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UF researchers explore the psychology of cancer treatment choices

University of Florida

If you have a headache, an aspirin will cure what ails you. If your child has a persistent ear infection, a common antibiotic will usually do the trick. But when it comes to cancer, it's rarely that simple.

University of Florida researchers say patients often must choose from several treatment options with no guarantees, forced to make what can amount to life-or-death decisions without the benefit of a crystal ball. And as a rising number of cancer patients explore nontraditional therapies, recent studies are just beginning to delve into exactly what prompts some to stick with standard treatment such as radiation or chemotherapy, while others also choose to pursue experimental approaches, from hypnosis to herbs to medicines that just haven't yet been put to a rigorous test in a clinical trial.

Getting to the bottom of that dichotomy would improve the medical decision-making process, say UF doctors who have reported data from a pilot study of advanced breast cancer patients in the March issue of the journal Bone Marrow Transplantation.

Their findings contradict the previously accepted image of the typical woman seeking alternative care, who has been depicted by some researchers as "self-assertive, psychologically strong and well-adjusted."

The patients in the UF study all had bone marrow transplants, but those who opted to enter all available experimental trials were more likely to be distressed and anxious. In the end, health practitioners should be mindful that some patients who readily agree to participate in investigative therapies might be depressed or otherwise psychologically stressed.

"It was a surprise. We thought the ones who accepted more therapies would be psychologically stronger, more educated and intelligent, but they actually were the ones who had a much higher chance of being distressed," said Paulette Mehta, medical director of pediatric hematology oncology and bone marrow transplantation at UF's College of Medicine. Mehta collaborated with clinical psychologist Jim Rodrigue, of UF's College of Health Professions, and John R. Wingard, director of the UF bone marrow transplant program at Shands at UF medical center.

"It's paradoxical," Mehta added. "We'd like everyone to participate in our clinical trials, but we should be aware that people who accept too readily may be doing it from stress rather than reasons of choice. We need to be aware some women are coming from a state of weakness, depression, loneliness or desperation. They may still do the studies if they want to do them, but they should be offered additional psychological support."

UF researchers studied 42 breast cancer patients, ages 31 to 65, all of whom underwent high-dose chemotherapy at Shands followed by bone marrow transplantation, at that time considered an experimental procedure. (Doctors have not yet been able to prove that bone marrow transplantation has a therapeutic advantage over conventional chemotherapy.)

Each woman completed various questionnaires that assessed quality-of-life issues and an array of psychological characteristics. These questionnaires are required for routine baseline assessments of the psychological health for all patients who undergo bone marrow transplantation. Researchers then looked at the 60 percent of the patients who readily elected to participate in one or more of three extra experimental studies testing medicines and other treatments to improve the transplant's success.

They discovered that the women who chose the added experimental therapies had high levels of psychological distress that might be influencing their decision-making, Mehta said. They were more likely to be anxious and also less likely to be able to do what they were accustomed to doing in their daily lives, despite having similar physical abilities to the patients who did not enroll in the added studies.

While it will take further study to determine exactly why, researchers speculate that these women may have a greater need to feel in control of their treatment -- and may feel more desperate to find one that works.

Mehta conceded the study was small and further research is needed to definitively answer why some patients aren't as hesitant when it comes to trying an experimental therapy.

But exactly what motivates patients to pursue nontraditional treatments -- whether they be experimental clinical trials, on the one hand, or alternative therapies such as herbal medicine, massage or hypnosis on the other -- is the subject of growing scientific scrutiny. Consider the findings published in the New England Journal of Medicine last year by researchers at the Dana-Farber Cancer Institute and Harvard Medical School. Of 480 newly diagnosed early-stage breast cancer patients in the study, the 28 percent who supplemented traditional treatment plans with alternative therapies such as mental imagery or acupuncture were more likely to be anxious or depressed and scored lower on quality-of-life surveys than their counterparts who did not.

While there were substantial differences in the research questions posed by the Harvard and UF studies, both raise important issues about the influence of psychological factors on treatment choices. An improved understanding of these issues would help doctors better detect distress in patients, enabling them to offer appropriate mental health counseling and improve how they counsel them about treatment options.

"All of us who take care of cancer patients are interested in how patients make decisions about their cancer therapy," said Dr. Harold J. Burstein, an instructor in medicine at the Dana-Farber Cancer Institute and Ha

rvard Medical School, and the Harvard study's lead author. "There are few relatively straightforward decisions in cancer treatment. What psychological or social factors predict whether someone will sign up for an experimental protocol? We'd like to better understand what it's like to be a breast cancer patient; we'd like to ultimately help people get better treatment."


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