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Journal Issue: Vol.8, No.4 - October 2009

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Editorial

Editorial: Fatigue, the Most Common Problem within People Afflicted with Cancer: Challenge for Health Care Professionals - Widening Our Perspectives on Existential Issues

Cancer-related fatigue is an almost worldwide disorder among cancer patients and has been identified as an essential problem. Causes for cancer-related fatigue have many origins; for example the illness itself, the side effects of most all therapy, mode changes, depression and other bio-psychosocial factors. Fatigue has a much more intense effect on patients with cancer than any other psychological or physical consequence of the disorder or its therapy. A numerous of studies argue for cancer-related fatigue but it is still often ignored, under-recognized and under-treated even if medical discipline has been presenting stable progress in cancer therapy itself. Fatigue is multidimensional in its appearance and influence. Fatigue can be suffered by patients as a very frustrating state of chronic energy reduction, leading to loss of production, which may diminish self-esteem. Some individuals with cancer develop fatigue, whereas others do not. Stress-induced illness is commonly seen as blameless, whereas labeling an illness as psychogenic may raise doubts about both the reality of the illness and even the character of the sufferer. Anxiety has been seen as a correlate of fatigue and anxiety is considered to be a promoting source of fatigue. Some studies present findings that fatigue associated with untreatable cancer is a lived physical experience of approaching death. Even if it is possible for depression and fatigue to co-exist, health care professionals ought to try to distinguish between them in order to guide management. Patients with fatigue tell inability to finish some activities due to a lack of energy, while grief and depression are associated with a patient explanation that is more global, for instance being unable to do "anything." Two factors of cancer-related fatigue have been well documented. First, the physical factor is described as exhaustion or muscle weakness. The muscle weakness, causing the inability to perform activities of daily living, can be defined as asthenia. Second, the psychological factor is described as decreased capacity for activity of mental exertion causes problems in solving problems and focusing /concentrating on intellectual activities. Fatigue can be considered as being a general term covering a range of phenomena that are often, but not necessary, associated with exertion. The meaning of the term is therefore both intuitively obvious, based on one's own experience, but also indefinable. A clear definition of fatigue is difficult to derive from the literature because many disciplines such as medicine, nursing, physiology, psychology, and ergonomics have investigated this problem with as many different perspectives. According to National Comprehensive Cancer Network, the definition of cancer-related fatigue is a distressing persistent, subjective sense of physical, emotional and/or cognitive tiredness or exhaustion related to cancer or cancer treatment that is not proportional to recent activity and interferes with usual functioning. Looking at a definition proposed for nursing usage: fatigue is a subjective, unpleasant symptom, which incorporates total body feelings ranging from tiredness to exhaustion creating an unrelenting overall condition, which interferes with individuals` ability to function to their normal capacity. Fatigue is a subjective state of overwhelming, sustained exhaustion and decreased capacity for physical and mental work that is not relieved by rest. Despite recognition of its subjective nature, the majority of research undertaken has set out to objectify and quantify the fatigue experience. Several instruments have been developed to measure fatigue and there is a critical review of fatigue instruments to provide clinicians information on which to base decisions of alternatives. There is also fatigue issues included in several quality of life instruments. One problem with fatigue is that a clear definition of fatigue is difficult to derive from the literature. The question then must be are we measuring the same issue? Is there an agreement between the researcher's definition of fatigue of what it is or is not and the cancer patients responding to the instruments? Are there some variables that we have been missing? Could this be the reason why studies sometimes present contradictory results? and leaving us with confusion on what to focus on. There is still work to be undertaken in understanding the phenomenon of fatigue and how to measure this. Is it possible to measure? What aspects of fatigue are to be measured? An understanding of the wider experience of fatigue is required. Evidence is now emerging from qualitative studies that point out the considerable impact of fatigue on individuals' self esteem, role function, quality of life, adjustment to a cancer diagnosis and experiences of suffering leading to existential issues. Fatigue is reported to affect more than the half of the cancer patients and have a considerable impact on quality of life; as a common and distressing symptom. Although the majority of healthcare professionals in different studies tell that they prescribe therapy for more than half of patients, approximately 10-15 % of patients report getting such treatment. Could this be due to the cancer patients experience affected emotions such as feelings of anxiety, fear and distress regarding the present situation but also the unpredictable future and were prescribed therapy for physical activities? The effect of exercise has been focused on fatigue in several studies, thinking on fatigue as a physical symptom. Looking at symptom clusters across time there is a psycho-neurological cluster being quite stable over time according to the following symptoms/problems; depressed mood, cognitive disturbance, fatigue, insomnia and pain. The significant predictors are age and baseline physical performance status. It seems as psychological factors have a great impact on fatigue. Fatigue is a poorly understood and defined phenomena and we do not know how existential issues in cancer patients are coming forth; via anxiety, changed mood, sadness, apathy energy loss or fatigue. CONCLUSION Cancer fatigue is an almost worldwide disorder among cancer patients and has been identified as an essential problem. A clear definition of fatigue is difficult to derive from the literature; hence two factors of cancer-related fatigue have been well documented. First, the physical factor is described as exhaustion or muscle weakness. The muscle weakness is causing the inability to perform activities of daily living. Second, the psychological factor is described as decreased capacity for activity of mental exertion causes problems in solving problems and focusing /concentrating on intellectual activities. Clinicians, health care professionals as well as researchers ought to try to distinguish between them in order to guide management. They should examine other predictors or variables to understand what fatigue is caused by. It could be that fatigue has its reason in changed mood, depressed mood, anxiety or perhaps just existential issues. If the patient is pre-occupied with existential issues there is no energy left to physical, mental and social activities. The capacity of all the existing instruments of fatigue to represent differences in the fatigue experience is lacking as well as the understanding of the influence of age, gender and social and cultural factors. There are a lot of works left in working for a more informed understanding of the experiences of fatigue. REFERENCES * Boyland, L., & Davis, C. Patients' experiences of carcinoma of unknown primary site: dealing with uncertainty. (2008) Palliative Medicine, 22, 177-183. * Cella, D, Peterman A, et al. 'Progress toward guidelines for the management of fatigue.' (1998) Oncology, 12, 369-377. * Curt, G.A., Breitbart, W., Cella, D., Groopman, J.E., Horning, S.J., Itri, L.M., Johnson, D.H., Miakowski, C., Scherr, S.L., Portenoy, R.K., Vogelzang, N.J. Impact of cancer-related fatigue on the lives of patients: new findings from the Fatigue Coalition. (2000) Oncologist, 5, 353-360. * Glaus A. Fatigue in patients with cancer. Analysis and assessment. Recent results cancer research, (1998) Berlin-Heidelberg, Germany: Springer. p. 145. * Holley SK. Evaluating Patients Distress From Cancer-Related Fatigue: An instrument development study. (2000) Oncology Nursing Forum, 27,1425-1431. * Jonsson, A., Aus, G., Berterv, C. Men4s perception of fatigue when newly diagnosed with localised prostate cancer.(2007) Scandinavian Journal of Urology and Nephrology, 41, 20-25. * Jonsson, A., Aus, G., & Berterv. Men's experience of their life situation when diagnosed with advanced prostate cancer. (2009) European Journal of Oncology Nursing, online june doi:101016/j.ejon.2009.02.006 * Kim H-J, Barsevick A.M, Tulman L. Predictors of the intensity of symptoms in a cluster in patients with breast cancer. (2009) Journal of Nursing Scholarship, 41, 158-165. * Lindqvist, O., Widmark, A., Rasmussen, B.H. Meanings of the phenomenon of fatigue as narrated by 4 patients with cancer in palliative care.(2004) Cancer Nursing, 27, 237-243. * Morrow, G.R., Shelke, A.R, Roscoe, J.A., Hickok, J.T., & Mustian, K. Management of cancer-related fatigue. (2005) Cancer Investigation, 23, 229-239. * Piper B, Lindsey A, Dodd M. Fatigue mechanisms in cancer patients: Developing nursing theory. (1997) Oncology Nursing Forum, 14, 17-23. * Ream E and Richardson A. Fatigue: a concept analysis. (1996) International Journal of Nursing Studies, 33, 519-529. * Servaeus P, Verhagen CA, Bleijenberg G. Relations between fatigue, neuropsychological functioning, and physical activity after treatment for breast carcinoma: daily self-report and objective behaviour. (2002) Cancer, 95, 2017-2026. * Stone P, Richardson A, Ream E, Smith A, Kerr DJ, Kearney N. Cancer-related fatigue: inevitable, unimportant and untreatable? Results of a multi-centre patient survey, Cancer Fatigue Forum. (2000) Annals of Oncology, 11, 971-975. * Stone, P, Richards, M, A4Hern, R, Hardy, J. A study to investigate the prevalence, severity and correlates of fatigue among patients with cancer in comparison with a control group of volunteers with cancer. (2000) Annals of Oncology, 11, 561-567 * Ware NC. Sociosomatics and illness in chronic fatigue syndrome. (1998) Psychosomatic Medicine, 60, 394-401. * Whitehead L. The Measurement of Fatigue in Chronic Illness: A Systematic Review of Unidimensional and Multidimensional Fatigue Measures. (2009) Journal of Pain and Symptom Management, 37, 107-128 Dr. Carina Berterv, RN, RNT, PhD Associate Professor Department of Medical and Health Sciences Division of Nursing Science Faculty of Health Sciences Linkvping University, SE-581 85 Linkvping, Sweden


Profile

Profile: Dr. Ilja Frank Ciernik

Dr. Ilja Frank Ciernik, a reputed Radiation Oncologist and expert in PET/CT based radiotherapy planning is former Head of Radiation Oncology at Ospedale San Giovanni in Bellinzona, Switzerland, Privatdozent of the Medical Faculty of the University of Zurich and is a member scientist at the Center of Clinical Research at the University Hospital of Zurich University. Dr. Ciernik is Swiss and French citizen and was born in February 1965 in Novy Jicin, Czech Republic. He grew up in Z|rich, Switzerland and received his pre-university education at the Freudenberg Gymnasium in Zurich, with proficiency in English and Latin. After schooling, he studied Medicine at the Medical faculty of the University of Zurich, including clinical rotations as a sub-intern in pediatrics at the Beth Israel Medical Center in New York, and in Medical Genetics at the Yale University Hospital in New Haven, U.S.A. in 1989. At Yale, he got exposed to basic and preclinical biomedical research including molecular biology and DNA recombination. The federal diploma to practice as a physician in Switzerland was granted to Dr. Ciernik in 1990. During the last year of training, he passed the ECFMG American medical board exams and he did his medical thesis with Professor Albert Hollinger from the Medical Faculty of Zurich University on the conservative treatment of humeral fractures (J Trauma 31:230). Dr. Ciernik started his professional career as a research fellow in the laboratory of Professor Rolf M. Zinkernagel from the Institute for Experimental Immunology, at the Zurich University Hospital, on viral persistence and cellular immunology (J Virol 66:3661. J Virol 68: 3650), where he got interested in the role of the cellular immune responses to tumors and tumor specific-antigens and the possibilities of targeting these antigens for clinical use. Determined to continue in the field of cancer biology and oncology, Dr. Ciernik started his clinical training with Professor Urs M. L|tolf in Radiation Oncology at the Zurich University Hospital in Switzerland (J Clin Oncol 12:1484). He then joined Drs. David P. Carbone and John D. Minna at the Southwestern Medical Center, University of Texas, U.S.A. for a research fellowship in tumor immunology and immunological tumor-targeting in 1993. Together with Dr. David P. Carbone and Dr. Jay A. Berzofsky, from the National Cancer Institute in Bethesda, Maryland, Dr. Ciernik participated in development, pre-clinical, and clinical testing of the first mutant tumor-specific onco-peptide vaccines to treat metastatic cancer patients with breast, lung, colorectal, and pancreatic cancer. In preclinical studies, they showed, that a range of tumor-specific p53-derived peptides surrounding a point mutation can be immunogenic in murine hosts. In the clinic, peptides were loaded on irradiated carrier peripheral blood lymphocytes and were re-transfused to patients as a cellular vaccine. The vaccines were sufficiently potent to elicit mutation-specific cellular immune responses in cancer patients with metastatic disease, and the immune responses to mutant p53 and K-ras were correlated with prolonged survival, as reported in the final paper of the clinical trial in 2005 (J Clin Oncol. 23:5099). In the field of vaccine immunology, Dr. Ciernik investigated novel possibilities of immunization strategies, such as the use of DNA vaccines with single T-cell epitopes for DNA for the purpose of targeted cellular immune responses and investigating the role of ionizing radiation or haplo-deficiency in order to improve immune reactions against tumor-associated T cell epitopes (J Immunol 156:2369. Clin Cancer Res 2:877. Clin Cancer Res 3:483. Hum Gene Therapy 8:187. Int J Radiat Oncol Biol Phys 45:735). Intrigued by the various mechanisms of immunological escape mechanisms of tumors, Dr. Ciernik investigated how HIV-associated Kaposi sarcoma may escape the growth-suppressive influence of TGF-beta a paracrine and a commonly found factor produced by the tumor cells to inhibit immune cell function and anti-tumor lymphocytes. He found that Kaposi sarcoma cells uniformly loose the expression of TGFR1, preventing heterodimerization with TGFR II thus escaping the growth inhibiting effect of TGFbeta. (Clin Cancer Res 1:119). After retuning to Switzerland in 1996, Dr. Ciernik finished his clinical training in internal medicine at the Centre Hospitalier Universitaire Vaudois (CHUV) of the University of Lausanne and the Department of Internal Medicine at the University of Zurich and received the board certificate in internal medicine in 2000 (Clin Rheumatol 16:477. Arch Intern Med 158:192). During that time, his interest remained in the overlapping fields of immunology-oncology-hematology. Intrigued by the various possible interferences of HIV with hematopoesis, Dr. Ciernik investigated the heterogeneous entity of thrombocytopenia during HIV-infection and showed that ITP-like thrombocytopenia in AIDS is HIV-replication dependent and improves with anti-retroviral treatment, whereas ITP during AIDS is less common, usually associated with more pronounced thrombocytopenia and non-responsive to anti-retroviral treatment (AIDS 13:1913). After completing training in internal medicine, he pursued his training in radiation oncology with Professor Reni O. Mirimanoff at the CHUV at the University of Lausanne and Prof. Urs M. L|tolf at the University of Z|rich since 2000. His main focus remained in studying the influence of ionizing radiation on anti-tumor responses, the influence of ionizing radiation on the cell cycle and the definition of novel radiation-sensitizers, such as G2-interfering agents as taxans, or the novel group of epithilones (Int J Radiat Oncol Biol Phys 62:1390. Clin Cancer Res 11:1588. Gynecol Oncol 106:394). Special clinical interests relied within the field of radiotherapy in the context of the immune-compromised immune system as encountered during HIV-infection, lymphoma, or high-dose chemotherapy or myeloablative therapies (Bone Marrow Transplant 24:147. Hematol Oncol 26:82. J Clin Oncol 26: 2550.). Laboratory investigations continued on radiation sensitizers and the role of the genome wide methylation status in respect of radiation sensitivity and how epigenetic expression modulation might be exploited for the purpose of radiations sensitization. The university working environment furthermore allowed to Dr. Ciernik early to apply combined modality treatments of brain, lung, rectal, and head and neck cancer. The introduction of PET in the clinical routine opened a new way to define the potentials of functional-imaging-based in-line radiotherapy planning and to implement novel target structures for radiation treatment providing integrating patho-physiological or metabolic information into the treatment concepts and radio-therapeutic strategies, including adaptive treatment planning (Int J Radiat Oncol Biol Phys 57:853. Int J Radiat Oncol Biol Phys 62:893. Radiother Oncol 80:43. Technol Cancer Res Ther 6:23. Radiat Oncol 2:22. Int J Radiat Oncol Biol Phys 69:286). After the board certificate in radiation oncology in 2002, Dr. Ciernik was elected lecturer for Radiation Oncology and Cancer Research at the University of Z|rich in 2003, and he is member of the united Zurich Cancer Network of the University of Zurich and the Swiss Federal Institute of Technology in Zurich. Dr. Ciernik served as head of Radiation Oncology at the Ospedale San Giovanni in Bellinzona, Siwtzerland from 2006 until 2008 and is a member scientist at the Center of Clinical Research of the University of Zurich. His current focus remain advanced image guided- and functional imaging based radiotherapy planning with PET/CT. He continues investigating highly conformal adaptive radiotherapy to define new and improve d beam geometries such as non-coplanar continuous arc treatment techniques with simultaneous beam modulation, termed intensity modulated non-coplanar arc therapy (INCA) (Radiother Oncol 81:151). He continuous to contribute his efforts to investigate and apply novel radiotherapy technologies, in order to better define the role and utilities of radiotherapy for difficult-to-treat situations such as hemi-thoracic intensity-modulated radiotherapy after resection of mesothelioma (Int J Radiat Oncol Biol Phys 69:1593). Dr. Ciernik is co-investigator in the controlled phase II trial SAKK 17/04 investigating the role of postoperative radiotherapy after pleuropneumectomy and is principle investigator of SAKK trial 77/07, a multi-center trial on the role of curative radiotherapy in non-resectable primary liver cancer. His current laboratory activities have been focusing on the role of T cell memory subsets in the context of total body irradiation and lymphopenia in order to better understand how to enhance or stimulate anti-tumor immune responses of T cell precursor and memory cells after vaccination in combination with cytotoxic treatment.


Manuscript

Benign Granular Cell Tumor of the Soft Tissue of the Pelvis

Dr Eiman Tawheed, Jean Yves Bobin, Kalid Khaldi

  1. Dr Eiman Tawheed
    Gynecology Unit, Kuwait Cancer Centre
  2. Jean Yves Bobin
  3. Kalid Khaldi

Granular cell tumor (GCT) is a very rare mesenchymal benign tumor of the cervix or the vagina. We are reporting a new case and a short review of the literature.


Serum Transaminases Ratio in Breast Cancer Patients

Dr K Thriveni, Rani James, Lakshmi Krishnamoorthy, Vijayalaxmi Deshmane, P.P. Bapsy, Girija Ramaswamy


Aberrant Methylation of Pyk2 Gene Promoter Influences its Expression in Gastric Cancer Cell

Dr Xin Wang, Gang Hu, Jing Zhu, Tao Wu, Yi-Sheng Pan, Yu-Cun Liu, Yuan-Lian Wan

  1. Dr Xin Wang
    Department of general surgery, Peking University First Hospital
  2. Gang Hu
  3. Jing Zhu
  4. Tao Wu
  5. Yi-Sheng Pan
  6. Yu-Cun Liu
  7. Yuan-Lian Wan

Objective: Proline-rich tyrosine kinase 2 Pyk2 has been recognized as potential tumor suppressors in the occurrence and development of tumors. Aberrant methylation of CpG islands was found to be connected to the loss of gene function in tumor cells. DNA Methylation-specific PCR and real-time PCR were done in order to evaluate Pyk2's role in gastric cancer. Methods: Eight CCGG sites of Pyk2 (proline-rich tyrosine kinase 2) gene promoter in gastric cancer cells were detected by enzyme-cutting PCR. Besides, we detected aberrant methylation of Pyk2 gene promoter in 55 respected primary gastric cancer tissues compared to 55 corresponding nonmalignant gastric tissues by MSP (methylation specific-PCR). Moreover, we investigated the effects of DAC (5-aza-2-deoxycytidine) and TSA (trichomycin A) in the expression of Pyk2 in gastric cancer cell lines. Results: Six sites methylated in gastric cancer cell lines and only one site methylated in normal gastric cell line (P<0.05). Pyk2 gene methylation was detected in 34.5% tumor samples, which exists in only 1.82% of normal samples (P<0.05). However, there is no significant correlation between the methylation status and clinic pathological characteristics (P>0.05). It was found that TSA could increase the Pyk2 expression slightly, while DAC can significantly increase the expression of Pyk2, and the combination of DAC and TSA can increase its expression most. Conclusion: Methylation of Pky2 promoter is highly expressed in gastric cancer, and TSA together with DAC can increase the expression of Pyk2 in gastric cancer.


Profile of Pediatric Cancer Patients Treated with External Beam Radiation Therapy Under Anesthesia at a Regional Cancer Center of India

Dr Dayanand Sharma, Goura Kishor Rath, Monica Malik, Sushma Bhatnagar, Amit Bahl, Parmod Kumar Julka

  1. Dr Dayanand Sharma
    Department of Radiation Oncology, All India Institute of Medical Sciences
  2. Goura Kishor Rath
  3. Monica Malik
  4. Sushma Bhatnagar
  5. Amit Bahl
  6. Parmod Kumar Julka

Aim: To study the clinical profile of children treated by external beam radiation therapy (EBRT) under anesthesia at our center. Material and Methods: Clinical case records of all the pediatric patients who underwent EBRT under anesthesia were retrieved. From each case file, data regarding the patient's demographic details, diagnosis, EBRT details, site of irradiation, events occurring during the course of EBRT, etc. were recorded. Results: During the 2 years period (June 2002 to June 2004), 130 case records were retrieved. A total of 1793 treatment fractions were administered in 130 patients (average 13.8 fractions per patient) with some kind of anesthesia or behavioral therapy (BT). Age ranged from 1-13 years (median age 5 year). Common malignancies included acute lymphocytic leukemia (ALL), retinoblastoma (RB), Wilm's tumor (WT), lymphomas and rhabdomyosarcoma (RMS). Seven patients received palliative radiation therapy (RT) and 123 received curative/adjuvant RT. Common sites of irradiation were cranium, head and neck, orbit and abdomen. The intended duration of treatment course ranged from 1-42 days. Twenty two patients required treatment interruption due to treatment related toxicity. Median duration of treatment interruption was 6 days. Conclusion: About 2% of all EBRT treatments are carried out under anesthesia at our centre. Good BT reduces the need of anesthesia. Such measures should be fully explored in countries with limited setup for EBRT under anesthesia. But, the increasing use of modern RT techniques like IMRT, 3D-CRT where strict immobilization is the key aspect, may increase the need of anesthesia in pediatric RT.


Recent Advances in Nephrogenetics and Molecular Diagnostics: Are Current Approaches Becoming Obsolete?

Dr Constantinos Deltas

  1. Dr Constantinos Deltas
    PharmR, PhD
    Professor of Genetics and Chair, Department of Biological Sciences, Head, Laboratory of Molecular and Medical Genetics, University of Cyprus
    Visit Website

Molecular diagnostics is a promising scientific sector on the rise, enhanced to a great extent by technological developments. Massive mutation screening methods and direct automated DNA sequencing have enabled researchers and diagnostics laboratories to identify frequent and rare genetic defects, thus contributing to medical translational research. Despite all the progress, the complexity of gene systems, even of monogenic disorders, makes molecular testing a formidable task, especially for relatively small molecular medicine laboratories. Nephrogenetics is one such field where genetic and consequent phenotypic heterogeneity are particularly complex, with tens of genes involved and interacting, often times in unpredictable ways, to cause disease. It turns out that useful approaches of the older generation will continue to be useful for many years to come, while supported and facilitated by more recent and advanced high throughput technologies.


Syndrome of Inappropriate Antidiuretic Hormone Secretion Complicated with Stem Cell Transplantation

Dr Ryoji Kobayashi

  1. Dr Ryoji Kobayashi
    M.D, PhD
    Department of Pediatrics, Sapporo Hokuyu Hospital

Hyponatremia is a common electrolyte disorders in hospitalized patients. However, reports about hyponatremia complicated with stem cell transplantation (SCT) were very rare. As single center analysis, syndrome of inappropriate secretion of anti-diuretic hormone (SIADH) after stem cell transplantation were reported. SIADH were observed 13.2% of 197 patients after stem cell transplantation. Risk factors for SIADH were younger in age, transplantation from HLA mismatched or unrelated donor, cord blood transplantation, and GVHD prophylaxis with methyl prednisolone. Multivariate analysis showed transplantation from alternative donor was independent of other factors for SIADH. Patients with SIADH had significantly higher probability of overall survival (66.4% versus 50.8%) and event free survival (68.8% versus 43.3%) compared with no SIADH. The median onset of SIADH following cord blood transplantation (CBT) and bone marrow transplantation (BMT) / peripheral blood stem cell transplantation (PBSCT) was 19.5 and 46 days after SCT, respectively, and the median numbers of WBC were 1.1 and 3.3 x 109 /l, respectively. Furthermore, severe symptoms such as seizures, somnolence, and rigidity of limbs were observed only in patients with CBSCT (8/16 versus 0/10). These differences were statistically significant (P<0.01). SIADH is common complication with SCT, especially in patients transplanted from alternative donor. Although the precise basis for SIADH following SCT remains still unknown, the different features of SIADH observed following CBSCT and BMT/PBSCT suggest that the mechanisms responsible for SIADH are different.


Cancer Patients' Opinions Concerning Post-Treatment Follow-up

Dr Solveig S?grov, Margarethe Lorensen

  1. Dr Solveig S?grov
    Assistant Professor, Cand. polit, Sogn og Fjordane University College,
  2. Margarethe Lorensen

Cancer is one of the most serious and wide-spread diseases known. Statistics show that of about 4 million Norwegians, every third person will be afflicted by some form of cancer during his lifetime. Around 20 000 Norwegians receive this diagnosis yearly. People who have cancer often indicate that they feel neglected after they have received the diagnosis and perhaps hospital treatment. This article describes a survey in which a questionnaire was employed to map the services and post-treatment care offered by county health services to cancer patients. The form was sent to 199 persons between the age of 18 and 70, all of whom had been diagnosed with cancer from 6 months to 3 years earlier. The questionnaire was addressed directly to the patients, and distributed by mail. Both the regional medical ethics committee and the Information Protection Agency gave their approval with respect to how the patients and control group were selected, and to the general procedures used in the project. Eighty six questionnaires were filled out and returned, giving a response-rate of 43%. Of those who returned the form, 44 were women and 42 were men. Their average age was 57 years. The majority of those who responded to the questionnaire had been diagnosed for cancer at least 2 years earlier. Of the responding patients, 49 persons said that they had been declared cured, 25 answered that they were still ill, and 12 did not reply to this question. The survey results indicate that few services or training programs had been offered to the patients after their treatment was completed. This conclusion is corroborated by a questionnaire filled out by doctors and administrative leaders in the home-nursing program as part of the same project. The cancer patients had not been clearly informed whether they should contact the hospital or the health services in their home county if they needed assistance. The patients also expressed a desire for better information and a more systematic post-treatment program, as well as clear guidelines delineating the specific areas of responsibility assigned to hospitals and the local public health services.


Metastatic Bone Disease: A Review of Literature

Dr Vijayakumar Narayanan, Cherian Koshy

  1. Dr Vijayakumar Narayanan
    St.Gregorios Medical Mission Hospital
  2. Cherian Koshy

Growth of aging population is a recognized feature all over the world. Better living standards, availability of good medical facilities, and awareness among people are contributory to it. Many of the communicable diseases are under control now, but the incidence of chronic illnesses like cancer is going up. Most of the cancers tend to metastasize to bone. Contrary to the belief that the prognosis of patients with metastatic bone disease (MBD) as bad, the literature showed good quality life span to these group of patients. Survival up to 10 yrs in patients with exclusive bone secondaries has been reported. The question whether this result can be duplicated among patients from developing countries is debatable, as the cost of interventions designed in each series were prohibitive, still, among those patients who can afford the treatment and with excellent supportive structure, an attempt can be made. Several authors had described the skeletal related events (SREs) in metastatic bone disease and the impact on the quality of life. Severe bone pain, pathological fractures, humoral hypercalcemia of malignancy (HHM), spinal cord compression (SCC) and bone marrow suppression are identified as the major SREs. Considerable morbidity is associated with these problems. The resorption and formative processes within the bone are dynamic and always remain coupled. When this is uncoupled in tumors, lesions do appear, depending on the predominant mode, either lytic /blastic or both. The micro environment of the bone and a variety of other factors like adolescent growth spurt, disease states, hormones, medications, age, nutritional status, also influences the skeletal turn over. The multifaceted cancer syndrome per se has a deleterious effect on bone. Once a SRE is suspected in a patient, the process of establishing a diagnosis for proper management has to be carried out. Investigations fall into two main categories, radiological and biochemical. They are useful in four ways. Screening, diagnosis, assessment of severity and monitoring response. Treatment modalities include pharmacotherapy, external beam radiotherapy, radio-pharmaceutical therapy, biphosphonates, surgery, chemotherapy and non conventional measures. Better understanding of the pain pathways and effective pharmacological interventions can result in the patient a qualitative life. Unraveling of the molecular mechanisms of bone metastasis will lead to better therapeutic options in the future. Bio engineering approaches for bone reconstruction are also in the offing. Optimal utilization of available resources for tackling the issue depends on a multi-disciplinary approach. The economic impact on the National exchequer due to SRE is yet to be studied world wide as the burden is universal. The economic strain for tackling this particular issue is simply huge.


Retroperitoneal Sarcomatoid Variant of Diffuse Large B-Cell Lymphoma: A Case Report

Dr H Amanguno, R Alabdulghani, P Munish, A Ali

  1. Dr H Amanguno
    Dept. of Pathology, Kuwait Cancer Control Centre
  2. R Alabdulghani
  3. P Munish
  4. A Ali

Extra-nodal, extra-cutaneous, and retroperitoneal spindle cell B cell lymphoma is a rare lesion, potentially to be misdiagnosed as a sarcoma. We describe a 65 year old man who presented with a retroperitoneal tumour mass, clinically suspected to be a sarcoma, also with a histologic sarcomatoid appearance on morphology and CD79a+, CD20+, MUM1+, bcl6+ immunophenotype. In contrast to other reports, the immunohistochemical analysis indicated a spindle cell B cell lymphoma of non-germinal centre origin with normal lactate dehydrogenase level and good response to therapy.


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