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Online Resources

Cancer Legal Resource Center
CLRC is a joint program of the Disability Rights Legal Center and Loyola Law School. The CLRC provides free and confidential information and resources on cancer-related legal issues to cancer survivors, their families, friends, employers, health care professionals, and others coping with cancer.
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A new industry-sponsored educational resource for patients and professionals.
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About Herbs
Evidence-based information about herbs, botanicals, supplements, and more.  Presented by the Integrative Medicine Service at Memorial Sloan-Kettering Cancer Center.
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Fertile Hope
Resources on fertility for cancer patients and survivors.  Fertile Hope, founded as an independent education and advocacy group, is now part of the Lance Armstrong Foundation's Livestrong program.
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Continuing Education


Yale Bioethics Center
End of Life Issues group
All meetings 5:00 - 7:30pm (CME)

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March 25
Timothy Quill, MD
Justice at End-of-Life
Cohen Auditorium, Child Study Center, 230 Frontage Road

April 6
John D. Lantos, MD

Extreme Prematurity
Cohen Auditorium, Child Study Center, 230 Frontage Road

Schwartz Rounds; 12:00 Noon
YNHH 9th floor East Pavilion conference room.
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March 15 
When Medical Advice and Religious Convictions Conflict

April 19
Too Young to be Dying

April 21
4th Annual Yale Cancer Survivorship Symposium:  Sexuality and Survivorship
New Haven Lawn Club.  (CME, CNE)
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April 9 & 16; 7:30am-4:30pm
ONS Chemotherapy & Biotherapy Course
Hospital of St. Raphael (CNE) Pre-registration required: (203) 789-3391

April 17
Oncology Nurses Connecting in Connecticut
3rd Annual Oncology Symposium. The Oakdale Theatre. 95 South Turnpike Road, Wallingford, CT.  Registration details to follow.
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April 23
Continuing the Conversation . . . Addressing Barriers to End-of-Life Care
Annual Spring Conference of Connecticut Coalition to Improve End-of-Life Care.   Albertus Magnus College, New Haven.
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April 27 - May 4, 2010
November 9 - 15, 2010
Program in Palliative Care Education and Practice
Harvard Medical School. Boston.  Perhaps the premier course for physicians and nurses in palliative care.
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March  2010          Volume 4 ยท No 2

Sleep Disorder in Cancer and Survivorship
Thomas Quinn, APRN, MSN

Fatigue and problems with sleep are among the most common and frustrating symptoms faced by people during and after cancer treatment.  While closely related, sleep problems and fatigue are not interchangeable concepts.  For example, in a particular patient, objective measures of sleep may improve, but the subjective sense of fatigue may be unchanged.  In one study cancer-related fatigue was the biggest predictor of overall quality of life.  

In a recent update, Berger, et al., (see link to reference list, below) use "sleep-wake disturbance" as a generic term for problems with sleep that have not been formally diagnosed as sleep disorder (or "insomnia syndrome").  About 33% of the general population report symptoms of problems with sleep, which include one or more of the following:  difficulty falling asleep; difficulty staying asleep (wake periods of > 30 minutes); early awakening (≥ 30 minutes before intended wake time); non-restorative sleep; daytime sleepiness.  Criteria for diagnosis of insomnia syndrome/sleep disorder adds a frequency dimension (at least 3 nights per week), and causes significant distress and/or daytime impairment.  Daytime impairment may include problems with attention and concentration, mood disturbance, headache or gastrointestinal problems, and other symptoms.  

Insomnia syndrome is present in 16-21% of the general population.  At least some difficulty with sleep is reported in 30-50% of newly diagnosed patients with cancer.  Psychoemotional and lifestyle factors contribute to insomnia.  In cancer patients additional factors may include tumor biology, cancer treatments, and side effects associated with treatments.  A recent study of patients undergoing chemotherapy documented that 80% had insomnia symptoms, half or those had insomnia syndrome, and only 20% were "good sleepers" during chemotherapy.  Another study showed that chemotherapy in breast cancer patients disrupts circadian rhythms and that the disruption becomes progressively worse in succeeding cycles.  In a large prospective study of patients with cancer, patients with insomnia syndrome or reporting insomnia symptoms had significantly more fatigue and depression than good sleepers.  In the same study slightly more women than men reported sleep problems.  Patients with lung cancer had the highest rate of insomnia syndrome, while those with GI cancers had the lowest rate.  Overall, women with breast cancer reported the highest number of sleep problems.

Among survivors, 52% reported sleep difficulties in one study.  About two-thirds of those reported sleep problems prior to their diagnosis, but 58% said cancer had made the problem worse.  

Clinician-patient communication is key to effective intervention.  An important and simple screening question that any clinician can ask of a patient or survivor is, "How are you sleeping?"  Further assessment can suggest potential multimodality interventions.  Multiple classes of medications are prescribed for problems with sleep.  An NIH-sponsored State-of-the-Science Conference on insomnia concluded in 2005 that behavioral therapies are the most effective treatments for insomnia in the general population.  Cognitive-behavioral (CBT) approaches have emerged in recent studies as being very effective in alleviating insomnia symptoms in people with cancer.  Study findings include confirmation that CBT improved sleep efficiency, total sleep time, improved fatigue and mood, and improved quality of life.  Improvements were maintained for up to 12 months, but one study suggests that, for patients successfully treated for insomnia during chemotherapy, additional treatment might be needed post-chemotherapy.

Sleep Reference List >>

In the News

News items from Pain Treatment Topics, one of the most reliable pain information sites on the web.
  • Nearly Half of Patients Misuse Their Pain Meds
    "Adherence to prescribed medication regimens is essential for effectively treating chronic pain conditions. However, a new study (in Belgium) reports that therapeutic nonadherence, or 'medical misuse,' of analgesics is common, with underuse more prevalent than overuse or abuse."
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  • Bogus Drugs & Opioids Touted by Online Pharmacies
    According to online pharmacy watchdogs, only a tiny percent of the over 5000 online pharmacies are legitimate.
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Connecticut Coalition to Improve End-of-Life Care
The newly-revised edition of Beginning the Conversation about Death, Dying and End-of-Life Care in Connecticut is available at cost ($5.00) from the Connecticut Coalition to Improve End-of-Life Care. 
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Journal Watch

Cassell E, Rich BA. Intractable end-of-life suffering and the ethics of palliative sedation.  Pain Med.  2010 Jan 15.

Crespi CM, et al. Measuring the impact of cancer.  J Cancer Surviv.  2010;4(1):45-58.

Crew KD, et al. Randomized, Blinded, Sham-Controlled Trial of Acupuncture for the Management of Aromatase Inhibitor-Associated Joint Symptoms in Women With Early-Stage Breast Cancer.  J Clin Oncol. 2010 Jan 25.

De Haas EC, et al. The metabolic syndrome in cancer survivors.  Lancet Oncol.  2010;11(2):193-203.

Ganz PA. Survivorship: adult cancer survivors.  Prim Care. 2009 Dec;36(4):721-41.

Gillison TL, Chatta GS. Cancer chemotherapy in the elderly patient.  Oncology.  2010;24(1):76-85.  (Reviews on pages 91 & 92)  Free full text (free registration required). 

King T, Porreca F. Opioids in cancer pain:  new considerations.  Pain Clinical Updates.  2010(18):1.  Free full text.

Mack JW, et al. End-of-Life Discussions, Goal Attainment, and Distress at the End of Life: Predictors and Outcomes of Receipt of Care Consistent With Preferences.  J Clin Oncol. 2010 Feb 1.

Manne S, et al. Cancer-related communication, relationship intimacy, and psychological distress among couples coping with localized prostate cancer.  J Cancer Surviv. 2010;(1):74-85.

Mazzarino-Willett A. Deathbed Phenomena: Its Role in Peaceful Death and Terminal Restlessness.  Am J Hosp Palliat Care. 2009 Oct 8.

Oeffinger KC, et al. Challenges after curative treatment for childhood cancer and long-term follow up of survivors.  Hematol Oncol Clin North Am. 2010 Feb;24(1):129-49.

Oeffinger KC, et al. Survivorship: childhood cancer survivors.  Prim Care. 2009 Dec;36(4):743-80.

Otte JL, et al. Prevalence, Severity, and Correlates of Sleep-Wake Disturbances in Long-Term Breast Cancer Survivors.  J Pain Symptom Manage. 2010 Jan 16.

Recklitis CJ, et al. Suicide ideation in adult survivors of childhood cancer: a report from the Childhood Cancer Survivor Study.  J Clin Oncol. 2010;28(4):655-61.

Schulman-Green D, et al. Benefits and challenges in use of a standardized symptom assessment instrument in hospice.  J Palliat Med. 2010 Feb;13(2):155-9.

Snyderman D, Wynn D. Depression in cancer patients.  Prim Care. 2009 Dec;36(4):703-19.

Urban D, et al. The management of cancer pain in the elderly.  Crit Rev Oncol Hematol.  2010;73(3):176-183.