2. Carbono 14
2.6. Carbono 14 y arqueología
2.6.1. La datación relacional Cronologías relativas
Psychosocial research
The topics in psycho-oncological research start out from two different perspectives: investigation of the psychological and social consequences of cancer for persons with cancer and their family members, and study of possible effects of psychological and social factors on the development and course of cancer. Psycho-oncological research is thus a very broad field, ranging from early detection to care for the dying and support to the bereaved. The benefit of this research for the care of persons with cancer and their families is uncontested. The benefit for health care professionals in medicine and nursing is less obvious. The answer to the question as to the extent to which psycho-oncological findings are put into clinical practice differs depending on the research topic.
Quality of life as a central concern
A central concern of psycho-oncological research is to improve or at least maintain the quality of life of persons with cancer and their families. Prior to the development of this research, mainly psychiatric cri- teria were used to indicate the need for psychosocial intervention or psychotherapy. During the course of cancer, 25 to 35 per cent of patients show classifiable psychiatric disorders, whereby the percentage varies strongly with diagnosis, cancer stage, and psychiatric assessment method. But questions about dealing with limitations and stresses caused by cancer and cancer treatment are much more complex and more subtle than can be assessed using psychiatric criteria alone. For example, facing existential questions and questions concerning biographical topics is a fre- quent reason for people to seek psycho-oncological support.
Prof. Jürg Bernhard, PhD
Head of the Psycho-Oncology Service in the Department of Medical Oncology, Bern University Hospital
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make the limitations and stresses caused by cancer more bearable. This process is impressively docu- mented in patients’ self-reports of their experience. If those treating the patient could communicate the prospect of this shift in values, it could mean a lot for patients, especially during a stressful treatment or if the cancer progresses.
Attentiveness to personal experience also leads to increased sensitivity for changes in one’s body and thus for the underlying disease process. Studies have shown that patients’ self-rating of aspects of quality of life, especially physical well-being, is one of the best prognostic indicators in many advanced stage cancers – also in statistical comparison with known biomedical prognostic factors.3 This finding confirms the validity of self-assessment and importance of a person’s own perceptions for decision making, such as the decision to continue or discontinue treatment when cancer develops to an advanced stage. Psycho-oncological interventions with patients Very important for clinical practice is that aspects of quality of life should not only be captured in research studies; the findings and their consequences should also inform treatment and care. There are basically two complementary types of psycho-oncological interventions. In direct contact with patients and their families, there are assessments and counselling, short and often behaviour-oriented interventions and also longer-term support and psychotherapy that focus on dealing with the illness and controlling symptoms (such as dealing with uncertainty). Inter- ventions for professionals in medicine, nursing, social work, and other areas include supervision and fur- ther and continued education and training focusing on communication (for example, communicating bad news) and conveying psycho-oncological informa- tion.
Within psycho-oncological research, persons with cancer assess aspects of their quality of life from their own point of view and report their personal ex- periences. This approach has produced a crucial find- ing: Patients’ “subjective” experience of the stresses caused by cancer and cancer treatment often do not match the perceptions of the health care profession- als. For instance, among patients with breast cancer, neuropsychological tests can demonstrate cognitive limitations such as memory problems caused by chemotherapy and hormone therapy, sometimes also years later.1 But when the breast cancer survivors are asked to rate their cognitive dysfunction on a scale, there is often no correlation or only a low correlation with the “objective” test results.2 This inconsistency is caused, among other things, by emotional stress. When values shift
These ratings by the patients may be unexpected, but they do not call into question the validity of self- assessment by patients. Instead, the findings lead us to new questions and areas of study. During the course of the disease, it is enormously demanding for persons with cancer to have to adapt the handling of their everyday lives to the new conditions, such as making adjustments due to physical weakness. Hav- ing to make these adjustments leads to a shift in their perceptions, as their perception of “good” well-be- ing comes to differ more and more from the notions of well-being of healthy persons. This shift in the in- dividual standard (for example, regarding sensation of pain) and personal needs and preferences can
115 The effect of many psycho-oncological interventions
in direct contact with persons with cancer and their families is very well documented, especially with re- gard to reducing anxiety and depression.4,5 In stu- dies, the treatment results vary greatly: Treatment success is considerably dependent upon whether the intervention is adjusted to the intensity of the pa- tient’s distress. The psycho-oncological treatments are generally much more effective with patients with high levels of distress than with patients with low levels.5 This finding is plausible not only clinically. It also confirms the experience that individualized pa- tient care is imperative, even with interventions that are standardized and integrated in the oncological care. Varying treatment effectiveness of psycho- oncological interventions is also found for different cancers and stages of cancer, but these differences have only begun to be studied.
In recent years, the “classical” psycho-oncological question regarding risk factors for morbidity and mortality has been relativized. Newer psycho-onco- logical studies investigating the effect of psycho- oncological treatment on the course of the cancer have found that intervention improves well-being and quality of life but has no effect on survival. These findings, too, are important for clinical practice, since they help therapists to convey a clear orientation to patients and to put empirically disproved but popu- lar notions into appropriate perspective. For exam- ple, the frequent assumption by persons with cancer, “I must not feel sad, because that will have a nega- tive effect on my immune system and thus make it harder to fight the cancer”, is not scientifically tena-
ble. Due to the methodological complexity of these issues, bio-psycho-social interactions are no longer studied today in an overall way but instead more with regard to specific factors, such as disturbance of the circadian rhythm (our “inner clock”) as a conse- quence of stress.
Psycho-oncological interventions with health care professionals
Psycho-oncological offerings for professionals in medicine and nursing consist mainly in courses on communicating with patients. The effect of commu- nication skills training on health care professionals has been studied less than the effect of interventions on persons with cancer. But there is documented evidence concerning important aspects,6,7 first and foremost on training patient-centred behaviour, such as training physicians to address emotions. This behaviour can be put into clinical practice compar- atively easily and helps to ease patients’ burden. I nterventions with health care professionals can also have a positive effect on patients’ psychosocial adaptation. For example, good preparation for inva- sive surgery results in less emotional distress and better psychosocial and in part also physical rehabil- itation. It is not yet clear how communication skills training can change the behaviour of health care professionals not only in the short and medium term but also long-term.
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Integrative understanding of illness
The need for treatment and care that is comprehen- sive also in the psychosocial sense must no longer be made dependent upon general evidence of the effec- tiveness of psycho-oncological interventions. Impor- tant for clinical practice is differentiated assessment of the needs of persons with cancer. In addition, psycho-oncological services have to keep up with developments in oncology. Psycho-oncological guide- lines, which are being developed in Switzerland and in many other countries, are an important step in in- tegrating these services into oncological care.8 Con- sequently, there should be a greater emphasis on health services research in this area in the coming years.
The question regarding “subjective” tolerance and support measures often arises also with the new and often complex treatment planning. With the addi- tional treatment possibilities for advanced stage can- cer, decision making and communication become more difficult for both the persons with cancer and healthcare professionals. For these issues, too, a com- prehensive understanding of illness and thus an inte- grated approach is the way towards clinically relevant results.
Prof. Jürg Bernhard, PhD
Jürg Bernhard studied clinical psychology and psychopathology at the University of Zurich and completed training in psychother- apy. Bernhard trained as a psycho- oncologist at Memorial Sloan- Kettering Cancer Center in New York. He is assistant professor of psychosocial medicine and psycho-oncology at the Medical Faculty of the University of Bern. He heads the Psycho-Oncology Service in the Department of Medical Oncology at Inselspital, Bern University Hospital. In addition to his clinical work he also works in psycho-oncological research, currently focusing on the effects of cancer treatment on quality of life and cognitive functioning, and decision making in physician/patient communication. He also works for psycho-oncology in the framework of the National Cancer Programme 2011– 2015.
Tel. +41 31 632 41 14 [email protected] www.onkologie.insel.ch
117 References
1. Jim HS, Phillips KM, Chait S, et al. Meta-analysis of cognitive functioning in breast cancer survivors previously treated with standard-dose chemotherapy.
J Clin Oncol. 2012; 30: 3578– 87.
2. Pullens MJ, De Vries J, Roukema JA. Subjective cogni- tive dysfunction in breast cancer patients: a systema- tic review. Psychooncology. 2010; 19: 1127– 38. 3. Montazeri A. Quality of life data as prognostic indi-
cators of survival in cancer patients: an overview of the literature from 1982 to 2008. Health and Quality
of Life Outcomes. 2009; 7: 102.
4. Jacobsen PB, Jim HS. Psychosocial interventions for anxiety and depression in adult cancer patients: achievements and challenges. CA Cancer J Clin. 2008; 58: 214 – 30.
5. Linden W, Girgis A. Psychological treatment outcomes for cancer patients: what do meta-analyses tell us about distress reduction? Psychooncology. 2012; 21: 343 – 50.
6. Rao JK, Anderson LA, Inui TS, Frankel RM. Communi- cation interventions make a difference in conversa- tions between physicians and patients: a systematic review of the evidence. Med Care. 2007; 45: 340 – 9. 7. Barth J, Lannen P. Efficacy of communication skills
training courses in oncology: a systematic review and meta-analysis. Ann Oncol. 2011; 22: 1030 – 40. 8. Grassi L, Watson M; IPOS Federation of Psycho-On-
cology Societies’ co-authors. Psychosocial care in can- cer: an overview of psychosocial programmes and na- tional cancer plans of countries within the
International Federation of Psycho-Oncology Socie- ties. Psychooncology. 2012; 21: 1027– 33.
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Psychosocial research
List of completed research projects in 2012
Bernhard Jürg | OCS 02232-04-2008 | CHF 158,600.–
Universitätsklinik für Medizinische Onkologie, Inselspital, Universitätsspital Bern, Bern
Erythropoiesis-stimulating factors and quality of life in cancer patients: individual patient data meta-analysis based on randomized controlled trials
Kiss Alexander | OCS 02400-02-2009 | CHF 187,200.–
Abteilung für Psychosomatik, Departement Innere Medizin, Universitätsspital Basel, Basel
A cognitive-behavioural mindfulness intervention to improve health-related quality of life, depression and fatigue among long-term haematopoietic stem cell transplant survivors
Lehr Hans-Anton | KFS 02775-02-2011 | CHF 79,000.–
Institut universitaire de pathologie de Lausanne (IUP), Centre hospitalier universitaire vaudois (CHUV), Lausanne
Biomedical research on human tissues: in the twilight zone between autonomy and data protection. What do health professionals, patients and lay persons think about issues of consent and transparency in medical research, teaching, and quality control?
Mueller Michael D. | KFS 02456-08-2009 | CHF 116, 500.–
Gynäkologie und Gynäkologische Onkologie, Universitätsklinik für Frauenheilkunde, Inselspital, Universitätsspital Bern, Bern
Creating and validating a patient-pertinent instrument to assess symptoms experienced related to surgical wounds in women with vulvar neoplasms – a mixed methods study (WOMAN-PRO)
Tschudin Sibil | KLS 02577-02-2010 | CHF 62,800.–
Gynäkologische Sozialmedizin und Psychosomatik, Frauenklinik, Universitätsspital Basel, Basel
Fertility preservation in young female cancer patients – assessment of needs regarding decision-making and development of a decision-aid
119 Conclusions
In cancer patients, particularly patients receiving chemo- therapy, we found that ESAs provide a small but clinically important improvement in anaemia-related symptoms. For fatigue-related symptoms, the overall effect did not reach the threshold for clinically important difference. In patients treated with a curative approach it is unlikely that the observed benefits will outweigh the negative effects of ESAs on short-term mortality and thromboembolic events.
Project coordinator Prof. Dr. Jürg Bernhard
Universitätsklinik für Medizinische Onkologie Inselspital, Universitätsspital Bern
CH-3010 Bern
Kiss Alexander | A cognitive-behavioural mindfulness intervention to improve health-related quality of life, depression, and fatigue among long-term haemato- poietic stem cell transplant survivors
(OCS 02400-02-2009)
Mindfulness-based intervention (MBI) is a group pro- gramme aimed at improving dimensions of well-being for patients with a broad spectrum of chronic disorders. This preliminary study examined whether MBI is a feasible and effective intervention for haematopoietic stem cell trans- plantation (HSCT) survivors of 6 months or longer in terms of enhancing different dimensions of health-related quality of life (HRQoL) (e. g. psychological functioning, positive emotions, social contact, and ability to enjoy life) and decreasing depression, fatigue, and anxiety. In a pa- tient preference trial carried out with 65 patients, patients received their preferred choice of either the experimental intervention MBI or augmented optimal medical care (AOMC) as the control comparison. Patients without clear preference were randomly assigned to one of the treat- ment arms. The AOMC control procedure comprised (1) standard optimal medical treatment and (2) 15–30 min- utes psycho-oncologist-administered medical and psy- chosocial consultations by telephone twice per month during the active 8-week intervention phase. Assessments occurred at pre-intervention (T1) and post-intervention (T2) and 3-months post-intervention follow-up (T3). Pri- mary outcome measurement was at T1.
Results indicated benefits for HRQoL, anxiety, and depres- sion at T2; fatigue was not affected by either intervention. Additionally, the results suggested 3-month follow-up benefits for HRQoL and anxiety but not for depression.
Bernhard Jürg | Erythropoiesis-stimulating agents and quality of life in cancer patients: individual patient data meta-analysis based on randomized controlled trials (OCS 02232-04-2008)
Erythropoiesis-stimulating agents (ESAs) reduce the need for red blood cell transfusions and may improve quality of life in cancer patients. However, they increase the risk of thromboembolic events and mortality during the active study phase, and there is some evidence that they shorten overall survival. We aimed to evaluate and quantify the effects of ESAs on quality of life in cancer by an individ- ual patient data meta-analysis. Previous meta-analyses demonstrated that ESAs effectively reduce fatigue-re- lated symptoms in cancer patients. However, these meta- analyses were based on fewer clinical trials, restricted to the published literature, and might be compromised by publication and reporting biases.
Methods
We included randomized controlled trials studying the ef- fects of ESAs on quality of life in cancer patients. Studies were identified by searching electronic data bases up to January 2011. We conducted meta-analyses on fatigue- and anaemia-related symptoms, as reported by patients using the FACT-Fatigue (FACT-F) and FACT-Anaemia (FACT-An) subscales (primary outcomes), or other vali- dated scales. We did not get permission to use individual patient data. Instead, we analysed the data on group level. We included published and unpublished data from clinical study reports.
Results
We included 37 trials with 10,581 randomized patients. For FACT-F (23 studies, n = 6,108) the effect of ESAs was statistically significant but below the threshold for a clini- cally important difference. Results for FACT-An (14 stud- ies, n = 2,765) showed ESAs had a positive, statistically significant effect on anaemia-related symptoms that was clinically relevant. We noted selective reporting for FACT- An outcomes: Compared to published data, unpublished data stemming from clinical study reports showed on average smaller treatment effects. In patients receiving chemotherapy, the differences by ESAs were below the threshold for FACT-F and above for FACT-An (both statis- tically significant).
Psychosocial research
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symptoms and symptom-related distress from women’s perspective. The mean number of symptoms per woman was 20.2 (SD 5.77), with a range of 5 to 31 symptoms reported during the first week after discharge.
Conclusions and patient benefit
The data reveal a high symptom prevalence and distress, and thus call for comprehensive symptom assessment, and may allow identification of relevant topics in symp- tom management. A follow-up project (WOMAN-PRO II) aims to make symptom assessment a standard component of clinical practice (to promote the early detection and treatment of symptoms) and research.
Project coordinator
Prof. Dr. med. Michael D. Mueller
Gynäkologie und Gynäkologische Onkologie Universitätsklinik für Frauenheilkunde Inselspital, Universitätsspital Bern CH-3010 Bern
Tschudin Sibil | Fertility preservation in young female cancer patients: assessment of needs regarding decision-making and development of a decision-aid (KLS 02577-02-2010)
Many young patients with cancer are confronted with impaired fertility as a consequence of their treatment. Fertility preservation has to be performed in the short time period after diagnosis and before onset of cancer treatment. Adequate counselling and support are thus of utmost importance.
Objectives
The aim of this study was to gain deeper insight into pa- tients’ motives, priorities, and conflicts during decision- making for or against any fertility-preserving procedures. Further, the study aimed to provide the basis for develop- ing a standardized instrument that complements and supports shared decision-making on fertility preservation for young patients with cancer and their health care team.
Methods
The study addressed former and current female patients with cancer at a young age and consisted of two parts. Part 1 was an anonymous online survey, which was available via a link on cancer and fertility websites. Part 2 consisted of standardized focus groups facilitated by a psychologist.
Results
The online survey (n = 155) showed that knowledge about fertility preservation is limited. The attitudes towards fer- tility-preserving procedures are predominantly positive, however. The availability of helpful information was con- sidered low. Besides their partners, the patients’ physi- cians were the most important sources of information and support during the decision-making process.
These findings suggest that MBI improves various dimen- sions of quality of life among HSCT survivors over the short-term but does not reduce fatigue symptoms. How- ever, this patient-preference trial should be considered a pilot study, since it is the first of its kind with HSCT, the