Hnc Qol Perspective Where Are We Going

The number of articles addressing QOL in the HNC literature should heighten the awareness of practitioners as to the importance of such considerations, although the current focus is largely still on the rather basic and incomplete aspect of functional status accompanying various cancer treatments. The mind-body-spirit connection is being addressed in the QOL literature at large, although such factors are still largely absent in the HNC literature. Several examples are included in this discussion to illustrate these considerations and how they may be addressed in daily practice. It is easy to anticipate resistance to addressing issues such as religion and spirituality in medicine. Some or many physicians may believe that such considerations are unimportant (except regarding blood transfusions in Jehovah's Witnesses) because they mean little to them personally. However, there is increasing evidence that attention to such concerns is important54 in the areas of prevention, coping, and recovery.55

Although it is unrealistic to expect office time-challenged otolaryngologists-head and neck surgeons who have previously used only closed-ended questioning with patients (i.e., questions that can be answered with a "yes" or "no") to facilitate brief encounters, to suddenly start asking patients whether they are happy, depressed, and alcoholic, and how they feel about their cancer treatment, it is necessary to be aware of the domains encompassed in "well-being" and to be aware of issues relating to patient empowerment. Failure of medical practitioners to concern themselves with such issues is a factor in the burgeoning industry of alternative medicine into which patients are currently pouring billions of dollars and more practitioner visits than to family doctors.56

Well-being remains to be clearly defined in patients with altered states of health. It is tentatively defined as a person's perception of life quality, a personal experience that is influenced by both the individual's past experiences and current expectations. This emphasizes the importance of imparting realistic expectations in cancer treatment planning to the patient before treatment is administered. One article illustrates the types of domains that are taken into consideration in attempting such definitions.25 This study is described in some detail to indicate the complex and sophisticated level to which QOL research has developed, and to illustrate the types of factors currently thought to be relevant and that are probably not typically taken into consideration by many HNC treatment managers. Well-being under a stressful life circumstance such as illness may be mediated by three factors: (1) the extent to which people see themselves as being in control of their environment; (2) the access to, and use of, family, friends, and associates; and (3) judgments one makes concerning self-worth. In formulating a theoretical model to predict subjective well-being, these three factors—presumably related to well-being in individuals diagnosed with cancer—were examined:32 influence of locus of control, social support, and self-esteem.

It is believed that psychosocial morbidity, of which many clinicians are unaware, is reduced when people have the ability to exercise choice and to retain a sense of self-sufficiency (locus of control), strengthened by support from a social matrix, and the maintenance of self-esteem and integrity. According to Rotter's 1954 social learning theory, an individual's behavioral response to a specific event is contingent on one's locus of control (LOC), which may be internal or external. External LOC relates to luck, to chance, and to "powerful others." Medical personnel are typically conceptualized as the "powerful others," but in Dirksen's study,25 25% of subjects express a personal belief that God was in control of the cancer. Therefore, a "powerful other" may also be a religious figure. The importance of LOC is that persons who believe that chance governs an unordered environment will behave differently from those who believe that "powerful others" are in control. Depending on which LOC the patient favors, feeling that "powerful others" are in control of the cancer can either add to or subtract from a sense of well-being. Those who are comfortable with others being in control might find a traditional health care model comforting, in which physicians assume a paternalistic role in the doctor/patient relationship. Those who do not would presumably have enhanced well-being if empowered to make some of their own decisions. The "chance" LOC is often associated with helplessness; a lack of perceived control over life events can result in depression and anxiety, a decreased perception of well-being, and feelings of low self-esteem.

Social support has been hypothesized to play a major role in alleviating stress when illness occurs and is thought to be a good predictor of subsequent well-being.57 Self-esteem is defined as positive judgment of self-worth and indicates the degree to which a person feels capable, significant, successful, and worthy. Self-worth is based on the ability to influence and control events and the attention received from others. Satisfaction with self-esteem has been identified in some studies as a strong predictor of an individual's perceived well-being. In persons with chronic illness, low self-esteem may have more of an impact on perceived well-being than the disability or the disease itself.

Dirksen's study used several instruments to assess these apparently important aspects of well-being: the cancer health locus of control scale (18 items with 6 in each of 3 locus of control subscales), the Norbeck Social Support Questionnaire and Personal Resource Questionnaire (used to measure the multiple dimensions of social support), and the Self-Esteem Inventory and Index of Well-Being (to measure the cognitive dimensions of subjective well-being, which rates present satisfaction with life on a 7-point continuum). The time required to complete all the questionnaires was approximately 1 hour. It was found that upon finishing, subjects would frequently want to discuss how their life had been affected by the cancer experience. Obviously, such evaluations can be complex and lengthy, and their interpretation is probably not totally within the purview of the cancer clinician. The importance of such factors suggests the need to have someone qualified and interested in psychosocial morbidity (a "psychosocialist") who will listen and be able to interpret as a new team member for the HNC patient.

The mind-body connection is under investigation in many areas of cancer. One hypothesized example is that hormonal and other somatic aspects of depression (including hypercortisolemia) might exert some influence on tumor growth, and molecular mechanisms have been proposed whereby hormone levels can influence the expression of cancer oncogenes in humans related to depression, by analogy with the finding in animals that over-activation of the adrenocorticotropic hormone (ACTH)-cortisol system can lead to more rapid tumor progression.58 Other postulated mechanisms include the immunosuppressive effects of glucocorticoids. The impact of stress-induced or alcohol-induced immunosuppression in cancer surveillance is also complex, possibly relevant, and deserving of more study.59 Some studies have shown no association between psychological distress and rate of relapse or mortality from cancer, although it is intuitively logical that suppression of distress, active coping strategies, and psychosocial intervention would be beneficial.

Measuring distress is complex and multifaceted.58 This subject is not straightforward because patients who try to suppress affect are often, if anything, more anxious and depressed than those who are less defensive. Measures of stress scales may reflect a genuine absence of anxiety, depression, and other symptoms or lack of awareness of such problems or breakthrough of symptoms despite genuine efforts to repress them. The theory holds that people with substantial distress, despite efforts to avoid coming to terms with that distress, are at most risk of stress-induced somatic symptoms. Conversely, some studies have shown that coping styles predict medical outcome, with an attitude characterized as "fighting spirit" associated with longer survival among some cancer patients. There are few answers in this area, but the need to study the effects of psychological intervention on disease progression has been recognized. Clearly, there is a growing interest in the interaction between psychological and medical variables in cancer as well as other diseases. There is a need for better definition of psychological constructs and controlled intervention trials. "It is not simply mind over matter, but instead... in future research, it may be possible to determine how mind does matter."59

Anxiety and Depression 101

Anxiety and Depression 101

Everything you ever wanted to know about. We have been discussing depression and anxiety and how different information that is out on the market only seems to target one particular cure for these two common conditions that seem to walk hand in hand.

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