Betsy Bates

ANAHEIM, CALIF. – Notable survival differences between depressed and nondepressed patients with non–small cell lung cancer may be attributable to EGFR-mutation status, according to a small but provocative study conducted by Dr. William Pirl of the cancer center at Massachusetts General Hospital in Boston.

The investigation arose from the observation by Dr. Pirl that NSCLC patients with EGFR (epidermal growth factor receptor) mutations were rarely referred for psychiatric evaluation of depression, which is a common comorbid diagnosis among cancer patients and one that is increasingly linked to decreased survival.

He wondered whether the 15% of lung cancer patients with EGFR mutations might be less susceptible to depression because they would know of their more optimistic prognosis, relative to other patients with the disease. Could their avoidance of depression relate to smoking status, since more patients with EGFR mutations are nonsmokers? Or is it possible that a biological explanation might underlie the relationship between depression and survival in NSCLC?

Results of his study of newly diagnosed NSCLC patients point to biology, although potential biological pathways are still under investigation, Dr. Pirl said in an interview following a presentation of his latest findings at the annual conference of the American Psychosocial Oncology Society.

In a previous study of 43 recently diagnosed NSCLC patients, he and associates found that patients who were depressed according to Hospital Anxiety and Depression Scale scores lived a median of 2.5 months, compared with median survival rates of 10.4 months in nondepressed patients (Psychosomatics 2008 May-June [doi:10.1176/appi.psy.49.3.218]).

To determine whether tumor genotypes played a role, Dr. Pirl’s team administered the MDS (Major Depression Rating Scale, which is a scale derived from the Hamilton Rating Scale for Depression and the Melancholia Scale, and aligned with DSM-IV criteria for major depressive disorder) and the PHQ-9 (Patient Health Questionnaire–9) to 148 patients with metastatic NSCLC prior to the processing of their genotype results. They found the following:

• None of 16 patients with an EGFR mutation had depression, based on either instrument.
• In all, 4 of 27 patients (15%) with wild-type mutations as well as 17 of 105 (16%) of those with unknown mutations met criteria for depression, according to the MDS.
• Even more patients with wild-type mutations (9 of 27, or 33%) and unknown mutations (32 of 105, or 39%) met criteria for depression, according to the PHQ-9.

After 3 years, significantly more depressed patients than nondepressed patients had died (hazard ratio, 1.75; P = .03). Patients with an EGFR genotype also had a significant survival advantage over other patients in the study (P = .004).

"[If we put] genotype into the survival model, depression is no longer significantly associated with survival," reported Dr. Pirl, director of the hospital’s center of psychiatric oncology and behavioral sciences.

A study will soon be underway to explore plausible biological pathways linking EGFR, depression, and survival.

One candidate is tumor growth factor–alpha (TGF-alpha), a ligand of EGFR known to cause circadian rhythm dysfunction. Dr. Pirl noted in his talk that EGFR mutants do not produce TGF-alpha.

If replicated, the study could "raise larger questions about the biological pathways to depression and could possibly uncover a novel pathway in people with medical illnesses," he added in an interview.

Dr. Pirl’s coinvestigators included Dr. Jennifer S. Temel, a medical oncologist, and Joseph Greer, Ph.D., associate director of behavioral medicine at the hospital. They reported having no relevant financial disclosures.

ANAHEIM, CALIF. – Notable survival differences between depressed and nondepressed patients with non–small cell lung cancer may be attributable to EGFR-mutation status, according to a small but provocative study conducted by Dr. William Pirl of the cancer center at Massachusetts General Hospital in Boston.

The investigation arose from the observation by Dr. Pirl that NSCLC patients with EGFR (epidermal growth factor receptor) mutations were rarely referred for psychiatric evaluation of depression, which is a common comorbid diagnosis among cancer patients and one that is increasingly linked to decreased survival.

He wondered whether the 15% of lung cancer patients with EGFR mutations might be less susceptible to depression because they would know of their more optimistic prognosis, relative to other patients with the disease. Could their avoidance of depression relate to smoking status, since more patients with EGFR mutations are nonsmokers? Or is it possible that a biological explanation might underlie the relationship between depression and survival in NSCLC?

Results of his study of newly diagnosed NSCLC patients point to biology, although potential biological pathways are still under investigation, Dr. Pirl said in an interview following a presentation of his latest findings at the annual conference of the American Psychosocial Oncology Society.

In a previous study of 43 recently diagnosed NSCLC patients, he and associates found that patients who were depressed according to Hospital Anxiety and Depression Scale scores lived a median of 2.5 months, compared with median survival rates of 10.4 months in nondepressed patients (Psychosomatics 2008 May-June [doi:10.1176/appi.psy.49.3.218]).

To determine whether tumor genotypes played a role, Dr. Pirl’s team administered the MDS (Major Depression Rating Scale, which is a scale derived from the Hamilton Rating Scale for Depression and the Melancholia Scale, and aligned with DSM-IV criteria for major depressive disorder) and the PHQ-9 (Patient Health Questionnaire–9) to 148 patients with metastatic NSCLC prior to the processing of their genotype results. They found the following:

• None of 16 patients with an EGFR mutation had depression, based on either instrument.
• In all, 4 of 27 patients (15%) with wild-type mutations as well as 17 of 105 (16%) of those with unknown mutations met criteria for depression, according to the MDS.
• Even more patients with wild-type mutations (9 of 27, or 33%) and unknown mutations (32 of 105, or 39%) met criteria for depression, according to the PHQ-9.

After 3 years, significantly more depressed patients than nondepressed patients had died (hazard ratio, 1.75; P = .03). Patients with an EGFR genotype also had a significant survival advantage over other patients in the study (P = .004).

"[If we put] genotype into the survival model, depression is no longer significantly associated with survival," reported Dr. Pirl, director of the hospital’s center of psychiatric oncology and behavioral sciences.

A study will soon be underway to explore plausible biological pathways linking EGFR, depression, and survival.

One candidate is tumor growth factor–alpha (TGF-alpha), a ligand of EGFR known to cause circadian rhythm dysfunction. Dr. Pirl noted in his talk that EGFR mutants do not produce TGF-alpha.

If replicated, the study could "raise larger questions about the biological pathways to depression and could possibly uncover a novel pathway in people with medical illnesses," he added in an interview.

Dr. Pirl’s coinvestigators included Dr. Jennifer S. Temel, a medical oncologist, and Joseph Greer, Ph.D., associate director of behavioral medicine at the hospital. They reported having no relevant financial disclosures.

ANAHEIM, CALIF. – Notable survival differences between depressed and nondepressed patients with non–small cell lung cancer may be attributable to EGFR-mutation status, according to a small but provocative study conducted by Dr. William Pirl of the cancer center at Massachusetts General Hospital in Boston.

The investigation arose from the observation by Dr. Pirl that NSCLC patients with EGFR (epidermal growth factor receptor) mutations were rarely referred for psychiatric evaluation of depression, which is a common comorbid diagnosis among cancer patients and one that is increasingly linked to decreased survival.

He wondered whether the 15% of lung cancer patients with EGFR mutations might be less susceptible to depression because they would know of their more optimistic prognosis, relative to other patients with the disease. Could their avoidance of depression relate to smoking status, since more patients with EGFR mutations are nonsmokers? Or is it possible that a biological explanation might underlie the relationship between depression and survival in NSCLC?

Results of his study of newly diagnosed NSCLC patients point to biology, although potential biological pathways are still under investigation, Dr. Pirl said in an interview following a presentation of his latest findings at the annual conference of the American Psychosocial Oncology Society.

In a previous study of 43 recently diagnosed NSCLC patients, he and associates found that patients who were depressed according to Hospital Anxiety and Depression Scale scores lived a median of 2.5 months, compared with median survival rates of 10.4 months in nondepressed patients (Psychosomatics 2008 May-June [doi:10.1176/appi.psy.49.3.218]).

To determine whether tumor genotypes played a role, Dr. Pirl’s team administered the MDS (Major Depression Rating Scale, which is a scale derived from the Hamilton Rating Scale for Depression and the Melancholia Scale, and aligned with DSM-IV criteria for major depressive disorder) and the PHQ-9 (Patient Health Questionnaire–9) to 148 patients with metastatic NSCLC prior to the processing of their genotype results. They found the following:

• None of 16 patients with an EGFR mutation had depression, based on either instrument.
• In all, 4 of 27 patients (15%) with wild-type mutations as well as 17 of 105 (16%) of those with unknown mutations met criteria for depression, according to the MDS.
• Even more patients with wild-type mutations (9 of 27, or 33%) and unknown mutations (32 of 105, or 39%) met criteria for depression, according to the PHQ-9.

After 3 years, significantly more depressed patients than nondepressed patients had died (hazard ratio, 1.75; P = .03). Patients with an EGFR genotype also had a significant survival advantage over other patients in the study (P = .004).

"[If we put] genotype into the survival model, depression is no longer significantly associated with survival," reported Dr. Pirl, director of the hospital’s center of psychiatric oncology and behavioral sciences.

A study will soon be underway to explore plausible biological pathways linking EGFR, depression, and survival.

One candidate is tumor growth factor–alpha (TGF-alpha), a ligand of EGFR known to cause circadian rhythm dysfunction. Dr. Pirl noted in his talk that EGFR mutants do not produce TGF-alpha.

If replicated, the study could "raise larger questions about the biological pathways to depression and could possibly uncover a novel pathway in people with medical illnesses," he added in an interview.

Dr. Pirl’s coinvestigators included Dr. Jennifer S. Temel, a medical oncologist, and Joseph Greer, Ph.D., associate director of behavioral medicine at the hospital. They reported having no relevant financial disclosures.

ANAHEIM, CALIF. – Notable survival differences between depressed and nondepressed patients with non–small cell lung cancer may be attributable to EGFR-mutation status, according to a small but provocative study conducted by Dr. William Pirl of the cancer center at Massachusetts General Hospital in Boston.

The investigation arose from the observation by Dr. Pirl that NSCLC patients with EGFR (epidermal growth factor receptor) mutations were rarely referred for psychiatric evaluation of depression, which is a common comorbid diagnosis among cancer patients and one that is increasingly linked to decreased survival.

He wondered whether the 15% of lung cancer patients with EGFR mutations might be less susceptible to depression because they would know of their more optimistic prognosis, relative to other patients with the disease. Could their avoidance of depression relate to smoking status, since more patients with EGFR mutations are nonsmokers? Or is it possible that a biological explanation might underlie the relationship between depression and survival in NSCLC?

Results of his study of newly diagnosed NSCLC patients point to biology, although potential biological pathways are still under investigation, Dr. Pirl said in an interview following a presentation of his latest findings at the annual conference of the American Psychosocial Oncology Society.

In a previous study of 43 recently diagnosed NSCLC patients, he and associates found that patients who were depressed according to Hospital Anxiety and Depression Scale scores lived a median of 2.5 months, compared with median survival rates of 10.4 months in nondepressed patients (Psychosomatics 2008 May-June [doi:10.1176/appi.psy.49.3.218]).

To determine whether tumor genotypes played a role, Dr. Pirl’s team administered the MDS (Major Depression Rating Scale, which is a scale derived from the Hamilton Rating Scale for Depression and the Melancholia Scale, and aligned with DSM-IV criteria for major depressive disorder) and the PHQ-9 (Patient Health Questionnaire–9) to 148 patients with metastatic NSCLC prior to the processing of their genotype results. They found the following:

• None of 16 patients with an EGFR mutation had depression, based on either instrument.
• In all, 4 of 27 patients (15%) with wild-type mutations as well as 17 of 105 (16%) of those with unknown mutations met criteria for depression, according to the MDS.
• Even more patients with wild-type mutations (9 of 27, or 33%) and unknown mutations (32 of 105, or 39%) met criteria for depression, according to the PHQ-9.

After 3 years, significantly more depressed patients than nondepressed patients had died (hazard ratio, 1.75; P = .03). Patients with an EGFR genotype also had a significant survival advantage over other patients in the study (P = .004).

"[If we put] genotype into the survival model, depression is no longer significantly associated with survival," reported Dr. Pirl, director of the hospital’s center of psychiatric oncology and behavioral sciences.

A study will soon be underway to explore plausible biological pathways linking EGFR, depression, and survival.

One candidate is tumor growth factor–alpha (TGF-alpha), a ligand of EGFR known to cause circadian rhythm dysfunction. Dr. Pirl noted in his talk that EGFR mutants do not produce TGF-alpha.

If replicated, the study could "raise larger questions about the biological pathways to depression and could possibly uncover a novel pathway in people with medical illnesses," he added in an interview.

Dr. Pirl’s coinvestigators included Dr. Jennifer S. Temel, a medical oncologist, and Joseph Greer, Ph.D., associate director of behavioral medicine at the hospital. They reported having no relevant financial disclosures.

ANAHEIM, CALIF. – Notable survival differences between depressed and nondepressed patients with non–small cell lung cancer may be attributable to EGFR-mutation status, according to a small but provocative study conducted by Dr. William Pirl of the cancer center at Massachusetts General Hospital in Boston.

The investigation arose from the observation by Dr. Pirl that NSCLC patients with EGFR (epidermal growth factor receptor) mutations were rarely referred for psychiatric evaluation of depression, which is a common comorbid diagnosis among cancer patients and one that is increasingly linked to decreased survival.

He wondered whether the 15% of lung cancer patients with EGFR mutations might be less susceptible to depression because they would know of their more optimistic prognosis, relative to other patients with the disease. Could their avoidance of depression relate to smoking status, since more patients with EGFR mutations are nonsmokers? Or is it possible that a biological explanation might underlie the relationship between depression and survival in NSCLC?

Results of his study of newly diagnosed NSCLC patients point to biology, although potential biological pathways are still under investigation, Dr. Pirl said in an interview following a presentation of his latest findings at the annual conference of the American Psychosocial Oncology Society.

In a previous study of 43 recently diagnosed NSCLC patients, he and associates found that patients who were depressed according to Hospital Anxiety and Depression Scale scores lived a median of 2.5 months, compared with median survival rates of 10.4 months in nondepressed patients (Psychosomatics 2008 May-June [doi:10.1176/appi.psy.49.3.218]).

To determine whether tumor genotypes played a role, Dr. Pirl’s team administered the MDS (Major Depression Rating Scale, which is a scale derived from the Hamilton Rating Scale for Depression and the Melancholia Scale, and aligned with DSM-IV criteria for major depressive disorder) and the PHQ-9 (Patient Health Questionnaire–9) to 148 patients with metastatic NSCLC prior to the processing of their genotype results. They found the following:

• None of 16 patients with an EGFR mutation had depression, based on either instrument.
• In all, 4 of 27 patients (15%) with wild-type mutations as well as 17 of 105 (16%) of those with unknown mutations met criteria for depression, according to the MDS.
• Even more patients with wild-type mutations (9 of 27, or 33%) and unknown mutations (32 of 105, or 39%) met criteria for depression, according to the PHQ-9.

After 3 years, significantly more depressed patients than nondepressed patients had died (hazard ratio, 1.75; P = .03). Patients with an EGFR genotype also had a significant survival advantage over other patients in the study (P = .004).

"[If we put] genotype into the survival model, depression is no longer significantly associated with survival," reported Dr. Pirl, director of the hospital’s center of psychiatric oncology and behavioral sciences.

A study will soon be underway to explore plausible biological pathways linking EGFR, depression, and survival.

One candidate is tumor growth factor–alpha (TGF-alpha), a ligand of EGFR known to cause circadian rhythm dysfunction. Dr. Pirl noted in his talk that EGFR mutants do not produce TGF-alpha.

If replicated, the study could "raise larger questions about the biological pathways to depression and could possibly uncover a novel pathway in people with medical illnesses," he added in an interview.

Dr. Pirl’s coinvestigators included Dr. Jennifer S. Temel, a medical oncologist, and Joseph Greer, Ph.D., associate director of behavioral medicine at the hospital. They reported having no relevant financial disclosures.

ANAHEIM, CALIF. – Notable survival differences between depressed and nondepressed patients with non–small cell lung cancer may be attributable to EGFR-mutation status, according to a small but provocative study conducted by Dr. William Pirl of the cancer center at Massachusetts General Hospital in Boston.

The investigation arose from the observation by Dr. Pirl that NSCLC patients with EGFR (epidermal growth factor receptor) mutations were rarely referred for psychiatric evaluation of depression, which is a common comorbid diagnosis among cancer patients and one that is increasingly linked to decreased survival.

He wondered whether the 15% of lung cancer patients with EGFR mutations might be less susceptible to depression because they would know of their more optimistic prognosis, relative to other patients with the disease. Could their avoidance of depression relate to smoking status, since more patients with EGFR mutations are nonsmokers? Or is it possible that a biological explanation might underlie the relationship between depression and survival in NSCLC?

Results of his study of newly diagnosed NSCLC patients point to biology, although potential biological pathways are still under investigation, Dr. Pirl said in an interview following a presentation of his latest findings at the annual conference of the American Psychosocial Oncology Society.

In a previous study of 43 recently diagnosed NSCLC patients, he and associates found that patients who were depressed according to Hospital Anxiety and Depression Scale scores lived a median of 2.5 months, compared with median survival rates of 10.4 months in nondepressed patients (Psychosomatics 2008 May-June [doi:10.1176/appi.psy.49.3.218]).

To determine whether tumor genotypes played a role, Dr. Pirl’s team administered the MDS (Major Depression Rating Scale, which is a scale derived from the Hamilton Rating Scale for Depression and the Melancholia Scale, and aligned with DSM-IV criteria for major depressive disorder) and the PHQ-9 (Patient Health Questionnaire–9) to 148 patients with metastatic NSCLC prior to the processing of their genotype results. They found the following:

• None of 16 patients with an EGFR mutation had depression, based on either instrument.
• In all, 4 of 27 patients (15%) with wild-type mutations as well as 17 of 105 (16%) of those with unknown mutations met criteria for depression, according to the MDS.
• Even more patients with wild-type mutations (9 of 27, or 33%) and unknown mutations (32 of 105, or 39%) met criteria for depression, according to the PHQ-9.

After 3 years, significantly more depressed patients than nondepressed patients had died (hazard ratio, 1.75; P = .03). Patients with an EGFR genotype also had a significant survival advantage over other patients in the study (P = .004).

"[If we put] genotype into the survival model, depression is no longer significantly associated with survival," reported Dr. Pirl, director of the hospital’s center of psychiatric oncology and behavioral sciences.

A study will soon be underway to explore plausible biological pathways linking EGFR, depression, and survival.

One candidate is tumor growth factor–alpha (TGF-alpha), a ligand of EGFR known to cause circadian rhythm dysfunction. Dr. Pirl noted in his talk that EGFR mutants do not produce TGF-alpha.

If replicated, the study could "raise larger questions about the biological pathways to depression and could possibly uncover a novel pathway in people with medical illnesses," he added in an interview.

Dr. Pirl’s coinvestigators included Dr. Jennifer S. Temel, a medical oncologist, and Joseph Greer, Ph.D., associate director of behavioral medicine at the hospital. They reported having no relevant financial disclosures.

ANAHEIM, CALIF. – Building relationships with compassionate, up-to-date primary care physicians and specialists will be key in transitioning oncology patients out of cancer centers and back into the community as survivors, researchers are learning at the comprehensive cancer center at the University of Michigan in Ann Arbor.

In a pilot study at the institution, apprehension about appropriate follow-up care was the second most common concern of breast cancer survivors at a median of 1 year post diagnosis, closely following predictable questions about how to avoid cancer recurrence.

Study researchers asked 20 recent breast cancer survivors to rank, in order, their most important concerns on a checklist of 23 items in five categories, including recurrence, health maintenance, family needs, and genetic cancer risk.

The item, "What can I do to reduce my risk of recurrence?" was selected by 90% of respondents as being among their top five concerns.

After 1-hour, customized transition visits with an advanced practice nurse, recurrence concerns remained on the top five list for 60% of survivors.

Virtually every other issue considered most pertinent to survivors involved transitional care, including specific questions about surveillance schedules and concerns about general health risks after cancer.

For example, prior to a transition visit, 70% of patients wondered, "Which providers should I call with what symptoms?" according to the study presented in poster form at the annual meeting of the American Psychosocial Oncology Society.

Fully 85% of patients wanted to know the most appropriate follow-up schedule for examinations and testing, and 75% sought information about which symptoms would warrant medical attention in a long-term survivor.

Surveys done after the transition visits revealed that just 25% of survivors still said they didn’t know what follow-up schedule was appropriate, or which providers to call with specific symptoms, Patricia M. Clark, director of the adult cancer survivorship program at the University of Michigan, noted in an interview at the meeting.

Concerns about bone health after breast cancer were voiced by 80% of patients before the transition visit and by 45% post visit.

Prior to the visit, 70% of women wondered whether they should follow a specific nutritional plan, but only 20% of women still had that question afterward.

Other significantly reduced concerns involved family needs, long-term sleep problems, and the risk of breast cancer in family members, said Ms. Clark, a family nurse practitioner who specializes in breast cancer.

Christina H. Jagielski, research coordinator, and Dr. Jennifer J. Griggs, an oncologist who directs the university’s breast cancer survivorship program, were among the study’s coinvestigators.

Themes from the pilot study underscore the medical and psychosocial necessity of developing survivorship care as a "distinct phase of cancer care," as recommended in the Institute of Medicine’s 2005 report "From Cancer Patient to Cancer Survivor: Lost in Transition," Ms. Clark said.

"We are trying hard to follow the recommendations," she noted. "We did take to heart the notion of a transition visit."

But the passing of the baton has not always been smooth, she admitted.

Pulling together an accurate and complete breast cancer treatment summary for each patient proved daunting, even with electronic medical records’ becoming more common in health care settings.

Issues of mistrust and unfamiliarity can also complicate the handoff, emphasized Dr. Patricia A. Ganz, professor of health sciences and medicine at the comprehensive cancer center of the University of California, Los Angeles, who served on the IOM panel.

"We really do a lousy job [coordinating care of] 12 million Americans ... living in this posttreatment space," she said during a plenary talk at the meeting.

The "gulf and divide" between oncologists and community physicians provides little opportunity for cross-talk and the building of confidence in patients returning to primary care, Dr. Ganz noted.

Instead, patients are likely to remember remarks such as, "Your doctor missed this. They’re not up to date on this," she said.

In fact, during her "road show" to speak about cancer survivorship across the country, Dr. Ganz said she has identified "empathetic, caring, skilled internists and family physicians" who are very much interested in learning how to care for the special needs of cancer survivors throughout their lives, much as they care for patients following heart attacks or strokes.

The investigators reported no relevant financial disclosures.

ANAHEIM, CALIF. – Building relationships with compassionate, up-to-date primary care physicians and specialists will be key in transitioning oncology patients out of cancer centers and back into the community as survivors, researchers are learning at the comprehensive cancer center at the University of Michigan in Ann Arbor.

In a pilot study at the institution, apprehension about appropriate follow-up care was the second most common concern of breast cancer survivors at a median of 1 year post diagnosis, closely following predictable questions about how to avoid cancer recurrence.

Study researchers asked 20 recent breast cancer survivors to rank, in order, their most important concerns on a checklist of 23 items in five categories, including recurrence, health maintenance, family needs, and genetic cancer risk.

The item, "What can I do to reduce my risk of recurrence?" was selected by 90% of respondents as being among their top five concerns.

After 1-hour, customized transition visits with an advanced practice nurse, recurrence concerns remained on the top five list for 60% of survivors.

Virtually every other issue considered most pertinent to survivors involved transitional care, including specific questions about surveillance schedules and concerns about general health risks after cancer.

For example, prior to a transition visit, 70% of patients wondered, "Which providers should I call with what symptoms?" according to the study presented in poster form at the annual meeting of the American Psychosocial Oncology Society.

Fully 85% of patients wanted to know the most appropriate follow-up schedule for examinations and testing, and 75% sought information about which symptoms would warrant medical attention in a long-term survivor.

Surveys done after the transition visits revealed that just 25% of survivors still said they didn’t know what follow-up schedule was appropriate, or which providers to call with specific symptoms, Patricia M. Clark, director of the adult cancer survivorship program at the University of Michigan, noted in an interview at the meeting.

Concerns about bone health after breast cancer were voiced by 80% of patients before the transition visit and by 45% post visit.

Prior to the visit, 70% of women wondered whether they should follow a specific nutritional plan, but only 20% of women still had that question afterward.

Other significantly reduced concerns involved family needs, long-term sleep problems, and the risk of breast cancer in family members, said Ms. Clark, a family nurse practitioner who specializes in breast cancer.

Christina H. Jagielski, research coordinator, and Dr. Jennifer J. Griggs, an oncologist who directs the university’s breast cancer survivorship program, were among the study’s coinvestigators.

Themes from the pilot study underscore the medical and psychosocial necessity of developing survivorship care as a "distinct phase of cancer care," as recommended in the Institute of Medicine’s 2005 report "From Cancer Patient to Cancer Survivor: Lost in Transition," Ms. Clark said.

"We are trying hard to follow the recommendations," she noted. "We did take to heart the notion of a transition visit."

But the passing of the baton has not always been smooth, she admitted.

Pulling together an accurate and complete breast cancer treatment summary for each patient proved daunting, even with electronic medical records’ becoming more common in health care settings.

Issues of mistrust and unfamiliarity can also complicate the handoff, emphasized Dr. Patricia A. Ganz, professor of health sciences and medicine at the comprehensive cancer center of the University of California, Los Angeles, who served on the IOM panel.

"We really do a lousy job [coordinating care of] 12 million Americans ... living in this posttreatment space," she said during a plenary talk at the meeting.

The "gulf and divide" between oncologists and community physicians provides little opportunity for cross-talk and the building of confidence in patients returning to primary care, Dr. Ganz noted.

Instead, patients are likely to remember remarks such as, "Your doctor missed this. They’re not up to date on this," she said.

In fact, during her "road show" to speak about cancer survivorship across the country, Dr. Ganz said she has identified "empathetic, caring, skilled internists and family physicians" who are very much interested in learning how to care for the special needs of cancer survivors throughout their lives, much as they care for patients following heart attacks or strokes.

The investigators reported no relevant financial disclosures.

ANAHEIM, CALIF. – Building relationships with compassionate, up-to-date primary care physicians and specialists will be key in transitioning oncology patients out of cancer centers and back into the community as survivors, researchers are learning at the comprehensive cancer center at the University of Michigan in Ann Arbor.

In a pilot study at the institution, apprehension about appropriate follow-up care was the second most common concern of breast cancer survivors at a median of 1 year post diagnosis, closely following predictable questions about how to avoid cancer recurrence.

Study researchers asked 20 recent breast cancer survivors to rank, in order, their most important concerns on a checklist of 23 items in five categories, including recurrence, health maintenance, family needs, and genetic cancer risk.

The item, "What can I do to reduce my risk of recurrence?" was selected by 90% of respondents as being among their top five concerns.

After 1-hour, customized transition visits with an advanced practice nurse, recurrence concerns remained on the top five list for 60% of survivors.

Virtually every other issue considered most pertinent to survivors involved transitional care, including specific questions about surveillance schedules and concerns about general health risks after cancer.

For example, prior to a transition visit, 70% of patients wondered, "Which providers should I call with what symptoms?" according to the study presented in poster form at the annual meeting of the American Psychosocial Oncology Society.

Fully 85% of patients wanted to know the most appropriate follow-up schedule for examinations and testing, and 75% sought information about which symptoms would warrant medical attention in a long-term survivor.

Surveys done after the transition visits revealed that just 25% of survivors still said they didn’t know what follow-up schedule was appropriate, or which providers to call with specific symptoms, Patricia M. Clark, director of the adult cancer survivorship program at the University of Michigan, noted in an interview at the meeting.

Concerns about bone health after breast cancer were voiced by 80% of patients before the transition visit and by 45% post visit.

Prior to the visit, 70% of women wondered whether they should follow a specific nutritional plan, but only 20% of women still had that question afterward.

Other significantly reduced concerns involved family needs, long-term sleep problems, and the risk of breast cancer in family members, said Ms. Clark, a family nurse practitioner who specializes in breast cancer.

Christina H. Jagielski, research coordinator, and Dr. Jennifer J. Griggs, an oncologist who directs the university’s breast cancer survivorship program, were among the study’s coinvestigators.

Themes from the pilot study underscore the medical and psychosocial necessity of developing survivorship care as a "distinct phase of cancer care," as recommended in the Institute of Medicine’s 2005 report "From Cancer Patient to Cancer Survivor: Lost in Transition," Ms. Clark said.

"We are trying hard to follow the recommendations," she noted. "We did take to heart the notion of a transition visit."

But the passing of the baton has not always been smooth, she admitted.

Pulling together an accurate and complete breast cancer treatment summary for each patient proved daunting, even with electronic medical records’ becoming more common in health care settings.

Issues of mistrust and unfamiliarity can also complicate the handoff, emphasized Dr. Patricia A. Ganz, professor of health sciences and medicine at the comprehensive cancer center of the University of California, Los Angeles, who served on the IOM panel.

"We really do a lousy job [coordinating care of] 12 million Americans ... living in this posttreatment space," she said during a plenary talk at the meeting.

The "gulf and divide" between oncologists and community physicians provides little opportunity for cross-talk and the building of confidence in patients returning to primary care, Dr. Ganz noted.

Instead, patients are likely to remember remarks such as, "Your doctor missed this. They’re not up to date on this," she said.

In fact, during her "road show" to speak about cancer survivorship across the country, Dr. Ganz said she has identified "empathetic, caring, skilled internists and family physicians" who are very much interested in learning how to care for the special needs of cancer survivors throughout their lives, much as they care for patients following heart attacks or strokes.

The investigators reported no relevant financial disclosures.

ANAHEIM, CALIF. – Building relationships with compassionate, up-to-date primary care physicians and specialists will be key in transitioning oncology patients out of cancer centers and back into the community as survivors, researchers are learning at the comprehensive cancer center at the University of Michigan in Ann Arbor.

In a pilot study at the institution, apprehension about appropriate follow-up care was the second most common concern of breast cancer survivors at a median of 1 year post diagnosis, closely following predictable questions about how to avoid cancer recurrence.

Study researchers asked 20 recent breast cancer survivors to rank, in order, their most important concerns on a checklist of 23 items in five categories, including recurrence, health maintenance, family needs, and genetic cancer risk.

The item, "What can I do to reduce my risk of recurrence?" was selected by 90% of respondents as being among their top five concerns.

After 1-hour, customized transition visits with an advanced practice nurse, recurrence concerns remained on the top five list for 60% of survivors.

Virtually every other issue considered most pertinent to survivors involved transitional care, including specific questions about surveillance schedules and concerns about general health risks after cancer.

For example, prior to a transition visit, 70% of patients wondered, "Which providers should I call with what symptoms?" according to the study presented in poster form at the annual meeting of the American Psychosocial Oncology Society.

Fully 85% of patients wanted to know the most appropriate follow-up schedule for examinations and testing, and 75% sought information about which symptoms would warrant medical attention in a long-term survivor.

Surveys done after the transition visits revealed that just 25% of survivors still said they didn’t know what follow-up schedule was appropriate, or which providers to call with specific symptoms, Patricia M. Clark, director of the adult cancer survivorship program at the University of Michigan, noted in an interview at the meeting.

Concerns about bone health after breast cancer were voiced by 80% of patients before the transition visit and by 45% post visit.

Prior to the visit, 70% of women wondered whether they should follow a specific nutritional plan, but only 20% of women still had that question afterward.

Other significantly reduced concerns involved family needs, long-term sleep problems, and the risk of breast cancer in family members, said Ms. Clark, a family nurse practitioner who specializes in breast cancer.

Christina H. Jagielski, research coordinator, and Dr. Jennifer J. Griggs, an oncologist who directs the university’s breast cancer survivorship program, were among the study’s coinvestigators.

Themes from the pilot study underscore the medical and psychosocial necessity of developing survivorship care as a "distinct phase of cancer care," as recommended in the Institute of Medicine’s 2005 report "From Cancer Patient to Cancer Survivor: Lost in Transition," Ms. Clark said.

"We are trying hard to follow the recommendations," she noted. "We did take to heart the notion of a transition visit."

But the passing of the baton has not always been smooth, she admitted.

Pulling together an accurate and complete breast cancer treatment summary for each patient proved daunting, even with electronic medical records’ becoming more common in health care settings.

Issues of mistrust and unfamiliarity can also complicate the handoff, emphasized Dr. Patricia A. Ganz, professor of health sciences and medicine at the comprehensive cancer center of the University of California, Los Angeles, who served on the IOM panel.

"We really do a lousy job [coordinating care of] 12 million Americans ... living in this posttreatment space," she said during a plenary talk at the meeting.

The "gulf and divide" between oncologists and community physicians provides little opportunity for cross-talk and the building of confidence in patients returning to primary care, Dr. Ganz noted.

Instead, patients are likely to remember remarks such as, "Your doctor missed this. They’re not up to date on this," she said.

In fact, during her "road show" to speak about cancer survivorship across the country, Dr. Ganz said she has identified "empathetic, caring, skilled internists and family physicians" who are very much interested in learning how to care for the special needs of cancer survivors throughout their lives, much as they care for patients following heart attacks or strokes.

The investigators reported no relevant financial disclosures.

ANAHEIM, CALIF. – Building relationships with compassionate, up-to-date primary care physicians and specialists will be key in transitioning oncology patients out of cancer centers and back into the community as survivors, researchers are learning at the comprehensive cancer center at the University of Michigan in Ann Arbor.

In a pilot study at the institution, apprehension about appropriate follow-up care was the second most common concern of breast cancer survivors at a median of 1 year post diagnosis, closely following predictable questions about how to avoid cancer recurrence.

Study researchers asked 20 recent breast cancer survivors to rank, in order, their most important concerns on a checklist of 23 items in five categories, including recurrence, health maintenance, family needs, and genetic cancer risk.

The item, "What can I do to reduce my risk of recurrence?" was selected by 90% of respondents as being among their top five concerns.

After 1-hour, customized transition visits with an advanced practice nurse, recurrence concerns remained on the top five list for 60% of survivors.

Virtually every other issue considered most pertinent to survivors involved transitional care, including specific questions about surveillance schedules and concerns about general health risks after cancer.

For example, prior to a transition visit, 70% of patients wondered, "Which providers should I call with what symptoms?" according to the study presented in poster form at the annual meeting of the American Psychosocial Oncology Society.

Fully 85% of patients wanted to know the most appropriate follow-up schedule for examinations and testing, and 75% sought information about which symptoms would warrant medical attention in a long-term survivor.

Surveys done after the transition visits revealed that just 25% of survivors still said they didn’t know what follow-up schedule was appropriate, or which providers to call with specific symptoms, Patricia M. Clark, director of the adult cancer survivorship program at the University of Michigan, noted in an interview at the meeting.

Concerns about bone health after breast cancer were voiced by 80% of patients before the transition visit and by 45% post visit.

Prior to the visit, 70% of women wondered whether they should follow a specific nutritional plan, but only 20% of women still had that question afterward.

Other significantly reduced concerns involved family needs, long-term sleep problems, and the risk of breast cancer in family members, said Ms. Clark, a family nurse practitioner who specializes in breast cancer.

Christina H. Jagielski, research coordinator, and Dr. Jennifer J. Griggs, an oncologist who directs the university’s breast cancer survivorship program, were among the study’s coinvestigators.

Themes from the pilot study underscore the medical and psychosocial necessity of developing survivorship care as a "distinct phase of cancer care," as recommended in the Institute of Medicine’s 2005 report "From Cancer Patient to Cancer Survivor: Lost in Transition," Ms. Clark said.

"We are trying hard to follow the recommendations," she noted. "We did take to heart the notion of a transition visit."

But the passing of the baton has not always been smooth, she admitted.

Pulling together an accurate and complete breast cancer treatment summary for each patient proved daunting, even with electronic medical records’ becoming more common in health care settings.

Issues of mistrust and unfamiliarity can also complicate the handoff, emphasized Dr. Patricia A. Ganz, professor of health sciences and medicine at the comprehensive cancer center of the University of California, Los Angeles, who served on the IOM panel.

"We really do a lousy job [coordinating care of] 12 million Americans ... living in this posttreatment space," she said during a plenary talk at the meeting.

The "gulf and divide" between oncologists and community physicians provides little opportunity for cross-talk and the building of confidence in patients returning to primary care, Dr. Ganz noted.

Instead, patients are likely to remember remarks such as, "Your doctor missed this. They’re not up to date on this," she said.

In fact, during her "road show" to speak about cancer survivorship across the country, Dr. Ganz said she has identified "empathetic, caring, skilled internists and family physicians" who are very much interested in learning how to care for the special needs of cancer survivors throughout their lives, much as they care for patients following heart attacks or strokes.

The investigators reported no relevant financial disclosures.

ANAHEIM, CALIF. – Building relationships with compassionate, up-to-date primary care physicians and specialists will be key in transitioning oncology patients out of cancer centers and back into the community as survivors, researchers are learning at the comprehensive cancer center at the University of Michigan in Ann Arbor.

In a pilot study at the institution, apprehension about appropriate follow-up care was the second most common concern of breast cancer survivors at a median of 1 year post diagnosis, closely following predictable questions about how to avoid cancer recurrence.

Study researchers asked 20 recent breast cancer survivors to rank, in order, their most important concerns on a checklist of 23 items in five categories, including recurrence, health maintenance, family needs, and genetic cancer risk.

The item, "What can I do to reduce my risk of recurrence?" was selected by 90% of respondents as being among their top five concerns.

After 1-hour, customized transition visits with an advanced practice nurse, recurrence concerns remained on the top five list for 60% of survivors.

Virtually every other issue considered most pertinent to survivors involved transitional care, including specific questions about surveillance schedules and concerns about general health risks after cancer.

For example, prior to a transition visit, 70% of patients wondered, "Which providers should I call with what symptoms?" according to the study presented in poster form at the annual meeting of the American Psychosocial Oncology Society.

Fully 85% of patients wanted to know the most appropriate follow-up schedule for examinations and testing, and 75% sought information about which symptoms would warrant medical attention in a long-term survivor.

Surveys done after the transition visits revealed that just 25% of survivors still said they didn’t know what follow-up schedule was appropriate, or which providers to call with specific symptoms, Patricia M. Clark, director of the adult cancer survivorship program at the University of Michigan, noted in an interview at the meeting.

Concerns about bone health after breast cancer were voiced by 80% of patients before the transition visit and by 45% post visit.

Prior to the visit, 70% of women wondered whether they should follow a specific nutritional plan, but only 20% of women still had that question afterward.

Other significantly reduced concerns involved family needs, long-term sleep problems, and the risk of breast cancer in family members, said Ms. Clark, a family nurse practitioner who specializes in breast cancer.

Christina H. Jagielski, research coordinator, and Dr. Jennifer J. Griggs, an oncologist who directs the university’s breast cancer survivorship program, were among the study’s coinvestigators.

Themes from the pilot study underscore the medical and psychosocial necessity of developing survivorship care as a "distinct phase of cancer care," as recommended in the Institute of Medicine’s 2005 report "From Cancer Patient to Cancer Survivor: Lost in Transition," Ms. Clark said.

"We are trying hard to follow the recommendations," she noted. "We did take to heart the notion of a transition visit."

But the passing of the baton has not always been smooth, she admitted.

Pulling together an accurate and complete breast cancer treatment summary for each patient proved daunting, even with electronic medical records’ becoming more common in health care settings.

Issues of mistrust and unfamiliarity can also complicate the handoff, emphasized Dr. Patricia A. Ganz, professor of health sciences and medicine at the comprehensive cancer center of the University of California, Los Angeles, who served on the IOM panel.

"We really do a lousy job [coordinating care of] 12 million Americans ... living in this posttreatment space," she said during a plenary talk at the meeting.

The "gulf and divide" between oncologists and community physicians provides little opportunity for cross-talk and the building of confidence in patients returning to primary care, Dr. Ganz noted.

Instead, patients are likely to remember remarks such as, "Your doctor missed this. They’re not up to date on this," she said.

In fact, during her "road show" to speak about cancer survivorship across the country, Dr. Ganz said she has identified "empathetic, caring, skilled internists and family physicians" who are very much interested in learning how to care for the special needs of cancer survivors throughout their lives, much as they care for patients following heart attacks or strokes.

The investigators reported no relevant financial disclosures.

ANAHEIM, CALIF. – Coping with the emotional burdens of cancer can be a lonely struggle in rural America, results of a population-based, cross-sectional study suggest.

Researchers analyzed mental health data from a statewide cancer registry in Kentucky, and found that non–small cell lung cancer (NSCLC) survivors in rural counties had profoundly greater levels of mental health distress, but fewer interpersonal and intrapersonal coping resources, than did those living in nonrural regions of the state.

Rural survivors fared worse on every mental health outcome variable that was measured by the university researchers, including subscales of the Medical Outcomes Study (MOS-36), the Hospital Anxiety and Depression Scale (HADS), and the National Comprehensive Cancer Network Distress Thermometer Rating and Problem List.

Michael A. Andrykowski, Ph.D., professor of behavioral science at the University of Kentucky in Lexington, presented results of the study at the annual meeting of the American Psychosocial Oncology Society.

While conducting previous studies of symptoms and psychosocial outcomes among cancer patients, Dr. Andrykowski became interested in possible disparities in disease burden among rural populations in a diverse state of bustling university towns, bluegrass thoroughbred farms, coal mines, and forested Appalachian hills.

"I thought there was a pretty compelling reason to believe that cancer survivors living in rural areas experience more stress in association with the cancer experience, and fewer resources – a double whammy," said Dr. Andrykowski.

He also began to wonder whether presumed supportive factors associated with living in small, tight-knit communities might actually foster "attitudes, beliefs, and social norms less supportive of using formal and informal mental health resources," he said during his podium presentation.

To explore the question of potential disparities (a key goal of federal Healthy People 2020 guidelines), Dr. Andrykowski and associates sent questionnaires to – and conducted telephone interviews with – 144 NSCLC survivors, 76 of whom lived in counties that were designated as rural by USDA Rural-Urban Continuum Codes. The remaining 68 survivors lived in nonrural counties of Kentucky.

The two groups were well matched in terms of age (average, early 60s), minority status (7%-9%), and comorbidities (3.0-3.6). Patients from both groups had been diagnosed approximately 12-15 months prior to the study.

The rural patients had significantly less formal education (10.7 years vs. 12.9 years). They were also less optimistic, as measured by the Life Orientation Test, and less efficacious in seeking mental health support and cancer information than were nonrural patients, with significant effect sizes on those variables of 0.31, 0.39, and 0.34.

Highly significant differences were also seen in social constraint, which Dr. Andrykowski defined as a response to signals from family and friends that lead a person to limit the sharing of thoughts and feelings about a stressful event, such as a diagnosis or recurrence of cancer. Rural patients were far more likely to notice or perceive such behaviors, and to behave accordingly, he said.

Significant or highly significant differences were seen in scores on the MOS mental health subscale (63.0 rural vs. 73.2 nonrural), the HADS anxiety subscale (7.4 vs. 5.7), the HADS depression subscale (6.4 vs. 4.4), and the HADS total score (13.9 vs. 10.1).

Rural patients had access to fewer tangible and informational mental health resources, including a psychologist within 30 miles (67% vs. 75%), a support group within 30 miles (25% vs. 49%), a household computer (50% vs. 70%), the use of a computer for Internet access (54% vs. 79%), and the use of a computer "quite a bit" for the Internet (11% vs. 36%) or e-mail (7% vs. 36%).

Financial resources were scarcer as well, with 39% of rural residents reporting mental health insurance coverage and 28% reporting that they had some money left after paying bills, compared with 59% and 33%, respectively, of nonrural residents.

In an interview following his presentation, Dr. Andrykowski said simply providing rural cancer patients with more mental health resources may be too simplistic a solution to address disparities.

Earlier studies suggest that in some small, rural communities, social norms cast doubt on individuals who access help in the form of support groups, psychologists, spiritual counselors, or psychotropic medications. "Friends and family may be less supportive if [the survivors] use mental health services," he said.

Privacy and confidentiality may also be compromised, said Dr. Andrykowski, although he has not yet collected data to investigate this possibility.

Until he began collecting research on geographic disparities, he said, "I thought it was a good thing [that rural patients] were embedded in a close-knit community. But it could be too close knit. [Patients may feel that] ‘if I talk to a local mental health provider or a minister, there is no possibility of anonymity. They know everyone I know.’ "

The investigators reported no relevant financial conflicts of interest. Funding for the study was provided through the Commonwealth of Kentucky’s tobacco settlement fund.

ANAHEIM, CALIF. – Coping with the emotional burdens of cancer can be a lonely struggle in rural America, results of a population-based, cross-sectional study suggest.

Researchers analyzed mental health data from a statewide cancer registry in Kentucky, and found that non–small cell lung cancer (NSCLC) survivors in rural counties had profoundly greater levels of mental health distress, but fewer interpersonal and intrapersonal coping resources, than did those living in nonrural regions of the state.

Rural survivors fared worse on every mental health outcome variable that was measured by the university researchers, including subscales of the Medical Outcomes Study (MOS-36), the Hospital Anxiety and Depression Scale (HADS), and the National Comprehensive Cancer Network Distress Thermometer Rating and Problem List.

Michael A. Andrykowski, Ph.D., professor of behavioral science at the University of Kentucky in Lexington, presented results of the study at the annual meeting of the American Psychosocial Oncology Society.

While conducting previous studies of symptoms and psychosocial outcomes among cancer patients, Dr. Andrykowski became interested in possible disparities in disease burden among rural populations in a diverse state of bustling university towns, bluegrass thoroughbred farms, coal mines, and forested Appalachian hills.

"I thought there was a pretty compelling reason to believe that cancer survivors living in rural areas experience more stress in association with the cancer experience, and fewer resources – a double whammy," said Dr. Andrykowski.

He also began to wonder whether presumed supportive factors associated with living in small, tight-knit communities might actually foster "attitudes, beliefs, and social norms less supportive of using formal and informal mental health resources," he said during his podium presentation.

To explore the question of potential disparities (a key goal of federal Healthy People 2020 guidelines), Dr. Andrykowski and associates sent questionnaires to – and conducted telephone interviews with – 144 NSCLC survivors, 76 of whom lived in counties that were designated as rural by USDA Rural-Urban Continuum Codes. The remaining 68 survivors lived in nonrural counties of Kentucky.

The two groups were well matched in terms of age (average, early 60s), minority status (7%-9%), and comorbidities (3.0-3.6). Patients from both groups had been diagnosed approximately 12-15 months prior to the study.

The rural patients had significantly less formal education (10.7 years vs. 12.9 years). They were also less optimistic, as measured by the Life Orientation Test, and less efficacious in seeking mental health support and cancer information than were nonrural patients, with significant effect sizes on those variables of 0.31, 0.39, and 0.34.

Highly significant differences were also seen in social constraint, which Dr. Andrykowski defined as a response to signals from family and friends that lead a person to limit the sharing of thoughts and feelings about a stressful event, such as a diagnosis or recurrence of cancer. Rural patients were far more likely to notice or perceive such behaviors, and to behave accordingly, he said.

Significant or highly significant differences were seen in scores on the MOS mental health subscale (63.0 rural vs. 73.2 nonrural), the HADS anxiety subscale (7.4 vs. 5.7), the HADS depression subscale (6.4 vs. 4.4), and the HADS total score (13.9 vs. 10.1).

Rural patients had access to fewer tangible and informational mental health resources, including a psychologist within 30 miles (67% vs. 75%), a support group within 30 miles (25% vs. 49%), a household computer (50% vs. 70%), the use of a computer for Internet access (54% vs. 79%), and the use of a computer "quite a bit" for the Internet (11% vs. 36%) or e-mail (7% vs. 36%).

Financial resources were scarcer as well, with 39% of rural residents reporting mental health insurance coverage and 28% reporting that they had some money left after paying bills, compared with 59% and 33%, respectively, of nonrural residents.

In an interview following his presentation, Dr. Andrykowski said simply providing rural cancer patients with more mental health resources may be too simplistic a solution to address disparities.

Earlier studies suggest that in some small, rural communities, social norms cast doubt on individuals who access help in the form of support groups, psychologists, spiritual counselors, or psychotropic medications. "Friends and family may be less supportive if [the survivors] use mental health services," he said.

Privacy and confidentiality may also be compromised, said Dr. Andrykowski, although he has not yet collected data to investigate this possibility.

Until he began collecting research on geographic disparities, he said, "I thought it was a good thing [that rural patients] were embedded in a close-knit community. But it could be too close knit. [Patients may feel that] ‘if I talk to a local mental health provider or a minister, there is no possibility of anonymity. They know everyone I know.’ "

The investigators reported no relevant financial conflicts of interest. Funding for the study was provided through the Commonwealth of Kentucky’s tobacco settlement fund.

ANAHEIM, CALIF. – Coping with the emotional burdens of cancer can be a lonely struggle in rural America, results of a population-based, cross-sectional study suggest.

Researchers analyzed mental health data from a statewide cancer registry in Kentucky, and found that non–small cell lung cancer (NSCLC) survivors in rural counties had profoundly greater levels of mental health distress, but fewer interpersonal and intrapersonal coping resources, than did those living in nonrural regions of the state.

Rural survivors fared worse on every mental health outcome variable that was measured by the university researchers, including subscales of the Medical Outcomes Study (MOS-36), the Hospital Anxiety and Depression Scale (HADS), and the National Comprehensive Cancer Network Distress Thermometer Rating and Problem List.

Michael A. Andrykowski, Ph.D., professor of behavioral science at the University of Kentucky in Lexington, presented results of the study at the annual meeting of the American Psychosocial Oncology Society.

While conducting previous studies of symptoms and psychosocial outcomes among cancer patients, Dr. Andrykowski became interested in possible disparities in disease burden among rural populations in a diverse state of bustling university towns, bluegrass thoroughbred farms, coal mines, and forested Appalachian hills.

"I thought there was a pretty compelling reason to believe that cancer survivors living in rural areas experience more stress in association with the cancer experience, and fewer resources – a double whammy," said Dr. Andrykowski.

He also began to wonder whether presumed supportive factors associated with living in small, tight-knit communities might actually foster "attitudes, beliefs, and social norms less supportive of using formal and informal mental health resources," he said during his podium presentation.

To explore the question of potential disparities (a key goal of federal Healthy People 2020 guidelines), Dr. Andrykowski and associates sent questionnaires to – and conducted telephone interviews with – 144 NSCLC survivors, 76 of whom lived in counties that were designated as rural by USDA Rural-Urban Continuum Codes. The remaining 68 survivors lived in nonrural counties of Kentucky.

The two groups were well matched in terms of age (average, early 60s), minority status (7%-9%), and comorbidities (3.0-3.6). Patients from both groups had been diagnosed approximately 12-15 months prior to the study.

The rural patients had significantly less formal education (10.7 years vs. 12.9 years). They were also less optimistic, as measured by the Life Orientation Test, and less efficacious in seeking mental health support and cancer information than were nonrural patients, with significant effect sizes on those variables of 0.31, 0.39, and 0.34.

Highly significant differences were also seen in social constraint, which Dr. Andrykowski defined as a response to signals from family and friends that lead a person to limit the sharing of thoughts and feelings about a stressful event, such as a diagnosis or recurrence of cancer. Rural patients were far more likely to notice or perceive such behaviors, and to behave accordingly, he said.

Significant or highly significant differences were seen in scores on the MOS mental health subscale (63.0 rural vs. 73.2 nonrural), the HADS anxiety subscale (7.4 vs. 5.7), the HADS depression subscale (6.4 vs. 4.4), and the HADS total score (13.9 vs. 10.1).

Rural patients had access to fewer tangible and informational mental health resources, including a psychologist within 30 miles (67% vs. 75%), a support group within 30 miles (25% vs. 49%), a household computer (50% vs. 70%), the use of a computer for Internet access (54% vs. 79%), and the use of a computer "quite a bit" for the Internet (11% vs. 36%) or e-mail (7% vs. 36%).

Financial resources were scarcer as well, with 39% of rural residents reporting mental health insurance coverage and 28% reporting that they had some money left after paying bills, compared with 59% and 33%, respectively, of nonrural residents.

In an interview following his presentation, Dr. Andrykowski said simply providing rural cancer patients with more mental health resources may be too simplistic a solution to address disparities.

Earlier studies suggest that in some small, rural communities, social norms cast doubt on individuals who access help in the form of support groups, psychologists, spiritual counselors, or psychotropic medications. "Friends and family may be less supportive if [the survivors] use mental health services," he said.

Privacy and confidentiality may also be compromised, said Dr. Andrykowski, although he has not yet collected data to investigate this possibility.

Until he began collecting research on geographic disparities, he said, "I thought it was a good thing [that rural patients] were embedded in a close-knit community. But it could be too close knit. [Patients may feel that] ‘if I talk to a local mental health provider or a minister, there is no possibility of anonymity. They know everyone I know.’ "

The investigators reported no relevant financial conflicts of interest. Funding for the study was provided through the Commonwealth of Kentucky’s tobacco settlement fund.

ANAHEIM, CALIF. – Coping with the emotional burdens of cancer can be a lonely struggle in rural America, results of a population-based, cross-sectional study suggest.

Researchers analyzed mental health data from a statewide cancer registry in Kentucky, and found that non–small cell lung cancer (NSCLC) survivors in rural counties had profoundly greater levels of mental health distress, but fewer interpersonal and intrapersonal coping resources, than did those living in nonrural regions of the state.

Rural survivors fared worse on every mental health outcome variable that was measured by the university researchers, including subscales of the Medical Outcomes Study (MOS-36), the Hospital Anxiety and Depression Scale (HADS), and the National Comprehensive Cancer Network Distress Thermometer Rating and Problem List.

Michael A. Andrykowski, Ph.D., professor of behavioral science at the University of Kentucky in Lexington, presented results of the study at the annual meeting of the American Psychosocial Oncology Society.

While conducting previous studies of symptoms and psychosocial outcomes among cancer patients, Dr. Andrykowski became interested in possible disparities in disease burden among rural populations in a diverse state of bustling university towns, bluegrass thoroughbred farms, coal mines, and forested Appalachian hills.

"I thought there was a pretty compelling reason to believe that cancer survivors living in rural areas experience more stress in association with the cancer experience, and fewer resources – a double whammy," said Dr. Andrykowski.

He also began to wonder whether presumed supportive factors associated with living in small, tight-knit communities might actually foster "attitudes, beliefs, and social norms less supportive of using formal and informal mental health resources," he said during his podium presentation.

To explore the question of potential disparities (a key goal of federal Healthy People 2020 guidelines), Dr. Andrykowski and associates sent questionnaires to – and conducted telephone interviews with – 144 NSCLC survivors, 76 of whom lived in counties that were designated as rural by USDA Rural-Urban Continuum Codes. The remaining 68 survivors lived in nonrural counties of Kentucky.

The two groups were well matched in terms of age (average, early 60s), minority status (7%-9%), and comorbidities (3.0-3.6). Patients from both groups had been diagnosed approximately 12-15 months prior to the study.

The rural patients had significantly less formal education (10.7 years vs. 12.9 years). They were also less optimistic, as measured by the Life Orientation Test, and less efficacious in seeking mental health support and cancer information than were nonrural patients, with significant effect sizes on those variables of 0.31, 0.39, and 0.34.

Highly significant differences were also seen in social constraint, which Dr. Andrykowski defined as a response to signals from family and friends that lead a person to limit the sharing of thoughts and feelings about a stressful event, such as a diagnosis or recurrence of cancer. Rural patients were far more likely to notice or perceive such behaviors, and to behave accordingly, he said.

Significant or highly significant differences were seen in scores on the MOS mental health subscale (63.0 rural vs. 73.2 nonrural), the HADS anxiety subscale (7.4 vs. 5.7), the HADS depression subscale (6.4 vs. 4.4), and the HADS total score (13.9 vs. 10.1).

Rural patients had access to fewer tangible and informational mental health resources, including a psychologist within 30 miles (67% vs. 75%), a support group within 30 miles (25% vs. 49%), a household computer (50% vs. 70%), the use of a computer for Internet access (54% vs. 79%), and the use of a computer "quite a bit" for the Internet (11% vs. 36%) or e-mail (7% vs. 36%).

Financial resources were scarcer as well, with 39% of rural residents reporting mental health insurance coverage and 28% reporting that they had some money left after paying bills, compared with 59% and 33%, respectively, of nonrural residents.

In an interview following his presentation, Dr. Andrykowski said simply providing rural cancer patients with more mental health resources may be too simplistic a solution to address disparities.

Earlier studies suggest that in some small, rural communities, social norms cast doubt on individuals who access help in the form of support groups, psychologists, spiritual counselors, or psychotropic medications. "Friends and family may be less supportive if [the survivors] use mental health services," he said.

Privacy and confidentiality may also be compromised, said Dr. Andrykowski, although he has not yet collected data to investigate this possibility.

Until he began collecting research on geographic disparities, he said, "I thought it was a good thing [that rural patients] were embedded in a close-knit community. But it could be too close knit. [Patients may feel that] ‘if I talk to a local mental health provider or a minister, there is no possibility of anonymity. They know everyone I know.’ "

The investigators reported no relevant financial conflicts of interest. Funding for the study was provided through the Commonwealth of Kentucky’s tobacco settlement fund.

ANAHEIM, CALIF. – Coping with the emotional burdens of cancer can be a lonely struggle in rural America, results of a population-based, cross-sectional study suggest.

Researchers analyzed mental health data from a statewide cancer registry in Kentucky, and found that non–small cell lung cancer (NSCLC) survivors in rural counties had profoundly greater levels of mental health distress, but fewer interpersonal and intrapersonal coping resources, than did those living in nonrural regions of the state.

Rural survivors fared worse on every mental health outcome variable that was measured by the university researchers, including subscales of the Medical Outcomes Study (MOS-36), the Hospital Anxiety and Depression Scale (HADS), and the National Comprehensive Cancer Network Distress Thermometer Rating and Problem List.

Michael A. Andrykowski, Ph.D., professor of behavioral science at the University of Kentucky in Lexington, presented results of the study at the annual meeting of the American Psychosocial Oncology Society.

While conducting previous studies of symptoms and psychosocial outcomes among cancer patients, Dr. Andrykowski became interested in possible disparities in disease burden among rural populations in a diverse state of bustling university towns, bluegrass thoroughbred farms, coal mines, and forested Appalachian hills.

"I thought there was a pretty compelling reason to believe that cancer survivors living in rural areas experience more stress in association with the cancer experience, and fewer resources – a double whammy," said Dr. Andrykowski.

He also began to wonder whether presumed supportive factors associated with living in small, tight-knit communities might actually foster "attitudes, beliefs, and social norms less supportive of using formal and informal mental health resources," he said during his podium presentation.

To explore the question of potential disparities (a key goal of federal Healthy People 2020 guidelines), Dr. Andrykowski and associates sent questionnaires to – and conducted telephone interviews with – 144 NSCLC survivors, 76 of whom lived in counties that were designated as rural by USDA Rural-Urban Continuum Codes. The remaining 68 survivors lived in nonrural counties of Kentucky.

The two groups were well matched in terms of age (average, early 60s), minority status (7%-9%), and comorbidities (3.0-3.6). Patients from both groups had been diagnosed approximately 12-15 months prior to the study.

The rural patients had significantly less formal education (10.7 years vs. 12.9 years). They were also less optimistic, as measured by the Life Orientation Test, and less efficacious in seeking mental health support and cancer information than were nonrural patients, with significant effect sizes on those variables of 0.31, 0.39, and 0.34.

Highly significant differences were also seen in social constraint, which Dr. Andrykowski defined as a response to signals from family and friends that lead a person to limit the sharing of thoughts and feelings about a stressful event, such as a diagnosis or recurrence of cancer. Rural patients were far more likely to notice or perceive such behaviors, and to behave accordingly, he said.

Significant or highly significant differences were seen in scores on the MOS mental health subscale (63.0 rural vs. 73.2 nonrural), the HADS anxiety subscale (7.4 vs. 5.7), the HADS depression subscale (6.4 vs. 4.4), and the HADS total score (13.9 vs. 10.1).

Rural patients had access to fewer tangible and informational mental health resources, including a psychologist within 30 miles (67% vs. 75%), a support group within 30 miles (25% vs. 49%), a household computer (50% vs. 70%), the use of a computer for Internet access (54% vs. 79%), and the use of a computer "quite a bit" for the Internet (11% vs. 36%) or e-mail (7% vs. 36%).

Financial resources were scarcer as well, with 39% of rural residents reporting mental health insurance coverage and 28% reporting that they had some money left after paying bills, compared with 59% and 33%, respectively, of nonrural residents.

In an interview following his presentation, Dr. Andrykowski said simply providing rural cancer patients with more mental health resources may be too simplistic a solution to address disparities.

Earlier studies suggest that in some small, rural communities, social norms cast doubt on individuals who access help in the form of support groups, psychologists, spiritual counselors, or psychotropic medications. "Friends and family may be less supportive if [the survivors] use mental health services," he said.

Privacy and confidentiality may also be compromised, said Dr. Andrykowski, although he has not yet collected data to investigate this possibility.

Until he began collecting research on geographic disparities, he said, "I thought it was a good thing [that rural patients] were embedded in a close-knit community. But it could be too close knit. [Patients may feel that] ‘if I talk to a local mental health provider or a minister, there is no possibility of anonymity. They know everyone I know.’ "

The investigators reported no relevant financial conflicts of interest. Funding for the study was provided through the Commonwealth of Kentucky’s tobacco settlement fund.

ANAHEIM, CALIF. – Coping with the emotional burdens of cancer can be a lonely struggle in rural America, results of a population-based, cross-sectional study suggest.

Researchers analyzed mental health data from a statewide cancer registry in Kentucky, and found that non–small cell lung cancer (NSCLC) survivors in rural counties had profoundly greater levels of mental health distress, but fewer interpersonal and intrapersonal coping resources, than did those living in nonrural regions of the state.

Rural survivors fared worse on every mental health outcome variable that was measured by the university researchers, including subscales of the Medical Outcomes Study (MOS-36), the Hospital Anxiety and Depression Scale (HADS), and the National Comprehensive Cancer Network Distress Thermometer Rating and Problem List.

Michael A. Andrykowski, Ph.D., professor of behavioral science at the University of Kentucky in Lexington, presented results of the study at the annual meeting of the American Psychosocial Oncology Society.

While conducting previous studies of symptoms and psychosocial outcomes among cancer patients, Dr. Andrykowski became interested in possible disparities in disease burden among rural populations in a diverse state of bustling university towns, bluegrass thoroughbred farms, coal mines, and forested Appalachian hills.

"I thought there was a pretty compelling reason to believe that cancer survivors living in rural areas experience more stress in association with the cancer experience, and fewer resources – a double whammy," said Dr. Andrykowski.

He also began to wonder whether presumed supportive factors associated with living in small, tight-knit communities might actually foster "attitudes, beliefs, and social norms less supportive of using formal and informal mental health resources," he said during his podium presentation.

To explore the question of potential disparities (a key goal of federal Healthy People 2020 guidelines), Dr. Andrykowski and associates sent questionnaires to – and conducted telephone interviews with – 144 NSCLC survivors, 76 of whom lived in counties that were designated as rural by USDA Rural-Urban Continuum Codes. The remaining 68 survivors lived in nonrural counties of Kentucky.

The two groups were well matched in terms of age (average, early 60s), minority status (7%-9%), and comorbidities (3.0-3.6). Patients from both groups had been diagnosed approximately 12-15 months prior to the study.

The rural patients had significantly less formal education (10.7 years vs. 12.9 years). They were also less optimistic, as measured by the Life Orientation Test, and less efficacious in seeking mental health support and cancer information than were nonrural patients, with significant effect sizes on those variables of 0.31, 0.39, and 0.34.

Highly significant differences were also seen in social constraint, which Dr. Andrykowski defined as a response to signals from family and friends that lead a person to limit the sharing of thoughts and feelings about a stressful event, such as a diagnosis or recurrence of cancer. Rural patients were far more likely to notice or perceive such behaviors, and to behave accordingly, he said.

Significant or highly significant differences were seen in scores on the MOS mental health subscale (63.0 rural vs. 73.2 nonrural), the HADS anxiety subscale (7.4 vs. 5.7), the HADS depression subscale (6.4 vs. 4.4), and the HADS total score (13.9 vs. 10.1).

Rural patients had access to fewer tangible and informational mental health resources, including a psychologist within 30 miles (67% vs. 75%), a support group within 30 miles (25% vs. 49%), a household computer (50% vs. 70%), the use of a computer for Internet access (54% vs. 79%), and the use of a computer "quite a bit" for the Internet (11% vs. 36%) or e-mail (7% vs. 36%).

Financial resources were scarcer as well, with 39% of rural residents reporting mental health insurance coverage and 28% reporting that they had some money left after paying bills, compared with 59% and 33%, respectively, of nonrural residents.

In an interview following his presentation, Dr. Andrykowski said simply providing rural cancer patients with more mental health resources may be too simplistic a solution to address disparities.

Earlier studies suggest that in some small, rural communities, social norms cast doubt on individuals who access help in the form of support groups, psychologists, spiritual counselors, or psychotropic medications. "Friends and family may be less supportive if [the survivors] use mental health services," he said.

Privacy and confidentiality may also be compromised, said Dr. Andrykowski, although he has not yet collected data to investigate this possibility.

Until he began collecting research on geographic disparities, he said, "I thought it was a good thing [that rural patients] were embedded in a close-knit community. But it could be too close knit. [Patients may feel that] ‘if I talk to a local mental health provider or a minister, there is no possibility of anonymity. They know everyone I know.’ "

The investigators reported no relevant financial conflicts of interest. Funding for the study was provided through the Commonwealth of Kentucky’s tobacco settlement fund.

ANAHEIM, CALIF. – Highlighting shifting priorities after the recession, nearly half of all recent psychosocial consultations with patients at a leading cancer center involved financial worries, rather than adjustment issues or other pressing mental health concerns.

Among 313 single-episode encounters at the Cleveland Clinic’s Taussig Cancer Institute during one month in late summer 2010, 49% focused on financial issues, according to a study presented at the annual conference of the American Psychosocial Oncology Society.

These included a lack of adequate health insurance, inability to afford medications, housing crises, and/or difficulties in meeting basic financial obligations during cancer treatment, reported Christa Poole, a social worker at the institute.

"This study was a result of the [social work] team noticing a trend in increased consultation requests and interventions related to financial need," Ms. Poole said in an interview.

Among patients’ presenting concerns were losses of benefits from layoffs, high COBRA premiums, and housing foreclosures, with these challenges often taking precedence over the more existential struggles faced by patients facing life-altering or life-threatening cancer diagnoses.

In the study, mental health distress – including coping challenges, adjustment to the diagnosis or treatment, and acute risk assessment for suicidality – constituted 37% of social work consultations, followed by other issues, including coordination of family meetings to discuss goals of care or decision making (5%), and domestic or family violence (2%).

The institute’s five social workers are now very often placed in a position of having to focus immediate attention on patients’ basic needs, while staying attuned to their depression, anxiety, grief, and changes in life roles and self-image, according to Ms. Poole.

"Cancer care, in most cases, cannot wait. These financial worries cause significant distress and when not addressed, may cause barriers to quality care," she said.

At times, money woes are now directly impinging on medical care, she added, affecting choices patients and families make about cancer treatment regimens or symptom management. "Unfortunately, some patients choose care or treatment that will avoid debt or hardship for their loved ones," even when those choices may affect their survival or comfort, said Ms. Poole.

"We don’t want to see patients in situations where they are choosing between paying an electric bill and paying for a drug to control nausea, when we know that patients need both."

Financial burdens influence adherence as well, she noted: "When patients can’t afford gas or copays, they often cancel or ‘no-show’ for appointments."

The "devastation of financial recession" has not only jolted the priorities of cancer patients, but also has taxed the institutional and external philanthropic assistance programs that once addressed such needs, said Ms. Poole.

"Resources are continuing to dwindle. Programs are simply running out of funding and are much less able to extend financial assistance," she said. "This issue deserves continued attention and investigation, as the problem may worsen. How will hospital policies and programs respond to absorbing unpaid medical debt?"

Ms. Poole said her department continues to track trends in consultation, "as the full impact of the economic crisis continues to unfold in health care."

Investigators reported no relevant financial disclosures.

ANAHEIM, CALIF. – Highlighting shifting priorities after the recession, nearly half of all recent psychosocial consultations with patients at a leading cancer center involved financial worries, rather than adjustment issues or other pressing mental health concerns.

Among 313 single-episode encounters at the Cleveland Clinic’s Taussig Cancer Institute during one month in late summer 2010, 49% focused on financial issues, according to a study presented at the annual conference of the American Psychosocial Oncology Society.

These included a lack of adequate health insurance, inability to afford medications, housing crises, and/or difficulties in meeting basic financial obligations during cancer treatment, reported Christa Poole, a social worker at the institute.

"This study was a result of the [social work] team noticing a trend in increased consultation requests and interventions related to financial need," Ms. Poole said in an interview.

Among patients’ presenting concerns were losses of benefits from layoffs, high COBRA premiums, and housing foreclosures, with these challenges often taking precedence over the more existential struggles faced by patients facing life-altering or life-threatening cancer diagnoses.

In the study, mental health distress – including coping challenges, adjustment to the diagnosis or treatment, and acute risk assessment for suicidality – constituted 37% of social work consultations, followed by other issues, including coordination of family meetings to discuss goals of care or decision making (5%), and domestic or family violence (2%).

The institute’s five social workers are now very often placed in a position of having to focus immediate attention on patients’ basic needs, while staying attuned to their depression, anxiety, grief, and changes in life roles and self-image, according to Ms. Poole.

"Cancer care, in most cases, cannot wait. These financial worries cause significant distress and when not addressed, may cause barriers to quality care," she said.

At times, money woes are now directly impinging on medical care, she added, affecting choices patients and families make about cancer treatment regimens or symptom management. "Unfortunately, some patients choose care or treatment that will avoid debt or hardship for their loved ones," even when those choices may affect their survival or comfort, said Ms. Poole.

"We don’t want to see patients in situations where they are choosing between paying an electric bill and paying for a drug to control nausea, when we know that patients need both."

Financial burdens influence adherence as well, she noted: "When patients can’t afford gas or copays, they often cancel or ‘no-show’ for appointments."

The "devastation of financial recession" has not only jolted the priorities of cancer patients, but also has taxed the institutional and external philanthropic assistance programs that once addressed such needs, said Ms. Poole.

"Resources are continuing to dwindle. Programs are simply running out of funding and are much less able to extend financial assistance," she said. "This issue deserves continued attention and investigation, as the problem may worsen. How will hospital policies and programs respond to absorbing unpaid medical debt?"

Ms. Poole said her department continues to track trends in consultation, "as the full impact of the economic crisis continues to unfold in health care."

Investigators reported no relevant financial disclosures.

ANAHEIM, CALIF. – Highlighting shifting priorities after the recession, nearly half of all recent psychosocial consultations with patients at a leading cancer center involved financial worries, rather than adjustment issues or other pressing mental health concerns.

Among 313 single-episode encounters at the Cleveland Clinic’s Taussig Cancer Institute during one month in late summer 2010, 49% focused on financial issues, according to a study presented at the annual conference of the American Psychosocial Oncology Society.

These included a lack of adequate health insurance, inability to afford medications, housing crises, and/or difficulties in meeting basic financial obligations during cancer treatment, reported Christa Poole, a social worker at the institute.

"This study was a result of the [social work] team noticing a trend in increased consultation requests and interventions related to financial need," Ms. Poole said in an interview.

Among patients’ presenting concerns were losses of benefits from layoffs, high COBRA premiums, and housing foreclosures, with these challenges often taking precedence over the more existential struggles faced by patients facing life-altering or life-threatening cancer diagnoses.

In the study, mental health distress – including coping challenges, adjustment to the diagnosis or treatment, and acute risk assessment for suicidality – constituted 37% of social work consultations, followed by other issues, including coordination of family meetings to discuss goals of care or decision making (5%), and domestic or family violence (2%).

The institute’s five social workers are now very often placed in a position of having to focus immediate attention on patients’ basic needs, while staying attuned to their depression, anxiety, grief, and changes in life roles and self-image, according to Ms. Poole.

"Cancer care, in most cases, cannot wait. These financial worries cause significant distress and when not addressed, may cause barriers to quality care," she said.

At times, money woes are now directly impinging on medical care, she added, affecting choices patients and families make about cancer treatment regimens or symptom management. "Unfortunately, some patients choose care or treatment that will avoid debt or hardship for their loved ones," even when those choices may affect their survival or comfort, said Ms. Poole.

"We don’t want to see patients in situations where they are choosing between paying an electric bill and paying for a drug to control nausea, when we know that patients need both."

Financial burdens influence adherence as well, she noted: "When patients can’t afford gas or copays, they often cancel or ‘no-show’ for appointments."

The "devastation of financial recession" has not only jolted the priorities of cancer patients, but also has taxed the institutional and external philanthropic assistance programs that once addressed such needs, said Ms. Poole.

"Resources are continuing to dwindle. Programs are simply running out of funding and are much less able to extend financial assistance," she said. "This issue deserves continued attention and investigation, as the problem may worsen. How will hospital policies and programs respond to absorbing unpaid medical debt?"

Ms. Poole said her department continues to track trends in consultation, "as the full impact of the economic crisis continues to unfold in health care."

Investigators reported no relevant financial disclosures.

ANAHEIM, CALIF. – Highlighting shifting priorities after the recession, nearly half of all recent psychosocial consultations with patients at a leading cancer center involved financial worries, rather than adjustment issues or other pressing mental health concerns.

Among 313 single-episode encounters at the Cleveland Clinic’s Taussig Cancer Institute during one month in late summer 2010, 49% focused on financial issues, according to a study presented at the annual conference of the American Psychosocial Oncology Society.

These included a lack of adequate health insurance, inability to afford medications, housing crises, and/or difficulties in meeting basic financial obligations during cancer treatment, reported Christa Poole, a social worker at the institute.

"This study was a result of the [social work] team noticing a trend in increased consultation requests and interventions related to financial need," Ms. Poole said in an interview.

Among patients’ presenting concerns were losses of benefits from layoffs, high COBRA premiums, and housing foreclosures, with these challenges often taking precedence over the more existential struggles faced by patients facing life-altering or life-threatening cancer diagnoses.

In the study, mental health distress – including coping challenges, adjustment to the diagnosis or treatment, and acute risk assessment for suicidality – constituted 37% of social work consultations, followed by other issues, including coordination of family meetings to discuss goals of care or decision making (5%), and domestic or family violence (2%).

The institute’s five social workers are now very often placed in a position of having to focus immediate attention on patients’ basic needs, while staying attuned to their depression, anxiety, grief, and changes in life roles and self-image, according to Ms. Poole.

"Cancer care, in most cases, cannot wait. These financial worries cause significant distress and when not addressed, may cause barriers to quality care," she said.

At times, money woes are now directly impinging on medical care, she added, affecting choices patients and families make about cancer treatment regimens or symptom management. "Unfortunately, some patients choose care or treatment that will avoid debt or hardship for their loved ones," even when those choices may affect their survival or comfort, said Ms. Poole.

"We don’t want to see patients in situations where they are choosing between paying an electric bill and paying for a drug to control nausea, when we know that patients need both."

Financial burdens influence adherence as well, she noted: "When patients can’t afford gas or copays, they often cancel or ‘no-show’ for appointments."

The "devastation of financial recession" has not only jolted the priorities of cancer patients, but also has taxed the institutional and external philanthropic assistance programs that once addressed such needs, said Ms. Poole.

"Resources are continuing to dwindle. Programs are simply running out of funding and are much less able to extend financial assistance," she said. "This issue deserves continued attention and investigation, as the problem may worsen. How will hospital policies and programs respond to absorbing unpaid medical debt?"

Ms. Poole said her department continues to track trends in consultation, "as the full impact of the economic crisis continues to unfold in health care."

Investigators reported no relevant financial disclosures.

ANAHEIM, CALIF. – Highlighting shifting priorities after the recession, nearly half of all recent psychosocial consultations with patients at a leading cancer center involved financial worries, rather than adjustment issues or other pressing mental health concerns.

Among 313 single-episode encounters at the Cleveland Clinic’s Taussig Cancer Institute during one month in late summer 2010, 49% focused on financial issues, according to a study presented at the annual conference of the American Psychosocial Oncology Society.

These included a lack of adequate health insurance, inability to afford medications, housing crises, and/or difficulties in meeting basic financial obligations during cancer treatment, reported Christa Poole, a social worker at the institute.

"This study was a result of the [social work] team noticing a trend in increased consultation requests and interventions related to financial need," Ms. Poole said in an interview.

Among patients’ presenting concerns were losses of benefits from layoffs, high COBRA premiums, and housing foreclosures, with these challenges often taking precedence over the more existential struggles faced by patients facing life-altering or life-threatening cancer diagnoses.

In the study, mental health distress – including coping challenges, adjustment to the diagnosis or treatment, and acute risk assessment for suicidality – constituted 37% of social work consultations, followed by other issues, including coordination of family meetings to discuss goals of care or decision making (5%), and domestic or family violence (2%).

The institute’s five social workers are now very often placed in a position of having to focus immediate attention on patients’ basic needs, while staying attuned to their depression, anxiety, grief, and changes in life roles and self-image, according to Ms. Poole.

"Cancer care, in most cases, cannot wait. These financial worries cause significant distress and when not addressed, may cause barriers to quality care," she said.

At times, money woes are now directly impinging on medical care, she added, affecting choices patients and families make about cancer treatment regimens or symptom management. "Unfortunately, some patients choose care or treatment that will avoid debt or hardship for their loved ones," even when those choices may affect their survival or comfort, said Ms. Poole.

"We don’t want to see patients in situations where they are choosing between paying an electric bill and paying for a drug to control nausea, when we know that patients need both."

Financial burdens influence adherence as well, she noted: "When patients can’t afford gas or copays, they often cancel or ‘no-show’ for appointments."

The "devastation of financial recession" has not only jolted the priorities of cancer patients, but also has taxed the institutional and external philanthropic assistance programs that once addressed such needs, said Ms. Poole.

"Resources are continuing to dwindle. Programs are simply running out of funding and are much less able to extend financial assistance," she said. "This issue deserves continued attention and investigation, as the problem may worsen. How will hospital policies and programs respond to absorbing unpaid medical debt?"

Ms. Poole said her department continues to track trends in consultation, "as the full impact of the economic crisis continues to unfold in health care."

Investigators reported no relevant financial disclosures.

ANAHEIM, CALIF. – Highlighting shifting priorities after the recession, nearly half of all recent psychosocial consultations with patients at a leading cancer center involved financial worries, rather than adjustment issues or other pressing mental health concerns.

Among 313 single-episode encounters at the Cleveland Clinic’s Taussig Cancer Institute during one month in late summer 2010, 49% focused on financial issues, according to a study presented at the annual conference of the American Psychosocial Oncology Society.

These included a lack of adequate health insurance, inability to afford medications, housing crises, and/or difficulties in meeting basic financial obligations during cancer treatment, reported Christa Poole, a social worker at the institute.

"This study was a result of the [social work] team noticing a trend in increased consultation requests and interventions related to financial need," Ms. Poole said in an interview.

Among patients’ presenting concerns were losses of benefits from layoffs, high COBRA premiums, and housing foreclosures, with these challenges often taking precedence over the more existential struggles faced by patients facing life-altering or life-threatening cancer diagnoses.

In the study, mental health distress – including coping challenges, adjustment to the diagnosis or treatment, and acute risk assessment for suicidality – constituted 37% of social work consultations, followed by other issues, including coordination of family meetings to discuss goals of care or decision making (5%), and domestic or family violence (2%).

The institute’s five social workers are now very often placed in a position of having to focus immediate attention on patients’ basic needs, while staying attuned to their depression, anxiety, grief, and changes in life roles and self-image, according to Ms. Poole.

"Cancer care, in most cases, cannot wait. These financial worries cause significant distress and when not addressed, may cause barriers to quality care," she said.

At times, money woes are now directly impinging on medical care, she added, affecting choices patients and families make about cancer treatment regimens or symptom management. "Unfortunately, some patients choose care or treatment that will avoid debt or hardship for their loved ones," even when those choices may affect their survival or comfort, said Ms. Poole.

"We don’t want to see patients in situations where they are choosing between paying an electric bill and paying for a drug to control nausea, when we know that patients need both."

Financial burdens influence adherence as well, she noted: "When patients can’t afford gas or copays, they often cancel or ‘no-show’ for appointments."

The "devastation of financial recession" has not only jolted the priorities of cancer patients, but also has taxed the institutional and external philanthropic assistance programs that once addressed such needs, said Ms. Poole.

"Resources are continuing to dwindle. Programs are simply running out of funding and are much less able to extend financial assistance," she said. "This issue deserves continued attention and investigation, as the problem may worsen. How will hospital policies and programs respond to absorbing unpaid medical debt?"

Ms. Poole said her department continues to track trends in consultation, "as the full impact of the economic crisis continues to unfold in health care."

Investigators reported no relevant financial disclosures.

SANTA BARBARA, CALIF. — Gestational surrogacy remains mired in legal limbo from state to state and nation to nation, despite its promise as a road to parenthood for the most difficult-to-treat infertility patients.

Resulting uncertainties have discouraged the majority of Society for Assisted Reproductive Technology (SART) member centers from performing surrogacy, to the detriment of patients in need, said Dr. Gabriel Garzo of the University of California, San Diego.

The number of surrogacy cycles reported by SART edged upward in 2008, a reversal of a 15.5% decline in 2007, he reported at the meeting sponsored by the University of California, Los Angeles.

Figures for 2009 are not yet available, Sean Tipton, director of public affairs for the American Society for Reproductive Medicine, said in an interview.

In 2008, there were 847 surrogacy cycles reported, not including those involving egg donation, which Dr. Garzo estimated may have added about 150 to the total. In 2005, 731 cycles were reported, followed by 784 in 2006, and just 662 in 2007.

Indications for surrogacy most often include an absent or nonfunctional uterus, medical conditions that pose a risk during pregnancy, repeated in vitro fertilization failure, and/or recurrent pregnancy loss.

Contracting with a surrogate in such cases offers the possibility of having a child that is genetically related to one or both members of a couple.

Medically, the practice is quite straightforward and similar to egg donation, said Dr. Garzo.

However, legal, ethical, and psychological challenges abound.

The majority of states have no statutes regarding surrogacy, and in a handful of jurisdictions, including Michigan, New York, and Washington, D.C., surrogacy contracts are considered a crime.

“In many states, genetic parents have to adopt their genetic child born to a surrogate mother,” he said.

Monetary questions are always an issue. In Illinois, for instance, government bodies are debating the issue of whose health insurance pays maternity benefits: the surrogate's or the “intended parent's” insurance?

In Wisconsin, insurance policies that cover maternity expenses cannot exclude coverage for women acting as surrogate mothers, that state's Supreme Court held.

Potential controversies are especially acute in the case of paid surrogacy, when compensation covers more than the surrogate's medical and health expenses.

Bitter legal disputes have arisen, in which egg donors, sperm donors, surrogates, and divorcing “intended parents” fight for custody in the absence of clear statutes, precedents, or federal guidelines.

Legal dilemmas have crossed international borders as well. In India, where surrogacy for couples around the world has become a $445 million-a-year business, human rights activists have questioned the practice of requiring some surrogates to remain in supervised dormitories with limited visits from their families. The citizenship of surrogate children born in Indian clinics has been called into question, as in the case of genetic twins of a British mother who were “stateless” for weeks when the United Kingdom determined they were Indian citizens and India declared them to be British citizens.

Intended parents from Germany and Japan also have faced challenges in having their genetic children recognized by their governments after surrogate births in India.

A Canadian couple who underwent DNA testing as part of the adoption of twins they assumed were their offspring discovered that they had no genetic link to the infants born to a surrogate in India. Those babies are now being raised in an orphanage, said Dr. Garzo.

Some American surrogacy agencies are under scrutiny as well, including one in Beverly Hills, Calif., that is being sued by seven couples from Spain who alleged that they were duped into spending hundreds of thousands of dollars for surrogacy contracts that never materialized.

In the midst of such turmoil, Dr. Garzo encouraged physicians who decline to participate in surrogacy to refer couples not to an agency, but to an ART center that performs surrogacy, since agencies are not subject to any oversight or licensing requirements. “The professional psychosocial screening of surrogates and genetic parents is really essential to prevent potential problems,” he said.

Surrogate medical screening is also necessary, but simpler, aiming at ensuring the candidate is healthy, is under age 35, and has a BMI of less than 30 kg/m

Single embryos should be transferred unless extraordinary circumstances exist, said Dr. Garzo.

Any legal contract must conform with state statutes or case law, and should include preconditions and consideration of health-related behaviors of the surrogate, as well as contingencies in the case of prenatal diagnosis of genetic or chromosomal abnormalities, birth of a child with disabilities, and/or death or divorce of any of the parties involved, he said.

Oversight of interactions between the surrogate and infertile couple should be mediated, the underlying premise being that the surrogate should bond with the couple rather than the child.

Several small studies have found that this goal is usually achieved, with no psychological problems detected in well-screened surrogates or commissioning mothers, Dr. Garzo said.

Dr. Garzo reported no relevant financial conflicts of interest.

In India, surrogacy for couples around the world has become a $445 million-a-year business.

Source ©India Today Group/Getty Images

SANTA BARBARA, CALIF. — Gestational surrogacy remains mired in legal limbo from state to state and nation to nation, despite its promise as a road to parenthood for the most difficult-to-treat infertility patients.

Resulting uncertainties have discouraged the majority of Society for Assisted Reproductive Technology (SART) member centers from performing surrogacy, to the detriment of patients in need, said Dr. Gabriel Garzo of the University of California, San Diego.

The number of surrogacy cycles reported by SART edged upward in 2008, a reversal of a 15.5% decline in 2007, he reported at the meeting sponsored by the University of California, Los Angeles.

Figures for 2009 are not yet available, Sean Tipton, director of public affairs for the American Society for Reproductive Medicine, said in an interview.

In 2008, there were 847 surrogacy cycles reported, not including those involving egg donation, which Dr. Garzo estimated may have added about 150 to the total. In 2005, 731 cycles were reported, followed by 784 in 2006, and just 662 in 2007.

Indications for surrogacy most often include an absent or nonfunctional uterus, medical conditions that pose a risk during pregnancy, repeated in vitro fertilization failure, and/or recurrent pregnancy loss.

Contracting with a surrogate in such cases offers the possibility of having a child that is genetically related to one or both members of a couple.

Medically, the practice is quite straightforward and similar to egg donation, said Dr. Garzo.

However, legal, ethical, and psychological challenges abound.

The majority of states have no statutes regarding surrogacy, and in a handful of jurisdictions, including Michigan, New York, and Washington, D.C., surrogacy contracts are considered a crime.

“In many states, genetic parents have to adopt their genetic child born to a surrogate mother,” he said.

Monetary questions are always an issue. In Illinois, for instance, government bodies are debating the issue of whose health insurance pays maternity benefits: the surrogate's or the “intended parent's” insurance?

In Wisconsin, insurance policies that cover maternity expenses cannot exclude coverage for women acting as surrogate mothers, that state's Supreme Court held.

Potential controversies are especially acute in the case of paid surrogacy, when compensation covers more than the surrogate's medical and health expenses.

Bitter legal disputes have arisen, in which egg donors, sperm donors, surrogates, and divorcing “intended parents” fight for custody in the absence of clear statutes, precedents, or federal guidelines.

Legal dilemmas have crossed international borders as well. In India, where surrogacy for couples around the world has become a $445 million-a-year business, human rights activists have questioned the practice of requiring some surrogates to remain in supervised dormitories with limited visits from their families. The citizenship of surrogate children born in Indian clinics has been called into question, as in the case of genetic twins of a British mother who were “stateless” for weeks when the United Kingdom determined they were Indian citizens and India declared them to be British citizens.

Intended parents from Germany and Japan also have faced challenges in having their genetic children recognized by their governments after surrogate births in India.

A Canadian couple who underwent DNA testing as part of the adoption of twins they assumed were their offspring discovered that they had no genetic link to the infants born to a surrogate in India. Those babies are now being raised in an orphanage, said Dr. Garzo.

Some American surrogacy agencies are under scrutiny as well, including one in Beverly Hills, Calif., that is being sued by seven couples from Spain who alleged that they were duped into spending hundreds of thousands of dollars for surrogacy contracts that never materialized.

In the midst of such turmoil, Dr. Garzo encouraged physicians who decline to participate in surrogacy to refer couples not to an agency, but to an ART center that performs surrogacy, since agencies are not subject to any oversight or licensing requirements. “The professional psychosocial screening of surrogates and genetic parents is really essential to prevent potential problems,” he said.

Surrogate medical screening is also necessary, but simpler, aiming at ensuring the candidate is healthy, is under age 35, and has a BMI of less than 30 kg/m

Single embryos should be transferred unless extraordinary circumstances exist, said Dr. Garzo.

Any legal contract must conform with state statutes or case law, and should include preconditions and consideration of health-related behaviors of the surrogate, as well as contingencies in the case of prenatal diagnosis of genetic or chromosomal abnormalities, birth of a child with disabilities, and/or death or divorce of any of the parties involved, he said.

Oversight of interactions between the surrogate and infertile couple should be mediated, the underlying premise being that the surrogate should bond with the couple rather than the child.

Several small studies have found that this goal is usually achieved, with no psychological problems detected in well-screened surrogates or commissioning mothers, Dr. Garzo said.

Dr. Garzo reported no relevant financial conflicts of interest.

In India, surrogacy for couples around the world has become a $445 million-a-year business.

Source ©India Today Group/Getty Images

SANTA BARBARA, CALIF. — Gestational surrogacy remains mired in legal limbo from state to state and nation to nation, despite its promise as a road to parenthood for the most difficult-to-treat infertility patients.

Resulting uncertainties have discouraged the majority of Society for Assisted Reproductive Technology (SART) member centers from performing surrogacy, to the detriment of patients in need, said Dr. Gabriel Garzo of the University of California, San Diego.

The number of surrogacy cycles reported by SART edged upward in 2008, a reversal of a 15.5% decline in 2007, he reported at the meeting sponsored by the University of California, Los Angeles.

Figures for 2009 are not yet available, Sean Tipton, director of public affairs for the American Society for Reproductive Medicine, said in an interview.

In 2008, there were 847 surrogacy cycles reported, not including those involving egg donation, which Dr. Garzo estimated may have added about 150 to the total. In 2005, 731 cycles were reported, followed by 784 in 2006, and just 662 in 2007.

Indications for surrogacy most often include an absent or nonfunctional uterus, medical conditions that pose a risk during pregnancy, repeated in vitro fertilization failure, and/or recurrent pregnancy loss.

Contracting with a surrogate in such cases offers the possibility of having a child that is genetically related to one or both members of a couple.

Medically, the practice is quite straightforward and similar to egg donation, said Dr. Garzo.

However, legal, ethical, and psychological challenges abound.

The majority of states have no statutes regarding surrogacy, and in a handful of jurisdictions, including Michigan, New York, and Washington, D.C., surrogacy contracts are considered a crime.

“In many states, genetic parents have to adopt their genetic child born to a surrogate mother,” he said.

Monetary questions are always an issue. In Illinois, for instance, government bodies are debating the issue of whose health insurance pays maternity benefits: the surrogate's or the “intended parent's” insurance?

In Wisconsin, insurance policies that cover maternity expenses cannot exclude coverage for women acting as surrogate mothers, that state's Supreme Court held.

Potential controversies are especially acute in the case of paid surrogacy, when compensation covers more than the surrogate's medical and health expenses.

Bitter legal disputes have arisen, in which egg donors, sperm donors, surrogates, and divorcing “intended parents” fight for custody in the absence of clear statutes, precedents, or federal guidelines.

Legal dilemmas have crossed international borders as well. In India, where surrogacy for couples around the world has become a $445 million-a-year business, human rights activists have questioned the practice of requiring some surrogates to remain in supervised dormitories with limited visits from their families. The citizenship of surrogate children born in Indian clinics has been called into question, as in the case of genetic twins of a British mother who were “stateless” for weeks when the United Kingdom determined they were Indian citizens and India declared them to be British citizens.

Intended parents from Germany and Japan also have faced challenges in having their genetic children recognized by their governments after surrogate births in India.

A Canadian couple who underwent DNA testing as part of the adoption of twins they assumed were their offspring discovered that they had no genetic link to the infants born to a surrogate in India. Those babies are now being raised in an orphanage, said Dr. Garzo.

Some American surrogacy agencies are under scrutiny as well, including one in Beverly Hills, Calif., that is being sued by seven couples from Spain who alleged that they were duped into spending hundreds of thousands of dollars for surrogacy contracts that never materialized.

In the midst of such turmoil, Dr. Garzo encouraged physicians who decline to participate in surrogacy to refer couples not to an agency, but to an ART center that performs surrogacy, since agencies are not subject to any oversight or licensing requirements. “The professional psychosocial screening of surrogates and genetic parents is really essential to prevent potential problems,” he said.

Surrogate medical screening is also necessary, but simpler, aiming at ensuring the candidate is healthy, is under age 35, and has a BMI of less than 30 kg/m

Single embryos should be transferred unless extraordinary circumstances exist, said Dr. Garzo.

Any legal contract must conform with state statutes or case law, and should include preconditions and consideration of health-related behaviors of the surrogate, as well as contingencies in the case of prenatal diagnosis of genetic or chromosomal abnormalities, birth of a child with disabilities, and/or death or divorce of any of the parties involved, he said.

Oversight of interactions between the surrogate and infertile couple should be mediated, the underlying premise being that the surrogate should bond with the couple rather than the child.

Several small studies have found that this goal is usually achieved, with no psychological problems detected in well-screened surrogates or commissioning mothers, Dr. Garzo said.

Dr. Garzo reported no relevant financial conflicts of interest.

In India, surrogacy for couples around the world has become a $445 million-a-year business.

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