Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Where's the evidence for the increased cancer risk?
- Thomas J P Verberne (17 August 2002)
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Here is the evidence
- Craig A White (21 August 2002)
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Suicide and cancer
- Thomas J Verberne (27 August 2002)
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Patient Centred Cancer Information
- Pawan K Randev, Orest Mulka (30 August 2002)
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ABC of Psychological Medicine: Cancer
- Craig A White, Glasgow, G12 0XH. (30 August 2002)
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Guilt in the psychology of cancer
- C Kevin Connolly (4 September 2002)
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Thomas J P Verberne, none 14 Crampton Crescent, Rosanna VIC, 3084,Australia
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White and Macleod in their "ABC of psychological medicine - Cancer" (BMJ 2002;325:377-380) state that "[t]he risk of suicide is increased in the early stages of coping with cancer," but do not refer to the evidence that supports this statement. Especially in the context of cancer, any further cause for alarm should be well-founded before it is given publicity. Thomas Verberne Clinical Neuropsychologist |
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Craig A White, Cancer Research UK Fellow in Psychosocial Oncology Department of Psychological Medicine, University of Glasgow, Glasgow, G12 0XH
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The style and nature of the ABC series is such that, although article content is based on evidence and expert opinion, editorial guidelines do not allow every statement to be referenced with studies that have been published in support. I am, however, prepared to provide the evidence in support of the statement referred to by Mr Verberne. Tanaka et al., (1999) reported an increased suicide risk among the 23 979 people with cancer that were studied, stating that the risks were greater in the first five years following diagnosis and that the risk was enhanced at the time of hospital discharge. Crocetti et al. (1998) reported a high suicide mortality risk among a cohort of 27 123 people with cancer and that the highest risk was during the first six months after diagnosis. The findings of these studies illustrate that the inclusion of the sentence in the orginal article was well-founded. I question the validity of the suggestion that its inclusion would cause "alarm". References Crocetti, E., Arniani, S. et al. (1998). 'High suicide mortality soon after diagnosis among cancer patients in central Italy'. British Journal of Cancer, 77(7), 1194-6. Tanaka, H., Tsukuma, H. et al. (1999). 'Suicide risk among cancer patients: experience at one medical center in Japan, 1978-1994. Japanese Journal of Cancer Research, 90(8), 812-7. |
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Thomas J Verberne, none 14 Crampton Crescent, Rosanna, Vic., 3084, Australia
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Yes, several studies have shown raised suicide rates amongst cancer patients. But what is the practical significance of those findings for clinicians? The fact is that, even with twice the general population risk, the risk for suicide of cancer patients is still very low. By far the majority of cancer patients do not die by suicide. For example, of the 18,566 cancer patient deaths in the Crocetti et al. study (1), 99.8 per cent were not due to suicide. A reference to raised suicide rates that has been recast in this way should indeed not be a cause for alarm. Yet, in my experience, clinicians are alarmed by the mention of suicide. And, in my judgement, for good reason. The best hope the clinician has of identifying those very rare patients, who will die by suicide, is to screen each and every patient–not just those who are depressed–for current suicide plans or past aborted or failed suicides. And to repeat this screening process periodically. This is not only impractical, but it is also unlikely to uncover all those at risk. Would- be suicides often hide the urge to end their own life. And even if the clinician should uncover a would-be suicide, there is still the hard fact that there is no convincing evidence that suicide can be prevented. But there is yet another cause for alarm. This arises from the belief that not only the disease but also the treatment can lead to suicide: ". . . pain, loss of autonomy, depression and consciousness of treatment failure could lead to the loss of hope and to suicide." (1, p.1195) That there is evidence to question this belief (e.g., 2), is not widely known. 1. Crocetti E, Arniani S, Acciai S, Barchielli A, and Bucatti E. High suicide mortality soon after diagnosis among cancer patients in central Italy. British Journal of Cancer 1998; 77: 1194-1196. 2. Neeleman J, Wessely S, Wadsworth M. Predictors of suicide, accidental death, and premature natural death in a general-population birth cohort. Lancet 1998; 351: 93-97. |
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Pawan K Randev, GP Amersham HC, Chiltern Ave,Amersham,Bucks,HP6 5 AY, Orest Mulka
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Dear Sir/Madam White and Macleod discuss the causes of distress in patients with cancer. Intervention to benefit carers and families of cancer patients is also important. The recent CHI Report (1) talks of patients perceiving “no system to the whole procedure”, highlighting the difficulty for patients in seeing a way through the maze of actions and decisions that have to be made. The Kings Fund recently produced a discussion paper (2) examining the role of primary care organisations in providing psycho-social support. While information is important in helping to relieve anxiety, it has to be understood and given at a time that is appropriate. We have been involved in setting up a patient centred publication “i-can” (3). This quarterly magazine and website aims to provide information about issues relating to cancer for patients and their families. Recent articles have looked at emotional support, pain control and intimacy. The magazine is free and is published in a format which is colourful and jargon-light. We expect this publication will be available at hospital out-patients and within primary care. As practicing general practitioners we value the quality of information that is given to us and our patients. This article has highlighted the potential benefits of good quality information. Yours sincerely
Competing Interests – OPM and PKR are part of the editorial board of i-can and receive an honorarium. Complementary Interests – OPM and PKR have had an interest in improving cancer care for their patients for a number of years and have developed a systematic approach to improving cancer care in primary care (4) 1. NHS Cancer care in England and Wales, National Sevice Framework Assessments No 1, CHI and Audit Commission : December 2001 2. Psychosocial Support for Dying People: Shipman, Levenson and Ross:Kings Fund Discussion Paper : July 2002 3. www.ican4u.com 4. www.cancer-apc.org |
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Craig A White, Cancer Research UK Fellow in Psychosocial Oncology Department of Psychological Medicine, University of Glasgow, Glasgow, G12 0XH.
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This was not an article on suicide and cancer. It is not possible to cover the many complex issues pertaining to this or other specific issues alluded to within the original ‘ABC’ article. Mr Verberne has accepted that the original statement was factually correct. The practical significance of the increased risk is outside of the scope of the article and a matter for individual clinicians to consider. Some, like Mr Verberne, may believe that the sort of screening mentioned is “impractical”. Others may choose to formulate a different approach to this issue within their clinical work. Readers with an interest in following up literature that addresses the issues in more detail are advised to consult the chapter on the topic of suicide in Holland (1998), referred to in the ‘Further reading’ section of the article. The National Cancer Institute website referred to in ‘Useful sources of information’ also covers the issues in more detail (see the Supportive Care documents on Depression within the PDQ section of the site). |
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C Kevin Connolly, Semi -retired consultant Physician Aldbrough House, Aldbrough St John, Richmond, North Yorkshire, DL11 7TP
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Editor ABC OF PSYCHOLOGICAL MEDICINE: CANCER
In their article on the psychological aspects of cancer I was surprised that Drs White and Macleod did not mention guilt, which in my experience of more than 30 years in the management of lung cancer is often the most distressing psychological factor. Anger and guilt about delay in diagnosis are often felt by both the patient and his relatives, either party blaming either himself, the other, both or the medical profession. This is almost always directed at perceived delay the initial diagnosis and perhaps surprisingly much less frequently at delay in the process once that diagnosis has been made. Unfortunately this distress is often compounded by educational material over-stating the benefit of so-called early diagnosis after the onset of symptoms and compounded by process targets such as the 10 day rule which can only be justified on psychological rather than therapeutic grounds. In practice it is rare that delay in diagnosis during the symptomatic period of internal solid tumours effects outcome, as it is rare that this is a biologically critical phase of the disease. This is a statement not of complacency but of realism. It is a principal reason for the slow secular trend to better outcome. True early diagnosis amounts to detection at the cellular level before metastasis. Until research delivers this, those, well meaning as they are, who published this advice and promote these targets should remember that their activities are sometimes counterproductive, making it extremely difficult to manage the guilt by reassuring those concerned that the delay in fact almost certainly made little or no difference. C K CONNOLLY |
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