Clinical Briefs
December 30, 1999
Clinical Briefs
Psychological Response and Breast Cancer Survival
Though a role for the psychological status of patients and outcome of cancer has been hypothesized for some time, studies to date have been inconclusive or hampered by small size or short follow-up. One study, which did demonstrate an effect, indicated that women who were described as possessing a "fighting spirit" as opposed to "helpless" were significantly more likely survivors of breast cancer at both five- and 10-year marks, but because the study was small (n = 57), did not adjust for baseline lymph node status, and used a psychological interview rather than a detailed, validated psychometric instrument for assessment, the issue is far from conclusively resolved.
Watson and colleagues used the mental adjustment to cancer (MAC) and Courtauld emotional control (CEC) scales for evaluation, women were followed for a minimum of five years, and a large population of women (n = 578) was enrolled.
Cancer relapse occurred in 27% of women at an average interval of two years. No significant effect of psychological response was evident on either overall or event-free survival. Of the measured issues on the MAC, the subgroup area with a high level of helplessness or hopelessness was found to have a significantly higher likelihood of death at five years, but the "fighting spirit" was not associated with improved survival. Watson et al opine that clinicians should be more cautious in their suggestion of benefits achieved by "maintaining a fighting spirit." Indeed, they note that sometimes women may feel guilty when maintaining a fighting spirit becomes difficult or impossible; it may be possible for clinicians to relieve patients of some of this burden.
Watson M, et al. Lancet 1999;354: 1331-1336.
Interferon Gamma, Low-Dose Prednisolone, and IPF
Survival in idiopathic pulmonary fibrosis (IPF) is poor, averaging only 4-5 years. Among patients who receive oral glucocorticoids, the standard treatment for IPF, less than one-third improve. Though the mechanisms inducing the disorder are not understood, it is typified by progressive proliferation of populations of fibroblasts that deposit collagen in the lung interstitium. Since interferon gamma has been shown to inhibit lung fibroblast growth, it has been a sensible candidate for trial in IPF.
Ziesche and associates studied 18 patients with IPF who had failed to respond positively to traditional therapies, including 50 mg/d of oral prednisolone for one month. Patients were assigned to receive either 200 mcg of interferon gamma-1b thrice weekly subcutaneously plus oral prednisolone (7.5 mg/d) or the same dose of prednisolone alone, for one year.
Only in patients who received interferon were positive changes in ventilation, gas exchange, and total lung capacity seen. Overall, prednisolone-alone recipients showed a 4% decline in total lung capacity, compared to a 9% improvement in recipients of interferon plus steroid.
Interferon resulted in substantial improvements in partial pressure of arterial oxygen at rest and during exercise, requirement for supplemental oxygen, and ability to perform activities of daily living.
Initial treatment is problematic in that patients predictably exhibit fever, chills, and muscle pain, but these effects diminish over the first 9-12 weeks of treatment. These early results provide encouraging news about interferon as an effective treatment for IPF.
Ziesche R, et al. N Engl J Med 1999; 341:1264-1269.
Sleep Debt on Metabolic and Endocrine Function
In the early part of this century, average amount of nightly sleep was nine hours; as this century closes, we average only 7.5 hours of nightly sleep, due to increased time demands of both work and leisure activities. Claims have been made that since only 4-5 hours per night represent "core sleep," persons might progressively reduce their total sleep hours without compromising these essentials, but studies to examine the effects upon vigilance and mood subsequent to revision of sleep time by 2-3 hours have been conflicting.
Spiegel and colleagues studied healthy subjects (n = 11) in a sleep laboratory, varying sleep nightly from 4-12 hours over 16 days. The first three nights held eight hours of sleep, followed by six nights of four hours sleep, concluding the study with seven nights of 12 hours sleep. Periodic measurements of saliva for cortisol and glucose tolerance tests were done.
REM sleep was significantly reduced during periods of sleep deprivation, calling into question the wisdom that sleep time can be reduced while maintaining core sleep time. During times of sleep deprivation, glucose tolerance was significantly impaired. Also, cortisol elevations were evident during sleep deprivation periods.
Spiegel et al suggest that sleep deprivation has demonstrable endocrine and metabolic consequences. The long-term effects of such alterations remain unknown.
Spiegel K, et al. Lancet 1999;354: 1435-1439.
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