or steroid treatments, the analysis indicated a survival time difference (18 months longer) favoring the intervention participants.
Finally, there are two frequent complications of disseminated disease: delirium and pain. Delirium is the second most commonly diagnosed psychiatric disorder in cancer patients and is characterized by acute perceptual and behavioral disturbances such as impairment of attention, orientation, and memory (Tope et al., 1993). Massie, Holland, and Glass (1983) found that approximatley 75% of patients with metastatic cancer meet criteria for delirium as compared to 8% of all cancer patients. Delirium in cancer patients can be caused by a number of factors, including treatment side effects (e.g, type/dosage of chemotherapy), medications (e.g., narcotics), disease progression (e.g, brain metastases), and other treatment and/or disease-related complications (e.g, metabolic and endocrine disorders; see Tope et al., 1993, for a review). Whereas delirium is a reversible brain disorder, it is often misunderstood and underdiagnosed by medical personnel, with symptoms often being attributed to depression and anxiety (Levine, Silberfarb, & Lipowski, 1978).
Although it might be one of the first symptoms of cancer or be present when disease is localized, pain is more common and less controllable for those with metastatic disease (Ahles, Ruckdeschel, & Blanchard, 1984). Eighty percent of patients with recurrent cancer report moderate to severe pain, as compared to 40% of earlier stage patients (see Ashburn & Lipman, 1993, for a review). The major cause of cancer pain, accounting for roughly 70% of the cases, is due to direct tumor involvement (e.g., nearby metastatic bone disease, nerve compression), and the remainder is usually due to medical therapy (e.g., postoperative pain, radiation- induced pain). Thus, the pain experienced by cancer patients can be any combination of acute malignant pain, chronic malignant pain, and/or chronic nonmalignant pain (Ashburn & Lipman, 1993).
With this variable presentation, it is important that a pain assessment be completed before and during treatment for pain control (Ashburn & Lipman, 1993; Coyle, Adlehardt, Foley, & Portenoy, 1990). Besides pain-specific qualities and diagnostic/treatment considerations, other factors are also important in assessing the patient's experience of pain. For instance, pain is associated with depression, anxiety, and delirium (Massie & Holland, 1992), and may increase suicidal ideation (Coyle et al., 1990). If pain worsens or is difficult to control, then quality of life deteriorates and emotional distress increases (Massie & Holland, 1992), physical mobility may decline (Ashburn & Lipman, 1993), and social interactions may suffer (Strang & Qvarner, 1990). It is striking that inadequately controlled pain has been cited as a primary reason for requests of physician-assisted suicide among cancer patients (Foley, 1991,1995; Seale & Addington-Hall, 1994).
The most difficult circumstance of pain control is when chronic pain accompanies disease progression. Treatment combinations of antitumor therapy, anesthetic blocks, and behavioral approaches are considered. When palliative therapy is of little use and/or brings further debilitation, psychological interventions may provide support and pain control and, secondarily, treat pain sequelae (e.g., sleep disturbances, reduced appetite, irritability).
Significant progress has been made in understanding the psychological, social, and behavioral aspects of cancer. More is known about the psychological processes and reactions to the diagnosis and treatment of cancer than is known about any other chronic illness. Breast cancer patients (see Glanz 8z Lerman, 1992, for a review), have been well studied, but other disease sites, men, and children are becoming more commonly studied. Future research will test the generalizability of these descriptive data and formulate general principles of adjustment to illness. While providing estimates of the magnitude of quality of life problems, these data can be used for models that predict which patients might be at greatest risk for adjustment difficulties (see Andersen, 1996, for a discussion). The latter is an important step toward designing interventions tailored to the difficulties and circumstances of cancer patients. The mental health community emphasizes the need to reduce stress and prevent deteriorations in quality of life for those with cancer. The importance of such efforts is underscored by three contextual factors. First, the stability of many cancer mortality rates (particularly those with the highest incidence such as lung and breast) makes it imperative that new, innovative treatments be developed to improve survival rates. Second, research has demonstrated that psychological interventions result in significant improvements in quality of life (see Andersen, 1992, for a review). Third, both qualitative (Maier et al., 1994) and quantitative (Herbert & Cohen, 1993) summaries of the psychoneuroimmunology (PNI) literature conclude that psychological distress and stressors (e.g., negative life events, both acute and chronic) are reliably associated with changes-down regulation-in immunity. Thus, addressing the mental health needs of those with cancer will have important quality of life benefits and the possibility is raised of positive biologic (or health) consequences as well. Finally, the biobehavioral model offered here provides a theoretical framework for examining questions of the interaction of psychological, behavioral, and biological variables in disease course.
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