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Compromises of Cancer Supportive Care and Quality of Life
Ernest H. Rosenbaum, MD

Cancer Survivorship
Weight Loss Relates to Poor Prognosis
Additional References

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Quality cancer care is compromised by a lack of available services. Jimmie C. Holland, M.D. (Memorial Sloan Kettering Hospital), has been leading the fight to help recognize this gap in services. Only recently, in the last thirty years, have we acknowledged the problems of cancer, and it is still one of the most feared diseases. The word itself still elicits more fear than any other disease. One of the main problems is the lack of sufficient psychological and psychosocial services available to patients nationwide. Cancer Centers are now being developed to help meet this need.

Jimmie Holland relates In a recent study at Johns Hopkins Medical Center, 5,000 patients were interviewed at their Sidney Kimmel Comprehensive Cancer Center, using the Brief Symptom Inventory. They found that 35% of patients had significant levels of distress, including anxiety and symptoms of depression. The leading cancers were lung cancer at 43%, followed by brain and pancreatic cancers, and gynecological cancer at the low of 29%. Thus, about a third of patients are suffering from distress, requiring intervention, which can be effective, although patients do not usually receive these services. It has been noted by Dr. Holland that with psychosocial interventions, there's a reduction in distress and improved quality of life. She asks why Patients are not receiving services?1

The reasons patients don't receive care for distress is:
Psychological due to the stigma of a mental disease
Doctors often do not discuss this because of time and lack of understanding of anxiety and depression
Patients often don't complain about their anxieties, fears or depression, as they don't want to be perceived as being crazy and the policy of a don't ask, don't tell attitude prevails

These barriers to adequate psychosocial care are now being highlighted. There is a problem with health services reimbursing for time spent in psychological counseling and the lack of available services for treatment of problems of distress. Oncology practices cannot afford to offer these services because of a lack of reimbursement to cover the cost. With the current budget crisis, psychosocial services will probably be the first to be cut by both federal and private insurance programs. Patients, such as older patients, cannot afford these services, and more recently the Medicare copes increased. It has been shown that costs of healthcare can be decreased, using the services of psychological and psychosocial programs. 2,3,4

Possible solutions include:
Studies are needed to show that management of distress can improve quality of life
Health benefits need to become available to help meet the psychosocial and distress needs of depression and anxiety and confused states
There needs to be additional studies to show there are cost savings with psychological interventions
Such studies have been recommended by the NCCN in their guidelines for distress.

Cancer Survivorship
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There are nearly ten million cancer survivors at this time, who each still face the personal problem of having had cancer, which can persist throughout life. The President's Beat Cancer Panel has addressed this issue, and there are problems still to be solved for survivors.

Facts about cancer survivors:
One in six people aged 65 or older are cancer survivors
The five-year survival rate is approximately 64%
Between 75 and 79% of children diagnosed with cancer are alive at five years, and 75% are alive at ten years
The majority, 61%, of cancer survivors are 65 years or older
Fifty percent of survivors experienced one of three cancers: breast 22%, prostate 17% and colorectal 11%
The end of cancer treatments is just an early landmark in a patient's life, and there can still be a need for psychosocial support and help in the cost of follow-up care.

The President's Cancer Panel (PCP) has recommended that each person receive a copy of his cancer records.
1. This includes diagnosis, tests, therapy and recommendations for follow-up care.
2. The panel recommends psychosocial counseling and support for survivors, as well as caregivers, during and following therapy as needed.

Weight Loss Relates to Poor Prognosis
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1. The weight loss includes loss of muscle mass and is a frequent problem following a cancer diagnosis and therapy. In part, it can be due to nutritional deficits, and proper nutritional counseling is advised.
2. Fatigue is a common problem that often leads to inactivity, increased time in bed, and lack of exercise.

Even with instructions for nutrition and exercise, it's often hard for cancer patients, especially during and post therapy, to reverse the a weight loss experienced.

When a patient loses 5% of body weight, the risk of treatment complications and death increases, and when the loss is 15%, major problems exist. When there is a 20% weight loss, the complication rate increases. 40-80% of cancer patients have significant weight loss due to metabolic changes and cachexia, which comes from the Greek kachexia meaning bad condition.

Early efforts need to be initiated during and post therapy to help prevent weight loss and cachexia.

Unfortunately, these problems are not addressed, and patients need to receive information on how to combat the weight loss, anorexia problems. The loss of mean muscle tissue rather than fat occurs, in part, due to inactivity, and the problems with fatigue promote a decrease in exercise.

Drugs are often used, such as Oxandrin® - Oxandrolone. Results at the ASCO meeting, abstract 3013, showed that patients who take the drug gained weight and increased muscle mass.

Exercise and a nutritional approach are vital to prevent weight loss. Even bedridden patients need to be involved in an exercise program. Taking 100 grams of protein plus exercise and improved nutrition caloric consumption can also be of help. This is vital for patients receiving anticancer treatments.

Additional References
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1. Jimmie Holland MD interview. Oncology News International vol 13,#8 Aug 2004
2. Simson S., Carlson, L.E., Trew, M.E.: ''Impact of Group Psychosocial Intervention on Health Care Utilization by Breast Cancer Patients.'' Cancer Practice 9:19-26, 2001.
3. Childs, J.A., Lambert, M.J., Hatch, A.L.: ''The Impact of Psychosocial Interventions on Medical Cost Offset: An Analytic Review.'' Clin Psycho 6: 2004-2020, 1999.
4. Holland, J.C., Anderson, B., et al.: ''Distress Management Clinical Practice Guidelines in Oncology.''JNCCN 1: 344-374, 2003.

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First appeared September 15, 2004; updated November 02, 2007