Caroline Helwick

NEW ORLEANS — Primary care providers often feel unequipped to deal with issues of cancer survivorship, according to a survey of 103 physicians, nurse practitioners, and physician assistants at the Henry Ford Health System in Detroit.

More than half (61%) were uncertain about their role in follow-up care (surveillance) for the most common types of cancer, Teresa Lynch, Ph.D., reported at the annual conference of the American Psychosocial Oncology Society. These included lung, breast, prostate, colorectal, bladder, melanoma, non-Hodgkin's lymphoma, kidney/renal cell, leukemia, and endometrial malignancies.

Nearly half (46%) were uncertain of the patterns of morbidity associated with cancer treatments, she added, and 31% were uncertain as to what medical interventions are recommended for preventing or remediating morbidities associated with common cancers.

“Surveys of patients and professionals indicate that posttreatment cancer care is at best fragmented and at worse nonexistent,” said Dr. Lynch, a psychologist at the Josephine Cancer Center at Henry Ford. “PCPs do want to care for cancer patients. They believe it is part of their role, but they are currently very unclear as to what their exact responsibilities are.”

Dr. Lynch and her colleagues are initiating a survivorship program to address the posttreatment needs of approximately 4,000 new cancer patients a year at their center. The program will incorporate care plans into the electronic medical record (EMR), and provide education to fill the gaps in knowledge that they are identifying in surveys of PCPs.

This study involved 103 PCPs who provide services within the large, diverse health care system and who had access to EMRs. The online survey questioned their beliefs and attitudes about providing survivorship care—specifically, knowledge of survivorship care and surveillance.

About half of the respondents were house officers, 30% were senior staff, and the rest were nurse practitioners or physician assistants. In all, 42% were 20-30 years of age, 17% were 31-40, 14% were 41-50, and 27% were 51 years or older.

In all categories, older providers felt less familiar with the issues, and house officers felt most confident, Dr. Lynch reported. Significantly, older providers also said that they were not completely comfortable in caring for cancer patients.

“Providers definitely thought it was important for them to understand cancer follow-up plans, but over 40% thought they did not receive timely information about changes in their patients' cancer status, medications, or treatments,” she said. “Almost 30% of PCPs had difficulty determining patients' follow-up plans in the EMR.”

More than half of the providers said they “rely” on patients to inform them of their follow-up plans. Yet more than 80% of providers believed their patients are confused about follow-up.

“Based on these survey results, we believe that providers need a reliable source to guide their care of cancer patients, and patients need to be better informed about recommendations for follow-up care,” she concluded.

Regarding psychosocial services, only about half of the respondents indicated that they were comfortable asking their patients about emotional, family, and spiritual distress. Those who were more comfortable were also more likely to know when and where to refer patients for psychosocial services, and felt that their patients' needs were met by these referrals. Only 35% felt that the psychosocial needs of their patients were being met.

Disclosures: Dr. Lynch disclosed no conflicts of interest.

NEW ORLEANS — Primary care providers often feel unequipped to deal with issues of cancer survivorship, according to a survey of 103 physicians, nurse practitioners, and physician assistants at the Henry Ford Health System in Detroit.

More than half (61%) were uncertain about their role in follow-up care (surveillance) for the most common types of cancer, Teresa Lynch, Ph.D., reported at the annual conference of the American Psychosocial Oncology Society. These included lung, breast, prostate, colorectal, bladder, melanoma, non-Hodgkin's lymphoma, kidney/renal cell, leukemia, and endometrial malignancies.

Nearly half (46%) were uncertain of the patterns of morbidity associated with cancer treatments, she added, and 31% were uncertain as to what medical interventions are recommended for preventing or remediating morbidities associated with common cancers.

“Surveys of patients and professionals indicate that posttreatment cancer care is at best fragmented and at worse nonexistent,” said Dr. Lynch, a psychologist at the Josephine Cancer Center at Henry Ford. “PCPs do want to care for cancer patients. They believe it is part of their role, but they are currently very unclear as to what their exact responsibilities are.”

Dr. Lynch and her colleagues are initiating a survivorship program to address the posttreatment needs of approximately 4,000 new cancer patients a year at their center. The program will incorporate care plans into the electronic medical record (EMR), and provide education to fill the gaps in knowledge that they are identifying in surveys of PCPs.

This study involved 103 PCPs who provide services within the large, diverse health care system and who had access to EMRs. The online survey questioned their beliefs and attitudes about providing survivorship care—specifically, knowledge of survivorship care and surveillance.

About half of the respondents were house officers, 30% were senior staff, and the rest were nurse practitioners or physician assistants. In all, 42% were 20-30 years of age, 17% were 31-40, 14% were 41-50, and 27% were 51 years or older.

In all categories, older providers felt less familiar with the issues, and house officers felt most confident, Dr. Lynch reported. Significantly, older providers also said that they were not completely comfortable in caring for cancer patients.

“Providers definitely thought it was important for them to understand cancer follow-up plans, but over 40% thought they did not receive timely information about changes in their patients' cancer status, medications, or treatments,” she said. “Almost 30% of PCPs had difficulty determining patients' follow-up plans in the EMR.”

More than half of the providers said they “rely” on patients to inform them of their follow-up plans. Yet more than 80% of providers believed their patients are confused about follow-up.

“Based on these survey results, we believe that providers need a reliable source to guide their care of cancer patients, and patients need to be better informed about recommendations for follow-up care,” she concluded.

Regarding psychosocial services, only about half of the respondents indicated that they were comfortable asking their patients about emotional, family, and spiritual distress. Those who were more comfortable were also more likely to know when and where to refer patients for psychosocial services, and felt that their patients' needs were met by these referrals. Only 35% felt that the psychosocial needs of their patients were being met.

Disclosures: Dr. Lynch disclosed no conflicts of interest.

NEW ORLEANS — Primary care providers often feel unequipped to deal with issues of cancer survivorship, according to a survey of 103 physicians, nurse practitioners, and physician assistants at the Henry Ford Health System in Detroit.

More than half (61%) were uncertain about their role in follow-up care (surveillance) for the most common types of cancer, Teresa Lynch, Ph.D., reported at the annual conference of the American Psychosocial Oncology Society. These included lung, breast, prostate, colorectal, bladder, melanoma, non-Hodgkin's lymphoma, kidney/renal cell, leukemia, and endometrial malignancies.

Nearly half (46%) were uncertain of the patterns of morbidity associated with cancer treatments, she added, and 31% were uncertain as to what medical interventions are recommended for preventing or remediating morbidities associated with common cancers.

“Surveys of patients and professionals indicate that posttreatment cancer care is at best fragmented and at worse nonexistent,” said Dr. Lynch, a psychologist at the Josephine Cancer Center at Henry Ford. “PCPs do want to care for cancer patients. They believe it is part of their role, but they are currently very unclear as to what their exact responsibilities are.”

Dr. Lynch and her colleagues are initiating a survivorship program to address the posttreatment needs of approximately 4,000 new cancer patients a year at their center. The program will incorporate care plans into the electronic medical record (EMR), and provide education to fill the gaps in knowledge that they are identifying in surveys of PCPs.

This study involved 103 PCPs who provide services within the large, diverse health care system and who had access to EMRs. The online survey questioned their beliefs and attitudes about providing survivorship care—specifically, knowledge of survivorship care and surveillance.

About half of the respondents were house officers, 30% were senior staff, and the rest were nurse practitioners or physician assistants. In all, 42% were 20-30 years of age, 17% were 31-40, 14% were 41-50, and 27% were 51 years or older.

In all categories, older providers felt less familiar with the issues, and house officers felt most confident, Dr. Lynch reported. Significantly, older providers also said that they were not completely comfortable in caring for cancer patients.

“Providers definitely thought it was important for them to understand cancer follow-up plans, but over 40% thought they did not receive timely information about changes in their patients' cancer status, medications, or treatments,” she said. “Almost 30% of PCPs had difficulty determining patients' follow-up plans in the EMR.”

More than half of the providers said they “rely” on patients to inform them of their follow-up plans. Yet more than 80% of providers believed their patients are confused about follow-up.

“Based on these survey results, we believe that providers need a reliable source to guide their care of cancer patients, and patients need to be better informed about recommendations for follow-up care,” she concluded.

Regarding psychosocial services, only about half of the respondents indicated that they were comfortable asking their patients about emotional, family, and spiritual distress. Those who were more comfortable were also more likely to know when and where to refer patients for psychosocial services, and felt that their patients' needs were met by these referrals. Only 35% felt that the psychosocial needs of their patients were being met.

Disclosures: Dr. Lynch disclosed no conflicts of interest.

NEW ORLEANS — A survey of cancer patients confirms that financial hardship is part of the disease package. Investigators found that 28% of patients, mostly those with advanced disease, were in danger of losing their homes, and financial hardships were strongly associated with mental health issues.

Responses from 428 consecutive cancer outpatients revealed that 64% had limited or very limited financial resources as a result of their disease. Only 38% reported no financial hardship, Sharla Wells-Di Gregorio, Ph.D., reported at the annual conference of the American Psychosocial Oncology Society.

“We were completely unprepared to see patients losing their homes, and others presenting with stage IV disease as a result of financial issues.… Many patients reported that they avoided going to the doctor for months, or years in some cases, because they didn't have insurance and could not afford it,” said Dr. Wells-Di Gregorio, a clinical psychologist with the center for palliative care at the Ohio State University in Columbus.

Exacerbating cost-of-care issues, only 8% of the patients were employed full time; 65% were not working because of medical disability, and 7% worked part time. Prior to developing cancer, 89% had a stable employment history, and 93% said they were satisfied with their jobs.

The investigators had hypothesized that patients who experienced moderate to severe financial difficulties would exhibit higher rates of major depressive disorder and generalized anxiety disorder than would patients who reported no financial difficulties, along with more depressive symptoms, pain, pain catastrophizing (out-of-proportion perception of pain), and symptom distress.

Half of the patients surveyed were female, 83% were white, 53% were married, and the average patient had at least a high school education. More than half had metastases, and two-thirds were undergoing chemotherapy or radiotherapy at the time of the survey at one Ohio cancer center.

Measures included the Center for Epidemiologic Studies Depression Scale (CES-D), the Brief Pain Inventory (BPI), the Pain Catastrophizing Scale (PCS), and the Memorial Symptom Assessment Scale (MSAS). Patients also completed an interview to determine whether they had major depression or generalized anxiety.

“These financial difficulties also put the patients at greater risk for depression, anxiety, pain, and symptom distress,” Dr. Wells-Di Gregorio reported, based on their scores on the validated instruments.

Criteria for depression were met by 43% of patients who reported financial issues, compared with 23% of patients without money problems (P = .02); criteria for anxiety were met by 36% and 15%, respectively (P = .001).

Those with financial difficulties had significantly higher pain severity scores on the BPI (P = .001), significantly more physical symptoms on the MSAS (P = .039), and significantly more psychological symptoms on the MSAS (P = .001). Pain catastrophizing scores were not significantly different.

Dr. Wells-Di Gregorio noted that previous studies have shown that 20% of cancer patients with health insurance use all or most of their savings to pay for care, and 10% borrow money from relatives. Out-of-pocket expenses for insured women with breast cancer account for 26%-98% of their monthly income, depending on whether their income was more than $60,000 or less than $30,000, she said. Among those without insurance, 50% use up all their savings to help pay medical expenses, 40% are unable to pay for basic necessities, 25% decline or delay treatment, and 6% file for bankruptcy. Furthermore, 6% of patients lose coverage as a result of having cancer, and 10% are unable to purchase it after a diagnosis. “While these numbers don't sound high, based on national figures we are talking about 88,000 [6% of 1.5 million new cases] and 720,000 patients [6% of 12 million survivors]… a year,” Dr. Wells-Di Gregorio said.

“And in addition to physical and financial disability, patients suffer emotional disability,” she added. “They become fearful of losing their jobs. Due to common beliefs about disability and welfare, they begin to feel financially incompetent and stigmatized.”

Disclosures: None was reported.

NEW ORLEANS — A survey of cancer patients confirms that financial hardship is part of the disease package. Investigators found that 28% of patients, mostly those with advanced disease, were in danger of losing their homes, and financial hardships were strongly associated with mental health issues.

Responses from 428 consecutive cancer outpatients revealed that 64% had limited or very limited financial resources as a result of their disease. Only 38% reported no financial hardship, Sharla Wells-Di Gregorio, Ph.D., reported at the annual conference of the American Psychosocial Oncology Society.

“We were completely unprepared to see patients losing their homes, and others presenting with stage IV disease as a result of financial issues.… Many patients reported that they avoided going to the doctor for months, or years in some cases, because they didn't have insurance and could not afford it,” said Dr. Wells-Di Gregorio, a clinical psychologist with the center for palliative care at the Ohio State University in Columbus.

Exacerbating cost-of-care issues, only 8% of the patients were employed full time; 65% were not working because of medical disability, and 7% worked part time. Prior to developing cancer, 89% had a stable employment history, and 93% said they were satisfied with their jobs.

The investigators had hypothesized that patients who experienced moderate to severe financial difficulties would exhibit higher rates of major depressive disorder and generalized anxiety disorder than would patients who reported no financial difficulties, along with more depressive symptoms, pain, pain catastrophizing (out-of-proportion perception of pain), and symptom distress.

Half of the patients surveyed were female, 83% were white, 53% were married, and the average patient had at least a high school education. More than half had metastases, and two-thirds were undergoing chemotherapy or radiotherapy at the time of the survey at one Ohio cancer center.

Measures included the Center for Epidemiologic Studies Depression Scale (CES-D), the Brief Pain Inventory (BPI), the Pain Catastrophizing Scale (PCS), and the Memorial Symptom Assessment Scale (MSAS). Patients also completed an interview to determine whether they had major depression or generalized anxiety.

“These financial difficulties also put the patients at greater risk for depression, anxiety, pain, and symptom distress,” Dr. Wells-Di Gregorio reported, based on their scores on the validated instruments.

Criteria for depression were met by 43% of patients who reported financial issues, compared with 23% of patients without money problems (P = .02); criteria for anxiety were met by 36% and 15%, respectively (P = .001).

Those with financial difficulties had significantly higher pain severity scores on the BPI (P = .001), significantly more physical symptoms on the MSAS (P = .039), and significantly more psychological symptoms on the MSAS (P = .001). Pain catastrophizing scores were not significantly different.

Dr. Wells-Di Gregorio noted that previous studies have shown that 20% of cancer patients with health insurance use all or most of their savings to pay for care, and 10% borrow money from relatives. Out-of-pocket expenses for insured women with breast cancer account for 26%-98% of their monthly income, depending on whether their income was more than $60,000 or less than $30,000, she said. Among those without insurance, 50% use up all their savings to help pay medical expenses, 40% are unable to pay for basic necessities, 25% decline or delay treatment, and 6% file for bankruptcy. Furthermore, 6% of patients lose coverage as a result of having cancer, and 10% are unable to purchase it after a diagnosis. “While these numbers don't sound high, based on national figures we are talking about 88,000 [6% of 1.5 million new cases] and 720,000 patients [6% of 12 million survivors]… a year,” Dr. Wells-Di Gregorio said.

“And in addition to physical and financial disability, patients suffer emotional disability,” she added. “They become fearful of losing their jobs. Due to common beliefs about disability and welfare, they begin to feel financially incompetent and stigmatized.”

Disclosures: None was reported.

NEW ORLEANS — A survey of cancer patients confirms that financial hardship is part of the disease package. Investigators found that 28% of patients, mostly those with advanced disease, were in danger of losing their homes, and financial hardships were strongly associated with mental health issues.

Responses from 428 consecutive cancer outpatients revealed that 64% had limited or very limited financial resources as a result of their disease. Only 38% reported no financial hardship, Sharla Wells-Di Gregorio, Ph.D., reported at the annual conference of the American Psychosocial Oncology Society.

“We were completely unprepared to see patients losing their homes, and others presenting with stage IV disease as a result of financial issues.… Many patients reported that they avoided going to the doctor for months, or years in some cases, because they didn't have insurance and could not afford it,” said Dr. Wells-Di Gregorio, a clinical psychologist with the center for palliative care at the Ohio State University in Columbus.

Exacerbating cost-of-care issues, only 8% of the patients were employed full time; 65% were not working because of medical disability, and 7% worked part time. Prior to developing cancer, 89% had a stable employment history, and 93% said they were satisfied with their jobs.

The investigators had hypothesized that patients who experienced moderate to severe financial difficulties would exhibit higher rates of major depressive disorder and generalized anxiety disorder than would patients who reported no financial difficulties, along with more depressive symptoms, pain, pain catastrophizing (out-of-proportion perception of pain), and symptom distress.

Half of the patients surveyed were female, 83% were white, 53% were married, and the average patient had at least a high school education. More than half had metastases, and two-thirds were undergoing chemotherapy or radiotherapy at the time of the survey at one Ohio cancer center.

Measures included the Center for Epidemiologic Studies Depression Scale (CES-D), the Brief Pain Inventory (BPI), the Pain Catastrophizing Scale (PCS), and the Memorial Symptom Assessment Scale (MSAS). Patients also completed an interview to determine whether they had major depression or generalized anxiety.

“These financial difficulties also put the patients at greater risk for depression, anxiety, pain, and symptom distress,” Dr. Wells-Di Gregorio reported, based on their scores on the validated instruments.

Criteria for depression were met by 43% of patients who reported financial issues, compared with 23% of patients without money problems (P = .02); criteria for anxiety were met by 36% and 15%, respectively (P = .001).

Those with financial difficulties had significantly higher pain severity scores on the BPI (P = .001), significantly more physical symptoms on the MSAS (P = .039), and significantly more psychological symptoms on the MSAS (P = .001). Pain catastrophizing scores were not significantly different.

Dr. Wells-Di Gregorio noted that previous studies have shown that 20% of cancer patients with health insurance use all or most of their savings to pay for care, and 10% borrow money from relatives. Out-of-pocket expenses for insured women with breast cancer account for 26%-98% of their monthly income, depending on whether their income was more than $60,000 or less than $30,000, she said. Among those without insurance, 50% use up all their savings to help pay medical expenses, 40% are unable to pay for basic necessities, 25% decline or delay treatment, and 6% file for bankruptcy. Furthermore, 6% of patients lose coverage as a result of having cancer, and 10% are unable to purchase it after a diagnosis. “While these numbers don't sound high, based on national figures we are talking about 88,000 [6% of 1.5 million new cases] and 720,000 patients [6% of 12 million survivors]… a year,” Dr. Wells-Di Gregorio said.

“And in addition to physical and financial disability, patients suffer emotional disability,” she added. “They become fearful of losing their jobs. Due to common beliefs about disability and welfare, they begin to feel financially incompetent and stigmatized.”

Disclosures: None was reported.

NEW ORLEANS – Psychiatrists and other mental health professionals often lack sufficient background in oncology to effectively provide psychosocial care to cancer patients.

The Henry Ford Health System (HFHS) in Detroit has designed a program to fill this need, resulting in improved access to specialized care for their large patient base.

The program was described by Wendy Goldberg, a nurse practitioner at the Josephine Ford Cancer Center (JFCC) of the HFHS, at the annual conference of the American Psychosocial Oncology Society.

A review of the literature showed that one-third to one-half of all cancer patients experience significant psychosocial distress, and that psychological interventions are effective in remediating distress (Psychooncology 2004;13:837-49), Ms. Goldberg and colleagues noted in their poster.

“We have 7,000 cancer patients in our health care system … in southeast Michigan. We know that providing psychosocial care to this cancer population is important, but our psycho-oncology program consists of only a psycho-oncology nurse practitioner (myself) and a health psychology fellow,” she said.

Because of the volume of this population, the patients' disease states, and issues of transportation, many patients requiring psychosocial services now see counselors within their communities who lack expertise in cancer care. The patients who were seen in the community have been highly dissatisfied with such care, Ms. Goldberg explained in an interview.

“Patients complained to their oncologists that their therapists did not understand their situation or were not helpful,” she noted.

Envisioning a program that would prepare psychotherapy generalists in the community to deliver specialized psycho-oncology services, Ms. Goldberg and colleagues designed an intensive, specialized, mastery-based training program that covered cancer “basics” as well as the psychological and behavioral dimensions of cancer. (See box.)

The program was attended by 91 mental health care providers, including psychiatrists, psychologists, social workers, and nurse practitioners from within the HFHS and the southeast Michigan region. Faculty included a psychologist, health psychology fellow, psychiatric nurse practitioner, psychiatric social worker, and oncology nurse practitioner, all with advanced training in the field.

The content for the 8-hour course included cancer biology and treatment issues, psychiatric comorbidity, psychological and psychopharmacologic interventions, ethics, and genetic testing in cancer populations. Interactive lectures, case presentations, and panel discussions with patients and family members focused on the mastery of essential knowledge, attitudes, and skill development in psycho-oncology care. Enrollees from the HFHS were invited to participate in the next two phases of the program, which entailed ongoing, small-group, peer supervision via telephone conferences and a 1-day clinical observation.

At the conclusion of the seminar, participants reported high satisfaction with the course. On a quality-rating scale of 0–5, mean ratings were 4.5 or higher on all content and organizational categories. Virtually all respondents said that the program was highly applicable to their profession and yielded information that would be professionally useful.

“The response was unbelievably positive,” Ms. Goldberg reported. “We were optimistic that the program would be appreciated, but many participants said it was the best course they had ever taken, and they did not realize how much they didn't know.”

Ms. Goldberg and her colleagues are now formalizing the course and training model for implementation by others.

Case Histories Show Impact of Program on Patients

Therapists reported a gain in knowledge that helped them counsel cancer patients. These are some of their “before and after” stories, as described by Teresa Lynch, Ph.D., a psychologist at the JFCC, and Ms. Goldberg.

▸ Case No. 1. The therapist could not understand why his very ill patient resisted discussions about end-of-life issues. But after reviewing the patient's clinical status, he learned the patient was midway through his initial treatment, was ill from the side effects of surgery and radiation rather than from disease, and–most importantly–had an excellent chance of cure. The therapist then understood that exploring fears about death and dying was not relevant, and he redirected the focus of therapy toward emotional resiliency during treatment.

▸ Case No. 2. The patient did not understand her oncologists' insistence that she needed both chemotherapy and radiation therapy. The therapist was able to use her fundamental knowledge of cancer biology to probe the patient's understanding of these issues. She combined psychoeducation techniques with anxiety management to help the patient face an unpleasant reality. This interaction increased the patient's confidence in the therapist, which ultimately helped the patient receive optimal care.

▸ Case No. 3. The patient approached the program's psychiatrist about her difficulty in proceeding with treatment recommendations until she could better manage her anxiety, attend to important personal business, and think more about her treatment options. The psychiatrist and nurse practitioner discussed the case together, and concluded that further delays in initiating cancer treatment could jeopardize the patient's chance for a good response, including cure. The team strategized ways to shift the focus of therapy to concerns about the risks of delay, rather than the patient's need to be “perfectly ready” before beginning treatment. The psychiatrist adjusted her treatment approach from reflective listening to a psychoeducational/problem-solving strategy that helped the patient overcome a dangerous state of paralysis and avoidance. The patient later directly expressed her gratitude for this intervention to the oncology team.

▸ Case No. 4. A therapist who was working with a breast cancer patient wanted a greater appreciation of what her patient would face after completing chemotherapy. The therapist had no knowledge of tumor biology, including the meaning of estrogen receptor positivity. Therapists do have access to patients' electronic medical records (EMRs) in the health care system–the aim being to promote integrated care–but most therapists do not know what information to look for or where to find it in the EMR. To address this need, the psychosocial educational program devoted a telephone supervisory session to teaching therapists how to navigate the relevant aspects of the patient's EMR. At the same time, the teaching team reinforced some of the didactic information presented during the psycho-oncology seminar.

NEW ORLEANS – Psychiatrists and other mental health professionals often lack sufficient background in oncology to effectively provide psychosocial care to cancer patients.

The Henry Ford Health System (HFHS) in Detroit has designed a program to fill this need, resulting in improved access to specialized care for their large patient base.

The program was described by Wendy Goldberg, a nurse practitioner at the Josephine Ford Cancer Center (JFCC) of the HFHS, at the annual conference of the American Psychosocial Oncology Society.

A review of the literature showed that one-third to one-half of all cancer patients experience significant psychosocial distress, and that psychological interventions are effective in remediating distress (Psychooncology 2004;13:837-49), Ms. Goldberg and colleagues noted in their poster.

“We have 7,000 cancer patients in our health care system … in southeast Michigan. We know that providing psychosocial care to this cancer population is important, but our psycho-oncology program consists of only a psycho-oncology nurse practitioner (myself) and a health psychology fellow,” she said.

Because of the volume of this population, the patients' disease states, and issues of transportation, many patients requiring psychosocial services now see counselors within their communities who lack expertise in cancer care. The patients who were seen in the community have been highly dissatisfied with such care, Ms. Goldberg explained in an interview.

“Patients complained to their oncologists that their therapists did not understand their situation or were not helpful,” she noted.

Envisioning a program that would prepare psychotherapy generalists in the community to deliver specialized psycho-oncology services, Ms. Goldberg and colleagues designed an intensive, specialized, mastery-based training program that covered cancer “basics” as well as the psychological and behavioral dimensions of cancer. (See box.)

The program was attended by 91 mental health care providers, including psychiatrists, psychologists, social workers, and nurse practitioners from within the HFHS and the southeast Michigan region. Faculty included a psychologist, health psychology fellow, psychiatric nurse practitioner, psychiatric social worker, and oncology nurse practitioner, all with advanced training in the field.

The content for the 8-hour course included cancer biology and treatment issues, psychiatric comorbidity, psychological and psychopharmacologic interventions, ethics, and genetic testing in cancer populations. Interactive lectures, case presentations, and panel discussions with patients and family members focused on the mastery of essential knowledge, attitudes, and skill development in psycho-oncology care. Enrollees from the HFHS were invited to participate in the next two phases of the program, which entailed ongoing, small-group, peer supervision via telephone conferences and a 1-day clinical observation.

At the conclusion of the seminar, participants reported high satisfaction with the course. On a quality-rating scale of 0–5, mean ratings were 4.5 or higher on all content and organizational categories. Virtually all respondents said that the program was highly applicable to their profession and yielded information that would be professionally useful.

“The response was unbelievably positive,” Ms. Goldberg reported. “We were optimistic that the program would be appreciated, but many participants said it was the best course they had ever taken, and they did not realize how much they didn't know.”

Ms. Goldberg and her colleagues are now formalizing the course and training model for implementation by others.

Case Histories Show Impact of Program on Patients

Therapists reported a gain in knowledge that helped them counsel cancer patients. These are some of their “before and after” stories, as described by Teresa Lynch, Ph.D., a psychologist at the JFCC, and Ms. Goldberg.

▸ Case No. 1. The therapist could not understand why his very ill patient resisted discussions about end-of-life issues. But after reviewing the patient's clinical status, he learned the patient was midway through his initial treatment, was ill from the side effects of surgery and radiation rather than from disease, and–most importantly–had an excellent chance of cure. The therapist then understood that exploring fears about death and dying was not relevant, and he redirected the focus of therapy toward emotional resiliency during treatment.

▸ Case No. 2. The patient did not understand her oncologists' insistence that she needed both chemotherapy and radiation therapy. The therapist was able to use her fundamental knowledge of cancer biology to probe the patient's understanding of these issues. She combined psychoeducation techniques with anxiety management to help the patient face an unpleasant reality. This interaction increased the patient's confidence in the therapist, which ultimately helped the patient receive optimal care.

▸ Case No. 3. The patient approached the program's psychiatrist about her difficulty in proceeding with treatment recommendations until she could better manage her anxiety, attend to important personal business, and think more about her treatment options. The psychiatrist and nurse practitioner discussed the case together, and concluded that further delays in initiating cancer treatment could jeopardize the patient's chance for a good response, including cure. The team strategized ways to shift the focus of therapy to concerns about the risks of delay, rather than the patient's need to be “perfectly ready” before beginning treatment. The psychiatrist adjusted her treatment approach from reflective listening to a psychoeducational/problem-solving strategy that helped the patient overcome a dangerous state of paralysis and avoidance. The patient later directly expressed her gratitude for this intervention to the oncology team.

▸ Case No. 4. A therapist who was working with a breast cancer patient wanted a greater appreciation of what her patient would face after completing chemotherapy. The therapist had no knowledge of tumor biology, including the meaning of estrogen receptor positivity. Therapists do have access to patients' electronic medical records (EMRs) in the health care system–the aim being to promote integrated care–but most therapists do not know what information to look for or where to find it in the EMR. To address this need, the psychosocial educational program devoted a telephone supervisory session to teaching therapists how to navigate the relevant aspects of the patient's EMR. At the same time, the teaching team reinforced some of the didactic information presented during the psycho-oncology seminar.

NEW ORLEANS – Psychiatrists and other mental health professionals often lack sufficient background in oncology to effectively provide psychosocial care to cancer patients.

The Henry Ford Health System (HFHS) in Detroit has designed a program to fill this need, resulting in improved access to specialized care for their large patient base.

The program was described by Wendy Goldberg, a nurse practitioner at the Josephine Ford Cancer Center (JFCC) of the HFHS, at the annual conference of the American Psychosocial Oncology Society.

A review of the literature showed that one-third to one-half of all cancer patients experience significant psychosocial distress, and that psychological interventions are effective in remediating distress (Psychooncology 2004;13:837-49), Ms. Goldberg and colleagues noted in their poster.

“We have 7,000 cancer patients in our health care system … in southeast Michigan. We know that providing psychosocial care to this cancer population is important, but our psycho-oncology program consists of only a psycho-oncology nurse practitioner (myself) and a health psychology fellow,” she said.

Because of the volume of this population, the patients' disease states, and issues of transportation, many patients requiring psychosocial services now see counselors within their communities who lack expertise in cancer care. The patients who were seen in the community have been highly dissatisfied with such care, Ms. Goldberg explained in an interview.

“Patients complained to their oncologists that their therapists did not understand their situation or were not helpful,” she noted.

Envisioning a program that would prepare psychotherapy generalists in the community to deliver specialized psycho-oncology services, Ms. Goldberg and colleagues designed an intensive, specialized, mastery-based training program that covered cancer “basics” as well as the psychological and behavioral dimensions of cancer. (See box.)

The program was attended by 91 mental health care providers, including psychiatrists, psychologists, social workers, and nurse practitioners from within the HFHS and the southeast Michigan region. Faculty included a psychologist, health psychology fellow, psychiatric nurse practitioner, psychiatric social worker, and oncology nurse practitioner, all with advanced training in the field.

The content for the 8-hour course included cancer biology and treatment issues, psychiatric comorbidity, psychological and psychopharmacologic interventions, ethics, and genetic testing in cancer populations. Interactive lectures, case presentations, and panel discussions with patients and family members focused on the mastery of essential knowledge, attitudes, and skill development in psycho-oncology care. Enrollees from the HFHS were invited to participate in the next two phases of the program, which entailed ongoing, small-group, peer supervision via telephone conferences and a 1-day clinical observation.

At the conclusion of the seminar, participants reported high satisfaction with the course. On a quality-rating scale of 0–5, mean ratings were 4.5 or higher on all content and organizational categories. Virtually all respondents said that the program was highly applicable to their profession and yielded information that would be professionally useful.

“The response was unbelievably positive,” Ms. Goldberg reported. “We were optimistic that the program would be appreciated, but many participants said it was the best course they had ever taken, and they did not realize how much they didn't know.”

Ms. Goldberg and her colleagues are now formalizing the course and training model for implementation by others.

Case Histories Show Impact of Program on Patients

Therapists reported a gain in knowledge that helped them counsel cancer patients. These are some of their “before and after” stories, as described by Teresa Lynch, Ph.D., a psychologist at the JFCC, and Ms. Goldberg.

▸ Case No. 1. The therapist could not understand why his very ill patient resisted discussions about end-of-life issues. But after reviewing the patient's clinical status, he learned the patient was midway through his initial treatment, was ill from the side effects of surgery and radiation rather than from disease, and–most importantly–had an excellent chance of cure. The therapist then understood that exploring fears about death and dying was not relevant, and he redirected the focus of therapy toward emotional resiliency during treatment.

▸ Case No. 2. The patient did not understand her oncologists' insistence that she needed both chemotherapy and radiation therapy. The therapist was able to use her fundamental knowledge of cancer biology to probe the patient's understanding of these issues. She combined psychoeducation techniques with anxiety management to help the patient face an unpleasant reality. This interaction increased the patient's confidence in the therapist, which ultimately helped the patient receive optimal care.

▸ Case No. 3. The patient approached the program's psychiatrist about her difficulty in proceeding with treatment recommendations until she could better manage her anxiety, attend to important personal business, and think more about her treatment options. The psychiatrist and nurse practitioner discussed the case together, and concluded that further delays in initiating cancer treatment could jeopardize the patient's chance for a good response, including cure. The team strategized ways to shift the focus of therapy to concerns about the risks of delay, rather than the patient's need to be “perfectly ready” before beginning treatment. The psychiatrist adjusted her treatment approach from reflective listening to a psychoeducational/problem-solving strategy that helped the patient overcome a dangerous state of paralysis and avoidance. The patient later directly expressed her gratitude for this intervention to the oncology team.

▸ Case No. 4. A therapist who was working with a breast cancer patient wanted a greater appreciation of what her patient would face after completing chemotherapy. The therapist had no knowledge of tumor biology, including the meaning of estrogen receptor positivity. Therapists do have access to patients' electronic medical records (EMRs) in the health care system–the aim being to promote integrated care–but most therapists do not know what information to look for or where to find it in the EMR. To address this need, the psychosocial educational program devoted a telephone supervisory session to teaching therapists how to navigate the relevant aspects of the patient's EMR. At the same time, the teaching team reinforced some of the didactic information presented during the psycho-oncology seminar.

NEW ORLEANS — Psychiatrists and other mental health professionals often lack sufficient background in oncology to effectively provide psychosocial care to cancer patients.

The Henry Ford Health System (HFHS) in Detroit has designed a program to fill this need, resulting in improved access to specialized care for their large patient base, said Wendy Goldberg, a nurse practitioner at the Josephine Ford Cancer Center (JFCC) of the HFHS, at the annual conference of the American Psychosocial Oncology Society.

A review of the literature showed that one-third to one-half of all cancer patients experience significant psychosocial distress, and that psychological interventions are effective in remediating distress (Psycho-Oncology 2004;13:837-49), Ms. Goldberg and her colleagues noted in their poster.

Because of the volume of this population, the patients' disease states, and issues of transportation, many patients requiring psychosocial services now see counselors within their communities who lack expertise in cancer care. Although patients and families who were seen at the JFCC have expressed satisfaction with the psychological services at that cancer center, the patients who were seen in the community have been highly dissatisfied with such care, Ms. Goldberg explained in an interview.

“Patients complained to their oncologists that their therapists did not understand their situation or were not helpful,” she noted. “We had to see if we could better prepare the psychotherapists in the community.”

Ms. Goldberg and her colleagues designed an intensive, specialized, mastery-based training program that covered cancer “basics” as well as the psychological and behavioral dimensions of cancer.

The program was attended by 91 mental health care providers from within the HFHS and the southeast Michigan region. Faculty included a psychologist, health psychology fellow, psychiatric nurse practitioner, psychiatric social worker, and oncology nurse practitioner.

The content for the 8-hour course included cancer biology and treatment issues, psychiatric comorbidity, psychological and psychopharmacologic interventions, ethics, and genetic testing in cancer populations. Interactive lectures, case presentations, and panel discussions with patients and family members focused on the mastery of essential knowledge, attitudes, and skill development in psycho-oncology care. Enrollees from the HFHS were invited to participate in the next two phases of the program, which entailed ongoing, small-group, peer supervision via telephone conferences and a 1-day clinical observation.

Participants reported high satisfaction with the course. On a quality-rating scale of 0-5, mean ratings were 4.5 or higher on all content and organizational categories. Virtually all respondents said that the program was highly applicable to their profession and yielded information that would be professionally useful. (See box.)

“The response was unbelievably positive,” Ms. Goldberg reported. “Many participants said it was the best course they had ever taken, and they did not realize how much they didn't know.”

The peer telephone supervision session, which was offered to the 61 participants from the HFHS, provided instruction in reading the electronic medical record to better understand the patients' clinical status. It also provided a setting for refining the patient-referral process.

Ms. Goldberg and her colleagues are now formalizing the course and training model for implementation by others.

Psychotherapy for Cancer Patients Improved by Education

Therapists reported a gain in knowledge that helped them counsel cancer patients. These are some of their “before and after” stories, as described by Teresa Lynch, Ph.D., a psychologist at the JFCC, and Ms. Goldberg.

▸ Case No. 1. The therapist could not understand why his very ill patient resisted discussions about end-of-life issues. But after reviewing the patient's clinical status, he learned the patient was midway through his initial treatment, was ill from the side effects of surgery and radiation rather than from disease, and—most importantly—had an excellent chance of cure. The therapist then understood that exploring fears about death and dying was not relevant, and he redirected the focus of therapy toward emotional resiliency during treatment.

▸ Case No. 2. The patient did not understand her oncologists' insistence that she needed both chemotherapy and radiation therapy. The therapist was able to use her fundamental knowledge of cancer biology to probe the patient's understanding of these issues. She combined psychoeducation techniques with anxiety management to help the patient face an unpleasant reality. This interaction increased the patient's confidence in the therapist, which ultimately helped the patient receive optimal care.

▸ Case No. 3. The patient approached the program's psychiatrist about her difficulty in proceeding with treatment recommendations until she could better manage her anxiety, attend to important personal business, and think more about her treatment options. The psychiatrist and nurse practitioner discussed the case together, and concluded that further delays in initiating cancer treatment could jeopardize the patient's chance for a good response, including cure. The team strategized ways to shift the focus of therapy to concerns about the risks of delay, rather than the patient's need to be “perfectly ready” before beginning treatment. The psychiatrist adjusted her treatment approach from reflective listening to a psychoeducational/problem-solving strategy that helped the patient overcome a dangerous state of paralysis and avoidance. The patient later directly expressed her gratitude for this intervention to the oncology team.

▸ Case No. 4. A therapist who was working with a breast cancer patient wanted a greater appreciation of what her patient would face after completing chemotherapy. The therapist had no knowledge of tumor biology, including the meaning of estrogen receptor positivity. Therapists do have access to patients' electronic medical records (EMRs) in the health care system—the aim being to promote integrated care—but most therapists do not know what information to look for or where to find it in the EMR. To address this need, the psychosocial educational program devoted a telephone supervisory session to teaching therapists how to navigate the relevant aspects of the patient's EMR.

NEW ORLEANS — Psychiatrists and other mental health professionals often lack sufficient background in oncology to effectively provide psychosocial care to cancer patients.

The Henry Ford Health System (HFHS) in Detroit has designed a program to fill this need, resulting in improved access to specialized care for their large patient base, said Wendy Goldberg, a nurse practitioner at the Josephine Ford Cancer Center (JFCC) of the HFHS, at the annual conference of the American Psychosocial Oncology Society.

A review of the literature showed that one-third to one-half of all cancer patients experience significant psychosocial distress, and that psychological interventions are effective in remediating distress (Psycho-Oncology 2004;13:837-49), Ms. Goldberg and her colleagues noted in their poster.

Because of the volume of this population, the patients' disease states, and issues of transportation, many patients requiring psychosocial services now see counselors within their communities who lack expertise in cancer care. Although patients and families who were seen at the JFCC have expressed satisfaction with the psychological services at that cancer center, the patients who were seen in the community have been highly dissatisfied with such care, Ms. Goldberg explained in an interview.

“Patients complained to their oncologists that their therapists did not understand their situation or were not helpful,” she noted. “We had to see if we could better prepare the psychotherapists in the community.”

Ms. Goldberg and her colleagues designed an intensive, specialized, mastery-based training program that covered cancer “basics” as well as the psychological and behavioral dimensions of cancer.

The program was attended by 91 mental health care providers from within the HFHS and the southeast Michigan region. Faculty included a psychologist, health psychology fellow, psychiatric nurse practitioner, psychiatric social worker, and oncology nurse practitioner.

The content for the 8-hour course included cancer biology and treatment issues, psychiatric comorbidity, psychological and psychopharmacologic interventions, ethics, and genetic testing in cancer populations. Interactive lectures, case presentations, and panel discussions with patients and family members focused on the mastery of essential knowledge, attitudes, and skill development in psycho-oncology care. Enrollees from the HFHS were invited to participate in the next two phases of the program, which entailed ongoing, small-group, peer supervision via telephone conferences and a 1-day clinical observation.

Participants reported high satisfaction with the course. On a quality-rating scale of 0-5, mean ratings were 4.5 or higher on all content and organizational categories. Virtually all respondents said that the program was highly applicable to their profession and yielded information that would be professionally useful. (See box.)

“The response was unbelievably positive,” Ms. Goldberg reported. “Many participants said it was the best course they had ever taken, and they did not realize how much they didn't know.”

The peer telephone supervision session, which was offered to the 61 participants from the HFHS, provided instruction in reading the electronic medical record to better understand the patients' clinical status. It also provided a setting for refining the patient-referral process.

Ms. Goldberg and her colleagues are now formalizing the course and training model for implementation by others.

Psychotherapy for Cancer Patients Improved by Education

Therapists reported a gain in knowledge that helped them counsel cancer patients. These are some of their “before and after” stories, as described by Teresa Lynch, Ph.D., a psychologist at the JFCC, and Ms. Goldberg.

▸ Case No. 1. The therapist could not understand why his very ill patient resisted discussions about end-of-life issues. But after reviewing the patient's clinical status, he learned the patient was midway through his initial treatment, was ill from the side effects of surgery and radiation rather than from disease, and—most importantly—had an excellent chance of cure. The therapist then understood that exploring fears about death and dying was not relevant, and he redirected the focus of therapy toward emotional resiliency during treatment.

▸ Case No. 2. The patient did not understand her oncologists' insistence that she needed both chemotherapy and radiation therapy. The therapist was able to use her fundamental knowledge of cancer biology to probe the patient's understanding of these issues. She combined psychoeducation techniques with anxiety management to help the patient face an unpleasant reality. This interaction increased the patient's confidence in the therapist, which ultimately helped the patient receive optimal care.

▸ Case No. 3. The patient approached the program's psychiatrist about her difficulty in proceeding with treatment recommendations until she could better manage her anxiety, attend to important personal business, and think more about her treatment options. The psychiatrist and nurse practitioner discussed the case together, and concluded that further delays in initiating cancer treatment could jeopardize the patient's chance for a good response, including cure. The team strategized ways to shift the focus of therapy to concerns about the risks of delay, rather than the patient's need to be “perfectly ready” before beginning treatment. The psychiatrist adjusted her treatment approach from reflective listening to a psychoeducational/problem-solving strategy that helped the patient overcome a dangerous state of paralysis and avoidance. The patient later directly expressed her gratitude for this intervention to the oncology team.

▸ Case No. 4. A therapist who was working with a breast cancer patient wanted a greater appreciation of what her patient would face after completing chemotherapy. The therapist had no knowledge of tumor biology, including the meaning of estrogen receptor positivity. Therapists do have access to patients' electronic medical records (EMRs) in the health care system—the aim being to promote integrated care—but most therapists do not know what information to look for or where to find it in the EMR. To address this need, the psychosocial educational program devoted a telephone supervisory session to teaching therapists how to navigate the relevant aspects of the patient's EMR.

NEW ORLEANS — Psychiatrists and other mental health professionals often lack sufficient background in oncology to effectively provide psychosocial care to cancer patients.

The Henry Ford Health System (HFHS) in Detroit has designed a program to fill this need, resulting in improved access to specialized care for their large patient base, said Wendy Goldberg, a nurse practitioner at the Josephine Ford Cancer Center (JFCC) of the HFHS, at the annual conference of the American Psychosocial Oncology Society.

A review of the literature showed that one-third to one-half of all cancer patients experience significant psychosocial distress, and that psychological interventions are effective in remediating distress (Psycho-Oncology 2004;13:837-49), Ms. Goldberg and her colleagues noted in their poster.

Because of the volume of this population, the patients' disease states, and issues of transportation, many patients requiring psychosocial services now see counselors within their communities who lack expertise in cancer care. Although patients and families who were seen at the JFCC have expressed satisfaction with the psychological services at that cancer center, the patients who were seen in the community have been highly dissatisfied with such care, Ms. Goldberg explained in an interview.

“Patients complained to their oncologists that their therapists did not understand their situation or were not helpful,” she noted. “We had to see if we could better prepare the psychotherapists in the community.”

Ms. Goldberg and her colleagues designed an intensive, specialized, mastery-based training program that covered cancer “basics” as well as the psychological and behavioral dimensions of cancer.

The program was attended by 91 mental health care providers from within the HFHS and the southeast Michigan region. Faculty included a psychologist, health psychology fellow, psychiatric nurse practitioner, psychiatric social worker, and oncology nurse practitioner.

The content for the 8-hour course included cancer biology and treatment issues, psychiatric comorbidity, psychological and psychopharmacologic interventions, ethics, and genetic testing in cancer populations. Interactive lectures, case presentations, and panel discussions with patients and family members focused on the mastery of essential knowledge, attitudes, and skill development in psycho-oncology care. Enrollees from the HFHS were invited to participate in the next two phases of the program, which entailed ongoing, small-group, peer supervision via telephone conferences and a 1-day clinical observation.

Participants reported high satisfaction with the course. On a quality-rating scale of 0-5, mean ratings were 4.5 or higher on all content and organizational categories. Virtually all respondents said that the program was highly applicable to their profession and yielded information that would be professionally useful. (See box.)

“The response was unbelievably positive,” Ms. Goldberg reported. “Many participants said it was the best course they had ever taken, and they did not realize how much they didn't know.”

The peer telephone supervision session, which was offered to the 61 participants from the HFHS, provided instruction in reading the electronic medical record to better understand the patients' clinical status. It also provided a setting for refining the patient-referral process.

Ms. Goldberg and her colleagues are now formalizing the course and training model for implementation by others.

Psychotherapy for Cancer Patients Improved by Education

Therapists reported a gain in knowledge that helped them counsel cancer patients. These are some of their “before and after” stories, as described by Teresa Lynch, Ph.D., a psychologist at the JFCC, and Ms. Goldberg.

▸ Case No. 1. The therapist could not understand why his very ill patient resisted discussions about end-of-life issues. But after reviewing the patient's clinical status, he learned the patient was midway through his initial treatment, was ill from the side effects of surgery and radiation rather than from disease, and—most importantly—had an excellent chance of cure. The therapist then understood that exploring fears about death and dying was not relevant, and he redirected the focus of therapy toward emotional resiliency during treatment.

▸ Case No. 2. The patient did not understand her oncologists' insistence that she needed both chemotherapy and radiation therapy. The therapist was able to use her fundamental knowledge of cancer biology to probe the patient's understanding of these issues. She combined psychoeducation techniques with anxiety management to help the patient face an unpleasant reality. This interaction increased the patient's confidence in the therapist, which ultimately helped the patient receive optimal care.

▸ Case No. 3. The patient approached the program's psychiatrist about her difficulty in proceeding with treatment recommendations until she could better manage her anxiety, attend to important personal business, and think more about her treatment options. The psychiatrist and nurse practitioner discussed the case together, and concluded that further delays in initiating cancer treatment could jeopardize the patient's chance for a good response, including cure. The team strategized ways to shift the focus of therapy to concerns about the risks of delay, rather than the patient's need to be “perfectly ready” before beginning treatment. The psychiatrist adjusted her treatment approach from reflective listening to a psychoeducational/problem-solving strategy that helped the patient overcome a dangerous state of paralysis and avoidance. The patient later directly expressed her gratitude for this intervention to the oncology team.

▸ Case No. 4. A therapist who was working with a breast cancer patient wanted a greater appreciation of what her patient would face after completing chemotherapy. The therapist had no knowledge of tumor biology, including the meaning of estrogen receptor positivity. Therapists do have access to patients' electronic medical records (EMRs) in the health care system—the aim being to promote integrated care—but most therapists do not know what information to look for or where to find it in the EMR. To address this need, the psychosocial educational program devoted a telephone supervisory session to teaching therapists how to navigate the relevant aspects of the patient's EMR.

Major Finding: More than half (61%) of primary care providers expressed uncertainty about their role in providing care to survivors of the most common types of cancer.

Data Source: Survey of 103 PCPs in the Henry Ford Health System.

Disclosures: Dr. Lynch disclosed no conflicts of interest.

NEW ORLEANS — Primary care providers often feel unequipped to deal with issues of cancer survivorship, according to a survey of 103 physicians, nurse practitioners, and physician assistants at the Henry Ford Health System in Detroit.

More than half (61%) were uncertain about their role in follow-up care (surveillance) for the most common types of cancer, Teresa Lynch, Ph.D., reported at the annual conference of the American Psychosocial Oncology Society. These included lung, breast, prostate, colorectal, bladder, melanoma, non-Hodgkin's lymphoma, kidney/renal cell, leukemia, and endometrial malignancies.

Nearly half (46%) were uncertain of the patterns of morbidity associated with cancer treatments, she added, and 31% were uncertain as to what medical interventions are recommended for preventing or remediating morbidities associated with common cancers.

“Surveys of patients and professionals indicate that posttreatment cancer care is at best fragmented and at worse nonexistent,” said Dr. Lynch, a psychologist at the Josephine Cancer Center at Henry Ford. “PCPs do want to care for cancer patients. They believe it is part of their role, but they are currently very unclear as to what their exact responsibilities are.”

Dr. Lynch and colleagues are initiating a survivorship program to address the posttreatment needs of approximately 4,000 new cancer patients a year at their center. The program will incorporate care plans into the electronic medical record (EMR), and provide education to fill the gaps in knowledge that they are identifying in surveys of PCPs.

This study involved 103 PCPs who provide services within the large, diverse health care system and who had access to EMRs. The online survey questioned their beliefs and attitudes about providing survivorship care—specifically, knowledge of survivorship care and surveillance.

About half of the respondents were house officers, 30% were senior staff, and the rest were nurse practitioners or physician assistants. In all, 42% were 20–30 years of age, 17% were 31–40, 14% were 41–50, and 27% were 51 years or older.

In all categories, older providers felt less familiar with the issues, and house officers felt most confident, Dr. Lynch reported. Significantly, older providers also said that they were not completely comfortable in caring for cancer patients.

“Providers definitely thought it was important for them to understand cancer follow-up plans, but over 40% thought they did not receive timely information about changes in their patients' cancer status, medications or treatments,” she said. “Almost 30% of PCPs had difficulty determining patients' follow-up plans in the EMR.”

More than half of the providers said they “rely” on patients to inform them of their follow-up plans. Yet more than 80% of providers believed their patients are confused about follow-up.

“Based on these survey results, we believe that providers need a reliable source to guide their care of cancer patients, and patients need to be better informed about recommendations for follow-up care,” she concluded.

Regarding psychosocial services, only about half of the respondents indicated that they were comfortable asking their patients about emotional, family, and spiritual distress. Those who were more comfortable were also more likely to know when and where to refer patients for psychosocial services, and felt that their patients' needs were met by these referrals. Only 35% felt that the psychosocial needs of their patients were being met.

Major Finding: More than half (61%) of primary care providers expressed uncertainty about their role in providing care to survivors of the most common types of cancer.

Data Source: Survey of 103 PCPs in the Henry Ford Health System.

Disclosures: Dr. Lynch disclosed no conflicts of interest.

NEW ORLEANS — Primary care providers often feel unequipped to deal with issues of cancer survivorship, according to a survey of 103 physicians, nurse practitioners, and physician assistants at the Henry Ford Health System in Detroit.

More than half (61%) were uncertain about their role in follow-up care (surveillance) for the most common types of cancer, Teresa Lynch, Ph.D., reported at the annual conference of the American Psychosocial Oncology Society. These included lung, breast, prostate, colorectal, bladder, melanoma, non-Hodgkin's lymphoma, kidney/renal cell, leukemia, and endometrial malignancies.

Nearly half (46%) were uncertain of the patterns of morbidity associated with cancer treatments, she added, and 31% were uncertain as to what medical interventions are recommended for preventing or remediating morbidities associated with common cancers.

“Surveys of patients and professionals indicate that posttreatment cancer care is at best fragmented and at worse nonexistent,” said Dr. Lynch, a psychologist at the Josephine Cancer Center at Henry Ford. “PCPs do want to care for cancer patients. They believe it is part of their role, but they are currently very unclear as to what their exact responsibilities are.”

Dr. Lynch and colleagues are initiating a survivorship program to address the posttreatment needs of approximately 4,000 new cancer patients a year at their center. The program will incorporate care plans into the electronic medical record (EMR), and provide education to fill the gaps in knowledge that they are identifying in surveys of PCPs.

This study involved 103 PCPs who provide services within the large, diverse health care system and who had access to EMRs. The online survey questioned their beliefs and attitudes about providing survivorship care—specifically, knowledge of survivorship care and surveillance.

About half of the respondents were house officers, 30% were senior staff, and the rest were nurse practitioners or physician assistants. In all, 42% were 20–30 years of age, 17% were 31–40, 14% were 41–50, and 27% were 51 years or older.

In all categories, older providers felt less familiar with the issues, and house officers felt most confident, Dr. Lynch reported. Significantly, older providers also said that they were not completely comfortable in caring for cancer patients.

“Providers definitely thought it was important for them to understand cancer follow-up plans, but over 40% thought they did not receive timely information about changes in their patients' cancer status, medications or treatments,” she said. “Almost 30% of PCPs had difficulty determining patients' follow-up plans in the EMR.”

More than half of the providers said they “rely” on patients to inform them of their follow-up plans. Yet more than 80% of providers believed their patients are confused about follow-up.

“Based on these survey results, we believe that providers need a reliable source to guide their care of cancer patients, and patients need to be better informed about recommendations for follow-up care,” she concluded.

Regarding psychosocial services, only about half of the respondents indicated that they were comfortable asking their patients about emotional, family, and spiritual distress. Those who were more comfortable were also more likely to know when and where to refer patients for psychosocial services, and felt that their patients' needs were met by these referrals. Only 35% felt that the psychosocial needs of their patients were being met.

Major Finding: More than half (61%) of primary care providers expressed uncertainty about their role in providing care to survivors of the most common types of cancer.

Data Source: Survey of 103 PCPs in the Henry Ford Health System.

Disclosures: Dr. Lynch disclosed no conflicts of interest.

NEW ORLEANS — Primary care providers often feel unequipped to deal with issues of cancer survivorship, according to a survey of 103 physicians, nurse practitioners, and physician assistants at the Henry Ford Health System in Detroit.

More than half (61%) were uncertain about their role in follow-up care (surveillance) for the most common types of cancer, Teresa Lynch, Ph.D., reported at the annual conference of the American Psychosocial Oncology Society. These included lung, breast, prostate, colorectal, bladder, melanoma, non-Hodgkin's lymphoma, kidney/renal cell, leukemia, and endometrial malignancies.

Nearly half (46%) were uncertain of the patterns of morbidity associated with cancer treatments, she added, and 31% were uncertain as to what medical interventions are recommended for preventing or remediating morbidities associated with common cancers.

“Surveys of patients and professionals indicate that posttreatment cancer care is at best fragmented and at worse nonexistent,” said Dr. Lynch, a psychologist at the Josephine Cancer Center at Henry Ford. “PCPs do want to care for cancer patients. They believe it is part of their role, but they are currently very unclear as to what their exact responsibilities are.”

Dr. Lynch and colleagues are initiating a survivorship program to address the posttreatment needs of approximately 4,000 new cancer patients a year at their center. The program will incorporate care plans into the electronic medical record (EMR), and provide education to fill the gaps in knowledge that they are identifying in surveys of PCPs.

This study involved 103 PCPs who provide services within the large, diverse health care system and who had access to EMRs. The online survey questioned their beliefs and attitudes about providing survivorship care—specifically, knowledge of survivorship care and surveillance.

About half of the respondents were house officers, 30% were senior staff, and the rest were nurse practitioners or physician assistants. In all, 42% were 20–30 years of age, 17% were 31–40, 14% were 41–50, and 27% were 51 years or older.

In all categories, older providers felt less familiar with the issues, and house officers felt most confident, Dr. Lynch reported. Significantly, older providers also said that they were not completely comfortable in caring for cancer patients.

“Providers definitely thought it was important for them to understand cancer follow-up plans, but over 40% thought they did not receive timely information about changes in their patients' cancer status, medications or treatments,” she said. “Almost 30% of PCPs had difficulty determining patients' follow-up plans in the EMR.”

More than half of the providers said they “rely” on patients to inform them of their follow-up plans. Yet more than 80% of providers believed their patients are confused about follow-up.

“Based on these survey results, we believe that providers need a reliable source to guide their care of cancer patients, and patients need to be better informed about recommendations for follow-up care,” she concluded.

Regarding psychosocial services, only about half of the respondents indicated that they were comfortable asking their patients about emotional, family, and spiritual distress. Those who were more comfortable were also more likely to know when and where to refer patients for psychosocial services, and felt that their patients' needs were met by these referrals. Only 35% felt that the psychosocial needs of their patients were being met.

Major Finding: Financial resources were limited or very limited for nearly two-thirds of cancer patients—28% were at risk of losing their homes—and patients with financial stress had more mental health issues.

Data Source: A survey of 428 consecutive outpatients at an Ohio cancer center.

Disclosures: Dr. Wells-Di Gregorio disclosed no financial conflicts of interest.

NEW ORLEANS — A survey of cancer patients confirms that financial hardship is part of the disease package. Investigators found that 28% of patients, mostly those with advanced disease, were in danger of losing their homes, and financial hardships were strongly associated with mental health issues.

Responses obtained from 428 consecutive cancer outpatients revealed that 64% had limited or very limited financial resources as a result of their disease.

Only 38% of the patients reported no financial hardship, Sharla Wells-Di Gregorio, Ph.D., reported at the annual conference of the American Psychosocial Oncology Society.

“We were completely unprepared to see patients losing their homes, and others presenting with stage IV disease as a result of financial issues…. Many patients reported that they avoided going to the doctor for months, or years in some cases, because they didn't have insurance and could not afford it,” said Dr. Wells-Di Gregorio, who is a clinical psychologist with the center for palliative care at Ohio State University in Columbus.

Exacerbating cost-of-care issues, only 8% of the patients were employed full time; 65% were not working because of medical disability, and 7% worked part time.

Prior to developing cancer, 89% had a stable employment history, and 93% said they were satisfied with their jobs.

The investigators had hypothesized that patients who experienced moderate to severe financial difficulties would exhibit higher rates of major depressive disorder and generalized anxiety disorder than would patients who reported no financial difficulties, along with more depressive symptoms, pain, pain catastrophizing (out-of-proportion perception of pain), and symptom distress.

Half of the patients surveyed were female, 83% were white, and 53% were married. The average patient had at least a high school education.

More than half had metastases, and two-thirds were undergoing chemotherapy or radiotherapy at the time of the survey, which was done at one Ohio cancer center.

Measures included the Center for Epidemiologic Studies Depression Scale (CES-D), the Brief Pain Inventory (BPI), the Pain Catastrophizing Scale (PCS), and the Memorial Symptom Assessment Scale (MSAS). Patients also completed an interview to determine whether they had major depression or generalized anxiety.

“These financial difficulties also put the patients at greater risk for depression, anxiety, pain, and symptom distress,” Dr. Wells-Di Gregorio reported, based on their scores on the validated instruments.

Criteria for depression were met by 43% of patients who reported financial issues, compared with 23% of patients without money problems (P = .02); criteria for anxiety were met by 36% and 15%, respectively (P = .001).

Those with financial difficulties had significantly higher pain severity scores on the BPI (P = .001), significantly more physical symptoms on the MSAS (P = .039), and significantly more psychological symptoms on the MSAS (P = .001). Pain catastrophizing scores were not significantly different.

Dr. Wells-Di Gregorio noted that previous studies have shown that 20% of cancer patients with health insurance use all or most of their savings to pay for care, and 10% borrow money from relatives.

Out-of-pocket expenses for insured women with breast cancer account for 26%–98% of their monthly income, depending on whether their income was more than $60,000 or less than $30,000, she said.

Among patients without insurance, 50% use up all of their savings to help pay their medical expenses, 40% are unable to pay for basic necessities, 25% decline or delay treatment, and 6% file for bankruptcy.

Furthermore, 6% of patients lose insurance coverage as a result of having cancer, and 10% are unable to purchase it after a diagnosis.

“While these numbers don't sound high, based on national figures we are talking about 88,000 [6% of 1.5 million new cases] and 720,000 patients [6% of 12 million survivors] … a year,” Dr. Wells-Di Gregorio said.

“And in addition to physical and financial disability, patients suffer emotional disability,” she added. “They become fearful of losing their jobs. Due to common beliefs about disability and welfare, they begin to feel financially incompetent and stigmatized.”

Noting that patients also worry about the impact on their families, Dr. Wells-Di Gregorio concluded her talk with the suggestion that advance care planning for cancer patients include some way “to assure that families can survive in the case of patient death.”

Major Finding: Financial resources were limited or very limited for nearly two-thirds of cancer patients—28% were at risk of losing their homes—and patients with financial stress had more mental health issues.

Data Source: A survey of 428 consecutive outpatients at an Ohio cancer center.

Disclosures: Dr. Wells-Di Gregorio disclosed no financial conflicts of interest.

NEW ORLEANS — A survey of cancer patients confirms that financial hardship is part of the disease package. Investigators found that 28% of patients, mostly those with advanced disease, were in danger of losing their homes, and financial hardships were strongly associated with mental health issues.

Responses obtained from 428 consecutive cancer outpatients revealed that 64% had limited or very limited financial resources as a result of their disease.

Only 38% of the patients reported no financial hardship, Sharla Wells-Di Gregorio, Ph.D., reported at the annual conference of the American Psychosocial Oncology Society.

“We were completely unprepared to see patients losing their homes, and others presenting with stage IV disease as a result of financial issues…. Many patients reported that they avoided going to the doctor for months, or years in some cases, because they didn't have insurance and could not afford it,” said Dr. Wells-Di Gregorio, who is a clinical psychologist with the center for palliative care at Ohio State University in Columbus.

Exacerbating cost-of-care issues, only 8% of the patients were employed full time; 65% were not working because of medical disability, and 7% worked part time.

Prior to developing cancer, 89% had a stable employment history, and 93% said they were satisfied with their jobs.

The investigators had hypothesized that patients who experienced moderate to severe financial difficulties would exhibit higher rates of major depressive disorder and generalized anxiety disorder than would patients who reported no financial difficulties, along with more depressive symptoms, pain, pain catastrophizing (out-of-proportion perception of pain), and symptom distress.

Half of the patients surveyed were female, 83% were white, and 53% were married. The average patient had at least a high school education.

More than half had metastases, and two-thirds were undergoing chemotherapy or radiotherapy at the time of the survey, which was done at one Ohio cancer center.

Measures included the Center for Epidemiologic Studies Depression Scale (CES-D), the Brief Pain Inventory (BPI), the Pain Catastrophizing Scale (PCS), and the Memorial Symptom Assessment Scale (MSAS). Patients also completed an interview to determine whether they had major depression or generalized anxiety.

“These financial difficulties also put the patients at greater risk for depression, anxiety, pain, and symptom distress,” Dr. Wells-Di Gregorio reported, based on their scores on the validated instruments.

Criteria for depression were met by 43% of patients who reported financial issues, compared with 23% of patients without money problems (P = .02); criteria for anxiety were met by 36% and 15%, respectively (P = .001).

Those with financial difficulties had significantly higher pain severity scores on the BPI (P = .001), significantly more physical symptoms on the MSAS (P = .039), and significantly more psychological symptoms on the MSAS (P = .001). Pain catastrophizing scores were not significantly different.

Dr. Wells-Di Gregorio noted that previous studies have shown that 20% of cancer patients with health insurance use all or most of their savings to pay for care, and 10% borrow money from relatives.

Out-of-pocket expenses for insured women with breast cancer account for 26%–98% of their monthly income, depending on whether their income was more than $60,000 or less than $30,000, she said.

Among patients without insurance, 50% use up all of their savings to help pay their medical expenses, 40% are unable to pay for basic necessities, 25% decline or delay treatment, and 6% file for bankruptcy.

Furthermore, 6% of patients lose insurance coverage as a result of having cancer, and 10% are unable to purchase it after a diagnosis.

“While these numbers don't sound high, based on national figures we are talking about 88,000 [6% of 1.5 million new cases] and 720,000 patients [6% of 12 million survivors] … a year,” Dr. Wells-Di Gregorio said.

“And in addition to physical and financial disability, patients suffer emotional disability,” she added. “They become fearful of losing their jobs. Due to common beliefs about disability and welfare, they begin to feel financially incompetent and stigmatized.”

Noting that patients also worry about the impact on their families, Dr. Wells-Di Gregorio concluded her talk with the suggestion that advance care planning for cancer patients include some way “to assure that families can survive in the case of patient death.”

Major Finding: Financial resources were limited or very limited for nearly two-thirds of cancer patients—28% were at risk of losing their homes—and patients with financial stress had more mental health issues.

Data Source: A survey of 428 consecutive outpatients at an Ohio cancer center.

Disclosures: Dr. Wells-Di Gregorio disclosed no financial conflicts of interest.

NEW ORLEANS — A survey of cancer patients confirms that financial hardship is part of the disease package. Investigators found that 28% of patients, mostly those with advanced disease, were in danger of losing their homes, and financial hardships were strongly associated with mental health issues.

Responses obtained from 428 consecutive cancer outpatients revealed that 64% had limited or very limited financial resources as a result of their disease.

Only 38% of the patients reported no financial hardship, Sharla Wells-Di Gregorio, Ph.D., reported at the annual conference of the American Psychosocial Oncology Society.

“We were completely unprepared to see patients losing their homes, and others presenting with stage IV disease as a result of financial issues…. Many patients reported that they avoided going to the doctor for months, or years in some cases, because they didn't have insurance and could not afford it,” said Dr. Wells-Di Gregorio, who is a clinical psychologist with the center for palliative care at Ohio State University in Columbus.

Exacerbating cost-of-care issues, only 8% of the patients were employed full time; 65% were not working because of medical disability, and 7% worked part time.

Prior to developing cancer, 89% had a stable employment history, and 93% said they were satisfied with their jobs.

The investigators had hypothesized that patients who experienced moderate to severe financial difficulties would exhibit higher rates of major depressive disorder and generalized anxiety disorder than would patients who reported no financial difficulties, along with more depressive symptoms, pain, pain catastrophizing (out-of-proportion perception of pain), and symptom distress.

Half of the patients surveyed were female, 83% were white, and 53% were married. The average patient had at least a high school education.

More than half had metastases, and two-thirds were undergoing chemotherapy or radiotherapy at the time of the survey, which was done at one Ohio cancer center.

Measures included the Center for Epidemiologic Studies Depression Scale (CES-D), the Brief Pain Inventory (BPI), the Pain Catastrophizing Scale (PCS), and the Memorial Symptom Assessment Scale (MSAS). Patients also completed an interview to determine whether they had major depression or generalized anxiety.

“These financial difficulties also put the patients at greater risk for depression, anxiety, pain, and symptom distress,” Dr. Wells-Di Gregorio reported, based on their scores on the validated instruments.

Criteria for depression were met by 43% of patients who reported financial issues, compared with 23% of patients without money problems (P = .02); criteria for anxiety were met by 36% and 15%, respectively (P = .001).

Those with financial difficulties had significantly higher pain severity scores on the BPI (P = .001), significantly more physical symptoms on the MSAS (P = .039), and significantly more psychological symptoms on the MSAS (P = .001). Pain catastrophizing scores were not significantly different.

Dr. Wells-Di Gregorio noted that previous studies have shown that 20% of cancer patients with health insurance use all or most of their savings to pay for care, and 10% borrow money from relatives.

Out-of-pocket expenses for insured women with breast cancer account for 26%–98% of their monthly income, depending on whether their income was more than $60,000 or less than $30,000, she said.

Among patients without insurance, 50% use up all of their savings to help pay their medical expenses, 40% are unable to pay for basic necessities, 25% decline or delay treatment, and 6% file for bankruptcy.

Furthermore, 6% of patients lose insurance coverage as a result of having cancer, and 10% are unable to purchase it after a diagnosis.

“While these numbers don't sound high, based on national figures we are talking about 88,000 [6% of 1.5 million new cases] and 720,000 patients [6% of 12 million survivors] … a year,” Dr. Wells-Di Gregorio said.

“And in addition to physical and financial disability, patients suffer emotional disability,” she added. “They become fearful of losing their jobs. Due to common beliefs about disability and welfare, they begin to feel financially incompetent and stigmatized.”

Noting that patients also worry about the impact on their families, Dr. Wells-Di Gregorio concluded her talk with the suggestion that advance care planning for cancer patients include some way “to assure that families can survive in the case of patient death.”

CHICAGO — The incidence of the oldest side effect of anticancer treatment—diarrhea—is rising in parallel with the use of targeted agents, and clinicians need to manage this proactively in order to keep patients on treatment, said Dr. Joanna M. Brell of the Division of Cancer Prevention at the National Cancer Institute.

“Diarrhea occurs in about 80% of chemotherapy patients, and about 30% is grade 3/4 toxicity. It is common, it is associated with newer targeted therapies, it is additive with combination treatment, and patients are receiving treatment for longer periods. We'd better be good at managing it,” she told attendees at the annual Chicago Supportive Oncology Conference.

Diarrhea is a class effect of many older drugs and of the small-molecule agents that are approved in treating at least 10 malignancies, with many more compounds in the pipeline. (See box.) The fact that more targeted agents will be used in maintenance therapy means that more patients will experience diarrhea for longer periods of time, Dr. Brell warned.

The physical consequences include dehydration, electrolyte imbalance, acute renal failure, renal insufficiency, weight loss, malnutrition, and risk of infection. It causes generalized malaise, diminishes activities of daily living, enhances treatment noncompliance, and reduces quality of life. Importantly, an abnormal GI tract may affect absorption of oral chemotherapy, and dose reductions of anticancer drugs or discontinuations of treatment are sometimes required.

“Treatment delays have uncertain effects on the tumor, and this is distressing to the patient, who wants full treatment,” she said.

Why Diarrhea Occurs With Targeted Agents

The mechanisms by which diarrhea occurs with targeted agents were recently described (Nat. Clin. Pract. Oncol. 2008;5:268-78). They vary according to the class of agent.

With the epidermal growth factor receptor inhibitor erlotinib (Tarceva), the incidence—but not the severity—of diarrhea is dose related. Sorafenib (Nexavar), a multitargeted vascular inhibitor, causes diarrhea in 30%-43% of patients. This is thought to be related to small-vessel ischemia or ischemic colitis with mucosal changes, and to direct damage to mucosal cells. With bortezomib (Velcade), an NF kappaB inhibitor, diarrhea can have a relatively quick onset (with associated postural hypotension, syncope, or near-syncope) and can be dose limiting. Flavopiridol, which inhibits multiple cyclin-dependent kinases, enhances the efficacy of other chemotherapies. Cholestyramine can bind to flavopiridol and therefore protect against diarrhea, but how this may affect anticancer treatment is unknown, Dr. Brell said.

Management of Diarrhea Due to Targeted Agents

There is little to no evidence to guide the management of diarrhea that is specifically associated with targeted therapies, Dr. Brell said. Unlike conventional chemotherapy, the goal with these agents is not to increase response, and they are not dosed according to body surface area. The actual effective dose of the drugs, therefore, is generally unknown.

Given these considerations, the major management strategy with these agents is dose delay, she said. Brief dose interruptions are usually adequate, and the dose can usually be maintained in spite of the toxicity, “which we don't do with [5-fluorouracil] or irinotecan,” she noted. Dose reductions are done, if required, to maintain quality of life.

Cholestyramine can be tried for diarrhea that is associated with sorafenib, sunitinib (Sutent), and flavopiridol.

The usual management strategies also apply, added Dr. Brell. Clinicians should monitor stool output closely; stop supportive medications for constipation; use oral loperamide (Imodium) up to 16 mg/day, or diphenoxylate plus atropine (Lomotil) 5 mg two to four times per day; give intravenous fluids; rule out C. difficile; prescribe empiric antibiotics; and give octreotide (Sandostatin LAR Depot) 100 mcg three times daily, or at higher doses).

Clinicians should check for the use of medications that might increase diarrhea, such as CYP3A4 inhibitors that can affect drug metabolism such that levels of the anticancer therapy are increased and therefore toxicity is enhanced.

For prophylaxis, data are even more limited. Dr. Brell suggested trying cholestyramine prior to dosing sorafenib and sunitinib, giving octreotide LAR monthly, and giving octreotide and loperamide prior to chemoradiation to the pelvis.

The meeting was sponsored by Elsevier Oncology, a sister company to this news organization.

There is little to no evidence to guide the management of diarrhea due to targeted therapies.

Source DR. BRELL

Elsevier Global Medical News

CHICAGO — The incidence of the oldest side effect of anticancer treatment—diarrhea—is rising in parallel with the use of targeted agents, and clinicians need to manage this proactively in order to keep patients on treatment, said Dr. Joanna M. Brell of the Division of Cancer Prevention at the National Cancer Institute.

“Diarrhea occurs in about 80% of chemotherapy patients, and about 30% is grade 3/4 toxicity. It is common, it is associated with newer targeted therapies, it is additive with combination treatment, and patients are receiving treatment for longer periods. We'd better be good at managing it,” she told attendees at the annual Chicago Supportive Oncology Conference.

Diarrhea is a class effect of many older drugs and of the small-molecule agents that are approved in treating at least 10 malignancies, with many more compounds in the pipeline. (See box.) The fact that more targeted agents will be used in maintenance therapy means that more patients will experience diarrhea for longer periods of time, Dr. Brell warned.

The physical consequences include dehydration, electrolyte imbalance, acute renal failure, renal insufficiency, weight loss, malnutrition, and risk of infection. It causes generalized malaise, diminishes activities of daily living, enhances treatment noncompliance, and reduces quality of life. Importantly, an abnormal GI tract may affect absorption of oral chemotherapy, and dose reductions of anticancer drugs or discontinuations of treatment are sometimes required.

“Treatment delays have uncertain effects on the tumor, and this is distressing to the patient, who wants full treatment,” she said.

Why Diarrhea Occurs With Targeted Agents

The mechanisms by which diarrhea occurs with targeted agents were recently described (Nat. Clin. Pract. Oncol. 2008;5:268-78). They vary according to the class of agent.

With the epidermal growth factor receptor inhibitor erlotinib (Tarceva), the incidence—but not the severity—of diarrhea is dose related. Sorafenib (Nexavar), a multitargeted vascular inhibitor, causes diarrhea in 30%-43% of patients. This is thought to be related to small-vessel ischemia or ischemic colitis with mucosal changes, and to direct damage to mucosal cells. With bortezomib (Velcade), an NF kappaB inhibitor, diarrhea can have a relatively quick onset (with associated postural hypotension, syncope, or near-syncope) and can be dose limiting. Flavopiridol, which inhibits multiple cyclin-dependent kinases, enhances the efficacy of other chemotherapies. Cholestyramine can bind to flavopiridol and therefore protect against diarrhea, but how this may affect anticancer treatment is unknown, Dr. Brell said.

Management of Diarrhea Due to Targeted Agents

There is little to no evidence to guide the management of diarrhea that is specifically associated with targeted therapies, Dr. Brell said. Unlike conventional chemotherapy, the goal with these agents is not to increase response, and they are not dosed according to body surface area. The actual effective dose of the drugs, therefore, is generally unknown.

Given these considerations, the major management strategy with these agents is dose delay, she said. Brief dose interruptions are usually adequate, and the dose can usually be maintained in spite of the toxicity, “which we don't do with [5-fluorouracil] or irinotecan,” she noted. Dose reductions are done, if required, to maintain quality of life.

Cholestyramine can be tried for diarrhea that is associated with sorafenib, sunitinib (Sutent), and flavopiridol.

The usual management strategies also apply, added Dr. Brell. Clinicians should monitor stool output closely; stop supportive medications for constipation; use oral loperamide (Imodium) up to 16 mg/day, or diphenoxylate plus atropine (Lomotil) 5 mg two to four times per day; give intravenous fluids; rule out C. difficile; prescribe empiric antibiotics; and give octreotide (Sandostatin LAR Depot) 100 mcg three times daily, or at higher doses).

Clinicians should check for the use of medications that might increase diarrhea, such as CYP3A4 inhibitors that can affect drug metabolism such that levels of the anticancer therapy are increased and therefore toxicity is enhanced.

For prophylaxis, data are even more limited. Dr. Brell suggested trying cholestyramine prior to dosing sorafenib and sunitinib, giving octreotide LAR monthly, and giving octreotide and loperamide prior to chemoradiation to the pelvis.

The meeting was sponsored by Elsevier Oncology, a sister company to this news organization.

There is little to no evidence to guide the management of diarrhea due to targeted therapies.

Source DR. BRELL

Elsevier Global Medical News

CHICAGO — The incidence of the oldest side effect of anticancer treatment—diarrhea—is rising in parallel with the use of targeted agents, and clinicians need to manage this proactively in order to keep patients on treatment, said Dr. Joanna M. Brell of the Division of Cancer Prevention at the National Cancer Institute.

“Diarrhea occurs in about 80% of chemotherapy patients, and about 30% is grade 3/4 toxicity. It is common, it is associated with newer targeted therapies, it is additive with combination treatment, and patients are receiving treatment for longer periods. We'd better be good at managing it,” she told attendees at the annual Chicago Supportive Oncology Conference.

Diarrhea is a class effect of many older drugs and of the small-molecule agents that are approved in treating at least 10 malignancies, with many more compounds in the pipeline. (See box.) The fact that more targeted agents will be used in maintenance therapy means that more patients will experience diarrhea for longer periods of time, Dr. Brell warned.

The physical consequences include dehydration, electrolyte imbalance, acute renal failure, renal insufficiency, weight loss, malnutrition, and risk of infection. It causes generalized malaise, diminishes activities of daily living, enhances treatment noncompliance, and reduces quality of life. Importantly, an abnormal GI tract may affect absorption of oral chemotherapy, and dose reductions of anticancer drugs or discontinuations of treatment are sometimes required.

“Treatment delays have uncertain effects on the tumor, and this is distressing to the patient, who wants full treatment,” she said.

Why Diarrhea Occurs With Targeted Agents

The mechanisms by which diarrhea occurs with targeted agents were recently described (Nat. Clin. Pract. Oncol. 2008;5:268-78). They vary according to the class of agent.

With the epidermal growth factor receptor inhibitor erlotinib (Tarceva), the incidence—but not the severity—of diarrhea is dose related. Sorafenib (Nexavar), a multitargeted vascular inhibitor, causes diarrhea in 30%-43% of patients. This is thought to be related to small-vessel ischemia or ischemic colitis with mucosal changes, and to direct damage to mucosal cells. With bortezomib (Velcade), an NF kappaB inhibitor, diarrhea can have a relatively quick onset (with associated postural hypotension, syncope, or near-syncope) and can be dose limiting. Flavopiridol, which inhibits multiple cyclin-dependent kinases, enhances the efficacy of other chemotherapies. Cholestyramine can bind to flavopiridol and therefore protect against diarrhea, but how this may affect anticancer treatment is unknown, Dr. Brell said.

Management of Diarrhea Due to Targeted Agents

There is little to no evidence to guide the management of diarrhea that is specifically associated with targeted therapies, Dr. Brell said. Unlike conventional chemotherapy, the goal with these agents is not to increase response, and they are not dosed according to body surface area. The actual effective dose of the drugs, therefore, is generally unknown.

Given these considerations, the major management strategy with these agents is dose delay, she said. Brief dose interruptions are usually adequate, and the dose can usually be maintained in spite of the toxicity, “which we don't do with [5-fluorouracil] or irinotecan,” she noted. Dose reductions are done, if required, to maintain quality of life.

Cholestyramine can be tried for diarrhea that is associated with sorafenib, sunitinib (Sutent), and flavopiridol.

The usual management strategies also apply, added Dr. Brell. Clinicians should monitor stool output closely; stop supportive medications for constipation; use oral loperamide (Imodium) up to 16 mg/day, or diphenoxylate plus atropine (Lomotil) 5 mg two to four times per day; give intravenous fluids; rule out C. difficile; prescribe empiric antibiotics; and give octreotide (Sandostatin LAR Depot) 100 mcg three times daily, or at higher doses).

Clinicians should check for the use of medications that might increase diarrhea, such as CYP3A4 inhibitors that can affect drug metabolism such that levels of the anticancer therapy are increased and therefore toxicity is enhanced.

For prophylaxis, data are even more limited. Dr. Brell suggested trying cholestyramine prior to dosing sorafenib and sunitinib, giving octreotide LAR monthly, and giving octreotide and loperamide prior to chemoradiation to the pelvis.

The meeting was sponsored by Elsevier Oncology, a sister company to this news organization.

There is little to no evidence to guide the management of diarrhea due to targeted therapies.

Source DR. BRELL

Elsevier Global Medical News

Rosiglitazone use was associated with an increased prevalence of vertebral fractures among men in a small cross-sectional study.

Most previous studies on the effect of thiazolidinediones on bone have been done in postmenopausal women, who are already at risk for osteoporosis. The present study provides evidence that osteoporotic fractures may be a general complication of this treatment, said Dr. Tatiana Mancini of San Marino (Italy) Hospital, and her associates.

On the basis of their findings, the investigators advocated that health care providers use spine x-ray in combination with dual-energy x-ray absorptiometry (DXA) to assess bone status in diabetic patients treated with these agents (Bone 2009;25:784–8). Of 43 men with type 2 dia-betes (mean age 69 years), 22 men used metformin alone and 21 used metformin plus rosiglitazone; 22 nondiabetic men from an outpatient bone clinic served as controls. Bone mineral density (BMD) was assessed by DXA, and quantitative morphometric analysis was used to identify radiological vertebral fractures.

Vertebral fractures were found in 46.5% of the men with diabetes with a significantly higher prevalence in patients treated with rosiglitazone plus metformin (66.7%) versus metformin alone (27.3%) or versus controls (22.7%).

Compared with diabetic men who received only metformin, those who received both drugs were significantly younger and had greater body mass index. Multivariate analysis corrected for these and other factors but still demonstrated a significant 6.5-fold increased risk associated with rosiglitazone.

Rosiglitazone use was associated with an increased prevalence of vertebral fractures among men in a small cross-sectional study.

Most previous studies on the effect of thiazolidinediones on bone have been done in postmenopausal women, who are already at risk for osteoporosis. The present study provides evidence that osteoporotic fractures may be a general complication of this treatment, said Dr. Tatiana Mancini of San Marino (Italy) Hospital, and her associates.

On the basis of their findings, the investigators advocated that health care providers use spine x-ray in combination with dual-energy x-ray absorptiometry (DXA) to assess bone status in diabetic patients treated with these agents (Bone 2009;25:784–8). Of 43 men with type 2 dia-betes (mean age 69 years), 22 men used metformin alone and 21 used metformin plus rosiglitazone; 22 nondiabetic men from an outpatient bone clinic served as controls. Bone mineral density (BMD) was assessed by DXA, and quantitative morphometric analysis was used to identify radiological vertebral fractures.

Vertebral fractures were found in 46.5% of the men with diabetes with a significantly higher prevalence in patients treated with rosiglitazone plus metformin (66.7%) versus metformin alone (27.3%) or versus controls (22.7%).

Compared with diabetic men who received only metformin, those who received both drugs were significantly younger and had greater body mass index. Multivariate analysis corrected for these and other factors but still demonstrated a significant 6.5-fold increased risk associated with rosiglitazone.

Rosiglitazone use was associated with an increased prevalence of vertebral fractures among men in a small cross-sectional study.

Most previous studies on the effect of thiazolidinediones on bone have been done in postmenopausal women, who are already at risk for osteoporosis. The present study provides evidence that osteoporotic fractures may be a general complication of this treatment, said Dr. Tatiana Mancini of San Marino (Italy) Hospital, and her associates.

On the basis of their findings, the investigators advocated that health care providers use spine x-ray in combination with dual-energy x-ray absorptiometry (DXA) to assess bone status in diabetic patients treated with these agents (Bone 2009;25:784–8). Of 43 men with type 2 dia-betes (mean age 69 years), 22 men used metformin alone and 21 used metformin plus rosiglitazone; 22 nondiabetic men from an outpatient bone clinic served as controls. Bone mineral density (BMD) was assessed by DXA, and quantitative morphometric analysis was used to identify radiological vertebral fractures.

Vertebral fractures were found in 46.5% of the men with diabetes with a significantly higher prevalence in patients treated with rosiglitazone plus metformin (66.7%) versus metformin alone (27.3%) or versus controls (22.7%).

Compared with diabetic men who received only metformin, those who received both drugs were significantly younger and had greater body mass index. Multivariate analysis corrected for these and other factors but still demonstrated a significant 6.5-fold increased risk associated with rosiglitazone.

The presence of metabolic syndrome significantly increased the risk of incident type 2 diabetes independent of impaired fasting glucose, researchers studying a Japanese population have found.

The finding suggests that metabolic syndrome can be used to identify persons at high risk for developing the disease, they said.

The study adds to a body of data showing mixed results for the value of metabolic syndrome as a predictor of type 2 diabetes. One cohort study showed it to be superior to simple impaired fasting glucose alone, while others have found metabolic syndrome to be comparable or inferior to IFG alone. Further, most previous studies were performed in Western populations; the present study adds information in an Asian cohort (Diabetes Care 2009 Sept. 3 [doi:10.2337/dc09-0896

Led by Dr. Naoko Mukai and associates at Kyushu University, Fukuoka, Japan, the study comprised 1,935 nondiabetic subjects aged 40–79 years who were enrolled in an ongoing population-based study of cardiovascular disease and its risk factors between 1988 and November 2002 in the town of Hisayama on Kyushu Island. The subjects were followed up prospectively for a mean of 11.8 years. At baseline and during regular examinations, the subjects underwent a fasting oral glucose tolerance test.

During follow-up, 286 subjects (145 men and 141 women) developed diabetes. Compared with those who did not have metabolic syndrome, the multivariate-adjusted risk for incident diabetes was significantly higher in subjects with metabolic syndrome in both sexes, even after adjustment for confounding factors that included age, family history of diabetes, total cholesterol, alcohol intake, smoking habits, and regular exercise. Hazard ratios were 2.58 for men and 3.69 for women.

Among the individual components of metabolic syndrome, impaired fasting glucose was the strongest predictor of diabetes in both sexes, raising the risk more than threefold.

In normal fasting glucose subjects, risk increased significantly according to number of metabolic syndrome components. Metabolic syndrome defined without the fasting plasma glucose component was also a significant risk factor.

To the authors' knowledge, this is the first report indicating that metabolic syndrome is associated with future diabetes for both sexes in a general Japanese population.

The authors mentioned two possible study limitations, the first being that metabolic syndrome diagnosis was based on a “a single measurement of its components at baseline. … The risk factor levels might have changed during the follow-up due to modifications in lifestyle or medication.” Also, data on antilipidemic medication use was not included in the study.

However, the researchers wrote: “These biases have the potential to underestimate the association between [metabolic syndrome] and incident [type 2 diabetes], and thus the true impact of [metabolic syndrome] on the occurrence of [type 2 diabetes] may be stronger than that shown in our findings.”

The authors said they had no relevant conflicts of interest.

The presence of metabolic syndrome significantly increased the risk of incident type 2 diabetes independent of impaired fasting glucose, researchers studying a Japanese population have found.

The finding suggests that metabolic syndrome can be used to identify persons at high risk for developing the disease, they said.

The study adds to a body of data showing mixed results for the value of metabolic syndrome as a predictor of type 2 diabetes. One cohort study showed it to be superior to simple impaired fasting glucose alone, while others have found metabolic syndrome to be comparable or inferior to IFG alone. Further, most previous studies were performed in Western populations; the present study adds information in an Asian cohort (Diabetes Care 2009 Sept. 3 [doi:10.2337/dc09-0896

Led by Dr. Naoko Mukai and associates at Kyushu University, Fukuoka, Japan, the study comprised 1,935 nondiabetic subjects aged 40–79 years who were enrolled in an ongoing population-based study of cardiovascular disease and its risk factors between 1988 and November 2002 in the town of Hisayama on Kyushu Island. The subjects were followed up prospectively for a mean of 11.8 years. At baseline and during regular examinations, the subjects underwent a fasting oral glucose tolerance test.

During follow-up, 286 subjects (145 men and 141 women) developed diabetes. Compared with those who did not have metabolic syndrome, the multivariate-adjusted risk for incident diabetes was significantly higher in subjects with metabolic syndrome in both sexes, even after adjustment for confounding factors that included age, family history of diabetes, total cholesterol, alcohol intake, smoking habits, and regular exercise. Hazard ratios were 2.58 for men and 3.69 for women.

Among the individual components of metabolic syndrome, impaired fasting glucose was the strongest predictor of diabetes in both sexes, raising the risk more than threefold.

In normal fasting glucose subjects, risk increased significantly according to number of metabolic syndrome components. Metabolic syndrome defined without the fasting plasma glucose component was also a significant risk factor.

To the authors' knowledge, this is the first report indicating that metabolic syndrome is associated with future diabetes for both sexes in a general Japanese population.

The authors mentioned two possible study limitations, the first being that metabolic syndrome diagnosis was based on a “a single measurement of its components at baseline. … The risk factor levels might have changed during the follow-up due to modifications in lifestyle or medication.” Also, data on antilipidemic medication use was not included in the study.

However, the researchers wrote: “These biases have the potential to underestimate the association between [metabolic syndrome] and incident [type 2 diabetes], and thus the true impact of [metabolic syndrome] on the occurrence of [type 2 diabetes] may be stronger than that shown in our findings.”

The authors said they had no relevant conflicts of interest.

The presence of metabolic syndrome significantly increased the risk of incident type 2 diabetes independent of impaired fasting glucose, researchers studying a Japanese population have found.

The finding suggests that metabolic syndrome can be used to identify persons at high risk for developing the disease, they said.

The study adds to a body of data showing mixed results for the value of metabolic syndrome as a predictor of type 2 diabetes. One cohort study showed it to be superior to simple impaired fasting glucose alone, while others have found metabolic syndrome to be comparable or inferior to IFG alone. Further, most previous studies were performed in Western populations; the present study adds information in an Asian cohort (Diabetes Care 2009 Sept. 3 [doi:10.2337/dc09-0896

Led by Dr. Naoko Mukai and associates at Kyushu University, Fukuoka, Japan, the study comprised 1,935 nondiabetic subjects aged 40–79 years who were enrolled in an ongoing population-based study of cardiovascular disease and its risk factors between 1988 and November 2002 in the town of Hisayama on Kyushu Island. The subjects were followed up prospectively for a mean of 11.8 years. At baseline and during regular examinations, the subjects underwent a fasting oral glucose tolerance test.

During follow-up, 286 subjects (145 men and 141 women) developed diabetes. Compared with those who did not have metabolic syndrome, the multivariate-adjusted risk for incident diabetes was significantly higher in subjects with metabolic syndrome in both sexes, even after adjustment for confounding factors that included age, family history of diabetes, total cholesterol, alcohol intake, smoking habits, and regular exercise. Hazard ratios were 2.58 for men and 3.69 for women.

Among the individual components of metabolic syndrome, impaired fasting glucose was the strongest predictor of diabetes in both sexes, raising the risk more than threefold.

In normal fasting glucose subjects, risk increased significantly according to number of metabolic syndrome components. Metabolic syndrome defined without the fasting plasma glucose component was also a significant risk factor.

To the authors' knowledge, this is the first report indicating that metabolic syndrome is associated with future diabetes for both sexes in a general Japanese population.

The authors mentioned two possible study limitations, the first being that metabolic syndrome diagnosis was based on a “a single measurement of its components at baseline. … The risk factor levels might have changed during the follow-up due to modifications in lifestyle or medication.” Also, data on antilipidemic medication use was not included in the study.

However, the researchers wrote: “These biases have the potential to underestimate the association between [metabolic syndrome] and incident [type 2 diabetes], and thus the true impact of [metabolic syndrome] on the occurrence of [type 2 diabetes] may be stronger than that shown in our findings.”

The authors said they had no relevant conflicts of interest.

In a small study of low-income, diabetic African American and Hispanic adults diagnosed with depression, a popular antidepressant not only significantly improved hemoglobin A_1c, but also significantly decreased systolic blood pressure.

In the double blind, randomized trial conducted by Dr. Diana Echeverry and her colleagues at Charles Drew University, Los Angeles, 75 patients in an L.A. County diabetes clinic who were diagnosed with depression and had HbA_1c levels of at least 8% were randomized to receive 50–100 mg sertraline or placebo for 6 months.

HbA_1c levels fell significantly in both groups, but the decrease in the sertraline group was more than twice that of the placebo group, at −2.0% and −0.9%, respectively. Systolic blood pressure also fell significantly in both groups, but once again, more so in the sertraline group (−15 mm Hg) than in the placebo group (−6 mm Hg), the researchers wrote.

Hamilton Depression Scale (HAM-D) scores fell significantly in both groups, but no difference was seen between them, the researchers reported. A very significant correlation of 0.45 (P less than 10doi:10.2337/dc09-0785

Dr. Echeverry and her colleagues wrote that the results suggested “an effective approach to the time constraints hindering primary care physicians caring for patients in poor glycemic control in whom depression is suspected, especially in low income, minority populations,” they wrote, adding that although these patients may traditionally be more difficult to treat successfully, the researchers wrote, “in this manner, both depression and uncontrolled diabetes and systolic blood pressure may be improved.”

The robust effect of sertraline in lowering HbA_1c levels differs from most other studies of depression in diabetes, they wrote. The similar improvements in depression, quality of life, and pain scores observed within the two groups might be explained by the frequent interaction with the study coordinator, i.e., a placebo effect in the control group.

The study was funded by the University of California, Los Angeles, and the National Institutes of Health. The researchers reported that they had no conflicts of interest.

In a small study of low-income, diabetic African American and Hispanic adults diagnosed with depression, a popular antidepressant not only significantly improved hemoglobin A_1c, but also significantly decreased systolic blood pressure.

In the double blind, randomized trial conducted by Dr. Diana Echeverry and her colleagues at Charles Drew University, Los Angeles, 75 patients in an L.A. County diabetes clinic who were diagnosed with depression and had HbA_1c levels of at least 8% were randomized to receive 50–100 mg sertraline or placebo for 6 months.

HbA_1c levels fell significantly in both groups, but the decrease in the sertraline group was more than twice that of the placebo group, at −2.0% and −0.9%, respectively. Systolic blood pressure also fell significantly in both groups, but once again, more so in the sertraline group (−15 mm Hg) than in the placebo group (−6 mm Hg), the researchers wrote.

Hamilton Depression Scale (HAM-D) scores fell significantly in both groups, but no difference was seen between them, the researchers reported. A very significant correlation of 0.45 (P less than 10doi:10.2337/dc09-0785

Dr. Echeverry and her colleagues wrote that the results suggested “an effective approach to the time constraints hindering primary care physicians caring for patients in poor glycemic control in whom depression is suspected, especially in low income, minority populations,” they wrote, adding that although these patients may traditionally be more difficult to treat successfully, the researchers wrote, “in this manner, both depression and uncontrolled diabetes and systolic blood pressure may be improved.”

The robust effect of sertraline in lowering HbA_1c levels differs from most other studies of depression in diabetes, they wrote. The similar improvements in depression, quality of life, and pain scores observed within the two groups might be explained by the frequent interaction with the study coordinator, i.e., a placebo effect in the control group.

The study was funded by the University of California, Los Angeles, and the National Institutes of Health. The researchers reported that they had no conflicts of interest.

In a small study of low-income, diabetic African American and Hispanic adults diagnosed with depression, a popular antidepressant not only significantly improved hemoglobin A_1c, but also significantly decreased systolic blood pressure.

In the double blind, randomized trial conducted by Dr. Diana Echeverry and her colleagues at Charles Drew University, Los Angeles, 75 patients in an L.A. County diabetes clinic who were diagnosed with depression and had HbA_1c levels of at least 8% were randomized to receive 50–100 mg sertraline or placebo for 6 months.

HbA_1c levels fell significantly in both groups, but the decrease in the sertraline group was more than twice that of the placebo group, at −2.0% and −0.9%, respectively. Systolic blood pressure also fell significantly in both groups, but once again, more so in the sertraline group (−15 mm Hg) than in the placebo group (−6 mm Hg), the researchers wrote.

Hamilton Depression Scale (HAM-D) scores fell significantly in both groups, but no difference was seen between them, the researchers reported. A very significant correlation of 0.45 (P less than 10doi:10.2337/dc09-0785

Dr. Echeverry and her colleagues wrote that the results suggested “an effective approach to the time constraints hindering primary care physicians caring for patients in poor glycemic control in whom depression is suspected, especially in low income, minority populations,” they wrote, adding that although these patients may traditionally be more difficult to treat successfully, the researchers wrote, “in this manner, both depression and uncontrolled diabetes and systolic blood pressure may be improved.”

The robust effect of sertraline in lowering HbA_1c levels differs from most other studies of depression in diabetes, they wrote. The similar improvements in depression, quality of life, and pain scores observed within the two groups might be explained by the frequent interaction with the study coordinator, i.e., a placebo effect in the control group.

The study was funded by the University of California, Los Angeles, and the National Institutes of Health. The researchers reported that they had no conflicts of interest.