 fatty acid intake and depression in Japanese cancer patients. Omega-3 fatty acid intake in 771 patients with newly diagnosed primary lung cancer was evaluated using a food frequency questionnaire, and the prevalence of depression was examined using the cut-off values for the depression subscale included in the Hospital Anxiety and Depression Scale. After adjustment for potential confounding factors, the odds ratio (OR) for depression among patients in the highest quartile of the total eicosapentaenoic acid (C20:5n-3) and docosapentaenoic acid (C22:6n-3) intake group compared with patients in the lowest quartile was not significantly different. On the other hand, the OR among the highest quartile of a-linolenic acid (C18:3n-3) intake (adjusted OR=0.50, 95%CI: 0.31–0.71, p for trend=0.004) and the highest quartile of total omega-3 fatty acid intake (adjusted OR=0.55, 95%CI: 0.35–0.88, p for trend=0.022) were significantly different. These results suggest that total eicosapentaenoic acid and docosapentaenoic acid intake might not be associated with depression in Japanese patients with newly diagnosed lung cancer, but that a-linolenic acid intake and total omega-3 fatty acid intake might be.

149 The Impact of Cancer During the Process of Psychological Adaptment Tempia Valenta P1, Minacapelli P1, Cinti P1, Lomonaco E3, Clerico M2 1 Psychoncology, ASL 12, Biella, Italy; 2Oncological Pole, ASL 12, Biella, Italy; 3Mental Health, ASL 12, Biella, Italy INTRODUCTION: International literature highlights the raised rate of co-morbidity existing between cancer and depression. To give a single example, referring to the entrance into the long tunnel of chronic illness, communication of the diagnosis only marginally coincides with the real acquisition of the awareness of the illness. This involves a process of individual adaptation, of variable duration from person to person. The first results of the research, in collaboration with the Department of Mental Health, are illustrated in

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this study which is finalized to render the entire process measurable and, in particular, the impact of organizational changes on the process itself. The research’s general objectives consist in: 1. Evaluating the incidence of psychiatrical disturbances; 2. Connecting the incidence, the course and the outcome of such conditions by organizing the caring services. METHODS AND TOOLS: The detection of the data was carried out during 2002–2004 and involved all the staff of the Oncological Pole. Psychological Tests used: 1. 2. 3. 4. 5.

Personal Details Form Medical Form Anxiety and Depression Analysis of Needs Quality of Life

CONCLUSION: Three hundred and nine patients from our Oncological day-hospital, giving informed consent, took part in the research. Three aspects have thus been studied and correlated, and are here put forward: 1. The phase of the oncological illness; 2. The description of the individual, family and caring context; 3. The patient’s psychic and emotional dimension.

150 Memories and Meaning Finding in Breast Cancer Patients}The Relation with Distress Thomsen DK1, Jensen AB2, Zachariae R1 1 Psycho Oncology Research Unit, Aarhus University Hospital, Aarhus, Denmark; 2Department of Oncology, Aarhus University Hospital, Denmark PURPOSE: To investigate the association between how breast cancer patients remember situations from their treatment course, how they find meaning in their illness and distress. METHODS: 15 women with breast cancer who had received adjuvant chemotherapy were recruited for an interview at their control visit 3 months post treatment. They were interviewed in their home

Copyright # 2004 John Wiley & Sons, Ltd.

and asked (1) whether they saw any kind of meaning in their illness and to briefly describe how if they did, (2) to recall five situations from their illness and treatment course, (3) if they experienced the memory from an observers perspective, i.e. from ‘‘the outside’’, (4) if they saw the memory as a personal ‘‘turning point’’ and (5) to complete Impact of Event Scale. RESULTS: 8 of the women saw some kind of meaning with their illness. The women who saw meaning in their illness experienced fewer of their memories as turning points and scored lower on the IES (p50.05). IES also correlated positively with number of experienced turning points and experiencing the memory from ‘‘the outside’’ (p50.05). CONCLUSION: The results suggest that not being able to see meaning in the illness, seeing many personal turning points in the illness and treatment and experiencing memories from an observer’s perspective is associated with higher distress among breast cancer patients.

151 Symptom Distress in Patients with Lung Cancer: are we Measuring the Right Dimensions? Tishelman C1,2, Degner LF3, Broberger Wiberg E1,2, Runesdotter S1,2, Bertilsson K1,2 1 Department of Nursing Karolinska Institutet, Stockholm, Sweden; 2R&D unit/Palliative Care Foundation, Stockholms Sjukhem, Stockholm, Sweden; 3Faculty of Nursing, University of Manitoba, Winnipeg, Canada Despite the particularly vulnerable situation for patients with lung cancer, publications on their symptom experience remain relatively sparse. Distinctions between dimensions of intensity and distress have generally not been clarified in existing research, nor has the question of how distressing patients perceive different symptoms to be, irrespective of their current intensity levels, been specifically addressed. The primary aim of this project is therefore to explore patterns of intensity and distress from symptoms in newly diagnosed lung cancer patients, in order to provide a framework for nursing and palliative interventions. Four hundred patients with newly diagnosed inoperable lung cancer have been interviewed up to six times during the first year post-diagnosis.

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The main dependant variable was the ranking of distress from nine common symptoms, using a Thurstone Scale of pairwise comparisons. Instruments assessing perceived symptom intensity and quality of life were also completed at each time point. This data has been complemented with inductive structured and unstructured interview data, to heighten the validity and understanding of generated results. Data analysis indicates that the ranking of perceived intensity differs from the ranking of perceived distress. The mean ranking of distress in the total group remains constant over time, with breathing, pain and fatigue rated as most distressing; while the mean ranking of intensity fluctuates and varies by subgroup and over time. The implications of this data for introducing a paradigm of preventative palliation will be discussed. The usefulness of this data for considering both group and individual needs will also be addressed.

152 Affective Disorders Among Hospitalized Cancer Patients Tosic Golubovic STG, Gugleta DG, Miljkovic SM, Golubovic NG Psychiatry UKC Gornja Toponica, Serbia and Montenegro Cancer and its treatment can lead to major changes in a patient’s mental status. PURPOSE: This paper reports on date from a prospective study comparing anxiety and depression among cancer patients (N=30) in which primary site was genital tract. Among physically healthy persons (N=30) hospitalized because of recent suicide attempts, and among patients with myoma uteri (N=30). METHODS: Anxiety was assessed using Cornel index for anxiety and Hamilton Scale for anxiety, and depression was assessed using Hamilton Scale for depression. We used MMPI too. Anxiety and Depression Scales were used at two points, at the administration and 3 months after. RESULTS: The cancer patients had significantly lower total scores for anxiety and depression at the first investigation comparing with the psychiatry in-patients, but higher, although not significantly, comparing with the patients suffering from myoma uteri. At follow up

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investigation depression significantly increased, while it decreased among the psychiatric patients due to psychopharmacology and psychotherapy. CONCLUSIONS: The cancer patients reported more somatic variable, which are common in both depression and cancer, and it is difficult to tell which is responsible. It is preferable to rely on purely psychological symptoms of depression when studding its prevalence in the psychically ill. The literature dates suggest that cancer patients showing symptoms of marked guilt and worthlessness warrant psychiatric evaluation.

153 Mental Adjustment after Surgery for Non-small Cell Lung Cancer Uchitomi Y1,2, Akechi T1,2, Fujimori M1, Okamura M2, Oba A2 1 Psycho-Oncology Division, National Cancer Center Research Institute, East Kashiwa, Japan; 2 Psychiatry Division, National Cancer Center Hospital, East Kashiwa, Japan BACKGROUND: Although surgery for early stage non-small cell lung cancer (NSCLC) is generally considered curative, the outcome is still unsatisfactory, leaving patients face with uncertainty and fear of recurrence for a long time after surgery. The purpose of this study was to clarify the course of patients’ mental adjustment after surgery for NSCLC and to identify predictors of long-term outcome. METHODS: A total of 205 patients completed a baseline interview for patient characteristics at 1 month after curative resection of NSCLC and for social support at 3 months, and the Mental Adjustment to Cancer scale at 3 and 12 months. Univariate and multivariate analyses were used to identify predictors of their psychological outcome. RESULTS: The helplessness/hopelessness subscale score improved slightly after curative resection (P50.001), but the score on the fighting spirit subscale score was unchanged (P=0.659). Significant predictors of helplessness/hopelessness at 12 months included helplessness/hopelessness at 3 months, advanced disease stage, and satisfaction with confidants. Significant predictors of fighting spirit at 12 months included fighting spirit at 3 months, current smoker, and existence of confidants. CONCLUSIONS: The results suggested

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that mental adjustment improved slightly after curative resection for NSCLC. They also suggested the need to maintain continuity of psychosocial care that provides social support, and that an approach that includes careful attention to patients with advanced stage disease and current smokers may be a strategy for improving mental adjustment after surgery for NSCLC.

154 Cancer-related Fatigue in Patients Attending a Cancer Rehabilitation Programme Van Weert E1,2, Hoekstra-Weebers JEHM2, Van der Schans CP2 1 Centre of Rehabilitation, University Hospital Groningen, Groningen, The Netherlands; 2 Comprehensive Cancer Centre, North-Netherlands, Groningen, The Netherlands OBJECTIVE: A multi-dimensional rehabilitation programme for cancer survivors was developed in order to overcome cancer-related problems, including fatigue. The purpose of the study was to describe the effectiveness of the programme on fatigue. METHODS: Subjects: cancer survivors with different diagnoses, and cancer-related physical and psychosocial problems, including fatigue. Intervention: A 15-week rehabilitation programme including individual exercise, sports, psycho-education, and information. Measures: Fatigue was measured with the MFI, including general fatigue, physical fatigue, reduction in activation, reduction in motivation, and mental fatigue. Measurements were performed before (T0) and after the rehabilitation programme (T1), and at a 3-months follow up (T2). RESULTS: After the rehabilitation programme, candidates (N=63) showed statistically significant reduction of all dimensions of fatigue. Effect sizes (ES) were of 0.44, 0.76, 0.52, 0.34, 0.34 of general fatigue, physical fatigue, reduction in activation, reduction in motivation, and mental fatigue, respectively, were found after the programme. Most improvements persisted at 3months follow up. CONCLUSION: A multidimensional rehabilitation programme has statistically and clinically relevant beneficial effects on cancer-related fatigue in cancer patients with different types of cancer.

Copyright # 2004 John Wiley & Sons, Ltd.

155 Explaining Levels of Psychosocial Adjustment in Women Diagnosed with Early-stage Breast Cancer Vos PJ1, Garssen B1, Visser AP1, Duivenvoorden HJ2, de Haes JCJM3 1 Research Helen Dowling Institute, Utrecht, The Netherlands; 2Department of Medical Psychology and Psychotherapy Erasmus, MC, Rotterdam, The Netherlands; 3 Department of Medical Psychology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands PURPOSE: In many women the diagnosis of breast cancer leads to psychosocial adjustment problems. Biodemographic variables, coping and social support are factors that influence psychosocial adjustment. The main objective of the present study was to identify the associations between psychosocial adjustment and biodemographic variables, coping and social support by using structural equation modelling (SEM). METHODS: Eighty-seven women with newly diagnosed primary breast cancer completed several questionnaires covering these areas within 4 months after surgery. We created several models by using SEM to identify which associations could be found in this study sample. RESULTS: We could not confirm the positive role of social support found in other studies. Biodemographic variables were both directly and indirectly associated with psychosocial adjustment: older women and women who had breast conserving treatment used a more optimistic coping style; the latter group also reported a more positive body image. Women with a more advanced stage of disease reported a reduction in recreational activities. Illness-specific coping, was associated with most of the psychosocial adjustment indicators. Women with an optimistic attitude were well adjusted. Women who had an illness-orientated coping style reported more distress and a negative body image. Women with a repressive coping style reported more distress and less vitality. CONCLUSIONS: Shortly after surgery women with more optimistic attitude are well adjusted psychosocially. Social support seems of no importance in this study sample, while biodemographic variables are related with only some of the psychosocial adjustment indicators.

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Psychogenic Reactions in Hematological Malignancies Vybornykh DE BMT, National Research Center for Hematology, Moscow, Russia

Amygdala Volume in Patients with First Episode of Depression after Breast Cancer Yoshikawa E1, Matsuoka Y1,2, Kobayakawa M1, Akechi T1,3, Uchitomi Y1,3 et al. 1 Psycho-Oncology Division, National Cancer Center Research Institute, East Kashiwa, Japan; 2Adult Mental Health Division, National Center of Neurology and Psychiatry, Ichikawa, Japan; 3Psychiatry Division, National Cancer Center Hospital, East Kashiwa, Japan

Three groups of psychogenic reactions in hematological malignancies have been discovered (acute myeloblastic leukemia, chronic myeloleukosis, lymphoma): neurotic, affective and schizophrenic reactions. Reactions with neurotic denial and anxiousphobic reactions were combined into the first group. The former are connected with intentionally superficial attitudes to prognosis and outcome of disease, but signs of latent anxiety with somatising disorders have been found. Anxiousphobic reactions include peculiar fears and anxious apprehensions about one’s disease with aggravated self-observation and hypertrophied valuation of health-threatening consequences of disease. In some cases, panic attacks with somatoformic and hysteroconversional symptoms have been observed. Besides these reactions, some were (in schizoids) found with the mechanism of ‘‘key experience’’ (it is not experiences about hematological malignancies, but regrets about disturbed working plans connected with determination to overcome the disease). Affective reactions were presented by anxious hysterodepression and mixed affective states. The distinctive property of hysterodepressive states in hematological malignancies is relative, not all levels of affective disorders and predominance of hysteroformic disturbances reach psychotic level. Mixed affective disorders are characterized by association of ‘‘usual’’ hyperthymic periods with short episodes of depressive mood (provoked by deterioration of somatic condition). Schizophrenic reactions carry the character of anosognosy in relation to hematological disease and have a distant (egodystonical) attitude towards hemoblastosis. In these cases other mental disorders took the first place, but in marked deterioration of somatic condition such reactions will be reduced and passed to asthenic disorders.

Copyright # 2004 John Wiley & Sons, Ltd.

OBJECTIVE: Patients experiencing their first depressive episode, including minor depressive episode after cancer diagnosis are frequently seen in clinical oncology settings. However, little is known about the neurobiological basis of such depression. In previous studies, large amygdala volumes in magnetic resonance imaging study (MRI) have been observed in first major depression, although no studies in minor depression. The purpose of the present study was to investigate association between amygdala volume and a first major or minor depressive episode after cancer diagnosis. METHODS: The subjects were 50 female cancer survivors who had undergone breast cancer surgery 3 or more years earlier. The amygdala volumes of the 21 cancer survivors with history of depressive episodes (major depressive episode; n=11, minor depressive episode; n=10) after the cancer diagnosis, and those of 29 cancer survivors with no history of depressive episodes in their life, were measured by MRI. RESULTS: ANOVA revealed group effect of depressive episodes (p=0.045), that the normalized volume of the left amygdala, which is adjusted to intracranial volume, was smaller in history of first depressive episode as compared with those in the no history of depression. CONCLUSIONS: Small amygdala might be associated with first depressive episode after cancer diagnosis in female cancer survivors.

158 Fatigue in Disease-free Breast Cancer Patients: Prevalence and Psychosocial Moderators Young KE1, White CA1,2 1 Section of Psychological Medicine, Gartnavel Royal Hospital, Glasgow, Scotland, UK;

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Consulting and Clinical Psychology Services, NHS, Ayrshire and Arran, Irvine, Scotland, UK PURPOSE: To estimate the prevalence of severe fatigue in disease-free breast cancer patients according to draft ICD-10 criteria for cancerrelated fatigue (CRF), and to obtain further information on the validity of these criteria. Furthermore, to test hypotheses derived from psychosocial theories of fatigue regarding the association of fatigue with activity level, psychological distress and cognitive constructs. METHODS: Sixty-nine disease-free breast cancer patients were assessed at least 6 months post treatment, using self-report questionnaires and a structured interview. RESULTS: Nineteen percent of the sample met criteria for CRF. This subgroup differed significantly from the rest of the sample on multiple measures of fatigue and interference. Self-reported activity level bore no significant relationship to fatigue. Fear of recurrence contributed to fatigue indirectly, whilst psychological distress and beliefs about activity appeared to predict fatigue directly. CONCLUSION: The validity of the draft ICD-10 criteria for CRF was supported. Further research is required into the relationship between fatigue, emotional distress and cognitive-behavioural factors. Future studies should utilise both self-report and objective measures of activity.

vulnerable and high-risk populations with a prospective model of care. Implementation of these guidelines provides numerous advantages for clinicians such as identification of high-risk patients, use of a specific intervention such as problem-solving education for distinct symptoms or problems, and the ability to construct an outcomes system to document the effectiveness of psychosocial interventions. This presentation will address these issues in the context of prospective psychosocial programs at a comprehensive cancer centre with a focus on the following specific issues: (1) Prevalence of distress among cancer patients (Zabora et al., Journal of Psychooncology, 2001); (2) Use of the Brief Symptom Inventory-18 (BSI-18) as a psychosocial screening instrument (Zabora et al., Psychosomatics, 2001); (3) A model of practice that describe the linkages between levels of distress with the type and intensity of interventions, and; (4) Strategies to effectively address institutional barriers to a prospective model of care. In conclusion, implementation of this type of model is critical to truly meet the complex psychosocial needs of high-risk patients. Unless this approach is employed, the significant distress experienced by these patients will manifest itself. . . [truncated].

160 159 Psychosocial Screening goes Mainstream: From Identification to Intervention Zabora JR School of Social Service, Catholic University of America, Washington, DC, USA In 1999, the National Comprehensive Cancer Network published their first set of Distress Management Guidelines in the United States (NCCN, 1999). Despite this increased focus on psychosocial care, few cancer centres have implemented essential components of these guidelines such as psychosocial screening and linkages to early interventions. Limited staff and lack of specific screening policies and procedures often create institutional obstacles. Consequently, clinicians continue to lose opportunities to target

Copyright # 2004 John Wiley & Sons, Ltd.

Social Constraint: The Association with PTSDsymptoms and Depression in a Population-based Sample of Women Treated for Breast Cancer Zachariae R1, Christensen S1, Jensen AB1, Ravnsbæk J2, Mller S3 et al. 1 Oncology, Aarhus University Hospital, Aarhus, Denmark; 2Mammkirurgisk Klinisk Aalborg Hospital, Aalborg, Denmark; 3Danish Breast Cancer Cooperative Group (DBCG), Rigshospitalet, Copenhagen, Denmark PURPOSE: To investigate the influence of social constraint on distress in women treated for breast cancer. METHODS: As a part of an ongoing population-based prospective study of psychosocial factors and prognosis of breast cancer, baseline data were analyzed for the first 1000 women (mean age 53.8; SD=9.2 yr) included in the study. Twelve weeks after surgery the women had

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completed Beck’s Depression Inventory (BDI-II), the Impact of Events Scale (IES), and the Social Support Questionnaire for Transactions (SSQT). RESULTS: 52 women (5.4%) reported symptoms indicating PTSD, and 67 (6.8%) were classified as having moderate to severe depression. A hierarchical logistic regression showed that cancer-related PTSD-symptoms were associated with (a) being married (B:0.94; p50.05; odds ratio: 2.6) and (b) experienced cancer-related social constraint from others (B:0.16; p50.01; odds ratio: 1.2) but not from spouse or other close person, while controlling for age, having children, and social support. Similarly, having moderate-to-severe depression was positively associated with experienced social constraint from others (B:0.18; p50.001; odds ratio: 1.2), and inversely associated with the SSQT subscale of social companionship (B: 0.16; p50.01; odds ratio: 0.85). Before entering social constraint and social support in the equation, being married was not significantly associated with either PTSD-symptoms or depression. CONCLUSIONS: Emotional expression is an important means of coping with stressful experiences such as cancer, and our results confirm that social barriers to emotional expression may be associated with adverse psychological effects in women treated for breast cancer.

gated psychological distress in dependence from the subjective perceived risk for HNPCC. METHODS: Seventy-two persons at risk for HNPCC (33 male, 39 female, mean age 44.5 years) completed questionnaires 2 weeks before and 2 weeks after genetic counselling. The questionnaires consist of different instruments for the measurement of distress and well-being (e.g. HADS, SCL, SF-12) and other psychosocial variables as for example the individual beliefs about the seriousness of HNPCC and the personal risk for this illness. RESULTS: Data showed an elevated level of psychological distress among the counselees. Approximately 25% have mental problems. The highest distress was measured before genetic counselling. No differences in psychological distress have been found between healthy persons and patients diagnosed with colon cancer or between men and women. The distress is not associated with objective (Amsterdam-/Bethesda-) criteria but strongly associated with the subjective perceived risk for HNPCC and the personal beliefs about the seriousness of colon cancer. CONCLUSIONS: The small number of persons in our ongoing study does not allow final conclusions at this time. The prevalence of distress is higher than in the general population. The personal beliefs about the seriousness of colon cancer and the perceived risk for HNPCC are important for the development of psychological distress.

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Causes for Psychological Distress in Persons at Risk at Hereditary Colon Cancer Berth H1, Krueger S2, Kreuz FR3, Balck F1 1 Universita.tsklinikum Carl Gustav Carus Dresden, Medizinische Psychologie, Dresden, Germany; 2 Universita.tsklinikum Carl Gustav Carus Dresden, Chirurgische Forschung, Dresden, Germany; 3Universita.tsklinikum Carl Gustav Carus Dresden, Institut fu.r Klinische Genetik, Dresden, Germany

Genetic Counseling for Colorectal Cancer: Worries and Psychological Distress in the Pre-test Phase: A Prospective, Multicenter Study Bleiker EMA1, Aaronson NK1, Menko FH2, Sijmons RH3, Brocker-Vriends AHJT4 et al. 1 Psychosocial Research and Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands; 2Clinical Genetics, VU University Medical Center, Amsterdam, The Netherlands; 3 Medical Genetics, Acadmic Hospital Groningen, Groningen, The Netherlands; 4Clinical Genetics, Leiden University Medical Center, Leiden, The Netherlands

PURPOSE: Recent studies on the psychological and psychosocial consequences of hereditary nonpolyposis colorectal cancer (HNPCC) showed different results. Studies found a higher level of psychological distress in persons at risk. Differences between mutation positive and negativetested persons were described. Our study investi-

Copyright # 2004 John Wiley & Sons, Ltd.

PURPOSE: One of the aims of this prospective study is to assess the effect of genetic counseling/ testing on psychological distress in individuals at

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increased risk for hereditary non-polyposis colorectal cancer (HNPCC) or familial colorectal cancer (FCRC). METHODS: Individuals requesting genetic counseling in five Dutch family cancer clinics completed questionnaires at four points in time: before the first counseling session, after this session, and 3 weeks and 6 months after the final genetic counseling session. Results reported here are about the pre-test period. RESULTS: Questionnaires were received from 229 individuals both before their first counseling session as well as 4 weeks after this session. The majority came as the first person in their family to request genetic counseling; 37% had relatives who had already been counseled and/or tested. A statistically significantly higher level of cancer-worries was observed after the intake, as compared to the level in the week before the intake (p=0.01). No difference in the level of general distress (MHI-5) was observed between the two points in time. Of the counselees, 7% exhibited clinically significant levels of cancer-specific distress (IES-intrusion) following intake. Individuals who were the first in their family to request counseling had statistically significantly higher levels of distress (IES) after intake (p=0.03). CONCLUSIONS: Cancer-worries increase significantly during the pre-test phase of genetic counseling. However, only 7% exhibit clinically significant levels of distress. Being the first in the family to request counseling appears to be a risk factor for cancer-specific distress.

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2. whether genetic counselling received after referral reduced anxiety more than counselling received after waiting; 3. client perceptions of genetic testing and expectations of the effects of testing on themselves and families; 4. client expectations of carrying a mutation, risk of developing breast cancer and changes after counselling. METHOD: Pairs of high-risk families were randomized into an intervention (I) or waiting (W) control group. At baseline both groups were mailed first GHQ-12. The intervention group was offered counselling 1 week after baseline, the control group waited 3 weeks with anxiety measured during this period. One week after counselling groups received another GHQ and evaluation questionnaires. A final GHQ and questionnaire was mailed after an affected family member received genetic testing. GHQ-12 scores were analysed using ANOVA, paired and independent sample t tests. RESULTS: Both groups (combined) were significantly less anxious 2 weeks after baseline. There was no evidence that the reduction in anxiety in the Intervention group was greater than in the Waiting group. Paired sample t tests showed that anxiety was significantly reduced after counselling in the Intervention group, not in the Waiting group although a downward trend was evident. Final study findings will be presented.

163 A Multi-centre Study of High-risk Breast Cancer Families Referred for Genetic Testing/Counselling Elliott DR1, Straton J1, Stein M2 1 Department of Population Health, University of Western Australia, Perth, Australia; 2Department of Psychiatry, University of Western Australia, Perth, Australia High-risk breast/ovarian cancer families were recruited from referrals for genetic counselling from hospitals in Western Australia. PURPOSE: To investigate: 1. the effect of genetic counselling on clients’ anxiety/general psychological distress using the GHQ-12;

Copyright # 2004 John Wiley & Sons, Ltd.

164 Experiences and Patterns of Dissemination of Genetic Information to Family Members in Women with BRCA 1/2 Mutations Participating in a Support Group Study Esplen MJ1,2, Clarke S2, Butler K1 1 Behavioral Sciences and Health Research Division, University Health Network, Toronto, Canada; 2 Department of Psychiatry, University of Toronto, Toronto, Canada Women who carry BRCA1 or 2 mutations are at high risk for breast/ovarian cancer. Genetic test results have implications for family members, including offspring, each having a 50% chance of carrying the mutation. PURPOSE: The objective

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of the overall study was to conduct testing on a supportive-expressive group intervention designed for women with BRCA 1 or 2 mutations. The purpose of this sub-study was to investigate experiences and patterns of family communication of genetic information. METHODS: Quantitative measures were collected on women at pre and post-intervention. Therapy sessions for each group (total of 11 groups with 12 sessions each) were videotaped. Videotapes were transcribed verbatim and analyzed for themes/experiences. Descriptive statistics were used to analyze quantitative data and qualitative data analysis was completed on the transcripts. RESULTS: Seventy women (n=32 with a prior diagnosis of breast cancer; n=38 with no prior diagnosis) participated in the intervention study. The mean age of the women was 45.4 years, 76% were married and 67% had children. The intervention improved measures of psychological functioning (e.g. cancer worries p=0.004; anxiety p=0.037; depression p=0.0234). Knowledge and surveillance were high at baseline and remained stable. Primary themes related to dissemination of genetic information included: Lack of guidance around ‘‘when’’ and ‘‘how’’ to notify offspring; Feelings of responsibility; Ethical challenges around the ‘‘right not to know’’; Interference by Family Dynamics; Need to protect vs. pressure to have daughters screened; Women as the Primary Disseminators. Findings have implications for genetic counselling and psychosocial screening and follow-up.

and BRCA2) on mental health, perceived risk of developing cancer, and risk management following ascertainment and disclosure of gene carrier status. METHODS: 315 adults (male and female) from 9 UK genetic centres were invited to participate. Assessment was by pre-validated questionnaire at baseline (pre-test) and at 1, 4, 12 months, and 3 years following disclosure of the genetic test result. This paper focuses on the 3-year data (baseline data and 12month follow-up data have already been reported). There were 100 gene mutation carriers and 185 non-carriers. RESULTS: In the 12 months following disclosure of the test result non-carriers experienced significant reductions in cancer worry. Amongst carriers, cancer worry rose in the month following disclosure of the result and returned to baseline levels at 1 year. Female gene mutation carriers engaged in significantly more risk management strategies than non-carriers in the year following testing. At 1 year, 23% of female carriers reported insurance discrimination. In this paper we report levels of cancer worry, uptake of risk management options, perceived risk and insurance discrimination 3 years following the genetic test result. CONCLUSIONS: The results clarify the issues that arise when people unaffected by cancer are offered genetic testing as part of routine clinical practice. It is important that genetic counselling and support is available in carrier clinics following disclosure of the test result aimed at improving management of medical and psychological outcomes.

165 166 Predictive Genetic Testing for BRCA 1/2 in the UK: The Long-term Psychosocial Impact Foster C1, Eeles R1, Evans DGR2, Eccles D3, Ashley S4 et al. 1 Psychology Research Group, The Institute of Cancer Research, Sutton, UK; 2Department of Medical Genetics, St. Mary’s Hospital, Manchester, UK; 3Wessex Clinical Genetics Service, Princess Anne Hospital, Southampton, UK; 4Department of Computing, The Royal Marsden NHS Trust, Sutton, UK PURPOSE: This multi-centre UK study assesses the impact of predictive genetic testing for breast/ovarian cancer gene mutations (BRCA1

Copyright # 2004 John Wiley & Sons, Ltd.

Development of a Brief Screening Instrument for Psychosocial Problems in Genetic Counseling for Cancer Hahn DEE1, Bleiker EMA2, Grosfeld FJM3, Lulofs R4, Tan MBM5 et al. 1 Family Cancer Clinic/Psychosocial Service & Support, The Netherlands Cancer Institute/AVL Amsterdam, The Netherlands; 2Psychosocial Research & Epidemiology/Family Cancer Clinic, Netherlands Cancer Institute, Amsterdam, The Netherlands; 3Medical Psychology University Medical Center, Utrecht, The Netherlands; 4Medical Genetics University Medical Center, Maastricht, The Netherlands; 5Psychiatry Daniel den Hoed

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Clinic/Erasmus University Rotterdam, Rotterdam, The Netherlands Fortunately, genetic testing for susceptibility to cancer is now widely available. However, there is lack of guidelines yet for (1) the management of psychosocial distress during genetic testing and (2) referral of new counselees to proper resources for professional support. A screening tool as an aid in identifying individuals at high risk for developing psycho-social problems is needed. In an attempt to develop a model protocol for psychosocial service delivery, a project group of the Dutch NVPO Familial Cancer Working Group developed a brief screening instrument. Previously, in terms of model development, the Family Cancer Clinic/Department of Psychosocial Service and Support of The Netherlands Cancer Institute offered a brief routine psychosocial problem assessment to new clinic attendees. It turned out that one out of three individuals requested further psychosocial support (Hahn et al., 2000). The next step was a nationwide study to investigate the organization of psychosocial care in all Family Cancer Clinics. Most clinics had developed their own protocol for psychosocial service delivery, including standard psychosocial care for presymptomatic individuals with a HBOC family history (Bleiker et al., 2001). We now see a tendency to leave standard protocol care and offer psychosocial care on (quite unclear) indications, running a risk of underserving consultees. A brief screening instrument was developed for identifying ‘‘vulnerable’’ individuals who might benefit from (early) psychosocial interventions. The development of the screening tool, content, usefulness and further strategies of implementation in Family Cancer Clinics in the Netherlands will be presented.

167 Predictive BRCA1/2 Genetic Testing: Why Do Men Do It? Hallowell N1, Foster C1, Moynihan C1, Watson M2 1 Psychology Research Group, The Institute of Cancer Research, Sutton, UK; 2Psychological Medicine, The Royal Marsden Hospital, Sutton, UK

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PURPOSE: Men who have a family history of breast and/or ovarian cancer may be offered a predictive genetic test to determine whether or not they carry the family specific BRCA1/2 mutation. Male BRCA1/2 carriers may be at increased risk of breast/colon/prostate cancers. Relatively little is known about at-risk men’s decision-making about BRCA1/2 testing. This qualitative study explores the influences on male patients’ genetic test decisions and the impact of BRCA1/2 predictive genetic testing upon high risk men and their immediate family. METHODOLOGY: Twentynine in-depth interviews have been undertaken with both carrier and non-carrier men and immediate family members (17 male patients, 8 female partners, 4 adult children), thus far. These explore: their experiences of cancer and genetic testing, decision-making about testing, family support, communication of test results within the family, risk perception and risk management. FINDINGS: Influences on men’s testing decisions, such as risk awareness, anxiety about children’s risks, curiosity, parental duty and children’s rights will be examined. The role of deterministic explanations in accounting for family history and family members’ at-risk status will be discussed. It will be observed that when accounting for their feelings following receipt of the test result, men mobilise deterministic explanations about their own and other’s health in an effort to absolve themselves of blame for transmitting a deleterious mutation to their offspring. Finally, the impact upon one’s identity of being identified as a carrier/ non-carrier will be examined.

168 The Effects of Ambivalence About Prophylactic Mastectomy on Distress and Screening Hurley K1, Valdimarsdottir H2, Kaufman E3, Brown K2, Schwartz M3 et al. 1 Psychiatry & Behavioral Sciences Memorial SloanKettering Cancer Center, New York, NY, USA; 2 Ruttenberg Cancer Center, Mt. Sinai School of Medicine, New York, NY, USA; 3Lombardi Cancer Center, Georgetown University, Washington, DC, USA PURPOSE: To investigate the impact of decision types about prophylactic mastectomy on

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risk-related distress and screening behavior in women undergoing genetic counselling and testing for BRCA1/2 mutations. METHOD: 367 women (mean age 51.1) completed a telephone interview prior to their pre-test genetic counselling for BRCA1/2 testing on: interest in prophylactic mastectomy, mammography adherence in the past year, intrusive ideation (IES), avoidance (IES) and general distress (BSI). RESULTS: Cluster analysis on pros/cons of prophylactic mastectomy yielded three decision types: Disengaged (low on all pros/ cons); Ambivalent (high on most pros/cons); and Risk-Focused (high on risk reduction pros; low on all other pros/cons). The Ambivalent and RiskFocused types had similarly high levels of intrusive ideation compared to the Disengaged type (p50.02) and were more interested in prophylactic mastectomy than the Disengaged type (p50.05). Indeed, in the sample as a whole, logistic regression showed that intrusive ideation was significantly associated with interest in prophylactic mastectomy after controlling for age (p50.001), whereas avoidance and general distress were not. However, the Ambivalent type was more distressed (p50.009) and avoidant p50.008) than the Risk-Focused type, and less likely to have had a mammogram in the past year (p50.004). CONCLUSION: Linear regression analyses of relations between variables may wash out important differences that affect both psychosocial adjustment and preventive behaviors. Individuals may arrive at the same decision via different processes, and thus have different genetic counselling needs.

of comprehensive interdisciplinary counselling and genetic testing in a clinical sample of families at risk of HNPCC. METHODS: 261 counselees (83 patients (P), 178 at-risk persons (RP)) attending an interdisciplinary counselling session were consecutively recruited. Assessment consisted of selfadministered standardised (HADS, IES, GBB) and author-derived measures before and 6 weeks after counselling. Data on PE with familial cancer were collected during the counselling session. Linear regression was performed to examine the influence of PE on perceived risk, threat and distress. RESULTS: Prior to counselling, multiple PE in the P’s family contributed to an elevated perception of their children’s risk of cancer, whereas in RP, some aspects of PE (involvement in the care of an affected relative) did explain perceived threat of cancer (explained variance 15%), but not perceived risk. Distress was found to increase with PE at young age, female gender and high perceived risk (expl. var 19%). After counselling, perceived risk was found to be unrelated to the clinical risk on the probability of HNPCC. There is some indication suggesting that the response to risk information is modified by aspects of PE. CONCLUSION: P appear to differ from RP in terms of how PE influence perceived threat and risk of cancer. The differential impact of PE on perceived risk and distress should be taken into account when counselling families at risk of hereditary cancer.

170 169 Do Prior Experiences with Cancer in the Family Influence Risk Perception and Distress in Families at Risk of Hereditary Non-polyposis Colorectal Cancer (HNPCC)? Keller M1, Jost R1, Sattel H1, Mazitschek U2, Cremer F2 et al. 1 Psychosocial Care Unit, Department of Surgery, University Hospital, Heidelberg, Germany; 2Department of Human Genetics, University Hospital, Heidelberg, Germany PURPOSE: To investigate the impact of previous experience (PE) with familial cancer on perceived risk and HNPCC-related distress during the course

Copyright # 2004 John Wiley & Sons, Ltd.

Health Behavior and Psychosocial Reactions to Genetic Counseling among Women with Hereditary Breast- and/or Ovarian Cancer Risk Mikkelsen EM1, Johnsen SP1, Sunde L2, Johansen C3 1 Department of Clinical Epidemiology Aarhus University Hospital, A( rhus C, Denmark; 2Department of Clinical Genetics, Aarhus University Hospital, A( rhus C, Denmark; 3Institute of Cancer Epidemiology, Danish Cancer Society, Copenhagen Ø, Denmark BACKGROUND: Genetic counselling is offered to all Danish women at risk of developing hereditary breast- and/or ovarian cancer. The counselling is offered free of charge by the public

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health system after referral. It consists of counselling, pedigree drawing and verifying, risk assessment and, if possible, a genetic test. An increasing number of women are seeking counselling, however, the knowledge about the psychosocial consequences of this prevention strategy is still limited. PURPOSE: To investigate the consequences of genetic counselling in the following 3 areas: *

* *

Health-related quality of life, breast cancer anxiety, general anxiety and depression; General health-related behavior; Breast cancer risk perception.

METHOD: A population-based prospective cohort study based on 400 women attending genetic counselling for hereditary breast- and/or ovarian cancer risk and two reference groups. Data from the primary study population are collected by self-administered standardized, mailed questionnaires prior to counselling and at 14 days, 6 and 12 months post-counselling. The reference groups consist of 400 women attending breast cancer screening, and 1500 randomly selected women from the Danish population. Data from the reference groups are collected by similar questionnaires, but only twice with one year apart. Data from the doctors providing the genetic counselling are collected by questionnaires right after the counselling session. RESULTS: Preliminary baseline and 2 weeks follow-up results will be presented. The perspectives for the further results will be discussed.

171 Psychological Distress after Disclosure of Genetic Test Results Regarding HNPCC: A Preliminary Report Murakami Y1, Okamura H2, Sugano K3, Yoshida T4, Kazuma K5 et al. 1 Psycho-Oncology Division, National Cancer Center Research Institute, East Kashiwa, Japan; 2 Division of Occupational Therapy, Institute of Health Sciences, Faculty of Medicine, Hiroshima University, Hiroshima, Japan; 3Oncogene Research Unit/Cancer Prevention Unit, Tochigi Cancer Center Research Institute, Utsunomiya Japan; 4 Genetics Division National Cancer Center

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Research Institute, Tokyo, Japan; 5Department of Adult Nursing/Terminal and Long-term Care Nursing, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan PURPOSE: There have been few studies for the psychological distress after disclosure of genetic test results for HNPCC. The purposes of the study were to identify the prevalence rates and predictors of psychological distress and to evaluate the feelings of guilt after the disclosure of test results. METHODS: Probands and unaffected relatives were interviewed just after the first genetic counselling session and then 1 month after the disclosure of genetic test results. The prevalence of major and minor depression, acute stress disorder (ASD), posttraumatic stress disorder (PTSD), and posttraumatic stress symptoms (PTSS) were assessed using Structured Clinical Interview based on the DSM-III-R or DSM-IV; feelings of guilt were investigated using a numerical scale and a semi-structured interview. RESULTS: Of the 47 subjects who completed the baseline interview, 42 (89%) completed the 1-month follow-up interview. Although none of the subjects met the criteria for major depression, ASD, or PTSD at the follow-up interview, 3 of the 42 subjects (7%) met the criteria for minor depression and 2 subjects (5%) had PTSS. The predictor of psychological distress was only presence of a history of major or minor depression (odds ratio, 19.41; 95% confidence interval, 1.42–264.95; P50.05). Of the 42 subjects, 5 (12%) had feelings of guilt. CONCLUSIONS: The disclosure of genetic test results may not cause significant psychological distress in Japanese subjects, both in probands and relatives. However, healthcare providers should not neglect the need to assess the psychological responses of these individuals.

172 Psychological Impact and Preventive Strategies Following Genetic Testing for BRCA1/2 Mutations Perry S1, Evron E1, Stemmer S1, Taub A2, Papa M3 1 Institute of Oncology, Rabin Medical Center, Petach-Tikva, Israel; 2Institute of genetics, Rabin Medical Center, Petach-Tikva, Israel; 3Department of Surgery, Sheba Medical Center, Ramat Gan, Israel

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PURPOSE: To evaluate the emotional response to genetic testing and the risk-reduction strategies of healthy carriers of BRCA1/2 mutations and of cancer patients with and without a mutation. PATIENTS AND METHODS: The study groups included 40 cancer patients that tested positive for a BRCA mutation, 40 cancer patients that tested negative for a mutation and 32 healthy BRCA carriers. Genetic testing was performed between 1998 and 1999 in 3 hospitals in Israel. A semi structured interview and 3 self-reported questionnaires were used to learn the participants’ emotional responses to the genetic information and their subsequent use of preventive measures. RESULTS: Most women (82%) were satisfied with their decision to take the genetic test. Mild psychological distress was found in both carrier and non-carrier cancer patients. More Avoidance and Intrusion thoughts were associated with having cancer rather than with the genetic information. Avoidance and Intrusion related to positive test results were similar in healthy carriers and in carrier cancer patients. About half of the eligible carriers underwent preventive oophorectomy during the study period, but none of them opted for prophylactic mastectomy. CONCLUSIONS: Genetic testing for BRCA mutations is perceived as valuable by women at high risk for HBOC and is not associated with major psychological distress. None of the women in this study underwent prophylactic mastectomy, reflecting cultural and ethnic diversity.

mutation. An example is the I1307 K mutation associated with a 112 to 2-fold increase in colon cancer risk among Ashkenazi Jews. METHOD: One hundred and thirty-eight subjects with a personal history of colon cancer completed a baseline interview after extensive genetic counselling but before receiving mutation results. One month after results disclosure, all I1307 K carriers (n=17) and a randomly chosen 20% of noncarriers (n=29) completed a follow-up interview. RESULTS: At baseline, subjects reported low general distress on the Profile of Mood States (POMS mean = 6.8, SD=17.4 out of possible 128 points) and low cancer-specific distress on the Impact of Event Scale (IES mean=12.0, SD=13.8 out of possible 75 points). Based on published IES cut-offs, 17.2% of the sample reported moderateto-high distress. Carriers and non-carriers did not differ on follow-up POMS and IES scores (p’s>0.2). On a measure of genetic testing-specific distress, the MICRA, carriers and non-carriers reported similar levels of distress (p>0.4) and uncertainty (p>0.3). However, non-carriers reported higher levels of positive experiences related to the genetic testing situation (p50.001). CONCLUSION: On average, subjects who undergo testing for a low-penetrant mutation report low levels of distress before and after results disclosure. This is consistent with results from psychosocial studies of BRCA 12 and may be due, in part, to the receipt of extensive education and counselling prior to mutation testing.

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Genetic Testing for a Low Penetrant, Cancerassociated Mutation: General, Cancer-specific, and Genetic Testing-specific Distress Peterman AH1, Locker GY2, Cashy J1, Coronel S3, Lynch HT3 1 Center on Outcomes, Research and Education, Evanston Northwestern Healthcare, Evanston, IL, USA; 2Department of Medicine, Evanston Northwestern Healthcare, Evanston, IL, USA; 3Hereditary Cancer Institute, Creighton University, Omaha, NE, USA

Development and Pilot Testing of a Decision Aid for Genetic Testing for Hereditary Non-polyposis Colorectal Cancer (HNPCC) Wakefield C1,2, Meiser B2, Homewood J1, Kirk J3, Tucker K2 et al. 1 Department of Psychology, Macquarie University, North Ryde, NSW, Australia; 2Department of Medical Oncology, Prince of Wales Hospital, Randwick, NSW, Australia; 3Familial Cancer Service, Westmead Hospital, Westmead, NSW, Australia

PURPOSE: One unexplored area of the growing literature on genetic testing for cancer risk is the psychosocial impact of testing for a low penetrant

PURPOSE: The demand for genetic counselling and genetic testing for individuals with a family history of cancer is considerable and increasing.

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Current best practice in genetic counselling may not allow a full deliberation of the consequences of decisions about genetic testing for cancer susceptibility. In this study, a decision aid was designed to help clients actively participate in discussions with practitioners during the decision-making process about having genetic testing for hereditary nonpolyposis colorectal cancer (HNPCC) susceptibility. METHODS: Stage 1: A decision aid for individuals considering genetic testing for HNPCC susceptibility was developed and pilot tested. Stage 2: The decision aid will be evaluated by a randomised controlled trial with 120 patients assessed by questionnaire at two time points after genetic counselling. RESULTS: Stage 1: A description of the development and pilot testing of the 40 page two-colour decision aid, which uses words, numbers, graphs, pie-charts and illustrations will be presented. The decision aid addresses (a) background information about HNPCC (b) the cumulative risk for patients with high-risk genetic mutations, (c) the individual’s suitability for genetic testing, (d) the differences between mutation search and predictive testing, (e) the potential benefits and risks of genetic testing, and (f) screening and management options. A worksheet asks individuals to rate the personal importance of each potential risk and benefit. We present the results of pilot testing with 20 individuals considering genetic testing for HNPCC susceptibility. Stage 2 of the study will be on-going and a detailed description of its methodology will be presented.

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Scale (HADS) questionnaire is mailed before the first genetic counselling (T1). HADS is repeated after this consultation (T2), after the second consultation (T3), when an estimated risk is transmitted and a genetic testing is proposed, at 3 months (T4) and 1 year (T5) after the second consultation or after genetic testing results (third consultation). RESULTS: At T1 (n=96), the median score of the HADS anxiety subscale is 7 (range 0–16). This value decreases to 6.5 (range 0– 15) at T2 (p=0.01). No further changes are noted for the subsequent evaluation time points. When stratifying anxiety by cancer status, mean HADS at T1 is 6 (range 2–14) for the affected (n=45) and 8.5 (range 0–16) for the non-affected (n=50) (p=0.01). At T5, median anxiety level is 5 (range 1–13) for the affected (n=12) and 8 (range 1–12) for the non-affected (n=21) (p=0.09). At T1, among the non-affected, the moderate/high risk probands (n=12) have higher anxiety levels than the low risk probands (n=29): 10.5 (0–16) versus 9 (3–15) (p=0.11). Similar results are noted at T5 (p=0.07). At 1 year (T5), we found a trend (p=0.06) for subjects tested to be less anxious than the non-tested, independently of the genetic testing results. CONCLUSION: Before counselling, being non-affected and at moderate/high risk is associated with higher anxiety levels. Having a genetic testing is correlated with lower anxiety levels at 1 year follow-up, independently of its results.

176 175 Psychosocial Issues in Predictive Oncology: Evaluation of Anxiety Pre-, Per- and Post-genetic Counseling and Testing for Familial Breast and Colorectal Cancer Waltz P1, Gex-Fabry M2, Murphy A1, Hoesli P1, Chappuis P1,3 1 Oncology Ho#pitaux Universitaires de Gene"ve, Geneva, Switzerland; 2Psychiatry Ho#pitaux Universitaires de Gene"ve, Geneva, Switzerland; 3 Medical Genetics Ho#pitaux Universitaires de Gene"ve, Geneva, Switzerland PURPOSE: Prospective evaluation of anxiety during a multistep genetic counselling process. METHODS: Hospital Anxiety and Depression

Copyright # 2004 John Wiley & Sons, Ltd.

Genetic Testing in Care of Cancer Patients Weiflog G, Singer S, Schwarz R Independent Department of Social Medicine, Institute for Occupational and Social Medicine, University of Leipzig, Leipzig, Germany PURPOSE: Topic of investigation was to describe the transfer of knowledge provided by human genome research into clinical care of cancer patients. Perception of primary and secondary preventive options for cancer patients and their relatives are dependent of patients’ knowledge about the possibility of (diagnostic and predictive) genetic counselling and testing. Therefore the purpose of this investigation was to assess the frequency of genetic counselling and testing

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among cancer patients. METHODS: In the sample patients with different cancer sites were included: breast, ovary, prostate, stomach, colon, rectum, liver, pancreas and thyroid. Data were collected in a prospective design using interviews (t1 and t2) and questionnaires (t1 and t3). First a pedigree was taken to assess cancer family history (t1). Then genetic risk of patients was stratified into three categories: risk by clinical criteria, risk by expert rating and no risk. RESULTS: A follow- up interview (t2) of patients with genetic risk 10 weeks after acute treatment showed following results: There is a only a minor part of patients with increased genetic risk that clarify their genetic risk by frequenting genetic counselling and testing after primary care. Results of for the 1-year-follow-up confirm these findings. CONCLUSION: Explanations like lack of genetic knowledge, lack of referring guidelines to genetic expert, lack of confidence in sense of diagnostic testing and other were discussed. Future research has to focus on the role of primary care physicians as pilot for assigning expert services in the health care system.

Guidelines 177 Improving the Psychosocial and Clinical Care of Younger Women Diagnosed with Breast Cancer: The Need for Evidence-based Clinical Practice Guidelines Rankin NM1,2, Campbell DM2,3, Turner MJ4, Zorbas H4, Luxford K4 1 Psychosocial Oncology Research Consultant, N/A Stanwell Tops, Australia; 2Formerly National Breast Cancer Centre, Sydney, Australia; 3Centre for Health Services Research, Westmead Hospital, Sydney, Australia; 4National Breast Cancer Centre, Sydney, Australia It is widely recognised that the diagnosis and treatment of breast cancer in younger women has special consequences. Younger women are at greater risk of developing psychological distress following a diagnosis. Ensuring that younger women are offered and receive the most appropriate treatment, information and psychosocial care can be challenging for clinicians. Existing clinical practice guidelines for breast cancer

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provide only limited recommendations about best practice for managing younger women’s care. Clinical practice guidelines: an evidence-based approach to the management and support of younger women with breast cancer has been prepared by the National Breast Cancer Centre with funding from the Australian Government. Guideline approval was granted by the Australian National Health and Medical Research Council in late 2003. The guidelines aim to assist younger women, specialist clinicians and family physicians in making decisions about all aspects of breast cancer care and are designed to be used in conjunction with and complement existing guidelines. Specific guideline topics include: detection and diagnosis; the psychological impact of the disease; chemotherapy; treatment of advanced disease; menopausal symptoms within the context of ovarian function and hormonal issues; pregnancy during and following treatment; and exercise. The development process utilised the expertise of multidisciplinary group of health professionals and consumers. This presentation reflects the conference themes by considering the need for clinical guidelines for psychosocial care of cancer patients and their families. The challenges and benefits of developing guidelines that integrate evidence from psychosocial and clinical research will be considered, along with potential implementation strategies.

Health Behaviour/Prognostic Factors 178 From Chemo-induced Fatigue to Exercise-induced Fatigue Adamsen L1, Midtgaard J1, Roerth M2, Andersen C2, Quist M1 et al. 1 The University Hospitals Centre for Nursing and Care Research, Department 7331, Copenhagen University Hospital, Copenhagen O, Denmark; 2 Department of Oncology, Department 5073, Copenhagen University Hospital, Copenhagen O, Denmark PURPOSE: The purpose of this paper was to examine fatigue in cancer patients at different stages of disease and with different diagnoses

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undergoing chemotherapy and concurrently participating in an exercise intervention. METHODS: Intervention: Supervised, exercise program (physical exercise, relaxation, massage, and bodyawareness training) 9 h weekly over 6 weeks. A total of 69 semi-structured qualitative interviews were performed with 23 patients (age between 18 and 65 years}median 40 years) on three occasions: prior to, during, and at termination of the program. RESULTS: Physical debilitation, fatigue, and uncertainty of physical capacity were the patients’ motivation to enrol in the intervention. Throughout the program, the majority of the patients experienced exercise-induced fatigue, which they associated with a sense of increased physical strength, improvement in energy and physical well-being. This positive sense of fatigue can be seen as a contrast to the negative chemotherapy-induced fatigue, which is characterized by physical discomfort and uncontrollable exhaustion. The cancer patients included required exercise to be carried out under guidance and observation in order to regain their sense of security about their own physical potentials and limitations. At the conclusion of the program the patients learned to manoeuvre through periods of intense fatigue by using exercise as a self-care strategy to adjust their sense of physical debilitation. CONCLUSIONS: The transformation process of fatigue identified in this study supports the theory of exercise as a beneficial intervention strategy, and must be taken into consideration in the development of exercise programs for cancer patients undergoing chemotherapy.

179 Association of MAC-scales Scores and Survival of Leukaemia Patients Admitted for Allogeneic BMT Bailer H, Grulke N, Kaechele H Psychosomatic Medicine and Psychotherapy University Hospital of Ulm, Ulm, Germany PURPOSE: In women with breast cancer, Watson et al. (Lancet, 1999) found correlations between the Mental Adjustment to Cancer-Scale ‘‘Helplessness/Hopelessness’’ and Hospital Anxiety and Depression Scale ‘‘Depression’’ with survival. Will these results hold in a sample of patients undergoing BMT? METHODS: Patients

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scheduled for BMT at the BMT-unit of Ulm (Germany) were administered the MAC and HAD Scales before conditioning for transplantation. Outcome was survival at 2 years post BMT. RESULTS: Fifty-three leukaemia patients (64.2% male) were recruited from 10/1999 to 12/ 2001. Only the MAC Scale ‘‘Avoidance’’ showed a significant association to survival (p=0.041; higher avoidance, better outcome) and HADS ‘‘Anxiety’’ had a trend (p=0.098; higher anxiety, poorer outcome). After controlling for somatic risk factors, no association was significant. CONCLUSION: The failure of replication in our sample may depend on small sample size, gender, or the time of measurement. The prognostic value of the MAC-Scales may not be given for other diagnoses than breast cancer.

180 Psychological Distress and Use of Alcohol in a Population-based Sample of Danish Women Treated for Invasive Breast Cancer Christensen S1, Zachariae R1, Jensen AB1, Ravnsbæk J2, Mller S3 et al. 1 Oncology Aarhus University Hospital, Aarhus, Denmark; 2Section of Breastsurgery Aalborg Hospital, Aalborg, Denmark; 3Danish Breast Cancer Cooperative Group Rigshospitalet, Copenhagen, Denmark PURPOSE: To investigate the associations between selected measures of distress and use of alcohol among women treated for invasive breast cancer. METHODS: As a part of an ongoing population-based prospective study of the independent prognostic significance of psychosocial factors in breast cancer, baseline data were analyzed for the first 1000 participants. The women were mailed a questionnaire 12 weeks after surgery, including Beck’s Depression Inventory (BDI-II), the Impact of Events Scale (IES) the Helplessness/Hopelessness scale from the Mental Adjustment to Cancer scale (MAC-H/H), sociodemographic measures and a measure of alcohol habits. RESULTS: The mean score on IES and BDI-II was 19.7 (15.3) and 8.5 (6.6), respectively. The mean score on MAC-H/H was 8.6 (3.7). No differences were found between current alcohol users (N=845) and never-users (N=87). However

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ex-users (N=55) reported higher scores on BDI-II than both never-users (Z= 2.7, p50.01) and users (Z= 4.0, p50.001). Similarly higher scores on IES was reported among ex-users than both users and never-users, but no differences were found on the cancer-specific distress measure MAC-H/H. CONCLUSIONS: Higher levels of distress among ex-users of alcohol on more general distress scales but not on a measure of cancer specific distress may reflect underlying physical comorbidity. The result indicates that previous use of alcohol is a potential confounder that must be controlled for in (prognostic) psychosocial studies of cancer.

F&V (20.4% reported >5 daily servings). Routine exercise was reported by 44.6% of respondents. All three behaviors were significantly interrelated suggesting a high degree of behavioral clustering, and also were significantly associated with physical function (p50.05). Results of multiple regression analyses indicated that only routine exercise (p50.0001) and a low fat diet (p=0.03) significantly and independently related to higher levels of physical functioning. CONCLUSIONS: Low-fat diets and routine exercise may exert a positive influence on elderly cancer survivors’ physical functioning}an effect which may have tremendous psychosocial and economic consequences, and which calls for further study.

181 182 Physical Function in Older Cancer Survivors: Associations with Diet and Physical Activity Demark-Wahnefried W1,2, Clipp E2,3,4,5, Morey M2,3,4, Pieper C2, Sloane R2 et al. 1 Surgery Duke University Medical Center, Durham, USA; 2Center for Aging Duke University Medical Center, Durham, USA; 3Geriatric Research & Education Center, VA Medical Center, Durham, USA; 4Medicine Duke University Medical Center, Durham, USA; 5School of Nursing, Duke University Medical Center, Durham, USA PURPOSE: Declines in physical functioning often occur with cancer, and threaten quality of life and ability to maintain independence. Functional decline is a serious problem among elderly individuals with cancer, since age-related functional decline may already exist. Adherence to healthy lifestyle behaviors may be one way that older cancer survivors can regain or maintain higher levels of functioning. METHODS: Associations between lifestyle factors and functional status were explored among elderly with locoregional breast (N=286) or prostate cancer (N=402). Mailed surveys ascertained data on physical function (SF 36), dietary fat (Block Dietary Fat Screener), fruit and vegetable (F&V) consumption (5 a Day items) and physical activity (‘‘On average, do you do continuous vigorous exercise for at least 20 min, 3 or more times per week?’’). RESULTS: Mean dietary intakes were 29.5+21.8% total energy from fat (61% claimed intakes 530%) and 4.1+2.9 daily servings of

Copyright # 2004 John Wiley & Sons, Ltd.

Studying Smoking Initiation among Danish Adolescents Envold Hansen J1, Grnbæk M2, Haudrup Christensen P2, Schitz M2, Johansen C1 et al. 1 Department of Psychosocial Cancer Research, The Institute of Cancer Epidemiology, The Danish Cancer Society, København Ø, Denmark; 2National Institute of Public Health, København Ø, Denmark PURPOSE: The effects of smoking on risk for cancer are well documented. Each year approximately 31 000 cancer cases are diagnosed in Denmark and smoking is related to about 10 000 of these cancer cases. In order to set up effective cancer prevention programs we need more information about why some Danish adolescents start smoking. This study will investigate the role of social cognitive factors in smoking initiation using theoretical concepts from the social cognitive ASE-model (attitude, social influence, and selfefficacy). METHODS: A total of 4000 adolescents will be followed from 7th to 9th grade in connection with the implementation of a schoolbased prevention program conducted by the Danish National Board of Health. In cooperation with the Danish National Institute of Public Health a randomised questionnaire study will be conducted and we will be focusing on data concerning cognitive factors and smoking initiation. We will furthermore do ethnographic field observations in two classes as well as personal interviews with a group of adolescents in order to

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investigate how the individual’s situation may influence social cognitive factors and smoking initiation. RESULTS AND CONCLUSION: This poster presentation will report on the methodological experiences made during the design and implementation of a large-scale randomised study of social cognitive factors and smoking initiation. The results of this study will be important for future cancer prevention programs as well as for further development of a field of cancer prevention research in Denmark.

183 Developing a Questionnaire Measure of Patient Competence to be Used in Oncology Giesler JM, Weis J Psychosocial Department, Tumor Biology Center, Freiburg i. Br, Germany PURPOSE: ‘‘Patient competence’’ appears to be a term used primarily to express the view that patients are willing and able to take a more active role in decisions concerning medical treatment and, consequently, should be given more opportunity to do so. As can be shown, however, it might become a useful hypothetical construct describing individual differences in cancer patients’ illness behavior as well provided it can be adequately defined conceptually and precisely measured empirically. In order to achieve this goal we decided to develop a questionnaire measure of ‘‘patient competence’’ to be used in the field of oncology and are presently conducting a multi-centre study with patients suffering from various cancers (N=60) and with (psycho-)oncological professionals (N=30). METHODS: Subjects are interviewed in a semi-structured format to elicit those behaviors that, according to them, reflect ‘‘patient competence’’. In addition, they are asked to rate the degree to which each of a sample of 101 behaviors extracted from the coping and self-efficacy literature is an indicator of ‘‘patient competence’’. RESULTS/OUTLOOK: Presentation of results will include those behaviors considered most indicative of ‘‘patient competence’’ by respondents as well as comparisons of the ratings of patients and professionals. Behaviors appearing most relevant for measuring ‘‘patient competence’’ on this basis will constitute

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the preliminary version of the intended questionnaire that will be tested for validity and reliability in another sample and, thereafter, be used in a prospective study of the influence of ‘‘patient competence’’ on the course of cancer.

184 Level of Psychological Distress in Newly Diagnosed Breast Cancer Patients Predicts Survival Groenvold M1, Petersen MAa1, Idler E2, Bjorner JB3, Fayers PM4 et al. 1 Palliative Medicine Bispebjerg Hospital, Copenhagen, Denmark; 2Sociology Rutgers University, New Jersey, USA; 3QualityMetric Inc., Lincoln, USA; 4 Public Health Aberdeen University, Medical School, Aberdeen, UK PURPOSE: To examine whether psychological distress in newly diagnosed breast cancer patients was associated with their survival. METHODS: We analyzed data from 1582 Danish breast cancer patients who filled in the EORTC QLQ-C30 questionnaire and the Hospital Anxiety and Depression Scale (HADS) 2 months after their primary operation. The median follow-up time was 6.7 years. RESULTS: Psychological distress (EORTC QLQ-C30 emotional function; HADS anxiety; HADS depression) and EORTC fatigue, physical function, and overall ratings were used to predict recurrence-free and overall survival, controlling for the known clinical and histopathological prognostic factors (biological model) using Cox multivariate regression analysis. Low psychological distress independently predicted longer recurrence-free and overall survival, controlling for biological factors. The same was the case for low fatigue, good physical function, and positive overall ratings of health and quality of life. The patient-rated scales were highly correlated. When all were added in combination to the biological model, fatigue and emotional function remained significant predictors of recurrence-free survival with p values 0.0067 and 0.0193; risk ratios were 1.78 (1.23–2.58) and 1.23 (1.04–1.47). The physical and emotional function scales predicted overall survival with p values 50.0001 and 0.0309; risk ratios were 1.21 (1.10–1.33) and 1.25 (1.02–1.52). DISCUSSION: Several studies have shown that psychological factors predict survival in patients

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with symptomatic disease. This study is the first to show that in disease-free cancer patients, psychological distress (and scores on other HRQL domains) predicts survival and disease course independent of biological factors.

gen University Hospital, Copenhagen, Denmark; 3 Institute of Exercise and Sport Sciences, University of Copenhagen, Copenhagen, Denmark

Dallund is the only centre in Denmark offering rehabilitation to cancer patients as a residential course. Each year approx. 800 patients spend 1 week at Dallund. BACKGROUND: According to Dallund’s screening measures prior to the stay, complaints concerning body, muscles and joints are common. 59% (667/1131) indicate a changed body feeling, 44% (506/1146) have stiff or hurting joints and muscles, 36% (407/1139) have pain, while a total of 70% (482/686) indicate that their physical activity is not as good as before. These findings must have implications for the patients’ physical activity during and after their treatment. Consequently, physical activity is an essential part of the rehabilitation process at Dallund. METHODS AND RESULT: Data are collected internally and externally. Dallund’s physiotherapist collects information on the most common questions and problems during the course, just as the patients register their physical problems prior to and after their stay at Dallund. Furthermore, an external research group (Focare) follow the work at Dallund in both a descriptive and a randomized design. A combined status will be presented at the congress.

BACKGROUND: Little is known about the role of exercise in improving cancer patients’ psychological status while undergoing chemotherapy. PURPOSE: To examine the effects of structured exercise intervention (6 weeks, 9 h weekly) on selfreported psychological distress in cancer patients undergoing chemotherapy. The outcomes were changes in anxiety and depression levels. METHODS: A total of 100 patients between 18 and 65 years completed a Hospital Anxiety and Depression Scale Questionnaire (HADS) (response rate 91%). Medical and demographic variables, including information about level of physical activity and exercise habits, were drawn from patients’ medical records and through semi-structured interviews. RESULTS: The mean age of the patients was 42.5 years; and 68% were female. The sample was heterogeneous in terms of diagnosis, illness status, and pre-illness activity level. The mean score on the anxiety subscale for all patients was 4.8 (SD 2.9) with a range between 0 and 12. The mean score for the depression subscale was lower at 3.6 (SD 2.8) with a range between 0 and 11. Paired sample t-tests indicated a highly significant decrease (27.3%) in anxiety, t(90)= 4.22, p50.001, and a more moderate but still significant decrease (12.4%) in depression, t(90)= 2.06, p=0.042. CONCLUSION: The results provided evidence that cancer patients (with different diagnoses and at various stages of disease), who participated in structured exercise intervention while concurrently being treated with chemotherapy, significantly reduced their levels of anxiety and depression. This research was supported through grants from The Danish Cancer Society

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Structured Exercise Intervention for Cancer Patients in Chemotherapy}An Examination of Psychological Benefits Midtgaard J1, Adamsen L1, Roerth M2, Stelter R3, Tveteraas A1 1 UCSF/7331, Copenhagen University Hospital, Copenhagen, Denmark; 2Oncology/5073, Copenha-

Continued Smoking after Successful Treatment in Patients with Resectable Non-small Cell Lung Cancer: A 12-Month Follow-up Study Mikami I1, Akizuki N2, Akechi T2, Yamawaki S3, Uchitomi Y2 1 Psychiatry Division, National Shikoku Cancer Center, Matsuyama, Japan; 2Psycho-Oncology

185 Rehabilitation after Cancer: Need for Physiotherapy Mark KMK Physiotherapy, The Dallund Centre for Rehabilitation of Cancer Patients, Søndersø, Denmark

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Division, National Cancer Center Research Institute East, Kashiwa, Japan; 3Department of Psychiatry and Neurosciences, Hiroshima University School of Medicine, Hiroshima, Japan Some cancer patients continue to smoke even after successful cancer treatment. In general, continued tobacco use is a risk factor for second primary cancer and mortality. To clarify the nature and prevalence of continued smoking after successful treatment, we therefore conducted structured interview (including Structured Clinical Interview for DSM-III-R) and a Self-rating Scale measuring severity of nicotine dependence (Fagerstrom test for Nicotine Dependence; FTND) in patients with resectable non-small cell lung cancer. We determined smoking status by plasma cotinine concentration. Out of 79 current smokers, 20 (25%) smoked again at 12 months. Compared with quit smokers, continued smokers are more likely to work fulltime or part time, to have history of major or minor depression, to show higher score of FTND significantly in univariate analysis. In logistic regression analysis, score of FTND was the predictive factor of continued smoking. In conclusion, it is helpful for prevention of continued smoking to assess high-risk group by using of FTND.

188 Impact of Psychological Factors on Survival and Recurrence of Early Cancer}Critical Literature Review Mitchell AJ Liaison Psychiatry, Leicester General Hospital, Leicester, UK INTRODUCTION: The question of whether psychological factors influence the physical outcome of patients with cancer is controversial. A number of conflicting reviews have appeared in the literature (Fox, 1998; Petticrew et al., 2003). PURPOSE: We hypothesised that one reason for this inconsistency has been a failure to adequately account for the stage of cancer itself. We therefore decided to systematically appraise

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all studies that have examined a relationship between psychological outlook (variably defined) and prognosis (length of survival or risk of relapse) specifically in early stage cancers. METHODS: We conducted a thorough literature search using Medline, Embase, Science Direct, Ovid Full text, Web of Knowledge and supplemented this with hand searching. We identified six studies of subjects with early-stage cancers and several additional studies where stage of the disease was accounted for post hoc. RESULTS: In all available studies a significant relationship between psychological variables and later survival or recurrence was demonstrated. However, several methodological issues remain. CONCLUSIONS: Studies involving patients with early-stage cancers demonstrate a consistent association between psychological outlook and later physical disease outcome. It is likely that in latestage cancer, other physical variables mask the influence of psychological factors in all but the largest studies.

189 Health Professionals’ Beliefs on the Influence of Psychological Factors on Outcomes of Cancer} A Pilot Survey Mitchell AJ, Friedman T Liaison Psychiatry, Leicester General Hospital, Leicester, UK INTRODUCTION: The question of whether psychological factors influence the physical outcome of patients with cancer is highly debated. One common fear is that if a link is acknowledged then patients may be blamed for not ‘‘thinking positively’’. Surprisingly, no group has yet systematically surveyed the beliefs of health professionals. PURPOSE: We were interested in the prevailing attitudes to this question amongst health professionals working in cancer care. METHODS: We designed a pilot questionnaire to examine the degree of agreement with a number of statements exploring the link. Degree of agreement was rated on a Likert scale from ‘‘totally disagree’’ to ‘‘totally agree’’. We then conducted a postal survey of attitudes amongst health professionals working in the cancer fields.

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This included staff from a wide range of disciplines. RESULTS: Most professionals felt that there was an influence of coping style and psychological outlook on survival, although even in this small sample, polarized views were common. Perhaps surprisingly, many professionals also thought patients should be helped to ‘‘think positively’’. CONCLUSIONS: Most health professionals, working in the cancer care field believe that there is an association between psychological outlook and physical survival that can be altered by professional intervention.

simultaneously sliding into an ever deeper state of alienation. I conclude that modernity is cancer-prone, due in large part to the toxic alienation it fosters, and that future approaches to treatment and prevention will need to incorporate de-alienation strategies to recover the self, restore social meaning, and promote the development of essential creative capacities.

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Modernity, Alienation, and Cancer Sivashinskiy M Surgery City Hospital #40 Sestroreck, St. Petersburg, Russia

Social Desirability in Older Cancer Patients: Levels, Racial Differences and Associations with Self-reported Physical Function Snyder DC1, Pieper CF1, Sloane R1, DemarkWahnefried W1, Morey M1,2 et al. 1 Duke University Medical Center, Durham, North Carolina, USA; 2VA Medical Center, Durham, North Carolina, USA

The incidence of cancer in Western society has increased significantly during the last century. Simultaneously, there has been an acceleration of changes associated with the steady rise of consumerism, materialism, and a profit-oriented mentality. I argue that contemporary Western lifestyles and consciousness patterns (modernity), related to alienation, can explain certain trends in cancer morbidity and mortality. LeShan found that ‘‘perceiving the cosmos as uncaring and unconcerned, the typical patient does not conceive of any meaning beyond the human being and his particular relationships, but at the same time he has the feeling that he has been singled out by fate’’. This is distinctive of the alienation. The degree of emotional estrangement from life, according to LeShan, has a direct bearing on the virulence of cancer. Karl Marx understood that an overemphasis on material things amplifies what he termed the ‘‘alienated life’’, and that the ability to live creatively and give expression to life diminishes in proportion to one’s degree of focus on possessions. While creative activity is a crucial species-specific human motivation, money has become a goal in itself in modern consumer culture, and people are being deprived of a satisfaction regarding their creativity needs, while

PURPOSE: Despite marked advances in cancer survivorship, older cancer survivors remain an understudied group. A home-based diet and exercise intervention was designed to improve physical function and tested among survivors 65+. Social desirability (SD) was measured to assess its potential impact on self-reported measures of function and adherence. METHODS: One hundred and eighty-two individuals aged 65+ who were diagnosed with breast or prostate cancer within the past 18 months were randomised to a 6 month intervention or attention control condition with a 6 month follow up. Self-reported functional status (SF-36 physical function subscale) was measured at baseline and follow-up, with physical performance testing (6 min walk, chair rises, etc.) performed on a 25% sub-set. Social desirability (Marlowe–Crowne) was measured at baseline. Data on counselling session completion and reported behaviors, e.g., number, frequency and duration of activity sessions, was collected. RESULTS: Relative to published norms (16.4  6.5), SD scores were high in this sample (mean = 23). Non-whites scored higher than whites (diff=2.39, p=0.006). No significant associations were observed with age, education, income or gender. Controlling for level of physical performance, SD was not related to an overestimate of function at

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baseline (r= 0.04, p=0.54) nor change in function at follow-up (p=0.51). In the intervention group, SD showed a trend toward increased report of exercise (p=0.13). CONCUSIONS: SD does not influence the validity level of or change in selfreported measures of function, but may be important in determining adherence to behavioral recommendations such as exercise.

192 A Control Study of the Effect of Marriage, Social Support on Recurrence and Metastasis of Breast Cancer Tang LT, Zhang YZ, Zhang YZ School of Oncology, Peking University, Beijing, China PURPOSE: To evaluate the effect of marriage, social support on recurrence and metastasis of breast cancer. METHODS: The Locke-Wallace Marital Adjustment and Prediction Test and Social Support Rating Scale (SSRS) were used to rate the breast cancer patients with recurrence and metastasis (n=81) and contral subjects (n=90). RESULTS: The statistically significant differences were found on the Locke-Wallace Marital Adjustment and Prediction Test and the part of the variables of SSRS between the patients with recurrence and metastasis and the control subjects (p50.05). Marriage state was found to be positively correlated with social support. CONCLUSION: Marriage state and social support may influence the recurrence and metastasis of breast cancer. We should pay more attention to both the psychosocial factors and breast cancer during the treatment.

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Exercise and physical activity provide several health-promoting benefits before, during and following cancer treatment, including: improved functional capacity (Schwartz, 1999), increased muscle strength (Durak and Lilly, 1998) and decreases in anxiety, depression and fatigue (Segar et al., 1999; Dimeo et al., 1998). Recently, there has been increasing interest in health-related physical activity outside the realm of traditional exercise. A subgroup of complementary/alternative medical practices pertaining to mindful bodily movement (e.g., yoga, tai chi, chi gong) has increasingly become integrated into mainstream cancer treatment programs. Such activities have been promoted in hospital and community-based cancer wellness centres as enhancing one’s quality of life through mind–body work, movement therapy and gentle exercise. Although these wellness activities have been performed for centuries, very little empirical evidence exists regarding their efficacy and underlying mechanisms with cancer patients. In addition, other, more contemporary forms of alternative physical activity have made their way to forefront of health and wellness programs, such as recreation-based activities like hiking, rock-climbing and kayaking, to name a few. Due to the diversity of systems and modalities found within and between these different camps, this presentation proposes the use of the collective label, complementary/alternative physical activity (CAPA), for any physical activity that is not considered the standard or usual practice in medical and psychosocial programs. A detailed definition of CAPA will be presented as well as a critical review of the available literature on traditional exercise, CAPA and health-related quality of life during and following cancer treatment.

193 Health Care Personnel Complementary/Alternative Physical Activity (Capa) and Health-related Quality of Life Among Cancer Patients Victorson DV1, Doninger GL2, Lauzon JJ3 1 Center on Outcomes, Research and Education, Evanston Northwestern Healthcare Evanston, Illinois, USA; 2Department of Psychiatry and Behavioral Sciences, Loyala University Medical Center, Maywood, Illinois, USA; 3Institute of Psychology, Illinois Institute of Technology, Chicago, Illinois, USA

Copyright # 2004 John Wiley & Sons, Ltd.

194 Incidence in Burnout Syndrome in Oncologic Staff in Catalonia, Spain Carulla J1, Sirgo A2, Gil F3 1 Medical Oncology Vall d’Hebron Hospital, Barcelona, Spain; 2Psychooncology Sant Joan Hospital, Reus, Spain; 3Psychooncology Duran Reynals Hospital, Barcelona, Spain

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PURPOSE: Emotional exhaustion, depersonalization and lack of personal motivation define the ‘‘Burnout Syndrome’’(B.O.S.). To evaluate the incidence and ethiology in B.O.S. in staff working with oncologic patients, to design preventive plans as ‘‘counselling’’ in order to decrease this incidence. METHODS: Observational study in the semistructured questionnaires with four modules each developed in ‘‘1st Meeting in Staff Exhaustion Prevention in Oncology’’ (Sitges. Barcelona, May 2001) were analyzed. Descriptive and statistical results of the ‘‘Maslach Burnout Inventory’’ were answered by 60 professionals (oncologic and palliative care physicians and nurses). RESULTS: More than 50% of the staff identifies the standard stressors. No cases of B.O.S. was identified. More emotional exhaustion (p=0.034), more depersonalization (p=0.029) and less personal achievement (p=0.039) in the nurses of Medical Oncology Units was identified. CONCLUSIONS: The staff population studied do not show the complete B.O.S. but risk areas of work are identified. Individual strategies to implement prevention and diagnostic of B.O.S. are necessary.

195 Telephone Crisis and Counselling Service for Cancer Nurses: Unexpected Results Dauchy S1, Teller AM2 1 Supportive Care Department, Gustave Roussy Institute, Villejuif, France; 2Nursing Department Gustave Roussy Institute, Villejuif, France PURPOSE: Provision for an access-free supportive telephone counselling service for healthcarers. METHOD: Previous studies of stress in healthcarers working with cancer patients have indicated a high prevalence of psychological distress, related to work organisational problems, low job satisfaction, and high levels of emotional stress. In France nurse shortages result in an increased workload, and difficulties in providing organisational solutions. Alternative supportive solutions must be found. Support meetings during working hours are time-consuming and difficult to implement, as carers may be reluctant to express their emotions in front of peers. Both Psycho-Oncology Unit and the Department of Nursing in a large French Cancer Care Centre decided to propose a tele-

Copyright # 2004 John Wiley & Sons, Ltd.

phone crisis and counselling service for the 850 onsite paramedical carers. A psychologist could be reached anonymously in working hours by an access-free telephone number. The intervention was focused on listening, empathy, emotional expressiveness, and counselling. RESULTS: This measure was proposed for 6 months in 2003; only one call was received. CONCLUSIONS: Two main hypotheses may explain this result. Firstly, healthcarers, even when psychologically distressed, are able to distinguish between job stress and the need for psychological help. Secondly, the provision of this service is in itself a recognition by the institution of an eventual need, much appreciated by carers. Telephone counselling may represent a low-cost way of support in large cancer centres, and thus it may be feasible to propose a longer trial with a prospective evaluation of job stress.

196 Personal Aspects of Burn-out Syndrome among Hospice Home Care Workers de Walden-Galuszko KWG1, Majkowicz MM2 1 Paliative Medicine Medical University, Gdansk, Poland; 2Clinic of Psychiatry Medical University, Gdansk, Poland PURPOSE: To determine the relation between the components of burn-out syndrome (dependent variables) and personal factors (independent variables). METHODS: One hundred and ninety four persons were examined. There were 168 women (86.6%) and 26 men (13.4%). The study group consisted of 99 (51%) nurses, 75 (38.7%) doctors and 20 (10.2%) other individuals. The study was performed using Maslasch Burn-Out Questionnaire, NEO-FFJ-5 Big Five Factors Inventory and Semi-structured Interview (social and demographic characteristics). RESULTS: Three components of Burn-Out Syndrome: emotional exhaustion, depersonalisation and self-esteem were assessed. Most of the hospice workers did not have any Burn-Out Symptoms (BOS). Thirty-one persons (16%) presented low stage, 20 (10.3%) persons a medium stage and 6 (3.1%) persons a high stage of BOS. We treated these components of BOS as dependent variables and correlated them with factors of personality. We showed that emotional exhaustion was correlated with neuroticism score

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depersonalisation}with agreeableness and low self-esteem with openness. These results revealed positive correlation between neuroticism and emotional exhaustion and negative correlation between two other components of BOS (depersonalisation, low self-esteem) and agreeableness and openness as well. We did not find any correlation between BOS and sociodemographic characteristics. CONCLUSIONS: 1. There is a correlation between Burn-Out Syndrome and some traits of personality. 2. Neuroticism and agreeableness are the main determinants of Burn-Out Syndrome.

197 Evaluation of ‘‘Psychooncology Rounds’’ as a Meaningful Interdisciplinary Approach to Psychosocial Skill-building Among Staff in a Comprehensive Cancer Center Henrickson ACSW BCD CG1, Hammelef RN MS KJ2, Riba, MD MB3 1 Social Work, University of Michigan Health System, Ann Arbor, MI, USA; 2Comprehensive Cancer Center, University of Michigan Health System, Ann Arbor, MI, USA; 3Department of Psychiatry, University of Michigan Health System, Ann Arbor, MI, USA An interdisciplinary program was created to help promote and expand psychosocial care skills among professional, technical, and support staff in an NCI-approved comprehensive cancer centre. Described previously, ‘‘Psychooncology Rounds’’ has evolved in 4 years from an informal case discussion group to a monthly event that includes didactic and panel presentations and discussion for all cancer centre staff. The program is coordinated through the Psychooncology Team of the cancer centre, which includes Psychiatry, Social Work, Nursing, Psychology, and Art Therapy. Recent topics have included ‘‘Illness and Family Systems’’, ‘‘Boundaries in Professional Relationships: When Helping is Not Helpful’’, ‘‘Interpersonal Aspects of Pain and Pain Management’’. The program not only represents a costeffective mechanism for staff training and development, but more importantly promotes interdis-

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ciplinary collaboration in the learning process, increased biopsychosocial awareness and skillbuilding across job families, and an exhibition of the expertise of the centre’s behavioral health staff. This presentation will report data from evaluations undertaken in the past 2 years to assess staff satisfaction with the program. Demographics of participants, strategies for program promotion, and staff satisfaction survey results will be included in the discussion, as well as the implications for future development and research.

198 Rehabilitation for Metastatic Spinal Compression}Changes Brought About by Mental Stress in Medical Staff Maruno N Department of Rehabilitation Medicine, Teikyo University School of Medicine, Tokyo, Japan I hypothesized that mental health will deteriorate in all medical staff concomitantly with the progression of their patients’ disease. A 55-years-old female was diagnosed as having renal cancer with spinal metastasis. After a nephrectomy, radiation therapy failed to improve her paraplegia. The cancer pain was controlled with narcotics. The patient and her family members were informed of the situation. Staff enrolled were a urologist (Uro), nurse (Ns), physical therapist (PT), occupational therapis (OT) and physiatrist (RH). The 30 items version General Health Questionnaire (GHQ) and Maslach Burnout Inventory (MBI) were used. MBI was calculated according to 3 items: Emotional Exhaustion (EE), Depersonalization (DP), and Personal Accomplishment (PA). The staff had the first examination after the patient was discharged to other hospital, the second examination on readmission. RESULTS: The changes in the scores were as follows; MBI-EE rose in the Uro, PT and RH. MBI-DP increased in the Ns and RH, and decreased in the PT. MBI-PA increased in the PT and OT, and decreased in the Uro and RH. The GHQ was improved in Ns. DISCUSSIONS: A change for the worse in the state of their mental health concomitant with worsening of the patient’s condition was not seen in all medical staff. A definitive conclusion cannot be drawn from an individual case.

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199 Oncostress. A Multicentric Study of Burnout Valuation in Medical Oncology and Radiotherapy of Calabria Piattello A, Rea A, Turone S, Palazzo S Oncology Azienda Ospedaliera, Cosenza, Italy PURPOSE: To estimate burnout in hospitals of Calabria, county of Italy, and to point out differences among burnout levels in several professional categories, among sociodemographic data by a multifactorial analysis and multiple regression of independent (professional qualifications, sociodemographic data, patient cure time (p.c.t.) and dependent (MBI: emotional exhaustion (EE), depersonalization (DP) and personal accomplishment (RP) variables. METHODS: 154 subjects, 77 M and 77F; mean age 41(r28–59); 73% married, with =/>1 children (67%); catholic (97%); oncologists 51, radiotherapists 12, nurses 62, radiotherapy technicians (r.t.) 23, other 6. Correlation between percent of p.c.t. and burnout levels was investigated. Data were analyzed with the SPSS program (version 11.5). RESULTS: Nurses employ more p.c.t than physicians (mean 72% vs. 65% not significant). The EE resulted significantly higher in r.t. nurses and oncologists than in radiotherapists; nurses and r.t. have higher scores of EE respect to physicians (p=0.02, test-c2). The DP resulted higher in r.t. than others professional categories (not significant). The levels of RP were middle-low in 82%, but no significantly different in professional categories. Age 5=45 is correlated with high levels of DP. CONCLUSIONS: Our results confirm literature data, but an important data is that level of RP is middle-low in 82% of sample. This study points out the need to realize regional training programs, with the aim to change main oncological end-point: to take care of patients, not only to cure them, with a global approach, mobilizing the ‘‘cope’’ to acquire specific abilities and prevent burnout.

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Nucleo Cure Palliative Azienda ULSS N. 3 Bassano del Grappa (VI), Italy; 2U.O. di Oncologia Medica Azienda Ospedaliera ‘‘A. Manzoni’’ Lecco, Italy; 3Coordinamento di Psico-Oncologia Azienda Ospedaliera di Padova, Padova, Italy PURPOSE: This study evaluated the level of burnout and the emotional state (anxiety, depression, defence mechanisms) in a group of nurses working with oncological patients. METHODS: The sample consists of 100 nurses (M: 14, F: 86; mean age; 36,1; range age: 27–50), 54 (M: 7, F: 47; mean age: 37.8; range age: 29–50) involved in home care assistance in Veneto Region and 46 (M: 7, F: 39, mean age: 34, range age: 27–43) working within the hospital day and/or ward sections in Lombardia Region. The instruments used are: (1) ASQ (Anxiety Scale Questionnaire), (2) CDQ (Cattel Depression Questionnaire), (3) MBI (Maslach Burnout Inventory), (4) DMI (Defense Mechanism Inventory). RESULTS: Regarding ASQ and CDQ, respectively, 11 and 17,2% of the nurses are above average. Among MBI, Emotional Exhaustion (EE) is reported by 17%, Depersonalization (DP) in 12% and Personal Accomplishment (PA) is low only in 5%. The EE, DP and PA mean scores result significantly higher than normative mean scores (P50.01). The DMI shows in all the nurses a significantly higher score of TAS (Turning Against Self) and REV (Reversal) (P50.01); the female subjects present also a significantly lower score of TAO (Turning Against Object) (P50.01) and PRN (Principalization) (P50.05). Significant differences were found between the two Regions only in defence mechanisms: PRO (Projection) and PRN. CONCLUSIONS: These results indicate that anxiety and depression are present in a low proportion and no burnout is evident; however the significant use of reversal and turning against self-suggests a more critical analysis.

201 200 Burnout and Emotional State in a Group of Nurses Working with Oncological Patients Serpentini S1, Rota Stabelli M2, Nosarini C1, Bittante M1, Capovilla ED3 et al.

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Single Session Group Intervention with Caregivers of Hospice Patients Sharma MP Clinical Psychology, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, India

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Cancer continues to be a serious public health problem all over the world and associated with pain, suffering and despair. Diagnosis and treatment for cancer is traumatic for patient and family and hospital admission is the climax of the crisis. PURPOSE: The aim of the present study was to study the psychosocial problems experienced by the caregivers of cancer patients admitted in a hospice and to improve caregivers’ quality of life by reducing distress experienced by them. METHODS: The sample consisted of twenty-eight family members who participated in five single group sessions of 30–45 min duration. They were also subjected to training in a simple relaxation procedure in another 30-min session. The group process involved ventilation, guidance, acceptance, self-understanding and interpersonal learning. RESULTS: It was noted that caregivers of a cancer patient admitted in a hospice experience significant levels of distress and they also have other psychosocial needs. The single-session group intervention was found to be useful in bringing down the distress experienced by the caregivers and in addressing their other psychosocial needs. Most of the participants could learn relaxation procedure. CONCLUSIONS: The single-session group intervention and training in relaxation were found to be useful in reducing distress experienced by the caregivers of cancer patients admitted in a hospice. It also addressed their other psychosocial needs.

202 Canadian Health Professionals’ Perception, Knowledge and Comfort of Sexuality Issues in Cancer Patients}A Regional Cancer Center’s Experience in Raising Awareness Steggles S1, Rivard S2, Gauthier-Frohlick D3 1 Psycho-Oncology Services, St. Luke’s Hospital, Dublin Republic of Ireland; 2Supportive Care Program, Northeastern Ontario Regional Cancer Center/Ho#pital re!gional de Sudbury Regional Hospital, Sudbury, Canada; 3Supportive Care Oncolgy Research Unit, Northeastern Ontario Regional Cancer Center/Ho#pital re!gional de Sudbury Regional Hospital, Sudbury, Canada This presentation will describe the process used to survey healthcare providers as to their perception,

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knowledge and comfort in addressing sexuality issues experienced by cancer patients. The healthcare providers surveyed deliver direct patient care at the Northeastern Ontario Regional Cancer Centre (NEORCC), in Ontario, Canada. The process herein described consists of a survey, an educational presentation reporting results of the survey and an evaluation of the educational presentation}a process aiming to increase professional awareness and knowledge of sexuality issues as experienced by cancer patients. Research and anecdotal reports indicate that cancer patients experience specific issues relating to sexuality (Schover, 1997). However, it is also understood that for healthcare providers to invite discussions around sexuality, they require adequate training, knowledge and access to appropriate resources. Healthcare providers at NEORCC participated in a survey exploring the following issues: the frequency, themes and the providers’ comfort level of discussions around sexuality; the use of sexual history taking; and the knowledge of resources and support available to address cancer patients’ sexuality issues. The results of this survey were then presented to NEORCC’s healthcare providers as part of an educational presentation addressing sexuality and cancer and the resources available through the Supportive Care Program at NEORCC. The participants subsequently evaluated the presentation. This presentation will report on the results obtained through surveying this population, summarise the educational session provided to staff, highlight the participant’s impressions of the educational presentation, and lastly remark on other possible research projects stemming from this process.

203 Wounded Healers: The Paradox of Living and Working with Cancer Turner LJ Psychosocial and Spiritual Resources Cross Cancer Institute, Edmonton, Canada Working with a cancer population can create challenges and unavoidable resonance when health care professionals themselves have been diagnosed

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with cancer. When a diagnosis occurs, the ability to utilize the natural distance that occurs between therapist and patient disappears. Suffering that is usually kept at a safe distance from the professional’s experience is now an intimate part of his/her own experience. Accurate empathy is no longer a concept or professional tool. It is a reality. This new-found empathic reality can enhance the connection between patient and professional and it can also throw the professional into such chaos that renders him or her incapable of performing their professional duties. This paper also explores the practical considerations of health care professionals returning to work and the unavoidable resonance that naturally occurs when one’s professional and personal life is intertwined. This paper is written by a psychologist who had been diagnosed and treated for cancer while working in an oncology setting. As such, treatment implications involved in disclosing one’s cancer history to patients is discussed as well as the strengths and vulnerabilities that can surface when there is a shared illness between a patient and therapist. It weaves the author’s experience with the, largely, anecdotal research of other health care professionals who have had cancer and other life-threatening illnesses and with the Jungian archetype of the wounded healer.

Inequality/Race/Cross-cultural 204 Comparison of Racial and Body Image Differences in Coping Among Women Diagnosed with Breast Cancer Pikler VI1, Winterowd C2 1 Department of Counseling, Educational Psychology, University of Missouri, Kansas City, USA; 2 Excercise Science, University of Missouri, Kansas City, USA Although in the United States more White women develop breast cancer, African American women die more frequently of the disease (American Cancer Society, 2003). Despite higher morbidity among African American women, few studies have included racially diverse samples, consisting instead of mostly White middle class women. The purposes of this study were to address the paucity

Copyright # 2004 John Wiley & Sons, Ltd.

in the breast cancer literature related to minority populations by exploring racial and body image differences in coping and self-efficacy in coping and to explore potential racial differences in body image perceptions among breast cancer patients. The participants consisted of 92 racially diverse women diagnosed with breast cancer, ranging in age from 28 to 86 years (M=57.64, SD=12.48). Results of the analyses were such that participants with higher body image perceptions had significantly higher self-efficacy in coping with breast cancer compared with participants with lower body image perceptions. There were no significant racial or ethnic differences in coping, self-efficacy in coping, or body image perceptions.

205 An Exploration by a Mainstream Health Service into Implementing Cancer Education-Support Programmes With the Vietnamese Community of South Western sydney Au G1, Pryor A1, Lu B2, Tripathi G3, Nadalin M3 et al. 1 South Western Sydney Cancer Service, South Western Sydney Area Health Service, Sydney, Australia; 2Liverpool Health Service, South Western Sydney Area Health Service, Sydney, Australia; 3New South Wales Cancer Council, Sydney, Australia Confronted with the diversified culturo-socioeconomic-linguistic backgrounds of the local cancer population, the cancer service of the South Western Sydney Area Health Service together with the New South Wales (NSW) Cancer Council piloted a cancer education-support project with the local Vietnamese community as an attempt to enhance this community’s access to health services, cancer information in their first language, and social support. Strategies employed: (i) Enlisting the health service’s relevant ethnic health workers, and Vietnamese patients as advocates into the working party to identify the community’s cultural concerns for cancer and education-support group programmes, to devise steps to address such issues and barriers, and to network local resources for assistance and publicity. (ii) A 2-phase approach was adopted: First, a community cancer information day (over 70 patients and caregivers attended)

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to promote interests, gauge demands and receptivity, and to identify types of information Vietnamese patients and families would want in an education group programme. Second, basing on the first phase’s findings, a 4-week education group programme was developed. Eighty-one percent of the 16 participants (patients and caregivers) rated the programme as useful; 62% indicated feeling more positive in coping with their cancer. The project resulted in the establishment of a consumer-led Vietnamese cancer support group, a facilitators’ manual for conducting similar programmes with relevant Vietnamese resource materials available in CD-ROMs, and a consumer recommendation to the NSW Cancer Council for establishing a Vietnamese cancer helpline.

206 Multi-Disciplinary Approaches to Teaching Health Disparities in Breast Cancer Aviv CS1, Levine EG2, Yoo GJ3, Ewing C4 1 Sociology University of Denver, Denver, USA; 2 Psychosocial Oncology, California Pacific Medical Center, San Francisco, USA; 3Asian-American Studies, San Francisco State University, San Francisco, USA; 4Surgery University of California, San Francisco, USA PURPOSE: Researchers in Northern California collaborated to develop and teach a course on health disparities in breast cancer. The project outlined two goals: to train racially diverse students in breast cancer psycho-oncology research for a 4-year study funded by the National Cancer Institute; and to encourage students from under-represented and ethnically diverse groups to pursue research careers in psycho-oncology. METHOD: 2 sociologists, one psychologist, and one surgeon developed and co-taught a multidisciplinary course to 16 undergraduate and graduate students, from more than 6 different ethnic groups, who were enrolled at a state university. Readings on disparities and inequality included articles from epidemiology, psycho-oncology, sociology, and biomedical research. Students learned quantitative and qualitative research methods, including survey design, interviewing techniques, ethnography, and data analysis using computer software programs. RESULTS:

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Students successfully acquired theories and methodological skills in breast cancer research. Researchers learned that collaborative, multidisciplinary approaches enhanced student understanding of health disparities in cancer. Students from diverse backgrounds bring unique experiences, cultural knowledge, and language to contribute to psycho-oncology research. All participants learned that multi-disciplinary, mixed method approaches improve the design, implementation, and analysis of future research studies. Several students now work as research assistants on a 4-year study of breast cancer survivorship, quality of life, and racial diversity, and plan to pursue careers in psycho-oncology research. CONCLUSIONS: Breast cancer researchers can successfully collaborate, develop and teach multi-disciplinary courses to train future researchers from under-represented and ethnically diverse populations.

207 Interpreters Views about Patient-Health Care Provider Communication Barriers: Cultural and Linguistics Challenges Barroetavena MC1,2, Kwong S2 1 Health Care and Epidemiology, UBC, Vancouver, Canada; 2Rehabilitation Network, BC Cancer Agency, Vancouver, Canada With more than 200 ethnic groups living in Canada and more than 18% of the total population born outside Canada, understanding and addressing the barriers to access to health care for ethnic and culturally diverse groups has become a national priority. Research has documented that ignoring the cultural needs of patients may lead to negative health outcomes such as missed opportunities for screening, lack of compliance with treatment, mistrust of professional services and poorer health outcomes. To improve communication among clinicians and patients who speak different languages some institutions have organized interpreter services. With the aim of increasing our understanding of the cultural challenges of a good clinician–patient interaction we conducted focus groups with interpreters working at the BC Cancer Agency for Chinese and South Asian patients. The guiding research

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questions were: What do you feel are the most serious communications issues for your clients? Which points in the cancer care continuum posses the most difficulty? Do you feel there are issues that do not get discussed between patient and practitioner? Coding categories were identified and grouped under the following three main themes: (1) Family and social responsibility; (2) Healing practices; and (3) Interferences.

208 Findings from the Mammography Screening in Urban American Indians Study Burhansstipanov L1, Dignan MB2, Hariton J1, Harjo L1, Rattler T1 1 Increasing Mammography Adherence among American Indians Native American Cancer Research Pine, Colorado, USA; 2Kentucky Prevention Research Center, Lucille P. Markey Cancer Center, Lexington, Kentucky, USA This study addressed adherence to breast cancer screening guidelines among American Indian women, ages 40 and older, living in the greater Denver metropolitan area, and had not had a mammogram within the previous 18 months. By participating in annual breast health screening, those women who do have breast cancer are more likely to be diagnosed in early stages of the disease, which is directly related to improved survival. The goal of this project was to increase urban American Indians adherence to annual breast health screening. The comparison group was American Indian women in the Colorado Mammography Project (CMAP). Once eligible women were identified, they participated in an informed consent process, and for those who agreed to participate, the ‘‘Native Sisters’’ administered a breast health survey. After the survey, the women were randomly assigned to one of two education interventions: telephone or face-to-face. Survey information was integrated within a tailored/ personalized breast health education booklet. All women were contacted during the last year of the study to complete the post-intervention survey. 71% of those enrolled were retained in the study and completed the post-test. The increase in the proportion of intervention group participants

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reporting having a mammogram within the past 12 months from pre-test to post-test was statistically significant (p=0.013). There was no significant difference between the two intervention formats (Chi Square = 2.68, p=0.10). There was statistically significant difference regarding adherence to breast health screening between the education intervention and the comparison (CMAP) group.

209 Descriptive Analysis of Psychosocial, Cultural and Clinical Variables in Three Psycho-oncology Unit in Spain Cort!es-Funes F1, Abi!an L1, Go! ngora B2, Narva!ez A3, Rubin* os C4 et al. 1 Psycho-Oncology Unit Hospital U, 12 de Octubre, Madrid, Spain; 2Psycho-Oncology Unit Hospital, Torreca!rdenas, Almeria, Spain; 3Psycho-Oncology Master Universidad Complutense, Madrid, Spain; 4 Psycho-Oncology Unit Asociacio!n Espan*ola Contra el Ca!ncer, Orense, Spain We created a record of the different sociodemographic, cultural, clinical and psychosocial variables of 150 patients from three different cities in Spain: Almeria (south), Madrid (centre) and Orense (North). We elaborated a register of all the patients attended in three Psycho-Oncology Units in Spain. We analysed the patient’s profile: characteristics and variables influencing their psychological adaptation. The variables we measured are demographic (civil state, age, gender, etc.), cultural (education, religion, background, etc.), clinical (tumour location, stage, prognosis, etc.) and psychosocial (anxiety, depression, etc.). We are trying to find the relation of these variables with the psychological coping. We are also comparing the characteristics from the different areas in order to see if the cultural context is affecting. These results will help us to design better psychological interventions.

210 Double Social Inequalities in the Occurrence of Malignant Diseases?

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Geyer S Medical Sociology, Medizinische Hannover, Hannover, Germany

Hochschule

It was examined whether health inequalities in terms of morbidity and mortality are present for lung cancer, stomach cancer, intestinal carcinoma and breast cancer. Inequalities were examined in terms of income and occupational position. Analyses were based on health insurance records of 170 848 women (43.9%) and men (56.1%) between 35 and 70 years of age. Diagnoses were drawn from inpatient data. For lung cancer morbidity a gradient between the highest and the lowest 20% of the income distribution (reference category) emerged. The relative risk for the lowest category was RR=7.03 (95% CI: 3.24–5.81). For occupational position the respective figure for the lowest as compared to the highest category was RR=6.98 (95% CI: 2.54–18.96). Considering stomach cancer, the relative risks were RR=5.33 (95% CI: 1.68–16.91) for income and RR=7.11 (95% CI: 2.15–23.45) for occupational position. For intestinal carcinoma only income was significantly related to morbidity (RR=4.37; 95% CI: 2.08– 9.15), for breast cancer no health inequalities emerged. For mortality interpretable results emerged for lung cancer, but only for income; the relative risk for the lowest 20% of the income distribution was RR=2.46 (95% CI: 1.34–4.50). Conditions associated with occupational position and income are both shaping health inequalities in malignant diseases with the exception of breast cancer.

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women with breast cancer. This work builds on pilot study findings that explored the cancer care experiences of low-income women (Gould, 2002). Findings revealed that women had grave difficulty affording unanticipated treatment-related expenses including some medications, sideeffect care, and transportation fees. This next phase involves engaging with health and income security professionals to understand the role of institutional factors in the socioeconomic experience of low-income women with breast cancer. This study uses participatory research methodology and is thus guided by an Advisory Group of cancer survivors, health providers, and government health policy personnel. METHODS: Focus groups and interviews (N=35) were conducted with institutionally based cancer care providers (oncologists, nurses, social workers, pharmacists), providers of community-based cancer services, representatives from the public insurance industry, and government health policy staff. Participants were asked to discuss the institutional barriers and facilitators related to access to financial resources; what they require from the institution to better financially assist patients; and, strategies for working within relevant systems to increase access to financial resources. The transcripts were analyzed using grounded theory principles. RESULTS: Preliminary findings reveal that the onus should be on the cancer care system to assume all patients will encounter financial difficulties and therefore provide the necessary services to increase access to resources. Additional findings from this study will generate hypotheses regarding links between institutional factors and the cancer and cancer care experiences of low-income women.

211 How might Professionals within Cancer and Income Security Systems Assist Low-income Women with Breast Cancer to Access Financial Resources? Gould J1, Peng I2, Cameron C1 1 Ontario Breast Cancer Community Research Initiative, Sunnybrook & Women’s College Health Sciences Centre, Toronto, Canada; 2Sociology University of Toronto, Toronto, Canada PURPOSE: Low-income women with breast cancer have higher mortality rates and lower 5-year survival rates than do higher income

Copyright # 2004 John Wiley & Sons, Ltd.

212 Economics and Cancer in the Developing World Khan PK Department of Obstetrics/Gynaecology, Calcutta Hospital, Medical Research Institute, Calcutta, India In the developing world the science of economics has been observed to have intimate relationship with Cancer. The epidemiology, clinical features, diagnostic modalities, management, prognosis, terminal care, and hospice have got

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definite bearing with the economical status of the individual in various strata of the society. Indian Psycho-Oncology Society have conducted a 10 year survey on this parameter and employed six Research Fellows to evaluate the statistical bearing of Economics and Cancer. The following areas of Cancer have been selected on which Research has been conducted: (a) Cancer Cervix; (b) Breast Cancer; (c) Head neck Cancer. During presentation tables of statistics will be put forward to prove how much bearing economics have got in relation to different aspects of Cancer. This will also highlight the taboos, customs, superstitions, habits, religions, addictions to different carcinogenic agents specially tobacco products. Philosophical aspect of coping with cancer of the people of the developing world will also be evaluated during presentation.

213 Social Support and Breast Cancer Survivorship: Understanding Disparties Among Ethnic Groups Levine EG1, Yoo GJ2, Aviv C3, Ewing C4 1 Research California Pacific Medical Center, San Francisco, USA; 2Ethnic Studies, San Francisco State University, San Francisco, USA; 3University of Denver, Denver, USA; 4Surgery University of California, San Francisco, USA Research on the physical and psychosocial difficulties of breast cancer survivors has been based predominantly on white women, despite increasing incidence of breast cancer detection and diagnosis across many cultural and ethnic groups in the United States. While for many patients, the distress of cancer treatment declines within 1 year, up to about 30% of women diagnosed with breast cancer continue to report disruption in their quality of life 1 year after treatment. The goal of this study is to examine how survivors from ethnically diverse populations perceive, interpret, and experience quality of life, depression, spirituality, and social support. Four hundred African American, Latina, Asian American, and white women are being

Copyright # 2004 John Wiley & Sons, Ltd.

recruited in Northern California to complete interviews and psychological measures every 6 months for 2 years, in order to assess whether existing social support and quality of life measures are culturally and conceptually equivalent. If there are ethnic differences, our goal is to develop and validate new measures of social support and quality of life that are culturally sensitive. During preliminary qualitative and quantitative findings from initial interviews with the first 40 participants, themes that have arisen include support from family and friends, spirituality, reactions to diagnosis and treatment, coping with treatment decision making, and racism.

214 Differences in use of Caregiver and Bereavement Support Groups by Ethnically Diverse Family Members of Cancer Patients McLaughlin L Clinical Sciences Cancer Research Center of Hawaii, Honolulu, Hawaii, USA Although caregiver and bereavement support groups can be effective ways to help family members cope with illness and death, members of certain ethnic groups do not readily attend. Ethnic trends in participation emphasize the need to better understand the role of ethnicity and culture on end-of-life caregiving and bereavement. Focus groups were conducted to identify the influence of culture and cultural practices on illness, caregiving, death and dying. PURPOSE: The purpose of the focus groups was to better understand: (1) cultural influences at the end of life; (2) attitudes and behaviours that reflect the unique attributes of each cultural group with respect to illness and death; (3) the value of support groups; and (4) culturally relevant support interventions as alternatives to support groups. METHOD: Four focus groups were conducted with Asian and Pacific Islander family caregivers in Hawaii: (1) caregiver support group participants; (2) bereavement support group participants; (3) caregivers that did not attend caregiver support groups; and (4) caregivers that did not attend bereavement support groups. Participants were asked about their attitudes toward illness, caregiving, death, and dying, and the value of support

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groups. RESULTS: Results of qualitative inquiry obtained through this process can be used to inform larger studies on caregiving, cancer, and bereavement among Asian and Pacific Islanders. Findings from this study may be used to increase the efficacy of caregiver and bereavement support groups among ethnically diverse populations.

215 Culture and Care: Aboriginal Women’s Experiences of Cancer and Cancer Care Mitchell TL1, Burhansstipanov L2, Baker E3 1 Psychology Wilfrid Laurier, Waterloo, Canada; 2 Native American Aboriginal Cancer Centre, Denver, USA; 3Community Health and Epidemiology, Memorial University, St. John’s, Newfoundland, Canada The Aboriginal Women’s Cancer Care Project (AWCCP) was developed in Ontario, Canada and New York, USA in 2003 to develop increased understanding of the role of culture and Aboriginal minority status in cancer care and cancer outcomes. We investigate beliefs, decisions, experiences, and outcomes of Aboriginal women with breast and gynecological cancer to inform system policy change which may be implemented to address existing health disparities. METHODS: The AWCCP is using a social constructivist and participatory research approach to the study. A Mohawk woman with the support of an Aboriginal Advisory Group manages linkages and ongoing communications with three distinct Aboriginal communities. Interviewers hired from within the three communities are conducting indepth interviews with 6 cancer survivors, 2 family members, and two cancer care providers, N=30. We are using a combination of narrative and discourse analyses approaches to reveal the individual lived experiences as well as the how the dominant social structures shape and constrain the cancer care access and health experiences of these participants.

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Nelson JJ Centre for Research in Women’s Health, University of Toronto, Toronto, Ontario, Canada PURPOSE: While a growing body of literature exists on women’s experiences with breast cancer in Canada, investigations of the specific support needs of women of colour are usually overlooked. This poster will present the results from a pilot study with a breast cancer support network for women of colour in Ontario, Canada. METHODS: This qualitative study employs interview and focus group methodologies and utilizes discourse analysis in illuminating its findings. Central themes are drawn from the interviews, and analyzed with attention to the broader social context in which women of colour are marginalized socially, economically and institutionally in Canada. RESULTS: The study is examining the psychosocial issues facing women of colour living with breast cancer, and inquiring about the barriers women experience in finding support. This poster will illustrate the central themes emerging from the research, including the ways in which women of colour have felt marginalized by mainstream support groups or services. It will also present the challenges to creating a supportive environment within the community involved, and the women’s views on what needs to change in cancer care centres to create accessible and appropriate services for racially marginalized women. CONCLUSIONS: The poster will suggest broader implications for psychosocial work with cancer patients of colour. An understanding of the historical and social contexts in which continued racial domination takes place is important in addressing the problems women face when utilizing existing programs or services.

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Tailoring Print Material for Five Ethnic and Four Language Groups Pasick RJ1, Stewart SL1, Otero-Sabogal R2 1 Comprehensive Cancer Ctr, UCSF, San Francisco, CA, US; 2Institute for Health & Aging, UCSF, San Francisco, CA, US

Women of Colour Living with Breast Cancer: Barriers and Bridges to Supportive Care

PURPOSE: Technologic advances have made individually tailored print communication a

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reality. However, the feasibility among ethnically diverse populations has not been explored. In a randomized controlled trial to increase breast and cervical cancer screening in a multi-lingual cohort of 1465 African American, Chinese, Filipino, Latino, and White women in Alameda County, California, US, we developed printed Personal Health Guides to reinforce a telephone counselling intervention. Because this was a first effort to tailor across cultures, an independent analysis of the Guides was conducted. METHODS: The Guides were tailored: culturally (cultural themes framed key health messages, and graphics include cultural icons and ethnic-specific photos); linguistically (written Chinese, English, Spanish, Tagalog); by adoption stage, attitudes and barriers (based on the Transtheoretic Model); by health insurance status; and personally (by name). Development included formative research (to create the message ‘‘library’’, graphics, and overall design); survey data informed selection of messages via a tailoring algorithm; and extensive pre-testing was conducted for clarity, credibility, and cultural appropriateness. RESULTS: Significant increases in recent mammogram were reported following receipt of the Guides by Filipina (p=0.005) and Latina women (p=0.022), and in recent Pap for Filipinas (p=0.026) in the invention compared with the control group. CONCLUSIONS: Tailoring print material for multiple ethnic and language groups is feasible, and for some groups, can independently influence cancer screening.

218 Gender and Racial Differences in Antidepressant Prescribing at a Large Comprehensive Cancer Centre Sherman LK1, Adamus AT2, Baile WF1, Hung FC2, Fisch MJ3 1 Neuro-Oncology, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA; 2 Pharmaceutical Policy and Outcomes Research, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA; 3Palliative Care and Rehabilitation Medicine, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA BACKGROUND/METHODS: Antidepressant (AD) medications are commonly prescribed in

Copyright # 2004 John Wiley & Sons, Ltd.

the cancer population, not only for treatment of depression but also for symptom management. This retrospective cohort study describes AD prescribing patterns in a large, comprehensive cancer centre, including patterns related to gender and race. RESULTS: In the year 2001, 54 902 patients were seen at our comprehensive cancer centre. 1782 patients (3.2%) filled an AD prescription at our Center’s outpatient pharmacy. Of those patients, 76% were Caucasian, while 9.48% were African-American; this closely reflects the racial demographics at our Centre. Of Caucasian patients, 56% were female while 44% were male; this is in contrast to the African-American population: 74% female and 26% male (p50.001). Subdividing AD into ‘‘SSRI’’ (serotonin reuptake inhibitors), ‘‘TCA’’ (tricyclic antidepressants) and ‘‘Other’’ categories, there was a significant difference in distribution of drugs between Caucasians and African-Americans (p=0.037). SSRIs were the most commonly prescribed, with a higher percentage in Caucasian patients. Most TCA prescriptions were written at low doses for symptom control, not at doses for AD efficacy. Only 13% of patients were prescribed the drug by a psychiatrist (no racial difference). Patients medicated by a psychiatrist had an ICD-9 diagnosis code for a psychiatric illness in 92% of cases, in contrast to 35% of patients oncologistprescribed. CONCLUSIONS: This study reveals both racial and gender differences in AD prescribing patterns for those patients who filled prescriptions at the outpatient pharmacy of at our comprehensive cancer centre. Furthermore it demonstrates that most AD are prescribed by oncologists rather than psychiatrists.

219 Intersecting Vulnerabilities: Gender, Poverty, Age, Aboriginal Status in Women’s Lived Experience of Breast and Gynecological Cancers Sinding C1,2, Gould J2, Mitchell T3,2, Fitch M4, Gustafson D5 et al. 1 Health Studies Programme & School of Social Work, McMaster University Hamilton, Ontario, Canada; 2Ontario Breast Cancer Community Research Initiative, Sunnybrook and Women’s College Health Sciences Centre, Toronto, Ontario, Canada; 3 Psychology Wilfrid Laurier University, Waterloo,

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Ontario, Canada; 4Psychosocial and Behavioural Research Unit, Sunnybrook and Women’s College Health Sciences Centre, Toronto, Ontairo, Canada; 5 Faculty of Medicine Memorial University, St. John’s, Newfoundland, Canada

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PURPOSE: Numerous studies examine associations between health and specific social locations, notably socio-economic status and gender. However, very little research has explored illness or quality of life in relation to multiple and intersecting social locations. The Intersecting Vulnerabilities research program was designed to develop analytic tools and substantive knowledge about how social positions}independently and together}act as determinants of health and quality of life in the cancer care context. Recognizing that social position is associated with a range of health vulnerabilities, this research does not ‘start from’ cancer. Rather, it starts from the social positions of poverty, Aboriginal identity and older age, and takes the lived experience of cancer among women who occupy these social positions as a critical case, a critical site for knowledge development. METHODS: The IV research program employs qualitative and participatory methods: qualitative to foreground the psychosocial contexts of respondents’ lives, and participatory to increase the likelihood that equity-promoting initiatives generated by the research will be taken up and sustained. RESULTS: This presentation offers an overview of the Intersecting Vulnerabilities Program, bringing forward results from our studies with low income, Aboriginal, and older women. We then draw on cross-group comparisons to propose frameworks for understanding how multiple social vulnerabilities operate, intersect and shape quality of life for women with cancer. In particular, we describe how cancer care and support services both facilitate and undermine equity for marginalized women. Finally, we sketch plans for community-level and institutional interventions designed to address health disparities.

PURPOSE: A cancer diagnosis in an older woman’s life often intersects with precarious social and material circumstances; along every axis of the social determinants of health, older women are vulnerable and yet evidence suggests that older women bring life stage perspectives that may serve to sustain them in the face of cancer. This project addresses the intersections of these biographical and social processes and explores how they shape older women’s experiences of cancer and cancer care. METHODS: The study approach was participatory, engaging cancer survivors and representatives of community agencies in study design, implementation, and dissemination of findings. Ten breast and five gynaecological cancer patients over age 70 (stratified by age and income) participated in two in-depth interviews. Using critical ethnography, qualitative interviews offered an entry point for understanding the wider social and institutional structures framing individual experience. RESULTS: Containment emerged as a central theme. Study participants asserted their capacities to accommodate the cancer experience into their identities and thinking. Within their social relationships, they spoke of deliberate decisions not to reveal their cancer diagnoses to family and friends. Related to the health care system, their narratives were replete with language that muted or short-circuited their complaints about cancer care. In this paper, we consider links between the theme of containment and women’s reports of their interactions with cancer care professionals. We also report on results of a workshop at which study findings were used to design equity-promoting interventions for older women with cancer.

Health Studies Programme and School of Social Work, McMaster University, Hamilton, Canada; 2 School of Social Work, McMaster University, Hamilton, Canada; 3Department of Nursing, Hamilton Regional Cancer Centre, Hamilton, Canada

221 220 Older Women, Cancer and Cancer Care: Accommodation and Containment Sinding C1, Aronson J2, Wiernikowski J3

Copyright # 2004 John Wiley & Sons, Ltd.

Communication Skills Training}An Innovative Model for the Developing World Venkiteswaran C1, Venu M1, Marathakot G1, Kumar TM2

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Palliative Medicine Pain & Palliative Care Society, Calicut, Kerala, India; 2Liaison Psychiatry St., James’s University Hospital, Leeds, UK In this paper, we describe a pioneering attempt to train community volunteers in India to be trainers for other volunteers to improve the basic communication skills that underpin all aspects of medical care. BACKGROUND: The Pain and Palliative Care Society in Kerala, India has been successful in developing a model of palliative care delivery that uses existing hospitals, non-medical and medical networks in order to ensure low costs and easy accessibility. Since 1994, the Society has become the nodal agency for training and a model for service delivery for the rest of India. The model is based on training doctors and other staff, but most importantly volunteers, in delivering basic palliative care. From Calicut, a network of link centres has evolved with volunteers operating in local communities. TRAINING PROGRAMME IN COMMUNICATION SKILLS: From the beginning, there has been an emphasis on inclusion of psychosocial care as part of routine palliative care in this model. The success of delivering palliative care through trained volunteers has led to the same approach being tried in ensuring delivery of good psychosocial care. Training in communication skills is seen as the first step in improving skills involved in recognising and managing psychosocial problems. A psychiatrist and two nurses form the core psychosocial team. The first batch of volunteers so trained now act as trainers for other volunteers in their communities. Various aspects of the training, which is in the local language and adapted to the local culture, and further developments are discussed.

PURPOSE: The available data in the USA show up to 45% of patients visiting cancer clinics are significantly distressed. Yet less than 10% of these patients seek out or are referred to supportive services. It is anticipated that high proportion of cancer patients in Taiwan would also experience a great deal of distress and need prompt support and treatment. METHOD: All new patients visiting a cancer centre in Taiwan for treatment of oncology diseases between 01/01/2002 and 12/31/2003 were given a 14-item questionnaire to assess their level of anxiety and depression. All patients scored above the thresholds were considered in the high-risk group and immediately contacted by a social worker for proper intervention. RESULTS: Out of 1194 patients that returned the questionnaire, about 55% reached the threshold of significant anxiety, and 20% for depression. Almost all in the group that had significant depression also had significant anxiety. Of the patients that received interventions and could be reassessed 3 months later, up to 70% were no longer in the high-risk group. These preliminary results and the feedback from patients and families are very positive. CONCLUSION: Psychosocial impact on cancer patients in Taiwan is as prevalent as in the West. Proper intervention appears to be very beneficial. All cancer patients should be assessed as early as possible. Appropriate support and treatment can then be given in a timely and effective manner.

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Culturally Competent Counseling of African American Women with Breast Cancer Wong VAR Counseling Psychology, University of Southern California, Los Angeles, USA

Psychosocial Impact and Intervention for Cancer Patients in Taiwan Wang GL1, Hsu SH1, Chiou B2, Cheng CC3, Feng AC4 1 Psychiatry Koo Foundation, Sun Yet-Sen Cancer Center, Taipei, Taiwan; 2Social Services Koo Foundation, Sun Yet-Sen Cancer Center, Taipei, Taiwan; 3 Nursing Koo Foundation, Sun Yet-Sen Cancer Center, Taipei, Taiwan; 4Research Koo Foundation, Sun Yet-Sen Cancer Center, Taipei, Taiwan

African Americans have endured a long history of mistreatment in the United States that predates the signing of the US Constitution. While the US has made great strides by abolishing slavery, many of the inequities of this shameful time period remain evident in modern US society. One such area is the disparities among the races seen in the US health care system. Much of the research done in this area indicates that African Americans receive a poorer standard of health care than Caucasians, which

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extends to both medicine and mental health services. For those mental health professionals specializing in health psychology, it is particularly important to be aware of this history and its interaction with racial identity models and cultural beliefs in order to competently counsel African Americans with serious health concerns, such as breast cancer. This paper, through a review and synthesis of the relevant literature (e.g., commonly held beliefs of African Americans that affect health care behavior, influential psychological theories of health behavior and change, and the theory and practice of culturally competent counselling), aspires to form a foundation to begin that process.

Mind-body/CAM 224 Religiosity and Spirituality in a German Sample of Psycho-oncologists Bailer H1, Grulke N1, Albani C2 1 Psychsomatic Medicine and Psychotherapy, University Hospital of Ulm, Ulm, Germany; 2 Psychotherapy and Psychosomatic Medicine, University Hospital of Leipzig, Leipzig, Germany PURPOSE: Research has addressed the religious and spiritual needs of patients, but there seems to be only little quantitative investigations of the caring psychosocial professionals, especially in Germany. We want to explore religiosity and spirituality in German psycho-oncologists in comparison to the general population, and assume that they are more religious and spiritual. METHODS: During the annual meeting of the Deutsche Arbeitsgemeinschaft fu. r psychosoziale Onkologie (dapo, German Society of Psychosocial Oncology) in June 2003 and a training course in psychooncology in July 2003 the participants were asked to answer to the German version of the Systems of Belief Inventory (SBI-15-R) and to the Questionnaire of Transpersonal Faith (TPV). RESULTS: One hundred and forty-two questionnaires were distributed to the participants, 62 (43.7%) were given back. Most respondents are female (73%), between 35 and 54 years old (79%), live in a partnership (76%), are active in (psycho-) oncology between 21 and 50 hours per week (63%), and

Copyright # 2004 John Wiley & Sons, Ltd.

work in the psycho-oncology field between 2.5 and 10 years (60%). As expected the sample shows up with substantially higher scores on the SBI: total score=19.3 vs. 14.4 in the general population, and the TPV: 23.1 vs. 12.2. No correlation is seen between degree of religiosity/spirituality and years of working in the field. CONCLUSION: Psychooncologists seem to be more religious than the general population, but analyses are preliminary since differences between East and West Germany are not considered yet. Results in more detail will be presented.

225 Literature Review and Clinical Experience on Psychological Aspects in Pediatric Patients Amputated for Malignancies Clerici CA1,2, Ferrari A1, Luksch R1, Cefalo G1, Fossati Bellani F1 et al. 1 Unita" Operativa Pediatria Istituto Nazionale per lo Sudio e la Cura dei Tumori, Milan, Italy; 2Department of Psychology, University of Milano-Bicocca, Milan, Italy AIMS AND BACKGROUND: Amputation surgery in paediatric patients suffering from malignant tumors is less common than in the past, but carries a great emotional impact for patients, their families and the medical team. Studies addressing the psychological aspects of limb amputation in childhood cancer are still relatively limited, and the results are sometimes contradictory. METHODS: At the Paediatric Oncology Unit of Istituto Nazionale Tumori, Milan, a psychological support was provided for the candidates for amputation and their families, involving medical oncologists, clinical psychologist, and social assistants. Twenty-two patients were analysed, and 16 underwent mutilating surgery. RESULTS: Different emotional reactions were observed; surgery was easier to accept when the tumor caused pain and functional loss. Specialist medical psychological support was needed in cases of defence mechanisms (e.g. splitting and projection) and depressive reactions evolving into isolation or intolerance. CONCLUSIONS: The reported experience could be helpful to provide adequate support for childhood patients with tumors requiring maiming surgery.

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226 CAM}Which is Which? Courtney UM Director of Services ARC Cancer Support Centre, Dublin, Ireland Alternative medicine must be distinguished from complementary therapies by examining the promoted purpose of the method in order to clarify this dissimilar collection of therapeutic techniques. Alternative cancer therapies are products and treatments recommended for use instead of mainstream cancer care and can be a vast collection of disparate, unrelated regimens and products ranging from adjunctive modalities which can enhance quality of life to bogus therapies that claim to cure cancer and thus may harm the patient both directly and indirectly. Consumers are at the mercy of those who promote unproved remedies, many of which can be purchased over the counter or Internet. These treatments are unproven, harmful, costly, time-wasting and possibly invasive. Complementary therapies, in contrast, serve a complementary role in conjunction with conventional medicine and their aim is to improve quality of life and symptom control. They are often used as part of wellness and health maintenance programmes and many regimens are part of preventive medicine and supportive care. Complementary therapies tend to be non-invasive, inexpensive and widely helpful. However, frequently when reference is made to ‘‘alternative’’ approaches, the therapy under discussion is ‘‘complementary’’ and this adds confusion in terms of perception and understanding. This paper aims to describe and identify the differences between alternative and complementary therapies as used by people diagnosed with cancer. The efficacy of various treatments are discussed and recommendations are made in relation to patient safety.

227 The Desire For Death among Cancer Patients}An Indian Study Gandhi AR, Chaturvedi SK et al. Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, India

Copyright # 2004 John Wiley & Sons, Ltd.

Among some controversies plaguing contemporary medical care of patients with cancer, are issues of desires regarding hastened death, euthanasia, and physician-assisted suicide albeit, in the western literature. A desire for death, among the terminally ill, may be indicative of a potentially treatable psychiatric disorder, uncontrolled pain and various social factors that may undermine the capacity to cope in an individual. PURPOSE: There is ample western literature focusing on desire for death, its stability, determinants, etc. No systematic studies in the Indian setting, however, have tried to examine the prevalence and determinants of desire for death in cancer patients. The purpose of this study was to determine the desire for death among cancer patients and explore the relationships between desire for death and other demographic variables, diagnosis, illness duration, treatment intent, and social supports. METHODS: Two hundred patients were recruited from the Neurosurgical outpatient NIMHANS, Radiotherapy Manipal hospital, and Hospice. Before participation, all patients gave written acknowledgement of informed consent. All patients recruited had the primary diagnosis of cancer. Patients too cognitively impaired, weak, ill to complete the assessments were excluded. Patients were rated on the modified Desire for Death scale devised by Chochinov et al. (1995). Concerns of patients were recorded using Manchester Concerns Scale. RESULTS: Will be discussed during the presentation. CONCLUSIONS: Understanding temporal patterns of desire for death and its correlates represents an important step towards understanding the mental state and intervening, thus improving care for terminally ill cancer patients.

228 Caregivers: Building a Sense of Emotional Competency Kettler Phyddy Neuro-oncology, M.D. Anderson Cancer Center, Houston, USA PURPOSE: It is vital that family cancer caregivers build a personal theory of emotional competency in addressing the myriad of tasks that present as they care for their loved one. In the course of

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caring, a caregiver may report a sense of significant physical fatigue, but rarely identify an equal or greater element of exhaustion, i.e. emotional fatigue, in meeting the rigors of their loved one’s complex medical care. Unless a sense of organization of thought and feeling is developed, a caregiver may begin to feel that they are ‘‘going crazy’’ or inferior to the task. This growing sense of incompetence can create a threat to the emotional stability of the caregiver. METHOD: We offer a weekly psychiatric support group that addresses building emotional competency, including the following: 1. What is the meaning contained in this suffering? 2. Where is God in this and why does He allow good people to suffer? 3. How does one live, really live, one day at a time? How does one control fear? 4. What are my spiritual beliefs about the afterlife? RESULTS: Caregivers who have begun formulating a personal theory report less emotional chaos. They report greater relief in having support that diminishes social isolation and loneliness often involved in caregiving. CONCLUSIONS: Emotional fatigue may be a result of a lack of a personal theory regarding suffering, meaning, life and death. Once the theoretical components are addressed, a new level of awareness may develop that acts to conserve emotional energy in meeting the [truncated]

229 The Lived Experience of Spirituality and Meaningbased Coping in the Advanced Cancer Population Lethborg C Oncology, St. Vincent’s Hospital, Fitzroy, Australia Of the four domains of palliative care, the spiritual domain is clearly the least explored and understood. Conceptualizing spirituality involves comprehension of such complex ideas as ‘‘inner life’’, meaning in life, and transcendence. These components of personhood have been shown to impact positively on the lives of those living with serious illness and can act as a buffering agent, protecting against depression, hopelessness and desire for hastened death. Yet, suffering in life can also

Copyright # 2004 John Wiley & Sons, Ltd.

challenge meaning and spirituality when it is too difficult to reconcile in relation to the individuals’ existing world-view. PURPOSE: Ultimately, a better understanding of the spiritual domain of palliative care will enable the development of targeted interventions that enhance well-being. While a number of innovative interventions are being trailed in relation to meaning, dignity conservation and spirituality there remains much to learn about the lived experience of spirituality for this patient group. This study considers the experience of spirituality and meaning for one group of patients with advanced cancer (n=10). METHODS: Participants were interviewed individually at one or two time points using a semistructured open-ended questionnaire. Interviews were tape recorded, transcribed and analysed to assign broad general themes. RESULTS: The lived-experience of spirituality and meaning is described in relation to the following themes; positive re-appraisal, problem-focused coping, spiritual beliefs, ordinary events, relationships, nature, purpose in life, transcendence, inner world, global meaning, facing negatives and hope. CONCLUSIONS: Implications for practice and future research will be discussed.

230 Effects of Yoga on Quality of Life among Breast Cancer Patients in Bronx, New York Moadel AB1, Shah C1, Shelov D1, Wylie-Rosett J1, Sparano J2 1 Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, USA; 2Albert Einstein Cancer Center, Montefiore Medical Center, Bronx, USA PURPOSE: This ongoing randomized controlled study seeks to examine the effects of yoga on quality of life (QOL) among underserved breast cancer patients in Bronx, New York. Analyses presented examine the relationship between yoga compliance, medical factors, and QOL. METHODS: Breast cancer patients were randomly assigned to either a 12-week yoga intervention or a 12-week wait-list control group, with measures obtained at baseline (T1) and 3 months (T2) using standardized QOL measures (i.e., FACT). The sample was predominantly African-American

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(43%) and Hispanic (30%), with an average age of 53.41+ 10.21. Women were diagnosed within 1 year (57%), in stages I–II (79%), and receiving chemotherapy (45%) or hormonal therapy (36%). Data from three subgroups were compared: control (n=25), intervention subjects with low compliance (attending52 yoga classes; n=24), and those with higher compliance (attending >3 classes; n=27). RESULTS: Women in the intervention group were likely to attend fewer yoga classes if they were receiving chemotherapy (p50.01), or reported greater emotional wellbeing at T1 (p50.01). Control group patients experienced increased physical symptoms (p50.04) and decreased social well-being (p50.003) from T1 to T2, while intervention patients with higher compliance experienced greatly increased emotional well-being (p50.0001) and no significant deterioration in physical functioning. CONCLUSIONS: Results suggest that yoga may protect and even enhance QOL among breast cancer patients in emotional distress. While debilitating cancer treatments may pose a barrier to attending yoga class, modification in intervention delivery should be explored.

231 Effects of a Brief Mindfulness Meditation Intervention in Cancer Patients Moscoso MS1, Reheiser EC2, Hann DA3 1 Psychology, University of South Florida, Tampa, FL, USA; 2Psychology University of South Florida, Tampa, FL, USA; 3Psychology Brown University, Providence, RI, USA This pilot study evaluates the effectiveness of a brief mindfulness meditation intervention on the reduction of emotional distress and fatigue in cancer patients. The sample consists of 34 male and female cancer patients recruited from the Morton Plant Hospital Cancer Centre in Clearwater Florida. Each subject was offered the opportunity to participate in a brief training course in mindfulness meditation, which consisted of four, 1 h sessions held once per week. The 17 individuals that chose to attend the mindfulness meditation training sessions comprise the intervention group. The control group consisted of the 17 subjects who

Copyright # 2004 John Wiley & Sons, Ltd.

chose not to attend the mindfulness meditation sessions, but were willing to participate in the study by attending the regular support groups available at the Cancer Patients Support Services, and completing the questionnaire at baseline, 1and 3-month follow-up. Results of the study found no significant differences between the intervention and control groups on any of the measures. However, there were significant findings in the test–retest analyses of these measures. The data indicates that the brief mindfulness meditation-based stress reduction training resulted in a greater reduction in anxiety for the intervention group than for the control subjects from the pre-intervention baseline to both the post and follow-up samplings.

232 Psychological Advantage of Traditional Faith Healers for Tobacco De-addiction in Tribal/Rural Parts of India Pramod S, Narayanan R Health Alert Organisation of India, Dhule, India ISSUES: Adolescents are highly susceptible to the tobacco use. We used traditional/faith healers to motivate by the interventional study protocol. METHODOLOGY: Retrospective analysis of the implementation of FCTC-WHO was done by three NGO evaluation teams. Each district was divided into seven target villages. Due representation to demographic pattern and socio-economic criteria. Total participants were 260, in the age group of 14–24. Traditional faith healers were mobilised by the community leaders [total 13]. Tobacco addicts graded clinically according to consumption of tobacco, years of use. The study carried on over 4 months. Study subjects were counselled for cause of using tobacco, educational & social background. Traditional faith healers conducted 11 follow-up sessions during the course of study. RESULTS: Of the total 260 tobacco users, 250 continued to participate [10 dropouts]. Of these 250, 227 participants showed positive attitude towards quitting tobacco use. Of these 227, 215 subjects has quit the habit of tobacco application. Twelve subjects were able to abstain for a short period, but eventually restarted the habit. Post project surveillance showed the need

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for community help & Rehabilitation. Of the 227 who responded positively, majority [220] of the adolescents started using tobacco due to peer pressure [84%], imitation of tobacco advertising on media [11%]. CONCLUSION: Scientific knowledge & expertise of traditional faith healers in tribal areas is controversial, they are only available resource for influencing adolescents. They act as channel to implement tobacco deaddiction programmes through community participation. RECOMMENDATIONS: Developing nations have little resources & technologies. Governmental & NGOs have to carry out interventional programmes with these resources. Traditional faith healers can achieve WHO tobacco control targets for long-term success strategy.

ment of Chronic Illness Therapy-Spirituality (FACIT-Sp) Scale were significantly increased as were scores on the physical, emotional, functional and spiritual subscales (all p50.01). Salivary cortisol levels were significantly decreased (p50.05). These results suggest that the 10-day residential program run by The Gawler Foundation has beneficial effects on mood, mental adjustment to cancer, quality of life and salivary cortisol levels in cancer patients. This is a preliminary report of results from an on-going, controlled, prospective study. In conclusion, this preliminary data provides support for the effectiveness of this psychosocial treatment program in a heterogeneous group of cancer patients.

233 234 A Preliminary Report of the Effect of Psychosocial Support on the Psychological and Physical Wellbeing of a Heterogeneous Group of Cancer Patients Reavley N, Vitetta L, Cortizo F, Sali A Graduate School of Integrative Medicine, Swinburne University of Technology, Melbourne, Australia Psychosocial treatment programs for cancer patients range from traditional approaches offered by mainstream medical institutions to less orthodox approaches. The Gawler Foundation in Melbourne, Australia provides active cancer support programs designed to improve quality of life and if possible, to impact on length of life. The programs are complementary to mainstream medical treatment and focus on relaxation and meditation, a low-fat vegetarian diet, positive thinking and drawing on effective support. In this paper we report preliminary findings on the efficacy of The Gawler Foundation programs. The results show a significant reduction in Profile of Mood States (POMS) total mood disturbance, tension–anxiety, depression–dejection, anger–hostility, fatigue and confusion–bewilderment scores and an increase in vigor score (all p50.01). Scores on the helplessness–hopelessness subscale of the mini-Mental Adjustment to Cancer (mini-MAC) were significantly reduced and scores on the fighting spirit subscale were significantly increased (p50.01). Total scores on the Functional Assess-

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Assessment of the Patients’ Spiritual Needs: A Phase I Study With the Semi-structured Interview SPIR Riedner C1, Biechele I2,3, Froer P2, Borasio GD3, Frick E4 1 Psycho-Oncology, Munich Oncology Practice, Munich, Germany; 2Pastoral Care Team, University Hospital, Grosshadern, Munich, Germany; 3 Interdisciplinary Palliative Care Unit, University of Munich, Munich, Germany; 4Department of Psychotherapy and Psychosomatics, University of Munich, Munich, Germany BACKGROUND: Research has found a strong positive relationship between effective coping and the religious/spiritual beliefs. We investigated the patients’ spiritual needs using a semi-structured interview (SPIR). SUBJECTS AND METHODS: The study takes place in two outpatient and an inpatient setting. Patients are first assessed with the SPIR interview. They are then asked to rate, using Visual Analogue Scales (0–10), the selfperceived helpfulness of the interview, the degree of distress due to the interview, and the overall importance of spiritual issues in their present situation. The interviewer answers the same questions independently for him/herself. RESULTS: Thirty-one oncological patients have been evaluated so far. The data indicate a low distress imparted by the interview (patients 1.29  0.45,

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interviewers 1.15  0.23), a high degree of perceived helpfulness of the interview (pts. 6.77  0.46, int. 7.31  0.35), and a high importance of spiritual/religious questions (pts. 6.45  0.51, int. 5.95  0.49). There is good agreement between the patients and the interviewers on all questions. Spiritual issues seem to play an important role for patients and determine how helpful the interview is for them. DISCUSSION: Previous research has shown the importance of spiritual well-being for the quality of life of cancer patients. This study indicates that the SPIR is a simple, effective method of assessing the patients’ spiritual needs. In addition, the data show a high acceptance of a spiritual assessment performed by the treating physician. We hope that this study will help strengthen the role of spiritual care within the provision of medical services to patients with cancer.

235 The Disease as Necessity of Conditionings Evolution for a New Consciousness: The Spiritual Self Salvetti CS Psychotherapy C.R.E.D.E.S., Milano, Italy In a holistic view, disease carries a message of change that cannot find other ways to reach the consciousness and stimulate the individual in being protagonist and not victim of changes. The symptom tries, through body language, to radically express the individual evolutive needs. Tumour is the bodily expression of a psychological uneasiness that talks through the body and metaphorically expresses the need for change, understood subconsciously but not consciously. Psychotherapy may help the patient to interpret the disease’s voice, listening to the last suffering voice of the self. The analytical work allows the subject to recover consciousness of his own crystallised relational, familiar and social models and changes them to touching emotions and most authentic feelings. Usually the person with cancer identifies itself with the immediate perception of itself and no longer projects itself into the future. The person has a restrictive view of life, where the perspective is the execution of a model and not the self-knowledge and of the evolutive potential. Recognising this potential means contacting one’s

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self and following it beyond conditioning and codes learnt. This represents the chances to overcome an inner uneasiness and a possible somatisation. Existing, dealing with the inside and outside, dancing and fighting with an innate and learnt knowledge. An evolution allowing the understanding and integration of body, mind and spirit language. Expanding the consciousness, the person can be taken back to its origins and meet itself in the universal instant, where everything is ‘‘presence’’. Examples of clinical cases are illustrated in. . . [truncated]

236 Role of Hypnosis as an Adjunct in Cancer Management Srinivasaiah S1, Santosh SK2 1 Clinical Psychology, NIMHANS, Bangalore, India; 2Psychiatry, NIMHANS, Bangalore, India There are at least 20 alternative therapies like hypnosis, meditation, zen, yoga, pranayama, shamanism, acupuncture and the like the world over. They all target body–mind relationship in alleviating the disease and pain. The subject of hypnosis is both ancient and modern, though ‘‘the modern garb of hypnosis is woven with the ancient threads of rituals and magic’’. Hypnosis as an ‘‘altered state of consciousness’’ (ASC) refers to a broad range from the light hypnoidal condition bordering on waking suggestibility to the plenary trance (Tart, 1975). Findings based on psychoneuroimmunology (Robert Ader), and the discovery of Ultradian Healing Response (Rossi, 1982) appear to be at the core of cures claimed by most of the alternative therapies. Technique of ‘‘psychological cloning of physiological signals’’ involving thermodynamic holograms and eidetic imagery (Ahsen, 1999) is quite innovative and promising. Hypnosis in a way resembles yoga nidra (meditative deep relaxation) in the Indian context. This aims to relax the body and mind initially and dissociating oneself ultimately from both toward higher states of consciousness. The progression occurs through 5 koshas (sheaths) viz., (annamaya kosha ‘‘food body; pranamaya kosha}pranic

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body; manomaya kosha}mental body; vignanamaya kosha}astral body; and anandamaya kosha}bliss body and the quality of consciousness changing correspondingly like}jagrat (waking), swapna (inwardly cognitive), sushupti (dreamless sleep) and turiya (superconsciousness). In India Yoga nidra passes off unnoticed either as a religious or spiritual practice. Both western and Indian approaches have a place in improving the quality of life in cancer patients.

237 Does Spirituality Make a Difference? Report From the Southern European Psycho-Oncology Study (SEPOS) Travado L1,2, Gil F3, Ventura C1, Martins C1, Grassi L4,5 1 Psychotherapy Service Hospital S. Jose!, Lisbon, Portugal; 2Faculty of Psychology and Educational Sciences, Independent University, Lisbond, Portugal; 3Psycho-Oncology Unit, Catalan Institute of Oncology, Hospital Duran i Reynals, Barcelona, Spain; 4Department of Behavior and Communication, Section of Psychiatry University of Ferrara, Ferrara, Italy; 5Department of Mental Health, General University, S. Anna Hospital, Ferrara, Italy PURPOSE: In the last decade some attention has been given to spirituality and its role in cancer patients’ coping. Few data is available about spirituality among cancer patients in Southern European countries, which have a big tradition in religious spirituality, namely catholic religion. As part of a more general investigation (Southern European Psycho-Oncology Study}SEPOS), the aim of this study was to examine the effect of spirituality in molding psychosocial implications in Southern European cancer patients. METHODS: A convenience sample of 307 outpatients with a diagnosis of cancer between 6 and 18 months, a good performance status (KPS>80), no cognitive deficits or CNS involvement by disease were approached in university and affiliated cancer centres in Italy, Spain and Portugal. Each patient was evaluated for spirituality (VAS 0–10), psychological morbidity (HAD), coping strategies (Mini-MAC) and concerns about illness (CWI).

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RESULTS: The majority of patients (79.3%) referred being supported by their spirituality/faith throughout their illness. Significant differences were found between the spirituality versus nonspirituality groups (p50.01) in terms of education, coping styles and psychological morbidity. Spirituality was significantly correlated with fighting spirit (r=0.27), fatalism (r=0.50) and avoidance (r=0.23) coping styles and negatively correlated with education (r= 0.25), depression (r= 0.22) and HAD total (r= 0.17). CONCLUSION: Spirituality is frequent among southern European cancer patients with lower education and seems to play some protective role towards psychological morbidity, specifically depression. Further studies should examine this trend in Southern European cancer patients.

Organisation of Treatment 238 Improvements in Patient Satisfaction at an Outpatient Clinic for Women with Breast Cancer Bergenmar M, Nyl!en U, Lidbrink E, Bergh J, Brandberg Y Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden In order to promote patient-centred care, patient satisfaction has to be taken into account. PURPOSE: To evaluate the development from 2000 to 2003 of patient satisfaction at an out-patient clinic for patients with breast cancer. During that time, efforts to improve care with respect to continuity were implemented. METHODS: The assessment was performed during 3 weeks in year 2000 and the second during 2 weeks in 2003. Consecutive patients were asked to anonymously complete a questionnaire after their medical examination and to put it in a locked post box in the waiting room, cleared by research staff. The questionnaire was developed at our clinic and consists of multiplechoice questions: waiting time (2), interpersonal skills of physician and nurse (2), continuity of care (2), length of medical visit (2), communication (1), expectations (1), cared for (1), recommend (1). RESULTS: Three hundred and sixteen patients completed the questionnaire in 2000 and 156 in 2003. Statistically significant improvements were

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found for 7 of the 12 questions: waiting time (2), length of medical visit (2), communication (1), expectations (1) and continuity of care (1). Regarding continuity of care, a higher proportion of patients reported having met the same doctor as at the previous visit in 2003 as compared to 2000. No differences were found regarding the importance of meeting the same doctor, the evaluation of physicians’ and nurses’ interpersonal skills, feeling cared for and if the patient would recommend the clinic. Further results will be presented and the changes in the clinical practice will be discussed.

239 Psychosocial Oncology in Developing Countries: Obstacles and Roadblocks Chaturvedi SK Psychiatry, NIMHANS, Bangalore, India PURPOSE: To discuss the progress of psychosocial oncology in developing countries. DISCUSSION: The development of psychosocial oncology in developing countries, has not kept pace with the developments in other parts of the world. The main reasons are: 1. Lack of trained professionals. 2. Lack of resources for services. 3. Lack of trained professionals who could train others in the developing countries. 4. Lack of awareness among concerned health staff about the importance of psychosocial factors in the management of cancer patients. 5. Lack of appropriate facilities 6. Lack of adequate mental health professionals who could take up the role of providing such services. Action taken in India: a. Training programmes are held periodically to train doctors and nurses, social workers and psychologists in different aspects of psychosocial oncology. b. Special clinics to address psychosocial problems are being tried. c. Facilities are being organised.

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Obstacles & roadblocks: i. Lack of support from health administrators. ii. Lack of motivation among health staff. iii. Feelings of inadequacy to deal with psychosocial problems among health staff. iv. Priorities towards care of the physical aspects. v. Lack of funds and resources. CONCLUSIONS: Attempts need to be made to overcome these obstacles to improve the quality of life of cancer patients, by recognising and minimising their psychological distress.

240 Assessment of an Interdisciplinary Supportive Care Department for the Oncology Patient in France Dolbeault S1, Bredart A1, Baille-Bareille V1, Savignoni A2, Copel L3 et al. 1 Psycho-Oncology Unit, Institut Curie, Paris, France; 2Biostatistics Department, Institut Curie, Paris, France; 3Supportive Care Department, Institut Curie, Paris, France BACKGROUND: The Interdisciplinary Supportive Care Department for the Oncology Patient (DISSPO) has been implemented to improve care of patients facing complex and multiple physical or psycho-social problems as a result of their disease. DISSPO is composed of 5 care units: mobile unit of support and continuous care, psycho-oncology unit, social service, functional rehabilitation unit, nutrition unit. Patients referred to the DISSPO meet eligibility criteria and require intervention of 3 of the 5 DISSPO units. OBJECTIVES: (1) collect information on the quality of life and perceptions of care quality of DISSPO patients, (2) assess the DISSPO effect on patient satisfaction with the care received at Institut Curie. METHODS: One hundred consecutive patients referred to the DISSPO will be prospectively compared with 100 control patients matched on age, gender and care setting attendance (hospital ward, day hospital or ambulatory radiotherapy). Information on quality of life and perceptions of care quality will be collected (baseline and 2 months) using the European Organisation for Research and Treatment of Cancer core quality of life questionnaire and satisfaction with care modules. Results of the study pilot phase will be presented here.

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241 Standard of Psychosocial Care for Cancer Patients and their Families: Guidelines For the Management of Psychosocial Distress Gil F1, Mat!e J1, Hollenstein MF1, Novellas A2, Barbero E2 1 Psycho-Oncology Unit, Institut Catala" d’Oncologia, Barcelona, Spain; 2Social Worker Unit, Institut Catala" d’Oncologia, Barcelona, Spain The necessity to develop standards of psychosocial care for cancer patients and their families has been recognised (National Cancer Centers Network and the Canadian Association of Psychosocial Oncology). The aims of our Standard Care are: (1) to define the principles of practice in psychosocial oncology, (2) to describe the psychosocial team’s competence: psycho-oncologist and social worker; (3) to propose self-report instruments for a rapid assessment of patients and relatives; (4) to organise the professional practice in psychosocial care (regular meetings, supervision, monitor emotional improvement during the psychosocial intervention, translating research into practice); (5) to define the participation of the psychosocial team in educational programs (cancer diagnosis and treatment, anxiety and emotional management) for patients and relatives; (6) to facilitate the continuing professional education, ensuring that healthcare professionals have knowledge and skills in the management of distress; and (7) to reinforce the development of psychosocial oncology research studies. Screening for psychological distress, at appropriate intervals, identifying the level and the nature of it, we could recognise, monitor, and treat it promptly at all stages of disease. Our Clinical Session (inpatients) and Psychosocial Committee (outpatients) help to discuss the cases and offer the best treatment to the patients or relatives. Other services, as pastoral counselling and support group, should be offered to them. For more information about our Standard Care, please consult our web: www.iconcologia.catsalut. net.

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Gudbergsson SBG, Dahl AAD Clinical Research, The Norwegian Radium Hospital, Oslo, Norway BACKGROUND: At a Comprehensive Cancer Centre (CCC) the referrals to psychosocial support services (PSS) the reasons for referral are not always well-defined. Available resources may therefore not be used effectively. AIM: To improve the referral practice and efficiency of the PSS at a CCC. METHODS: Specific criteria for referrals to PSS were defined giving priority to patients who were: younger than 22 years, parents of young children (517 year), or patients in need of multi-professional rehabilitation. The criteria are based on registration data during 1996–2000 and where announced to all clinicians and nurses in 2001. All referrals to PSS for 2000 and 2002 were compared. We preempted youngsters before parents, before rehabilitation patients. RESULTS: There was a significant increase of criteria-based referrals, and particularly of patients in need of multi-professional rehabilitation (Table). Priority Patients Group

2000

Patients 522 32 (5.3) years, N (%) 126 (20.5) Patients with children 517 years, N (%) Patients in 50 (8.1) need of multi-professional rehabilitation, N (%) Total N (%) 208 (33.8)

2002

P

(n=614)

(n=526)

44 (8.4)

0.04

122 (23.1)

0.28

65 (12.4)

0.001

231 (43.9)

50.001

CONCLUSION: Effective use of PSS at CCC improves when referral practice follow defined criteria of priority. This is particularly important in situation with restricted resources of PSS.

243 242 Improved Efficiency of Psychosocial Support Service After Definition of Referral Criteria

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Integration of Early Psycho-oncological Diagnostic in the Daily Conference of an Comprehensive Cancer Centre

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Heussner PH1, Huber BH1, Herschbach PH2, Siewert JRS3, Sellschopp AS1 1 Psycho-oncological Care Unit, Interdisciplinary Cancer Centre, Klinikum Rechts der Isar, Technical University, Munich, Germany; 2Psychosomatic Medicine and Psychotherapy, Klinikum Rechts der Isar, Technical University, Munich, Germany; 3 Department of Surgery, Klinikum Rechts der Isar, Technical University, Munich, Germany Psycho-oncological care has already been established in many cancer centres and taken for granted for years. However little is known about indicators of urgent needs of specific psycho-social support for oncological patients. To identify those individuals who will benefit most from psycho-oncological care, an integrated psycho-social screening has been developed. At the University Hospital rechts der Isar, Munich all patients who might benefit from a multidisciplinary treatment regimen are discussed in the daily cancer centre conference for visceral tumors. In this interdisciplinary panel the experts are conferring about all examination findings of each patient to determine the best individual treatment plan. With the objective of an integrated psychooncological diagnostic we developed an assessment instrument (will be presented) for each patient newly admitted to the cancer centre. The questionnaire contains physical, emotional, social and familial aspects. If necessary a psycho-oncologist is summoned. The results of the psycho-social exploration will then be discussed with the findings of the physical examination and tumor staging at the interdisciplinary tumorboard. Thus psycho-oncological evaluation initially has an influence on the individual treatment planning. At the time of admission and discharge from hospital the patients fill in a selection of selfassessment questionnaires (QLQ-C30, HADS-D, FPZ). Self-assessment is correlated with the doctor’s risk factor analysis on the one hand, and on the other hand with the psycho-oncologists expertise. The final evaluation is supposed to show how the initial integration of psycho-social data changes patients quality of life during hospital stay. First results will be presented.

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244 Introducing Psychooncology to an Outpatient University Cancer Center Lautenschl.ager KA1, Baumann M2, Sundermeier A1, Weidner K1 1 Department of Psychosomatics and Psychotherapy, University Hospital Dresden, Dresden, Germany; 2Department for Radiotherapy and Radiooncology, University Hospital Dresden, Dresden, Germany Psycho-oncology is still gaining importance in the clinical practice in Germany due to a continuing undersupply. The trend to integrate outpatient oncological services into multidisciplinary ‘‘cancer centres’’ has fostered the implementation of psychooncological health care to a great extent. At the University Hospital Dresden, a cancer centre was established in July 2003 and a psycho-oncological unit was started to be integrated from October 2003. The experiences of development and implementation during the first 10 months will be presented, concentrating on the different steps of implementation. Additionally arisen problems and steps towards their solution as well as the frequency of psychooncological requests by staff and patients and data on the expected change in practice of referral by the staff will be demonstrated.

245 Psychosocial Support for Cancer Patients and Their Families in Hungary}A New Programme Muszbek K, Szo. llosi M Hungarian Hospice Foundation, Budapest, Hungary PURPOSE: While cancer has a high morbidity rate in Hungary, psychosocial care of cancer patients is very poor, though our new study shows that over 40% of patients express an advanced level of distress, anxiety and depression related with their illness. Psychosocial support of families is far less behind. A new psychosocial program intends to broaden the availability of support for patients and their families, and also to promote the integration of psychosocial support as an element of comprehensive cancer care in Hungary. METHODS: Three elements of psychosocial

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support are: (1) Toll-free counselling line; (2) Screening and counselling at 5 regional oncology centres of Hungary; (3) face-to-face counselling at Budapest Hospice House (increased capacity). RESULTS: Our experiences show that there is a great need in Hungary, but lack of psychological culture, lack of knowledge of oncology staff and people in need resulted in a slowly increasing number of patients referred to care as a part of this programme. Number of patients will be discussed in the presentation. Campaign to introduce the elements of the program}which is a crucial point}will be presented as well. CONCLUSIONS: We have to increase number of patients referred to adequate care including psychosocial care. It is essential that the oncology staff recognize the importance of psychosocial support and receive a training on this topic. This combined with a good publicity campaign and a good screening at different settings can help.

246 Implementing Psychological Care for Cancer Patients}A Model of Service Development O’Dwyer AM, Collier S Psychological Medicine, St. James’s Hospital, Dublin, Ireland Deficiencies in the psychological care of cancer patients were eloquently summarized in a document produced by the Department of Health and Children in Ireland (1999). It noted that psychological problems in cancer patients, though common, are often undiagnosed and untreated; that psychological issues are often stigmatized and isolated; and that ‘‘counselling’’ and ‘‘self-help’’ groups are often un-regulated and uncontrolled. More recently (2003) the UK NICE guidance (draft report) highlighted similar concerns. Both documents have sought to suggest minimum standards of care, proposing that psychological morbidity should be regularly and routinely assessed throughout care, and that a wide spectrum of psychological and psychiatric interventions should be available for patients with cancer. Implementation of these guidelines will be difficult, however. The numbers of cancer patients are vast; trained mental health specialists few; and issues of isolation and stigmatization remain

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significant. The Psycho-oncology/Psychological Medicine service at St James’s Hospital, Dublin has been addressing these issues over the past 12 months. It has devised a multi-layered strategy aimed at integrating psychological care within the patient’s overall care, providing a range of psychological interventions over the wide spectrum of psychological and psychiatric morbidity that these patients present. This paper will present the initial results of the implementation of this strategy focusing on a multi-disciplinary, stratified model of psychological care for cancer patients.

247 Trends in Psychooncological Care and Rehabilitation of Cancer Patients in Germany Rogge HR1, Rogge AR2 1 Onkologie und Ha.matologie Reha-Klinik Schlob Scho.nhagen, Scho.nhagen/Brodersby, Germany; 2 Abt. fu.r Psychologie Reha-Klinik Schlob Scho.nhagen, Scho.nhagen/Brodersby, Germany The oncological rehabilitation in Germany is financed mostly by the retirement insurance funds (BfA, LVA). In contrast to the fields of musculoskeletal or cardiac disorders, there is a steady annual increase in rehabilitation patients with malignant disorders. The costs for in-patients are estimated 3000 per case. From the economic point of view, 4 months of work after reconvalescence pay these costs. New trends in cancer care are being seen e.g. with the establishment of breast centres, the starting of disease management programs (DMP), and the refunding of acute-phase costs by DRG’s. More thoughts are given to the integrated (somatic) care for the cancer patients, transgressing the still existing borders between acute, rehabilitative and ambulant care. Little thought has so far been given to a vertical psycho-oncological care. As a vision, the cancer patient should have access to qualified psychotherapeutic help at the time of diagnosis. Also during time-consuming therapies as chemoor radiotherapy, psychooncological help should be provided. Substantial deficits are being seen in these fields. During in-patient rehabilitation, psychotherapists with psychooncological

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experience are available. However, post-rehabilitative psychooncological care is rarely established in Germany, in spite of the fact that psychooncological stress impedes many patients from returning to work soon. The structural problems involved are discussed in the poster. Finally, there is a trend in Germany from in- to outpatient rehabilitation in oncology, suitable perhaps in larger cities and selected medical or social situations.

248 Canadian Comprehensive Supportive Care Program: Quality Assurance and Organizational Structure Steggles S1,2, Gauthier-Frohlick D3, DamorePetingola S3, Rivard S3, Brown E3 et al. 1 Psycho-Oncology Services, St. Luke’s Hospital, Dublin, Republic of Ireland; 2Department of Psychology, University College, Dublin Republic of Ireland; 3Supportive Care Oncology Research Unit, Supportive Care Program, Northeastern Ontario Regional Cancer Centre, Ho#pital re!gional de Sudbury Regional Hospital, Sudbury, Canada A range of services and collaborative partnerships are required to meet the supportive care needs of cancer patients and their families. Within the comprehensive Supportive Care Program that was developed at the Northeastern Ontario Regional Cancer Centre (NEORCC) and the Ho# pital r!egional de Sudbury Regional Hospital (HRSRH) in Ontario, Canada, you will find a variety of services which include individual counselling, group services, educational activities and research. This interdisciplinary program currently consists of six different professional disciplines: Social Workers, Clinical Psychologist, Dietitians, a Physiotherapist, Speech Pathologists and a Research Officer (Applied Sociologist). A concerted effort is encouraged within the program to measure performance indicators. An assessment tool is used to evaluate client satisfaction for all individual and group clinical services; it is assessed with the shortened version of the Client Satisfaction Questionnaire (CSQ-8; Attkinson 1979), developed by Attkinson. In addition to providing details on client satisfaction, this presentation will also provide information on the organizational

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structure of the program, description of the referral and documentation process, communications strategies, and research activities.

249 Survey of Psycho-oncology Services in the Republic of Ireland Steggles S1, Gauthier-Frohlick D2, Carr A3 1 Psycho-Oncology Services, St. Luke’s Hospital, Dublin, Ireland; 2Supportive Care Program, Northeastern Ontario Regional Cancer Centre, Sudbury, Canada; 3Department of Psychology, University College, Dublin, Ireland In 1999, the first ‘‘National Review of Support Services for Patients with Cancer’’, led by the Department of Health and Children took place in the Republic of Ireland. This national review recommended that the management of a patient’s psychological state should be an integral part of cancer care at all levels of care and that each regional health board should provide multidisciplinary psycho-oncology services to manage distress in patients with cancer. The results of a survey that was conducted to examine the nature and extent of psychosocial oncology services provided to cancer patients in the hospitals, cancer treatment facilities and in the community in the Republic of Ireland are presented in this poster. The questionnaire utilized for this study contained items from the ‘‘National Review of Support Services for Patients with Cancer’’, from the ‘‘International Psychosocial Oncology Society Survey’’, and from the ‘‘Canadian Cancer Strategy for Cancer Control, Psychosocial Resources Human Resources Planning Work Group Survey’’.

250 Provision of Supportive Cancer Care: Time for a New Paradigm? Sussman J Supportive Cancer Care McMaster University/ Juravinski Cancer Centre, Hamilton Canada BACKGROUND: Forty percent of cancer patients report unmet needs for information, emotional/psychological support, social and symptom

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issues. This proportion has not changed much over the past decade despite organizational changes in cancer care. Patients continue to identify physicians as coordinators of supportive care. It was hypothesized that this may be discrepant with practitioner perceptions of roles. METHODS: Survey of all practicing oncologists, surgeons and oncology nurses and a random sample of family physicians in 3 regions of Ontario, Canada designed to measure: assessment of supportive care needs (4 domains), awareness of services (27 items) and perception of role responsibility in coordination of care. The survey was conducted between March and June 2003 using a modified Dilman approach. RESULTS: Response rate was 45% (511/1129) with no difference in responses by practitioner type. Mean assessment scores were higher for nurses than for physicians in all domains of practice (p50.001 ANOVA). Nurses and family physicians had higher awareness of needs and services compared with oncologists. There was significant variation in the perception of responsibility for coordination of supportive care although nurses tended to identify more with this role. CONCLUSIONS: Barriers to meeting the supportive care needs of patients with cancer may be as a result of divergence of perspective of responsibility. These results are important in informing potential interventions to improve the supportive care of cancer patients that might include education of patients, rethinking who is in the best position to coordinate supportive care and interventions to improve practitioner awareness of needs and resources.

251 Methodical Psychosocial Care by Specilized Nurses: Can we Use it in Daily Practice Vos PJ, de Boer M, Leenhouts G Projectmanagement, Comprehensive Cancer Center Rotterdam, Rotterdam, The Netherlands In Dutch hospitals there is a growing trend that specialized nurses signal psychosocial problems among cancer patients. Nurses are expected to offer psychosocial help or refer patients to other psychosocial care providers. However, most specialized nurses do not have the tools to offer cancer patients psychosocial care.

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The Rotterdam University created a specific training in which nurses learn how to offer psychosocial help. One condition to use this method is that the nurses should be able to schedule three appointments with a patient. In an earlier stage, 16 referees of the Comprehensive Cancer Centers, region Rotterdam and West judged the training and based on their recommendations, the training has been adapted to be used for cancer patients. The aim of this project is to investigate whether the learned method of psychosocial care by nurses can be used in the daily practice of specialized oncology nurses. The Comprehensive Cancer Center Rotterdam offered 10 specialized nurses to participate in the training on condition that they would also participate in a workgroup. Participants of this workgroup will meet two times. In these meetings usability of the method will be evaluated and conditions for implementation of will be investigated. In a report, the workgroup will give suggestions how to adapt the training even more for use in cancer care, how to improve the usability, especially since it might not always be possible to schedule 3 appointments, and finally, they will give the conditions which are necessary to implement this method in hospitals.

252 Is There a Diversity of Patient Involvement in Therapeutic Decision-making Process for Rectal Cancer? Zenasni F1, Sideris L2, Dauchy S1, Di palma M3, Pocard M2 1 Psycho-oncology Unit, Institut Gustave Roussy, Villejuif, France; 2Department of Surgery, Institut Gustave Roussy, Villejuif, France; 3Supportive Care Department, Institut Gustave Roussy, Villejuif, France PURPOSE: Some studies demonstrated that preference for active participation in the choice of treatment for colorectal cancer is low. The purpose of this study is to examine the relationship between patient preference and real involvement in decision-making. METHODS: We are conducting a retrospective study with patients sustaining low rectal cancer exclusively and operated at the Gustave Roussy Institute between 1986 and

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2002. A surgeon and a psychologist explored what has been considered by the patients as the most important element(s) guiding their decision during the surgeon–patient consultation. We also assessed the discrepancy between patients’ preference and real involvement in the decisionmaking process. Finally, we examined the patients’ satisfaction about the decision-making process, surgery and post-operative course and whether they had any regret about it. The French adaptation of both Control Preference Scale (Degner et al., 1997) and Decisional Conflict Scale (O’Connor, 1995) were used. PRELIMINARY RESULTS: Among 550 patients operated for low rectal cancer, 265 were eligible (alive and diseasefree). The others had died or were lost to followup. At the middle of the study, 100 patients were included. Participation level is high: 100% of contacted patients (75% underwent an interview; 25% were sent a questionnaire by mail). First results indicate a diversity concerning preference for involvement in decision-making process, but less for the actual involvement. All results, including those concerning the French adaptation of some questionnaires will be presented and discussed. CONCLUSION: This study will allow the medical staff to better consider individual differences among patients concerning shared decision-making.

cancer surgery (BCS). In 27 Breast cancer patients changes in endocrine and immune function in response to surgery were determined. Blood samples were taken at 6 days and 1 day before surgery and 1 day and 5 days after surgery. Changes in endocrine function (cortisol), enumerative immune measures (CD3+, CD4+, CD8+, CD19+ CD3-16-56+, CD14+, cells), functional measures (Natural Killer cell cytotoxicity, monocytic MHC class II expression, monocyte mediated toxicity) and cytokine levels (pro-inflammatory cytokines IL-1, IL-6 (LPS) and TNF-a, Th1 cytokines IL-2, TNF-a, IFN-?, IL-12, Th2 cytokines IL-6 (PHA), IL-10, IL-4 and Th differentiation cytokines IL-12 and IL-4) were determined. BCS induces a pro inflammatory response shown by an increase in C-reactive protein, leucocytosis, IL-1, IL-6 (LPS) and TNF-a. Immune suppression is illustrated by decreased HLADR expression, decreased Natural Killer Cell cytotoxicity and a delayed Th1 response as shown by increased IL-2, 5 days after surgery. BCS does not induce a metabolic response as cortisol levels remained unchanged. Although BCS is regarded as minor surgery, the surgical procedure produces marked immunomodulation. However, in contrast to data available from the literature based on major surgery, BCS, does not give rise to an increase in cortisol level.

Other 254 253 Breast Cancer Surgery Induced Immunomodulation Boomsma MF1,2,3, Garssen B1, Visser A1, Beelen RHJ2, Meijer S3 et al. 1 Psycho-Oncology, Helen Dowling Institute, Utrecht, The Netherlands; 2Immunology, VU Medical Centre, Amsterdam, The Netherlands; 3Surgical Oncology, VU medical Centre, Amsterdam, The Netherlands Surgical procedures may cause dissemination of tumour cells to the circulatory system. This spread of metastatic cells can be limited through immune activity. However, the main effect of surgery on physiological variables is in the direction of immunosuppression. The aim is to assess hormonal and immunological changes induced by breast

Copyright # 2004 John Wiley & Sons, Ltd.

Stress Management Training in Breast Cancer Induces no Changes in Surgery Induced Immunomodulation Boomsma MF1,2,3, Garssen B1, Visser A1, Beelen RHJ2, Meijer S3 et al. 1 Psycho-Oncology, Helen Dowling Institute, Utrecht, The Netherlands; 2Immunology, VU Medical Centre, Amsterdam, The Netherlands; 3Surgical Oncology, VU Medical Centre, Amsterdam, The Netherlands AIMS: Surgical procedures may cause dissemination of tumour cells to the circulatory system. This spread of metastatic cells can be limited through immune activity. However, the main effect of surgery on physiological variables is in the direction of immunosuppression. It would be of

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clinical relevance if Stress Management Training (SMT) would modulate surgery induced immune changes, which is the focus of the present study. METHODS: Breast cancer patients were randomly assigned to SMT or no intervention (regular care only). In the intervention condition, patients followed SMT sessions at 6 days and at 1 day before surgery and 2 days after surgery. To determine endocrine and immune function, blood samples were taken at 6 days and 1 day before surgery and 1 day and 5 days after surgery. Changes in endocrine function (cortisol), enumerative immune measures (CD3+, CD4+, CD8+, CD19+ CD3-16-56+, CD14+, cells), functional measures (Natural Killer cell cytotoxicity, expression of monocytic MHC class II expression, monocyte mediated toxicity) and cytokine levels (pro-inflammatory cytokines IL-1, IL-6 (LPS) and TNF-a, Th1 cytokines IL-2, TNF-a, IFN-?, IL-12, Th2 cytokines IL-6 (PHA), IL-10, IL-4 and Th differentation cytokines IL-12 and IL-4) were determined. RESULTS: No influence of SMT was observed on any of these endocrine and immune parameters. The authors therefore conclude that there is no influence of stress management training on immunity in breast cancer patients.

255 Psychological Interventions Targeting Immunity in Cancer Patients Boomsma MF1,2,3, Garssen B1, Visser A1, Beelen RHJ2, Meijer S3 et al. 1 Psycho-Oncology, Helen Dowling Institute, Utrecht, The Netherlands; 2Immunology, VU Medical Centre, Amsterdam, The Netherlands; 3Surgical Oncology, VU Medical Centre, Amsterdam, The Netherlands Several PsychoNeuroImmune (PNI) studies have investigated the potential of psychological interventions to optimise immune function, based on the idea that the immune system plays an important role in holding cancer initiation and progression in check. The ultimate goal of such interventions is to improve morbidity and even survival. After some striking results in this field regarding survival, several clinical trials of psychological interventions targeting immunity in

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cancer patients have been conducted. A review of these studies will be presented. We conclude in this review that, although it has been reliably proven in human stress models that psychological interventions can induce immune changes, it is less plausible that psychological interventions can consistently induce clinically relevant immune alterations in cancer patients.

256 A Psychoneuroimmunology Study}a Hug to the Cancer Patient, as a Demonstration of Acceptance and Affection at the Psychotherapeutic Set Brando MC Psycho-Oncology, Nossa Casa Psico-Oncologia, Sa*o Paulo, Brazil PURPOSE: Through the psychoneuroimmunology, a research to find out how meaningful can a hug be to cancer patients at this critical moment of their lives, at a psychotherapeutic set. METHODS: The study was made with patients from a public institution. First of all, it was analyzed what would be the most appropriate attitude of a psychologist towards these patients. Affection was also focused, because it determines the patients’ reactions. A review of the limbic system was also considered, where the emotion begins. The immune system was another important subject matter. Each particular cancer patient and his/her characteristics were duly segregated. With all these concepts in mind, I followed up with the main techniques to interact with the patients. The research comprised 3 separate cancer patients, with different diagnosis, prognosis and endings. RESULTS: It was a satisfactory effort to me, comparing to the period of my own personal treatments as a breast cancer patient and survival. CONCLUSION: The small gesture can make a huge difference. The cancer patient needs to be listened to and more than this, he needs to touch and to be touched throughout his/her treatment. He/she has a latent necessity of affection. Yes, it does make a difference when you give a hug to a cancer patient, to demonstrate acceptance and affection at the psychotherapeutic set, which has a positive impact on the immunological system.

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257 The Use of Stress Biomarkers in the Determination of Prostate Cancer Patients’ Stress Level Guns E1, Selim A2, Stephen J3, Davidson J1, Leis A4 1 The Prostate Centre, Vancouver General Hospital, Vancouver, Canada; 2Surgery, University of British Columbia, Vancouver, Canada; 3Provincial Rehab Network, British Columbia Cancer Agency, Vancouver, Canada; 4Community Health & Epidemiology, University of Saskatchewan, Saskatoon, Canada PURPOSE: To consider stress and its potential impact on disease progression by identifying whether a correlation exists between quantified urinary biomarkers and stress levels of prostate cancer patients. METHODS: Cortisol, epinephrine and norepinephrine were quantitatively analysed from 20 men awaiting prostate biopsy results and 20 aged matched controls in morning urine samples which were collected prior to seeing their urologist. These biomarkers are widely used since they are indicative of stress and also have a mechanistic role in immune function. Gas chromatography–mass spectrometry was applied using creatinine determination to control for urinary flow rate. The Spielberger State Trait Anxiety Inventory as well as the Lie scale were used at the time of sample collection to cross reference with biomarker levels. RESULTS: Physiological findings were compared to questionnaire responses in an attempt to provide a definitive assessment of stress biomarkers. Results will be discussed. CONCLUSION: Stress significantly impacts factors such as immune function, DNA repair enzyme activity and risk of metastasis in cancer patients. Cortisol, epinephrine and norepinephrine are secreted during stressful experiences and, as a result, are readily exploited for their use as biological stress indicators. Validation of physiological and self-reported stress biomarkers will be a useful tool for other researchers interested in stress.

258 Body Image and Mental Health Following Bilateral Risk Reducing Mastectomy (BRRM). A Clinical Perspective

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Hopwood P1, Baildam A2, Brain AN2, Swindell R3, Howell A4 1 CRC Psychological Medicine Group, Christie Hospital, NHS Trust, Manchester, UK; 2Department of Surgery, Christie Hospital, NHS Trust, Manchester, UK; 3Department of Medical Statistics, Christie Hospital, NHS Trust, Manchester, UK; 4Department of Medical Oncology, Christie Hospital, NHS Trust, Manchester, UK PURPOSE: To evaluate long-term effects of bilateral risk reducing mastectomy on body image concerns, cancer worry and general mental health, in routine clinical practice. METHODS: Women undergoing BRRM completed the 10-item Body Image Scale (BIS, scored 0–30), the 6-item modified Cancer Worry Scale (CWS, scored 6– 24) and the 28-item General Health Questionnaire (GHQ, scored 0–28, with a cut off of >/=10 for probable ‘‘cases’’). RESULTS: 152 unaffected high-risk women, mean age 39 (range 23–63) completed questionnaires at routine clinic visits; 109 pre-operative, 103 1-year post-operative and 43 at a minimum of 4 years follow-up. 81% women had breast reconstruction: median BIS score at 1 year was 4.0 (range 0–28), with no significant change over 4 years. 18% women reported body image concerns warranting further discussion. There was a significant reduction in the CWS score from pre- to post-surgery (p50.0005), sustained over 4 years. GHQ scores and ‘‘caseness’’ rates were comparable with population rates, with no significant change over time. CONCLUSIONS: For most women, BRRM results in a favourable trade off between risk reduction and psychosocial outcomes but a minority warrant further assessment and support.

259 The Human Science Approach to Psycho-Oncology Jacobsen B C.Res.Exist.Soc., Sociology University of Copenhagen, Copenhagen, DK The human science approach to psychosocial cancer research are formulated in opposition to the prevalent natural science approach. The natural science approach is related to classical medical research. The human science research is

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more in line with sociological, psychological and anthropological methods and theories. The distinction between the two goes back to Dilthey’s distinction between Erkl.aren und Verstehen. The natural science approach to psychosocial cancer research has as its purpose to trace and establish causal relations between factors. This type of knowledge is relevant for planning and governing. The human science approach has as its purpose to trace and establish patterns of understanding and insight. This type of knowledge is relevant for guiding doctors and nurses in how to understand the life and thinking of their patients and also in helping patients and relatives understand their own problems connected to the disease. The lecture will conclude that there presently is a serious imbalance between the two types of psychosocial cancer research.

260 Stigma Attached to Cancer and Erasing it in Syria Kaadan AK Aleppo University, Syrian Society against Cancer, Aleppo, Syria PURPOSE: Cancer has traditionally been surrounded by community misunderstanding, fear, and stigma. The aim of this paper is to present details of development of stigma, and a proposal of how could we release an enlightening campaign in our country, aiming to erase or fight stigma associated with cancer. METHODS: The paper provides an analysis of the historical processes by which stigma has emerged and become associated with cancer. It also explores the process by which these associations have been loosened, identifying distinctive features of stigma that may guide intervention programs; and evaluating changes in the magnitude and character of stigma over time and in response to interventions and social changes. RESULTS: (1) Stigma towards people with cancer has sometimes a detrimental effect on their ability to obtain services, the type of treatment and support they receive, and their acceptance in the community. (2) The stigma associated with cancer is in large part promoted by the media. (3) Improving community attitudes by increasing knowledge and understanding about

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cancer is essential if people with cancer are to live in, and contribute to, the community, free from stigma. CONCLUSIONS: Stigma associated with cancer is one of those social maladies that will probably never be totally eliminated, but there are ways in which it can be diminished. Although, research on stigma has grown dramatically over the past two decades, particularly in the western countries, I hope that this paper may provoke for more studies and researches to be carried out in our region.

261 Psychosocial Support Services for Children and Young People with Cancer and Leukaemia and their Parents: Identifying and Meeting Different Needs Mitchell W, Clarke S, Sloper P Social Policy Research Unit, University of York, York, UK PURPOSE: (1) Explore psychosocial support service provision in the UK for children/young people with cancer and leukaemia and their parents. (2) Describe the needs of children/young people and their parents across the disease trajectory. (3) Compare patterns of support provided with children/young people and parents’ views of their needs, and develop recommendations for service provision. METHODS: Two postal surveys were conducted. The first, a survey of British National Health Service paediatric oncology treatment centres, explored current psychosocial support provision. The second drew upon a large sample of children, young people and their parents (active and post treatment) to obtain their views on their psychosocial support needs and whether these had been met. Qualitative interviews with children, young people and parents guided development of the survey questionnaires for parents and children. RESULTS: Although valued, the treatment centre survey indicates that psychosocial support varies between centres, as it is rarely formalised. Key areas of diversity and unmet need were identified. Children, young people and their parents want different kinds of services and support at different phases of the illness trajectory, the family survey and interviews highlight areas of psychosocial

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support that different family members value and feel are currently well provided. They also identify areas of unmet need. CONCLUSIONS: The paper compares the support that treatment centres feel they provide with the actual support needs identified and valued by different family members. Suggestions as to how professionals could begin to address these support service gaps.

262 Psycho-oncology and Legal Context in Spanish Health Care Moreno Mil!an B1, Pascual Fernandez C2, Fernandez Crespo AI2 1 Clinical Psychology, Fuenfr!ıa Hospital, Madrid Spain; 2Psychosocial Spanish Cancer Association, Madrid, Spain In recent times the understanding of the concept of health has acquired a significant development. Consequently, there has been an important change in the basic models of health care, as the patient has become the centre of such care. The Patient’s Autonomy Law as well as the Cohesion and Quality law involves a legal recognition of the patient’s rights and the procedures that ensure that they are respected and adhere to. The inherent moral principle is that the ill person must enjoy autonomy and must have an active role in determining his/her rights and duties in his/her interaction with health care professionals. Moreover, the Real Decree, which establishes and regulates the speciality of Clinical Psychology definitely warrants the clinical psychologist’s membership of the health professions and service. We, psychologists, must be well informed of the changes that these laws and decrees entail in relation to patients, their family and the clinical staff. In this paper we outline those aspects of this topic, which directly affect the psychologist’s professional practice in relation to issues such as the patient’s right to confidentiality, intimacy, respect and autonomy. The way we keep clinical records is also important here. Ethical and practical aspects stemming out of these new rules and regulations and final conclusions are considered as well in this paper.

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263 Development of a Questionnaire of Satisfaction with Care in a Radiotherapy Unit Rozniatowski O1, Reich M1, Missy A2, Lartigau E2 1 Psycho-Oncology Unit, Centre Oscar Lambret, Lille, France; 2Radiotherapy Department, Centre Oscar Lambret, Lille, France BACKGROUND: Assessment of satisfaction with care for patients in oncology is becoming the cornerstone of quality of life. It has positive aftermath in terms of economic health care and medical treatment compliance. METHODS: Our aims were to measure the patient satisfaction with care in a radiotherapy unit using a self questionnaire. Specific items were explored including satisfaction with communication, interpersonal relations, caregivers’ disposability and care coordination. Review of literature and a validated scale in general oncology for in-patients: the Comprehensive Assessment of Satisfaction with Care gave us a temporary version. After the return of 26 questionnaires, a second version was produced. Then 110 questionnaires were given to patients with a return of 91 which validated it in terms of adaptability in the radiotherapy unit and in its distribution modality. RESULTS: A specific analysis shows high levels of satisfaction regarding politeness and respect of privacy during radiotherapy sessions. Nevertheless, some difficulties have been shown regarding transportation organization (31% dissatisfaction), waiting times (23% dissatisfaction) and the providing of information regarding the possibility of psychosocial help (30% dissatisfaction) and the follow-up (24% dissatisfaction). Moreover, some differences of satisfaction have been observed due to different localization. Patients affected by prostate tumours show a better satisfaction for care than patients with others localization. Patients with cerebral tumours show the lowest satisfaction rate. CONCLUSIONS: A multidimensional approach of our questionnaire is more sensitive to out-patients treated in a radiotherapy unit. Nevertheless, a psychometric validation would give more power to this tool.

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Palliation/Pain 264 Signification, Knowledge and Attitudes Regarding Chronic Pain and its Management in Cancer Patients and Family Caregivers Bacalhau MR, Gomes A, Gil MJ, Reis MF Pain Clinic, Portuguese Institut of Oncology, Lisbon, Portugal In any state of the disease, pain is an important and common problem for cancer patients. The treatment on an outpatient basis, means a closer contact with the disease and symptoms and greater responsibilities, for patients and their care-giving families, in their management. The present research wishes to contribute to the understanding of the problematic of cancer pain and its management, through measuring the perceptions of cancer patients and family caregivers, regarding significations, knowledge and attitudes regarding pain and its management. Three types of measuring instruments were used: demographic and medical data tool, clinic interview and self-report instruments and rating scales: The Patient Pain Questionnaire; The Family Pain Questionnaire; The Caregiver Burden Scale; Beliefs about Medicine Questionnaire. RESULTS: For the patient coping with pain seems to be perceived as a very personal matter, that implies commitment, persistence and the gathering of personal resources in order to deal with the pain. For relatives, the most striking feature is their motivation and the need to provide to the patients the highest possible degree of comfort, which implies a special commitment in developing an active and direct role in coping with pain. The pain is mostly regarded as an autonomous entity, or as a result of the progression of the illness, which places the locus of control in the outside. The pain is perceived as serious, as representing an important threat to his or her life, which renders a sense of inevitability and fate, that both patients and relatives feel powerless to modify.

265 Gender Differences}The Impact of Cancer Pain on Quality of Life Perception}a Comparative Study

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Bacalhau MR, Gil MJ, Gomes A Pain Clinic, Portuguese Institut of Oncology, Lisbon, Portugal PURPOSE: The systematic evaluation of the patients followed in the Pain Clinic seeks to understand how pain interferes in the quality of life perceived by the outpatients with chronic pain, motivated by cancer. METHOD: The evaluation of quality of life is made in several moments using the FACT-G scale. The results refer to a sample of 80 cancer patients, 40 women with breast cancer, and 40 men with head and neck cancer. RESULTS: 54% of the patients perceive pain as being controlled 1 month after the first appointment, rate that increases to 69% 3 months after the first appointment. The results revealed by the women with controlled pain present generally high levels in the 4 stages of well-being. The male patients also with controlled pain present generically lower values. CONCLUSIONS: The pain control promotes the increase in the physical wellbeing, which appears more markedly in female patients. The female patients seem more critical in relation to the perceived pain control. The marked decrease of the perceived functional well-being, that was observed in male patients with controlled pain, may be understood in a cultural context that leads to the fact that they are not very involved in domestic chores or other tasks performed at home. Therefore, when it is no longer possible to maintain a professional activity, and even with controlled pain, there is a clear decrease in the perceived functional well-being, which seems to contribute to a perceived decrease in the quality of life.

266 Psychosocial Adaptation and Distress of Patients with Chronic Cancer Pain Bacalhau MR Master, Gil MJ, Dra., Reis MF Master Pain Clinic, Portuguese Institute of Oncology, Lisbon, Portugal The psycho-oncology studies (Psychological Collaborative Oncology Group, Derogatis et al., 1983) about the nature and prevalence of psychiatric disorders in cancer patients indicate that, from

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the psychological point of view, 50% of the cancer patients present normal responses to cancer, 30% present adjustment disorders with depressed/anxious symptoms and 20% present psychiatric disorders. The Pain Clinic seeks to understand how pain interferes in the quality of life perceived by the patients with chronical pain, and to what extent it limitates the psychosocial adaptation of the patient. The evaluation of quality of life is made in several moments using the FACT-G Scale, and clinical interview. Our sample is constituted by patients that have had their first appointment at the Pain Clinic within the period comprised between the beginning of 2002 and the first half of 2003, with three subsequent re-evaluation moments. The evaluation comprises the relevant social-demographic variables, the pain control, and the four dimensions of well-being provided by the FACT-G Scale: the physical, the social/family, the emotional and the functional well-being. The particularly vulnerable situation of these patients leads us to focus particularly on the emotional well-being and to study the relationship between the perceived cancer pain and the levels of distress.

267 Psyconcology Service in Every Headquarters of ‘‘Institute of Oncology in Romagna’’ and in Every Hospital Oncological Services Bellini G1, Erroi V2, Bertozzi A2, Gambi A1 1 Servizio Oncologico, Ospedale per gli Infermi, Faenza, (RA), Italia; 2Istituto Oncologico Romagnolo, Forl"ı (FC), Italia The ‘‘Institute of Oncology in Romagna’’ (IOR) is one of the founders of the ‘‘Federation treatments Palliatives’’ in which sphere falls the organic integration of therapies, psychological, socialwelfare and with solidarity supports dedicates to make good the quality of life of the people, who are afflicted with incurable and deadly diseases, which are in a progressive or terminal phase. In this context a lot of ‘‘Hospices’’ are being bored in Romagna, new welfare centres where the patients, who are in a progressive phase of disease, can stay and where very good quality and dignity are ensured by hospital staff (doctors, nurses,

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psychologists) and volunteers, who are prepared to work into an ambient gifted with good equipment. About Psyconcology Service in every headquarters of IOR and in every Hospital oncological services, last spring, a research was carried out by Dr. Giorgia Bellini and Dr. Angelo Gambi out of all their patients through a questionnaire and it was sent to the other doctors. The questions can be subdivided in three parts: one about psychologist’s role into IOR, another one about psychologist’s role into the hospital, and the last about organization and co-ordination of the IOR service in psyco-oncology. These questionnaire has supplied very interesting results and it was carried out to control psychologist’s work both into IOR headquarters and into hospital, to standardize psychologist’s work into every IOR headquarters, organizing a service of IOR with the same aims and methods, so next month it will work to realize this aim.

268 Palliation of Oral Mucositis Symptoms in Children Treated with Chemotherapy Cheng FK1, Chang AM2 1 Nursing, The Chinese University of Hong Kong, Shatin, Hong Kong; 2Nursing, Queensland University of Technology, Queensland, Australia Mouth pain, dysphagia and difficulty in eating/ chewing are among the most distressing oral mucositis-related symptoms exhibited by pediatric patients in chemotherapy. Palliation of oral symptoms is therefore a high priority for health care providers practicing in the oncology settings. PURPOSE: This prospective randomised twoperiod crossover study aimed at comparing the efficacy of two oral care protocols differing in the type of mouthwashes: chlorhexidine versus benzydamine in alleviating oral mucositis symptoms for children undergoing chemotherapy. METHODS: Forty subjects were randomly allocated to receive either chlorhexidine first then benzydamine protocols or benzydamine first then chlorhexidine protocols. Each protocol was started on the first day of chemotherapy and continued for 21 days. Subjects were evaluated in intervals of 3–4 days using the World Health Organization (WHO) grading for mucositis and 10-cm visual analogue

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scale for oral symptoms evaluations. RESULTS: Among 34 evaluable subjects, 26% and 48% of them using chlorhexidine and benzydamine had WHO grade II mucositis, respectively (P50.05). The results revealed a significant difference in mean area under the curve (AUC) of mouth pain (1.35  2.26 versus 3.09  3.21) (P=0.05), and a trend of a lessening of mean AUC of difficulty in eating/chewing (2.49  3.74 versus 2.71  4.1) (P=0.82), and swallowing (1.34  3.31 versus 1.91  4.03) (P=0.53) for subjects receiving chlorhexidine compared to benzydamine. CONCLUSION: In conclusion, chlorhexidine may be helpful in palliating mucositis symptoms for children in chemotherapy. The beneficial effect, however, is small and needs to be confirmed in a larger trial.

269 A Biopsychosocial Approach to the Treatment of Cancer Pain Ciaramella A1, Adami S2, Gioia A1, Poli P1 1 Azienda Ospedaliera Pisana, Pain Therapy and Palliative Care Unit, Pisa, Italy; 2University of Florence Psychology, Florence, Italy INTRODUCTION: Pain involves several dimensions which include not only nociceptive and physical aspects but also gender, psychological and social aspects. The treatment of cancer pain must take into consideration all of these factors. SAMPLE AND METHODS: Forty cancer pain patients were evaluated for the first time with: the Multidimensional Pain Questionnaire (MPQ), the Italian Pain Questionnaire (QUID) and the Visual Analogue Scale (VAS) for pain, Courtauld Emotional Control Scale (CEC), and Toronto Alexitimia Scale for pre-cancer personality. Anxiety and depression symptoms as well as some social factors were evaluated within MPQ. Pain Relief was evaluated after one week during which patients had been treated with either morphine or morphine and anti-epileptic drugs. RESULTS: No difference was found between sex in pain relief (T test analysis) and no correlation was found between age and pain relief (Z score correlation). The degree to which pain interferes with the quality of life and the sensation of being unable to control the pain do not interfere significantly with pain relief. Also family support in these

Copyright # 2004 John Wiley & Sons, Ltd.

primary analyses does not have a significant effect on pain relief. Further analysis into coping and the ability to carry out every day activities need to be done and in particular an analysis of the impact of two different treatments on these psychosocial factors. CONCLUSION: After a 1 week follow-up psychosocial factors were not found to be significant in such a small sample group. An increase in the number of subjects and the follow-up period are necessary.

270 Gender-Related Trends in the Physical and Psychological Dimensions of Quality of Life in Advanced Cancer Clavarino AM, Barnett A Longitudinal Studies Unit, School of Population Health, University of Queensland, Brisbane, Australia PURPOSE: While it is not surprising that people approaching death may experience symptoms of distress little is known about the specific changes that occur and whether or not there are gender differences in these changes. This study examined gender differences in the longitudinal course of commonly experienced physical and psychological symptoms as well as their impact on the quality of life of advanced cancer patients over the last year of life. METHODS: Data from 122 cancer patients (74 men and 48 women) with a date of death and evaluable data were analysed. Using the Memorial Symptom Assessment Scale, the Hospital Anxiety and Depression Scale and the Global Quality of Life Index, trends were investigated using Generalized Estimating Equations. RESULTS: Both males and females experienced dramatic changes in all measures approximately 3 months before death. Controlling for age, women experienced significantly higher levels of anxiety, pain and fatigue over the last year of life whereas men reported significantly higher levels of nausea and borderline higher levels of depression. Men also reported a greater impact on quality of life at lower levels of both pain and fatigue. CONCLUSIONS: Gender does appear to make a difference to the experience of dying and to the experience of symptoms commonly associated with dying. Gender-related differences should be considered in the

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assessment of quality of life and development of interventions aimed at improving outcomes for patients with advanced cancer.

271 Marijuana}Canabis Indica (Ganja)’ Wine & Steroids in Terminal Care Khan PK Department of Ob/Gyn, Calcutta Hospital & Medical Research Institute, Calcutta, India Twenty patients in terminal care were counselled and motivated. All were on pain relieving drugs but they were the victims of severe side effects, which were no less distressing than their original symptoms of advanced and uncontrollable progressive metastasis to various distant organs like lungs, liver, brain, etc. They were subjects of advanced ovarian, uterine, vulval and breast Cancer. Most of them were on analgesics, antidepressants, anti convulsants, psycholeptics, muscle relaxants, anxiolytics, morphine and allied compounds. Opium derivatives were the most important components. The distressing side effects}constipation, dyspnoea, diarrhoea, incoherence and insufficient pain relief. Following protocol was followed: (a) Red wine}50 ml. With lunch & dinner. (b) Dexamethasone}2–5 mg. Tab twice daily. (c) Marijuana (Ganja)}10–12 puffs at 6 p.m. starting with 2–3 puffs/day Effects observed: (a) Appetite improved}Constipation less. (b) Sleep}6 to 8 hours. (c) Pain}Morphine requirement}less than 50% pain free hours 6–8. (d) Enjoyed nature, music and company of relatives, friends and male partners, pets, grandchildren. (e) In 6 Libido came back. (f) The QOL}improved Two patients with breast prostheses, unilateral loss of lower limb, colostomy bag and ileal conduit went to hill stations for a vacation, resented help 3 weeks prior to eternal sleep.

Copyright # 2004 John Wiley & Sons, Ltd.

272 SymptomControl.com a Website about the Management of Symptoms in Seriously Ill Patients Klee M Developmental SymptomControl, Copenhagen, Denmark A large amount of systematic information about the management of symptom in the seriously ill and dying patients is found in the area of palliative medicine. The main part of this information should also be used in the rest of the health care system. The problem is that most doctors and nurses have not had any systematic teaching in the area of symptom control. SymptomControl.com is a unique concept that is developed according to modern principles of postgraduate learning, with a focus on the clinical aspects, the possibility for individual learning and easy access to relevant information. It covers the diagnosis and treatment of physical and psychological symptoms and information about communication and psychosocial aspects. Strengthening the health-care professionals competence in managing symptoms in the seriously ill and dying patients means that the professionals will feel more confident and they will realise how much can be done to alleviate suffering. The website is written in English and will be translated into a number of other languages. It will enable the important skills of symptoms control to be disseminated to all those health care professionals that do not have access to a palliative care program that includes postgraduate teaching. A teachers tool and an e-learning systems will be developed based on the website. Using the internet as a tool for information and teaching as well as changing attitudes will be useful not only in the clinical world but also in the area of implementing psychosocial issues.

273 Psychiatric Disorders in a Palliative Care Unit Muniz PS1, Campos FC2, Nardi AE2 1 Palliative Care Center, National Cancer Institute, Rio de Janeiro, Brazil; 2Psychiatry Institute, UFRJ, Rio de Janeiro, Brazil

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We evaluated the frequency of psychiatric disorders in 50 subjects in a palliative care unit. Psychiatric diagnoses were assessed with the Mini-International Neuropsychiatric Interview version 4.4. Thirty-eight patients (46%) reported at the current psychiatric disorder. The frequency was: Major depressive disorder (32%), generalized anxiety (14%), panic disorder (6%), agoraphobia (6%), alcohol abuse (4%), bulimia (4%), suicidal ideation (4%), manic episode (2%), obsessive compulsive disorder (2%), somatization (2%), psychotic syndromes (2%). 14% of patients fulfill more than one diagnoses. Co-morbid psychiatric disorders are clinically significant in palliative care patients and may alter symptoms control strategies and quality of life.

274 Quality of Life of Terminal Patients with Cancer in Palliative Care Unit Nagai YN1, Tajima TT2, Kusaka KK3, Agatsuma YA4, Tomita KT4 1 Division of Psycho-Oncology, Miyagi Cancer Center, Natori, Japan; 2Division of Palliative Medicine, Miyagi Cancer Center, Natori, Japan; 3 Division of Anaethesiology, Miyagi Cancer Center, Natori, Japan; 4Division of Nursing, Miyagi Cancer Center, Natori, Japan PURPOSE: To check if QOL of terminal patients is better in Palliative Care Unit (PCU). METHOD: QOL of all inpatients in Miyagi Cancer Center was surveyed twice a month using EORTC QLQ-C30J. Overall mean scores and mean scores of each patient who was at least once surveyed in both PCU and other general units (OGU) were compared between PCU and OGU. 64 patients (aged 41–86), 28 males and 36 females were included. RESULTS: Overall PS was 2.1 in OGU and 3.1 in PCU. Overall XPF was 48 in OGU and 15 in PCU. Overall XRF was 42.7 in OGU and 17.6 in PCU. Overall XEF was 67 in OGU and 64.8 in PCU. Overall XCF was 65 in OGU and 54.4 in PCU. Overall XSF was 55.2 in OGU and 45 in PCU. Overall XQL was 41.3 in OGU and 39.6 in PCU, but this difference was not significant by Mann–Whitney U test.

Copyright # 2004 John Wiley & Sons, Ltd.

275 Visual-Digital Scales as Measures of Anxiety and Depression in Palliative Care? Onelo. v E, Valdimarsdottir U, Hauksdottir A, Nyberg U, Steineck G et al. Clinical Cancer Epidemiology, Institute of Oncology–Pathology, Karolinska Institutet, Stockholm, Sweden BACKGROUND: Time and energy is limited in the palliative care setting and, thus, measurements of anxiety and depression should not be too time or energy consuming. We investigated the validity of simple visual-digital scales for measurement of anxiety and depression. METHODS: Data are retrieved from 5 nation-wide postal questionnaire studies comprising 3030 cancer patients, widows and parents who had lost their husband/child to cancer, as well as population controls. Centre for Epidemiological Depression Scale (CES-D) and Spielberger’s Trait measure from the Stait-Trait Anxiety Inventory (STAI-T) as well two sevenpoint visual digital scales enquiring about anxiety (vds-anxiety) and depression (vds-depression) during the last week, month or 6 months were included. RESULTS: Of 4009 subjects identified, 3030 (76%) answered and returned a questionnaire. Each score at the vds-depression corresponded to a stepwise increase of mean score at CES-D, with sensitivity and specificity being 80% and 74% respectively. Overall, correlation was not as high between vds-anxiety and STAI-T, but increased with longer time span interrogated on the vds-anxiety. Missing data for STAI-T and CES-D (517 of 20 items) were, respectively, 6% and 9%, while 2.5% for both vds-anxiety and depression scales. Missing data was 13% (STAIT), 17% (CES-D) and 4% (vds) for subjects 68 years or older. CONCLUSION: Owing to lower attrition and high agreement with more lengthier psychometric scales, the simple and short visualdigital scales may be valuable measures of depression in the palliative care setting. More research is needed on simplified methods to measure anxiety.

276 Palliative Care in Kerala, India}the Way Forward Palat G, Venkateswaran C, Shamsudeen M

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Pain and Palliative Care Clinic, Pain and Palliative Care Society, Calicut, Kerala, India Palliative Care is still a developing speciality in India. The Pain and Palliative Care Society, Calicut, Kerala, India has established a very wide network of services mostly in the northern districts. This has led to improved coverage of care provided to people with chronic illnesses, the majority being cancer patients. The Pain and Palliative Care Society (PPCS), Calicut, a registered charitable society established in September 1993, is an organisation of medical professionals and volunteers dedicated to the prevention and relief of suffering among patients and families with chronic incurable illnesses like Cancer, Chronic pain and HIV and AIDS. The Pain and Palliative Care Society succeeded in developing a model for the delivery of palliative care in terms of coverage, delivery and community participation suitable to socio-cultural milieu of India. In 1996 the World Health Organisation conferred on this society, the title Demonstration Project’ and it became their model to the developing world Training programmes for doctors, nurses and most importantly volunteers in the community has led to the expansion of this network and establishment of 31 link centres in Kerala. This society takes a major role in opioid availability that has led to improved control of pain in persons with incurable diseases. In 2003, Institute of Palliative Medicine was started and this functions as the inpatient, training and research arm of the society. This paper discusses the past, present and future plans of this movement.

277 The Psychological Suffering of the Child with Cancer Without Possibility of Cure Perina ME Mental Health Department, Centro Infantil Boldrini, Campinas, Brazil PURPOSE: To understand the dimension of care and the sense of existence to be able to offer continence to the psychological suffering, which follows the process of terminality. METHODS: Clinical psychological study with children and

Copyright # 2004 John Wiley & Sons, Ltd.

adolescents with cancer in progression. RESULTS: The results were interpreted through a psychoanalytic approach and indicated that as death threatens the child’s life, primitive mechanisms of defence, such as denial, scission, introjective and projective identification and idealization are triggered to protect themselves from the contact with self-dissolution and also from the anguish of losing their beloved objects. In their interpersonal relationships, a relation of total reliance and the desire to re-establish a symbiotic bond with the mother could also be observed. The fear of death increases due to their fantasies, which are stressed by the death instinct directed to themselves. They project their anger and guilt onto the health care team and on their relatives. In this ambivalent way, they experience an intense fear of loss, anxiety and guilt in relation with their own ‘‘self’’ and with internal and external objects. Persecutory anxieties and maniac defence predominate. It can also be observed a permanent search for ‘‘thanatalogical beings’’. CONCLUSION: Some interventional measures can be proposed to heal the suffering during the dying process, emphasizing child’s life quality, promote the elaboration of mourning by the family and prepare the staff to cope better with death.

278 Symptom Burden and Will to Live in Patients with Metastatic Cancer Rodin G1, Jones R1, Rydall A2, Moore M4, Donner A3 et al. 1 Psychosocial Oncology and Palliative Care, Princess Margaret Hospital, Toronto, Canada; 2Behavioral Sciences and Health Research, Toronto General Hospital, Toronto, Canada; 3Epidemiology and Biostatistics, University of Western Ontario, London, Canada; 4Medical Oncology, Princess Margaret Hospital, Toronto, Canada INTRODUCTION: Attitudes toward death and dying have been studied most often near the end of life. We are extending this work by conducting a longitudinal study of the desire for death in patients with metastatic gastrointestinal (GI) and lung cancer to determine its antecedents, course and associations. METHODS: Patients with stage IV GI and stage III/IV lung cancer are being

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recruited at Princess Margaret Hospital, Toronto. Subjects who pass a cognitive screen are administered self-report measures at 1–2 monthly intervals, including: Brief Pain Inventory, Memorial Symptom Assessment Scale, Beck Depression Inventory–II (BDI-II), Beck Hopelessness Scale (BHS), Schedule of Attitudes Towards Hastened Death (SAHD), Functional Assessment of Chronic Illness Therapy-Sp-12, Rosenberg Self Esteem Scale, Experiences in Close Relationships Inventory. RESULTS: 165 subjects have been recruited thus far (63.2% participation rate). At the first milestone, participants reported multiple physical symptoms (M=5.9+2.2) and 17.2% reported moderate to severe pain. Moderate to severe depressive symptoms (BDI-II>15) were reported by 23.8%, hopelessness (BHS>8) by 21.2%, and desire for hastened death (SAHD>5) by 10.6% of subjects. In this sample, severity of physical symptoms, spirituality, self-esteem and an anxious attachment style contributed significantly to the prediction of BDI-II, BHS, and SAHD scores. CONCLUSIONS: Significant symptoms of depression, hopelessness and physical distress are common in patients with metastatic cancer, but are not usually associated with the desire for hastened death. Physical suffering, spirituality, self-esteem and an insecure attachment style have emerged in these findings as important contributors to mood, morale and the will to live.

279 Strategic Supervision Experience of the Unit of Palliative Cares Tempia Valenta P1, Esposito CS2 1 Polo Oncologico, ASL12 Piedmont Region, Biella, Italy; 2Mental Health, ASL 12 Piedmont Region, Biella, Italy We have taken care of the supervision of the Unit of Palliative cares of Biella. This job was arranged in the widest frame of the ‘‘Chronic Project’’, that regards the collaboration between the Department of Mental Health and the Hospitals Units workers, who introduce problems of patients and relatives at the risk of psychological uneasiness. The UOCP’s operating group carry out their intervention at the domicile of patients, in a

Copyright # 2004 John Wiley & Sons, Ltd.

moment of great fragility, when a member of the family is dying. In these situations they are frequent moments of relations stiffening; Anguish of dying lead the patient to exasperate the operation of defence mechanisms, the individuals suffer individually and the family-system suffers in the way it works: in communication, and in the way to manage and resolve problems. The participation of the operators is centred on the cure of symptoms and treatment of pain, while making this they enter in contact with microcosms saturates of suffering and fear. Our job has been characterized by some points: Listening to the operators that introduce the case. Appraisal of the explicit}implicit demand. Appraisal of the operator’s peculiarities. Observation the group’s background. Analysis of solutions tried by operators and/or relatives. Problems solving. Adoption of supervisors. In this job we will introduce two cases of supervision.

280 Strong Opioid Usage for Patients with Malignancy who Died at Home Wada TW1, Irahara MI2, Fujii HF3, Yamanaka TY4, Fukushima CF5 1 Visiting services, Aozora Clinic Matsudo, Chiba Pref. Japan; 2Visiting services, Irahara Clinic Matsudo, Chiba Pref. Japan; 3Visiting services, Misato-kenwa Clinic Misato, Saitama Pref. Japan; 4 Visiting services, Tokyo Women’s Medical University Arakawa-ku, Tokyo, Japan; 5Visiting services, Yanagihara Hospital Adachi-ku, Tokyo, Japan PURPOSE: In Japan, most of the terminally-ill patients with malignancy in hospitals are given strong opioids for their pain relief until their death. On the other hand, patients with similar condition at home, sometimes do not experience severe pain, or often require no strong opioid analgesics. However, the frequency of strong opioid usage in cases who died at home is not

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well studied. Therefore, we investigated the ratio of those who required strong opiods in the population of patients with terminal stage of malignancy at home. METHODS: We investigated medical records of three medical clinics, which provide visiting medical services for patients at home until their death. The number of patients who received opioid analgesics at the terminal stage of malignancy, and who died at home were assessed. RESULTS: The physicians of the three facilities were very sympathetic to pain and discomfort of patients, and willing to use analgesics, if needed. In 165 patients who died at home, 85 patients (51.5%) received strong opioid analgesics. CONCLUSIONS: Half of patients who died with malignancy at home required strong opioids. But this ratio was much lower than that of those who died in hospital settings.

281 Philosophy of Life Among Patients with Advanced Cancer and their Spouses Winterling J1, Wasteson E1, Sidenvall B1, Glimelius B2, Sjo. den PO1 et al. 1 Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden; 2Department of Oncology, Uppsala University, Uppsala, Sweden PURPOSE: To investigate the importance of philosophy of life as well as optimism for the psychological distress of cancer patients and their spouses when death is approaching. METHOD: Forty-two patients newly diagnosed with advanced gastrointestinal cancer and 26 of their spouses were interviewed about their philosophy of life. Optimism was measured by the Life Orientation Test, and psychological distress by the Hospitality and Depression Scale. Interview statements were subjected to content analysis. RESULT: The results showed that optimistic respondents had less psychological distress and that a few aspects of philosophy of life were particularly important for such distress. It became clear that fewer patients with advanced cancer and their spouses in Sweden, compared to other Western countries, had faith in some divine power or in life after this. CONCLUSION: These results show that it is difficult to study relations between faith and psychological distress in Sweden, but it is important to do further detailed

Copyright # 2004 John Wiley & Sons, Ltd.

studies to understand how health care staff can support these patients and their spouses without any spiritual beliefs.

282 Denial of Death Revisited: a Sociological Perspective Zimmermann C1,2, Rodin G1,3 1 Psychosocial Oncology, Princess Margaret Hospital, Toronto, Canada; 2Medicine University of Toronto, Toronto, Canada; 3Psychiatry, University of Toronto, Toronto, Canada Terminally ill patients and their families are often referred to as being ‘‘in denial’’ of impending death and Western society is often characterized as being ‘‘death-denying’’. However, there has been little systematic examination of the meaning of this rhetoric and of the evidence that lies behind it. Using the qualitative method of discourse analysis, the usage of the word ‘‘denial’’ in the palliative care literature (1970–2002) was examined. Two dominant themes resulted from the analysis: denial was both portrayed as a defence mechanism at the level of the individual and as an impediment to palliative care. Contemporary social theory, however, suggests that denial may be viewed as a construct which reflects not only the psychology of the individual patient, but also circumstances within the clinician–patient relationship, conditions of clinical practice and the social structure of contemporary Western society. Sociological evidence is presented that contemporary Western society does not deny death, but instead organizes itself around it in a characteristically activistic manner. The current tendency to label patients who resist palliative care as ‘‘in denial’’ of death may reflect a discordance between the activistic tendency of contemporary Western society and the non-interventionist approach of classical hospice and palliative care. A more flexible model of palliative care may in turn result in less frequent labelling of patients as ‘‘in denial’’ and a greater number benefiting from palliative care.

283 Palliative Care Interventions in Patients with Metastatic Cancer

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Zimmermann C, Jones J, Rydall A, Walsh A, Rodin G et al. Psychosocial Oncology, Princess Margaret Hospital, Toronto, Canada PURPOSE: Despite increasing integration of palliative care into mainstream cancer care, specialized palliative care is still not routine for patients with advanced disease. As part of a longitudinal study of patients with metastatic cancer, we are examining referral patterns and their association with symptom burden and psychological distress. METHODS: Patients with stage IV GI and stage III/IV lung cancer attending clinics at Princess Margaret Hospital, Toronto were administered self-report measures at 1–2 monthly intervals, including: Brief Pain Inventory, Memorial Symptom Assessment Scale, Beck Depression Inventory-II (BDI-II), Beck Hopelessness Scale (BHS) and Schedule of Attitudes Towards Hastened Death (SAHD). Referral patterns to palliative care were determined for both the overall sample and for the patients who had died. RESULTS: Of the 165 subjects recruited thus far, only 23 (13.9%) were referred to palliative care. The mean time diagnosis to referral was 2.0+1.7 years. Of the 34 subjects who died, only 11 (35.5%) were referred to palliative care. The median time from referral to death was 56 days (range 1–181 days). The mean SAHD scores were twice as high and there was a trend for BDI-II and BHS scores to be higher among non-referred vs referred subjects. CONCLUSIONS: Despite considerable symptom burden and a well-developed palliative care service, the large majority of patients in our study were not referred to palliative care. Randomised controlled trials are needed to establish the effectiveness and cost-benefit of routine referral with metastatic disease.

1

Alessandria branch Italian League against Cancer, Alessandria, Italy; 2Department of Prevention, ASL 20 Piedmont Region, Alessandria, Italy; 3Health Education Group, ASL 21 Piedmont Region, Casale, M.to Italy; 4ST60 Communication and Marketing Agency, Alessandria, Italy For many years anti-smoking campaigns have carried a prevalently ‘‘threatening’’ message without positive proposals, i.e. ‘‘smoking can seriously damage your health’’. The time is right now to address directly to the individuals, asking a personal involvement to obtain a behavioural change. Two slogans were created highlighting the negative effect that smoking can have on relationships and reciprocal affection. ‘‘Smoking damages your relationships’’ is the first message, aimed at adults, especially parents and teachers; the direct objective is not to persuade them to quit smoking but to convince them not to smoke in front of their children or pupils. This strong and high-impact message expresses loudly and clearly the first of the campaign’s basic concepts}‘‘you can do whatever you like, but if you really like me, respect me, and that means don’t smoke, at least not while I’m around’’. ‘‘Smoking is for sissies’’ is the second message, which intends to persuade teenagers not to start smoking, and is aimed at their juvenile pride, which has always been particularly sensitive to the many-sided meaning of ‘strength’, and breaks down the image of the ‘tough guy’ behind a cigarette, who feels himself strong and fascinating. In line with this communication strategy the graphics were designed to reach the target effectively: the character ‘‘Smokette’’, original and easily recognisable, created to provide an immediate link between the message and its bearer, and a light-hearted, amusing strip cartoon featuring characters divided into two simple categories}the ‘baddies’ (the smokers) and the ‘goodies’ (the non-smokers).

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Evaluation of Lung Cancer Screening Psychological Issues Bussoletti F1, Pugliese P1, Giunta S2, Condoleo MF1, Bonucci A1 et al. 1 Psychology National Cancer Institute ‘‘Regina Elena’’, Rome, Italy; 2Radiology National Cancer Institute ‘‘Regina Elena’’, Rome, Italy

Psychographical Strategies in a Childhood-Oriented Educational Campaign Related to Passive Smoking in the Province of Alessandria (Italy) Betta PG1, Bottero G1, Brezzi MA2, Brusa M3, Gandini C4

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PURPOSE: To evaluate the screening impact on Quality of Life (QoL) and anxiety of enrolled subjects. To evaluate the subjective perception of screening program’s quality and the relationship between the participation to the screening program and the motivation to smoking cessation. METHODS: In Regina Elena Cancer Institute the evaluation of lung cancer screening psychological issues is part of a program, which utilized Low Dose Spiral Computerized Tomography (LDSCT) for early diagnosis. The psychological evaluation is based on a multidimensional strategy that included a Structured Interview for the assessment of the subjective perception of the program quality and psychometric instruments (SF-36 for QoL evaluation, STAI for state and trait anxiety evaluation). All the instruments were administered before the LDSCT and according to follow up schedules. RESULTS: The results from a total sample of 296 individuals (m=173, f=123) showed a high percentage (68%) of individuals who participated in a screening program for the first time. The motivation to participate was above all the prevention (57%) as an autonomous motivation (84%). 39% of individuals referred, moreover, who participated in this program motivated the decision for quitting smoking in the following months. The second evaluation made on 102 individuals (m=58, f=44) showed a positive perception of the program quality, 87% referred to be satisfied with the program organization and 85% referred to be satisfied with the information provided by the health care staff. Finally, the participation in this program did not cause, in most of patient (71%), anxiety symptoms and therefore a worsening of QoL.

286 Factors Affecting Cancer Screening Uptake Among People with a Family History of Colorectal Cancer. A Cross-National Perspective Fichtinger A, Sparks P Department of Psychology, University of Sussex, Brighton, UK PURPOSE: Colorectal cancer screening can prevent the development of colorectal cancer (CRC) and reduce the risk of death. Although effective screening methodologies for CRC are available,

Copyright # 2004 John Wiley & Sons, Ltd.

screening rates remain low, even among people with a family history (FH) of CRC who are at increased risk of developing this disease. Little information exists explaining why CRC screening is underused among this population. This in-depth study explored cognitive, emotional, and practical barriers to screening activity, knowledge about CRC and about screening methods, facilitators of screening, and previous cancer related experiences among people with a FH of CRC. METHOD: Semi-structured interviews (N=20) were conducted with people with a family history (FH) of colorectal cancer (CRC) in the UK and in Austria. Data were analysed using in-depth thematic analysis with a number of themes emerging from this process. RESULTS: Data analysis revealed that interviewees expressed weak knowledge, fear, feelings of invulnerability and strong interest when asked about their beliefs and emotions in respect to CRC and screening methodologies. Furthermore, results from two countries shed light on the influence of external barriers (i.e. costs, availability, role of General Practitioners [GPs]) to screening uptake. CONCLUSION: Results are discussed in terms of their implications for targeted interventions especially for a population with a FH of CRC. Overall, the findings suggest that effective strategies to control CRC may include efforts to improve attitudes, knowledge, and feelings about CRC and screening methods, but must also appeal to GPs to identify and address their own barriers to screening recommendations.

287 Illness Representations of Cervical Cancer Ioana Todor IT, Dumitru Popovici DP Department of Psychology, University of Alba Iulia, Alba Iulia, Romania According to the statistical data provided by the European Network of Cancer Registries Romania is situated on the first place in Europe with the highest mortality rate due to cervical cancer (Bray et al., 2002). The main cause for this situation is the sub-utilization of screening (the Papanicolau test in particular). The present study hypothesis the illness representations have a significant influence in women’s resort to screening procedures. The theoretical framework is provided by

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the illness-representation model, proposed by Leventhal et al. (Leventhal and colab., 1980; Leventhal and Nerenz, 1982; Lau and Hartman, 1983). The use of this model give us the possibility to outline some personal idiosyncrasies, irrational beliefs, socio-cultural or coping particularities and folk beliefs that differ from those of the medical community. The target group consists of women with ages between 30 and 60, healthy and selected at random. Regular use of the Papanicolau test is a criterion for statistic discrimination within the group. We use a qualitative as well as quantitative approach. With the use of semi-structured interview and the focus-group method, we aim to point to the critical aspects of illness representation, which provide themes for developing a questionnaire that is applied to a large group of people. The differences in illness representation between screeners and under-screeners are analysed and interpreted from the point of view of its practical uses in programmes for the prevention of cervical cancer.

Psychological Intervention 288 Song Creations by Children with Cancer}Process and Meaning Aasgaard T1,2 1 Nursing Oslo University College, Oslo, Norway; 2 Music Therapy, Aalborg University, Aalborg, Denmark PURPOSE: The point of departure for this PhDproject was the series of songs made by five children with leukaemia-diseases while they were in hospital. The focus of study was the ‘‘life histories’’ of these songs (how, where, when and by whom the songs were created, developed, performed and used). Although the songs’ lyrics and musical elements have also been considered, the song activities were particularly highlighted to investigate what they meant as to the child’s social role(s) in the paediatric oncology ward. To promote health was the primary goal of the music therapy described. METHODS: The research method chosen was a qualitative multiple instrumental case study. Four major sources of data were employed to construct the 19 ‘‘life histories’’

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of the songs: documentation/archival records, interviews, observations and physical artefacts. Both the individual song history and each of the five young patients could be understood as being ‘‘a case’’. RESULTS: Expression, achievement and pleasure were interpreted to be the most important themes related to the song activities. When these elements were prominent, the song activities fostered, at least momentarily, expanded social roles for the young patients. When the five children were assisted to create and to perform their own songs, these activities added new elements of health (‘‘well-being’’ & ‘‘ability’’) to their lives and to their social environment(s) during the long and complicated process of being treated for serious blood disorders.

289 Individual Psychosocial Support for Breast Cancer Patients Arving C1,2, Sjo. d!en PO1, Bergh J3, Glimelius B2,3, Brandberg Y3 et al. 1 Department of Public Health and Caring Sciences, Section of Caring Sciences, Uppsala University, Uppsala, Sweden; 2Department of Oncology, Radiology and Immunology, Uppsala University, Uppsala, Sweden; 3Department of Oncology–Pathology, Radiumhemmet, Karolinska Institute and Hospital, Stockholm, Sweden; Present address: Department of Oncology, Lund University Hospital, Lund, Sweden PURPOSE: To study effects of individual nurse vs psychologist support intervention of breast cancer patients on psychological distress, quality of life and utilisation of regular psychosocial support. METHODS: In a randomised controlled study, an individual psychosocial intervention performed by (1) specially trained oncology nurses (INS), or (2) psychologists (IPS), were compared with (3) standard care (SC). Consecutive patients about to start adjuvant treatment between December 2nd 1997 and December 31st 1999 (n=179) were included. Data were collected with the EORTC QLQ-C30, the HADS, the Spielberger STAI, and the IES questionnaires before randomisation and 1, 3 and 6 months later. Patient files provided data on their utilisation of regular psychosocial hospital support. RESULTS: Except for the subscales

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Global quality of life/health status, Nausea and vomiting (EORTC QLQ-C30), and Systemic therapy side effects (QLQ-BR23), there were no statistically significant Groups by Time interactions. The INS and IPS groups improved significantly more than SC regarding Insomnia, Dyspnoea and Financial difficulties (EORTC QLQ-C30). INS patients experienced less Intrusion (IES) compared to the SC group. Fewer patients in the INS and IPS groups used psychosocial hospital support compared with the SC group. CONCLUSION: The results indicate that there is some need for psychosocial support among breast cancer patients and that psychosocial support by nurses is as effective as that given by psychologists. Individual psychosocial support by specially trained nurses may therefore be a realistic alternative in cancer care.

290 The Role of the Psycho-oncology in Oncology in Faenza Bellini G Servizio Oncologico di Faenza Istituto oncologico Romagnolo, Forl"ı, Italia It proposes a short thought about the experience which has gone on since 2001 by IOR psychologist on the premises of Faenza who must highlight proposals, interventions, duties and everything else. The contexts, where it operates daily, are the oncological Day-Hospital and IOR headquarter, even if it must be added ill person’s home and department of admission. The role can be defined through tasks of psychological supports to ill people and relatives, co-operation at research and studies, psychological training at nurses, supervision and formation of volunteers. The psychologist has proposed and organised different interventions ad methodologies as: project of ill person and relatives’ show-case, card of side effects of chemotherapy, project of oncological library, patients’ recipes, relaxation meetings for patients and relatives. It has proposed for 2004 new interventions as creation of support groups for relatives in mourning, psycho-educational meetings, psycho-oncological integrated service.

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In conclusion this local experience can confirm that psychologist’s role in oncology and palliatives treatments is extremely important to ill people, relatives, health operators and volunteers to face the changes, fears, feelings, sufferings, linked to the illness as life, and in particular to die and to the dead.

291 Effects of Group Cognitive Behavioural Therapy in Quality of Life Bellver P!erez A, Almonacid Guinot V, Aguilar Can* abate P Psycho-Oncology Unit, Junta Provincial A.E.C.C., Valencia, Spain PURPOSE: In the last years there has been growing interest in the application of Cognitive Behavioural Therapy interventions within psychooncology, and some studies have reported on its efficacy, both with individuals and in group therapy. The aim of this study was to examine the effect of group cognitive behavioural therapy on quality of life over time in women with breast cancer. So we investigated the efficacy of the psychotherapy in QL and distress during therapy and 3 month’s follow-up. METHODS: The sample consisted of 39 women (mean age 49.6, SD=7.5) diagnosed of breast cancer without metastases. The participants have been tested on variables as quality of life (FACT-B), anxiety and depression (HAD) and satisfaction with psychotherapy at the beginning, at the end and three months after finished the group psychotherapy. The statistical analyses were descriptive and MANOVA repeated-measures. RESULTS: The results show significant differences over time on quality of life (p50.01). The effect of psychotherapy within-subjects in anxiety and depression was significant (p50.01). The improvements in mood were largely maintained at 3 months’ follow up. CONCLUSIONS: The results in this study show that the aim of the group psychotherapy, i.e. improving the quality of life and decreasing the distress symptoms of woman with breast cancer, was achieved. The results and women satisfaction dates indicate that this program meets the needs of woman and can be regarded as a successful intervention in oncology.

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292 Group Psychotherapy for Women with Breast Cancer Bellver P!erez A, Almonacid Guinot V, Aguilar Can* abate P Psycho-Oncology Unit, Junta Provincial A.E.C.C., Valencia Spain PURPOSE: The aim of this study was to evaluate the effect of group psychotherapy interventions on quality of life and its impact on distress response of women with breast cancer during the interventions. Furthermore, we analyzed the differences between two types of group psychotherapy in the same variables. The group interventions consisted on six weekly sessions, one group were working self-esteem and communication abilities, and the other were training cognitive behavioural techniques. METHODS: The sample consisted of 77 women (mean age 50, SD=8.3) with non-metastatic breast cancer who received group psychotherapy after medical treatment. The women were divided into two groups: self-esteem and communication abilities (n=22) and cognitive behavioural therapy (n=55). The women completed the Functional Assessment of Cancer Therapy-Breast FACT-B (4th version) and the Hospital Anxiety and Depression Scale (HADS) at the beginning and the end of group psychotherapy. The statistical analyses were MANOVA repeatedmeasures and design factorial mixed. RESULTS: The results show statistical significant improvements in all domains of quality of life and significant decrease in distress symptoms during the group psychotherapy. Comparative analyses between treatments group do not show statically significant differences on quality of life, anxiety and depression. CONCLUSIONS: Both groups are associated with significant benefits. Our results demonstrate evidence for the effectiveness of both group psychotherapy for women with breast cancer, increasing quality of life and decreasing anxiety and depression.

293 Medical Trauma Debriefing and Non-compliance in the South African Oncology Patient Benjamin RVN

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Psychiatry, University of Witwatersrand, Neurosciences, Johannesburg, South Africa Since the DSM4 gave room for the concept of Post Traumatic Stress to be applied to life threatening illnesses, several studies have been done on PTSD in the cancer patient. The present study on non-compliance with chemotherapy in the oncology patient with a good prognosis was done in the Johannesburg Hospital in South Africa. 114 compliant and 33 non-compliant oncology patients with a good prognosis showed significant differences (at the 5% level) on the MCMI2 on the following scales: Disclosure, Debasement, Avoidance, Passive Aggressive, Self-defeating, Schizotypal, Anxiety, Dysthymia, Alcohol Dependence and Major Depression. Bearing in mind the studies on PTSD in oncology, and the fact that several of these MCMI2 scales have been linked to Post Traumatic Stress, an intervention, a Medical Trauma Debriefing Model was worked out and used, which showed good potential for improving patient compliance. This was based on the Wits Trauma Intervention Model, which up to this time had been used for trauma debriefing of people who had experienced trauma due to violence and abuse on a criminal or political level within the South African context. This is in accordance with other recent studies which are beginning to show the link between PTSD and medical non-compliance. Non-compliance with treatment is an extensive and severe problem in many medical conditions besides cancer. It is suggested that Medical Trauma Debriefing, as a preventative measure, be incorporated automatically and routinely into the treatment of certain medical and surgical conditions, especially in Oncology.

294 The Psycho-oncologist and Cancer Patient Advocacy Bernay T1, Wellisch D2 1 President Porrath Foundation, Beverly Hills, USA; 2NPI UCLA Med Ctr, Los Angeles, USA Porrath and Bernay, Faller, Fawzy and other research tells us that cancer patients who are the

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most proactive and involved likely get the best treatment results and quality of life outcomes. Research also shows that patients already overwhelmed with treatment and a life they feel is out of control find it difficult to adopt such a stance and follow through. The Personal Cancer Management System (PCMS), developed by Saar Porrath MD and Toni Bernay PhD, is an evidence-based systematic and comprehensive methodology that helps patients achieve this goal. Used as a patient self-help tool or as a guided system, the PCMS helps primary care physicians and psycho-oncologists build an individualized cancer care program for patients. Acting as a ‘‘cancer patient coach/advocate’’, the psychooncologist, can employ the PCMS to help patient and caregiver navigate the entire cancer process from diagnosis to recovery or end of life. This panel presents the PCMS, its scientific underpinnings and the clinical applications it offers psycho-oncologists in working with cancer patients. Modules, case examples and over fifty behavioral tools and exercises enable practitioners to help patients and caregivers: (1) sort out options; (2) prepare for patient/physician meetings; (3) make medical, complementary medicine, quality of life and lifestyle decisions; (4) deal with emotional, psychological personal family issues; (5) refer patients/caregivers to second opinions, CAM and pain management practitioners, support groups, clinical trials, internet/in-person support and other needed resources including insurance, financial; (6) cut through hospital or other bureaucratic politics; (7) cut through insurance red tape.

295 Young Breast Cancer Survivors: The Effectiveness of a Socio-Educational Intervention Bloom JR1, Stewart SL2, Luce J3, D’Onofrio CN4, Banks PJ4 1 School of Public Health, University of California, Berkeley, USA; 2Department of Medicine, University of California, San Francisco, USA; 3Department of Oncology, University of California, San Francisco, USA; 4NCCC Union City, USA BACKGROUND: Now 59% 5-year cancer survival in USA; reductions in mortality are occurring

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at a greater rate for women age 50 or less at diagnosis (younger women). AIMS: To test an intervention for younger 5-year breast cancer survivors to improve (1) knowledge of breast cancer; (2) lifestyle; (3) communication with physicians & family. METHODS: Pre–post design with random assignment, 404 women (54% of the eligible). Four series of 3 monthly workshops that focused on quality of life issues related to study aims. RESULTS: At post-test (6 months) women in the intervention group (1) had higher knowledge scores (p=0.03) (higher with more education); (2) increased physical activity (p=0.03) (related negatively to mastectomy and positively to greater exercise initially; (3) but no improvement in communication skills except for the last workshop. CONCLUSION: A short-term intervention can improve knowledge levels and begin efforts toward behavioural change, but intensive intervention needed for sustained change.

296 A Psycho-Educational Intervention for Patients with Cutaneous Malignant Melanoma Boesen EHB1, Ross LR1, Frederiksen KF1, Thomsen BLT1, Dahlstrm KD2 1 Department of Psychosocial Cancer Research, Danish Cancer Society, Copenhagen, Denmark; 2 Department of Plastic Surgery, University Hospital Herlev, Herlev, Denmark PURPOSE: In 1993, a randomised intervention study among patients with malignant melanoma showed a significant improvement in psychological well-being and coping capacity 6 months after the intervention and enhanced survival 6 years later. We applied a similar intervention with a few modifications in a randomised controlled trial among Danish patients with malignant melanoma and added results on immediate and long-term effects on psychological well-being and coping capacity. PATIENTS AND METHODS: 242 patients with primary cutaneous malignant melanoma were randomised to control or intervention group. Patients in the intervention group were offered six weekly sessions of 2 h psycho-education, consisting of health education, enhancement of problem-solving skills, stress management and psychological support. The participants were

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assessed at baseline before randomisation as well as 6 and 12 months after surgery. The analyses of the main effects of the intervention were based on a linear mixed model. RESULTS: Patients in the intervention group showed significantly less fatigue, greater vigour and a trend towards decreased total mood disturbance compared to controls. These improvements were most pronounced at first follow-up. The patients in the intervention group used significantly more active-behavioural and active-cognitive coping than patients in the control group. This finding was most pronounced at first follow-up. CONCLUSION: The findings of the present study support the results of a former intervention study among patients with malignant melanoma and indicate that a psycho-educational group intervention for such patients can improve psychological well-being and enhance effective coping.

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over 60 responded. This quasi-experimental design uses multi-variate analyses to examine the interdependency of individual coping, couple adjustment, and their influence on the utilization of psychosocial treatment for breast cancer. RESULTS: Preliminary results indicate a positive relationship between active coping skills and utilization of psychosocial treatment. A strong positive relationship was also found between relationship satisfaction and psychosocial utilization. Gender effects were found with regard to satisfaction with partner’s coping skills and marital satisfaction, as well as the use and satisfaction with psychosocial treatment. DISCUSSION: The results of this study highlight the importance of understanding the interplay of individual and relational coping and utilization and satisfaction with psychosocial intervention. Implications for health and psychosocial treatment providers will be discussed.

297 298 The Influence of Coping and Relationship Satisfaction on Psycho-social Utilization in Breast Cancer Couples Briggs K1, Peterson CM2 1 Human Development & Family Science, Oklahoma State University, Stillwater, Oklahoma, USA; 2 Counseling University of Nevada, Las Vegas, Nevada, USA Research consistently indicates that poor coping, role problems and emotional distress for both cancer patients and their partners are strongly correlated with poor adjustment and increased severity of physical symptoms. Research also indicates that families who rely on each other for support and communicate effectively are more likely to have increased coping skills and stronger relationships. PURPOSE: The purpose of this study was to examine the relationship between partner’s coping styles, relationship satisfaction, and the utilization of psycho-social interventions. METHODS: Breast cancer survivors and their partners, identified by the American Cancer Society, were mailed questionnaires that asked each, survivor and partner, for information regarding coping skills, relationship dynamics, and treatment satisfaction and utilization. Questionnaires were mailed to over 150 couples and

Copyright # 2004 John Wiley & Sons, Ltd.

Improvements in Sleep Quality in Cancer Outpatients Participating in Mindfulness-Based Stress Reduction Carlson LE1, Garland S3, Speca M2 1 Oncology, University of Calgary, Calgary, Canada; 2Psychosocial Resources, Tom Baker Cancer Centre, Calgary, Canada; 3Psychology University of Calgary, Calgary, Canada PURPOSE: Mindfulness-Based Stress Reduction (MBSR) was investigated as a treatment modality for cancer patients with promise for helping to decrease some of the frequent, chronic and troubling sleep problems often experienced during and after cancer treatment. METHODS: One hundred and one cancer patients who participated in the MBSR program, and 12 spouses, provided pre-intervention data. Forty-four of those patients also provided post-intervention data following the program. Patients were an average age of 50 years, and had a variety of cancer types and degrees of severity. The Pittsburgh Sleep Quality Index (PSQI), the Symptoms of Stress Inventory (SOSI), and the Profile of Mood States (POMS) were administered pre- and post-MBSR. RESULTS: Patients initially scored much higher on the PSQI than the cut-off score of 5 indicated as sensitive to

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distinguish poor from good sleepers. Spouses, too, were suffering poor sleep, although not as severely as the patients. Significant improvements occurred for the patients on the sleep subscales of subjective sleep quality (p50.001), sleep duration (from an average of 6–7 h to greater than 7 h per night, p50.01), sleep efficiency (p50.01), sleep disturbances (p50.05) and on the PSQI total score (p50.01). Mood disturbance and stress symptoms also improved significantly (both p50.001). CONCLUSIONS: Cancer patients and spouses evidence high levels of sleep problems in general, which were associated with concomitantly elevated levels of stress and mood disturbance. MBSR is an effective program in improving sleep quality as well as decreasing mood disturbance and stress symptoms in a heterogeneous group of cancer outpatients.

299 Understanding the Self-Perceived Effects of Ongoing Mindfulness-Based Stress Reduction (MBSR) on Cancer Patients: A Grounded Theory Approach Carlson LE1, Mackenzie MJ2, Munoz M2 1 Oncology, University of Calgary, Calgary, Canada; 2Psychosocial Resources, Tom Baker Cancer Centre, Calgary, Canada PURPOSE: While previous studies of MBSR in cancer patients have begun to provide data from an empirically analytical and quantitative model, linkages between existing empirical data and the self-perceived effects of meditation by patients have yet to be explored. The current project explored the use of an ongoing MBSR drop-in class by cancer patients using a grounded theory approach. METHODS: Ten subjects were drawn from the Tom Baker Cancer Centre’s ongoing MBSR Drop-in group. Once recruited into the study, patients participated in several 2-h semistructured interviews. The specific aims of the interviews were to provide a theory that tapped into specific areas of patients’ subjective world, as they perceived their experiences of meditation in conjunction with the cancer experience. Qualitative interview data were transcribed and analysed using the QSR N6 program. As the researchers continued to ask questions of the data throughout the data gathering period, additional data was

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collected through subsequent interviews that helped to fill gaps in the theoretical formulation. RESULTS: The centerpiece of grounded theory research is to identify and interrelate emergent categories and the development of a theory closely related to the context of the phenomenon being studied. Emerging themes that will be discussed include: the importance of group practice, meditation as a form of healing, meditation as a source of control, and desire to share meditation practice with significant others. This information will be used to generate theory around mechanisms of how MBSR affects change within a psychosocial oncology setting.

300 Effects of Psychosocial Group Therapy on the Quality of Life in Women with First Recurrence of Breast Cancer Chujo MC1,2, Mikami IM3, Saeki TS4, Takashima NT4, Okamura HO5 1 Nursing Fukuoka Prefectural University, Tagawa, Japan; 2Graduate School of Medical Science, Hiroshima University, Hirosima, Japan; 3Psychiatry National Sikoku Cancer Center, Mastuyama, Japan; 4Surgery National Sikoku Cancer Center, Mastuyama, Japan; 5Health Science, Hiroshima University, Hirosima, Japan PURPOSE: The purpose of this study was to assess the effects of psychosocial group therapy on the quality of life (QOL) in the Japanese women with first recurrence of breast cancer. METHODS: The subjects were consecutively selected from patients who were diagnosed with first recurrence of breast cancer at the National Shikoku Cancer Centre. We conducted a 6-week psychosocial group therapy. The QOL was assessed using the Profile of Mood States (POMS), the Impact of Event Scale}Revised, the Mental Adjustment to Cancer (MAC) scale, the European Organization for Research and the Treatment of Cancer Quality of Life Questionnaire}Cancer 30/Breast module 23 (EORTC QLQ-C30/Br23) at baseline, immediately, 3 and 6 month after completion of the intervention. RESULTS: The final evaluation was conducted on 19 subjects. The repeated measured ANOVA revealed a significant change for tension– anxiety, depression–dejection, anger–hostility and

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total mood disturbance in the POMS, helplessness/ hopelessness in the MAC scale, and body image and future perspective in the EORTC QLQ-C30/ Br23 at the experimental group. The Dennett’s test revealed a significant difference in the scores between at the baseline and 3 month after in the intervention, but did not between at the baseline and 6 month after the intervention. CONCLUSION: The results suggest that the group therapy has the mid-term effectiveness in improving the QOL of the Japanese women with first recurrence of breast cancer.

301 Efficacy of a Psycho-educational Group with Breast Cancer Women in France: Results of a Randomised Study Dolbeault S1, Cayrou S1, Viala AL1, Saltel P2, Desclaux B et al.3 1 Psycho-Oncology Unit, Institut Curie, Paris, France; 2Psycho-Oncology Unit, Le!on Berard Center, Lyon, France; 3Psycho-Oncology Unit, Claudius Regaud Center, Toulouse, France PURPOSE: To assess positive and negative effects of a French psycho-educational group, supposed to reduce the level of anxiety of patients and improve their quality of life. METHODS: Two hundred and three non-metastatic breast cancer patients, ending their primary treatment, were included in three french cancer centres. Patients were randomised into two groups: immediate intervention (treated group TG) versus differed intervention (control group DG). The intervention program, led by two trained professionals, consisted of 8 weekly 2 h sessions, focusing on thematic discussions, providing information, and stress management training (relaxation, assertivity, problem solving, cognitive restructuration). The following variables were measured (pre- and postintervention, 1 month post-intervention): psychological distress (STAI, POMS), quality of life (EORTC QLQC30-BR23), coping (MAC Scale), social support and well-being. Satisfaction with group participation and potential negative effects were assessed post-intervention. RESULTS: psycho-educational groups significantly reduced distress (reduction of negative affects, increase of positive ones) and increased some aspects of

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quality of life in TG compared to DG. Nevertheless, effects on mental adjustment are insignificant between the two groups. Group intervention allows to accelerate the decrease of negative affects during the post-treatment phase.

302 Psycho-oncology Out Patient Clinic, Uppsala, Sweden Eriksson K, Granat A, Thal!en-Lindstro. m A, Johansson B, Lo. fvenberg E Department of Oncology, Uppsala University Hospital, Uppsala, Sweden The Psycho-oncology out patient clinic (OPM) at Uppsala University Hospital was implemented as a consequence of a number of studies on psychosocial support for cancer patients. OPM started in October 2000 and provides individual support and support groups for cancer patients and their significant others. The individual support is conducted by specially trained nurses, or a doctor specialised in oncology. The sessions focus on patients/significant others psychosocial problems due to cancer. The number of sessions (m=4, range 1–20) is based on the individual needs. The majority (83%) of patients reported that the sessions had helped them to handle their situation. The highest benefit was reported for ‘‘relieving of emotions of depression’’ and ‘‘the ability to handle negative thoughts’’. The support groups consist of 6 weekly sessions. The aim is to increase knowledge about cancer and to give patients and significant others an opportunity to discuss and exchange experiences with other persons in a similar situation. The evaluation show that self-efficacy has increased, especially concerning where to get help with practical issues related to the disease. The participants were overall satisfied with the support group, to meet others in the same situation and to learn more about cancer. A further option for information is open lectures for patients/relatives with different themes connecting cancer. Such lectures are arranged four times a year. The psychosocial support provided at OPM is evaluated continuously in collaboration with Department of Public Health and Caring sciences, University of Uppsala.

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303 Case Study: Narrative Group Therapy: An Evaluative Overview of the Use of Narrative Therapy with Breast Cancer Patients in a Pivate Oncology Unit in South Africa Greeff LE Psycho-Social Services, GVI Oncology, Cape Town, South Africa PURPOSE: This case study will summarise the use of a Narrative model of groupwork with breast cancer patients in a private oncology unit in South Africa. METHOD: The selection of members will be discussed. Pre- and post-group measures of functioning will be discussed. Written feedback from members after the group’s termination will be presented as a means of evaluation of the group’s benefits to the members. Attention will be given to the group structure and}process in relation to narrative therapy principles, discussing the use of a outsider witness group as a therapeutic intervention. RESULTS & CONCLUSIONS: A summary of objective and evaluative data re: group outcome will be presented with a critical overview of the theoretical base from which this work is derived and the implications and possible value of this model for application as a therapeutic intervention for use in psycho-oncology.

304 A Multidisciplinary Approach to Providing Psychooncology Services in a Matrix Cancer Center: A 5 Year Experience Hammelef KJ1, Wade KM2, Henrickson CG2, Mollen E3, Riba MB4 1 Cancer Center, University of Michigan, Comprehensive Cancer Center Ann Arbor, MI, USA; 2 Social Work, University of Michigan, Ann Arbor, MI, USA; 3Pediatric Oncology, University of Michigan, Ann Arbor, MI, USA; 4Psychiatry University of Michigan, Ann Arbor, MI, USA The emerging field of psycho-oncology offers unique opportunities for multidisciplinary collaboration. Psychosocial services are historically offered by a variety of clinicians from differing specialties with minimal collaboration and integration. This care delivery model is fraught with

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redundant services and frequently underserved populations. To achieve an integrated and comprehensive array of psychosocial services, a university-based cancer centre combined the efforts of their Departments of Psychiatry and Social Work in 1999 to create a PsychoOncology program. Developing comprehensive, collaborative psychosocial services for the cancer population proved a unique challenge in this matrix cancer centre. Program development steps included (1) developing a mission statement, (2) benchmarking, (3) analysing current services and gaps, (4) developing a strategic plan to include allocation of limited resources such as personnel and space, marketing strategies, and philanthropy opportunities. The current program is comprised of 23 clinicians from various disciplines including social work, psychiatry, art therapy, bereavement, psychology, nursing, complementary therapies, and child & family life. Clinical services are offered throughout the continuum of care for various levels of emotional distress. A PsychoOncology clinic will open in June 2004 to further consolidate services and endorse them as essential components of comprehensive cancer care. This paper will discuss the 5 year evolution of a PsychOncology Program. Preparatory steps taken, strategic initiatives and program development tactics employed will be reviewed. Successes achieved and challenges encountered will be illustrated. Implementing a multidisciplinary PsychoOncology Program within a matrix centre offers unique hurdles that may be applied in other cancer care areas.

305 Relevance of Fear of Progression (FOP) in Psycho-oncology Herschbach P1, Berg P1, Duran G1, Engst-Hastreiter U2, Waadt S1 1 Institute for Psychosomatic Medicine, Technical University of Munich, Munich, Germany; 2Psychological Department, Rheumatology Rehabilitation Centre of Federal Insurance, Institute for Salaried Employers (BA), Bad Aibling, Germany The realistic fear of progression (FOP) of disease is the most important cause of distress in cancer

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patients. The construct FOP has to be differentiated from irrational fears and can affect the quality of life in an enduring way and then has to be treated. The great relevance of FOP led to the development and psychometric testing of a specific questionnaire and conceptualisation and evaluation of a specific therapy of dysfunctional FOP. The result of the first stage is a self-assessment instrument, the FOP-Questionnaire (FOP-Q). Its development was based on the examinations of 914 rehabilitation patients (334 with cancer, other with diabetes mellitus or rheumatism). The FOP-Q consists of 43 Items, grouped into 5 scales: affective reactions, partner/family, work, loss of autonomy and coping with fears (Cronbachs alpha 0.70–0.95); test-retest-reliability-coefficients 0.77– 0.94. Standardised validation measures showed moderate correlation with HADS- and SCLAnxiety Scales (0.51–0.66), which indicates that the FOP-Q assesses the distinct fear of progression, aside from general anxiety. The FOP-Q is a valid, feasible and useful tool to identify patients with pronounced FOP. We shall present first results of the therapy evaluation study. The FOP-therapy stems from the principles of cognitive behaviour therapy. It aims at enabling the patient to manage his fear rather than eliminate the FOP, so that a patient can win back quality of life. The evaluation is based on a prospective control group design (N=328).

306 Differential Effects of Emotional Disclosure in Male and Female Cancer Patients Herzer M, Fidler A, Dittoe S, Quartana P Psychology, Chicago Medical School, North Chicago, USA PURPOSE: Emotional disclosure has been shown to be beneficial in individuals dealing with a variety of traumatic and stressful experiences. While little is known about gender differences in the effects of disclosure, it has generally been found that women are more likely to use emotional expression as a form of coping with stress than are men. It is therefore often assumed that men may be less likely to benefit from emotional disclosure.

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The present study investigated the effects of written emotional disclosure in male and female cancer patients. METHOD: Using Pennebaker’s writing paradigm, 80 gynaecological cancer patients and 84 prostate cancer patients were randomly assigned to two conditions. In the disclosure condition participants wrote about their emotions regarding their cancer experience for 20 min a day for three consecutive days. Controls wrote about their daily activities. Moods (POMS) were assessed at baseline, 3, and 6 months postwriting. RESULTS: A 2 (gender) by 2 (condition) repeated measures ANOVA revealed a significant gender by condition interaction (p50.01). Inspection of means showed that while women exhibited little change in response to the disclosure intervention, men reported reduced mood disturbance at 6 months post-intervention. CONCLUSIONS: Women may have other emotional outlets, possibly in their social environment, that mask the effects of writing. The results suggest the value of implementing interventions that provide male cancer patients with a means to express their emotions.

307 Health-related Quality of Life and Distress in Cancer Patients: Results from a Large Randomised Study Johansson B1, Berglund G2, Brandberg Y3, Hellbom M4, Petersson LM2 et al. 1 Oncology, Uppsala University Hospital, Uppsala, Sweden; 2Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden; 3OncologyPathology, Karolinska Institutet, Stockholm, Sweden; 4Oncology, Lund Univeristy Hospital, Lund, Sweden PURPOSE: The purpose of the Support Care and Rehabilitation-project was to evaluate the effects of Individual Support (IS), starting at diagnosis, and/or Group Rehabilitation (GR), 3 months after diagnosis, on cancer patients’ Health-related Quality of Life (HQOL) and psychological distress. METHOD: A consecutive sample of 485 newly diagnosed patients (eligible, n=760) were randomised to IS, GR, IS+GR or to a control group, receiving Standard Care (SC). The EORTC QLQ-C30, the Hospital Anxiety and Depression

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Scale, and the Impact of Event Scale were administered at baseline (before randomisation) 3, 6, 12 and 24 months after diagnosis. Data on HQOL were also compared to normative HQOLdata from a large sample of the Swedish population. RESULTS: HQOL improved and psychological distress decreased over time among all patients. However, there were no decisive differences between the randomisation groups at any time of assessment. Comparisons between patients HQOL and normative data revealed only a few clinically significant differences (10–13 on a 0–100 scale). Patients scored worse for global quality of life, fatigue and appetite, but only at diagnosis (baseline). Moreover, the cancer patients reported a statistically significantly higher emotional function than the normal population at 6, 12 and 24 months and less pain at 3, 6, 12 and 24 months after diagnoses. CONCLUSIONS: Extensive psychosocial support does not improve HQOL or decrease psychological distress more effectively than SC, in patients unscreened for such problems. The matter of response shift but also inclusion criteria, implementation of interventions and methods of data collection will be discussed.

The 125 patients in the intervention group were offered ten visits over a period of 2 years. A total of 1060 visits were carried out and after every visit the topics of the conversation were registered on a form. The areas of the patients’ interests concerned primarily physical subjects related to the disease and its treatment, and psychosocial factors. We found that the topics discussed varied over time, e.g. we talked about appetite, tiredness, digestive problems, and the disease primarily in the first two–three visits. Physical problems in general and talk about everyday life were topics that we increasingly discussed in the remaining visits. We discuss the perspectives for home visits as an offer for rehabilitation of cancer patients in Denmark.

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PURPOSE: Understanding diversity involves going beyond racial or cultural stereotypes, as there can be as much difference between members of the same cultural group as between members of different cultural groups. This presentation outlines a clinical approach to individualizing counselling and support for cancer patients and family members. METHOD: Clinical approach. RESULTS: Personality and coping styles, cultural sensitivity, preferred connecting with life modalities, and phases of the disease process are used to shape individualized interventions. This approach to addressing anxiety, depression, and related concerns of cancer patients and their families was developed in a large hospice setting and utilizes the theoretical work of Million, Viscott with personality guided therapy and Lazarus’ multimodal therapy. CONCLUSIONS: Individualizing interventions using personality and coping styles, and preferred connecting approaches with cultural sensitivity is effective in designing strategies and tactics for individuals and their families.

Supportive Home Visits after Surgery for Cancer Karlsen RV, Larsen LR, Johansen C Institute for Cancer Epidemiology, The Danish Cancer Society, Copenhagen, Denmark This presentation describes how a randomised trial of psychosocial intervention towards cancer patients was conducted in Denmark from September 1996 to May 2000. The main aim of the study was to evaluate the effect of home visits on the wellbeing of Danish colorectal cancer patients. Here we report on the practical conductance of the study, how the visits were standardised and which topics the patients preferred to talk about during the home visits. A total of 249 patients were included from eight different hospital departments on Zealand (the eastern part of Denmark) and treated with abdominal surgery for a primary colorectal cancer. They were all aged 18 or more, resided in their own home and had no symptoms of senility.

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309 Diversity on the Individual Level: Personality, Coping, and Culture Leaver VW1,2 1 Psychology Walden University, Minneapolis, MN, USA; 2Pathways Hope Hospice and Palliative Care Fort, Myers, FL, USA

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Developing a Tool to Collect Baseline Information on Psychosocial Oncology Services in Canada Leis A1, Maunsell E2, Taylor Brown J3, Doll R4 1 Community Health & Epidemiology, University of Saskatchewan, Saskatoon, Canada; 2Me!decine sociale et pre!ventive, Universite! Laval, Quebec City, Canada; 3Psychosocial Oncology & Supportive Care, CancerCare, Manitoba, Winnipeg, Canada; 4 Cancer Rehabilitation, British Columbia Cancer Agency, Vancouver, Canada

Assessment of Psychological Distress in Women Undergoing Brachytherapy for Breast Cancer. A Randomized Study Leon C1, Farrs B2, Rovirosa A2, Casas F2, Gic I3 et al. 1 Oncology, Hospital de Terrassa, Terrassa, Barcelona, Spain; 2Radiotherapy Hospital Clinic, Barcelona, Spain; 3Epidemiology Hospital de Sant Pau, Barcelona, Spain

PURPOSE: Although psychosocial oncology care has been shown to significantly improve quality of life, it seems only a small proportion of Canadian cancer patients receive it. Before undertaking a comprehensive inventory of psychosocial oncology services provided in Canada, Phase 1 of the project was to ascertain what kind of data were already available, how they were collected and how comparable they were across jurisdictions in Canada. This presentation will highlight the consensus building process and issues identified in Phase 1. METHODS: Thirty Canadian leaders in psychosocial oncology care were identified and asked to complete a telephone survey on the type of data routinely collected in their cancer facility or psychosocial oncology department. Subsequently, an advisory board made of representatives of partner cancer organizations met to examine and discuss the material, as well as to advise on the construction of the tool designed to carry out an environmental scan of psychosocial cancer care in Canada in Phase 2. RESULTS: To date, 12 interviews were completed. Despite existing psychosocial oncology guidelines, a wide range of resources, care practices and recording methods across provinces were identified. Nomenclature and definitions often differ. Issues arising from the lack of standardization will be highlighted and suggested solutions discussed. CONCLUSIONS: It is possible to identify a core set of indicators that would be comparable across settings/provinces. Based on this information, a survey tool will be created to collect baseline data on availability and utilization of psychosocial oncology care in Canada and to facilitate monitoring activities.

Copyright # 2004 John Wiley & Sons, Ltd.

PURPOSE: Patient psychological distress is associated with many aspects of the brachytherapy treatment. The discomfort that women experience during this process is characterised by an intense tension and fear, due in part by the isolation, prohibition of visits and measures of radiological protection. The aim of this study was to gather information about the effectiveness of a specific behavioural intervention in reducing psychological distress in women receiving brachytherapy for breast cancer. METHODS: Nineteen participants were recruited from Radiotherapy in Hospital Clinic (n=17) and Hospital de Sant Pau (n=2). All of them received brachytherapy for breast cancer. The patients were randomised into an intervention group (n=10) and a control group (n=9). Psychological intervention of a modified form of Jacobson’s method for Progressive Muscle Relaxation and guided imagery was taught to the patients of the intervention group. Anxiety and depression, according to the Hospital Anxiety and Depression Scale (HADS), were evaluated before, during and after the in-patient period in all patients. RESULTS: Patients who were in the experimental group showed lower levels of depression after brachytherapy intervention (p=0.1, SD=3.3). General linear model analyses showed statistical significant difference (p=0.05, SD=3.7) in anxiety, in patients who practice relaxation during brachytherapy process. CONCLUSIONS: The preliminary data show that women receiving brachytherapy for breast cancer seems to benefit from the psychological intervention-reducing depression. Statistical analysis showed significant reduction of anxiety in experimental group.

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312 Evaluation of Depression and Anxiety Among Gynecologic Cancer Patients. A Clinical Controlled Trial Leo! n C1, Rovirosa A2, Casas F2, Farrs B2, Gic I3 et al. 1 Oncology, Hospital de Terrassa, Terrassa, Barcelona, Spain; 2Radiotherapy Hospital Clinic, Barcelona, Spain; 3Epidemiology Hospital de Sant Pau, Barcelona, Spain PURPOSE: This randomised trial, conducted through two radiotherapy centres, compares the efficacy of a specific behavioural intervention, the relaxation, in reducing psychological distress in women receiving brachytherapy for gynaecologic cancer. METHODS: Forty-seven participants were recruited from the Radiotherapy at the Hospital Clinic and Hospital de Sant Pau from Barcelona. All of them received brachytherapy for gynaecologic cancer. The patients were randomised into an intervention group (n=22) and a control group (n=25). Psychological intervention of a modified form of Jacobson’s method for Progressive Muscle Relaxation and guided imagery was taught to the patients of the intervention group. Psychological status, according to the Hospital Anxiety and Depression Scale (HADs), were evaluated before, during and after the in-patient period in all patients. RESULTS: Thirty-four patients from Hospital Clinic and 13 patients from Hospital de Sant Pau have completed questionnaires. Sociodemographic data show an age average of 53 (from 24 to 82). General linear model analyses showed statistical significant difference (p=0.02), in depression in the experimental group, having a reduction of depression during the brachytherapy process. These data also indicated that those who practice relaxation have a decrease in anxiety (p=0.06). CONCLUSIONS: Our findings demonstrate that the practice of relaxation appears to be an effective and acceptable strategy for patients reduction of anxiety during brachytherapy treatment for gynaecologic cancer. Statistical analysis showed significant reduction of depression in experimental group.

313 Emotional Information Available from Videotapes vs. Transcripts

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Liess A1, Ellis W1, Giese-Davis J1, Golant M2, Spiegel D1 1 Department of Psychiatry, Stanford University, Stanford, USA; 2Research & Development, The Wellness Community, Santa Monica, USA Emotional analysis is complex, relying as much on intonation, facial expression, and body language as content. Computer-assisted text analysis programs, operating without these cues, may miss or misclassify important emotional information. We investigated the type of emotional information available from text transcripts and videotaped interactions. Videotapes and transcripts of four randomly selected 2-h group therapy sessions for two support groups were coded for emotional content by trained Specific Affect Coders (Gottman, 1994) and Linguistic Inquiry and Word Count (LIWC; Pennebaker and Francis, 1997). Women with primary breast cancer stages 1, 2, 3 were randomized to The Wellness Community support groups (N=18). Participants were from 36 to 70 yr (mean=56.3); 96% were Caucasian. We examined the percentage total time and total word count per woman per group of primary negative affect, positive affect, and defensive affect. Significantly less defensive affect was detected in text transcript (Z= 3.55, p50.001) than in videotape, suggesting that without tonal and facial cues defensive affect is lost to perception. Unexpectedly, significantly more positive affect was identified in the text transcripts (Z= 2.20, p50.03). Primary negative affect was similar across coding modes. Coder detection of primary negative affect in transcripts was correlated with LIWC (r=0.484, p50.05). However, no correlation was found for positive emotion, suggesting that LIWC characterizes positive emotion differently than human coders. These findings suggest that important emotional content is lost in the absence of visual and facial cues and, especially, when relying on computer-based analysis. Researchers should use caution when relying on these tools for accurate emotional information.

314 An Inpatient Program for Traumatic Spinal Cord Injury and Metastatic Spinal Damage Using the Practice of Mindfulness Meditation to Aid Adjustment and Grief

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Mann BL Psychology, Glenrose Rehabilitation Hospital, Edmonton, Canada Metastatic spinal damage with resultant paraplegia can cause sudden and devastating changes that are life-, anatomy-, and ability-altering. For the patient receiving a diagnosis entering into an acute care hospital and then subsequent rehabilitation, there may be shock, fear and terror, and feelings of fragility, vulnerability, and loss of control. Approaches to counselling patients with spinal cord tumors and metastatic spinal disease emphasize helping the individual to adjust to catastrophic losses. This paper describes the use of mindfulness as one way of helping a person with a diagnosis of primary spinal cord tumor or metastatic spinal damage through the process of grief and sorrow to move forward to a new self. It is a way of naturally being within the grief so as to allow and observe all the complex emotions with suspended judgment. It is a positive healing method that focuses one’s energies in positive ways. Although this approach certainly sees ‘‘doing’’ as very relevant, it also emphasizes who we are as unique individuals. Thus, agony, suffering, grief, and fear are not so much problems requiring simple mechanical solutions but are natural emotions that pose deep challenges. Challenges are to be met, not fixed, or eliminated, or cured. This presentation suggests ways of being ‘‘within the grief’’ as the patient makes his/her way through grief in the most positive and authentic way possible.

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tion upon distress reported early-stage breast cancer patients and their spouses. Couples were randomly assigned to either receive the group intervention or usual care. Couples assigned to the intervention condition attended a six session group. A didactic format was utilized, with two group leaders. Topics included stress and relaxation skills, communication about cancer, negotiating changes in sexuality, and survivorship. Two hundred and thirty-eight couples participated: 118 couples were randomly assigned to the usual care condition and 120 couples were assigned to the intervention condition. Couples completed surveys pre-intervention, 1 week post-intervention and 6 months post-intervention. Results of growth curve modelling indicated that patients in the intervention group reported significantly greater reductions in depressive symptoms over time. Tests for the moderating influence of patient perceptions of spouse unsupportive behaviors suggested that patients who perceived their spouses as unsupportive reported significant declines in depression, anxiety and general distress over time, whereas patients who did not perceive their spouses as unsupportive did not report significant reductions in depression, anxiety or general distress over time. Results suggest that our intervention was effective in reducing depressive symptoms, but was most effective for patients who felt their spouses were not supportive.

316 315 Couple Focused Intervention for Breast Cancer Patients and their Spouses Manne SL1, Ostroff JS2, Winkel G3, Grana G4, Fox K5 1 Population Science Fox Chase Cancer Center, Philadelphia, PA, USA; 2Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA; 3Psychology City UniversityGraduate Center, New York, NY, USA; 4Oncology Cooper Hospital, Camden, NJ, USA; 5Oncology Hospital of University of Pennsylvania, Philadelphia, PA, USA A randomized clinical trial was conducted testing the impact of a 6 session couples’ group interven-

Copyright # 2004 John Wiley & Sons, Ltd.

Camping Programs for Children with Cancer and their Families Martiniuk ALC Epidemiology & Biostatistics, University of Western Ontario & Trillium Childhood Cancer Support Centre, London, Ontario, Canada Psychosocial support programs exist to support families through childhood cancer. One such program is the recreation-based summer camp. Since the first camp for children with cancer in Florida, USA in 1976, more than 60 camps have been established worldwide. Although these camps are popular, to date little documentation exists in peer-reviewed journals on their existence, and little systematic evaluation of their risk-benefit has been conducted. The presentation will provide an

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opportunity to discuss the current state of the literature on this topic, hypothesized theories of action and future research directions. Therapeutic recreation will be discussed as background to the theoretical role of camping for this population. As well, nine previously published studies investigating recreation-based summer camps for children with cancer and their families will be summarized. Overall, these programs appear to be effective; however, an overall conclusion is difficult to state due to variations in design, heterogeneity of subjects, and differences in the definition of camp programs. The lack of knowledge regarding the efficacy of these programs is identified as the largest deficiency in the current literature on this topic. Last, future research needs in this area will be discussed.

317 Structured Cognitive Behavioural Intervention for Breast Cancer Patients Mc Kiernan A1, Steggles S2, Carr A1 1 Psychology, University College Dublin, Dublin, Ireland; 2Psycho-oncology Services Department, Saint Luke’s Hospital, Dublin, Ireland A brief account of the evidence for the effectiveness of psychological interventions aimed at helping cancer patients cope with their disease and related distress will be provided. This review will also address current research interests in Psychooncology, health-related quality of life and psychological adjustment in cancer patients, and coping with cancer. The presentation will also incorporate an outline of a current study aimed at examining for the first time the effect of a cognitive-behavioural psychoeducational group intervention on the quality of life, psychological adjustment and coping styles of adult breast cancer patients in the Republic of Ireland and exploring client perception of the benefits of the intervention. Sixty participants will be accessed through the Psycho-Oncology Services Department of St. Luke’s Hospital, Dublin, Ireland. The intervention proper will take a structured closed cognitive-behavioural group approach, utilising stress management and coping skills training. Psychosocial measures to be administered will include the Brief Symptom Inventory, the Psycho-

Copyright # 2004 John Wiley & Sons, Ltd.

social Adjustment to Illness Scale}Self-Report, the POMS-SV, and the COPE scale. Three 2  4 ANOVAs will be carried out to examine intervention effect. A regression analysis will be used to examine the relationship between HRQoL and scores on standardised measures of psychological adjustment and coping strategies. Likert scales from the client intervention appraisal questionnaire will be converted to dichotomous variables for analysis. Content analysis will be carried out on the open-ended questions. The results will have significant implications for the provision of oncology support services within the Republic of Ireland.

318 Clinical Efficacy of Psychological Interventions in Breast Cancer Patients: A Report of Three Meta-analyses Naaman SN1, Pappas JD2 1 Psychology University of Ottawa, Ottawa, Canada; 2Psychology, University of Regina, Regina, Canada PURPOSE: Existing meta-analytic research that addresses the clinical utility of psychological interventions in enhancing adjustment in cancer clients have been previously criticized on the grounds of marked clinical heterogeneity. The present investigation discusses a systematic review and meta-analytic investigation of all randomized clinical trials germane in assessing the efficacy of psychological and psychiatric interventions, which alleviate psychological morbidity in breast cancer clients. Three outcome variables were isolated in this review; namely, depression, anxiety, and quality of life. METHOD: A systematic search of all relevant databases, using key concepts that yielded a total of 30 articles, 17 of which met inclusion criteria, was used to conduct this review. In addition, articles were not limited to the English language nor to publication status in order to broaden the scope of inquiry. Several sensitivity analyses were carried out for each outcome variable to determine impact of trial quality, publication status, and a host of moderator variables on the overall effect sizes, respectively. RESULTS: Preliminary results suggest moderateto-large effects sizes for all three outcome variables

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with significant heterogeneity among trials. Moderator variables identified a priori (type of treatment; e.g. cognitive behavioural vs. expressivesupportive, level of clinician training; psychiatrist/ psychologist vs. oncology nurse), underwent sensitivity analyses to determine causes of heterogeneity. IMPLICATIONS: The authors argue that an optimal treatment planning is needed to incorporate type of treatment (group-based vs. individual), dose of treatment, and level of clinician training in relation to client prognosis.

319 Examination of the Effects of a Support Group Program for Cancer Patients Open to Local Communities in Japan Okuhara HO1, Morita MM2, Endo KE2, Yoshida MY2, Asakura TA3 et al. 1 School of Nursing, University of Shizuoka, Shizuoka, Japan; 2College of Nursing, The Japanese Red Cross College of Nursing, Tokyo, Japan; 3 Health & Sports Science, Tokyo Gakugei University, Tokyo, Japan This study examines the psychological effects of intervention by support groups that are open to communities and not restricted to particular institutional hospital settings. Three separate groups, men’s, women’s, men and women mixed, were composed of the patients of different types and stages of cancers. Under the program the patients had five consecutive 90-min weekly group sessions. The intervention method used was the supportive/expressive model. Based on face sheets, the Center for Epidemiologic Studies Depression Scale (CES-D), positive life attitude, and mental adjustment to cancer (MAC), 27 patients in three groups were evaluated for the effectiveness of support group participation. The findings demonstrate the positive effects of support group intervention. These effects were observed despite the perceived Japanese reserved personalities that tend to keep their emotions and feelings from being expressed. The support group intervention was also effective in the groups of patients with different types and stages of cancers. The research on the effects of a support group program is presented from the perspective of the Japanese social and cultural characteristics.

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320 Program of Psychosocial Interventions for Patients Cured of Cancer in Childhood Perina EM1, Capellaro K2, Mendon-ca R2, Moraes VDD3, Enes C4 et al. 1 Mental Health, Centro Infantil Boldrini, Campinas, Brazil; 2Pediatric Odontology, Centro Infantil Boldrini, Campinas, Brazil; 3Social Worker, Centro Infantil Boldrini, Campinas, Brazil; 4Pedagogy, Centro Infantil Boldrini, Campinas, Brazil PURPOSE: The aim of this work is to present the creation of a multiprofessional outpatient unit that gives support to the patient cured of cancer in childhood and adolescence. METHODS: The results presented in this study, with 437 patients between 2 and 35 years of age who were assisted between December 1, 2002 and December 30, 2003, show the most important points concerning each speciality. RESULTS: The recognition of the late effects as well as the damage caused by the treatment to the quality of life made the concepts of cure be reviewed. The proposal is to promote the bio-psychosocial reintegration of the patient out of therapy, contributing for the improvement of quality of life as well as the treatment, prevention and minimization of the late effects. CONCLUSION: The knowledge of the changes related to the oncologic treatment is of fundamental importance when considering that the survival itself is not enough. The true cure requires the need for reaching all the biological, intellectual, psychological, emotional and social potential which the child or adolescent was prepared to reach by the time he was affected by the disease.

321 Group Therapy in Patients with Breast Cancer: Rationale and Experience with Rehabilitation Inpatients Rogge AR Abt. fu. r Psychologie Reha-Klinik Schloß Scho.nhagen, Scho.nhagen/Brodersby, Germany RATIONALE: Breast cancer is a stressing life event leading to depressive reactions, fears, and reduction of self-esteem. In addition to the somatic cancer therapy, psychosocial support is important

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for successful coping strategies. Since in Germany the cancer patients have access to 3–4 weeks of inpatient rehabilitation in specialized clinics, group psychotherapy is being offered to them. The items focused are the psychodynamics after diagnosis and treatment of breast cancer, changes in psychosocial interactions in family and society, sexual counselling, impact of behavioural techniques as passive relaxation, and some information of general somatic issues. EXPERIENCE: We report on experience of 13 years of group therapy, having offered voluntary participation to more than 10 000 in-patients with breast cancer. The patients differed in activity of the malignoma, time elapsed since the primary treatment, experience with self-help groups, and expectance regarding group psychotherapy. For patients rather reluctant to group psychotherapy, the somatic session with a female physician facilitated the first step into the group. The psychic effects of the somatic changes, e.g. mastectomy or pharmacologically induced climacterium, were centred from the view of the patients. Changes in family and sexual life as well as in working life were additional important items. The response to the group therapy varied in the patients. Some of them experienced an augmented emotional stress and discontinued the participation. Other felt the support, also given by the co-patients, and intended to continue in selfhelp groups at home.

study (‘‘Children of Somatically Ill Patients’’}COSIP) we started to integrate a familyoriented intervention into the psychosocial routine care for all BMT patients at our University Hospital. Steps of this program are: Parents’ session with psychologist (focus: imaginations of treatment; stressors and resources), session with child psychiatrist (focus: parenting), individual sessions with children (focus: child’s self reflecting function). Optional are family sessions (focus: communication about illness). The intervention is evaluated with feedback questionnaires administered at the end of the intervention and 3–4 months later. The variables measured are process quality, quality of results and specific goal attainment from the perspectives of parents, children and therapists. RESULTS: Experiences to date show a smooth integration of this program into the BMT setting. Thirty-one BMT patients having children were seen for counselling. Seventeen children and adolescents (age 5–17) were seen for individual interventions. In 5 cases, a parent died during or after treatment. Evaluation data indicate that once in-patient treatment has started, families are less open for additional issues despite perceivable stress, whereas optimal support seems to be achievable when these interventions become an integral part of the family’s preparation prior to admittance, including that children’s fears of a parent’s possible death are addressed openly. In families’ feedbacks fostering parental competence and a. . . [truncated].

322 Bone Marrow Transplantation Patients as Parents and their Children: Development of an Integrated Family Oriented Intervention Romer G1, Schulz-Kindermann F2, Haagen M1, Saha R1, Pott M1 et al. 1 Department of Child and Adolescent Psychiatry and Psychotherapy, University Hospital, HamburgEppendorf, Hamburg, Germany; 2Department of Bone Marrow Transplantation, University Hospital, Hamburg-Eppendorf, Hamburg, Germany

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INTRODUCTION: High-dose therapy and bone marrow transplantation (BMT) pose severe physical and psychological stress on patients and their families. Little is known about the psychosocial adaptation of children of BMT-patients. METHOD: In the context of an EU-funded transnational

PURPOSE: Social intervention consisting of home visits by health care professionals may succeed as a formalized social relationship, in which cancer patients could be given emotional as well as informational support. We studied the effect of such home visits on the well-being of Danish

Copyright # 2004 John Wiley & Sons, Ltd.

A Randomized Psychosocial Intervention Study on the Effect of Home Visits on the Well-being of Danish Colorectal Cancer Patients}The INCA Project Ross L, Thomsen BL, Karlsen RV, Boesen EH, Johansen C Institute of Cancer Epidemiology, Danish Cancer Society, Copenhagen, Denmark

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colorectal cancer patients. METHODS: In 1996– 1999, a total of 249 incident Danish colorectal cancer patients treated with abdominal surgery were randomly assigned to a control group or to an intervention group. A project nurse or a medical doctor carried out the intervention that consisted of 10 home visits during the first 2 years after discharge. In addition, all 249 patients followed the regular monitoring program offered by the surgical department. Participants were interviewed by telephone 3, 6, 12, and 24 months after discharge in order to assess well-being. Data was analysed using a mixed model. RESULTS: In general, we found no effect of the intervention on the level of well-being nor was a differential effect with time observed during follow-up. However, we did see a non-significant effect on all subscales of the Hospital Anxiety and Depression Scale (HADS) and the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 at the 3-month follow-up subsequent to the most intensive period of intervention. CONCLUSIONS: Our study of supportive home visits by health care professionals did not improve the overall well-being of colorectal cancer patients, but suggests a possible effect of a short-term intensive intervention conducted as home visits, which may be investigated in future studies.

324 Factors Associated with Loss to Follow-up in a Randomized Psychosocial Intervention Study of Well-being Ross L, Thomsen BL, Boesen EH, Johansen C Institute of Cancer Epidemiology, Danish Cancer Society, Copenhagen, Denmark PURPOSE: The purpose of this study was to illustrate how randomized intervention studies can be threatened by bias due to missing observations because of death or non-response. METHODS: A randomized clinical trial of the effect of psychosocial intervention on well-being after an operation for colorectal cancer was carried out in Denmark. Patients were interviewed 3, 6, 12, and 24 months after discharge from hospital. We analysed the participation status at the succeeding follow-up among responders at each follow-up. We present the two separate logistic regression analyses that

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considered death vs. participation and non-response vs. participation, respectively. RESULTS: We found that the probability of non-response decreased with increasing anxiety score in the intervention group whereas it increased with increasing anxiety score in the control group. No differential associations were seen for death. Low physical functioning and low global health status/quality of life were related to an increased probability of dying before the next follow-up, and this association could explain the associations between anxiety and depression, respectively, and the probability of dying observed in crude analyses. CONCLUSION: Bias due to differential non-response may severely invalidate the results regarding the effect of this kind of intervention, and we therefore strongly recommend that psychosocial intervention studies include an analysis of the pattern of non-response before concluding on the effect of the intervention. In the present study, the patterns for the association for death and the association for non-response were not identical, indicating that these two sources of missing values should be evaluated separately.

325 A Prospective Open-trial of the Effects of Supportive-Expressive Group Psychotherapy in Breast Cancer Patients Rossi E, Sabato S, Gatti M, Grassi L Department of Behavior and Communication, Section of Psychiatry, University of Ferrara, Ferrara, Italy Supportive-Expressive Group Therapy (SEGT) was shown to be effective in reducing general psychological symptoms in cancer patients. No study has been tested this approach in cancer patients with established psychiatric disorders and in a different cultural context, such as Italy. Thirty-nine breast cancer patients with an ICD10 psychiatric diagnosis (i.e. affective disorders, adjustment disorders) participated in the SEGT and were assessed with regard to psychological stress symptoms (BSI), coping styles (Mini-MAC), social support (MSPSS), openness to the family about illness (OS), and cancer-related worries (CWI) at a three-point times (baseline, 6-month and 1 year).

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Significant reductions were observed on BSIdepression, anxiety, and global stress index, maladaptive coping (Mini-MAC hopelessness and anxious preoccupation) and CWI. Improvement was also shown on OS and MSPPS. In this pilot open trial, the SEGT was found to be a promising effective intervention for breast cancer patients with psychiatric comorbidity and to be feasible in the Italian cultural context.

326 Compliance Predictors of CBT Group Treatment in Breast Cancer Patients S!anchez N, Ja!en J, Vidal A, Peri JM, Salamero M Clinical Institute of Pyschiatry and Psychology Hospital Clinic, Barcelona, Spain INTRODUCTION: Research on group psychotherapy indicates that 33–50% of mental health clients drop out of treatment prematurely. To our knowledge these kind of studies in cancer patients are meager. The aim of this study is to determine some of the variables relating to treatment drop out in a naturalistic setting. METHOD: The subjects of the study were 38 women with a recent diagnosis of breast cancer in earlier stages I or II, being recently enrolled in oncologic treatment, and without psychiatric disorders. Psychological intervention lasted for 10 weekly sessions of cognitive-behavioral group therapy, which included stress management, coping skills enhancement, and psychosocial support. During the first sessions patients were assessed with EPQ, COPE, EORTC QLQ-BR23 and GHQ. According to whether they completed the treatment the patients were divided into two groups. Differences in clinical, sociodemographic and psychological variables were tested for both groups using Student’s t test. With variables that showed statistical signification a steepwise logistic regression analysis was performed. RESULTS: Eighteen patients (58.1%) completed the group therapy while 13 (41.9%) failed to complete it. Only ‘‘body image’’ (EORTC) and ‘‘suppression of competitive activities’’ (COPE) yielded p values of 0.032 and 0.045, respectively. The two variables were retained in logistic regression model with a 0.019 and 0.025 significance level. The model explained 82.1% of the outcomes. DISCUSSION:

Copyright # 2004 John Wiley & Sons, Ltd.

According to our results, predictors of compliance are related to focusing on illness as a way of coping and also a better body image. Other studies are needed to confirm this preliminary data.

327 Integrate Diversities for an Olistic and Evolutive Well-being Serina CS Psychotherapy C.R.E.D.E.S., Milano, Italy All human beings search for a balance between themselves and the world, compromising and hoping to satisfy their expressiveness and desire just enough to feel a sense of wellbeing. Therefore, they have to continuously reprogram their existential codes, not always quietly. Often their need for change does not fit into the context, or a new context is not welcome by them. The evolutive drive is the natural push towards the ‘‘becoming’’ and is responsible for consciousness changes and evolution. It also causes the crises that personally threaten and upset our quiet existential routine. The evolutive drive is unknown because not acknowledged. Our conscious system lacks the information necessary to deal with and elaborate this subconscious information. We usually deal with the evolutive drive indirectly, in our subconscious, sometimes violently, through the symptom, the malaise. Behind every symptom there is an unexpressed wish, the voice unheard, therefore unacknowledged, of the self. The disease, expression of existential suffering, forces the subject to examine himself, to verify his choices and ideas; in this situation it is important to start psychotherapy. The symptom, if admitted and understood, projects the subject towards a new self-consciousness. It transforms the ‘‘energylink’’ which keeps the subject passively tied to his old schemes and habits, and harmonises him with the ‘‘becoming’’, introducing a new way of thinking and being. If we freely drift in the river of life and choose to undertake this inner voyage, ‘‘aliens’’ become allies, no longer to be feared but new acquaintances, identities, stability to embrace. Examples. . . [truncated].

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328 The Effectiveness of Cognitive-behaviour Therapy in the Treatment of Insomnia in Cancer Patients: Three Case Studies from the Republic of Ireland Steggles S Psycho-Oncology Services, St. Luke’s Hospital, Dublin, Ireland PURPOSE: Three case studies are presented to illustrate the use of a cognitive-behavioural approach including hypnosis to treat insomnia for cancer patients who were undergoing 6-weeks of radiation treatment at St. Luke’s Hospital, Dublin, Ireland. METHOD: Case study participants underwent an initial assessment involving a clinical interview and the administration of questionnaires to assess their sleeping problems and related issues. Specifically, the Insomnia Symptom Questionnaire (ISQ) was administered before treatment began and 2-weeks after the completion of treatment. Participants also completed a sleep diary daily (SDD) before treatment began, during the treatment phase and for another 2-weeks after the completion of treatment. The clinical intervention involved six-sessions and included: (a) Psycho-education}education about the cognitivebehavioural model of anxiety and its relationship with sleeping difficulties, with emphasis on learning self-help skills to cope with sleeping problems; (b) hypnosis/self-hypnosis}participants were taught self-hypnosis, focusing on both relaxation and challenging their anxiety-producing and maladaptive sleep thoughts; and (c) cognitive restructuring}participants were taught to recognize, challenge and replace maladaptive sleep cognitions, challenging their validity, and reframing them into more adaptive substitutes. RESULTS: On the two outcome measures, the ISQ and the SDD, all case study participants showed varying degrees of improvement. CONCLUSIONS: Findings suggest that the clinical interventions utilized were effective in ameliorating sleeping problems for the case study participants. Caution should be exercised in generalizing the efficacy of the clinical intervention based upon these three case studies.

329 Daughters at the Edge of Life: A Grief Recovery Program for Families of Cancer Patients

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Turner LJ, Cumming CE Department of Psychosocial and Spiritual Resources, Cross Cancer Institute, Edmonton, Canada In our comprehensive cancer care centre in Western Canada, grief recovery for family members who have lost a close relative to cancer is facilitated through individual and group therapy. Until recently, all family members had access to only one general group format serving spouses, siblings, and adult children. In this presentation, a group specifically for daughters who had lost a mother to cancer will be described. The theoretical orientation, group format, and specific intervention techniques used in this innovative group will be described. The results of program evaluation undertaken using both quantitative and qualitative techniques will also be provided. One very special outcome of the 11-week group reported by the participants is the validation of their unique experience as daughters. Previously, they lacked validation and support. When together with other daughters who had actually been closely involved with the ‘‘living with cancer and with the death of the cancer patients, they experienced empathy and understanding that was unavailable to them anywhere else. These daughters illustrate the existence of under-served individuals impacted profoundly by cancer. Implications for future research and clinical practice will also be presented.

330 Causal Beliefs of Lymphoma Patients Concerning their Disease After Short-term Psychotherapy Tyroller MT1, Bumeder IB2, Halevy CH1, Frick EF1 1 Department of Psychosomatics and Psychotherapy, Clinic for Psychiatry Ludwig-MaximiliansUniversity, Munich, Germany; 2Department of Hematology and Oncology, Medical Clinic Ludwig-Maximilians-University, Munich, Germany PURPOSE: To examine effects of short-term psychotherapy in lymphoma patients in terms of patients’ subjective causal attributions regarding their disease. METHOD: This survey is part of a longitudinal study concerning the quality of life of patients after bone-marrow transplantation and

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psychotherapeutic intervention. Patients completed the Questionnaire of Personal Illness Causes (QPIC) before, directly after and 12 month after a short-term psychotherapy which lasted 6 months. We controlled medical parameters such as Karnofsky’s index and state of remission. RESULTS: Fifty-one lymphoma patients (43% women, 53% suffering from a multiple myeloma, 35% from non-Hodgkin-Lymphomas, 12% from other malignancies) were included. Directly after short-term psychotherapy, patients believe substantially and significantly (p50.05) less in fate as a cause for disease (measured by QPIC-item 7) but more in internal issues such as unfavourable life attitudes (QPIC-item 2), insufficient capacity to cope with burdens and crises (QPIC-item 16), and insufficient self-assertiveness in conflicts with other people (QPIC-item 19). This effect stays stable 12 months after therapy and is largely independent from medical parameters. CONCLUSION: Patients’ subjective causal attributions regarding their disease play an important role in coping. Our results indicate that therapeutic interventions can effectively influence patients’ attitudes towards their disease, foster patients’ awareness of inner processes, thus enabling them to cope actively with their disease.

women with recently diagnosed primary breast cancer were randomised into an early- or latestarting intervention program. Women received questionnaires concerning demographic and medical variables and psychosocial adjustment before the start (T1), at the end (T2) and 6 months after completion of the intervention (T3). RESULTS: In our study sample, time of starting the intervention was significantly related with distress. Women who started later with the intervention were more distressed than those who started earlier. In all women, there were some changes across time. After some time, women reported less distress, less social interactions, a more positive body image and recreation. Women treated with breast conserving therapy reported a more positive body image and better sexual functioning. Women with better prognoses reported better sexual functioning. Older women reported a more positive body image than younger women. CONCLUSIONS: Time of offering psychosocial interventions for women with primary breast cancer is not related with psychosocial adjustment at 6 months followup. However, since women who started later with the intervention program were more distressed, we suggest that it would be advisable to start with an intervention program soon after surgery, to prevent women from becoming distressed after some time.

331 Effects of Delayed Psychosocial Interventions Versus Immediate Psychosocial Interventions for Women with Early Stage Breast Cancer Vos PJ1, Garssen B1, Visser AP1, Duivenvoorden HJ2, de Haes JCJM3 1 Research Helen Dowling Institute, Utrecht, The Netherlands; 2Department of Medical Psychology and Psychotherapy, Erasmus, MC, Rotterdam, The Netherlands; 3Department of Medical Psychology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands PURPOSE: In the past years many psychosocial intervention programs for women with breast cancer have been tested, usually It could be that time of offering psychosocial counselling influences psychosocial adjustment. The aim of this study is to test whether sooner or later start of the psychosocial counselling results in different psychosocial adjustment. METHODS: Sixty-seven

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332 Effectiveness of Group Psychotherapy Compared with Social Support Groups in Patients with EarlyStage Breast Cancer Vos PJ1, Visser AP1, Garssen B1, Duivenvoorden HJ2, de Haes JCJM3 1 Research Helen Dowling Institute, Utrecht, The Netherlands; 2Department of Medical Psychology and Psychotherapy, Erasmus, MC, Rotterdam, The Netherlands; 3Department of Medical Psychology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands PURPOSE: Many intervention programs for cancer patients have been developed with most of them reporting positive results on psychosocial adjustment. The purpose of this study is to test the effectiveness of two types of interventions: A social support group (SSG) and an Experiential-Existen-

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tial group psychotherapy (EEGP). METHODS: Sixty-seven women with primary breast cancer participated in this randomised intervention study. Women were randomised after filling in the first questionnaire, before the start of the intervention (T1). Other questionnaires were filled in just after completion of the intervention (T2) and at 12 months follow-up (T3). Questionnaires concerned demographic, medical and psychosocial adjustment variables. RESULTS: Type of intervention was not related with most of the psychosocial adjustment indicators at 12-month follow-up. Only Social Interactions was slightly related with type of intervention: Women in the SSG reported less social interactions as a result of their illness. After some time, patients form both interventions reported to participate in more recreational activities, have a more positive body image and experience more vitality. Women treated with breast-conserving therapy reported a more positive body image and better sexual functioning. Stage of disease was weakly related with recreational activities: a worse stage is related with less recreation. CONCLUSIONS: In our study, sample type of intervention was not related with psychosocial adjustment. Women in our study were, however, already well adjusted at the start, making improvement difficult. Because of a lack of a randomised control group, we could not test whether participating in a psychosocial intervention program has prevented. . . [truncated].

333 The Effects of Psychological Intervention on the Quality of Life of Chinese Cancer Patients Wang WJP et al. Psychology, Beijing Normal University, Beijing, PR China PURPOSE: The purpose of this study was to examine the effects of relaxation and imagery training on the emotional and physical functioning of Chinese cancer patients. METHODS: Three hundred and eighty-nine cancer patients undergoing chemotherapy or radiotherapy were randomly assigned to either the intervention or the control group. Patients in the intervention group were trained in relaxation and imagery skills before medical treatment and practiced twice a

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day individually and once a week in groups via tape accompanied by clinical psychologists and nurses during hospitalization. Emotional and physical functioning and immune parameter variables of both groups were measured before and after chemotherapy and radiation therapy, by using the QLQ-C30 ‘‘Quality of Life Questionnaire-Core30’’, the POMS ‘‘Profile of Mood States’’ and NK (natural killer) cell activity as three main indicators. RESULTS: Results indicated that patients who received relaxation and imagery training reported significantly less emotional distress and higher global quality of life than did the control group. Most scores of scales in the QLQ-C30 and the scores of a few emotional scales in the POMS improved within the intervention group. NK cell activity was more sensitive to psychological intervention and changed significantly after intervention. CONCLUSIONS: These findings suggest that relaxation and imagery training are effective psychological interventions that are beneficial for Chinese cancer patients both on emotional and physical functioning.

Psychotropic Drugs 334 Quetiapine for Acute Anxiety in Cancer Inpatients Sherman LK, Khalsa D Neuro-Oncology, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA Anxiety, a very common comorbidity in cancer patients, manifests itself in many forms, including generalized anxiety, panic, anticipatory anxiety, phobias, and post-traumatic symptoms. Furthermore, drugs (e.g. corticosteroids) can exacerbate or cause anxiety, as can medical comorbidities (e.g. hypoxia). Benzodiazepines are commonly prescribed for anxiety in cancer patients, however these medications may be contraindicated in some. There are a number of reasons in the medically ill inpatient that may preclude the use of a benzodiazepine. Short-acting benzodiazepines can decrease respiratory drive, and must be used with extreme caution in patients with respiratory compromise. Furthermore, the inpatient cancer population has a high incidence of delirium, which can be precipitated or exacerbated by

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benzodiazepines. A large percentage of cancer patients are elderly, who are more prone to experiencing altered mental status from benzodiazepines than younger patients. This case series reviews our use of the atypical antipsychotic quetiapine (Seroquel) in acutely anxious cancer inpatients. Fourteen of 15 patients treated had improvement of acute anxiety on standing, divided doses of quetapine (maximum total daily dose 200 mg). The patients were widely ranging in age, cancer diagnosis, and severity of current medical issues. Additional quetiapine was occasionally utilized as-needed for some patients; quetiapine also appeared efficacious when used in this manner. This case series suggests that quetiapine is efficacious and safe for use in acutely anxious medical inpatients, and is a good alternative when benzodiazepines are contraindicated. Further investigation, including prospective trials, for assessing the efficacy of quetiapine in this population are warranted.

cancer patients of terminal stage. METHODS: We administered RSD-OS to patients with delirium (ICD-10) during 1 year. The effectiveness was judged with clinical global impression (CGI) score that compared the psychiatric conditions. RESULTS AND CONCLUSION: The average daily dose of RSD-OS was less than 2.0 ml and extrapyramidal syndrome was not found. Due to the decrease of CGI score, the effectiveness to the cancer patients with delirium was proved. Furthermore, compared with injections, liquid medicine prevents more the infection by needle-stick accidents. It is also simple to handle without any invasive, which lowers the invasive that physicians or medical staff has psychologically and physically towards the patients.

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335 Advantages of Risperidon Oral Solution to the Delirium of the Cancer Patients of Terminal Stage Todoroki KT1,2, Yamada YY3, Yoshida YY1, Sumiyoshi AS1, Miyaoka HM1 1 Psychiatry, Kitasato University of Medicine, Sagamihara, Japan; 2Psychiatry, Tsuruga Hospital, Nagano, Japan; 3Internal Medicine, Aiwa Hospital, Nagano, Japan PURPOSE: It is said that delirium can be seen with more than a half of the terminal cancer patients. The main drug treatment is the conventional antipsychotic agents, however, their effectiveness is not sufficient due to the appearance of extrapyramidal syndrome. In recent years, the strategies of the medicinal treatment for psychiatric cases have changed with the appearance of atypical antipsychotic agents and in Japan, risperidone oral solution (RSD-OS) has been made available since July 2002, in addition to tablets and powders. RSD-OS is proved to enjoy biologically the same effective as the tablets. Also, it is expected that RSD-OS provides rapid absorption and takes shorter time to reach peak plasma concentration. It can also be given in a small dose and to a patient with a swallowing difficulty. This is the report of some experiences of utilization of RSD-OS to

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Identifying Predictors of Quality of Life in a Randomized Sample of Breast Cancer Patients Andritsch E1, Baider L2, Dietmaier G1, Samonigg H1 1 Clinical Oncology, University of Medicine, Graz, Austria; 2Sharrett Institute of Oncology, Hadassah University, Jerusalem, Israel In Austria, breast cancer accounts for 15% of all cancers and 30% of all cancers in women. Although different studies state an acceptable level of quality of life for long-term survivors especially in breast cancer patients there is the need to know more about the different impacts of psychosocial variables on the level of quality of life. PURPOSE: The purpose of the study was to identify demographic, medical and psychosocial predictors of the level of quality of life in 210 breast cancer patients within 1–5 years after being diagnosed and disease free at the time of the investigation. METHODS: In this study being conducted in the Clinical Division of Oncology at the University of Medicine in Graz/Austria, the patients were interviewed with a semistructured interview and 5 standardized instruments, the Brief Symptom Inventory, the Psychological Adjustment to Illness Scale, the Impact of Event Scale, the Mental Adjustment to Cancer and the Perceived Family Support were used. The quality of life 5 years

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before the assessment, at present time and the expected quality of life level in 5 years from now was assessed on the Likert Scale. RESULTS: The multiple regression analysis showed that the most important predictors of the quality of life in this sample were the General Severity Index, the depression and the helplessness/hopelessness level. The relationship between quality of life and other psychosocial variables will be demonstrated and discussed.

tionally, the eight dimensions may be used to assess relevant factors that contribute to: (1) the risk of an individual survivor for poor HRQOL, and (2) group disparity in HRQOL outcomes. Moreover, the model provides a potential tool for identifying how cultural, socio-ecological and individual factors contribute to individual risk and group disparity in HRQOL.

338 337 A Paradigm for Expanding the HRQOL Framework: A Model for Assessing Health Disparities Among Cancer Survivors Ashing-Giwa KT Medicine-Ctr for Culture & Health, UCLA, Los Angeles, CA 90024, USA This paper will discuss the contextual model of survivorship, under development by Dr AshingGiwa. This model adds contextual dimensions of culture and social-ecology to the HRQOL framework. Culture can be defined as a way of life, a way to view and behave in the world. The socioecological dimensions include socioeconomic status (SES) and life burden (e.g., illness, discrimination). The model is informed by: the HRQOL model, the biopsychosocial model, research findings, cancer literature, and the multicultural and psychological literature. The dimensions of the model include: (1) Socioecological context, (2) Cultural context, (3) Demographic context, (4) Systemic context, (5) Cancer-related medical factors, (6) General health and co-morbidity, (7) Health practices and utilization, and (8) Psychological well-being. These dimensions are thought to be correlated with each other and independently related to HRQOL. Therefore, the assessment of the larger macro dimensions (#1–4) combined with the more micro (#5–8) dimensions may be a more clinically sensitive and valid tool for predicting HRQOL. Further, the more proximal variables namely psychological well-being; cancer-specific medical factors; health practice and utilization; and general health and co-morbidity can each be examined as an important outcome variable measuring a specific dimension of HRQOL outcomes. Addi-

Copyright # 2004 John Wiley & Sons, Ltd.

Psychological Aspects of the Life Quality of Teenagers with an Oncopathology in a Stable Remission Aslanyan KS1, Aralova MP2 1 Ambulance of Onco-hematological Center, Rostov Regional Children’s Hospital, Rostov-on-Don, Russia; 2Clinical Psychology, Rostov State University, Rostov-on-Don, Russia PURPOSE: Subjective evaluation of life quality (LQ)}value orientations, temporal outlook, emotional status}of teenagers with an oncopathology (13 people) in a stable remission (over 10 years) were compared with that of their healthy coevals in order to test the initial hypothesis: features of emotional status, temporal outlook and value orientations may be psychological indicators of LQ. METHODS: Modified self-appraisal test by Dembo-Rubinstein, method of Newtten (modified by Tolstyh), ‘‘Time trade’’ method by Buckingham, Rosenzweig Picture Frustration Study, methods of mathematical statistics. RESULTS AND CONCLUSIONS: Teenagers with oncopathology in stable remission have following indicators of their psychic status: considerable exceeding of situational and personal anxiety (background psychic state); fixation on their own health, on need of comfort for body and soul; parents’ priority and need to get their help in difficult situations; lack of striving for self-assertion and unimportance of cognitive necessities. Study of temporal-outlook as an indicator of satisfaction-with-life for youth age revealed predominance of interest to events of present, nearest (1 year) or far future, as well as low interest towards after-school professional education, process of becoming adult. These results differ from general age tendencies (literary sources) and from results of healthy coevals (our researches). The results obtained indicate disharmonic psychic

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maturity of teenagers after old oncopathology; they may also be indirect-indicators of lower LQ of our probationers according to objectiveindicators of their age-related personal maturity. Unfavourable}according to socialadaptation-criteria and personal-autonomy-acquiring}variant of becoming adult and of youth self-determination process is peculiar to them.

survivors; 47% for 5-year survivors; 34% for 10year survivors). Additional findings will be reported.

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The American Cancer Society’s Quality of Life Studies of Cancer Survivors Baker F, Stein K, Smith T Behavioral Research Center, American Cancer Society, Atlanta, USA

What are the Social Difficulties of Newly Diagnosed Cancer Patients and how are they Associated with Sociodemographic Factors and Quality of Life (QL)? Booth L1, Wright P1, Johnston C1, Winterbottom A2, Selby P1 1 Psychosocial & Clinical Practice Research Group, Cancer Research UK, Leeds, UK; 2Academic Unit of Haematology & Oncology, University of Leeds, Leeds, UK

An estimated 10 million Americans are cancer survivors, yet relatively little is known about their long-term needs and the factors that determine good survivorship and quality of life. Most research on adult survivors has been conducted at academic cancer centers using small samples and covering the period immediately after posttreatment. To address these limitations, the Behavioral Research Center of American Cancer Society is conducting two major research studies. The Study of Cancer Survivors-I (SCS-I) is a nationwide, longitudinal study of persons diagnosed with one of 10 common cancers. Patients are enrolled during the first year after diagnosis and are followed with periodic questionnaires for up to 10 years. To obtain data needed now on long-term survivors, the BRC has also developed the Study of Cancer Survivors-II (SCS-II), a cross-sectional study of survivors at 3 points in the survivorship continuum (2, 5, and 10 years). Although data collection is not yet complete, preliminary analyses are underway, and some significant findings are emerging. Preliminary results from 2093 survivors show that a large proportion report persistent problems even 2, 5, and 10 years after diagnosis. Specifically, problems reported as moderate-tosevere in over one-third of the survivors were fear of recurrence (44%), fatigue (44%), sleep difficulties (42%), concerns about ability to have sexual intercourse (40%), and fears about the future (35%). Of these problems, only fear of recurrence appeared to decline over time (46% for 2-year

The Social Difficulties Inventory (SDI) evaluates social difficulties of cancer patients. The SDI has been psychometrically tested on patients at various stages of disease. Previous work found social difficulties were significantly associated with recent diagnosis. PURPOSE: To discover social difficulties experienced by newly diagnosed cancer patients and to examine the association of these difficulties with psychological distress, QL and sociodemographic status. METHODS: As part of a longitudinal study patients completed, at baseline, SDI, Hospital Anxiety & Depression Scale, EORTC Quality of Life Questionnaire-C30 and sociodemographics using a computer touchscreen. RESULTS: One hundred and forty patients participated, 61 males, 79 females, mean age 54.1 (20–88). The majority proved resilient regarding social difficulties. Most commonly experienced difficulties were recreational activities (59%), domestic chores (56%) and holidays (55%). Multiple linear regression demonstrated significant association between social difficulties and younger age, psychological distress and poorer physical functioning explaining 42% of the variance. No association was found with gender or socioeconomic group. CONCLUSIONS: The experience of newly diagnosed cancer patients confirms results described in the psychometrics study. There are some differences between these and previous results, e.g. difficulty managing personal care is more marked in newly diagnosed patients but sexual difficulties less marked. The association between social difficulties and age, psychological

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distress and physical functioning shown in the initial study is confirmed, but again does not explain the whole picture. Patients will be followed up for 2 years, the baseline and follow-up results may inform the implementation of routine psychosocial and QL assessment in oncology practice.

341 Women with Breast Cancer: The Relationship of Anxiety, Depression, Age, Stage of Cancer and Cancer Treatment to the Quality of Life Bulotiene G, Veseliunas J Physical Medicine and Rehabilitation Institute of Oncology, Vilnius University, Vilnius, Lithuania PURPOSE: The aims of this study was to evaluate the dependency of quality of life of breast cancer patients upon the level of anxiety and depression, the age of the patients, the stage of cancer and cancer treatment. MATERIALS AND METHODS: The study cohort comprised 63 women with breast cancer treated in the Department of Breast Surgery of Institute of Oncology. EORTC QLQ-C30 questionnaire and Hospital Anxiety and Depression Scale (HADS) were used for the study. RESULTS: The study revealed that borderline and abnormal results in HAD scale correlates with worse results of General quality of life, Emotional and Cognitive functioning. Higher depression level correlates with worse results in Insomnia and Financial difficulties. The results in Physical functioning, Insomnia and Constipation were statistically reliably worse in women 60 years and elder than in younger ones, but the results in Social functioning were worse in younger patients. For the patients with I–II stages of breast cancer results of Role and Cognitive functioning scales were statistically reliably better than those of the patients with III–IV stage. There was no statistically reliable difference found in Quality of life of women treated for breast cancer for the first time and those treated repeatedly. CONCLUSIONS: Worse results in Quality of life of breast cancer patients depends upon higher level of anxiety and depression, elder age, higher stage of disease, but does not depend upon cancer treatment.

Copyright # 2004 John Wiley & Sons, Ltd.

342 Measuring a Sense of Empowerment in Cancer Patients Bulsara C1, Ward A1, Joske D2, Styles I3 1 General Practice, University of Western Australia, Perth, Australia; 2Haematology, Sir Charles Gairdner Hospital, Perth, Australia; 3School of Education, Murdoch University, Perth, Australia The concept of empowerment and the degree to which it exists amongst cancer patients is often overlooked within the clinical setting in hospitals and amongst health professionals. Although in theory, many doctors acknowledge the importance to patients of regaining some measure of control over their illness, in reality empowering patients proves problematic. Given the liminality of the cancer experience many patients struggle to maintain a sense of empowerment whilst coping with their condition. Nonetheless, it is evident that management of the illness in terms of understanding, acceptance and adapting one’s lifestyle is beneficial to most patients. Trying to identify markers for empowerment in terms of coping strategies employed by cancer patients is possible. Following a qualitative phase of the research, a preliminary scale has been developed which seeks to identify and name these markers to measure the degree of empowerment present in cancer patients. A Pilot Scale was developed and implemented amongst patients attending the Haematology Care Centre of a teaching hospital in Perth, Western Australia. The findings, analysed using Rasch analysis, identifies which markers have most relevance to cancer patients’ ability to cope with the management of their illness. A further refined scale is currently being administered to a wider group of cancer patients attending Medical Oncology and Radiation Oncology clinics. It is hoped that health professionals will use the scale to assist in establishing areas of strength and weakness in the cancer patient’s ability to adjust to and manage their condition.

343 Native American Cancer Education for Survivors (NACES) Burhansstipanov L1, Krebs LU2, Hariton J1, Dignan MB3, Gamito E2

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National Native American Cancer Survivors’ Support Network, Native American Cancer Research Pine, Colorado, USA; 2School of Nursing, University of Colorado, Health Sciences Center, Denver, Colorado, USA; 3Kentucky Prevention Research Center, Lucille P. Markey Cancer Center, Lexington, Kentucky, USA Native American Cancer Education for Survivors (NACES) is a study comprised of four interactive, personalized education modules designed to improve access to quality of life (QOL) resources by Native American breast cancer survivors enrolled within the ‘‘National Native American Breast Cancer Survivors’ Support Network’’ (hereafter referred to as ‘‘the Network’’). It is supported by the Susan G. Komen Breast Cancer Foundation. A total of 28 modules have been identified as high priority needs by Network members and additional applications have been submitted for the remaining modules. The presentation will share evaluation data from two of the quality of life (QOL) modules: improving patient-provider communication specific to QOL issues; and QOL clinical trials. The Network is a cohort of approximately 400 Native American breast cancer survivors. There is a disparity within our community in comparison with other ethnicities’ ability to access QOL services and resources. There are multiple reasons why this disparity remains in our community. The purpose of this proposed study is to develop and pre-test the effectiveness of a culturally appropriate intervention on quality of life of Native American breast cancer survivors. The primary research question of this randomized study is, ‘‘Does a cancer education intervention that is adaptable to the needs of Native American cancer patients increase access and utilization of resources that improve the survivor’s quality of life?’’

sity Hospital, Leeds, UK; 2Clinical Trials and Research Unit, The University of Leeds, Leeds, UK PURPOSE: Quality of Life questionnaires can be used routinely in oncology practice to inform physicians and monitor patient problems. This study explored patient and physician views on which symptoms/functional issues should be routinely measured. METHOD: Nine focus groups were held with cancer patients from two hospitals in Leeds, UK. Groups were stratified by age and treatment intent. Five groups were conducted with physicians and nurses, stratified by profession and seniority. The content of the groups focused on what was routinely discussed in consultations and what issues were deemed important but not always addressed. Transcripts were analysed using Interpretative Phenomenological Analysis. RESULTS: The results reported are based on analysis of three patient and one doctor group in one hospital. The other groups are ongoing and will be reported at the conference. Both patients and doctors stated that they most often talk about physical symptoms, treatment side-effects and test results. Important items, but not always addressed, included work and financial advice and coping emotionally with cancer. Patients differed in their opinion about discussing family and personal/intimacy problems. They found difficult to ask questions on disease course and life expectancy. Patients strongly felt that more input from other health professionals (nurses, psychologists) and greater availability of information would improve their care. CONCLUSIONS: The issues identified will be added to an existing questionnaire package and tested in a prospective randomised study. The overall purpose of the research seeks to maximise the effects of QL information on process of care and patient outcomes.

345 344 Focus Groups: Doctor and Patient Views on Routine Quality of Life Measurement in Oncology Practice Coles-Gale RE1, Velikova G1, Awad N1, Brown J2, Wright P1 et al. 1 Psychosocial and Clinical Practice Research Group, Cancer Research, UK}St. James’ Univer-

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Lymphedema and QOL in Breast Cancer Patients Condoleo MF1, Pugliese P1, Pietrangeli A2, Falcicchio C1, De Fulviis A2 1 Psychology, National Cancer Institute, Regina Elena, Rome, Italy; 2Neurology, National Cancer Institute, Regina Elena, Rome, Italy PURPOSE: To evaluate the effect of lymphedema on Quality of Life (QoL) and on psychological

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distress. METHODS: QoL was performed with the EORTC QLQ C30 and QLQ BR23 questionnaires. Anxiety and depression were evaluated with HADs. Patients with lymphedema were submitted to a structured interview focused on the patient perception of the symptom degree. We enrolled 80 breast cancer patients during followup, comparing them with a group of patients without limphedema. RESULTS: The QoL areas more affected by lymphedema were: role functioning, fatigue, pain, insomnia, health and global QoL, sexual functioning and pleasure, future perspectives and arm physical symptoms. The comparison of two groups showed significant differences in role functioning, pain; health and overall QoL (p50.005). The mean scores of QLQ BR23 showed significant differences in sexual pleasure and in arm symptoms (p50.005). The more experienced symptoms were pain (44%), swelling (10%), loss of arm strength (70%). In these symptoms the severity was upper 50 (range 0–100). In the independence area 84% of patients complained problems in their affected arm during daily lives. In the mental functioning area, 90% of patients avoided to dress some wears and 70% of them avoided using the affected arm. In the social support area, 70% of patients received an adequate consideration of their physical problem and a good support from their partner. In the hobbies and sports area, 73% of patients complained limited arm movements. Sixty percent of patients showed high rates in the Anxiety Scale.

346 Life Domain and Contextual Moderators of IllnessInduced Lifestyle Disruption: A Test of the Illness Intrusiveness Theoretical Framework in Six Common Cancers Devins GM1,2, Bezjak A3,4, Mah K1, Loblaw DA5, Gotowiec AP2 1 Psychosocial Oncology and Palliative Care, Princess Margaret Hospital, Toronto, Canada; 2Psychiatry, University of Toronto, Toronto, Canada; 3Radiation Oncology, Princess Margaret Hospital, Toronto, Canada; 4Faculty of Medicine, University of Toronto, Toronto, Canada; 5Radiation Oncology, Toronto Sunnybrook Regional Cancer Center, Toronto, Canada PURPOSE: The illness intrusiveness theoretical framework maintains that illness-induced lifestyle

Copyright # 2004 John Wiley & Sons, Ltd.

disruptions compromise quality of life in chronic life-threatening conditions and that this effect is moderated by social, psychological, and contextual factors. Considerable evidence indicates that lifestyle disruptions compromise quality of life in cancer and other diseases but the hypothesis that contextual factors moderate this effect has not been tested extensively. We investigated whether contextual factors (e.g., age, income, stressful life events) modify the experience of illness intrusiveness across three central life domains (Relationships and Personal Development, Intimacy, and Instrumental life) in six common cancers. METHODS: Cancer outpatients, including 335 men and 321 women with one of the six common cancers (breast, prostate, lymphoma, lung, head and neck, and gastrointestinal, all n’s>100) completed selfadministered questionnaires, including the Illness Intrusiveness Ratings Scale while awaiting followup appointments with the oncologist. RESULTS: Hierarchical multiple regression analyses indicated statistically significant (all p’s50.05) interactions, including Age  Life Domain, Income  Life Domain, and Stressful Life Events  Life Domain. In each case, greatest divergence was observed when illness intrusiveness involved instrumental life domains (e.g., work, finances, health, and active recreation). CONCLUSIONS: The psychosocial impact of chronic life-threatening disease depends on the life context in which it is experienced. Illness-induced lifestyle disruptions (illness intrusiveness) varied as a function of the patient’s stage in the life cycle (age), financial status, and recent eventful stressors. These findings further substantiate the illness intrusiveness theoretical framework and support its relevance for people living with cancer.

347 Quality of Life, Satisfaction with Care and Psychological Distress in Patients Randomized to Three Different Procedures for Implantable Portsystem for Long-term Chemotherapy Didier F1, Ghioni M1, Br!edart A2, Leon ME3, Biffi R4, et al. 1 Psycho-Oncology Unit, European Institute of Oncology, Milan, Italy; 2Psycho-Oncology Unit, Curie Institute, Paris, France; 3Biostatistics Division European Institute of Oncology, Milan, Italy;

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General Surgery Division, European Institute of Oncology, Milan, Italy OBJECTIVES: The aim of the study is to compare quality of life (QoL), satisfaction with care and psychological distress in patients with implantable port-system for long-term administration of chemotherapy through percutaneous subclavian versus internal jugular versus cephalic surgical venous cut-down. METHODS: Patients are randomized to surgical procedure in this trial. The comparison will include assessment of pain, discomfort and well-being. Quality of life is assessed using the European quality of life group questionnaire (EORTC QLQ-C30, version 3). Satisfaction with surgical procedure and care received is assessed by way of an instrument specifically constructed for the study. The content and format of the new instrument is based on our previous work using the Comprehensive Assessment of Satisfaction with Care (CASC). Patients’ psychological distress is assessed using the Hospital Anxiety and Depression Scale (HADS). Outcome data are being collected within 24 h (t1), 1 month (t2) and 4 months (t3) following the implantation of the port-system. RESULTS: From July 2003 to January 2004, 50 patients have been enrolled. The desired sample size is 250 patients per group, for a total of 750 patients. Preliminary results based on patients recruited up to the end of May (approximately 75 patients) will be presented.

348 ‘I’ll Play Golf Instead’: Quality of Life in Children Treated for Bone Cancer Earle EA1, Eiser C1, Grimer R2 1 Psychology, University of Sheffield, Sheffield, UK; 2 Oncology, Service Royal Orthopaedic Hospital, Birmingham, UK PURPOSE: Treatment for a bone tumour can be associated with compromised QOL, especially for young patients. We used qualitative methods to describe patients’ experiences and their coping strategies at approximately 6 months after diagnosis (n=12) and 1 year later (n=11). METHODS: Young people (aged 6–22 years) who were undergoing treatment for either osteosarcoma or Ewing’s sarcoma in the lower limb and a parent

Copyright # 2004 John Wiley & Sons, Ltd.

took part. We devised a semi-structured interview to assess participation in sport, social life and schooling and general mobility, Interviews were transcribed and analysed using content analysis. RESULTS: Similar discrepancies were reported on both assessments. All families reported strategies to resolve these discrepancies, with evidence of an overall shift from Problem (constructive attempts to reduce harm)}to Emotion (managing the situation through use of emotions) focused coping over time. CONCLUSION: Although the sample size is small, our results suggest that patients adopt a variety of coping strategies to deal with physical and social restrictions associated with treatment. Patients are more likely to rely on problem focussed coping 6 months after diagnosis compared with a year later. The findings suggest that young people continue to experience many stresses 2 years after diagnosis.

349 Parental Quality of Life and Childhood Cancer Goldbeck L Clinic of Child and Adolescent Psychiatry/Psychotherapy University, Ulm, Germany PURPOSE: The diagnosis and treatment of childhood cancer imposes severe stress on parents. Effects of diagnosis, time since diagnosis, gender and age of the child on parental quality of life (qol) were investigated to identify families with special needs for psychosocial support. METHODS: Sixty-two parents (33 mothers, 29 fathers) of a child newly diagnosed with a tumour or leukaemia participated in a longitudinal study. 60 parents of a child with insulin-dependent diabetes mellitus or epilepsy served as a control group. All parents filled in the Ulm Quality of Life Inventory for Parents (ULQIE) repeatedly 1–2 weeks after diagnosis and 2–3 months after diagnosis. RESULTS: Repeated measures ANOVAs revealed significant main effects of diagnosis and age of the child. Parents with a child diagnosed with a malignant disease described a lower own qol than parents with a child suffering from diabetes or epilepsy. Parents of infants and preschool children reported lower qol than parents of schoolchildren and adolescents. Time since diagnosis, parental gender, and type of malignancy (tumour vs.

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leukaemia) had no effect on parental qol. CONCLUSIONS: Within a family centred approach of psychosocial support in paediatric oncology, parents of young children newly diagnosed with cancer need special attention.

350 Coping and Adjustment in Indonesian Elderly Cancer Patients Halim MS, Sari AD Psychology, ATMA Indonesia Catholic University, Jakarta, Indonesia PURPOSE: The aim of this study was to examine the relation between coping strategy and adjustment in a sample of Indonesian elderly cancer patients. We assumed that the way cancer patient adjusted to their disease might be determined by their coping strategy. METHODS: Forty cancer patients (age above 60 years) participated in this study were recruited from Dharmais Cancer Hospital in Jakarta. They completed two instruments: Ways of Coping and Mini MAC. Multiple regression was used for statistic analysis. RESULTS: The results of this study showed a significant relationship between coping and adjustment. A tendency that most of Indonesian elderly cancer patients used more emotion focused coping strategy than problem focused coping strategy was also found. Moreover, the results also indicated that ‘distancing’ was a significant contributor either to fatalism or to cognitive avoidance. Further discussion will be explained later.

Their structured group educational model is held in retreat centres throughout the United States, Germany, Switzerland, Poland and Japan and includes a professional training and certification program. Using a simple questionnaire designed by Maxie Maultsby, MD from Howard University Medical School, the program incorporates a Cognitive Behavioral Model for systematically teaching patients to evaluate their beliefs and attitudes for their relative health value. Patients are taught strategies on how to change beliefs, minimize emotional pain, depression, anxiety, and how to habituate healthier emotional patterns. The important issues of hope, trust and purpose are addressed by systematically examining a patient’s foundational spiritual beliefs from an ecumenical viewpoint. One of the central components of this educational program has been the refined format for addressing the topic of death, which includes exploring and strengthening healthier beliefs to reduce fear and anxiety, which interfere with a person’s ability to maximize their healing response. A variety of Visual Imagery techniques and Mindful Meditation Practices are employed to train patients in the vital use of the Imagination in regaining health. The Process Communication Model developed by Taibi Kahler, PhD, and used by NASA for over 20 years is used to provide patients with a roadmap on how to positively relate to their spouses and physicians and to understand and manage their predictable distress patterns more effectively.

352 351 Specific Psychological Interventions to Decrease Emotional Distress and Improve Quality of Life for Cancer Patients Hranicky JS1, Simonton OC2 1 Psycho-Oncology, The American Health Institute, Los Angeles, USA; 2Psycho-Oncology Simonton Cancer Center, Los Angeles, USA

Late Treatment Effects, Health Behavior, and Quality of Life (QOL) in Testicular Cancer Jacobs LA1, Palmer S1, Matthews G1, Meadows A2, Vaughn DJ1 1 Abramson Cancer Center, University of Pennsylvania, Philadelphia, USA; 2Hematology/Oncology The Children’s Hospital of Philadelphia, Philadelphia, USA

Over the last 25 years, Janet Hranicky, PhD and Carl Simonton, MD have designed specific interventions to decrease emotional distress and improve the quality of life for cancer patients.

BACKGROUND: TC is the most common solid tumor diagnosed among men aged 15 to 34 with almost 7000 new cases/year in the United States. Most of these patients will be cured and become

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long-term survivors. Although physiological late consequences of treatment are well articulated, the impact of late treatment effects and health behavior on QOL is not known. METHODS: The Living Well After Cancer (LWAC) Survivorship Program at Penn monitors TC survivors >2 years since diagnosis and disease-free. To date, 55 subjects have been recruited for this ongoing study. Treatment variables, objective measures of late effects, health behavior, and the City of Hope QOL measure were examined. RESULTS: Subjects were young (M=39 yr) and 63% received cisplatin-based chemotherapy (CBCT). Physical (M=8.0) and Social well-being (M=7.0) were high; Psychological (M=4.6) and Spiritual wellbeing (M=5.0) moderate. Physical, Social, and Psychological well-being were positively related (all p50.03); Spiritual well-being was independent of other QOL indices. Time since diagnosis and receipt of CBCT were not related to QOL (p>0.12). Total cholesterol was elevated in 43%, LDL in 32% of the survivors. Health behaviors were examined; 42% of subjects reported a smoking history. Smoking was a marker for decreased Social well-being; increased fatigue; anxiety; depression; uncertainty about the future; concern about second cancers, recurrences, or metastases; and interference from illness with home and financial responsibilities (all p50.05). Objective measures of late treatment effects including lipid levels were not related to cisplatin status, smoking history, or QOL (p>0.23). CONCLUSIONS: These data suggest: (1) TC survivors. . . [truncated].

conventional axillary surgical techniques in women presenting with clinically node negative breast cancer. The putative benefits of SNB are reduction of unnecessary resection of the axilla, avoiding unwanted sequelae such as arm morbidity thus permitting a better quality of life (QOL), without sacrificing any staging accuracy. Interim analyses of up to 3 months post surgery are presented here. METHODS: 867 patients, randomised to either conventional management or SNB, are completing the FACT-B+4, a standardised QOL instrument for breast cancer with a validated subscale to assess arm morbidity, and Spielberger’s State Trait Anxiety Inventory prior to surgery, then at 1,3,6,12 and 18 months post surgery. RESULTS: Seven hundred and eighteen patients have completed baseline, 1 and 3 month assessments. Analysis shows that all post operative QOL scores are higher for patients randomised to the SNB arm at 1 and 3 months post operation. Scores for the arm morbidity subscale significantly favour the SNB group (p50.001). There were no significant differences in anxiety between groups at any timepoint. CONCLUSION: There are now several studies showing the accuracy of SNB in breast cancer. The QOL data presented here lend further support to the suggestion that the procedure should be accepted as the standard of care. SNB can spare women unnecessary axillary surgery: it achieves significantly less arm morbidity post operatively and improved QOL without unacceptable anxiety.

354 353 Quality of Life in Patients with Breast Cancer: Axillary Lymphatic Mapping Versus Nodal Axillary Clearance Johnson LR1, Fallowfield LJ1, Mansel RE2 1 Cancer Research UK Sussex Psychosocial Oncology Group, Brighton and Sussex Medical School, Brighton, UK; 2Department of Surgery, University of Wales, College of Medicine, Cardiff, Wales, UK PURPOSE: The ALMANAC trial (Axillary Lymphatic Mapping Against Nodal Axillary Clearance) is a multi-centre randomised clinical trial comparing sentinel node biopsy (SNB) with

Copyright # 2004 John Wiley & Sons, Ltd.

Eprex Influences Patient Outcomes Related to Emotional Wellbeing in Breast Cancer Keresteci MA1, Chang J2, Couture F3, Ferrazzi S4 1 Research Nexus Research Solutions, Thornhill, Canada; 2Oncology Lakeridge Health Sciences, Oshawa, Canada; 3Oncology Hotel Dieu Hospital, Quebec, Canada; 4Health Economics Janssen Ortho Inc., Toronto, Canada INTRODUCTION: Anemia associated with cancer and chemotherapy treatment produces a range of symptoms that can negatively affect emotional and overall well-being. We report on the role of epoetin alfa (Eprex) in impacting the attribute of emotion in breast cancer patients receiving che-

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motherapy. While most utility assessments calculate an overall utility score (0–1), the Health Utility Index 2 (HUI2) calculates an overall utility score and quantifies the desirability or undesirability of functional capacity within a single attribute such as emotion. METHODS: Three hundred and seventy-four breast cancer patients receiving myelotoxic chemotherapy were randomised to receive Eprex (40 000 IU weekly) or standard of care (SOC). We examined the patient reported utility outcomes, as measured by HUI2, HUI3 for these patients at baseline and after 12 weeks of chemotherapy. RESULTS: This study previously confirmed that Eprex prevents anemia, improves QOL, decreases transfusion requirements and improves hemoglobin responses (ASCO, 2003). Both HUI2 and HUI3 demonstrated a statistically significant difference in overall utility scores for the Eprex group (p=0.022, 0.005, respectively). From baseline to week 12, HUI2 emotion scores improved in the Eprex group with a mean increase of 0.040, while the standard care group’s scores changed negatively with a mean decline of 0.002 (p=0.015). CONCLUSION: In these breast cancer patients Eprex significantly improved the overall utility score, including the emotion attribute specifically. A change in score of 0.03–0.04 has been reported as being clinically meaningful, leading to our conclusion that the observed improvements in the Eprex patients are of clinical importance in this patient population.

355 Information for Suicide Attempt Prevention in Advanced Cancer Kuznecovs S1, Kuznecova G2 1 Cancer Epidemiology Unit, Public Health Research Laboratory, Riga, Latvia; 2Research Group for Psychosocial Support in Cancer, Public Health Research Laboratory, Riga, Latvia PURPOSE: The purpose of the present study was to identify risk factors for suicide attempts in persons with advanced cancer. METHODS: The study is based on available information about cancer patients with onset in the period 1986–2003 and the economic status of families living with cancer patients. The Norbeck Social Support

Copyright # 2004 John Wiley & Sons, Ltd.

Questionnaire was used to examine functional support (affect, affirmation, aid) and structural support (size of network, duration of relationships, frequency of contact). RESULTS: Findings reveal that subjects received little amount of affect (love, respect, admiration) and very little amounts of affirmation (support of one’s thoughts or action) and tangible aid. Results of multivariate analysis of variance carried out on 155 stories reveals that subjects did not perceive enough support from spouse and family. The average duration of the disease was 2.4 years. Eighty-seven percent of the women and 72% of men with cancer retired because of disability. Income was adequate to pay for basic living expenses in 83% families in 1986–1991, in 65% in 1992–1997 and 17% in 1998–2003. Income was adequate to pay for medical expenses in 32, 12.5 and 5%, for nursing in 24, 4.8 and 2.2% families. CONCLUSIONS: Recognition and treatment of depression and pain are important but not main for suicide attempt prevention in advanced cancer. Spousal caregivers and family play the leading role in suicide attempt prevention. If health care providers are going to meet all needs of a family with advanced cancer, a more comprehensive assessment of their economic status is needed.

356 Health-related Quality of Life and Brachytherapy Treatment on Prostate Cancer Patients Lacorte-P!ı TM1, Guix-Melcior B2 1 Psycho Oncology Unit, IMOR, Barcelona, Spain; 2 Oncology Service, IMOR, Barcelona, Spain PURPOSE: This is a preliminary study of 240 prostate cancer patients. This study tries to assess different parameters of Health Related Quality of Life (HRQOL) in prostate cancer patients. PATIENTS AND METHOD: Two hundred and forty prostate cancer patients with an average age of 67 (50–82) referred to the IMOR Foundation. All of them were submitted to brachytherapy techniques (HDR, I125 or others). QLQ55 is a 55items self-administered questionnaire from European Organization for Research and Treatment of Cancer (EORTC). RESULTS: A descriptive analysis of data was done. We can observe that HRQOL of patients submitted to brachytherapy

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improves significantly (p50.05) after 3, 6 and 12 months. CONCLUSIONS: *

*

Brachytherapy techniques improve significantly HRQOL of prostate cancer patients. The HRQOL of prostate cancer patients depends on area, stage and extension of the tumour.

357 A Study of Psychological Adjustment in Patients with Metastatic Cancer of Unknown Primary Lenzi R1, Abbruzzese JL1, Baile WF2, Cohen L3, Parker PA3 1 G.I. Medical Oncology, U.T.M.D. Anderson Cancer Center, Houston, TX, USA; 2Neurooncology, U.T.M.D. Anderson Cancer Center Houston, TX, USA; 3Behavioral Science, U.T.M.D. Anderson Cancer Center, Houston, TX, USA Patients with metastatic cancer of unknown primary (CUP), defined as a pathologically proven malignancy without a detectable primary site, are unique in that treatment recommendations, that are usually based on a precise diagnosis, are made without either physician or patient knowing the type of the primary cancer. It could be hypothesized that because of the advanced stage of the disease (IV by definition) and of the uncertainty involved may be detrimental to the patients’ psychosocial adjustment. To date, however, no study has examined the psychosocial adjustment of CUP patients. The goal of this study was to examine the extent of depressive symptoms (CES-D), current anxiety (STAI-state), illness uncertainty (MUIS) and sense of coherence (SOC) among a group of 72 patients with CUP. Patients were 62% male, an average of 59.7 years of age (range 39.6–85.8 years) and 86% were married. Patients’ mean CESD scores were 15.8 (SD=10.1) and 41% were above the clinical cut-off of 16 which indicates that further assessment of depression is warranted. Anxiety scores ranged from 20 to 7 0 (mean=39.5, SD=14.2). Patients’ uncertainty scores were higher than other cancer populations (mean=93.6, SD=10.4). Patients could find meaning in their illness (comprehensibility

Copyright # 2004 John Wiley & Sons, Ltd.

mean=50.8, SD=6.1; manageability mean=65.7, SD=6.9; and meaningfulness mean=46.0, SD=7.2). CUP patients experience significant levels of difficulty in psychological adjustment. Further study is necessary to further characterize their experiences and to develop specific interventions.

358 The Role of Social Support, Fatalism and Mood on the Relationship Between Spirituality and Quality of Life in Women with Breast Cancer Levine EG Research Institute, California Pacific Medical Center, San Francisco, USA In recent years there has been an emergence of interest in spirituality, mood, and quality of life in cancer patients. However, little research has examined the potential buffering effects of social support and fatalism on quality of life. This study examined the relationships between spirituality, fatalism, social support, mood, and quality of life of 181 women with breast cancer. All of the variables were significantly related to quality of life: spirituality r=0.53, social well-being r=0.33, mood r= 0.72, and fatalism r=0.61 (all p’s were 0.0000). Spirituality was significantly correlated with: mood r= 0.58, social well-being r=0.33, and fatalism r=0.61 (all p’s 0.0000). All of the variables were significantly correlated with each other (all p’s 0.0000). The amount of variance in quality of life explained by spirituality, social wellbeing and mood was r2=0.64. All of the variables in this model contributed significantly (p=0.003 for spirituality, p=0.0000 for social well-being and mood). This model explained the highest amount of variance in quality of life. Fatalism did not add significantly to the model and in fact lessened the influence of spirituality to quality of life. Clinicians should examine the role of spirituality in the patient’s life, especially as relates to social support and mood.

359 Quality of Life Research in Chinese Cancer Patients

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Luo J Department of Medical Oncology, Cancer Hospital (Institute), Chinese Academy of Medical Sciences (CAMS), Peking Union Medical College (PUMC), Beijing, PR China Quality of life (QOL) research, especially that of the cancer patients is an increasingly recognized subject. The foreign QOL research has a history of about 30 years which is the prime of human life, while that of Chinese cancer patients is now in its infancy, beginning at the end of 1980s. During the 1st WHO-China Training Course for Cancer Pain Relief and Palliative Care in 1990, Professor Yan Sun, initiated the Cancer Pain and Quality of Life Inventory, and from 1991 to 1992 conducted a multi-center prospective survey among 1543 cancer patients from 11 cancer hospitals or cancer division of general hospitals, which are distributed over the cities of Beijing, Nanjing and Nanchang. The preliminary results showed that the questionnaire was reliable, valid, sensitive and feasible.From May 1992 to May 1996, when I had been studying for MD, I had given an exploratory and systematic approach to the subject in the following areas: 1. Trying to find the effect of cancer pain on QOL: Cancer pain is one of the most common symptoms in cancer patients. One of the four priorities of WHO cancer control program is the management of cancer pain and other symptomspalliative care, in which seeking good quality of life is more paramount. Our results showed cancer pain might influence patients’ physical domain, psychological/spiritual domain and social domain, respectively, thus influencing the patients’ global QOL; 2. Introducing, pretesting and assessing three famous foreign Cancer-Specific QOL Scales: In 1992–1995, we were in the first place to introduce, pretest and evaluate several. . .[truncated].

360 Quality of Life Questionnaire for Chinese Cancer Chemobiotherapy (QLQ-CCC): Development and Assessment Luo J, Sun Y Wu G et al. Sun Yan Cancer Institute, CAMS, PUMC of Medical Sciences (CAMS), Peking Union Medical College (PUMC), Beijing, PR China

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Quality of life research (QOL) in cancer patients is a new, promising subject, which mainly covers the physical domain, spiritual/psychological domain, social domain and general domain. It is conducted primarily through the development, administration and assessment of the QOL scales, however, the introduction, revision and clinical administration of the scales is definitely restricted due to the cross-cultural differences. So, it has been very important for us to develop and assess our own QOL scales (inventories) while introducing and modifying foreign QOL scales concerning cancer patients. According to the Rolls–Royce model, the paper described the four stages for the scale suitable to measure the QOL of Chinese Cancer patients undergoing chemobiotherapy: 30 items were identified by selecting an initial item pool and choosing the ‘‘best’’ items from the pool, and the final format of quality of life questionnaire for Chinese cancer chemobiotherapy(QLQ-CCC, the fourth-generation questionnaire) including 35 questions was established through the stages of our deciding on the questionnaire format and pretesting the instrument. We are sure that the process of development and pre-testing of QLQCCC will greatly promote the QOL research in Chinese cancer patients. Finally, some methodological problems are addressed concerning the construction of any QOL Scale for cancer patients.

361 Emotional Control is Differently Associated with Psychological Reactions to Mammography in Young, Middle-aged and Older Women Mehlsen MY1, Jensen AB1, Christensen S1, Lehbrink M2, Zachariae R1 1 Oncology Aarhus University Hospital, Aarhus, Denmark; 2Radiology Aarhus University Hospital, Aarhus, Denmark PURPOSE: Older adults apply emotional coping strategies like emotional control more frequently than younger adults, but it is unclear whether the psychological consequences of emotional control in relation to the threat of cancer differ by age group. The aim of the present study was to examine whether age differences in emotional control influence psychological reactions to mammography. METHODS: Of 804 women referred to

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mammography by their GP, 701 women without current or previous cancer could be divided into the age groups: young 19–39 yr (n=168); middleaged 40–59 yr (n=458), old 60+ yr (n=75). The women completed the Courtauld Emotional Control Scale (CECS) and the Psychological Consequences of Cancer Questionnaire (PCQ), measuring cancer-related distress, before and 4 and 12 weeks after mammography. RESULTS: While there were no age differences in emotional control (CECS) before mammography (p-range: 0.093–0.200), the old group scored significantly higher on CECS compared to young and middleaged women (F: 3.142–9.906, p50.05) 4 and 12 weeks after mammography. Before mammography, there were no associations between CECS and PCQ. After 4 weeks, the inverse associations between PCQ and CECS found in older women differed significantly from the positive associations found in middle-aged and young women (z: 2.13–2.84, p50.05). CONCLUSION: Older women show a different pattern of psychological reactions to the threat of cancer experienced when going through mammography. Older women control their emotions more than younger women. Moreover, younger women who control their emotions experience increased distress, whereas emotional control may lead to reduced distress in older women.

scalp cooling, satisfaction with used headgear and the amount of hair loss will be used as control variables. Questionnaires to be used will be the EORTC QLQ-C30 and WHOQOL-Bref to measure QoL, two self-developed questionnaires for measuring tolerance to hair loss, the Measure of Body Apperception (MBA), the Body Image Scale (BIS), the Hospital Anxiety and Depression Scale (HADS) and the WHO-grading scale for measuring the amount of hair loss. The tolerance to scalp cooling is measured with a self-developed, Numerical Rating Scale. Patients in both conditions experiencing hair loss will, if applicable, be asked to rate their satisfaction with the used headgear. Measurement will take place at three times: a few days before start of chemotherapy, 3 weeks and 6 months after ending chemotherapy. Assessment of the tolerance to scalp cooling will be done after each cooling session. RESULTS: Both conditions will be compared using Structural Equations Modelling Analysis.

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Scalp Cooling and Quality of Life Mulders MCMA, Vingerhoets A, Breed WPM Sychology and Health, Tilburg University, Tilburg, Netherlands

Psychiatric Disorders Following Recurrent Breast Cancer: Prevalence, Associated Factors and Relation to Quality of Life Okamura M1, Akechi T1,2, Taniguchi K2, Yamawaki S3, Uchitomi Y1,2 et al. 1 Psychiatry Division, National Cancer Center Hospital, East Kashiwa, Japan; 2Psycho-Oncology Division, National Cancer Center Research Institute, East Kashiwa, Japan; 3Department of Psychiatry and Neurosciences, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan

INTRO: Hair loss has consistently been reported as a traumatic side effect of chemotherapy. Scalp cooling to prevent this hair loss appears to be growing in acceptance, use and effectiveness. Yet to date no research has been done into the assumed positive effects of successful scalp cooling. Therefore a study was initiated to gain insight into the relation between chemotherapy-related hair loss, scalp cooling and quality of life (QoL). METHOD: Female breast cancer patients receiving adjuvant chemotherapy are included. The effects of scalp cooling on QoL will be examined, compared to a non-cooling group. Tolerance to

PURPOSE: To investigate associated factors of psychiatric morbidity and impact of psychiatric disorders on QOL among recurrent breast cancer patients. METHODS: Baseline data on recurrent breast cancer patients who participated in a feasibility study of multifaceted psychosocial intervention were analyzed. Fifty women agreed to participate (a response rate of 85%). The prevalence of psychiatric disorders, including major depressive disorder (MDD), dysthymic disorder, panic disorder, posttraumatic stress disorder (PTSD), generalized anxiety disorder and adjustment disorders (AD) was evaluated

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according to the Structured Clinical Interview for the DSM-III-R and IV. The patients’ biomedical, demographic characteristics, social support, mental adjustment to cancer, personality traits and QOL were also evaluated. RESULTS: Total of 11 (22%) met the DSM-III-R and IV criteria for MDD, PTSD or AD (MDD; 2%, PTSD; 2%, AD; 20%). The results of univariate analyses indicated that presence of confidant, past history of MDD, Helplessness/Hopelessness and neuroticism were significantly associated with patients’ psychiatric disorders. Logistic regression analysis showed that past history of MDD and Helplessness/Hopelessness were final significant associated factors. The patients’ psychiatric disorders associated with lower Functional Scales (‘‘emotional functioning’’, ‘‘body image’’ and ‘‘future perspective’’) and Higher Symptom Scales (‘‘appetite loss’’, ‘‘diarrhoea’’, ‘‘fatigue’’ and ‘‘nausea and vomiting’’) in QOL. CONCLUSIONS: The result suggests that it is important to evaluate past history of MDD and mental adjustment to cancer. The patients’ psychiatric disorders associated with QOL. As we could not clarify whether the psychiatric disorders would cause impairment of psychosocial and physical aspects of QOL, further studies are needed.

method for early identification and planning for supportive care needs in cancer patients attending a tertiary oncology setting. METHOD: The method involved the development of a patient, self-report, screening questionnaire for new breast, gastrointestinal and lung patients (N=170) attending the ambulatory setting in a tertiary oncology setting. The screening questionnaire focussed on areas of physical, information, social, psychological, and spiritual needs. Patients and clinicians provided face and content validity. Following completion of the screening questionnaire, nurses (specifically trained) interviewed participants. A plan of care was formulated which included early referrals to the multidisciplinary team. RESULTS: There were high numbers (184) of early referrals made for 87 patients (Mean=2.1), needs varied by diagnostic group. Patients and staff indicated overall satisfaction with the process. The screening questionnaire is currently in use, reliability and validity are being evaluated in a larger sample. CONCLUSION: The two-step process of a patient self-completed questionnaire and the interview and referral process by staff appears to be effective in helping to meet supportive care needs for cancer patients.

365 364 The Clinical Application of Screening for Unmet Support Needs Pollard A1, Pigott C2, Aranda S2 1 Clinical Psychology, Peter MacCallum Cancer Centre, Melbourne, Australia; 2Department of Nursing Education and Supportive Care Research, Peter MacCallum Cancer Centre, Melbourne, Australia Research in cancer patients indicates a high incidence of unmet need across psychological, social, emotional and spiritual domains, which often results in adverse patient outcomes. Screening has been shown to identify unmet needs in the research context but has not been systematically applied to the clinical setting; research tools frequently have low acceptability. Early identification of needs can facilitate service provision only when linked with appropriate supportive interventions. PURPOSE: To apply a systematic routine

Copyright # 2004 John Wiley & Sons, Ltd.

Application of a Conceptual Model for Delivering Supportive Care in a Cancer Setting Pollard A1, Pigott C2, Aranda S2 1 Clinical Psychology, Peter MacCallum Cancer Centre, Melbourne, Australia; 2Department of Nursing Education and Supportive Care Research, Peter MacCallum Cancer Centre, Melbourne, Australia Cancer patients experience high incidence of unmet need across psychological, social, and emotional domains. Research studies have demonstrated the benefits of supportive care interventions; few publications indicate how such research can be applied systematically to supportive care delivery. Fitch (2000) suggested a model that targeted interventions according to need e.g. all patients require information whereas a few patients require intensive treatment. Generally, supportive interventions tend to target the needs of small numbers of patients with more obvious

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problems rather than addressing needs in the bulk of the population. PURPOSE: The aim of this project was to develop and apply a conceptual model of supportive care that could be implemented in a sustainable way in a comprehensive cancer centre. The project also aimed to integrate evidence-based interventions and support services. METHOD: There were four key components to this model: (1) Application of a conceptual model of supportive care; (2) Development and implementation of a unmet needs screening tool; (3) Development of multi-disciplinary program of support; (4) Development of a model of professional credentialing to facilitate referrals. RESULTS: The development and translation of this model of care into clinical practice has demonstrated significant improvement in: (1) organisation and delivery of supportive care programs and (2) has enhanced patient outcomes through establishing systems of early referral. CONCLUSION: Provision of supportive care can be enhanced through application of a theoretical model, services to cancer patients can be undertaken in a timely, integrated and systematic manner; this approach has demonstrated sustainability in the clinical setting.

366 Quality of Life During Adjuvant Chemo and Hormonal Therapy in Breast Cancer Patients Pugliese P1, Fabi A2, Nistico’ C2, Perrone M1, Cognetti F2 et al. 1 Psychology National Cancer Institute, ‘Regina Elena’, Rome, Italy; 2Oncology National Cancer Institute, ‘Regina Elena’, Rome, Italy PURPOSE: The aim of the study was to evaluate Quality of Life (QoL), anxiety and depression and patient perception of treatment sequelae during adjuvant chemo and hormonal therapy in early breast cancer patients. METHODS: Patients were followed by an e" quipe including psychologists and oncologists. The multidimensional assessment strategy consisted of a semi-structured interview

Copyright # 2004 John Wiley & Sons, Ltd.

to evaluate the treatment impact on psychological variables, side effects and sexual functioning. The FACT-An and the HADs were used for Qol and anxiety and depression evaluation, respectively. In this longitudinal study the evaluation instruments were administered every 3 months for 2 years. RESULTS: At the end of treatment the preliminary results on 35 patients (median age 53 years) showed: a higher rate of depression; a worsening of all areas of sexual functioning because of the poor interest for this variable during medical treatment (absence of desire 47%; no sexuality interest 41%; inability to reach orgasm 35%; decreased copulation frequency 52%; dispareunia 41%); an improvement of disease and treatment adaptation; a worsening of insomnia. The Fact-An showed high scores in the Fatigue Scale and stable scores in global Qol. Most of the patients refer to be satisfied with the information and support provided by the e" quipe. At the beginning, in the course and at the end of treatment the worst experienced symptoms were the expectation of alopecia (39%), the distress (26%) and the mucositis (33%), respectively.

367 Contribution of Quality of Life (QOL) Measurement to Treatment Decision-making: When Individual and Standardized Evaluation Approaches Diverge Rodary C1, Dauchy S2, Beauvallet C2, Baudin E3, Ruszniewski P4 et al. 1 Public Health Institut, Gustave-Roussy Villejuif, France; 2Psycho-oncology Institut, Gustave-Roussy Villejuif France; 3Medicine Institut, GustaveRoussy Villejuif, France; 4Gastro-Enterology Hospital, Beaujon Clichy, France PURPOSE: To determine how to best evaluate QOL in cancer patients in order to improve treatment decision-making. METHODS: The place of QOL evaluation in treatment decisionmaking is particularly important for cancers which involve functional manifestations that can severely disrupt the patient’s QOL and require constant symptomatic treatment. This study concerned patients with slow-growing endocrine tumours. The QOL of 130 patients from 2 centres was evaluated with 3 self-evaluation scales whose order

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was randomised: a standardised questionnaire specific to cancer (EORTC- QLQ-C30), a semistructured individual interview (SEIQOL-DW), and the Hospital-Anxiety-Depression-Scale (HADS). Scales were administered 6 months apart. The Karnofsky index (KPS) was used to measure overall performance. RESULTS: The QLQ-C30 and SEIQOL scores were significantly worsened when patients had clinical functional and/or tumor-induced signs with a decline in the KPS. However, the changes observed were not always consistent. Some patients with a severe clinical status, a low KPS and a low QLQ-C30 score had nonetheless a good QOL, as attested by the high individual SEIQOL score. The reverse was also observed. Examples will be presented and discussed raising the question about which QOL dimension(s) should be considered a priority during treatment decision-making.

particularly after the first 3 years subsequent to diagnosis, but may be negatively affected if cancer recurs during the first years of survivorship. Despite relatively high QOL, many patients do experience difficulties; about one-third of CRC patients indicate high levels of distress, and the presence of an ostomy, for example, increases distress and negatively affects multiple facets of these people’s lives. Factors related to higher ratings of QOL will be discussed, including social support, behavioral coping techniques and psychosocial intervention, and exercise. The author will present a literature review, elaborate on research methodology, including measures used in assessing QOL, and make recommendations about the relevance of these research findings to clinical practice.

369 368 Colorectal Cancer: Quality of Life and Psychosocial Intervention Rose SR1, Holland JC2 1 Department of Social Work, Memorial SloanKettering Cancer Center, New York, USA; 2 Department of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, New York, USA Colorectal cancer (CRC) ranks third in worldwide annual cancer incidence and is the third highest cause of cancer mortality for both sexes. Treatment for CRC, including chemotherapy, radiation therapy, and surgery may temporarily or permanently alter the function and/or appearance of patients’ bodies. These changes result in emotional distress and practical stressors, and QOL may be dramatically affected. Despite the psychosocial and physical threats the disease and treatments represent, survivors generally rate their QOL as comparable to, or better than, patients with other cancer diagnoses, and age-matched general populations. Notably, factors associated with decreased QOL in CRC patients seem less related to the cancer itself and more correlated to issues of aging, non-cancer-related comorbidities, and other factors, such as body mass index, and socioeconomic status. Survivors’ QOL also seems to improve,

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Assessment is not Enough: A Randomized Controlled Trial of the Effects of HRQL Assessment on Quality of Life and Satisfaction in Oncology Clinical Practice Rosenbloom SK, Victorson D, Hahn EA, Peterman AH, Cella DF Center on Outcomes, Research and Education, Evanston Northwestern Healthcare, Evanston, USA PURPOSE: Potential benefits of health-related quality of life (HRQL) assessment in oncology clinical practice include better detection of problems, enhanced disease and treatment monitoring and improved care. However, few empirical studies have investigated the effects of incorporating such assessments into routine clinical care. Recent randomized studies have reported improved detection of and communication about patients’ concerns, but few have found effects on patient HRQL or satisfaction. This study examined whether offering interpretive assistance of HRQL assessment results to treatment providers would improve patient outcomes, especially among those experiencing greater levels of distress. METHOD: Two hundred and thirteen participants with metastatic breast, lung or colorectal cancer were randomly assigned to one of three conditions: usual care, HRQL assessment, or HRQL assessment followed by a structured dialogue. Dialogues consisted of interviews about patients’ assessment responses

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conducted by a research nurse, who then presented information to the treating nurse. In only the assessment condition, the treating nurse received the completed HRQL Scale only. RESULTS: HRQL and treatment satisfaction outcomes were assessed at 3 and 6 months. Data were examined using area under the curve (AUC) and mixedeffects model analysis. No significant differences were found between study conditions in HRQL or satisfaction (p>0.05), regardless of patient distress level. CONCLUSIONS: Results suggest that routine HRQL assessment, even with informative dialogue about results, is insufficient to improve patient HRQL and satisfaction. Positive effects may not be realized without supplementing assessment results with specific suggestions for clinical management changes. Directions for future research are discussed.

370 Using Item Banks to Measure Positive and Negative Psychosocial Impact of Cancer Rosenbloom SK, Lai JS, Cella DF Center on Outcomes, Research and Education, Northwestern University/Evanston Northwestern Healthcare, Evanston, USA PURPOSE: Considerable research has demonstrated the negative psychosocial impact of cancer. Recent work has also highlighted positive psychosocial outcomes, such as greater life appreciation, interpersonal relationships and personal resources. Item ‘‘banks’’, from which a limited number of most informative questions are selected through computerized adaptive testing, may be an ideal way to minimize patient burden yet assure precise measurement of the impact of illness. This paper describes the development and properties of new item banks designed to measure the full range of Illness Impact (II) in cancer. METHOD: 205 general oncology patients, the majority white (93.2%) and female (59.2%), mean age 59.6  13.0 years, completed a 46-item Illness Impact (II) assessment via touch-screen computer. Data were analyzed with (1) factor analysis (FA) to determine item dimensions, and (2) Rasch analysis to examine goodness-of-fit of items. RESULTS: FA revealed positive II and negative II as two separate factors, confirmed by low correlation between item

Copyright # 2004 John Wiley & Sons, Ltd.

set scores (r=0.07, p=0.31). Rasch analysis was used to examine these factors separately; 21 and 17 items were retained in positive and negative II banks, respectively. Both banks demonstrated excellent internal consistency (positive II alpha=0.95, negative II alpha=0.93) and discriminated patients with different levels of performance status (positive II: F(3,201)=2.74, p50.05; negative II: F(3,201)=10.03, p50.001). CONCLUSION: Two item banks were developed to measure the positive and negative impact of illness, and both demonstrate good psychometric properties. Plans for future bank refinement, exploration of predictors and potential clinical utilization will be discussed.

371 A Preliminary Reliability Generalization of the FACT-G Rothrock NE, Barocas J, Victorson D Center on Outcomes, Research, and Education, Evanston Northwestern Healthcare Evanston, Illinois, USA PURPOSE: In the past decade a significant amount of attention has been given to the area of health-related quality of life (HRQL) among patients affected by cancer. It has become commonplace for HRQL to be included as an important variable in large-scale clinical trials investigating the effects of radiation and chemotherapeutic agents. The measurement of HRQL has also seen a good deal of growth in terms of the development and validation of different HRQL assessment tools. The Functional Assessment of Cancer Therapy (FACT-G; Cella et al., 1993) has become one of the most widely used HRQL measures among medical and psychosocial oncology research. Following guidelines set forth by Vacha-Haase (1998), the present study provided a reliability generalization (RG) of the FACT-G to identify, organize and consolidate psychometric properties of scores produced by this instrument. RG stems from the field of meta-analysis and examines variation in score reliability as well as distinguishes relevant sample characteristics that may be associated to score reliability variation. METHODS: 131 articles were identified and reviewed from an

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in-house research library and well-known oncology search engines. Thirty articles were selected for analysis based on their inclusion of reliability statistics. Cronbach’s alpha coefficient was used as a reliability estimate for analysis. RESULTS: Average FACT-G score reliability was alpha =0.88 (SD=0.03). Important study characteristics that predicted score reliability variation included sample size, gender and ethnicity. CONCLUSIONS: The FACT-G demonstrated good reliability evidence across the studies reviewed. Implications of these findings and future directions are discussed.

372 Predictors for Quality of Life Following Breast Cancer Surgery Schou Bredal ISB1, Ekeberg ØV2, Sandvik LS3 1 Surgery Ulleval, University Hospital, Oslo, Norway; 2Emergency Ulleval, University Hospital, Oslo, Norway; 3Research Ulleval, University Hospital, Oslo, Norway PURPOSE: Investigate personal characteristic (i.e. dispositional optimism and demographics) and medical variables as a predictors for QOL, 1 year after surgery. Compare optimists and pessimists QOL. METHODS: A total of 165 women completed the Life Orientation Test (LOT-R) at time of diagnosis. QOL was evaluated with the EORTC QOQ-C30 at time of diagnosis, 3 and 12 months postoperatively. RESULTS: Dispositional optimism was predictive for emotional and social functioning at 12-months (p50.01). However, initial QOL was the strongest predictor for global health QOL and all functioning at 12-months (p50.0001). Optimists reported better QOL at time of diagnosis and throughout the postoperative follow-up. Younger women reported more disruption in several domains of QOL at time of diagnosis. Women who underwent breast conserving surgery reported better global health QOL, physical and role functioning (p50.01). CONCLUSION: Pessimists are at greater risk than optimists to experience disruption in several domains of QOL throughout the trajectory of breast cancer. Type of surgery is important for some domains of women QOL.

Copyright # 2004 John Wiley & Sons, Ltd.

373 Quality of Life’s Moderating Factors in Cancer Patients Receiving Home Enteral Nutrition Sirgo A1, Bonada A2, Figueredo N2, Cabezas I3, Rodriguez D3 et al. 1 Psycho-oncology Unit, Oncology Department, University Hospital Sant Joan Reus, Spain; 2Nutrition Unit, University Hospital Sant Joan Reus, Spain; 3Oncology Department, University Sant Joan Reus, Spain PURPOSE: To assess cancer patients’ Quality of life (QoL) receiving home enteral nutrition (EN). To identify tumor related, nutritional status and nutritional support variables, which may determine QoL’s levels. To describe psychological variables which may be moderating this effect. METHODS: Forty-six cancer patients, 93.5% men, mean age 59.3 yr, who received home EN orally or by nasal-gastric or gastrostomy tube, initiated 1–2 months before, were included in a lineal model, with three groups of variables: (a) independent: tumor related, Karnofsky, nutritional status and type of nutritional support; (b) moderating: perceived social support, perceived pain, coping strategies, emotional distress (anxiety–depression–stress); (c) dependent: Quality of Life. RESULTS: Head and neck was the most frequent tumor (65.2%). Most of the patients were receiving radiation-therapy or treatment with chemoradiation (82.6%) and oral-home EN (80.4%). QoL was related with diagnosis, extension, Karnofsky, BMI and type of access to nutritional support. Diagnosis and extension were related to emotional status: anxiety (p=0.009), depression (p=0.004) and stress (p=0.017). A relation between maladaptive coping strategies, oral feeding (p=0.009) and type of nutritional support (p=0.021) was found. QoL was also influenced by perceived social support, emotional distress and perceived pain. CONCLUSIONS: Diagnosis and extension of tumor influence cancer patients’ QoL who were receiving home EN. QoL seemed to be moderated by emotional distress but not by coping strategies. Nutritional status is not influencing QoL but nutritional support is. This result is not moderated by any psychological variable. Improving patients’ emotional status we will increase QoL, provided nutritional support.

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Evaluation of a Chronic Disease Self-Management Program for People Affected by Cancer. Strassnick K1, Beckmann K2, Abell L1, Hermann J3, Oakley B4 1 Cancer Information and Support Services, The Cancer Council South Australia, Adelaide, Australia; 2Research and Development Unit, The Cancer Council South Australia, Adelaide, Australia; 3 Education Services, Arthritis Foundation SA Inc., Adelaide, Australia; 4Consumer Representative, The Cancer Council South Australia, Adelaide, Australia

A Study of Prospective Factors for Laryngectomees to Continue Esophageal Speech Training Terasaki AT1, Mase YM2, Tsuji KT1 1 Nagasaki University, Department of Nursing, The Health Sciences, Nagasaki, Japan; 2Kanagawa University, Human Services, Yokosuka, Japan

PURPOSE: The Chronic Disease Self-Management Program (CDSMP) was developed by Stanford University and has shown health benefits for people with chronic conditions such as arthritis. The purpose of this study was to investigate whether the CDSMP has benefits for people affected by cancer. METHODS: The Cancer Council South Australia conducted two CDSMPs. The programs were promoted as ‘‘Staying healthy after cancer’’, and targeted people affected by cancer and partners/carers. All who registered were invited to participate in the study that was qualitative in nature. Data was collected via guided telephone interviews approximately 6 weeks after the program had ended. The interviews were taped and transcribed for analysis by an independent researcher. RESULTS: The programs attracted participants who were at a variety of stages along the treatment}recovery continuum. Major themes identified were: (1) The value of mixing with and learning from others who had been through similar experiences (2) The positive impact of developing and carrying through action plans, and (3) The motivation gained to adopt healthier lifestyles. The degree to which people benefited from the CDSMP appears to have been influenced by where they were along the continuum. CONCLUSION: Evaluation indicates that most participants found the program beneficial to some degree.

Copyright # 2004 John Wiley & Sons, Ltd.

Voice restoration, which has a very large effect on the QOL of patients who have become voiceless due to cancer treatment that required laryngectomy, often depends on a patient’s participation in a self-help group (SHG), many of which are available internationally. The present study was conducted to identify prospective factors for such laryngectomees to continue esophageal speech training, in view of Bandura’s concept of selfefficacy and empowerment. Data from an interview survey of 40 participants in the beginners’ class of a group with 710 members were analyzed both qualitatively and inductively. As a result, 238 codes were extracted and divided into 48 subcategories under 14 categories. Laryngectomees were found to join the SHG with the expected outcome that they would be capable of [participating in society] and [expressing themselves] after acquiring the technique of esophageal speech. Immediate solutions cannot be achieved by those [impatient to resume communication], or those who [feel insecure about their success in mastering esophageal speech], or who [feel that the exercises are too difficult]. However, accomplishing the more attainable goals of [ joining the class] and [performing the exercises as part of a class group activity] served to promote continued training. Participants were empowered by the group activities to have experiences in [model acquisition], [speech guidance], [self-disclosure], [venturing outside the home], [overcoming their sense of isolation], and they also received [encouragement]. Having sessions three times each week facilitated the accomplishment of these lower, more attainable goals; repetition of experiences like this is effective and necessary.

376 The Influence of the Emotional Aspects of Histerectomy for the Purpose of Cancer on Quality of Life

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Tosic Golubovic STG MD1, Gugleta DG MD1, Miljkovic SM Prof. Dr2, Golubovic NG Dr1 1 Psychiatry UKC, Gornja Toponica, Serbia and Montenegro; 2Psychiatry UKC Nis, Serbia and Montenegro Quality of life has become an important issue in the modern quality management of measuring health outcomes (in functional and psychosocial sense), after radical surgery of cancer. PURPOSE: The aim of our prospective study was evaluating anxiety and depression, prior to and after total hysterectomy with bilateral oophorectomy, among the patients with gynaecology cancer, as well as to evaluate a potential influence of the psychological state on the subjective evaluation of quality of life. METHODS: Anxiety and depression were assessed using Hamilton Scale for anxiety and depression before surgery and 3 months after, WHOQOL-BREF was administered too, at the same time. Psychology state and quality of life of these subjects were also compared with one of patients that underwent cholecystectomy. RESULTS: Three months after surgery the patients that had undergone hysterectomy presented statistically significantly higher mean score of anxiety and depression (p50.0001), and statistically lower quality of life than the patients that had undergone cholecystectomy. The respondents? psychological state, especially depression among cancer patients, was found to be strongly associated with an assessment of their subjective quality of life for all domains. CONCLUSIONS: Regardless of this effect of psychological state, all domains of the WHOQOL-BREF were also influenced by objective living condition: health status, economic situation and culture, living arrangements, and region of living. One remaining question in the future concerns the impact of hysterectomy performed for any purpose, which may result with the emotional sequels, centred around the expected loss of the femininity symbols on the individual. . . [truncated].

377 Validation of Quality of Life Questionnaire} Indian Scenario Vidhubala E Cancer Institute, Adyar, Tamil Nadu, India

Copyright # 2004 John Wiley & Sons, Ltd.

BACKGROUND: Quality of Life is an important health outcome measure in oncology. There is a need to develop a regional tool and standardization to address the linguistic and socio-cultural factors. OBJECTIVE: To standardize a tool to assess Quality of Life of cancer patients to suit Indian scenario. METHODS: The sample was collected from Cancer Institute (WIA), Chennai, India. Sample size: Six hundred and fifty cancer patients in the age range from 18 to 70 years. Period: June 2000–December 2003. 78 items were pooled from various sources like review of literature, existing questionnaires, and patients and oncologists interview. After eliminating the overlapping issues and repetitive items, 38 items were selected for validation. Face validity and factorial validity were established. Stability and the internal consistency of the tool were also established. With the minimum modification, a new version of 42-item questionnaire was developed from the 38-item scale. The reliability and validity was also established for version II. STATISTICS USED: The data was subjected to factor analysis using Principal component method with Varimax rotation. Spearmen product moment correlation and Cronbach alpha coefficient were used for reliability analysis. RESULTS: Ten factors emerged with 62.6% of variance for version I. The Cronbach alpha coefficient value is 0.90. On factor analysis of version II, 11 factors emerged, which resulted in 66.7% of variance. The Cronbach alpha coefficient (0.90) and Split-half reliability (0.80) indicated a high reliability of the tool. CONCLUSION: The tool was found to be highly sensitive and feasible to administer at the clinical setting.

378 Evaluation of Professionally Led Support Groups for Men with Prostate Cancer Voerman AE1, Fischer MF1, Visser APh1, Garssen B1, van Andel G2 et al. 1 Helen Dowling Institute, Utrecht, The Netherlands; 2Urology Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands Prostate cancer is one of the most prevalent cancer types in Dutch men. While specialised psychosocial support is available for other cancer types,

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there is little professional psychosocial support for prostate cancer patients. To investigate what support format is useful for these men, professionally led support groups (seven sessions of 2.5 h) were organised for men with prostate cancer. METHODS: Forty-eight patients and 21 partners participated in four groups for patients alone and four groups for patients and their partners. After each session, a questionnaire was filled out concerning the usefulness of that session in dealing with their problems. After completion of the seven sessions, a questionnaire was filled out to evaluate various aspects of the intervention. RESULTS: Forty-one percent of the participants indicate a better ability to talk about their disease, for 56% the sessions contributed to increased acceptance of the disease and 19% state that the sessions helped them in coping with the disease. The overall mark (range 1–10) given is 7.5 (SD=1.1). Contact with important others, satisfaction with the support and the overall mark were higher in the groups for patients only, compared to the groups with partners. No differences in evaluation were found for men with or without metastasis, age or time since diagnosis. CONCLUSION: The support groups have helped a substantial part of the patients in dealing with their prostate cancer.

379 Utilizing Technology to Deliver a Patient and Provider Intervention for the Management of Cancer-related Fatigue, Pain, Anxiety, and Depression: Development of a Web-based Symptom Management Program Wagner LI, Rosenbloom S, Purpura-Kilroy L, Davis K, Cella D et al. Center on Outcomes, Research and Education, Evanston Northwestern Healthcare, Northwestern Universitiy Feinberg Medical School, Chicago, USA Assessing health-related quality of life and symptom burden among cancer patients yields important information about patients’ health status. However, assessment alone is not sufficient for the clinical management of prevalent cancer-related symptoms (see Rosenbloom et al., IPOS 2004). Cancer-related fatigue, pain, anxiety, and depression are commonly associated with cancer and its

Copyright # 2004 John Wiley & Sons, Ltd.

treatments and the adverse impact of these symptoms on patients’ functional status and quality of life has been well documented. Despite the availability of clinical practice guidelines, cancer-related fatigue, pain, anxiety, and depression are often not adequately managed. To improve the management of these symptoms, we adapted clinical practice guidelines developed by the National Comprehensive Cancer Network (NCCN) for use within a web-based symptom management program. We have designed this program to include the weekly assessment of target symptoms, longitudinal tracking of symptom severity, and tailored recommendations for patients and their providers on the clinical management of these symptoms. The utilization of a web-based program facilitates the real-time delivery of clinical recommendations that are tailored to patient-reported symptom severity and changes over time. Through this approach, patients can be provided with strategies for the self-management of their symptoms. Using a webbased platform also allows for the rapid communication of detailed information on patient symptom severity and accompanying tailored clinical recommendations to their health care team. Our presentation will include an overview of the development of this program, a demonstration of the program, and a description of our plans to empirically evaluate this program.

Rehabilitation 380 Cancer Rehabilitation as a Psycho-oncologinc Approach Abe PK Rehabilitation Chiba Cancer Centre, Chiba, Japan PURPOSE: Generally speaking, they think medial rehabilitation in hospitals is physical-oriented approach from beginning to end. But in the field of rehabilitation of cancer patient the situation has been different. So we analyse that what kind of approach they use in medial rehabilitation at Chiba Cancer Centre. METHODS & OBJECTIVES: Statistics method, Objectives are 759 in-patients at Chiba Cancer Centre from April 1995 to December 2003. The average age was 58.9

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(6–89) years old, female/male are approximately 1:1. They included lung cancer, breast cancer, colo-rectal cancer, C.N.S.tumours, sarcomas, malignant lymphoma, and leukemias. RESULTS: At first rehabilitation approach there are only 7.7% psychological one, another 92.3% physical-oriented one; i.e. walking, transfer techniques, toileting, etc. But at the end of rehabilitation there are only 6.2% physical-oriented approach. Therefore, over 90% of the rehabilitation approach has changed from physical to psychological. Firstly, we think physical activities are goal of rehabilitation, but finally, activities are only means to make a rehabilitation goal come true. CONCLUSIONS: We should notice that in the field of cancer rehabilitation most approach have psycho-oncologic aspect. In such a case, physical activities are not goal but means and psycho-oncologic approach has been crucial.

381 Effects of Cancer Rehabilitation on Patients and Their Partners Bergelt C, Lehmann C, Welk H, Koch U Institute of Medical Psychology, University Clinic, Hamburg-Eppendorf, Hamburg, Germany BACKGROUND: In Germany cancer rehabilitation is primarily carried out in an in-patient setting and partners can accompany patients during their stay in the clinic on their own cost. Although psycho-oncological studies show that partners are deeply affected by the disease and feel burdened in many ways, partnership in the context of cancer rehabilitation has not yet been addressed as a research topic. METHODS: Two groups of couples were assessed at the beginning and at the end of the rehabilitation: in one group partners accompanied the patients during the (3-week) rehabilitation treatment (n=209), in the second group partners stayed at home (n=317). Outcome was measured with the SF-36 (quality of life), the HADS Scales (anxiety and depression) and selfreported items. RESULTS: Partners initially report a significantly higher level of emotional distress than patients and partners who accompany the patient feel more distressed than partners who stay at home. Variance analyses (adjusted for age) indicate that all patients show substantial and

Copyright # 2004 John Wiley & Sons, Ltd.

significant improvement in quality of life, anxiety and depression at the end of the rehabilitation. These results also apply to accompanying partners, whereas partners at home show hardly any change in their condition. Female accompanying partners profit even more than male partners. In contrast to partners at home accompanying partners also significantly improve their ability to cope with the illness. CONCLUSION: Besides the evidence for the effectiveness of cancer rehabilitation for the patients with regard to classical outcome parameters the findings emphasize the positive effects on accompanying partners.

382 Rehabilitation after Cancer: How to Secure the Collection and the Transformation of Knowledge and Experience Bruun Piester C The Dallund Centre for Rehabilitation of Cancer Patients, Danish Cancer Society, Søndersø Denmark The Dallund Centre was established in 2001 as a 5year intervention and research project. Dallund is the first and only centre in Denmark offering rehabilitation to cancer patients as a residential course. The project’s vision is to secure the implementation of cancer rehabilitation as a natural part of any rehabilitation process for cancer patients. Each year approx. 800 patients spend 1 week at Dallund. The general aim is to run, document and evaluate the rehabilitation process as well as describing in these patients the consequences of the cancer illness and its treatment. One of the project key success factors is to secure the transformation of knowledge to a variety of interest groups and professionals with the objective to offer improved rehabilitation processes. It became clear during the establishment of the centre with the integration of different research projects that the day-to-day experience and collection of data is critical to collect and transfer. The presentation will demonstrate the project’s development during the last 2 years starting as a practically oriented rehabilitation centre and developing into a knowledge centre with

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competences of collecting, analysing and passing on knowledge to relevant target audience. Based on the experience with more than 1500 patients as well as their evaluations this presentation discusses the challenges in kick-starting cancer rehabilitation nationally.

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controls, the only significant outcome was a correlation between fulfilment and positive life events (p50.05). CONCLUSIONS: TCSs have a set of life goals, but experience themselves as being somewhat less in the process of fulfilling them than healthy men. Being single, unemployed, childless, and the experience of additional negative life events seem to be factors that threaten (the fulfilment of) goals of TCSs.

Testicular Cancer Survivors and (the fulfillment of) Life Goals Fleer J1, Hoekstra HJ1, Sleijfer DTh2, Tuinman MA1, Hoekstra-Weebers JEHM3,4 1 Surgical Oncology, University Hospital Groningen, Groningen, The Netherlands; 2Medical Oncology, University Hospital Groningen, Groningen, The Netherlands; 3Health Psychology, University Hospital Groningen, Groningen, The Netherlands; 4 Comprehensive Cancer Center, North-Netherlands, Groningen, The Netherlands

The Relation of Objective and Subjective Stress to the Psychological Adjustment of Melanoma Survivors Hamama Raz Y1, Solomon Z2 1 Social Service, Psycho-Oncology Unit, Rabin Medical Center, Beilinson Campus Petach, Tikva, Israel; 2School of Social Work, Tel Aviv University, Tel Aviv, Israel

PURPOSE: Having and fulfilling goals are considered to be important in the experience of a meaningful life. Cancer may threaten (the fulfilment of) goals. This study is aimed at examining (the fulfilment of) goals of testicular cancer survivors (TCSs), and the relationship with sociodemographic and illness variables. METHODS: Three hundred and fifty-four TCSs (mean time since treatment 10 years, SD 6.7) and 162 sociodemographically matched healthy men completed the Life Regard Index (LRI), measuring goals (‘Framework’) and the fulfilment of goals (‘Fulfilment’); occurrence of positive and negative life events; demographics (age, marital status, educational level, employment status, parenthood); illness variables (time since treatment, treatment type, new cancer event). RESULTS: TCSs had similar scores on framework as controls (p=0.09), but reported less fulfilment (p=0.02). However, the effect size of this difference was small (d= 0.25). In TCSs, significantly lower framework and fulfilment scores were reported by those who were single (both p50.01), unemployed (both p50.001), and childless (both p50.05) than those with a partner, work and children. Furthermore, framework and fulfilment correlated significantly with negative live events (both p50.01). Significant relationships between framework and fulfilment and illness variables were not found. In

The aim of this research is to examine differences in the psychological adjustment of melanoma survivors according to disease variables}objective stress, patients’ appraisal of their current medical situation as a threat or challenge, and their ability to cope with the situation, subjective stress, and demographic variables}on psychological distress, psychological well-being, and daily functioning. METHOD: The sample included 300 survivors of malignant melanoma that had been diagnosed in early stages (IA, IB, IIA). Participants had been in follow-up for at least 5 years with no indication of relapse. Participants filled in self-report questionnaires examining adjustment, cognitive appraisal, and demographic data. Disease variables were derived from the participants’ medical records. RESULTS: No relation was found between objective stress factors}stage of disease and time since diagnosis}and adjustment, but a relation was found with subjective stress factors}lower sense of threat and higher assessment of ability to cope are related to higher psychological wellbeing, lower distress, and better appraisal of functioning following the disease. Additionally, psychological well-being and appraisal of functioning increase with an elevated feeling of challenge. As for socio-demographic variables, a relation was found between marital status, level of religiosity, and employment status regarding the

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psychological adjustment of melanoma survivors. CONCLUSIONS: Both the care-giving team and survivors’ families must be very sensitive to the separate and combined implications of external factors of objective and subjective stress, and to personal and social attributes of the patients on the outcome of their adjustment and ability to reintegrate into normal life.

385 Disrupted Lives. An Anthropological Investigation of Women, Cancer and Rehabilitation Hansen HPH The Faculty of Health Sciences, Institute of Sport Sciences and Biomechanics, Odense, Denmark This presentation deals with some of the results from my ongoing research project about how women who have or have had cancer create meaning in a chaotic world. Data was primarily generated through a fieldwork study (participant observation and interviews) in three residential rehabilitation courses on different locations (a Folk High School, a SPA-hotel and a Holidaycentre) in Denmark. Each course lasted 5–6 days. In my presentation, I shall first present two conversations between three to four women with breast cancer joining the rehabilitation courses. The conversations are about ‘‘breasted experiences’’. Second, I shall use the conversations to analyse and interpret how rehabilitation courses can be understood as social technologies that have cultural effect. For a great part of the women the courses facilitate social relations between them, where emotional topics (for instance about the loss of a breast in relation to sexuality) can be brought on the agenda and discussed. By listening to one another the women gain new insight into their lives, their bodies etc. and receive new ideas of how to create meaning and continuity after an unexpected disruption (the cancer diagnoses, the investigations, the treatment and the side-effects). Third, I shall conclude by suggesting that order begins with the body, and that the body can be understood as the medium through which the women experience their cultural world. The sharing experiences of embodied distress may not only lead to greater bodily attention within the specific woman, but also facilitate social action.

Copyright # 2004 John Wiley & Sons, Ltd.

386 Rehabilitation after Cancer: The Dallund Centre for Rehabilitation of Cancer Patients in Denmark Hjortebjerg U The Dallund Centre for Rehabilitation of Cancer Patients, The Danish Cancer Society, Søndersø, Denmark In the year 2000, The Danish National Plan for Cancer recommended that rehabilitation should be offered to all cancer patients and must be adjusted to the needs of the individual patient. The National Plan further suggested a systematic collection of experience and an evaluation of the effort with the aim of establishing professional guidelines for the rehabilitation of patients after cancer. The Dallund Centre was established in 2001 as a 5-year project in order to fulfil this ambition. Dallund is the first centre in Denmark offering rehabilitation to cancer patients as a residential course. Patients are referred from all over Denmark. Each year approx. 800 patients spend 1 week at Dallund. The residents receive collective and individual education and guidance from a staff consisting of dieticians, medical doctors, nurses, psychologists, physiotherapists, and social workers. The general aim is to run, document and evaluate the rehabilitation process as well as describing in these patients the consequences of cancer and its treatment. The results of Dallund are monitored at two different levels. First, a management-driven collecting of data necessary for managing a rehabilitation centre, e.g. themes, methods, and teachers. Second, a research-driven, randomised study of the effects of rehabilitation. The former is performed by Dallund’s staff, while the latter is conducted by an external, independent research group. This presentation will display and discuss the basic operational facts and the general experience of Dallund after more than 2 years of existence and will be based on statistical data on more than 1500 patients.

387 Rehabilitation after Cancer: A Self-report Measure of the Need for Rehabilitation

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Kristensen T The Dallund Centre for Rehabilitation of Cancer Patients, Danish Cancer Society, Søndersø, Denmark In Denmark approx. 30 000 individuals are diagnosed with cancer each year. It is not known how many of these require rehabilitation after treatment. Dallund is the only centre in Denmark offering rehabilitation to cancer patients as a residential course. Dallund’s yearly capacity is approx. 800 patients. PURPOSE: Development and testing of a self-report measure for the identification of patients in need of rehabilitation. METHODS: Inspired by the methods for selfreported pain and the MSK distress-thermometer a yard-stick was constructed, where patients are asked to indicate on a 10-step VAS-like scale, how far they are from living their ideal life (selfreported ideal life distance, ILD). This yard-stick is followed by 65 symptoms or signs to be checked if the patients believe these are obstructing their life. This measure was presented to 160 patients referred to rehabilitation 3 weeks before, at the end of and 3 months after their stay at Dallund. Further, the measure was tested and retested on 108 healthy, non-enumerated blood donors (R=0.74). Reliability as judged by Cronbach’s a>0.70. RESULTS: In all three populations the distributions of ILD are clearly bimodal but not significantly different. Among rehabilitation patients, characteristic shifts in ILD can be identified before, during and after the stay at Dallund. When comparing ILD with the indications of symptoms and signs obvious patterns can be identified correlating to primary disease and treatment. Interestingly, the ILD of healthy blood donors are similar to cancer patients, but in the absence of signs and symptoms.

388 Rehabilitation after Cancer: 30 Statements Evaluated by more than 1000 Patients Kristensen T The Dallund Centre for Rehabilitation of Cancer Patients, Danish National Cancer Society, Søndersø, Denmark Dallund is the first and only centre in Denmark offering rehabilitation to cancer patients as a

Copyright # 2004 John Wiley & Sons, Ltd.

residential course. Each year approx. 800 patients spend 1 week at Dallund. PURPOSE: In order to facilitate the planning of the intervention at Dallund a summary description of each patient was attempted based on the patients’ evaluation of 30 statements. METHODS: The 30 statements were constructed to cover major physical, psychological, social and general problems occurring after diagnosis and treatment of cancer. The patients were asked to rate each statement on a 5 point scale (‘‘Suits me perfectly’’ to ‘‘Does not fit me at all’’). The statements were mailed to more than 1000 consecutive patients attending Dallund from the spring of 2002 until 2004 and were returned prior to the course. RESULTS: The answers were primarily used to plan each resident’s stay at Dallund. Secondly, the bulk of answers was analysed for internal structure using statistical methods (e.g. Factor analysis, ANOVA, ANCOVA). These data will be presented and discussed at the congress. CONCLUSIONS: It is possible to identify significant patterns of responses according to e.g. age, gender and diagnosis. It is conspicuous that statements on psychological distress generally suits patients with breast cancer, while patients with other diagnoses tend to agree with other statement categories. Individual answers to the 30 statements may be utilized to plan individual interventions. The trends disclosed by data mining the bulk of answers may be used to plan courses or interventions and information directed towards specific groups of patients.

389 Result from the Evaluation of an Inpatient Cancer Rehabilitation Program Kuhn KG, Johansen C Department of Psychosocial Cancer Research, Danish Cancer Society, Copenhagen, Denmark BACKGROUND: It is estimated that each year around 17 000 Danish cancer patients will need rehabilitation. As a recognition of this problem, the first Danish rehabilitation centre for cancer patients opened in 2001. This centre presents an ideal opportunity to analyse the effect of physical and psycho-social rehabilitation on Danish cancer patients. METHODS: Since the end of 2002, questionnaires have been distributed to all

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rehabilitation participants before their course and 1, 6 and 12 months after the end of the course. The questionnaires are based on validated psychometric scales to assess quality of life, coping, sense of coherence and mental adjustment. Results are analysed regularly according to these scales. These results represent analyses from baseline, 1- and 6month follow-up questionnaires. RESULTS: To date, 854 (92%) rehabilitation patients have chosen to participate in the study, 85% of which were female. The most common cancer types were breast (56%), lymph node (13%), ovarian (7%) and lung cancer (6%). Analyses of 1-month follow-up (n=700) show significant improvements in dietary habits, increase in exercise, and reduction of alcohol intake post-rehabilitation. Selfperceived health and quality of life were significantly improved. Analyses of 6-month follow-up (n=227) show similar trends but with lower statistical significance. CONCLUSION: At present we are unable to conclusively demonstrate any long-term effect of rehabilitation for Danish cancer patients. The newly initiated randomised allocation of patients to the rehabilitation course or a control group provides a better design for making firm conclusions about how rehabilitation affects cancer patients in Denmark.

390 Rehabilitation after Cancer: Cancer, Sexuality and Rehabilitation Larsen S Dallund Centre for Rehabilitation of Cancer Patients, Danish National Cancer Society, Søndersø, Denmark BACKGROUND: Several cancer patients experience a changed sense of self, altered sexuality and a transformed perception of their body. Dallund is the first and only centre in Denmark offering rehabilitation to cancer patients as a residential course. Each year approx. 800 patients spend 1 week at Dallund. RESULTS: According to Dallund’s screening measures prior to their stay, 59% of the patients (623/1056) experience a transformed perception of their body, while 55% (592/1071) feel a changed sense of self, and 43% suffer from an altered sexuality. These numbers are of course closely interrelated. Further analysis

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reveals other correlations, e.g. a connection to the diagnosis (and treatment) of the patients. 52% (321/612) of patients with breast cancer indicate an altered sexuality, compared to 79% (15/19) of patients with prostate cancer, 44% (54/123) of patients with gynaecological cancer and 46% (53/ 116) of patients with haematological cancer. DISCUSSION: These findings underline that aspects of sexuality must be included in our course of rehabilitation after cancer. At Dallund sexuality and sexual problems are addressed at several levels. More than 80% of all courses contain lectures by a certified sexologist as well as group discussions and the possibility of individual consultation and guidance. Further, one of Dallund’s nurses has been especially trained in sexuality and body image. The presentation will expand these data and will include information on the patients’ experience during and after the course.

391 Comparative Evaluation of Outpatient and Inpatient Cancer Rehabilitation Settings in Germany Lehmann C1, Bergelt C1, Berger D2, HagenAukamp C3, Koch U1 1 Institute of Medical Psychology, Hamburg University Clinic, Hamburg, Germany; 2Arbeitsgemeinschaft fu.r Krebsbeka.mpfung in NordrheinWestfalen ARGE, Bochum, Germany; 3Niederrhein-Klinik, Korschenbroich, Germany PURPOSE: In Germany cancer rehabilitation is mainly carried out in specialized rehabilitation clinics in the inpatient setting. Only during recent years have outpatient rehabilitation programs been implemented. The objective of this study is a systematic evaluation and comparison of outpatient and inpatient cancer rehabilitation. METHODS: Three groups of patients were investigated in a retrospective design: one group which participated in an outpatient and two groups which participated in an inpatient rehabilitation measure (close to their residence or more than 120 km from home). The questionnaire covered structural aspects of the rehabilitation settings, sociodemographic data, and evaluation from the patients’ perspective. Medical outcome was assessed on the basis of discharge reports

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written by the physicians in charge at the end of rehabilitation. RESULTS: Fifty-nine percent of the outpatient rehabilitants attribute their choice for the outpatient setting to their own decision; 70% of the inpatient group chose the setting based on the physician’s recommendation. The outpatient group receives more treatment per day than the inpatient groups (p50.001), and most subjects consider the amount of treatment to be sufficient (76%). Patients in the outpatient setting have significantly fewer options for creative therapy and leisure activity but more counselling and support for social and financial problems. They rate the quality of medical care significantly worse than the inpatient rehabilitants (p50.05). CONCLUSIONS: The results concerning the choice of setting indicate specific selection processes within the referral procedures. Higher discontent with medical care among the outpatient group provides information about aspects of outpatient rehabilitation, which can be optimised.

phenomenological-hermeneutical point of view, in accordance with the Empirical Phenomenological Psychological Method. RESULTS: Cancer caused a radical change on many levels and the experience of the body changed in several ways. A new sensitivity to bodily signals appeared, which could be related to insecurity connected to the disease and the treatment. Many worried strongly about recurrence. This was related to a questioning of trust of the body and of life. There were different strategies to cope with this. There was an existential dimension in listening to the body signals to many of the interviewees and the body was transformed into a messenger in a wide sense. CONCLUSION: It was meaningful to investigate the cancer experience through a bodily perspective. The results indicate that it can be helpful to communicate with the patient about body experience in cancer rehabilitation.

393 392 Body Experience and Body Reliance in Some Women who have been Diagnosed with Cancer Lundgren H1, Biguet G2, Bolund C3 1 Neurotec Department, Oncological Rehabilitation Center, Karolinska Hospital, 171 76 Solna, Sweden; 2 Neurotec Department, Division of Physiotherapy, 141 83 Huddinge, Sweden; 3Department of Oncology, Unit of Psychosocial Oncology and Rehabilitation, Karolinska Hospital, 171 76 Solna, Sweden Physical disease, like cancer, can be perceived as a psychological crisis. Part of the crisis concerns changes of the body. This essential and complex phenomenon has not been investigated systematically within rehabilitation and there is a lack of theory. AIM: The aim of this study was to describe the phenomenon Body Experience with special attention to Body Reliance among women with cancer. METHOD: The persons included in the study were ten women, with different cancer diagnosis, who had been treated with oncological medical care or were receiving such, in order to cure or to palliate the cancer symptoms. They were to start physiotherapeutic rehabilitation. Semistructured interviews were conducted and analysed from a

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A Model of Empowerment, Vision, and Hope for Counselling Persons Diagnosed with Malignant Spinal Cord Tumors Mann BL Psychology Glenrose Rehabilitation Hospital, Edmonton, Canada The Glenrose Rehabilitation Hospital in Edmonton, Canada is a large Adult, Geriatric, and Pediatric Rehabilitation Centre with 244 adult inpatient beds. Rehabilitation is offered by a team of professionals through inpatient programs, outpatient follow-up clinics, and outpatient programs to adult traumatic spinal cord injury, primary spinal cord tumors, and metastatic spinal disease. This paper focuses on those particular patients diagnosed with spinal cord tumors (malignant neoplastic growths in the spinal cord such as spinal ependymoma or astrocytoma and extradural tumor extensions that may occur with Ewings sarcoma, lymphoma, and metastases) who are transferred to our Spinal Cord Injury Program for rehabilitation from acute care hospitals and/or the Cross Cancer Institute. The purpose of this paper is to describe a psychological model used for counselling persons diagnosed with spinal cord tumors and/or metastatic disease. Most of these patients have been admitted to spinal cord

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rehabilitation to enhance possible physical gains, activities for daily living, quality of life, and independence. In emphasizing quality of life, our psychological model emphasizes empowerment, vision, and hope to gain mastery over some of the traumatic aspects of the illness. The psychological realities and complexities of adaptation and adjustment to cancer are emphasized by envisioning new ways of ‘‘being’’ and ‘‘doing’’. Empowerment, communication and self-disclosure, voice and self-identity, moving forward to a new self, mindfulness, and focussing one’s energies on positive healing methods are some of the other aspects of this model.

394 Practical Guideline for the Multidisciplinary Management of the Spinal Cord Compression Pera Jambrina MA1, Barbero Biedma E2, Hollenstein Prat MF3, Lozano Borbalas A4, Serrano G4 et al. 1 Physical Therapy Unit, Institut Catala D’oncologia L’hospitalet, Barcelona, Spain; 2Social Worker Unit, Institut Catala D’oncologia L’hospitalet, Barcelona, Spain; 3Psycho-Oncology Unit, Institut Catala D’oncologia L’hospitalet, Barcelona, Spain; 4Radiotherapy Service Institut, Catala D’oncologia L’hospitalet, Barcelona, Spain INTRODUCTION: The Spinal Cord Compression is an oncology emergency with physical, psychological and social deficits. PURPOSE: To make a practical and multidisciplinary guideline for the assessment and the management of the deficits that reduce the quality of life of these patients. An early detection and management of these deficits could reduce the physical, psychological and social consequences. MATERIAL AND METHODS: In our previous experience we have observed a neurological deficit that persists after the radiotherapy treatment. In order to assess the physical, psychosocial and social aspects related with this deficit, we have developed a multidisciplinary and practical guideline. This guideline includes the following measures: Frankel Scale (neurological deficit), Analogical Visual Scale (pain, anxiety and depression symptoms) and social problem list (practical and psychosocial problems). RESULTS: After several meetings with

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all the members of the multidisciplinary team, we would like to present during the IPOS meeting our guideline as an instrument for the assessment and the management of the physical and psychosocial aspects related to the neurological deficit. CONCLUSION: The multidisciplinary guideline will permit the early detection and management of the physical, psychosocial and social deficits, observed after the radiotherapy treatment and aims to improve the quality of life for patients affected by Spinal Cord Compression.

395 Physical Activities Lead to Improvement of the Physic State in Breast Cancer: A Study with 25 Inpatients in Rehabilitation Rogge HR, Karbe SK Onkologie und Ha.matologie Reha-Klinik Schlob Scho.nhagen, Scho.nhagen/Brodersby, Germany In the scientific literature data on the effect of physical activity on the psychic state are rarely found. Some data can be shown in our study. We studied 31 patients of which 25 were eligible with breast carcinoma stage pT1-2pN0-1cM0-1 in the age of 30–57 years. All probands had surgery and chemotherapy, 21 of 25 had additional radiotherapy. The physical training consisted in walking, treadmill, and an aerobic-like dance training, the latter being quite important to the emotional wellbeing. Some patients participated in a training for muscular strength. We show the data on the improvement of the aerob physical fitness, and of the psychological state, as determined by the method of Zerssen (1976). Two of the patients failed to improve under the given study conditions. Since a reliable control group could not be tested, we try to evaluate the contribution of factors other than the physical training. In summary, the data show that more than 90% had a psychological benefit from a physical training under the control of physicians and qualified sport therapists.

396 Social Rehabilitation after Laryngectomy

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Singer S1, Hornemann B2, Bloching M3, Oeken J4, Schwarz R1 1 Social Medicine University of Leipzig, Leipzig, Germany; 2Psychology Rehabilitation Center, ‘‘Bavaria’’, Kreischa, Germany; 3Head & Neck University of Halle, Halle, Germany; 4Head & Neck Municipal Hospital, ‘‘Flemmingstrasse’’, Chemnitz, Germany

Syrjala KL1, Abrams JR1, Dikmen S2, Heiman J3, Thomas A3 et al. 1 Biobehavioral Sciences, Fred Hutchinson Cancer Research Center, Seattle, USA; 2Rehabilitation Medicine, University of Washington School of Medicine; 3Psychiatry and Behavioral Sciences, University of Washington School of Medicine, USA

PURPOSE: Patients with advanced laryngeal cancer often have to be treated with laryngectomy. The consequence is the loss of the normal laryngeal speech and therefore the possibility of communication is reduced. The question is, how this loss has an effect on social rehabilitation. Does it lead to social isolation? In which extent do quality of voice and social withdrawal correlate? METHODS: Because of the rarity of laryngectomy a retrospective approach was chosen to enhance the sample size. All patients with laryngeal cancer who underwent laryngectomy within the last two decades in four big hospitals in Saxony, Eastern Germany were asked to participate in the study. A total of 250 patients were contacted. 52% of the patients took part, 11% refused participation, 6% were moved to an unknown place, 31% were deceased. The patients were interviewed face-to-face in their houses. To assess the above-mentioned issues a standardized multi-scale questionnaire was used}the Hospital Anxiety and Depression Scale (HADS), the EORTC-QLQ-C30 and H&N35, and a Questionnaire for Coping after laryngectomy ‘‘Fragebogen zur Psychosozialen Anpassung nach Laryngektomie’’ (FPAL). Speech intelligibility was assessed using the ‘‘Postlaryngektomie-Telefon-Verst.andlichkeits-Test’’ (PLTT). RESULTS AND CONCLUSIONS: The feeling of being stigmatised is a common problem in patients after a laryngectomy, even years after the operation. This feeling does not correlate with speech intelligibility or with social activity but with loneliness. Social activity seems to play a crucial role in learning the new voice and vice versa.

PURPOSE: RCT to improve outcomes for cancer survivors are few and virtually non-existent in HSCT. We tested an intervention to improve stamina/fatigue, adaptation to cognitive limits, emotional distress, family adaptation and sexual function. METHODS: Adults having their first HSCT for malignancy were eligible. Pretransplant, 199 patients consented and completed assessment. Ninety-two percent were non-Hispanic Caucasians, 60% were female, mean age was 42 (range 22–68). Post-transplant, 147 survivors completed a second baseline and were then randomised to treatment or usual care. Treatment included two or three (for women) 90-min psychoeducational workshops prior to discharge home, with booster phone calls after 2 and 9 months. Outcome was assessed at 12 months, with interim assessment at 6 months. Assessments included the SF36, Rehabilitation Scale (RS), SCL90-R, Cancer Treatment Distress (CTXD), Family, Work and Social Roles (FWSR) and the Sexual Function Questionnaire (SFQ). RESULTS: Repeated measures linear models with pre and post-transplant baselines as covariates indicated more rapid recovery for the treatment group in physical ability and adaptation on the RS (p=0.035), fatigue on the SF36 (p=0.030), satisfaction with roles on the FWSR (p=0.013), decline in treatment-related distress on the CTXD (p=0.049), and improved sexual function in satisfaction (p=0.036) and activity (p=0.036) on the SFQ. Fifty-eight percent of women in the control condition were sexually active at 1 year vs. 80% in the treatment condition. CONCLUSIONS: This brief intervention improved the pace of recovery for the most common functional problems in HSCT survivors.

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Efficacy of a Randomized Controlled Trial (RCT) to Enhance Recovery from Hematopoietic Stem Cell Transplantation (HSCT)

Rehabilitation at Hospital for Women Treated for Cervical Cancer Timm HUT1, Bjerrum Thisted LBT2

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Afsnit 7331, UCSF, Copenhagen, Denmark; Finsencentret, Copenhagen University Hospital, Copenhagen, Denmark 2

Rehabilitation at a University Hospital of women treated for cervical cancer. BACKGROUND: In Denmark as in other countries more people survive after cancer treatment. Survival is one important treatment success, quality of life is another. Women treated for cervical cancer with concomitant chemo- and radiotherapy experience different degrees of side effects and late side effects. Cancer rehabilitation is a new concept in Denmark and it is mostly known as patient-education and psycho-social interventions. PURPOSE: 1. To learn more about the experiences of women treated for survical cancer. 2. To develop and to evaluate a rehabilitation service for this group of patients. METHODS: 1. A literature study and a survey including 100 women (EORTC QOL C-30 standard and a special part concerning cervical cancer patients). 2. Interventions; education of 18 nurses, who are responsible for the interventions including patients: telephone and e-mails consultations, personal consultations or cancer classes. 3. Evaluation: a survey including 100 women after treatment and 12 year later, observations of all parts of the interventions and focus group interviews with nurses and patients involved in the project. RESULTS: The project period is March 2003– June 2005, so only primary results can be presented.

conceptualise elements in successful rehabilitation. METHODS: The findings are based on an ethnographic fieldwork conducted in May 2001 and from March to July 2004 at the rehabilitation centre. The empirical material stems from participant-observation and in-depth interviews with the course participants approximately 5 months after the course. RESULTS: At Rehabiliterings Center Dallund the course participants learn about cancer, healthy food, body exercises and the psychosocial problems following the illness and the treatment. The paper draws attention to some aspects of the rehabilitation process, which were not explicit items of the rehabilitation program. We found that minor happenings such as small conversations, interactions, exchanging of words and stories in several cases became crucial for the individual person’s life with cancer. Theoretically, we draw from Mattingly’s notion of healing drama and transformative moments and from anthropological theories of ritual processes. CONCLUSIONS: The qualitative material shows that many factors such as the individual life- and illness story, social relations, age and work life influence the ways knowledge and experiences obtained during the rehabilitation course are used and actualised in the patients own rehabilitating efforts. The rehabilitation courses also create dramas with transformative and rehabilitative potentials, which are not easily seen or conceptualised, but must be addressed empirically and analytically if we are to understand and conceptualise successful rehabilitation.

399 400 Ritual and Transformative Moments in Rehabilitation Tjrnhj-Thomsen T1, Terp Hybye M2, Johansen C2 1 Institute of Anthropology, University of Copenhagen, Copenhagen, Denmark; 2Department of Psychosocial Cancer Research, Institute for Cancer Epidemiology Danish Cancer Society, Copenhagen Denmark PURPOSE: The purpose of the study is to explore the effect of the rehabilitation courses offered at Rehabiliterings Center Dallund (Denmark) on the psychosocial well being on different groups of former cancer patient and to identify and

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Rehabilitation after Cancer: Back to Work Tofte J The Dallund Centre for Rehabilitation of Cancer Patients, Danish Cancer Society, Søndersø, Denmark Dallund is the first and only centre in Denmark offering rehabilitation to cancer patients as a residential course. PURPOSE: According to Dallund’s self-report measure approx. Twenty-one percent (226/1065) of the patients referred to rehabilitation are in doubt about their possibilities of returning to work. A main objective is to ascertain how the cancer patient, the workplace

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and the authorities may cooperate to create optimal possibilities for the patient’s return to work. During the course we aim at increasing the individual resident’s chances of returning to work. METHODS: Patients experiencing difficulties in relation to the labour market are identified prior to the course. Each course at Dallund contains items dedicated to patients returning to their workplace or already at work, and separate courses are devoted to this theme. Furthermore, identified patients are offered individual counselling by social workers. Following the course the patients are screened again on their way home and after 3 months using the same instruments as before. RESULTS: The number of patients in doubt about their possibilities of returning to work reflects their contact to the labour market: Patients Employed, full Employed, partly Employed, sick leave Unemployed Retired Other Total

METHODS: 1. A brief instruction of the work with action plans is given by the teacher. 2. The patients work out their individual plan. 3. Each patient presents her action plan to fellow patients. RESULTS: The patients’ evaluation of their work were: To what extent did you benefit from working with your action plan? (n=243) 0 (no benefit) – 5 (high benefit) 5 4 3 2 1 0 ? Blank 34% 25% 13% 3% 1% 1% 9% 15% To what extent do you think your action plan will help you? (n=249)

4% (6/162) 14% (18/125) 40% (140/351) 58% (11/19) 11% (39/366) 29% (12/42) 21% (226/1065)

Further data on the first 6 months of 2004 will be analysed, presented and discussed at the congress.

Very much Much Some Less Not at all Blank 21% 40% 26% 1% 0% 13% CONCLUSION: Approximately 60% of the patients seem to profit from the work with action plans.

Relatives 402

401 Rehabilitation After Cancer. Individual Action Plans Tofte J The Danish National Cancer Society, The Dallund Centre for Rehabilitation of Cancer Patients Søndersø, Denmark Dallund is the only centre in Denmark offering rehabilitation to cancer patients as a residential course. PURPOSE: A key element of the rehabilitation process at Dallund is the making of a future action plan by each patient. The purpose is (1) each patient formulates explicit goals for her rehabilitation in the future; (2) each patient identifies explicit modes of action in relation to her essential problems; and (3) the possibilities for completion of the desired changes are increased.

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Psychological Characteristics of a Sample of Parents of Ecuadorian Children with Cancer Alvarado MC Psychology Instituto del Ca!ncer, (SOLCACuenca) Cuenca, Ecuador INTRODUCTION: Diagnosis of cancer in a child constitutes one of the events of greatest impact for patients and relatives, who can present deep emotional reactions for extended time periods. OBJECTIVE: To identify the principal psychological problems in a sample of parents of children with cancer that received attention at the Institute of Cancer. METHOD: 33 parents participated, of children (average age: 8 years) diagnosed with different cancers, at least three months before the evaluation. Through individual interviews they answered the Self-Assessment Questionnaire, of CAPO-2003, and had an interview of social

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situation. RESULTS: Proper credibility (alpha=0.81) for the global Questionnaire was obtained. Most of the parents are deeply affected by the disease of their children in all areas. The most frequent problems (‘‘many times’’, or ‘‘all the time’’) were anxiety (84.9%), depression (60.3%), difficult in concentrating on their jobs (66.6%), and economic problems (84.8%). A meaningful correlation was found between anxiety and oncological treatment time. CONCLUSIONS: Parents are very affected by the disease of their children, independently of the time of treatment. This is explained by the uncertainty that cancer produces in families; it can lead to moments of peace and hope, and to moments of fear and anxiety (after a relapse, an infection, death of a child. . .). It is important to evaluate continually the affective situation of parents, to make sure they receive proper support when they go through an emotional crisis.

403 Children Exposed to Parental Cancer: The Role of Gender in Psychosocial Adjustment Baldus C, Saha R, Haagen M, Pott M, Romer G Clinic for Child and Adolescent, Psychiatry University Hospital, Hamburg Eppendorf, Hamburg, Germany PURPOSE: Previous research on the role of gender in children of parents, who have cancer, is heterogeneous. Some findings suggest that especially girls of ill parents are at increased risk for showing psychosocial symptoms. However, few studies have taken into account interactions between parental and child gender. The purpose of this investigation, which is embedded into a transnational multisite study on children of somatically ill parents (COSIP), is to investigate on the relevance of both child and parent gender regarding child psychosocial adjustment. Moreover, the role of gender in the child’s use of coping strategies is explored. METHODS: The sample consists of 50 children (age 4–17) of cancer patients who have been recruited via the adult medical care context. Psychosocial adjustment is operationalised through measures of quality of life and psychosocial symptoms. Data of the Revised Children Quality of Life Questionnaire (KINDL),

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the Youth Self-Report (YSR) and the Child Behaviour Checklist (CBCL) are used to integrate both child and parent perspectives. Moreover, data of the Schoolager’s Coping Strategies Inventory (SCSI) identify preferred coping strategies. Analyses of variance are performed to investigate gender effects. RESULTS: Gender match between ill parent and child decrements child psychosocial adjustment. Moreover, daughters of ill mothers show most symptoms. Gender differences in the use of coping strategies are shown. CONCLUSIONS: Ideas for possible implications for children of cancer patients are addressed, especially regarding the need of taking into account the role of gender in preventive interventions for affected families.

404 Attachment and Caregiving}Complementary Behavioral Systems Braun M1, Gagliese L1, Mikulincer M2, Rodin G1 1 Psychsocial Oncology and Palliative Care, Princess Margaret Hospital, Toronto, Canada; 2Psychology Bar-Ilan University, Ramat-Gan, Israel BACKGROUND: Attachment and caregiving have been regarded as complementary behavioral systems. The current study examines the associations of attachment style of spouse caregivers of cancer patients with their caregiving style and their emotional well-being. METHOD: Forty-four patients with stage IV GI cancer and their spouse caregivers have been recruited thus far to this study. Measures included: Experience in Close Relationships, ENRICH Marital Satisfaction Scale, Karnofsky, Caregiving Burden Scale, Caregiving Style, Beck Depression Inventory-II and Beck Hopelessness Scale. RESULTS: 21.4% of the caregivers reported moderate to severe depression and 23.8% reported on moderate to severe hopelessness. Levels of depression and hopelessness were not significantly different from those of the patients (p=0.26, p=0.20, respectively). Regression analyses revealed that caregivers’ attachment style accounted for 20% of the variance in spouse caregivers’ depression and 15% of the variance of spouse caregivers’ hopelessness. Spouse caregivers’ attachment style was negatively correlated with control (0.36, 0.44) and compulsive (0.58)

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caregiving styles. CONCLUSIONS: Attachment style is linked both to caregiving style and spouse caregivers’ emotional well-being. Future research should take into account the interactive nature of the attachment and caregiving behavioral systems.

PURPOSE: To assess the psychological needs of parents after the death of their child from cancer. METHODS: The study comprises a preliminary retrospective phase to identify parents that spontaneously contacted the medical staff, followed by a prospective phase in which families were contacted by telephone and were invited to a meeting. RESULTS: The retrospective study demonstrated that more than 50% of the families spontaneously sought contact with the department. In the prospective study, 17 families were contacted and the majority of them subsequently decided to come to the department for a talk. CONCLUSIONS: Our experience shows that parents have a strong need to have further contact with the team that took care of their children for months. In the process of coping with bereavement, anxiety and depression are common and not necessarily pathological, though there may be psychopathological reactions that can interfere with the parents’ quality of life.

PURPOSE: While telemedicine in paediatrics may offer the means to enhance quality and continuity of care, little is known about the attitudes and perceptions of parents and health professionals, especially potential barriers to implementation. This research programme had two broad aims. (1) To investigate the attitudes of parents and professionals to applications of interactive videoconferencing in paediatric oncology. (2) To trial an outreach service for families separated by cancer treatment via a purpose specific Webcam application: ‘‘KidCom’’ (a device which attaches to a standard television monitor). METHODS: Parents of children diagnosed with cancer (n=100) and associated health professionals (n=188), were surveyed on their understanding and attitudes toward interactive videoconferencing in specific oncology applications. Individual families were enrolled on a trial of ‘‘KidCom’’. RESULTS: Health Professionals and parents gave higher ratings for the usefulness of videoconferencing for enhancing psychosocial care or educational opportunities, rather than for clinical uses or treatment planning. In particular parents’ least favoured potential application was ‘‘diagnostic services’’, while the most favoured was ‘‘contact between separated family’’. ‘‘KidCom’’ has been well-received by families as a means for reducing the distress of separation. CONCLUSIONS: Parents of children diagnosed with cancer, and their professional carers, are receptive to applications of technology in healthcare, especially for non-medical services (e.g. supportive care, education). As a partial response to these findings, our centre has developed and is currently trialling ‘‘KidCom’’ to enhance communications between separated family. By providing families with portable reusable cost-effective webcam/internet units, ‘‘KidCom’’ may complement institutional fixed position videoconferencing.

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Interactive Videoconferencing in Australia for Enhancing Psychosocial Care in Paediatric Oncology: Attitudes of Parents and Professionals, and the Example of ‘‘KidCom’’ Cohn R, Goodenough B, Corlette S Centre for Children’s Cancer and Blood Disorders, Sydney Children’s Hospital, Randwick, Australia

Caregivers Psychological Morbidity in Oncology: Review of Risk Factors Cort!es-Funes F1, Abi!an L1, Go! ngora B2, Narv!aez A4, Rubin* os C3 et al. 1 Psycho-Oncology Unit Hospital, 12 de Octubre Madrid, Spain; 2Psycho-Oncology Unit Hospital Torreca!rdenas Almeria Spain; 3Psycho-Oncology

405 Psychological Support for Parents who have Lost their Child with Cancer Clerici CA1,2, Ferrari A1, Massimino M1, Terenziani M1, Spreafico F1 et al. 1 Unita" Operativa Pediatria Istituto per lo Studio e la Cura dei, Tumori, Milan, Italy; 2Department of Psychology, University of Milan, Bicocca, Milan, Italy

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Unit Asociacio!n, Espan*ola Contra el Ca!ncer, Orense, Spain; 4Psycho-Oncology Master Universidad Complutense, Madrid, Spain; 5Clinical Oncology Unit Hospital, 12 de Octubre, Madrid, Spain The oncological diagnosis produces a psychological distress in the whole family system. The ideal readjustment would be that all the members of the family system can accept the situation and supply to the patience a proper support in different areas. Nevertheless the figure of the caregiver is becoming more important each time. His roles embraces from physical care and problem solving to emotional support. Most of the patients face the presence of the caregiver without any added problems, but still we find an important minority that suffers from distress or some other emotional disorder. Several studies demonstrate that in this situations the caregivers presents higher levels of distress than those of the patient; especially the anxiety. Our study analyses the main predictable variables regarding the caregiver’s psychological morbidity. Our aim is to influence directly on them so the caregiver would get a better quality of life and less distress. The aim of our study is to make a first approach to some variables that are influencing the caregiver mood such as social support, family functioning, caregiver coping (optimistic versus pessimistic), marital adjustment and premorbid psychopathological history of the caregiver. The variables studied more often have been the ones that related the illness (stage, prognosis, tumour localisation. . .) to the sociodemographic variables (gender, age, cultural level), the physical dependence to the patient, etc.

143 men with early stage prostate cancer prior to undergoing radical prostatectomy. All participants were married or living with a partner, 78% were Caucasian, average age was 61 years, and 81% had some college education. Approximately 3 weeks before surgery, participants completed a questionnaire assessing relationship satisfaction (Dyadic Adjustment Scale); 1–2 days later they completed a measure of self-efficacy (confidence in managing issues related to surgery and recovery); and 2 weeks later (1–5 days before surgery) they completed a questionnaire assessing fears and concerns regarding surgery (e.g., complications during surgery, changes in sexual functioning). Analyses revealed that relationship satisfaction (r= 0.19, p=0.02) and self-efficacy (r= 0.27, p=0.001) were both negatively associated with surgery concerns; and relationship satisfaction was positively associated with self-efficacy (r=0.19, p50.02). Regression analyses, controlling for demographic variables, revealed that the association between relationship satisfaction and surgery concerns disappeared when self-efficacy was in the model, and selfefficacy remained a significant predictor of surgery concerns (beta= 0.25, p=0.003). Results suggest that self-efficacy mediated the association between relationship satisfaction and surgery concerns, in that patients’ satisfaction with their relationship influenced surgery concerns through its association with self-efficacy. Thus, given the importance of relationship satisfaction, psychosocial interventions occurring prior to prostate surgery should include the patient’s partner and focus on behavioral skills training to enhance the patient’s self-efficacy.

409 408 Self-efficacy Mediates the Association Between Relationship Satisfaction and Surgery Concerns among Men with Prostate Cancer Devine D, Parker PA, Carmack Taylor C, Harrison-Fortier A et al., Cohen L Behavioral Science, The University of Texas, M. D. Anderson Cancer Center, Houston, USA We examined associations among relationship satisfaction, self-efficacy, and surgery concerns in

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Update on the Hospital Wide Bereavement Program at Sir Charles Gairdner Hospital Elliott DR Cancer Clinical Service Unit, Sir Charles Gairdner Hospital, Perth, Australia Sir Charles Gairdner Hospital (SCGH) aims to provide a sustainable hospital wide bereavement service with a multidisciplinary, culturally sensitive approach. Continuity of care with pre and post death support is offered to patients’ families including early intervention for those ‘at risk’ of

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a severe grief reaction. Prompt contact of the deceased’s medical practitioner in the community and the provision of staff support are essential components of the program. The service has been running for over two years and was initially piloted on volunteer wards. It evolved from a needs analysis of bereaved families identified in a survey of deceased SCGH patients, current hospital practices in Australia and other services reported in the literature. Survey results will be discussed. The presentation will focus on (a) the aims of the program and how they were implemented, (b) problems encountered (including staff resistance) and (c) continual improvements made in the provision of best clinical practice in this culturally sensitive area.

410 Relatives of Colorectal Cancer Patients Participating in a Population-based Familial Colorectal Cancer Registry Esplen MJ1, Aronson M2, Rothenmund H2, Butler K1, Gallinger S2 1 Behavioral Sciences and Health University, Health Network, Toronto, Canada; 2Ontario Familial Cancer Registry, Mount Sinai Hospital, Toronto, Canada Relatives of colorectal cancer (CRC) patients have an increased risk of developing colorectal cancer. PURPOSE: The objective of this descriptive study was to describe the interest in and attitudes towards genetic testing for hereditary CRC, perceived risk, experience of loss and screening in relatives of CRC patients participating in a population-based familial colorectal cancer registry. METHODS: This is a cross-sectional questionnaire survey study with standardized measures that are mailed with postal and telephone followup. RESULTS: A total of 501 surveys were sent: Ninety-three to relatives from high-risk families, 259 to intermediate risk families and 149 to low risk families. The participation rate was 65% with a mean age of 52.1 years (14.4), 55.6% were female and 44.4% were male, 83.8% were married and 84.5% had children at the time of the study. Interest in genetic testing was high with 86.7%

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reporting that they were likely or very likely to pursue testing. Perceived risk of developing CRC was comparable to women with a family history of breast cancer with 59.1% indicating that their risk was 50% or higher. Levels of intrusion or cancer worry were also high with a mean score of 12.5 (SD=6.6). Seventy-five percent reported having lost a significant person in their life with 23.9% due to CRC. Levels of endoscopy were higher than expected with 76.1% reporting at least one examination although 41.5% of respondents were unsure about the risk of complications of colonoscopy. Findings have implications for genetic counselling, clinical screening and follow-up.

411 Predicting Coping among Lay-Caregivers of Patients Receiving Community-Based Palliative Care Fisher JA1, Robinson JA1, Clark M2,3 1 Psychology Flinders University, Adelaide, Australia; 2Medicine, Flinders University, Adelaide, Australia; 3Memory Disorders Unit, Repatriation General Hospital, Daw Park, Australia PURPOSE: Caring for someone with a terminal illness is one of the most stressful roles that one can experience. Family members and friends are increasingly responsible for the home care of palliative patients, encouraged by economic forces and personal preference for home care and death. A short-term longitudinal study tested the applicability of an adapted version of Lazarus and Folkman’s (1984) stress and coping model in predicting the coping and well-being of such caregivers. Intra-individual changes and interindividual differences in outcomes were examined. METHOD: Primary lay-caregivers (i.e., family members and friends) were interviewed up to three times after patient referral to a metropolitan palliative care service in South Australia. Such services facilitate the community care of patients by providing outreach nursing, 24-h assistance, counselling and caregiver respite. A questionnaire assessing relevant stress and coping constructs was completed at each interview. Of the 122 caregivers who completed Interview 1, 90 completed Interview 2 four weeks later, and 67 completed Interview 3, a further four weeks later. Patient decline and death was largely responsible for sample

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attrition. RESULTS: Large inter- and intraindividual differences in coping and well-being were found. Factors that predict both inter- and intra-individual differences were identified, and included a mixture of environmental, dispositional and appraisal constructs. Different variables predicted different measures of coping and well-being and the pattern of prediction varied across time. CONCLUSION: Clinical application of the stress and coping model may help to identify caregivers at-risk of poor outcomes and the areas to be targeted in interventions.

412 Participant Evaluations of an Open-Ended Hospital-Based Support Group for Parents of Children Diagnosed with Cancer Foreman T, Willis L, Goodenough B Centre for Children’s Cancer and Blood Disorders, Sydney Children’s Hospital, Randwick, Australia PURPOSE: While the benefits and limitations of support groups are well described in the literature, there are few reports of open-ended hospital-based programs for adults in paediatric settings. This project evaluated a 6-week program of psychoeducation for parents of hospitalised oncology and haematology patients, which aimed to provide peer support and information relevant to parent needs and interests. METHODS: The group was a weekly semi-structured psychoeducational morning session of ninety minutes conducted on the oncology inpatient ward. Sessions comprised a thirty minute topical presentation by a guest speaker, then a one hour interactive discussion. Parents provided quantitative and qualitative evaluation: using scales to rate the helpfulness of talks and group discussions, and written feedback on why they attended the group or found it valuable. RESULTS: Overall, twenty parents attended the program, representing 46% of those eligible to attend/invited. Parents gave high positive ratings of the helpfulness of the program content and group discussions (each attracted mean ratings of 2.5, where the scale maximum was ‘‘3-extremely helpful’’). Analysis on parents’ reasons for attending the group identified six main themes: (1) to gain information (33% of parents), (2) meet other parents (24%), (3) interested in talk

Copyright # 2004 John Wiley & Sons, Ltd.

(12%), (4) needed support (12%), (5) needed a break (9%), (6) help new parents (6%). CONCLUSIONS: Despite lower than anticipated attendance, findings indicated that open-ended hospital-based psychoeducational groups have specific relevance for parents dealing with the diagnosis and treatment of childhood cancer, providing a safe forum for support, information provision and knowledge-sharing.

413 A Longitudinal Study of the Impact of Childhood Cancer on Parental Quality of Life: A SelfRegulatory Approach Girling M Psychology, Cancer Research UK, University of Sheffield, Sheffield, UK BACKGROUND: Consistent evidence suggests that the variations of psychological and psychosocial problems that childhood cancer places on families are elevated by the financial and social costs associated with parental loss of employment due to care giving responsibilities. The importance of understanding the way people make sense of negative life events is a central concern to Wrosch et al.’s adaptive self-regulatory model. PURPOSE: Applying Adaptive Self-regulation Theory (Wrosch et al., 2003), we predicted that, among parents of children with cancer, QoL might be affected by the difficulties involved in disengaging from employment characterised by the inability to abandon unattainable goals and reengage effort in alternative goals. METHODS: 26 parents of children with cancer (n=26) completed a questionnaire to assess functional QoL (SF-36) and were interviewed shortly after their child was diagnosed (T1) and six months after diagnosis (T2). Interview data was qualitatively analysed using the 10-item stem Goal Disengagement and Goal Reengagement Scale (GDGRS, Wrosch et al., 2003). RESULTS: Overall, parents were typically able to disengage from the goal of employment and reengage in new goals. QoL scores on the SF-36 improved with successful adjustment to loss of employment at follow-up. CONCLUSION: Parental QoL may be promoted by a greater use of adaptive self-regulatory behaviour as assessed by the GDGRS. Persistent pursuit of employment

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goals may lead to a reduction in QoL, perhaps due to excessive preoccupation with unattainable goals.

414 Anxiety, Depression and Quality of Life in Caregivers of Patients with Metastatic Cancer Grov EK1, Foss(a SD2, Moum T3, Dahl AA2 1 Institute of Health, Buskerud University College, Drammen, Norway; 2Department of Clinical Research, The Norwegian Radium Hospital, University of Oslo, Oslo, Norway; 3Department of Behavioural Sciences in Medicine, University of Oslo, Oslo, Norway BACKGROUND: Limited empirical research has been done on the situation of caregivers to patients with metastatic cancer staying at home. Clinical experience tells that caregivers often have a considerable burden. AIM: This study examines quality of life (QOL), anxiety and depression in caregivers of patients with metastatic cancer, mainly breast cancer in females and prostate cancer in males. METHODS: Ninety-six caregivers in this prospective study filled in The Short Form (SF)-36 and Hospital Anxiety and Depression Scale (HADS) at baseline, and at four months follow-up. Only baseline data is reported here. Findings for each gender were compared to ageadjusted norm data from the population. RESULTS: Among the caregivers 47 were women (mean age 59.2 years), and 49 were men (mean age 56.9 years). Physical QOL was not significantly different from the norm in both genders. Mental QOL was significantly lower than the norm in males, but not in females. The level of anxiety was significantly higher than the norm in both genders, while there was not significant difference for depression. CONCLUSIONS: Mental distress in caregivers of both genders is higher than in the age-adjusted population. The caregivers’ need for diagnosis and treatment of mental disorders should be given attention by health care personnel.

415 Implementation of an Innovative Counselling Service for Children of Cancer Patients: Special Family Issues in Parental Brain Tumour Diseases

Copyright # 2004 John Wiley & Sons, Ltd.

Haagen M, Baldus C, Saha R, Pott M, Romer G Department of Child and Adolescent Psychiatry and Psychotherapy, University Hospital, HamburgEppendorf Hamburg, Germany PURPOSE: A preventive out-patient counselling service for children of somatically ill parents (COSIP), combined with an in-patient liaison service with oncological units for adult cancer patients having minor children was implemented in 2000 in our department. Experiences of the implementation process and the needs of the families seen so far are described and exemplified by the needs of parents suffering from brain tumours. METHOD: A descriptive analysis was made of all families seen for counselling (n=70) covering sociodemographic and illness-related data. In a part of the sample (n=50), psychometric instruments were administered prior to the beginning of counselling measuring children’s mental health status (CBCL, YSR), quality of life (KINDL) and family relational functioning (FAD). Frequent problems in these families were analyzed qualitatively from a developmental, psychodynamic and family dynamic perspective. RESULTS: In most families seeking counselling, a parent had cancer with insecure or terminal prognosis. Surprisingly, one third of the families had sought counselling after the death of a parent. When a parent has a brain tumour, the problem of communicating the diagnosis and it’s sequelae to the children are especially difficult. Casuistic examples illustrate our experiences. CONCLUSIONS: Preventive counselling should be provided for this target group on a lowthreshold base, especially for families with younger children. These services have to be prepared for already bereaved children. Problems met in the implementation of this innovative family and child oriented service in the context of adult medical care are discussed. Recommendations for future implementation strategies are derived.

416 The Influence of Carer Responses on Patient Psychological Adjustment: The CAREFOR Project } Preliminary Findings Hodges LJ1, Humphris GM2, Barrowclough C1

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Academic Division of Clinical Psychology, The University of Manchester, Manchester, England, UK; 2Bute Medical School, University of St. Andrews, St. Andrews Scotland, UK A growing international research literature highlights the key support role of carers in the cancer context, both practically and emotionally. There is now a large body of evidence demonstrating a positive relationship between cancer patient and carer psychological distress, yet these studies often give no indication of cause and effect or how distress is transmitted. Before interventions are designed, fundamental knowledge of the mechanisms underlying a given phenomenon should be described and understood. Explanatory or predictive models are lacking concerning patient and carer adaptation. The CARE-FOR Project (Carers and Relatives Experience & Fears Of Recurrence) is a prospective study of head and neck cancer patients and carers over a 6-month period following diagnosis. The head and neck cancer population remain a neglected focus of research, although the incidence of the disease is rising and it has been described as the most emotionally traumatic type of cancer. The project investigates the influence of two carer responses}‘Openness of communication’ and ‘Emotional Over-Involvement’}on both patient and carer adaptation. The proposed structural model will be presented, along with the preliminary findings from the initial recruitment of 40 patient-carer dyads. There appears to be a significant relationship between these two styles of carer support and a number of measures of patient/carer adjustment, including anxiety, depression and fears of recurrence.

417 Prevalence of Stress Response Symptoms in Adolescent Children of Cancer Patients: A Prospective Study Huizinga GA1, Visser A2, Graaf WTA, van der1, Hoekstra HJ3, Hoekstra-Weebers JEHM1,4 1 Medical Oncology, University Hospital, Groningen, Groningen, The Netherlands; 2Health Psychology, University of Groningen, Groningen, The Netherlands; 3Surgical Oncology, University Hospital Groningen, Groningen, The Netherlands;

Copyright # 2004 John Wiley & Sons, Ltd.

4

Comprehensive Cancer Center, North Netherlands, Groningen, The Netherlands PURPOSE: To study change in prevalence of stress response symptoms (SRS) reported by adolescent children of parents with cancer over the first six months after diagnosis. METHODS: Adolescents, aged 11–18 years, completed the Impact of Event Scale (IES) for assessment of SRS in terms of intrusion, avoidance and total distress shortly after diagnosis (T1) and six months later (T2). RESULTS: 65 adolescents (26 sons; 39 daughters, mean age=14.4 yrs, SD=2.2) participated at T1 and T2. Mean scores reported at T1: intrusion: sons 10.1  6.3, daughters 11.3  8.3; avoidance: sons 10.0  6.4, daughters 12.2  9.4; total distress: sons 20.2  11.0, daughters 23.6  15.2 and at T2: intrusion: sons 4.0  4.7, daughters 7.7  8.2; avoidance: sons 7.5  7.8, daughters 7.7  8.6 and total distress: sons 11.5  10.2 and daughters 15.4  14.5. Twentythree percent of the sons and 44% of the daughters reported clinically elevated SRS (IES total distress =26) at T1; 15% of the sons and 23% of the daughters did at T2. Wilcoxon signed ranks tests showed significantly fewer symptoms at T2 compared to T1 for intrusion (sons Z= 3.83, p50.001; daughters Z= 2.66, p50.01); avoidance (sons Z= 2.05, p50.05, daughters Z= 2.75, p50.01); and total distress (sons Z= 3.79, p50.001, daughters Z= 3.03, p50.005). Mann Whitney-tests showed no significant differences in SRS between sons and daughters at T1 or T2. CONCLUSIONS: Numbers of SRS of adolescent children of cancer patients decreased over the first six months after diagnosis. More than one third of the adolescents scored in the clinical range shortly after diagnosis; one fifth of them still reported clinically elevated levels of distress at 6 months. No gender differences in SRS were found.

418 RCT of Family Focused Grief Therapy During Palliative Care and Bereavement Kissane DW1, Bloch S2, McKenzie M2, Moskowitz C3, O’Neill I2 et al. 1 Department of Psychiatry & Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, New York,

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USA; 2Centre for Palliative Care, University of Melbourne, Melbourne, Australia; 3Department of Epidemiology & Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, USA PURPOSE: To examine the effectiveness of Family Focused Grief Therapy (FFGT), a preventive intervention for palliative care families viewed at greater risk of psychosocial morbidity. Families are classified into well functioning, intermediate and dysfunctional (sullen & hostile) types using the Family Relationships Index (FRI). METHODS: From 183 ‘‘at risk’’ families identified by screening using the FRI, 81 (44%) consented to enroll. Reasons for refusal were avoidant (59%), family alienation (19%), patient death (15%) and coping well (7%). Randomized in a 2:1 ratio, 53 families (233 members) received FFGT; 28 families (130 members) were notreatment controls. Outcome measures, 6 and 13 months post-death, included the Brief Symptom Inventory (BSI), short form Beck Depression Inventory (BDI) and Family Environment Scale (FES). Analyses used the Generalized Estimating Equation (GEE) method. RESULTS: The global impact of FFGT was modest, with a trend towards reduced distress (BSI) over 13 months [difference in change scores=0.11 (95%CI 0.01, 0.22), p=0.06]. Family functioning (FES) improved most in sullen families at 6 months [difference in change scores= 2.79 ( 5.25, 0.34), p=0.026]. For members with the 10% highest BSI scores, difference in change scores=0.67 ( 0.01, 1.37), p=0.05, with significant improvement in intermediate and sullen, but not hostile, families. For members with the 10% highest BDI scores, differences at 6 months=5.49 ( 0.82, 11.78), p=0.09. CONCLUSION: FFGT conveys a protective benefit upon intermediate and sullen classes, but care is needed not to aggravate hostile families.

and Transfusion Medicine, Cantonal Hospital, Aarau, Switzerland PURPOSE: This study will help to improve psychological support for cancer patients and/or their spouse. One part of the study will be explorative. Individual and systemic factors shaping the coping processes and outcomes will be investigated. For the other part, guiding hypotheses are derived from the literature. Contributions from several research fields have been integrated: Coping, Quality of Life, Personal Growth and Psychotherapy. Differential effects of adjuvant psychotherapy are examined. METHODS: Up to 200 newly diagnosed cancer patients, and their spouses, from two Swiss cancer centres will be assessed three times during the first year after diagnosis. Variables include Personal Growth, Quality of Life, psychiatric symptoms, Sense of Coherence, individual and dyadic coping, post-traumatic symptoms, social support, prior critical life events, social desirability, and relationship quality. Considered medical variables include performance (Karnofsky), stage of disease, treatment factors, and psychiatric medication. RESULTS: The study is in an early phase. Thus the bulk of the presentation will be to outline the study design. We expect, however, to be able to present descriptive data of the first 50 or so patients/couples. CONCLUSIONS: Results of the on-going study are expected to: – further differential insights into coping: what style for whom at what stage is most helpful?; – shed light on coping-relevant interactions between patient and spouse; – reveal predictors of posttraumatic growth/ stress in patients and spouses; – thus help to prospectively identify patients/ spouses who may profit from adjuvant psychological therapy.

420 419 Coping with Cancer}Outline of a One-Year Longitudinal Study of Individual and Dyadic Coping Effects Kuenzler A1,2, Zindel A1 1 Institute of Psychology, University of Bern, Bern, Switzerland; 2Center for Oncology, Hematology

Copyright # 2004 John Wiley & Sons, Ltd.

Intertwining Lives: Health Professionals Caring for Relatives who have Cancer McClunie-Trust PA Nursing and Health studies, Waikato Institute of Technology, Hamilton, New Zealand The relatively new field of psycho-oncology has enabled what Jimmie Holland (2001) terms

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‘‘honest’’ discussions about the implications of cancer as an illness and a life experience. Engaging in these ‘‘honest’’ discussions may enable us to enhance the wellbeing of people who live with cancer and those who care for them. The literary portrayal of illness narratives casts the client and family at centre stage in the ‘‘drama’’ that living with cancer produces for these people (Frank, 2002). Narratives that show the intimate details of personal life within the broader context of health care delivery enable a deeper understanding of the challenges and struggles that characterize this complex experience of living with cancer. This presentation tells the story of living with cancer from within the unique context of the New Zealand health care system and my practice and a nurse educator. It explores the meaning of life threatening illness from inside my professional life as a nurse and my private life as the wife of a 45year-old man diagnosed with metastatic melanoma. It shows how our professional experience profoundly influences how we engage with events in our personal lives, particularly when these events involve health crises for ourselves, or family members. As health care professionals we become involved in these private events in unique and particular ways that require new strategies to negotiate the boundaries between professional practice and private lives.

421 Psychological Adjustment among Partners of Women at High Risk of Developing Breast/Ovarian Cancer Mireskandari S1,2, Sherman K2, Meiser B1, Tucker KM3, Andrews L3 et al. 1 Psychosocial Research Group, Department of Medical Oncology, Prince of Wales Hospital, Sydney, Australia; 2Department of Psychology, Macquarie University, Sydney, Australia; 3Hereditary Cancer Clinic, Prince of Wales Hospital, Sydney, Australia While women at increased risk for breast/ovarian cancer have been studied extensively, the impact of their increased risk on their partners has gone unnoticed and to date partners have received little empirical attention. This two-phase study aims to investigate needs, concerns and psychological

Copyright # 2004 John Wiley & Sons, Ltd.

adjustment of partners of women at high risk of developing breast/ovarian cancer, and to explore the association between partners’ adjustment and women’s adjustment. Phase 1: Participants were identified through two Australian familial cancer clinics. Fifteen partners were interviewed using semi-structured telephone interviews. Phase 2: Based on these preliminary findings and utilising the cognitive-social health information processing model, this quantitative phase assesses both women and their partners. Approximately 100 couples were assessed using a purposely designed mailed self-report questionnaire using the results of Phase 1 and incorporating validated measures of psychological and dyadic adjustment. Partners of carriers and women of unknown mutation status were found to be more distressed than partners of non-carriers, with partners of mutation carriers reporting the most difficulties. Factors associated with better adjustment and coping for partners included dealing with this situation as a team with their wife, greater involvement in decision-making, satisfaction with their supportive roles and being optimistic.

422 Coping through Transitions; Parent Bereavement Support Group: A Manual Mollen E1, Feter L2 1 Pediatrics University of Michigan, Ann Arbor, USA; 2Angela Hospice Livonia, MI, USA Parents, whose children were treated at The University of Michigan Medical Center for cancer and subsequently died, advocated for a bereavement support program to be held within the medical center. This support group was developed to address the unique and universal bereavement needs of parents who have lost a child to cancer by providing a manualized support program. A pediatric psychologist from the medical center and a social worker from community hospice teamed up to co-facilitate the group and author the manual. The University of Michigan Comprehensive Cancer Center Grief and Loss Program sponsors the program. Series goals: provide education about grief (e.g., gender differences, sibling survival); provide tools for coping with grief; and offer a venue for

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building supportive relationships among grieving parents. This program is unique from community-based bereavement groups in three ways. It is offered to a homogeneous group of parents to receive and share support regarding bereavement and the common cancer experience within a single institution. It offers a supportive venue to return to the treating institution after a child’s death, which though difficult and painful, is often desired by parents. A pre-session dinner provides a comfortable venue for parents to meet with medical caretakers of their child (physicians, nurses, social workers, child life) prior to each session. The manual contains an outline for each seven monthly sessions. Each outline details a rationale (literature-based), didactic information, session activities, and handouts and topical bibliographies.

children in relapse phase, use illusory control strategies; 72% of parents of children with leukemias, use vicarious control; In general, 61% use predictive control. CONCLUSIONS: Higher social/cultural status parents feel the need to obtain more information on the disease. Parents of children in relapse phase believe in ‘‘chance’’; parents of children with longer treatment periods recognize power in medical staff, probably related with external control feelings; in general, parents have positive expectations during the disease.

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Evaluation of Coping Strategies by Parents of Children with Cancer Moura MJ Psycho-Onchology, IPO, Lisboa, Portugal

Classification of Family Function and Related Psychological Distress among Japanese Breast Cancer Survivors and their Families Ozono SO1, Saeki TS1, Mantani TM1, Yamawaki SY1, Inoue SI2 et al. 1 Department of Psychiatry and Neurosciences, Division of Frontier Medical Science, Programs for Biomedical Research, Graduate School of Biomedical Sciences, University of Hiroshima, Hiroshima, Japan; 2Palliative Medicine, Hiroshima City Medical Association-Administered Aki City Hospital, Hiroshima, Japan

PURPOSE: This project aims at the study of coping strategies used by parents of children with cancer. METHODS: An exploratory study in which a secondary control strategy scale has been used as described by Grootenhuis & Last, to access cognitive control strategies, created according to Rothbaum et al. (1982). This scale is divided into four control sub-scales: Predictive, vicarious, illusory and interpretative. The scale has been adapted for the portuguese population, with authorization from the author. A 60 parents of children with cancer sample has been used, aged between 25 and 45 years. Demographic data include the parents’ age, education, number of children and religion. Clinical data of their children include the remission phase and the relapse phase. Treatment period is divided between less than two years and over two years. Type of disease: Leukemia/Lymphoma and Solid Tumors. RESULTS: Highlights of the end results: When comparing social–cultural levels of parents we conclude that 66% of the higher level group use interpretative control strategies; 74% of parents of

PURPOSE: Family members of breast cancer patient can have a psychological distress such as anxiety and depression. But few studies revealed which type of family tend to have psychological distress. The aim of this study was to assess family function and classify their characters in Japanese breast cancer patient and their family members. METHODS: The subjects consisted of 115 family members of 74 early stage breast cancer patients after mastectomy. Documented informed consent for the study was obtained from each patient. Patients and families completed the Family Relationship Index (FRI), Zung Self-rating Depression Scale (SDS), and Zung Self-rating Anxiety Scale (SAS). RESULTS: The result of cluster analysis in FRI, patients and their family members were classified in 3 types; ‘‘Cohesion-Type (34%)’’, ‘‘Conflict-type (34%)’’, and ‘‘Intermediate-type (32%)’’. Among 3 family types, analysis of variance revealed that ‘‘Conflict-Type’’ patients or family members were higher level of depression and anxiety. CONCLUSIONS: These findings suggested that the FRI is a useful instrument as

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a screening tool for family typing, and early intervention for the ‘‘Conflict-Type’’ patients or family members could reduce their psychological distress.

vative mental health services in this field. Preliminary results after 30 months are presented from various centres.

426 425 Children of Cancer Patients: Needs for Family Oriented Concepts in Mental Health Prevention and Research Perspectives Romer G, Haagen M, Baldus C, Saha R, Pott M et al. Department of Child and Adolescent Psychiatry and Psychotherapy, University Hospital HamburgEppendorf Hamburg, Germany INTRODUCTION: Children of somatically ill parents are at increased risk for mental health problems. Intervention programs for this target group in the context of adult medical care are rare. As an introduction to this symposium, the current state of the art on psychosocial sequelae of parental cancer on children is reviewed. RESULTS: In previous studies, samples including only adolescents and those with ill mothers are overrepresented. Less is known about younger children and families with ill fathers. Ill parents tend to underestimate the psychic stress in their children, which predominantly shows itself in internalizing problems. Especially in cases of a terminal prognosis, children lack information by adults and thus remain disoriented about the stress they perceive in their social environment. One reason for this lacking communication in families is insecurity in adults how to speak with children of various ages about death and dying. DISCUSSION: Interventions for children of cancer patients should in the first place address their parents and support them in their parental competencies. Developmental knowledge on children’s life and death concepts, mourning reactions and coping strategies have to be considered as well as aspects of gender. PERSPECTIVES: In a 3-year research project funded by the EU (COSIP: ‘‘Children of Somatically Ill Parents’’) eight centres from various countries are collaborating. In five of these, cancer samples are studied. Studies include investigations on the psychosocial functioning of children of cancer patients as well as service development studies on implementation of inno-

Copyright # 2004 John Wiley & Sons, Ltd.

Family Functioning and Psychological Distress among Japanese Breast Cancer Survivors and their Families Saeki T1, Mantani T1, Ozono S1, Yamawaki S1, Okamura H2 et al. 1 Department of Psychiatry and Neurosciences, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan; 2Institute of Health Sciences, Faculty of Medicine, Hiroshima University, Hiroshima, Japan; 3Palliative Care Ward, Hiroshima City Medical Association-Administered Aki City Hospital, Hiroshima, Japan; 4Training and Research Center for Clinical Psychology, Graduate School of Education, Hiroshima University, Hiroshima, Japan PURPOSE: Very little research in Japan has focused on how cancer affects families. The present study aimed to investigate the relationship between physical-psychological-social factors including family functioning and psychological distress such as depression or anxiety among family members of breast cancer survivors in Japan. METHODS: The subjects consisted of 115 family members of 74 early stage breast cancer patients after mastectomy. Documented informed consent for the study was obtained from each patient. The subjects completed the Family Assessment Device (FAD), the Zung Self-rating Depression Scale, and the Zung Self-rating Anxiety Scale. RESULTS: Multiple regression analysis showed that family perceived General Functioning assessed by the FAD, lower education, present physical illness, past psychiatric treatment, and anxiety of survivors correlated with anxiety among family members, and that lower education and unemployment of survivor correlated with depression among family members. CONCLUSIONS: These findings suggested that psychosocial interventions that could reduce survivor’s anxiety and improve overall functioning of families might contribute to reducing family’s anxiety as well as promoting quality of life among breast cancer survivors and their families.

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427 Factors Associated with Family Functioning in Cancer Patient’s Families Schmitt F1, Saanisto T2, Helenius H2, Piha J1 et al. 1 Child Psychiatry, Turku University Hospital Turku, Finland; 2Department of biostatistics Turku, University Turku, Finland PURPOSE: The family members of cancer patients are often stressed by anxiety and depression. Some families seem to cope better than others. Studies of additional risk factors are required to identify families and children in special need for psychosocial intervention. METHOD: The Family Assessment Device, FAD is a self-report instrument designed to assess a number of dimensions of family functioning. It can be filled out by all family members over the age of 12. General scale assesses the overall health/pathology of the family. A multilevel analysis model has been constructed to find out, which are the relevant determinants associated with family functioning. In this model FAD score is explained by variables such as family structure, score of depression (measured by Beck Depression Inventory), number of children or gender of the ill parent. Data on 63 cancer families will be compared to 63 control-group families. RESULTS: Preliminary analysis shows that depression seems to be associated with poorer family functioning while other variables seem to affect it only slightly. The interplay of variables is under investigation and results will be reported. CONCLUSION: Accumulation of risk factors is wellknown as being stressful for children mental health. Findings suggest the need for detecting depression in cancer patients.

428 Psychosocial Distress in Children and Adolescents Living with a Parent Suffering from Cancer: Comparison with Other Medically Ill Families Seigneur E1, Levacher C1, Consoli SM1, Andrieu JM2, Duboust A3 et al. 1 Department of C-LPsychiatry, European Georges Pompidou Hospital, Paris, France; 2Department of Oncology, European Georges Pompidou Hospital, Paris, France; 3Department of Nephrology, European Georges Pompidou Hospital, Paris, France

Copyright # 2004 John Wiley & Sons, Ltd.

PURPOSE: To compare three groups of children aged 7 to 18, according to the disease one of their parent is followed up for: cancer (C), insulindependent-diabetes (IDD) or renal transplantation (RT). To explore the links between the level of children’s suffering and several data: the ill’s parent gender and educational level (EL) and also the quality of the communication about the illness in the family. METHODS: Self administered questionnaires were filled out by ill parents (ODCF), children (CDI, STAIC, SEI), or both parents describing their children (CBCL, CPRS). RESULTS: Respectively 20 C, 18 RT and 15 IDD children were included into the study. Emotional or behavioural disorders in children appeared to be higher when the ill parent was the mother (CBCL total score, somatic complaints and externalised disorders) and lower when EL of the ill parent was higher (most of the scores). After adjusting for these two confounding variables, children living with a parent suffering from cancer compared with the two control groups children, showed higher levels of STAIC anxiety, CBCL total score and CBCL internalised disorders. Independently of the clinical group, several CBCL scores were negatively correlated with quality of communication (ODCF). CONCLUSIONS: Suffering from a chronic and severe disease has a higher impact on the children living with the ill parent if the latter is the mother. EL of the ill parent can moderate such an impact. Children of cancer patients present higher psychological distress levels although there is no more communication defect in cancer families.

429 Spouses of Patients Suffering from Cancer Express Higher Levels of Psychosocial Distress than those of Renal Transplant or Diabetic Patients Seigneur E1, Consoli SM1, Levacher C1, Altman JJ2, Andrieu JM3 et al. 1 Department of C-L Psychiatry, European Georges Pompidou Hospital, Paris, France; 2Department of Diabetology, European Georges Pompidou Hospital, Paris, France; 3Department of Oncology, European Georges Pompidou Hospital, Paris, France BACKGROUND: Spouses of patients suffering from cancer undergo the impact of cancer on

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family circle as well and can considerably suffer without expressing their own need for help. PURPOSE: To assess psychosocial distress in spouses of patients followed up for cancer (Csp), compared with two control groups, respectively spouses of renal transplant patients (RT-sp) and insulin-dependent diabetics (IDD-sp). METHODS: 14 patients followed-up for a cancer (C), 10 who benefited from a renal transplant (RT) and 10 insulin dependent diabetics (IDD) were invited to fill out a quality of life questionnaire (MOS SF-36). Their spouses (13 C-sp, 9 RT-sp, 7 IDD-sp) filled out the GHQ-28. RESULTS: Spouses’ GHQ-28 total score and sub-scores (anxiety, depression, somatisation, social dysfunction) were not linked with gender, neither with age. Higher scores were found in C-sp, for total GHQ28 score (C-sp>RT-sp) and anxiety sub-score (Csp>RT-sp and C-sp>IDD-sp). Total spouses’ GHQ score and anxiety sub-score were negatively correlated with ill patient’s SF-36 physical capacity sub-score (respectively r= 0.40 and 0.50), whereas GHQ anxiety sub-score was negatively correlated with SF-36 emotional role sub-score and SF-36Mental Component Summary (both r= 0.41). CONCLUSION: These results confirm the presence of higher psychosocial distress levels among spouses of patients followed up for a cancer, compared with control groups, and suggest that different factors determine the anxiety level and the depressive mood level of a spouse living with a patient followed up for a severe physical illness.

430 Caring for a Loved One with Advanced Cancer: Determinants of Psychological Stress in Caregivers Serge Dumont SD1, Jean Turgeon JT2, Pierre Gagnon PG3, Pierre Allard PA4, Lucie Vezina LV5 1 School of Social Work, Laval University, Quebec, Canada; 2Faculty of Medicine, Laval University, Quebec, Canada; 3Ho#tel–Dieu Research Centre, Laval University, Quebec, Canada; 4Faculty of Medicine, University of Ottawa, Ottawa, Canada; 5 Ho#tel–Dieu Research Centre, Laval University, Quebec, Canada BACKGROUND: Caring for a terminally-ill cancer patient can be a very trying experience for

Copyright # 2004 John Wiley & Sons, Ltd.

family caregivers. The psychological distress that they experience has not been adequately documented. The purpose of this study is to describe the evolution of psychological distress in caregivers caring for a terminally-ill cancer patient and to identify the main determinants of this distress. METHODS: Researchers interviewed 212 primary caregivers at three different times based on the patient’s level of functional autonomy (T1, T2, T3). Information was collected on services and care received, the patient’s condition, and the caregiver’s characteristics and level of psychological distress. RESULTS: From T1 to T3, the average indicators of psychological distress increased from 25.2 to 33.5. The percentage of caregivers with a high level of distress (indicator>26.2) rose from 41% to 62%. There was a significant association between a high distress indicator and the patient’s young age (p=0.02), an increase in symptoms (p=0.0004), and the main caregiver’s young age (p=0.0006), poor perception of his/her health (p=0.0004) and dissatisfaction with emotional support (p=0.0002) and actual help received (p=0.03). CONCLUSIONS: The caregivers of patients in the advanced stages of cancer experience a high level of psychological distress, which increases significantly as the patient loses autonomy. Health care policies and programs need to be revisited in order to take the reality of these patients and their families into account.

431 How to Tell my Child about my Cancer? Development of an Intervention Based on Art Education Singer S1, Weiss K1, Buttst.adt M1, Bo. hler U2, Schwarz R1 1 Social Medicine, University of Leipzig, Leipzig, Germany; 2Psychotherapist, Heidelberg, Germany It’s often difficult for young parents to inform their children about their cancer and the consequences or implications of diagnosis and treatment. On the other hand is it known, that children feel better when the family openly communicate about the disease. A second problem for younger adults having cancer is that self help groups mostly meet in the afternoon}when they do their jobs}and that the average age is far beyond them. Therefore they

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often prefer to handle their problems alone, without help of other patients. We designed an intervention program to support cancer-parents in communication 1. among each other and 2. with their families. It is an art education program, lasting 20 sessions. Sample: 8 cancer patients with children between 2 and 18. Methods: Qualitative analysis of interviews, session protocols, and paintings. We want to present our program and discuss first experiences and data.

432 ‘‘The Courage to Survive’’ a 45 min Video Straker N Psychiatry & Behavioral Sciences Memorial, SloanKettering Cancer Center, New York, USA ‘‘The Courage to Survive’’ is a 45 min video that outlines the challenges and psychiatric treatment of Robert before and after the death of his wife from pancreatic cancer. The video begins with Robert giving a lecture at Sloan Kettreing Cancer Centre where he is describing the demoralizing challenges that he faced as a caregiver. He hopes that by making oncologists aware of these issues, they will be more sensitive to the needs of male caregivers and more likely to make referrals to mental health professionals. Robert is also engaged with his psychiatrist in reviewing the successful psychological and psychopharmaclological interventions that helped him overcome the challenges mentioned above including; his loss of hope, his loss of faith, his overwhelming anxiety, rage and panic, his preparation for his wife’s death, his grief, and his need to become the sole parent. The tactful management of denial and the encouragement of the male caregiver to be very active in the treament of his wife are emphasized as useful in lessening depression. Robert’s transformation from businessman to author, lecturer, and teacher was viewed as an adaptive way of making something good come out of something bad.

Thastum M1, Gubba L1, Berg Olesen L1, Romer G2 1 Department of Psychology, Aarhus University, Aarhus, Denmark; 2Klinik fu.r Kinder- und Jugenspsyc ’hiatrie und Psychotherapie, Universita.tsklinikum Hamburg-Eppendorf, Hamburg, Germany PURPOSE: To investigate the inner world of children with a parent with cancer. METHODS: Nine children (age 8–15) with a mother with cancer were interviewed concerning their knowledge about the disease, impact of the disease on family members, involvement in and restrictions due to the disease, social support, coping strategies, emotional reactions, own health, and the needs of children with ill parents. PRELIMINARY RESULTS: 8 revealed appropriate knowledge of the disease, diagnosis and treatment. All had been informed by their parents, 2 also by the hospital. One child had very limited knowledge. Seven had visited the hospital, 2 had not. The children expressed empathy for the family members, worried about the healthy parent, and felt responsibility for caring for the family. All had more duties in the family than before the illness. Most experienced this as positive. Five neglected periodically their needs of peer relations. Three had experienced bullying due to having an ill parent. The children could describe a variety of coping strategies, which they used to deal with the disease, e.g. positive self-statements, distraction, seeking social support, trying to forget it, wishful thinking, isolation. Most were occasionally overwhelmed by intrusive thoughts. All expressed sadness. Two said they were sad ‘‘inside’’ but indifferent ‘‘outside’’. Five expressed anger. Two were afraid of getting cancer. Six meant that children should be well informed by adults. CONCLUSION. Further qualitative analyses of the interviews is needed to be able to differentiate between those who needs help and those who manage by their own.

434 433 Children’s Experience of Having a Parent with Cancer

Copyright # 2004 John Wiley & Sons, Ltd.

Stress Response Symptoms in Spouses of Men who Survived Testicular Cancer Tuinman MA1, Fleer J1, Hoekstra HJH1, Sleijfer DT2, Hoekstra-Weebers JEHM3

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Surgical Oncology, Groningen University, Hospital Groningen, The Netherlands; 2Medical Oncology Groningen University Hospital, Groningen, The Netherlands; 3Medical Psychology, Groningen University Hospital, Groningen, The Netherlands PURPOSE: To gain insight into stress response symptoms (SRS) of spouses of testicular cancer survivors (TCSs). METHODS: 219 spouses who had a relationship with the TCS before diagnosis (‘‘spouses during TC’’) and 40 spouses who started a relationship after completion of treatment (‘‘spouses after TC’’) and their husbands completed the Impact of Event Scale. Response: TCS 50%, spouses 78%. Time since completion of treatment varied from 0.5 to 23.8 years. RESULTS: ANCOVA (covariate age) showed that spouses during TC reported more intrusion (F=4.2, p50.05), more avoidance (F=5.9, p50.05) and more total SRS (F=6.0, p50.05) than spouses after TC. Of spouses during TC, 14% reported SRS above the clinical cut-off point (total score>26). No significant relationship was found between time since completion of treatment and SRS in either spouse group. Level of intrusion (r=0.25, p50.000), avoidance (r=0.19, p50.01) and total SRS (r=0.24, p50.001) of the TCSs were significantly related to those of spouses during TC. Spouses during TC reported significantly more intrusion (t= 2.8, p50.01) and total SRS (t= 2.3, p50.05) than TCSs. Spouses during TC of TCSs who received extensive treatment (n=145) reported more intrusion (F=6.7, p50.01), more avoidance (F=5.1, p50.05) and total SRS (F=8.1, p50.01) than spouses of TCSs treated with surgery only (n=74). CONCLUSION: Spouses who went through the cancer experience with the TCSs reported more stress response symptoms than the TCSs themselves and than spouses who did not go through the period of cancer treatment. Time since completion of treatment was not related to spouses’ stress response symptoms, but a more extensive treatment was.

435 Prospective Study of Emotional and Behavioral Problems among Adolescents of Parents Diagnosed with Cancer

Copyright # 2004 John Wiley & Sons, Ltd.

Visser A1, Huizinga GA2, Hoekstra HJ3, Graaf WTA, van der2, Hoekstra-Weebers JEHM1,4 1 Health Psychology, University Hospital Groningen, Groningen, The Netherlands; 2Medical Oncology, University Hospital Groningen, Groningen, The Netherlands; 3Surgical Oncology, University Hospital Groningen, Groningen, 4 Comprehensive Cancer The Netherlands; Center, North Netherlands, Groningen, The Netherlands INTRODUCTION: Children may experience significant problems after a parents’ cancer diagnosis. This study examines prevalence of adolescents’ problems shortly after diagnosis (T1) and at six months (T2) in comparison to the norm group; and changes in adolescents’ functioning between T1 and T2. METHODS: Family members of 73 cancer patients participated (response=50%). Parents diagnosed with cancer and their spouses completed the Child Behavior Checklist (CBCL) for 110 adolescent children (11–18 years). Adolescent children completed the Youth Self-Report. RESULTS: At T1 adolescent daughters reported more internalizing problems than found in the norm group. No further differences in internalizing and externalizing problems were found between the norm group and ill parents’, spouses’ or adolescents’ reports. Paired t-tests of ill parent reports showed no significant differences over time. Spouse reports showed a decrease in problems over time for adolescent daughters on internalizing (p=0.007) and externalizing problems (p=0.05). Adolescent sons reported a decrease over time in internalizing problems (p=0.004). No significant changes were found in adolescent daughters’ reports. At T2, according to the spouses, adolescent sons and daughters suffered less internalizing (p=0.011; p=0.03, resp.) and externalizing problems (p=0.002; p=0.004, resp.); adolescent sons reported less internalizing (p=0.04) and externalizing problems (p50.001); and adolescent daughters less externalizing problems (p=0.03) at T2 in comparison with the norm group. CONCLUSION: Only adolescent daughters experienced internalizing problems at parents’ diagnosis. Six months after diagnosis all reports of adolescent functioning were on a level equal to better than that of their peers. Differences in informants’ perceptions, however, remain of interest.

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436 ‘‘Supportive-Friend’’}A Web-based Service for Relatives/Friends to Cancer Patients W.arn S1, Lindgren A1, Hammarlund L1, Brandberg Y1,2 1 Information and supportive unit, Swedish Cancer Society, Stockholm, Sweden; 2Oncology-Pathology Karolinska Institutet, Stockholm, Sweden In January 2002, a special website was created by the Swedish Cancer Society (SCS) for relatives/friends of cancer patients. The purpose was to focus on the relatives/friends and their situation. Included in the website was ‘‘Supportive-friend’’, a web-based service aiming at creating supportive contacts between relatives/friends. The site is presented at the SCS website, www.cancerfonden.se/anhorig. PURPOSE: To describe the users in terms of gender and age. The number of ‘‘supportive-friends’’ registered, number of ‘‘supportive-friends’’ connected to each registered friend, duration of contact, reason for being a supportive-friend and use of other psychosocial support will be presented, as well as accessibility to the web site. METHODS: Gender, age and the relatives/friends’ cancer diagnosis are registered at application to become a ‘‘supportive-friend’’. A questionnaire was sent by e-mail in February 2004 to all registered ‘‘supportive-friends’’. Responses were recorded anonymously for ethical reason, thus no reminders were sent. RESULTS: By December 2003, 344 individuals had registered to become a ‘‘supportive-friend’’, 81% women. About 50% were 30 years or younger. 9% were older than 50 years. The diagnosis of the relative was reported by 13% to be breast cancer, 12% lung cancer, 10% brain tumor, and 510% for other diagnoses. 21% did not report any diagnosis. Questionnaire data are now being analyzed and will be reported. CONCLUSION: ‘‘Supportive-friend’’ attracts a large number of relatives/friends of both sexes, primarily young people. Except for breast cancer, relatives/friends to patients with lung- or brain cancer, diseases associated with a bad prognosis, are frequent users of this service.

437 Parental Cancer: Family Characteristics Predicting Risk of Psychosocial Problems in School-Age

Copyright # 2004 John Wiley & Sons, Ltd.

Children. Results from the Eu Cosip Collaborative Group Watson M1,2, Tilney C1, St. James-Roberts I3, Brougham R1, Romer G4 et al. 1 Psychological Medicine, Royal Marsden NHS Trust, Sutton, UK; 2Psychological Research Group, Institute of Cancer Research, Sutton, UK; 3Thomas Coram Research Unit, Institute of Education, University of London, London, UK; 4Child & Adolescent Psychiatry, University Hospital Hamburg}Eppendorf, Germany PURPOSE: While psychological morbidity in cancer patients, their partners and adult family members is well documented, there is little evidence relating to their school-age children. This study documents psychological morbidity in children of cancer patients and identifies family characteristics that predict risk for, or resilience to, psychosocial problems. METHOD: Cross-sectional design including early/advanced stage breast cancer or brain tumour patients, with school aged children. Patients, approached during outpatient clinics, completed measures of depression [BDI], quality of life [SF-8], family characteristics [FAD and FRI] and children’s adjustment [CBCL, C-IES and Wellbeing scale CHQ]. Healthy partners, children (11– 17 years) and teachers provided assessments using the same measures, as appropriate. Children aged 6–10 did not complete questionnaires. RESULTS: 124 (57% response rate) families participated. Results indicate that 32% of adolescents scored in the clinical range for internalising or externalising problems and 38% borderline internalising or externalising scores. Teenage girls reported more problems (20% in the clinical range for internalising and 12% externalising problems) than boys or younger children. Complete results will be reported. CONCLUSIONS: Findings highlight the high level of morbidity and need for interventions for children of cancer patients.

438 Parents Helping Parents: Does this Psychological Mechanism Work when the Child is Affected by a High Risk Disease? Zarri DA, Massimo L Pediatric Hematology and Oncology, G. Gaslini Children’s Hospital, Genova, Italy

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Reciprocal help relationships are very important among families with children affected by severe pediatric diseases. Communication and discussion of common problems and experiences generally allow the development of coping strategies to face new situations with subsequent adjustment and restoration of a good quality of life after diagnosis and beginning of therapy. When a child is affected by a high risk disease, mostly in relapse or undergoing bone marrow transplantation, this communicative approach is hardly adopted. On the basis of our 10-year experience in the observation of the behavior and the relationships of many families, we suggest the reasons for this difficulty, namely: (1) increased life expectancy of children with high risk disease, in relapse, in BMT; (2) different time intervals between relapses and poor quality of life; (3) child’s perception of his precarious living in the absence of adequate information from parents and doctors; (4) promiscuous presence in departments and housing facilities of patients with different disease conditions, including those with more favorable prognosis; (5) increased pathologic psychological defences due to the steady reduction of the range of options and alternatives. It is necessary to suggest possible communication and behavior strategies to be adopted by physicians and other health care professionals that could improve communication with and among families of affected children and support their hope for recovery. For instance, it would be essential not to propose cure as a ‘‘war’’, but as a cooperation to build health and not to destroy the disease.

panel of four female public school teachers evaluated the translation. Six focus group interviews were conducted, with five to seven women who previously had had a false positive mammography. The consequences of false positive mammography were discussed and the women completed the questionnaire. They were then asked if each item was easy to understand, unambiguous, jargon-free, and if the response options were relevant. If not, they were asked to suggest alternative wordings. They were also asked if they found the items relevant and covering the consequences they had themselves experienced. The design and easiness to complete was also discussed. Ten women invited for screening and five women from a county without breast cancer screening took part in telephone interviews. RESULTS: Three items were ambiguous and 2 were double-barrelled. None of the original items were found to be irrelevant but the interviewees found that not all the consequences of a false positive screening mammography were covered by the questionnaire. Therefore all together 15 new items were added. Six hundred women completed the extended version of the questionnaire together with the Danish version of the Nottingham Health Profile. One third of the women had had an abnormal screening mammography and two third had had a normal. Analyses of these data to estimate the reliability, validity, dimensionality, additivity and order of the questionnaire are ongoing and will be presented at the conference.

440 Screening 439 Short-term Psychosocial Consequences of False Positive Screening Mammography}An Adaptation of the Psychological Consequences Questionnaire (PCQ) into Danish Brodersen J, Thorsen H, Andersen JS Department of General Practice, Institute of Public Health, Copenhagen University, Copenhagen, Denmark PURPOSE: To adapt and validate the PCQ into Danish. METHODS: Four bilinguals in English/ Danish translated the PCQ into Danish. A lay

Copyright # 2004 John Wiley & Sons, Ltd.

Long-term Psychosocial Consequences of False Positive Screening Mammography}Development and Validation of a Questionnaire Brodersen J, Thorsen H, Andersen JS Department of General Practice, Institute of Public Health, Copenhagen University, Copenhagen, Denmark PURPOSE: To develop a questionnaire measuring long-term consequences of false positive screening mammography. Today no such reliable and valid questionnaire is available. METHODS: Six focus group interviews were conducted, with five to seven women who previously had had a false positive mammography one to twelve months ago.

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Firstly, the consequences of a false positive mammography were discussed after open ended questions. Secondly, the women were asked to complete a preliminary questionnaire. After completing the preliminary questionnaire the women were asked for each item to think aloud and discuss the meaning of the items and to express, if they found the items easy to understand, unambiguous, jargon-free and the response options satisfactory. If not, they were asked to suggest alternative formulations of the items and response options. For each item they were also asked to express, if they found it relevant and covering the consequences they were experiencing themselves. The design of the questionnaire was also discussed in the focus groups. RESULTS: Thirteen new items were generated after completing the focus group interviews. In the study of reliability and validity of the questionnaire, 127 women who had had a positive screening mammography one to six months ago, and 197 women who had had a normal screening mammography, completed the questionnaire. Data have been preliminary analysed using Traditional Test Theory and Item Response Theory (Latent Test Theory). The final results of the analyses i.e. the reliability, validity, dimensionality, additivity and item order of the questionnaire will be presented at the conference.

Sexuality 441 Peculiarities of Sexual Identity of Teenagers with Oncopathology Aralova MP1, Aslanyan KS2, Yershova MP3, Tseytlin GY4 1 Clinical Psychology, Rostov State University, Rostov-on-Don Russia; 2Head of Ambulance Onco-hematological Center of Rostov Regional children?s Hospital, Rostov-on-Don, Russia; 3Psychology, Don Pedagogical College, Rostov-on-Don, Russia; 4Head of the Rehabilitation Deparment, Research Institute of children?s Oncology and Hematology of Russian Oncological Scientific Centre of Russian Academy of Medical Science, Moscow, Russia PURPOSE: The study of sexual identity of teenagers having oncopathologies with various remis-

Copyright # 2004 John Wiley & Sons, Ltd.

sion periods in comparison with their healthy coevals: traits of sexual stereotypes (cognitive level of sexual identity) and peculiarities of their attitude to images of femininity and masculinity (emotional level). PROBATIONERS: 144 teenagers, 15–17 years old: two groups of 72 people} Main group (which was subdivided according to remission period) and Test group. METHODS: Modified system ‘‘Semantic Differential’’ by Ch.Osgood: 7-grades scale evaluation of notions ‘‘majority of men’’, ‘‘majority of women’’; Relationship Colour Test: ranging of 8 coloured cards from standard Lusher test set according to the degree of proximity to categories ‘‘majority of men’’ (MM), ‘‘majority of women’’ (MW); factor analysis. RESULTS AND CONCLUSIONS: Probationers with oncopathology have somewhat one-sided structure of femininity-masculinity stereotypes: femininity stereotype is presented only by emotional-communicative traits while masculinity stereotype by instrumental-professional qualities. Structure of the major factors of sexual identity of healthy probationers tends to sexualrole democratization (androgenization) and cooperation psychology arising from it. In Main group emotional preferences related to sexual affiliation (emotional level of sexual identity) are less different than those in Test group. The longer remission period is (in the group with remission period over 10 years), the more sexual preferences coincide with those of healthy coevals. In the test group the other sex is considered to be emotionally attractive. Research results testified that teenagers with oncopathology (in comparison with their healthy coevals) lack ability of integral perception and of emotional attitude toward people according to their sex.

442 Information-Group with Female Colorectal Cancer Patients following Surgery, Chemotherapy and Pelvic Radiation Ashkenazi A1,2, Peleg S3, Picshniak L1, Yagil Y2, Figer A1 1 Gastrointestinal Malignency Service, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel; 2Social Services, Tel-Aviv Sourasky Medical Center, TelAviv, Israel; 3The Israeli Cancer Association, Givatayim, Israel

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BACKGROUND: Colorectal cancer patients are reported to endure physical and psychological distress. This is due to the disease functional implications and treatment side-effects. This is aggravated among female colorectal cancer patients, since they may suffer from a wide variety of symptoms including: vaginal dryness, dyspareunia, reduced ability to reach orgasm, premature ovarian failure, vaginal atrophy, thinning of the vulvar tissues and vagina, loss of tissue elasticity, decreased vaginal lubrication, hot flashes, increased frequency of urinary tract infections, mood swings, fatigue and irritability. METHOD: A 3-session psycho-educational group was conducted with 10 oncology participants (aged 35–50) at a general hospital in Israel. The intervention included lectures about the therapies and their side effects, with specific attention given to their impact on sexuality and sexual functioning. Each lecture was followed by an open discussion among the lecturers (a physician, a sexual therapist and a social worker) and the participants, in which problems were discussed and possible solutions were suggested. The intervention was evaluated using a set of self-report inventories that were completed by all participants at the 1st session and following the 3rd one. RESULTS: Turnover rates were 5/14 participants. Satisfaction was reported to be high in scales related to interpersonal empowerment and medical knowledge. Frustration was reported due to the fact that this support was not given prior to treatment. CONCLUSION: Information-group with female colorectal cancer patients is an important intervention modality and should be offered to all women in order to enhance their quality of life.

443 Psychosexual Rehabilitation and Support to Women with Genital Cancer BasuMallik I1, Mondal NR2, Pal P2, Chatterjee2, Chakrabarti B2 et al. 1 Psychology Revive, Mental Health, Calcutta, India; 2Gynecology, Thakurpukur Cancer Research Centre, Calcutta, India Sexual dysfunction in women suffering from genital cancer is a well known phenomenon. In a more traditional and conservative country like

Copyright # 2004 John Wiley & Sons, Ltd.

India, women suffering from genital cancer welcomed the initiation of psychosexual rehabilitation measures and support provided to them. Their sexual partners were also involved in the process. Sexual history before and after diagnosis and treatment were obtained for study. Depression, anxiety and fear were managed by antidepressants, anxiolytics and supportive counselling. For anatomical distortions, dilatations and use of lubricants were advised. Postural adjustments were also advised where applicable. Research findings and data will be presented in the conference.

444 Psychosexual Problems of Women with Genital Cancer Chakrabarti BK1, Mondal NR1, Basumallik I2, Chatterjee1, Pal1 et al. 1 Gynecology, Thakurpukur Cancer, Calcutta, India; 2 Psychology, Thakurpukur Cancer, Calcutta, India Most patients with cancer suffer from anxiety & depression after diagnosis of cancer, during treatment and after the treatment is completed for fear of recurrence. Women with genital cancer are no exception and have the added problem of sexual dysfunction because of anatomic distortion of sex organs with the feeling of not being a complete woman. Spouse is also worried about causing hurt Mutilating operations like radical vulvectomy, exenteration radiotherapy, chemotherapy (leading to alopesia) add insult to injury. Sexual functions of patients with genital cancer was analysed before diagnosis, after diagnosis, during treatment and after completion of treatment. Most patients even in a conservative society were thankful that the subject is discussed which they felt shy to ask. With quantitative improvement of survival the quality of life need to be improved, sexual rehabilitation is perhaps the most important parameter in quality of life, The Datas will be presented.

445 Sexual Functioning and Psychological Well-being in Men with Prostate Cancer Hervouet S1,2, Caplette-Gingras A1,2, Savard J1,2

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Cancer Research Center of l’Ho#tel-Dieu de Que!bec, Laval University, Que!bec, Canada; 2School of Psychology, Laval University, Que!bec, Canada

1

STUDY GOAL: This study aims to: (1) compare the prevalence of sexual difficulties across three modalities of treatment for prostate cancer: radiotherapy (RAD), brachytherapy (BR) and radical prostatectomy (RP), (2) assess the relationship between sexual difficulties, psychological distress (anxiety and depression) and quality of life. PROCEDURE: Participants were recruited in the radio-oncology department and the cancer surgery clinic of l’Ho# tel-Dieu de Qu!ebec. The sample was composed of 583 men who received treatment for prostate cancer. The participants completed the following questionnaires: the International Index of Erectile Function (IIEF), the Hospital Anxiety and Depression Scale and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire. RESULTS: Patients who received RP reported more sexual difficulties (84.4%) compared to patients who received RAD (75.9%) or BR (53.3%). Participants treated with RP obtained significantly lower scores, compared to those treated with RAD or BR, on the following subscales: erectile and orgasmic functioning, and satisfaction toward sexual relations. Greater sexual difficulties on the IIEF global score were significantly associated with higher scores of depression (rs(2)= 0.21, p50.05), anxiety (rs(2)= 0.10, p50.05), global psychological distress (rs(2)= 0.17, p50.01), as well as with lower scores of quality of life (rs(2)=0.22, p50.01). CONCLUSION: Sexual difficulties are more frequent in patients treated with RP and may contribute to increase the risk for psychological distress and impaired quality of life, thus emphasizing the importance of offering sexual counselling to these patients.

446 Prevalence of Sexual Dysfunction in Women with Cancer Referred to Psychiatric Outpatient Clinic Hughes MK Neuro-oncology, Psychiatry Section, The University of Texas, M.D., Anderson Cancer Center Houston, USA

Copyright # 2004 John Wiley & Sons, Ltd.

This presentation will describe the prevalence of sexual dysfunction of 294 women with cancer who were referred for a psychiatric disorder over the last 2 years. They were referred to one Psychiatric Clinical Nurse Specialist (CNS) in the Psychiatric outpatient clinic. Psychiatry is a section in the neuro-oncology department of a large community/ hospital based oncology centre in a large metropolitan area. A sexual assessment was done on all women during the psychiatric interview. Large percentages were found to have some sort of sexual dysfunction. Sexual dysfunction is when at least one aspect of the sexual response cycle does not function properly. It may be libido, arousal or orgasm that is involved. The majority of women complained of vaginal dryness, which is part of the arousal phase of the sexual response cycle. Including a sexual assessment in all assessments is important since sexuality is a quality of life issue. Using the PLISSIT model of sexual assessment, the practitioner can quickly address sexual issues of the patient and this model will be described. Patients think if sexuality is an important issue, the practitioner will address it, and the practitioner thinks if it is important to the patient, s/he will address it. Consequently, it goes unaddressed. Interventions to improve sexual functioning in women will also be described.

447 Referral Patterns of Oncology Patients for Sexual Dysfunction Hughes MK Neuro-oncology, Psychiatry Section, The University of Texas, M.D., Anderson Cancer, Center Houston, USA This presentation will describe the referral patterns of oncology patients who were referred for sexual dysfunction to a Psychiatric Clinical Nurse Specialist (CNS) over a 5-year period. The Psychiatry Section is in the Department of Neuro-oncology in a large community/hospital based centre in a large metropolitan area. All of the patients seen had a co-morbid cancer diagnosis that contributed to their sexual dysfunction. Since sexuality is a quality of life issue that was not being addressed elsewhere in the institution, it was addressed in the

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Psychiatric outpatient clinic. The sexuality clinic was started in 1999 as a pilot project that saw only men with prostate cancer, but has since expanded to include everyone. This presentation will discuss sources of referrals, epidemiology of patients, including race, gender and marital status. 204 patients have been seen in this clinic, which included 61 females. However, only one African American female has been seen for sexual dysfunction. Initially, most of the referrals came from the Genito-urinary service. The patient’s oncology diagnosis as well as any psychiatric diagnosis will be discussed. Even though the referral was for sexual dysfunction, any psychiatric disorder was also treated. None of the sexual dysfunction was psychological. The importance of including a psychiatric assessment on patients seen for sexual dysfunction will be discussed. It is important to treat any comorbid psychiatric condition before treating sexual dysfunction.

448 Long-term Psycho-Sexual Adjustment Following Treatment for Cervical and Endometrial Cancer Juraskova I1,2, Butow P1, Sharpe L2, Robertson R3 1 Medical Psychology Research Unit, School of Psychology, University of Sydney, Sydney, Australia; 2Clinical Psychology Unit, School of Psychology, University of Sydney, Sydney, Australia; 3 Gynaecological Cancer Centre, Royal Hospital for Women, Sydney, Australia PURPOSE: The role of psychological and physical factors in the development of chronic sexual morbidity within subgroups of gynae-oncological patients remains unclear. METHOD: This multicentre study provides a comprehensive longitudinal assessment of the psycho-sexual adjustment of patients undergoing treatment for early stage cervical and endometrial cancer (N=53). Control groups included; (i) benign gynaecological patients (N=60) controlling for the effect of gynaecological surgery and (ii) pre-invasive cancer patients (N=84) controlling for the ‘‘threat of cancer’’. All patients were assessed at baseline and at 6 months follow-up, using standardised measures. The cancer group was additionally assessed at 12

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months post-treatment to account for the delayed impact of radiotherapy on sexual functioning. RESULTS: The findings suggest that treatment for early stage cervical and endometrial cancer does not result in major, continuing sexual upheaval and sequelae. Despite many adverse vaginal changes and treatment side effects, the only lasting decline was seen in sexual satisfaction (p=0.006). The key predictors of post-treatment psycho-sexual adjustment were psychological factors (p=0.011) and the doctor-patient relationship (p=0.023). Anxiety levels remained elevated in approximately a third of patients in all groups. Only half of cancer patients had discussions about sexual matters with their oncologists and alarmingly low number of patients was aware of the existence of vaginal dilators. The presence of myths regarding contagiousness of cancer was noted in a small but significant minority of patients and partners. Patients treated for nononcological gynaecological conditions reported poorer adjustment than expected. These findings have important implications for clinical practice and future research.

449 Sexuality and Relationship in Breast Cancer Kuznecova G1, Kuznecovs S2 1 Research group for Psychosicial support in Cancer, Public Health Research Laboratory, Riga Latvia; 2 Cancer Epidemiology Unit, Public Health Research Laboratory, Riga, Latvia PURPOSE: Sexuality is an intrinsic part of human nature, which plays an important role in psychoemotional support in cancer. The purpose of the present study is to evaluate the impact of breast cancer (BC) on sexuality and relationship. METHODS: The Relationship Questionnaire was developed and used to determine the influence of mastectomia and chemotherapy on sexual functioning, family relationship, and quality of life. RESULTS: 302 women with BC (28–52 y.o.) participated, with lack of sexual interest (18.5%), inorgasmia (15.8%), poor lubrication (24.8%), reduced satisfaction with masturbation (13.2%), reduced frequency of masturbation (11.9%), painful intercourse (17.8%), vaginismus (4.9%). 94% reported at least one sexual problem, although

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25% reported either no or slight concerns about their sexual difficulties. It was found that one of the most commonly occurring secondary sexual symptom among women with BC is fatigue (92.7%). Fatigue greatly interferes with sexual desire and physical ability to initiate and sustain sexual activity. The physical changes (mastectomia, hair loss) due to BC and chemotherapy can also negatively affect body image. 76% of women might have difficulty feeling physically appealing or ‘‘sexy’’. Some of them (49%) may fear they are no longer sexually desirable to their partner. Additional problems may occur in the relationship when the partner assumes the role of caretaker (9.9%). CONCLUSIONS: Obtained information about sexuality and BC makes possible to develop the programme for psychosocial support and clinical guidelines to modify treatment regimes to best accommodate sexual needs.

65 years old diagnosed with Stage Ic to III cervix or endometrial cancer who received pelvic radiotherapy were randomised to either the experimental psychoeducational group or the informationonly control group. Assessment via questionnaire occurred prior to treatment, and at 6-week and 6 & 12 -month follow-up. RESULTS: The psychoeducational intervention was successful in increasing compliance with vaginal dilation. Also, while there was no group difference in the number of women who used vaginal lubricants post radiotherapy, the women in the psycho-educational group used a greater variety of lubricants than did the women in the control group. CONCLUSION: This is the first randomized controlled study to demonstrate the effectiveness of an intervention in increasing compliance with the use of vaginal dilators.

451 450 An Effective Intervention to Increase Vaginal Dilation by Women with Gynaecological Cancer Treated with Pelvic Radiotherapy Robinson JW1,2,4, Jeffries SA1,2, Craighead P3,4 1 Psychosocial Resources, Tom Baker Cancer Centre, Calgary, Canada; 2Program in Clinical Psychology, University of Calgary, Calgary, Canada; 3 Radiation Oncology, Tom Baker Cancer Centre, Calgary, Canada; 4Oncology University of Calgary, Calgary, Canada

Sexuality, Body Image and Desire of Maternity After Breast Cancer Scaffidi E1, Didier F2, Peccatori F3, Petit JY4, Goldhirsch A et al.5 1 Psychoncology Unit, European Institute of Oncology, Milan, Italy; 2Division of Haemato-Oncology, European Institute of Oncology, Milan, Italy; 3 Division of Reconstructive Plastic Surgery, European Institute of Oncology, Milan, Italy; 4Department of Medicine, European Institute of Oncology, Milan, Italy

PURPOSE: While vaginal dilation and the use of lubricants are often recommended to mitigate sexual side effects after pelvic radiotherapy, compliance with these recommendations has historically been very low. Therefore, effective intervention strategies are needed to enhance compliance with these remedial recommendations after radiotherapy for gynaecological cancer. This study was a randomised controlled clinical trial of a psycho-educational sexuality intervention specifically designed to increase compliance with vaginal dilation and enhance the use of vaginal lubricants. The Information–Motivation–Behavioural Skills model of enhancing compliance with behavioural change was the basis for the intervention design (Fisher and Fisher, 1992). METHODS: Forty-two sexually active women ages 21 to

PURPOSE: To evaluate impact of breast cancer surgery options (tumorectomy, quadrantectomy, mastectomy, nipple sparing subepithelial surgery) and medical treatments (chemotherapy, endocrine therapy, chemo+endocrine, radiotherapy) on sexuality. Assessments will take into account perceived changes by breast cancer patients in their sexuality after diagnosis, together with selfesteem and body image after breast treatments. The study will also try to highlights on patients’ difficulties in coping with anticipated menopause and desire of maternity. In fact, interruption of menstrual periods is only rarely reversible, especially when ovarian functioning has been depressed for a long time and when the woman is not far from her physiological menopause. Depression and anxiety will also be checked and put

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into relations with other variables. METHODS: Sexuality after breast cancer questionnaire Desire of maternity after breast cancer interview. Hospital Anxiety and Depression Scale; Body Image Scale. Socio-demographic information and clinical data. RESULTS: The lecture will focus on first outcomes of the study, also giving indication about validation process of the new instruments used; a feedback on the qualitative methods of information harvest will also be given. CONCLUSIONS: Evaluation of the above variables in breast cancer women is actually the only way to allow them to face a relevant aspect of their quality of life, most of the times neglected both by health professionals and themselves too. Importance of data will suggest hospital institutions to consider sexuality as a key point in cancer rehabilitation.

452 Sexual Functioning and Related Psychological Factors: A Prospective Study on Chinese Women with Gynecologic Cancer Tang SK Department of Psychology, Chinese University of Hong Kong, Shatin NT, Hong Kong PURPOSE: We examined psychological factors and sexual functioning of Chinese women after treatment of their gynecologic cancer. METHODS: In a prospective study we interviewed a convenience sample of 57 women with gynecologic cancer (Mean=43.82 years) 1 month to 12 months after confirmation of diagnosis, 1–8 weeks after surgical treatment of cancer, and at least 1 year after surgery. Interview items were devised from standardized psychological scales on sexual functioning, feminine gender role, psychological distress, body image, neurotic personality style, and spousal support. RESULTS: We found that participants’ drive for kissing and petting as well as sexual intercourse decreased after surgery and at 1-year follow-up. The average time for resumption of these activities was respectively 7 weeks and 13 weeks after surgery. At 1-year follow-up, 77% of the participants had resumed sexual intercourse and 60% also reported various sexual problems, with lack of vaginal lubrication and dysparenia being the most common complaints. Their level of sexual satisfaction also decreased after surgery and

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did not return to pre-surgery level even at 1-year follow-up. Bivariate correlation analyses showed that sexual dissatisfaction after surgery and at follow-up was related to high levels of neurotic personality style, poor body image, and psychological distress at pre-surgery. Resumption of sexual intercourse at follow-up was related to pre-surgery sexual information, rejection of sexual folk beliefs, and spousal support. CONCLUSIONS: Chinese women showed decreased sexual functioning after surgical treatment of gynecologic cancer and during rehabilitation. Psychological factors and cultural folk beliefs before surgery influenced subsequent sexual. . . [truncated].

453 Regaining Sex After Breast Cancer}Sexual Therapy in Psycho-Oncological Settings Traun-Vogt G, Korn V, Wagner Th, Kubista E Division of Senology, Medical University, Vienna, Austria PURPOSE: Many women suffer from functional sexual disorders after breast cancer diagnosis and treatment. A psychotherapist’s model of therapeutic interventions shall be presented about these women’s problems and possible ways to deal with them in a clinical psycho-oncological setting. METHODS: In this setting, sexuality is actively addressed in the course of counselling. It is important to choose the appropriate time in the course of crisis management to talk about sex. Metaphors are presented in which patients signal their needs to address sex issues. The socially accepted, but defensive ways doctors, nurses and psycho-oncologists react to these issues are discussed. SUMMARY OF RESULTS: In counselling breast cancer patients with functional sexual disorders, the following issues are of great importance: * * *

*

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female and male subjective theories of guilt; shame; sexual history of the individual and of the couple; new definitions of partnership perspectives after BC; reframing the desire for a child.

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CONCLUSIONS: As sexual therapeutic precondition for regaining partnership interactions, empowerment of the affected individual is substantial. The above-mentioned issues should be dealt with before proceeding to other topics as * *

*

*

*

masturbation as individual step towards vitality; recalling sexual resources from the past of the couple/the individual; changing the sexual concepts from right/wrong to adequate/inadequate; restarting verbal communication about sexuality with the partner; changing from sparing the affected partner to a new orientation in partnership.

454 Marital and Sexual Satisfaction in Testicular Cancer Survivors and Spouses Tuinman MA1, Fleer J1, Sleijfer DT2, Hoekstra HJ1, Hoekstra-Weebers JEHM3 1 Surgical Oncology, Groningen University Hospital, Groningen, The Netherlands; 2Medical Oncology, Groningen University Hospital, Groningen, The Netherlands; 3Medical Psychology, Groningen University Hospital, Groningen, The Netherlands PURPOSE: To gain insight into marital and sexual satisfaction in testicular cancer survivors (TCSs) and their female spouses. METHOD: 219 couples of TCSs and spouses who had a relationship before diagnosis (‘couples during TC’) and 40 couples who started a relationship after treatment (‘couples after TC’) completed the Maudsley Marital Questionnaire (MMQ). Response: TCSs 50%, spouses 78%. Reference groups of men and women were used for comparison. RESULTS: TCSs and spouses of couples during and after TC reported similar marital satisfaction as men and women of the reference group. TCSs (t=2.9, p50.01) and spouses (t=2.9, p50.01) of couples during TC and TCSs of couples after TC (t=1.9, p=0.05) did report less sexual satisfaction than the reference groups. Spouses after TC did not differ in sexual satisfaction from the reference group. TCSs of couples after TC reported less sexual satisfaction than TCSs of couples during TC (F=4.0, p50.05), no other differences between

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partners of couples during and after TC were found. CONCLUSION: Marital satisfaction did not appear affected by the testicular cancer experience in couples during and after TC. However, sexual satisfaction was decreased for all survivors and spouses who went through the experience. TCSs of couples after TC seem to be the most vulnerable since they reported even less sexual satisfaction than TCSs of couples during TC. Insecurity may arise in a new relationship, whereas long-term partners may experience a buffering effect of increased intimacy.

455 Sexuality for Breast Cancer Survivors: Reconstructing Sexual Self Images Turner LJ, Cumming CE Department of Psychosocial and Spiritual Resources, Cross Cancer Institute, Edmonton, Canada PURPOSE: The purpose of the research was to describe the in-depth experience of sexuality for breast cancer survivors. Previously, cross-sectional, quantitative methods have been used to investigate such topics as frequency of intercourse, rating of painful intercourse, and sexual desire. In the present study, breast cancer survivors were given the opportunity to become active participants in the construction of their own sexual paradigms. METHODS: Eight participants were interviewed using an open-ended format and the resulting data were transcribed and then analyzed in accordance with qualitative descriptive methodology. RESULTS: The results reflected the women’s rich descriptions of a reconstructed sexual self-image after breast cancer. The participants described their constructions of sexuality before breast cancer and indicated how breast cancer and its treatment challenged these constructions. They created meaning out of the changes in their bodies and their sense of selves as women, and integrated this with their previous understandings of their sexuality. These new meanings were then integrated into their new sexual self. The findings indicated a commonality and a coherence of experience despite sociocultural differences. Implications for future research and clinical practice will also be presented.

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Side Effects 456 An Investigative Study to Establish the Preferences of Well Men for Two Different Hormone Therapies in the Treatment of Prostate Cancer Edginton TL, Jenkins V Psychosocial Oncology Group, University of Sussex, Brighton, UK PURPOSE: To establish the preferences of well men for either daily oral administration of an antiandrogen therapy (Casodex) or monthly administration of a sub-cutaneous injection of a LHRH analogue (Zoladex), producing medical castration in the treatment of locally advanced non-metastatic prostate cancer. METHODS: 200 men aged between 50 and 80 years, who were appropriately stratified to take account of the prevalence of locally advanced prostate cancer in the UK and social economic classification, were recruited through adverts and via societies (e.g. golf clubs, bowls clubs, Rotary clubs) in the South of England. A questionnaire based survey was presented in which the men were asked to read a typical scenario for each treatment including side-effect profiles and route of administration. The men were then asked which therapy they would choose if they had been diagnosed with prostate cancer assuming equal effectiveness of both therapies. RESULTS: Work in progress. Results will show the percentage of men who chose each treatment plus information about the reasons for their choice. The relationship between the outcome and the following variables will be explored: age, marital status, education and previous experience of someone close having had cancer. CONCLUSIONS: The results will inform us whether the side-effect profile and route of administration of each drug significantly influences well men towards a preference for one treatment over another as well as raising questions for further research, such as whether the results of this study would be reflected amongst a patient population.

457 Understanding Sleep in a Cancer Patient Population Graci G Oncology, Northwestern University, Chicago, USA

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When patients are diagnosed with cancer, they enter a new and frightening realm of experience. This change in status, and the diagnostic and treatment protocols are accompanied by many symptoms, including alterations in sleep patterns. These are rarely addressed outright, as other concerns, such as morbidity and mortality, appear to take precedence. Yet sleep disturbance is three times more common among cancer patients and may persist over time. It may take the form of hypersomnia or insomnia but the cause of chronic sleep difficulties is multifaceted. In the past, health care professionals have unwittingly contributed to the problem. Until relatively recently, when patients complained of daytime fatigue, they were told to rest and take daytime naps. This advice may have actually worsened sleep difficulties and increased daytime fatigue by disrupting the normal patterns of sleep. This presentation addresses the etiology and risk factors for disturbed sleep, common sleep disturbances experienced by cancer patients, ways to identify sleep disturbances in this population, as well as implementation of treatment strategies (behavioral and pharmacological) to improve sleep functioning. The overarching objective of treating sleep difficulties is to improve daily functioning and increase quality of life ratings. Education about sleep and including questions about sleep functioning in our clinic practice is a way to alleviate the distress produced by sleepless nights. Cancer patients face many challenges; sleep problems do not have to be one of the necessary consequences associated with the cancer experience.

458 Sleep Disturbance in Cancer Patients Graci G Oncology, Northwestern University, Chicago, USA In the last decade, there has been increasing interest in the effects of cancer on sleep. However, there is a paucity of empirical research and very few studies involve objective measurements. The overarching goal of the present program of research is to discuss factors, which might significantly impair sleep of cancer patients and ways to treat sleep disturbance. A standardized

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sleep disorder intake was administered consecutively to cancer patients presenting with sleep disturbance (N=6). Patients identified as having sleep onset and/or maintenance difficulties were retrospectively reviewed. The majority (67%) of patients were Caucasian and female and were diagnosed with breast, metastatic, lung, or testicular cancers. Sixty-seven percent were diagnosed with psychophysiological insomnia and the remainder with insomnia secondary to a mood disorder. Patients received cognitive-behavioral treatment consisting of instructions on sleep hygiene, stimulus control and sleep restriction therapies, early morning bright light therapy, and antidepressant medication as appropriate. Sleep logs were required and sleep efficiencies were calculated based on weekly reviews of these logs. Treatment success was defined as having sleep efficiency (SE) scores greater than 85%. Five patients achieved SE scores greater than 85% with remission of sleep complaints (X=2.5 weeks). There was one treatment failure. Psychological, environmental, and pharmacological treatment strategies will also be discussed. More objective studies are needed to determine the efficacy of these treatment strategies and to improve our understanding of the influence of cancer on sleep.

459 Nausea and Vomiting During Chemotherapy for Breast Cancer: Triggers and Patient Experiences Johansson KAH1, Paulsen K1, Zachariae R1, Jensen AB2 1 Psycho-oncology Research Unit, Aarhus University Hospital, Aarhus, Denmark; 2Oncology, Aarhus University Hospital, Aarhus, Denmark PURPOSE: To explore psychological and environmental triggers of nausea and vomiting in women undergoing chemotherapy for breast cancer. METHODS: 125 women receiving chemotherapy for breast cancer were asked to record the duration and intensity of side effects and the triggers of these, along with a number of other psychological and physiological variables prior to the 1st, 4th, 6th and 9th infusion. RESULTS: 52.8% reported one or more psychological and/or environmental trigger to their unpleasant side effects, most commonly nausea and vomiting at

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some point during treatment. 37% of respondents experienced anticipatory nausea and/or vomiting prior to receiving chemotherapy, on at least one occasion. The study probed into what participants considered to be the trigger of these unpleasant somatic side effects. In contrast to previous assumptions, hospital-related stimuli was only the fourth most frequently reported trigger. Instead, olfactory cues and anxious thoughts and feelings relating to treatment were reported most frequently, followed by foodstuffs. Women who experienced anticipatory nausea expressed more distress towards the end of treatment (p=0.018) as measured on the Profile of Moods Scale (POMS), than those who did not have this experience. CONCLUSIONS: A large proportion of women receiving chemotherapy suffer adverse side effects. Findings indicate that triggers to nausea and vomiting are not only of the hospital-related kind but that every day items and situations appear to elicit a reminder about treatment in some way. Findings are discussed in terms of implications for the prevention of such unpleasant side effects, which may if untreated. . . [truncated].

460 Sexuality and Partnership in Long-Term Survivors of Tesicular Cancer}A Research of 131 Cases Martinschek A, Schmelz HU, Sparwasser C Urology, Federal Armed Forces Hospital, Ulm, Germany PURPOSE: Despite rising incidence rates of testicular cancer, mortality decreased due to therapeutic regimes during the last years. Young testicular cancer survivors must cope with longterm effects of cancer treatments on partnership and sexuality. Therefore, it is essential to know about testis cancer specific sequelae to advise patients in a stage, age and therapy specific manner. METHODS: Questionnaires were sent to 184 testicular cancer patients, receiving treatment from 1990 to 1997. 131 questionnaires returned and were evaluated according to the topics of partnership and sexuality. For the statistic analysis the Fishers exact test and the Qui square test were applied. RESULTS: Nearly a quarter of the patients felt a strengthening effect on their partnership, only 11% reported a more

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disruptive effect. No correlation could be found concerning therapy modalities or age, a positive effect on the partnership could be shown for an increasing stage of the disease and the duration of the partnership. Most of the patients reported a satisfying sexual life, but 16.5% complained about restrictions. No correlation could be found for age, therapeutic measures or the stage of the disease, but for patients with sexual disorders after treatment. There is a strong correlation between satisfaction in sexuality and partnership, as well as an influence of the information, given to the patient before treatment, concerning the problems in sexuality and partnership. CONCLUSIONS: Testis cancer patients adapt well to their posttreatment situation. Physicians should be aware of the fact that they are in a strategic position to diminish problems by informing patients before treatment.

461 Clinician Recorded QoL Shows Little Correlation with Patient Self-Report Price MH, Fallowfield LJ Cancer Research, UK Psychosocial Oncology Group, University of Sussex, Brighton, UK Although quality of life, as measured by selfreport is viewed as a mandatory outcome measure in clinical trials, more often than not, the toxicities and tolerability of treatments are inferred from clinician recorded adverse events. However, there is increasing indication that healthcare professionals may underestimate side effects By reviewing both previous research and symptom assessment data from 1602 patients across two multinational breast cancer trials, this article comments on the comparative reporting of side effects from both clinicians’. Case Report Forms and patients symptom self reports. Agreement between patients and clinicans in terms of the severity of symptoms are marginal, and tend to decrease further over time. In all cases, symptoms are either under-reported or not reported at all by clinicians. There are also clear discrepancies between clinician’s reports and patient self-reports on the presence of several symptoms, particularly those concerned with

Copyright # 2004 John Wiley & Sons, Ltd.

sexual issues, and those which cannot be objectively verified Identification of the presence and level of severity of endocrine symptoms is essential for the benefits of different novel therapies to be recognised and for the development and clinical use of supportive treatments aimed at minimising side effects. Appropriate communication with patients or the incorporation of regular assessments using a validated self-report measure is recommended and suggestions for future research and initiatives to improve clinical practice are proposed. Quality of life Breast Cancer Communication Symptoms

462 Negative Life Events and Distress in Healthy Women Following Mammography}A Prospective Study Zachariae R1, Jensen AB1, Lehbrink M2, Christensen S1, Lassesen B1 1 Oncology, Aarhus University Hospital, Aarhus, Denmark; 2Radiology, Aarhus University Hospital, Aarhus, Denmark PURPOSE: To investigate the influence of negative life-events on distress of healthy women following mammography. METHODS: A total of 804 women referred to mammography belonging to a high (N=288), medium (N=358), and low risk group (N=158) completed the List of Recent Events and the Social Support Questionnaire 1–2 weeks before the mammography, and a cancerrelated distress measure (Psychological Consequences of Cancer) 1–2 weeks before, 4 weeks, and 12 weeks after mammography. RESULTS: 717 women (Mean age: 47) did not have current or previous cancer. A within-subjects (time) betweensubjects (High vs low number of negative lifeevents; Married vs single) ANOVA revealed a significant effect of negative life-events on distress (F=12.7; p50.001) and a significant interaction (time  marital status) (F=3.1; p50.05). Single women were significantly more distressed than married women 4 weeks (p50.02) and 12 weeks after (p50.01), but not prior to the mammography (p=0.37). A multiple linear regression revealed that distress after 12 weeks was significantly

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associated with negative life-events (Beta=0.22; p50.01) and near-significantly inversely associated with social support (Beta= 0.12; p=0.06), when controlling for age, marital status, family history of cancer, and risk group. Negative life events continued to be significantly associated with distress at week 12, when controlling for distress prior to mammography (Beta=0.15; p50.05). CONCLUSIONS: Single women who experience a high number of negative life events and low social support may be at higher risk for developing distress after mammography.

463 Anticipatory Nausea}The Role of Trait Factors Related to Sensory Perception Zachariae R, Johansson A, Paulsen K, Jensen AB, Mehlsen M et al. Oncology, Aarhus University Hospital, Aarhus, Denmark PURPOSE: To investigate the possible influence of trait factors thought to be related to sensory perception on anticipatory nausea of women undergoing adjuvant chemotherapy for breast cancer. METHODS: Prior to the first infusion, 125 women (Mean age: 48.5 years) undergoing adjuvant chemotherapy for breast cancer rated their expected severity of side-effects and completed the Tellegen Absorption Scale (TAS), the Somato-Sensory Amplification Scale (SSAS), and the Autonomic Perception Questionnaire. The women rated their anxiety and worry concerning chemotherapy as well as anticipatory nausea (AN) for each of three days prior to the 4th, 6th, and 9th infusion. The women also rated the degree of postchemotherapy nausea (PN) after the 1st, 4th, 6th, and 9th infusion. RESULTS: 18%, 19%, and 26% reported AN before infusion 4, 6, and 9 respectively. A total of 37% reported AN before one or more infusions. Significant correlations (p50.05) were found between severity of AN and TAS, SSAS, APQ, expected nausea, anxiety, and severity of PN. A multiple logistic regression revealed that TAS-scores significantly predicted AN before one or more infusions (B=0.17; p50.003; Odds Ratio: 1.2; CI (95%): 1.1–1.3) when controlling for SSAS, APQ, toxicity (CEF or CMF), age, expected nausea, total severity of PN, and total

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anxiety prior to the infusions. CONCLUSIONS: Our results suggest that absorption is an independent predictor of AN and partly confirm the results of a previous study (Challis & Stam, 1992) showing absorption and autonomic perception as predictors of anticipatory side-effects in cancer patients receiving chemotherapy.

Social Network 464 An Examination of the Development of an Integrative Program for Children Who have a Family Member with Cancer Biank NM Clinical Program, Wellness House, Hinsdale, USA Each member of a family is affected when one of them is diagnosed with cancer. A great deal of attention has been focused on the needs of adult caregivers. Children in families with a diagnosis of cancer have needs that should be addressed and addressed in the context of the family system. As cancer has become more chronic, treatment of a parent can last 3–5 years, or 50% of the life of a 10 year old. During the treatment of one parent, the other parent is often involved in taking on new roles; both parents are distracted. FAMILY MATTERS is a comprehensive educational and support program that keeps children on track developmentally, normalizes and validates the feelings that children experience and offers individual and group opportunities for children, teens, and parents. It has evolved over an 8 year period in response to family inquiry and the 1999 Wellness House Needs Assessment that documents the psychosocial morbidity in children and adolescents who are members of a family where a member is diagnosed with cancer.

465 ‘‘Learning to Live with Cancer’’}The Irish Experience Courtney UM Director of Services, ARC Cancer Support Centre, Dublin, Ireland

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PURPOSE: Patients react to a cancer diagnosis with a variety of emotions and psychosocial oncology focuses on how the physical manifestations of cancer impact upon the cognitive, behavioural, social and spiritual components of the lives of patients with cancer. Psychosocial interventions aim to alleviate the emotional and social impact of cancer on patients and their families. Information is a basic form of support. Correct and adequate information is essential to helping patient and family adapt to a diagnosis of cancer and develop coping skills. Studies suggest that patients who receive good information are more satisfied with their care and demonstrate lowered levels of anxiety and depression. METHOD: The role of support groups has been well documented in cancer support. ‘‘Learning to live with Cancer’’ is an evidence-based education and support programme for cancer patients and their significant others and is the result of a scientific research project carried out in Sweden. Psychoeducative group support helps people who have similar problems to act as role models to one another, especially in the use of adaptive coping responses. RESULTS: The implementation of the ‘‘Learning to live with cancer’’ programme in ARC Cancer Support Centre in 1998 has been very successful and to date the programme has been completed by over 500 participants. CONCLUSIONS: This paper describes the perceived benefits of this course and its implementation in Ireland as a standardized education and support programme for people affected by a cancer diagnosis.

466 Emotional Support for Prostate Cancer Patients} Effects on Psychological Well-Being Helgason AR1,3,4, Dickman PW2, Adolfsson J3, Steineck G4 1 Centre of Public Health, Karolinska Institutet Stockholm, Sweden; 2Clinical Epidemiology, Karolinska Institutet, Stockholm Sweden; 3Oncology Centre, Karolinska Institutet, Stockholm, Sweden; 4 Cancer Epidemiology, Karolinska Institutet, Stockholm, Sweden PURPOSE: To investigate to what extent prostate cancer patients confide their emotional concerns,

Copyright # 2004 John Wiley & Sons, Ltd.

and if having no one to confide in affects wellbeing. METHODS: A population based study using epidemiological methods. An anonymous questionnaire mailed to all 431 living prostate cancer patients aged 50–80 at the time of selection, diagnosed 1.5–2 years previously in the Stockholm County in Sweden and 435 randomly selected men in the same age group. Main outcome measures included questions assessing the extent to which the men could share emotionally taxing feelings with their partner or others and questions assessing well-being. RESULTS: The questionnaire was returned by 79% of the patients and 73% of the randomly selected men. Approximately one in five patients had no one to confide in. Among patients living with a partner, only one out of ten entrusted in someone other than their partner. Three out of ten patients living in a relationship could not confide in their partner. Men having no one to entrust in were less content with their life and reported poorer psychological and over-all wellbeing compared with other men. The prostate cancer patients were not more likely than men in general to have someone to confide in. CONCLUSIONS: The results indicate that a lack of emotional support may be a problem for many prostate cancer patients and that traditional psychosocial support offered to most cancer patients in Sweden may not get through to male patients. There may be a need for a gender adapted approach to emotional support.

467 Online Interactions. Analysis of a Scandinavian Breast Cancer Mailing List Hoeybye MT1, Johansen C1, Thomsen TT2 1 Department of Psychosocial Cancer Research, Institute of Cancer Epidemiology, Copenhagen, Denmark; 2Institute of Anthropology, University of Copenhagen, Copenhagen, Denmark PURPOSE: This qualitative study sought to explore how sharing of ones story of living with breast cancer, on an Internet mailing list, creates communal counteraction to the isolation of illness experience. Our study investigates how people respond socially to the isolating effects of chronic suffering, and how this experience is counteracted on the Internet, by analysing the storytelling

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emerging on the Scandinavian Breast Cancer Mailing list (SCAN-BC-LIST). METHODS: The research is an ethnographic fieldwork conducted from April to December 2000 on SCAN-BC-LIST. Our study was designed as a qualitative case-study. Data was produced through methods of participant observation, on-line interviews and focusgroup interviews, as well as face-to-face interviews and the keeping of diaries. RESULTS: The material shows that the women use the Internet as a strategy of empowerment where the mailing list provides social exchange of knowledge and experience. The ability to use the Internet is understood by the individual as a possibility of finding ways to live with breast cancer. In daily interactions on the list the women formed verbal counteractions, through storytelling, to the experience of cancer and the often overwhelming experience of social isolation. CONCLUSIONS: Finding ways to act, when life has been disrupted by cancer is crucial to rehabilitation. Using the Internet serves as a personal strategy of empowerment. An independent mailing list corresponds to and reflects the immediate need of its participants. Participants valued the list as a place to relate emotional experiences of cancer without professional interference. The communal storytelling formed counteractions to experience.

quantitative data from the FOCARE baseline questionnaire, for the Dallund research project. RESULTS: From the 117 total eligible participants, 67% (n=78) participated in teaching sessions about the Internet. 34% (n=40) registered as users, and 27% (n=32) had actively used their Internet support group by 1 October 2003, through the 12 weeks of study. Four major factors influence participants’ motivation: Group dynamics at Dallund, age, social class and Internet access. Users and non-users of the Internet support groups differed concerning: Age, gender, education, cohabitation and marital status, occupational status and financial income. CONCLUSIONS: It is important that research on Internet use and cancer address barriers to Internet use, to reduce these barriers in future practice. The Internet groups provide a place, with users living physically apart, where they can share the worries and joys of their life. This could be an important factor of rehabilitation in all settings. We believe it could prove to have positive effects on self-esteem and the feeling of empowerment. We therefore find it very likely to see that Internet based interaction can prove to have an effect on the rehabilitation of cancer patients.

469 468 Internet Based Support in Cancer Rehabilitation Processes}A Pilot Study Hoeybye MT1, Thomsen TT2, Kuhn KG1, Johansen C1 1 Department of Psychosocial Cancer Research, Institute for Cancer Epidemiology, Copenhagen, Denmark; 2Institute of Anthropology, University of Copenhagen, Copenhagen, Denmark PURPOSE: We examined the feasibility of providing Internet support groups for Danish cancer patients. We explored the determinants of participation in Internet support groups. METHODS: Participants were recruited from rehabilitation courses at Rehabilitation Centre Dallund, with a total of 117 participants representing 13 cancer diagnosis. The prevalent methods were qualitative: Participant observation, interviews and online focus group interviews. This was combined with

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Social Connections, Social Support, and Quality of Life in Blacks and Whites with Colon Cancer Kinney AY1,2, Bloor LE1, Martin C3,4, Sandler RS3,4 1 Huntsman Cancer Institute, University of Utah, Salt Lake City, USA; 2College of Nursing, University of Utah, Salt Lake City, USA; 3Division of Digestive Gastroenterology and Hepatology, The Center for Gastrointestinal Biology and Disease, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, USA; 4Department of Epidemiology, School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, USA PURPOSE: Both structural and qualitative aspects of social ties have been associated with quality of life, but few investigations have evaluated these associations among non-Caucasian colon cancer patients. This cross-sectional, population-based study assessed structural (e.g., marital status, church attendance) and qualitative (e.g.,

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emotional and tangible support) aspects of support in association with perceptions of mental and physical health (SF12) among Blacks (n=294) and Whites (n=349) with pathologically-confirmed invasive colon cancer. METHODS: Analyzing data from the North Carolina Colon Cancer Study, we assessed whether race, gender and/or age modified these associations. Linear regression analyses adjusted for sociodemographic factors. RESULTS: Whites were more likely to be married (chi-square=28.96, p50.001), report greater availability of emotional support (chisquare=11.13, p50.001), and report receiving adequate emotional support (chi-square=20.01, p50.001) compared to Blacks, whereas Blacks were more likely to be a member of a church group (chi-square=22.56, p50.001) and to attend church more frequently (chi-square=8.25, p=0.004). A significant race  adequacy of emotional support interaction (beta coefficient= 3.508, t(1,515)= 3.21, p=0.001) was observed. Emotional support was not associated with mental health among Blacks; however, among Whites, receiving adequate emotional support was associated with improved mental health. No statistically significant main or interaction effects were observed for availability of support or structural aspects of social connections. CONCLUSIONS: These data suggest that adequacy and not mere availability of emotional support may be particularly important for adjustment to colon cancer and that underlying mechanisms of this relationship deserve greater attention.

470 ‘‘Once-off Groups’’ as a Tool for Supporting the Bereaved}an Extension of Oncology Unit Services in Cape Town Manicom CL Oncology Social Work, GVI Oncology, Cape Town, South Africa The grieving process for many people contains elements of loneliness and isolation. Families of those treated in oncology units may feel abandoned after the death of a loved one, and may miss the familiarity and security such a unit offered. Staff are generally unable to offer more than cursory support and condolences. In this paper,

Copyright # 2004 John Wiley & Sons, Ltd.

the use of ‘‘once-off’’ groups for bereaved family members and close friends is discussed, focussing on benefits for members, advantages for the oncology social work facilitator and for the oncology unit. Work done at a private oncology unit in Cape Town, over a period of three and a half years will be reflected on, with reference to the use of this type of group as a constructive strategy for matching clients’ needs to resource limitations.

471 Social Support and Acute Stress Reactions in Healthy Women Referred to Mammography Pedersen AF, Zachariae R, Jensen AB, Christensen S, Lassesen B et al. Oncology, Aarhus University Hospital, Aarhus, Denmark PURPOSE: To investigate the influence of social support on acute stress reactions in healthy women referred to mammography. METHODS: A total of 804 women referred to mammography and classified as belonging to a high (N=288), medium (N=358), and low risk group (N=158) completed the Social Support Questionnaire (SSQ-8) 1–2 weeks before the mammography and the Impact of Events Scale (IES) before, 4 weeks after, and 12 weeks after mammography. RESULTS: 717 women (Mean age: 47) did not have current or previous cancer. After 4 and 12 weeks, 15 and 5 healthy women respectively had a significant stress response (a total score >29 on IES). The women generally reported high levels of both social support (number of support persons) (37.73  17.44) and satisfaction with social support (33.95  7.46). A multiple logistic regression revealed that a high score on IES (above the median) after 4 weeks was significantly associated with number of support persons (B= 0.12; p=0.032; OR=0.99), when controlling for age, marital status, and risk group. Satisfaction with social support did not reach statistical significance. After 12 weeks social support was unrelated to distress. CONCLUSIONS: Previous studies have shown that mammography screening in healthy women can cause short- and long-term distress. Our results indicate that the number of individuals providing emotional support may influence the acute stress reaction following mammography.

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Contrary to our expectations, satisfaction with social support was not associated with either shortor long-term distress following mammography.

472 Patient-Physician Paradigm: Individual Center or Family Center Perry S1, Baider L2 1 Institute of Oncology, Rabin Medical Center, Petach-Tikva, Israel; 2Sharet Institute of Oncology, Hadassah Medical Center, Jerusalem, Israel Medical care had evolved into an expression of individual rights, where privacy, inform consent and confidentiality are the pivotal value. Patient– physician paradigm has been debate from the cultural perspective, especially in non-Western cultures, where families are highly integrated within the society and autonomy might be perceived as isolation. An extensive research in the field of psycho-oncology has revealed that cancer is indeed a ‘‘family affair’’ and not just an individual illness. However, the unique social implications of hereditary breast/ovarian cancer and end of life care, has posed a new challenge to the patient centre paradigm. In genetic diseases, information affects the concerned patient but also other members of the family. In situation of terminal illness the family support is essential for the basic care of the patient. This presentation will attempt to challenge the patient–physician centre paradigm and to show that from an initial health context, prevention}to terminal illness there is a continuum where the family should be an integral part of medical decision and treatment. Our goal as psycho-oncologists should be to search for a more appropriate model of care that will respect the universal values and culture diversity, while simultaneously safeguarding the boundary of the individual and the family bonds.

473 The Experience of Loneliness in the Gero-Oncology Population Reiner AC College of Nursing, University of Utah, Salt Lake City, Utah, USA

Copyright # 2004 John Wiley & Sons, Ltd.

Loneliness is a subjective negative state of feeling alone, accompanied by a lack of satisfaction with personal or social relationships and by limited interaction in stimulating relationships. Less frequent social contact is correlated with the perceived experience of loneliness. It is distinguished from solitude and existential loneliness. Studies establish loneliness as risk factor of aging, but do not support its inevitability. However, its prevalence is documented within the context of chronic illness and aging. People experiencing cancer of any age relate feelings of loneliness stemming from decreased interactions with others and associated with immediate and lingering side effects of cancer and its treatment. Does a population of elderly with cancer report this experience? With the assumption that cancer is a chronic illness, a review was conducted to examine evidence for the presence of loneliness during the cancer experience of older adults. Twenty-six qualitative and quantitative studies, plus one book chapter were reviewed for insights into loneliness in aging, chronic illness and cancer. Results yielded inconclusive support for loneliness being a concern for the gero-oncology population, yet questions remain. Despite the validity and reliability of quantitative measures used to quantify loneliness, the measures do not impart a thorough description of the experience. No qualitative study reviewed discussed how elderly manage loneliness in the cancer context. No study reviewed reported the impact of cancer on successful aging. With the aging demographic looming coupled with the expected exponential increase in the incidence of cancer, explorations of these questions are timely.

474 Post-Traumatic Stress Disorder in Female Survivors of Breast Cancer and the Role of Self-Efficacy and Support Groups Stefanovic S1, Court J1, Winefield H2, Byrne S1 1 Psychology, University of South Australia, Adelaide, Australia; 2Psychology, University of Adelaide, Adelaide, Australia Current research suggests that cancer survivors can develop symptoms of post-traumatic stress disorder. The present study was designed to identify factors that may be associated with the

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traumatic symptoms in a sample of (N=125) South Australian female survivors of breast cancer. The study also explored the role of selfefficacy, particularly in relation to the traumatic symptoms. Subjects were asked to complete the Generalised Self-Efficacy Scale, Beck Depression Inventory, Beck Anxiety Inventory, Cancer Behaviour Inventory, PTSD Checklist-Civilian Version (especially adapted for breast cancer survivors), and an information sheet that recorded sociodemographic and treatment type variables. The Generalised Self-Efficacy Scale (GSES-A) was also rewritten in the past tense to assess perception of self-efficacy prior to breast cancer (GSES-B). The hypothesis that strong self-efficacy beliefs will be associated with fewer traumatic symptoms was supported by the findings. It was further hypothesized that high self-efficacy will be associated with fewer traumatic symptoms, irrespective of age, treatment type, cancer stage, or whether there has been less time since treatment completion. This hypothesis was also confirmed by the findings. The last hypothesis explored the relationship between avoidance of support groups and avoidance symptoms related to PTSD. It was hypothesized that avoidance symptoms (related to trauma) will be associated with avoidance of support groups. This hypothesis was not supported by the findings. Higher avoidance symptoms, greater overall experience of trauma, and lower self-efficacy in coping with cancer, was found in women who attended support groups, as compared to those who did not attend support groups.

475 Influence of Changes in the Social Network on Survival Among Patients with Colorectal Cancer Villingshj M, Ross L, Thomsen BL, Johansen C Institute of Cancer Epidemiology, Danish Cancer Society, Copenhagen, Denmark This study examines whether changes in the extent of contact with the social network in a group of colorectal cancer patients influence survival. The study is based on a previous questionnaire survey of 848 patients, who had undergone colorectal cancer surgery between 1985 and 1990. The data was collected in 1991 and follow up regarding the patients’ vital status was retrieved in 2002 from

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the Danish Civil Registration System. Cox regression analysis was used to estimate the survival among patients with an altered contact frequency with their social network after surgery, opposed to patients with an unaltered contact frequency. After having adjusted for known prognostic factors, it is observed that patients, who have lost their partner prior to their operation, have an increased mortality (RR=1.48). Similar decreased survival is observed with patients who have an increased postoperative contact frequency with their children (RR=1.55), as well as patients who have a decreased postoperative contact frequency with their grandchildren (RR=1.54), friends (RR=1.46) or colleagues (RR=1.58). Despite the limited statistical power of this study, losing your partner prior to the operation or having a decreased contact frequency with parts of your social network, appears to have a true prognostic influence on survival.

Stem Cell Transplantation 476 Quality of Life and Work Reinstatement After the Bone Marrow Transplantation Coca C, Arranz P, Diaz L, Barraza S, Lo! pezFando T et al. Haematology and Haemotherapy Service, University Hospital, La Paz, Madrid, Spain PURPOSE: (a) To find out the employment status of adults who survived bone marrow transplantation after 2 years. (b) To estimate the relationship between the employment status and the perception of Quality of Life (QoL). METHOD: A prospective research has been carried out assessing 304 patients 10 days before the transplantation, 232 patients were assessed 100 days after, 158 patients 1 year after and 103 patients after 2 years. The items used were those from a QoL questionnaire (Cuestionario de Calidad de Vida UAB/La Paz) related to the employment status. RESULTS: Before the BMT 35% of the patients were on sick leave, 33% 100 days after, 6% 1 year after and 2% 2 years after continued on sick leave. The percentage of people who are working part-time increases from 2% before transplantation to 12% 1 and 2 years post-transplant. Before the BMT and

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100 days post-transplant, 3% worked full-time; 16% by 1 year and 27% by 2 years. Finally the percentage of retired patients increases from 5% before the marrow bone transplant to 15% 2 years after. Statistically significant differences were found only regarding QoL, 2 years after transplantation. (F(6.103)=3.244 p>0.009). CONCLUSION: A high level of unemployment is observed. It could be related to biological or psychosocial variables. No differences in QoL between unemployment/ employment were found post-transplant.

477 Does Perceived Social Support Predict Survival Following Autologous Peripheral Blood Stem Cell Transplantation (PBSCT)? Frick E1, Motzke C1, Fischer N2, Busch R3, Bumeder I4 1 Psychotherapy & Psychosomatics, Ludwig Maximilians University, Munich, Germany; 2Medical Department, Schwabing Municipal Hospital, Munich, Germany; 3Institute of Medical Statistics and Epidemiology, Technical University, Munich, Germany; 4Medical Clinic, Ludwig Maximilians University, Munich, Germany PURPOSE: In addition to biomedical predictors, previous research discussed the predictive utility of affective functioning, optimism, coping style, quality of life, and other psychosocial variables. The present study addresses the following research question: Does perceived social support prior to PSBCT have an impact on post-transplant survival? SUBJECTS AND METHODS: 93 patients suffering from a Multiple Myeloma (51), nonHodgkin Lymphoma (31), and other malignancies (11), completed the Illness Specific Scales of Social Support (ISSS) before undergoing PBSCT. ISSS is comprised of the subscales ‘‘positive social support’’ and ‘‘problematic social support’’. The median survival time following PBSCT was 46.5 months. 23 patients received treatment by interferon. Forty-eight accepted the proposed individualised psychodynamic short-time psychotherapy. RESULTS: The mean score in the subscale ‘‘positive social support’’ was 3.2 (SD 0.54), in the subscale ‘‘negative social support’’ 0.95 (SD 0.53, no significant changes between

Copyright # 2004 John Wiley & Sons, Ltd.

assessment prior to PBSCT and the following assessments). Those patients perceiving problematic social support, showed a correspondence with poor survival chances following PBSCT (subscale ‘‘problematic social support’’: Exp [B]=3.014; p=0.008, Cox-regression analysis). We controlled the following variables; diagnosis, illness stage prior to PBSCT and 6 months after, as well as interferon treatment and psychotherapy. Conversely, we did not find any association between the subscale ‘‘positive social support’’ and survival after PBSCT. CONCLUSION: Differentiating between positive and problematic interactions prior to PBSCT helps to recognise detrimental forms of social support. Future research should investigate the clinical implications of this fact and help tailor psychotherapeutic intervention.

478 Introducing the Basic Documentation for PsychoOncology (PO-Bado)}A New Expert Rating Scale for the Assessment of the Psychosocial Situation of Cancer Patients Herschbach P1, Brandl T1, Knight L2, Keller M2 1 Institut for Psychosomatic Medicine, Technical University of Munich, Munich, Germany; 2Psychosocial Care Unit, Department of Surgery, University of Heidelberg, Heidelberg, Germany The Basic Documentation for Psycho-Oncology (PO-Bado) is an expert rating scale intended for the evaluation of the subjective physical and psychosocial condition of cancer patients. The PO-Bado contains the following components: the documentation form, a manual, an interview guideline, a software package and a website (http://www.po-bado.med.tu-muenchen.de). The documentation form comprises Items covering the following domains: Somatic problems (4 Items) Psychological problems (8 Items) Additional (for example social) problems (4 Items) Need for professional psychosocial support (1 Item) The items covering somatic and psychological problems are to be rated on a five-point Likert scale.

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The PO-Bado has been developed in three stages. Two initial versions were applied in 70 institutions by over 100 professionals (medical doctors, psychologists, social workers). More than 1000 cancer patients were assessed. The following criteria were used for item selection: clinical relevance, statistical qualities of the items (discriminatory power, measures of central tendency, intercorrelations, validity, inter-rater-reliability). The validity of the PO-Bado was tested in a sample of 500 patients by concurrent administration of two psychometrically evaluated questionnaires, the German version of the Hospital Anxiety and Depression Scale (HADS-D) and the Questionnaire on Stress in Cancer Patients (QSC-R23). Only items showing significant correlations of rr>0.3 with the questionnaire results were included in the final version. The PO-Bado provides the means for standardised assessment and the basis for appropriate interventions in psycho-oncology. Its psychometric quality is established. The project is funded by Deutsche Krebshilfe (German Cancer Aid).

479 Screening for Posttraumatic Stress Disorder in Patients after Stem Cell Transplantation Lautenschl.ager KA1, Berger M1, Stock C1, Ehninger G2, Ko. llner V1 1 Department of Psychosomatics and Psychotherapy, University Hospital Dresden, Dresden, Germany; 2Department for Internal Medicine, University Hospital Dresden, Dresden, Germany OBJECTIVE: Posttraumatic Stress Disorder is an issue in patients after stem cell transplantation (SCT). In spite of research in this field screening and assessment must still be regarded as dissatisfactory. Our study compares two validated instruments to the gold standard. METHODS: 111 (100%) outpatients in a SCT-follow-up program participated by filling in questionnaires (PTSS-10, IES-R, HADS-D, SF-36) and underwent a structured clinical interview (SCID). Patients had to be adult and not less than 1 year post autologous or allogeneic SCT. RESULTS: Interview and questionnaires were accepted exceptionally well by patients. PTSS-10 identified 23.4% patients as high

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at risk for PTSD. 7.2% were diagnosed (regression formular by Maercker et al.) with PTSD by IES-R. All those identified by the IES-R were also found by the PTSS-10. Mean values for PTSS-10 were 29.7 (SD 12.2) and for the IES-R-scales Intrusion 6.93 (SD 6.47), avoidance 9.46 (SD 8.04), hyperarousal 9.32 (SD 7.64). Anxiety and depression (HADS-D) as well as the psychological quality of life (QOL) (SF-36) correlate with the results of PTSS-10 and all IES-R-scales (p=0.000) while physical QOL correlates much weaker and with less significance in particular with hyperarousal. The results of the SCID are in the process of independent rating and will be presented at the conference. Thus enabling a qualitative comparison between a PTSD-screening with PTSS-10 versus IES-R.

480 Treatment-Related Goal Interference Mediates the Relationship Between Symptoms and QOL Peterman AH, Beaumont J, Rosenbloom SK Center on Outcomes, Research and Education, Evanston, Northwestern Healthcare, Evanston, IL USA BACKGROUND/PURPOSE: Although there is often a strong, linear relationship between symptoms/side effects and quality of life (QOL), it is difficult to predict a symptom’s impact on an individual patient. In part, this may due to a lack of focus on personally relevant goals that vary across people and that are differentially affected by illness and treatment. This study examined whether patient-reported goal interference mediates the relationship between symptoms and global QOL. METHOD: Two months after the start of chemotherapy, 92 patients completed two measures of symptoms (FACIT Fatigue Scale, Symptom Impact Inventory), a measure of personal goal interference (Goal Interference Scale), and four measures of global QOL (Satisfaction with Life, FACIT Meaning and Peace subscale, RAND-36 General Health Perception subscale, and a two-item global QOL measure from the FACT-G). RESULTS: Measures of symptoms, goal interference, and QOL were significantly related to each other in 6 of the 8 equations (standardized beta’s from 0.09 to 0.49, p’s from 0.0001 to 0.39). After controlling for goal

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interference scores in each of the eight regression equations (two symptom measures  4 QOL measures), associations between symptoms and QOL were significantly reduced (standardized betas=0.03 to 0.31, all p’s for change50.02). CONCLUSION: Across multiple measures of symptoms and QOL, approximately half of the symptom-QOL relationship is accounted for by treatment-related goal interference. This finding may provide guidance for interventions directed at decreasing the impact of symptoms on QOL, even when it is not possible to significantly relieve the symptoms themselves.

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HADS, MFI and the Questionnaire of Subjectively Experienced Attention Deficits (FEDA). RESULTS: Shortly before closing the study 61 patients at T0 and 28 patients at T1 could be included and assessed with psychological questionnaires. 67% of diagnoses were leukaemia or pre-leukaemia, 13% multiple myeloma and 11% lymphoma. Of these, 39 patients before admission and 20 patients 3 months after discharge could be tested with the neuropsychological test battery. Data will be shown for prevalences of global and domain-specific cognitive impairments before and after treatment. Relations of neuropsychological test results with psychological variables like depression, anxiety, fatigue and other treatment/ disease-specific aspects of QoL will be discussed.

Cognitive Functions and Health-Related Quality of Life in the Course of High-Dose Therapy and Allogeneic Stem-Cell Transplantation: First Results of a Prospective Study in Patients with Hematological Malignancies Schulz-Kindermann F1, Schleimer B2, Mehnert A2, Scherwath A2, Koch U2 et al. 1 Center for Bone Marrow Transplantation, University Clinic Hamburg-Eppendorf, Hamburg, Germany; 2Institute of Medical Psychology, University Clinic Hamburg-Eppendorf, Hamburg, Germany

Adjustment During Haematological Transplantation: Rethinking the Role of Psychological Control Surgenor LJ1,2, Horn J1, Spearing RL2 1 Psychological Medicine, Christchurch School of Medicine and Health Sciences, University of Otago, Christchurch, New Zealand; 2Clinical Haematology, Canterbury District Health Board, Christchurch, New Zealand

PURPOSE: In the acute and late course of highdose therapy followed by stem cell transplantation neuropsychological complications mainly concerning attention, memory or executive functions are observed in up to 30%. These problems have serious impact on quality of life and the process of reintegration of patients into normal life. To date most studies were cross-sectional, including inhomogenous samples of cancer patients. The aim of this study was to evaluate the specific effects of treatment modalities, sociodemographic factors, and psychosocial variables on cognitive functions in a prospective design. METHOD: We included a homogenous group of patients with haematological malignancies treated with high-dose therapy and allogeneic stem cell transplantation. Patients were assessed before admission (T0) and 3 months after transplant (T1) with a standardized neuropsychological test battery (validated computerized and paper pencil tests) focussing attention, memory and executive functions and psychological questionnaires including EORTC QLQ-C30,

BACKGROUND: Control issues are thought to be important in predicting psychological adjustment to cancer, compliance with cancer treatment, and subsequent quality of life. Although ‘locus of control’ measures have dominated this particular research, recent conceptual reviews point to the multifaceted nature of control, and accordingly, the importance of employing multifaceted measures. AIM AND METHODOLOGY: Using one such measure, this prospective study describes the control profile of a clinical population (n=60–80) as they undergo and recover from transplantation for haematological malignancies. Specifically, the study investigates the relationship between psychological control, quality of life, and psychological distress during transplant planning, and then again 1 week after transplant, at hospital discharge, and several months later. RESULTS: While participant recruitment continues for another year, early results indicate that pre-transplant depressive symptoms are most likely to be associated with impaired control beliefs, a sense of

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loss of control, and impaired control in the specific domains of body, mind, self, and impulses. The time of greatest risk of clinically significant mood or anxiety symptoms is at hospital discharge. Issues such as ‘locus of control’, desire for control, or the methods by which people gain control, appear unrelated to psychological distress. DISCUSSION: These early trends have implications for the form, content, and timing of psychological consultations with transplant patients. In particular, the traditional advice currently given to patients about the optimal control style to ward of maladjustment may need serious reconsideration.

483 HRQL and Patient Expectations in a Mixed Diagnostic Autologous Stem Cell Transplant Sample Victorson DV1, Peterman AH1, Kaminer LS2 1 Center on Outcomes, Research and Education, Evanston Northwestern Healthcare, Evanston, IL, USA; 2Division of Hematology-Oncology, Evanston Northwestern Healthcare, Evanston, IL, USA INTRODUCTION: Patients undergoing autologous stem cell transplantation face several healthrelated quality of life (HRQL) challenges during and following hospitalization. Difficulties often include fatigue, insomnia, nausea, depression, anxiety and community/work reintegration. There also appears to be a mismatch between the amount and type of information desired by patients and the information provided by transplant team members. This study examined patient HRQL over time and sought to better understand the patient’s experience of transplant preparation and expectations. METHODS: 28 stem cell transplant patients (46% male, 54% female) completed widely used quality of life instruments: FACTBMT and (FACT-Fatigue). Measures were administered at baseline, 1 week, 1 month, 6 months and 1-year post transplantation. Patients also answered 4 open-ended questions dealing with preparation and expectations for stem cell transplantation. HRQL endpoints were selected prior to analysis and included physical, functional, emotional, social and bone marrow transplant well being, as well as fatigue. A repeated measures

Copyright # 2004 John Wiley & Sons, Ltd.

design examined differences in HRQL endpoints. Content analysis methodology was used to understand the 4 open-ended questions. RESULTS: It appeared that between 1 week and 1 month posttransplant HRQL was most affected across the majority of endpoints. Content analysis identified several important themes dealing with expectations, especially the importance of mental, physical and spiritual preparation. CONCLUSION: Findings from this patient sample suggest that 1 week to 1 month post transplant is a critical period for HRQL. Further, patients place considerable importance on mental, physical and spiritual preparation. Implications of findings, limitations and future directions are discussed.

Work 484 Working Life and Cancer Carlsen K, Johansen C Department of Psychosocial Cancer Research, The Danish Cancer society, Copenhagen, Denmark PURPOSE: To evaluate the consequences of cancer with regard to the affiliation to the labour market with special focus on the proportion of cancer patients receiving economic support from the state during and after treatment for cancer compared to a healthy part of the Danish population. We will see if there exist any socioeconomic variables that can predict the risk of expelling from the labour market. METHODS: We conducted a population-based case-cohort study including 65,595 persons diagnosed with cancer in the period 1980–2000 and who had survived for at least 1 year. This group was compared to a healthy cohort in the ratio one cancer patient per five healthy persons. The cohort was frequency matched on sex, month of birth and year of birth. Multivariate statistical analysis was made with Cox-regression and logistic-regression. RESULTS: We will present preliminary results at this congress. CONCLUSIONS: By analysing the size of economic support and expelling from the labour market among cancer patients compared to a healthy cohort it will be possible in the future to improve the return of the cancer patient to the labour market after diagnosis and treatment. That

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can reduce the psychosocial and economic consequences of cancer for the individual and the family, because cancer patients in risk for unemployment after treatment for their cancer can be identified before or during treatment.

Once initial treatments are complete, survivors of non-metatatic breast cancer are not absent more than other female workers in Quebec.

486 485 How does Breast Cancer Affect Absence from Work? Results from a Population-Based, Comparative Study Drolet M1, Maunsell E1, Mondor M2, Brisson J1, Brisson C1 et al. 1 Department of Social and Preventive Medicine, Universite! Laval Que!bec, Canada; 2Population Health Research Unit, Universite! Laval, Que!bec, Canada PURPOSE: Breast cancer is said to adversely affect work outcomes. However, work absence rather than breast cancer per se might be the source of problems. To better understand this phenomenon, we first assessed work absences during the 3 years after diagnosis among breast cancer survivors and women without cancer. METHODS: A population-based retrospective cohort study was conducted in Quebec based on a consecutive series of women aged 560 when first treated for non-metastatic breast cancer (identified through Quebec Tumour Registry) who had paid employment at diagnosis, and on random samples of similarly aged Quebec women without cancer (from provincial health care files) also working at the time of the survivors’ diagnoses (controls). Telephone interviews were conducted 3 years after diagnosis (similar calendar period for controls) with 567 survivors (73% of those eligible) and 890 controls (51%). RESULTS: Overall, more survivors (86%) than controls (32%) had at least 1 absence of 4 or more weeks’ duration (p=0.0001), with survivors reporting 6.8 months absent and controls, 3.4 months (p=0.0001). Excess time absent among survivors occurred mainly in the first year after diagnosis: year I, 5.6 and 1.7 months; year II, 2.7 and 1.9 months; year III, 2.1 and 1.9 months, for survivors and controls, respectively. Otherwise, number and duration of absences for any other reason than cancer were comparable in survivors and controls. CONCLUSIONS: These results are reassuring for employers.

Copyright # 2004 John Wiley & Sons, Ltd.

Reasons for Financial Difficulties Among Women Treated for Breast Cancer Three Years after Randomisation to Treatment Michelson H1, Bergh J2, Brandberg Y1 1 Oncology/Pathology, Karolinska Institutet, Solna, Sweden; 2Oncology, Karolinska University Hospital, Solna, Sweden PURPOSE: To investigate reasons for financial difficulties reported among women with breast cancer 3 years after initiation of high-dose treatment. METHODS: A total of 146 breast cancer patients in Sweden participating in Nordic multicentre clinical trial (NBG 9401) returned mailed questionnaire, EORTC QLQ C30(+3), 3 years after randomisation to high-dose treatment and of these women, 37 (25%) still reported financial difficulties. An information letter was sent to these 37 women asking for permission to participate in a telephone interview. Interviews contained questions about what women themselves conceived to be reasons for the financial difficulties. All women were asked about changes in income and costs regarding medicine and health care. They were asked about changes concerning employment/ working conditions. Inquiries about health condition were included in every interview. The women were invited to express their opinion as to the degree in which the financial difficulties were associated with their quality of life. RESULTS: A total of 20 women agreed to be interviewed, nine women declined, two women did not recall and six women did not respond. The main reason for financial difficulties was decreased income. An early retirement because of complete or partial inability to work, changes to part time employment, less paid positions and easier tasks were reported by almost all the women. Worry about future increased financial difficulties because the allowance for retirement or sick leave will remain on lower level in comparison with wages on labor market. Association between quality of life and financial difficulties was strongly perceived by. . . [truncated]

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ABSTRACTS OF THE 7TH WORLD CONGRESS OF PSYCHO-ONCOLOGY

S223

WORK

487 The Impact of Education and Occupation on Employment Status among Cancer Survivors ( brandt T1, Martikainen R1, Virtanen S1, Taskila-A Pukkala E2, Hietanen P3 et al. 1 Department of Epidemiology and Biostatistics, Finnish Institute of Occupational Health, Helsinki, Finland; 2Institute for Statistical and Epidemiology Cancer Research, Finnish Cancer Registry, Helsinki, Finland; 3Department of Oncology, University Hospital of Helsinki, Helsinki, Finland We explored the effect of cancer diagnosis on the employment status of cancer survivors according to their cancer type, education, occupation, age, gender, mother tongue (Swedish or Finnish), calendar time, and hospital district. All new cancer

Copyright # 2004 John Wiley & Sons, Ltd.

cases diagnosed in 1987–1988 and 1992–1993 and aged 15–59 at the time of the diagnosis were identified from the Finnish Cancer Registry. In the final data there were 12,539 people with cancer, and the same number of gender- and age-matched referents. On average, cancer survivors took part in work life almost as much as the general population: the cancer patients had only a 10% lower probability of being employed (RR) than their referents. We found, however, that education and occupation modified the effect of cancer on the employment status: the difference between the cancer survivors and their referents in the probability of being employed was greater in the lower than in the higher educational groups. The modifying effect of education on the probability of employment was strongest among people with lung cancer and nervous system cancer.

Psycho-Oncology 13: S1–S233 (2004)

S225

AUTHOR INDEX

Listed by Author and Abstract The following pages display the authors of the abstracts selected for the 7th World Congress of Psycho-Oncology together with their abstract numbers

A Aaronson NK Aasgaard T Abbruzzese JL Abe PK Abell L Abi!an L Abrams JR Absolom K Achille M Adami S Adamsen L Adamus AT Adenis A Adolfsson J Agatsuma YA Aguilar Can* abate P Ahles TA Akechi T

Akizuki N Albani C Alcasi C Almonacid Guinot V Altman JJ Alvarado MC Andersen C Andersen JS Andrews L Andrieu JM Andritsch E Antoni G Aralova MP Aranda S Aro AR Aronson J Aronson M Arranz P Arving C Asakura TA

162 288 357 380 374 56, 209, 407 397 16 77 269 178, 186 218 109 466 274 291, 292 45 60, 61, 96, 97, 119, 145, 148, 153, 157, 187, 363 97, 98, 145, 187 224 17, 23 291, 292 429 402 178 439, 440 421 428, 429 108, 336 33 18, 19, 20, 338, 441 364, 365 68 220 410 72, 476 289 319

Ashing-Giwa KT Ashkenazi A Ashley S Aslanyan KS Atkins L Au G Ausems M Aviv C Aviv CS Awad G Awad N

337 442 165 18, 19, 20, 338, 441 42 205 76 213 206 121 344

B Bacalhau MR Bagnulo BA Baider L Baildam A Baile W Baile WF Bailer H Baille-Bareille V Baker F Baker E Balck F Baldus C Ball D !M Balogh E Banks PJ Barbero Biedma E Barnett A Barocas J Barraza S Barrera ME Barroetavena MC Barrowclough C Bartsch HH Basumallik I Baudin E Bauerfeind I

Copyright # 2004 John Wiley & Sons, Ltd.

264, 265, 266 62, 63 336, 472 258 64 52, 218, 357 65, 115, 179, 224 240 339 215 161 403, 415, 425 80 133 295 241, 394 270 371 476 21 207 416 51 443, 444 367 86

Baumann M Beaumont J Beauvallet C Beaver K Beck JD Beckmann K Beelen RHJ Beemer F Bellini G Bellver P!erez A Benjamin RVN Bensing J Berg Olesen L Berg P Bergelt C Bergenmar M Berger D Berger M Bergh J Berglund G Bernay T Berth H Bertilsson K Bertozzi A Betta PG Beveridge HA Bezjak A Biank NM Biechele I Biffi R Biguet G Bittante M Bjerrum Thisted LBT Bjorner JB Bleiker EMA Bloch S Bloching M Bloom JR Bloomfield D Bloor LE Boege P Boesen EH

244 480 367 53 29 374 253, 254, 255 76 267, 290 99, 291, 292 293 76 433 305 3, 381, 391 238 391 479 238, 289, 486 307 294 161 151 267 284 43 346 464 234 347 392 200 398 184 162, 166 128, 418 396 295 44, 49 469 81 9, 296, 323, 324

Psycho-Oncology 13: S1–S233 (2004)

S226 Bo. hler U Bolund C Bonada A Boniver SJ Bonucci A Boomsma MF Booth L Borasio GD Borland R Bosserman LD Bottero G Brain AN Brain KE Brandberg Y Brandl T Brando MC Brandrup S Braun M Brazzi BS Brechtel A Br!edart A Breed WPM Brezzi MA Briggs K Brisson C Brisson J Broberger Wiberg E Broccoli TL Brocker-Vriends AHJT Brodersen J Broom D Broome B Brougham R Brown E Brown J Brown K Brugi"eres L Brusa M Bruun Piester C Bulotiene G Bulsara C Bultz B Bumeder IB Burhansstipanov L Burns CM Busch R Bussoletti F Butler K Butow P Buttst.adt M Byrne S

AUTHOR INDEX

431 87, 392 373 71, 73 285 253, 254, 255 340 234 80 88 284 258 100 238, 289, 307, 436, 486 478 256 81 404 63 146 240, 347 74, 362 284 297 485 485 151 136 162 439, 440 54 126 437 248 344 168 33 284 382 341 342 66 330, 477 208, 215, 343 54 477 285 164, 410 91, 92, 448 431 474

C Cabezas I Caldwell, MSWTC Cameron C Campbell DM Campos FC Capellaro K Caplette-Gingras A Capovilla ED Carlsen K Carlson L Carmack Taylor C Carnevali CN Carr A Carter SE Carulla J Casas F Cashy J Caspari C Catt SL Cayrou S Cefalo G Cella D Cesarco R Chakrabarti B Chan P Chang AM Chang J Chantler, MDMC Chappuis P Chatterjee Chaturvedi SK Cheng CC Cheng FK Chiou B Christensen S Chujo MC Ciaramella A Cinti P Clark M Clarke MJ Clarke S Clavarino AM Clerici CA Clerico M Clipp E Clisant S Coca C Cognetti F

Copyright # 2004 John Wiley & Sons, Ltd.

Cohen L 373 Cohn R Coles-Gale RE Collier S Compas BE Condoleo MF Conradt S Consoli SM Coombes L Copel L Corlette S Coronel S Cort!es-Funes F

101 211 177 273 320 445 200 102, 484 103, 298, 299 408 62 249, 317 88 194 126, 311, 312 173 86 55 301 225 369, 370, 379 75, 110 443, 444 77 268 354

Cortizo F Couper JW Court J Courtney UM Couture F Cox A Craft PS Craft T Craighead P Cremer F Crotti N Cumming CE

41, 52, 135, 357, 408 39, 40, 406 344 104, 246 144 285, 345 58 428, 429 85 240 406 173 56, 209, 407 233 128 474 89, 226, 465 354 55, 57 54 25 450 169 79 329, 455

D

101 175 443, 444 227, 239 222 268 222 10, 160, 180, 361, 462, 471 300 269 149 411 143 164, 261 270 17, 23, 225, 405 149 181 109 476 366

Dahl AA Dahl AAD Dahlstrm KD Dalton SO Damore-Petingola S Dauchy S Davidson J Davis K de Boer M De Fulviis A de Haes JCJM

105, 414 242 296 4, 5, 35, 106 248 252, 367 257 379 251 345 155, 331, 332

de Walden-Galuszko KWG 196 Debess JE 107 Degner LF 151 Delvaux N 58, 71, 73 Demark-Wahnefried W 181, 191 Desclaux B 301 Deutsch G 49 Devine D 52, 135, 408 Devins GM 346

Psycho-Oncology 13: S1–S233 (2004)

S227

AUTHOR INDEX

Di Dio L Di palma M Di Pretoro M Diaz L Dickman PW Didier F Dietmaier G Dignan MB Dikmen S Dittoe S Dolbeault S Doll R Dominguez S Doninger GL Donner A D’Onofrio CN Drew S Drolet M Du H Duboust A Duivenvoorden HJ Dumitru Popovici DP Duran G Duric V

77 252 110 476 466 347, 108, 208, 397 306 240, 310 109 193 278 295 22 485 50 428 155, 332

Fabi A Falcicchio C Fallowfield LJ 451 336 343 301

331,

287 305 83

E Earle EA Ebrahimi M Eccles D Edginton TL Eeles R Ehninger G Eiser C Ekeberg Ø Elad P Elliott DR Ellis W Endo KE Enes C Engholm G Engst-Hastreiter U Eremenco S Eriksson K Erroi V Esplen MJ Esposito CS Estap!e J Estap!e T Evans DGR Evron E Ewertz M Ewing C

G

F

348 131 165 44, 456 165 479 16, 348 67, 372 41 163, 409 313 319 320 27, 28 305 50 302 267 164, 410 279 1, 59 1, 59 165 172 107 206, 213

Farru! s B Fasser N Fateh A Fayers PM Feng AC Ferguson RJ Fernandez Crespo AI Ferrari A Ferrazzi S Ferretti FG Ferro NF Feter L Fichtinger A Fidler A Fielding R Figer A Figueredo N Fisch MJ Fischer C Fischer MF Fischer N Fisher JA Fitch M Fleer J Fleming CF Floderus B Foreman T Forjaz MJ Fortier A Forzan F Foss(a SD Fossati Bellani F Foster C Fournier C Fox K France E Frederiksen KF Frick E Friedlander M Friedman T Frierson G Froer P Fujii HF Fujimori M Fukudo S Fukushima CF

Copyright # 2004 John Wiley & Sons, Ltd.

366 137, 345 42, 55, 57, 70, 353, 461 311, 312 79 131 184 222 45

Gagliese L Gallinger S Gambi A Gamito E Gandhi AR Gandini C Garland S Garrido-Landivar E Garssen B

262 17, 23, 225, 405 354 62 110 422 286 306 111, 125 442 373 218 146 378 477 411 219 383, 434, 454 21 6 412 112 52, 135 95 105, 414

Garufi C Gasparini GI Gatti M Gauthier-Frohlick D

23, 225 165, 167 109 315 100 296 234, 330, 477 83 189 138 234 280 60, 61, 153 8 280

Goodenough B

Gelli P Gex-Fabry M Geyer S Ghioni M Gic I Giese-Davis J Giesler JM Gil F Gil MJ Gioia A Girling M Giunta S Glimelius B Golant M Goldbeck L Goldhirsch A Golubovic NG Gomes A Go! ngora B

Gotowiec AP Gould J Graaf WTA, van der Graci G Grana G Granat A Grassi L Grau JJ Gray J

139, 404 410 267 343 227 284 298 112 155, 253, 254, 255, 331, 332, 378 137 62, 63 114, 325 202, 248, 249 17, 23 175, 210 347 311, 312 90, 313 183 64, 113, 194, 237, 241 264, 265, 266 269 413 285 281, 289 24, 90, 313 349 451 152, 376 264, 265 56, 209, 407 25, 31, 39, 40, 406, 412 346 211, 219 419, 435 127, 457, 458 315 302 64, 114, 117, 325, 237 59 100

Psycho-Oncology 13: S1–S233 (2004)

S228 Greeff LE Griffiths A Grimer R Grnvold M Grnbæk M Grootenhuis MA Grosfeld FJM Grov EK Grulke N Gubba L Gudbergsson SBG Gugleta DG Guix-Melcior B Guns E Gustafson D

AUTHOR INDEX

303 16 348 184 3, 182 26, 37, 38 166 414 65, 115, 179, 224 433 242 152, 376 126, 356 257 219

H Haagen M

322, 403, 415, 425 Haaland CF 105 Hack T 66 Hagen-Aukamp C 391 Hahn DEE 166 Hahn EA 369 Haji-Mahmoodi M 131 Halevy CH 330 Halim MS 350 Hallowell N 167 Hamama Raz Y 384 Hammarlund L 436 Hammelef KJ 304, 197 Hann DA 231 Hansen HPH 385 Hansen PE 6, 182 Hariton J 208, 343 Harjo L 208 Harrison-Fortier A 408 Hartmann O 33 Haudrup Christensen P 182 Hauken MAa 12 Hauksdottir A 275 Heiman J 397 Helenius H 429 Helgason AR 466 Hellbom M 307 Hem E 67 Henrickson CG 304, 197 Heradstveit S 12 Hermann J 374 Hern!andez-Navarro F 72 Herschbach P 248, 305, 478 Hervouet S 445 Herzberg T 50 Herzer M 306

Heussner PH Hietanen P Hjortebjerg U Ho E Hobbs K Hodges LJ Hoekstra HJ Hoekstra-Weebers JEHM Hoesli P Hoeybye MT Holland J Hollenstein MF Hollenstein Prat MF Holli K Holmstrup U Homewood J Hopwood P Horn J Horne D Hornemann B Hosokawa T House AOH Howell A Hranicky JS Hsu SH Huber BH Huber OW Hughes MK Huizinga GA Humphris GM Hung FC Hurley K

243 68, 487 386 111, 125 92 118, 416 383, 417, 434, 435, 454 154, 383, 417, 434, 435, 454 175 467, 468 116, 117, 368 78, 113, 241 394 68 81 174 258 482 85 396 8 46 42, 258 351 222 243 69 446, 447 417, 435 118, 416 218 168

I Idler E Inagaki M Incerti IV Inoue SI Ioana Todor IT Irahara MI Iredale R Isabel Leal IL Iusin S Ivone Patr*ao IP Iwagami K

184 119 63 424 287 280 100 120 75 120 123

J Jacobs LA Jacobsen B

Copyright # 2004 John Wiley & Sons, Ltd.

352 259

Jacobsen E Jacobsen R Ja!en J Jean Turgeon JT Jeffries SA Jenkins V Jensen AB

Joensuu H Johansen C

Johansson A Johansson B Johansson KAH Johnsen SP Johnson L Johnston C Johnston K Jones J Jones R Jrgensen T Josephsson S Joske D Jost R Juraskova I

102 7 326 430 450 42, 43, 44, 49, 55, 57, 70, 456 10, 102, 150, 160, 180, 361, 462, 463, 471 68 3, 4, 5, 6, 9, 7, 27, 28, 35, 102, 106, 170, 182, 308, 323, 324, 389, 399, 467, 468, 475, 484 463 302, 307 459 170 57, 353 340 39, 40 139, 283 278 9 13 342 169 448

K Kaadan AK Kaechele H Kahlert S Kai I Kaminer LS Kaneko K Karbe SK Karlsen RV Katib Jamal Katz E Kaufman E Kauschke M Kazuma K Kejs AMT Keller M

260 65, 115, 179 86 82 483 82 395 308, 323 117 24 168 124 171 27, 28 146, 169, 478

Psycho-Oncology 13: S1–S233 (2004)

S229

AUTHOR INDEX

Keresteci MA Kettler P Khalsa D Khan PK Khatib J Kikuchi J Kinney AY Kirk J Kirsten LT Kissane DW Klee M Knight L Kobayakawa M Koch SV Koch U Koehm J Ko. llner V Komiyama Y Korn V Koyama A Krasnik M Krau O Krebs LU Kreuz FR Kristensen T Krueger S Kubista E Kuenzler A Kuhn KG Kumar T M Kuperberg A Kusaka KK Kuznecova G Kuznecovs S Kwong S

354 228 334 212, 271 121, 122 93 469 174 91, 92 128, 147, 418 272 146, 478 157 27, 28 3, 381, 391, 481 86 479 93 453 123 102 124 343 161 387, 388 161 453 419 389, 468 46, 221 24 274 355, 449 355, 449 207

L la Cour K Lacorte-P!ı TM Lai JS Lam WWT Lange K Langer Th Langridge C Larbig W Larsen LR Larsen S Lartigau E Lassesen B Last BF Laursen TM Lautenschl.ager KA

13 78, 356 370 111, 125 54 29 55, 57 65 308 390 263 10, 462, 471 26, 37, 38 4 244, 479

Lauzon JJ Leaver VW Lebel S Leenhouts G Lehbrink M Lehmann C Leis A Lenzi R Leo! n C Leon ME Leo! n-Pizarro C Lethborg C Levacher C Levine E Levine EG Lewis S Libert Y Lidbrink E Lieberman M Liess A Lindgren A Links M Loblaw DA Locker GY Loehr G Lo. fvenberg E Loge JH Lomonaco E Lo! pez Tendero P Lo! pez-Fando T Love A Low RDG Lowry R Lozano Borbalas A Lu B Luborsky M Lucchini D Luce J Lucie Vezina LV Luker KA Luksch R Lulofs R Lundgren H Luo J Luxford K Luzzatto P Lynch HT

193 309 77 251 10, 361, 462 381, 391 257, 310 357 78, 311, 312 347 126 229 428, 429 136 206, 213, 358 46 58, 71, 73 238 90 313 436 84 346 173 127 302 67 149 99 72, 476 128, 147 43 118 394 205 13 79 295 430 53 225 166 392 359, 360 177 11 173

M Macfarlane G Mackenzie MJ Macvean M

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118 299 128

Magwood B Mah K Majkowicz MM Makabe Reiko Manicom CL Mann BL Manne SL Mansel RE Mantani T Mantani TM Marathakot G Marchal S Mark KMK Marosi Ch Martikainen R Martin C Martin D Martiniuk ALC Martins C Martinschek A Maruno N Mase YM Massimino M Massimo L Mat!e J Mathews K Matsuoka Y Matthews G Maunsell E Mayer DK Mazitschek U Mc Kiernan A McClunie-Trust PA McKenzie M McKinney T McLaughlin L Meadows A Mehlsen M Mehnert A Meijer S Meiser B Meland GT Mellemkjar L Meller I Mendon-ca R Menko FH Merckaert I Michelson H Midtgaard J Mikami I Mikami IM Mikkelsen EM Mikulincer M Miljkovic SM

66 346 196 93 470 314, 393 315 353 129, 426 424 221 58, 71, 73 185 134 487 469 1 316 237 460 198 375 405 30, 438 113, 241 31 119, 157 352 310, 485 34, 36 169 317 420 418 118 214 352 361, 463 47, 130, 481 253, 254, 255 83, 84, 174, 421 12 5, 35 41 320 162 58, 71, 73 486 178, 186 187 300 170 404 152, 376

Psycho-Oncology 13: S1–S233 (2004)

S230 Minacapelli P Mireskandari S Missy A Mitchell AJ Mitchell T Mitchell W Miyaoka H Moadel AB Molina Saera J Mollen E Moller H Mller S Moln!ar M Mondal NR Mondor M Monreal E Montazeri A Moore M Moraes VDD Moreno Mil!an B Morey M Morita MM Morris R Mortensen PB Mortimer JM Moscoso MS Moskowitz C Motzke C Moum T Moura MJ Moynihan C Much JK Mulders MCMA Mulrooney TJ Mumm A Muniz PS Munoz M Murakami Y Murphy A Muszbek K Mykletun A

AUTHOR INDEX

149 421 263 188, 189 219, 215 261 148, 335 230 99 304, 422 27 160, 180 133 443, 444 485 112 131 278 320 262 181, 191 319 49 4, 5, 106 101 132, 231 418 477 414 32, 423 167 136 74, 362 48 51 273 299 171 175 133, 245 105

N Naaman SN Nadalin M Nagai YN Nakagawa K Nakano T Nakaya N Narayanan R Nardi AE Narv!aez A Nash J Nelson JJ

318 205 274 34, 36 96, 97 8 2394, 232 273 56, 209, 407 138 216

Niedermayer R Nielsen LF Nishida S Nistico’ C Nomizu T Nosarini C Nouws B Novellas A Nyberg U Nyl!en U

134 9 123 366 93 200 74 241 275 238

O O Hagan C Oakley B Oba A Odero S O’Dwyer AM Oeken J Ohkawa R Okamura H Okamura HO Okamura M Okuhara HO Okuyama T Olsen JH O’Neill I Onelo. v E Oppenheim D Ortner M Ostroff JS Otero-Sabogal R Owen J Ozono S

14 374 153 17 104, 246 396 82 129, 171, 426 300 97, 145, 153, 363 319 96 5 418 275 33 134 315 217 24 129, 424, 426

P Pal P Palat G Palazzo S Palmer S Palomar Abad L Papa M Pappas JD Parker P Parsons SK Pascual Fernandez C Pasick RJ Patrick-Miller LJ Paulsen K Peccatori F Pedersen AF Peleg S

Copyright # 2004 John Wiley & Sons, Ltd.

443, 444 276 199 352 99 172 318 52, 135, 357, 408 34, 36 262 217 136 459, 463 451 471 442

Peng I Pera Jambrina MA Peri JM Perina EM Perrone M Perry S Peterman AH Petersen MAa Peterson CM Petersson LM Petit I Petit JY Pettaway C Piattello A Picshniak L Pieper C Pierre Allard PA Pierre Gagnon PG Pieterse A Pietrangeli A Pigott C Piha J Pikler VI Pinto B Piriz I Plattig B Pocard M Poli P Pollard A Poppelreuter M Pott M Pramod S Prescott E Price MH Pritchard K Pryor A Pugliese P Puig ME Pukkala E Purpura-Kilroy L

211 394 326 277, 320 137, 366 172, 472 173, 369, 480, 483 184 297 307 75 451 135 199 442 181, 191 430 430 76 345 364, 365 427 204 138 110 29 252 269 364, 365 51 322, 403, 415, 425 2, 94, 232 3 461 66 205 137, 285, 345, 366 75 487 379

Q Quartana P Quist M

306 178

R Rabin C Ramos L Rankin NM Rattler T Ravnsbæk J

138 75 177 208 160, 180

Psycho-Oncology 13: S1–S233 (2004)

S231

AUTHOR INDEX

Rea A Reavley N Reheiser EC Reich M Reiner AC Reis MF Riba MB Riedner C Rinco! n C Rivard S Robertson R Robinson JA Robinson JW Rodary C Rodin G Rodriguez D Roerth M Rogge AR Rogge HR Roh!anszky M Romer G Rosberger Z Rose SR Rosenbloom S Ross L Rossi E Rossi R Rota Stabelli M Rothenmund H Rothrock NE Rovirosa A Rozniatowski O Rubin* os C Runesdotter S Ruszniewski P Rydall A

199 233 132, 231 109, 263 473 264, 266 197, 304 234 72 202, 248 448 411 450 367 139, 278, 282, 283, 404 373 178, 186 247, 321 247, 395 133 322, 403, 415, 425, 433, 437 77 368 369, 370, 379, 480 35, 296, 323, 324, 475 114, 325 95 200 410 371 311, 312 263 56, 209, 407 151 367 139, 278, 283

S Saanisto T Sabato S Sadeh-Tassa D Saeki T Saha R Saiki-Craighill S Sajadian A

427 114, 325 140 129, 300, 424, 426 322, 403, 415, 425 34, 36 131

Sakano Y Salamero M Salhi R Sali A Saltel P Salvetti CS Samonigg H S!anchez N Sandler RS Sandvik LS Santos FRM Santosh SK Sari AD Sato Mie Sattel H Savard J Savignoni A Scaffidi E Schapiro IR Scherwath A Schitz M Schleimer B Schmelz HU Schmidinger M Schmiegelow K Schmitt F Schofield PE Schou Bredal ISB Schreck M Schuett G Schulz-Kindermann F Schwartz M Schwarz R Segura Huerta A Seigneur E Selby P Selim A Sellschopp AS Sepulveda C Serge Dumont SD Serina CS Serpentini S Serrano G Shah C Shamsudeen M Sharma MP Sharpe L Shelov D Shergill N Sherman K Sherman LK Sherman ML Shilling V Shima Y

Copyright # 2004 John Wiley & Sons, Ltd.

60, 61 326 121 233 301 235 108, 336 78, 326 469 372 141 236 350 93 169 445 240 79, 451 9 47, 481 182 47, 481 460 134 28 427 80 372 68 50 47, 322, 481 168 124, 176, 396, 431 99 428, 429 340 257 243 117, 142 430 327 200 394 230 276 201 448 230 46 421 143, 218, 334 144 44, 49 96

Shimizu K Sidenvall B Sideris L Siewert JRS Sijmons RH Simonton OC Sinding C Singer S Sirgo A Sivashinskiy M Sjo. den PO Sleijfer DT Slesazeck H Sloane R Sloper P Smith J Smith K Smith T Smith WT Snyder DC Solomon Z Sommerfeldt S Sparano J Sparks P Sparwasser C Spearing RL Speca M Spiegel D Spiegler BJ Spreafico F Srinivasaiah S St. James-Roberts I Stadler J Stam H Stefanovic S Steggles S Stein K Stein M Steineck G Stelter R Stemmer S Stephen J Stewart SL Stock C Stockler M Straker N Strassnick K Straton J Street AF Stuart-Harris R Styles I Sugano K

97, 145 281 252 243 162 351 219, 220 124, 176, 396, 431 78, 194, 373 190 281, 289 383, 434, 454 124 181, 191 261 80 91 339 54 191 384 146 230 286 460 482 298 313 21 405 236 437 140 26, 37, 38 474 202, 248, 249, 317, 328 339 163 275, 466 186 172 257 217, 295 479 83 432 374 163 147 84 342 171

Psycho-Oncology 13: S1–S233 (2004)

S232 Sugawara Y Sumiyoshi AS Sun Y Sunde L Sundermeier A Suneson JK Surgenor LJ Sussman J Suzuki S Svarre HM Swindell R Syrjala KL Szo. llosi M

AUTHOR INDEX

96 335 360 170 244 39, 40 482 250 148 81 258 397 245

Trask P Traun-Vogt G Travado L Tripathi G Tseytlin GY Tsubono Y Tsuji I Tsuji KT Tucker K Tucker KM Tuinman MA Turner LJ

T Tajima TT Takahashi M Takashima NT Tan MBM Tang LT Tang SK Taniguchi K ( brandt T Taskila-A Taub A Tay K Taylor Brown J Teller AM Tempia Valenta P

274 82 300 166 192 452 148, 363 487 172 31 310 195 95, 149, 279 Terasaki AT 375 Terenziani M 405 Terp Hybye M 399 Terrin N 34, 36 Terzoli E 137 Thal!en-Lindstro. m A 302 Thastum M 433 Thewes B 83, 84 Thomas A 397 Thomassen LH 35, 106 Thomsen BL 323, 324, 475, 296 Thomsen DK 150 Thomsen TT 467, 468 Thorsen H 439, 440 Tilney C 437 Timm HU 398 Tishelman C 151 Tjrnhj-Thomsen T 399 Tochihara K 123 Todoroki KT 335 Tofte J 400, 401 Tolosa I 85 Tomamichel M 113 Tomita KT 274 Tosic Golubovic STG 152, 376

Turner MJ Turone S Tveteraas A Tyroller MT

138 453 64, 113, 237 205 18, 19, 20, 441 8 8 375 174 421 383, 434, 454 203, 329, 455 177 199 186 330

U Uchitomi Y

Ulla S Ussher J Ussher JM

60, 61, 119, 145, 148, 153, 157, 187, 363 72 91 92

V Valdimarsdottir H Valdimarsdottir U Van Aalst E van Andel G Van der Schans CP Van Dulmen S Van Weert E Varga K Vaughn DJ Velikova G Venkateswaran C Ventura C Venu M Veseliunas J Viala AL Victorson D Vidal A Vidhubala E Villingshøj M Vingerhoets A Virtanen S Visser A

Copyright # 2004 John Wiley & Sons, Ltd.

168 275 74 378 154 76 154 133 352 344 221, 276 237 221 341 301 193, 369, 371, 483 326 377 475 74, 362 487 435

Visser AP Vitetta L Vodermaier A Voerman AE Vos PJ Vybornykh DE

155, 332, 233 86 378 155, 331, 156

331, 378

251, 332

W Waadt S Wada TW Wade KM Wagner LI Wagner Th Wain G Wakefield C Walsh A Waltz P Wang GL Wang WJP Ward A W.arn S Washuta A Wasteson E Watanabe C Watson M Weidner K Weis J Weiss K Weiflog G Welk H Wellisch D Whelan T White CA Wiernikowski J Wilcken N Wiley TJ Williams B Willis L Winefield H Winkel G Winterbottom A Winterling J Winterowd C Winzelberg A Wong VAR Wright P Wu G Wylie-Rosett J Wyllie D

305 280 304 50, 379 453 91, 92 174 139, 283 175 222 333 342 436 31 281 82 437, 167 244 51, 183 431 176 381 294 66 158 220 84 30 100 412 474 315 340 281 204 24, 90 223 340, 344 360 230 14

Y Yagil Y

41, 140, 442

Psycho-Oncology 13: S1–S233 (2004)

S233

AUTHOR INDEX

Yamada YY Yamanaka TY Yamawaki S Yasuda K Yershova MP Yoo GJ Yoshida MY Yoshida T Yoshida YY

335 280 129, 187, 363, 424, 426 123 18, 19, 20, 441 206, 213 319 171 335

Yoshikawa E Young KE

119, 157 158

Z Zabora J Zachariae R

Zander A

Copyright # 2004 John Wiley & Sons, Ltd.

117, 159 10, 150, 160, 180, 361, 459, 462, 463, 471 47

Zaninetta G Zarri DA Zenasni F Zhang YZ Zielinski Ch Zimmermann C Zindel A Zoboli ZA Zorbas H

79 15, 438 252 192 134 282, 283 419 62, 63 177

Psycho-Oncology 13: S1–S233 (2004)