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To document the effect of a cancer specific question prompt list (QPL) on patients question asking and shared decision-making (SDM), and to evaluate the combined effect of the QPL and consultation audio recording (CAR) on patient outcomes.This exploratory study compared two groups of patients receiving either a QPL or combined QPL/CAR, to a control group. Measurements included number/types of questions asked, and physician SDM behavior (OPTION score). Questionnaire data included anxiety/depression and quality of life (QoL).A total of 93 patients participated (31 Control, 30 QPL and 32 Combined). Patients in the intervention groups asked more questions concerning prognosis (p .0001), the disease (p = .006) and quality of treatment (p .001) than patients in the control group, but no impact was found on the OPTION score. An increase in mean consultation length was observed in the intervention groups compared to the control group (44 vs. 36 min; p = .028). Patients rated both interventions positively.Provision of the QPL facilitates patients to ask a broader range of questions, but does not increase physician SDM behavior.The combination of QPL and CAR seems feasible and should be tested in an implementation study following the disease trajectory.

Spouses play an important role in how well patients with prostate cancer manage their illness. Whereas earlier studies mostly included both patients and spouses, this study focuses on the spouses' experiences during the course of the illness.The objective of this study was to explore how the daily life of female spouses is affected by their husband's prostate cancer.Qualitative interviews were conducted with 9 spouses of men receiving potential curative treatment for prostate cancer.Prostate cancer in men had significant impact on spouses' everyday life. The results showed that spouses strived to achieve a balance between focusing on their own needs and meeting their husbands' needs along the course of the illness. Four themes emerged: strong and optimistic versus vulnerable and overstrained, maintaining the partner's sense of manhood, being on the sideline, and the need for relationships outside the immediate family.Being a spouse to a man with prostate cancer is emotionally and practically demanding. There is a danger of the spouses suppressing their own needs in the process of supporting their husbands. Those spouses living in the situation over a period of years expressed fatigue and a shift in focus from their husbands' needs to their own needs for support.Healthcare providers should provide support for spouses during the course of the illness, encourage spouses to participate in seminars for couples living with prostate cancer, and be aware of the potential for situational fatigue in spouses many years after the diagnosis.

Objectives To explore how cancer patients actively participate in consultations by asking questions and expressing emotional cues/concerns and to what extent this is associated with physician shared decision making (SDM) behavior. Methods This observational study included audio recordings of 31 primary consultation with patients at the Oncology Outpatient Clinic at the University Hospital of North Norway. The content (topics) and frequency of health related questions from patients/caregivers were registered along with emotional cues and concerns (VR-CoDES) and observed shared decision-making (OPTION). Patient reported outcomes were measured before and one week after the consultation. Results On average, 17 (SD 15) questions were asked, and 1.9 (SD 1.9) emotional cues and concerns were expressed by patients per consultation. The questions mainly pertained to treatment and practical issues. The mean OPTION score was 12 (SD 7.9) and was neither associated with questions nor emotional cues and concerns from patients. Conclusion Although patients were active by asking questions, observed physician SDM behavior measured by OPTION was low and not associated with patient behavior during consultation. Practice implications Further research on patientś influence on physician SDM behavior is needed.

A question prompt list (QPL) is an inexpensive communication aid that has been proved effective in encouraging patients to ask questions during medical consultations. The aim of this project was to develop a QPL for Norwegian cancer patients. A multimethod approach was chosen combining literature review, focus groups, and a survey in the process of culturally adjusting an Australian QPL for the Norwegian setting. Participants were recruited from the University Hospital of North Norway. They were asked to review and comment on iterative drafts of the QPL. Eighteen patients, mean age 54, participated in the focus groups, and 31 patients, mean age 55, participated in the survey. Focus groups suggested that topics related to accompanying relatives, children as next of kin, and rehabilitation were important and should be added to the original QPL. The survey revealed that most questions from the original QPL were considered both useful and understandable. Although half of the patients found some questions about prognosis unpleasant, the vast majority considered the same questions useful. Questions regarding clinical studies, multidisciplinary teams, and public versus private hospitals had lower ratings of usefulness. QPLs require some adjustment to the local cultural context, and a mixed method approach may provide a useful model for future cultural adaptation of QPLs. The present QPL has been adjusted to the needs of oncology patients in the Norwegian health care setting.

Objective To evaluate disease pattern, patient characteristics, and survival in patients treated for brain metastases from renal cell carcinoma. Methods Retrospective analysis of all patients with brain metastases from renal cell carcinoma treated between 1983 and 2009 in northern Norway. Results The time interval between first cancer diagnosis and brain metastases was dependent on initial TNM stage (median 42 months in stage II vs. 10 months in both stage III and stage IV). Only few patients did not harbor extracranial metastases. Systemic therapy after diagnosis of brain metastases has been used in only three patients. Surgical resection and/or radiosurgery have been administered in 34% of patients, but whole-brain radiotherapy (WBRT) alone remained the cornerstone. Median survival was 4.1 months (3.7 months in the WBRT alone group, 10.1 months in the surgery and/or radiosurgery group). Two factors were significantly associated with better survival: solitary brain metastasis and age ≤64 years. The prognostic impact of the recursive partitioning analysis classes was not confirmed, while the new graded prognostic assessment index performed better. Conclusions Surgical resection and/or radiosurgery contribute to prolonged survival. As most patients harbor extracranial metastases that threaten their lives, systemic treatment theoretically might play a role in the management of these patients, but more data need to be collected to confirm the clinical impact of immunotherapy, angiogenesis inhibition, and other signal transduction inhibitor approaches.

Previous studies of living with prostate cancer have shown that the illness and the treatment cause physical as well as psychosocial problems.The aim of this study was to illuminate men's experiences living with localized or local advanced prostate cancer when curative treatment such as surgery or radiation therapy is not an option at the time of diagnosis.The study was conducted via qualitative interviews, using a phenomenological hermeneutic approach. Ten men treated with endocrine therapy or under active surveillance were interviewed.Being diagnosed with prostate cancer was described as a shock, with different aspects of the illness revealed gradually. The limited amount of time available for meeting with health care providers contributed to patients' feelings of being left alone with difficulty getting information and help. Sexual and urinary problems were perceived as a threat to their manhood. The spouses provided the closest everyday support.The life situation of these patients can be understood as living in a "state of readiness," expecting something to happen regarding their illness, and not always knowing where to get help.The results confirm existing knowledge of patient's experiences in living with prostate cancer regarding the initial shock perceived by the patients, the bodily alterations, and the important role of their spouses. Nurses, as well as general practitioners, must play a more active role in follow-up to ensure that the men and their spouses receive better help and support.

Objective To test whether young physicians improve their communication skills between graduating from medical school and completing clinical internship, and to explore contributing background and/or internship factors. Methods Norwegian medical students graduating June 2004 were invited to take part in a videotaped standardized patient interview February 2004. Of the 111 students who originally participated, 62 completed a second interview February 2006. Observed communication skills were assessed with the Arizona Communication Interview Rating Scale (ACIR). Results The level of communication skills increased significantly during the period for participants overall; and for females but not males. General social skills reached significantly higher levels than specific professional skills, both types of skill improving during the study. Independent predictors were working in local hospitals, learning atmosphere and low stress. At school completion, 50% reached a level defined as ‘advanced beginner’. Towards the end of the internship, 58% reached ‘capable’ and 27% ‘competent’ levels of communication skills. Conclusions Female physicians improved most in communication skills, the gender difference being multivariate mediated through low stress levels and learning atmosphere. The findings support the division of communication skills into general social and specific professional skills. Practice implications The relatively low proportion of young physicians, especially males, developing the capability to practise independently at internship completion indicates a need for more effective training in communication skills, during both medical school and internship.

Cancer patients receiving chemotherapy are prone to develop infections that might postpone treatment and lead to complications. The aim of our study was to investigate whether a heterogeneous population of patients with solid tumors and malignant lymphoma undergoing chemotherapy would respond serologically to vaccination against influenza and pneumococcal disease. There are no established routines in oncology departments in Norway regarding vaccination of these patients. The study included 35 cancer patients with median age 53 yr (range 20-74) and 38 controls with median age 57 yr (range 43-75). The chemotherapy regimens used were mild or moderately immunosuppressive. After one vaccination, 25 patients (72%) and 34 controls (87%) were serologically protected against two or three influenza strains. A higher proportion of patients with solid tumors (81%) than lymphoma (38%) achieved protection. Age, months on chemotherapy, and curative versus palliative treatment did not influence responses to vaccination. After vaccination with a 23-valent polysaccharide vaccine against pneumococci, most patients and controls achieved protective serum levels of antibodies against the different serotypes, with the exception that fewer patients were protected against serotype 4. The responses in controls were, however, generally stronger to all serotypes. Tumor type did not influence this vaccination response. We conclude that our cancer patients achieved adequate responses to influenza virus and Streptococcus pneumoniae. These are not live vaccines and are therefore safe for immunocompromised patients. Routine vaccinations against influenza virus and Streptococcus pneumoniae should be considered in cancer patients undergoing mild to moderately immunosuppressive chemotherapy.

Cancer patients are often encouraged to receive seasonal influenza vaccination. The monoclonal antibody rituximab is widely used in treatment of non-Hodgkin lymphoma. This results in a prolonged depletion of normal B cells, which might impair humoral responses. The aim of the present study was to investigate whether lymphoma patients undergoing rituximab-containing treatment regimens or having received such regimens within the past 6 months were able to mount protective antibody responses to the influenza A(H1N1) 2009 virus vaccine Pandemrix during the 2009 “swine flu” pandemic. Contrary to the control group, where 82% responded adequately to the vaccine, none of the 67 patients achieved protective antibody titers, suggesting that lymphoma patients receiving rituximab-containing regimens might not benefit from this vaccine. It is important that doctors who care for such patients are aware that they may fail to respond not only to the influenza vaccine, but also to other common vaccines.

Background In this study, we wanted to investigate the relationship between background variables, communication skills, and the bio-psychosocial content of a medical consultation in a general practice setting with a standardized patient. Methods Final-year medical school students (N = 111) carried out a consultation with an actor playing the role of a patient with a specific somatic complaint, psychosocial stressors, and concerns about cancer. Based on videotapes, communication skills and consultation content were scored separately. Results The mean level of overall communication skills had a significant impact upon the counts of psychosocial issues, the patient's concerns about cancer, and the information and planning parts of the consultation content being addressed. Gender and age had no influence upon the relationship between communication skills and consultation content. Conclusion Communication skills seem to be important for final-year students' competence in addressing sensitive psychosocial issues and patients' concerns as well as informing and planning with patients being representative for a fairly complex case in general practice. This result should be considered in the design and incorporation of communication skills training as part of the curriculum of medical schools.

Purpose: Pain severely impairs health-related quality of life and is a feared symptom among cancer patients. Unfortunately, patients often do not receive optimal care. We wanted to evaluate the quality of cancer pain treatment in Norwegian hospitals. Patients and methods: A one-day prevalence study targeting hospitalised cancer patients above 18 years of age was performed. A questionnaire based on the Brief Pain Inventory was used, and additional information regarding sex, age, diagnosis, break through pain (BTP), and treatment was included. Results: Fifty two percent of the included patients stated having cancer related pain (n = 453), and mean pain during the previous 24 hours for these patients was NRS 3.99 (Numeric Rating scale 1-10). Presence of metastasis, occurrence of BTP, and abnormal skin sensibility in the area of pain were associated with higher pain scores. Forty two percent of all patients used opioids. However, these patients still had higher pain scores, more episodes of BTP, and more influence of the pain on daily life functions than average. Thirty percent of patients with severe pain (NRS ≥ 5) did not use opioids, and some of these patients did not receive any analgesics at all. Conclusion: Although most cancer patients receive an acceptable pain treatment in Norwegian hospitals, there are patients who are not adequately managed. Lack of basic knowledge and individual systematic symptom assessment may be reasons for the underuse of analgesics and the resulting unnecessary suffering among the cancer patients.

Patients with non-curable cancer represent a large and heterogeneous group in which malnutrition and weight loss is a frequent finding. This article is based on relevant literature and our own clinical experience. For every patient a thorough examination of possible underlying causes should be explored and corrected as soon as possible (secondary cachexia). However, in many patients primary cachexia is the cause, a catabolic condition where muscle protein and lipids are degraded and even aggressive nutrition will not reverse the process. This condition is very different from starvation. Metoclopramide, corticosteroids and gestagens can relieve symptoms as anorexia, chronic nausea and asthenia which frequently occur in patients with cachexia. Treatments that may maintain or increase muscle function and modulate inflammatory processes are new approaches, such as eicosapentaneoic acid, adenosine triphosphate, specific amino acids and nonsteroidal antiinflammatory drugs. Nutrition is an integrated part of supportive therapy to all cancer patients, unless expected survival is short. At this time in life, nutrition will not influence survival and focus should be on symptom control.

Symptom relief as well as symptom prevention may be achieved in patients with advanced malignant disease and short life expectancy by use of radiotherapy and systemic cancer treatment (hormones and chemotherapy). Sometimes the treatment may be life prolonging as well. This knowledge is mostly based upon empirical data and personal experiences - to a much lower extent on evidence-based medicine. For these patients, it is of particular importance to minimise the level and duration of acute treatment-related toxicity. Shortened radiotherapy regiments may be effective, with few side effects. The efficacy of the systemic treatment must be evaluated at regular intervals and terminated if there is a lack of response or high level of toxicity. Bisphosphonates are standard treatment of hypercalcaemia. In addition, in patients with bone metastasies from various cancer sites with a life expectancy of six months or more, bisphosphonates may reduce the number of skeletal events.

Thirty-one previously untreated patients with follicular low-grade B-cell non-Hodgkin's lymphoma expressing the CD20 antigen were treated with iodine-131 tositumomab therapy between 1996 and 1998. The therapy led to a temporary depletion of peripheral blood B-lymphocytes. Recovery of B-cells occurred in most cases by 3 to 6 months and in all patients by 12 months posttherapy. A temporary decline in T-cell subpopulations, but no reduction in serum immunoglobulin levels, could be observed. ELISA techniques were used to detect specific antibodies against rubella, mumps, varicella zoster, measles, and tetanus. Almost all patients remained seropositive against the different antigens during the 1- to 2-year follow-up. No significant reduction in antibody concentrations to tetanus or measles could be detected. The data show that acquired humoral immunity against common antigens appears to be preserved despite a temporary loss of B-lymphocytes.

With the success of high dose therapy supported by autologous bone marrow transplantation (ABMT) for malignant lymphomas, medical late-effects and secondary effects on subjective health, like fatigue, are of concern. Fatigue is poorly understood and correlates have been barely addressed. Health-related quality of life (HRQL), fatigue, and correlates to fatigue, including endocrinological status and serum levels of interleukin-6, tumor necrosis factor, and soluble tumor necrosis factor receptors, were investigated in a cross-sectional study of 33 lymphoma patients (median age 39 years) 4–10 years after ABMT. The survivors were compared to general population norms. Fatigue was highly prevalent, and females reported significantly more fatigue and impaired HRQL compared to males and the normal population. Gonadal dysfunction was found in the majority of the patients, but no statistically significant endocrinological or immunological associations with fatigue could be demonstrated. The high level of fatigue among female long-term survivors after ABMT may be related to the gonadal dysfunction, but further studies of possible mechanisms behind fatigue are necessary.

The aim of this study was to investigate the late effects of ABMT on the immune system with regard to protective humoral immunity against common antigens and responses to recall antigens (vaccines). The vaccines were given according to EBMT guidelines from 1995. The protocol included 35 patients with malignant lymphoma in CR 4-10 years after ABMT, and 35 controls. The results show that prior to ABMT the proportion of patients with protective immunity against poliomyelitis, tetanus and diphtheria was similar to that of controls. At study entry 4-10 years after ABMT, the proportion of patients with protective immunity against poliomyelitis and diphtheria was reduced, while all patients maintained protection against tetanus. A significant decrease in geometric mean antibody concentrations or titres was observed against all three antigens during this period. Serum levels of antibodies against different pneumococcal serotypes were lower in the patients than in the controls prior to vaccination. The responses to pneumococcal vaccination, which is considered to be a T cell-independent vaccine, were studied. Unlike controls, a minority of patients achieved protective levels of antibodies after a single vaccination. Despite persistent levels of protective antibodies in many patients post ABMT, secondary booster responses after one vaccination with T cell-dependent vaccines (tetanus, diphtheria and polio) were absent. In conclusion, this study shows that post ABMT, a full re-vaccination program was necessary to mount responses comparable to those observed after a single vaccination in controls.