life and psychological reactions to uveal melanoma has
been published. In a retrospective study of quality of life
in patients with choroidal melanoma, patients treated
with enucleation showed higher levels of emotional
distress and lower levels of vitality than those treated
with ruthenium plaque radiotherapy about 5 years after
treatment.ll Improved knowledge of the psychological
impact of diagnosis and treatment may assist in
determining the preferred management and refining
post-operative routines for patients with uveal
melanoma.12
examinations during the first post-operative year and
were then followed annually. Periodic follow-up for
signs of metastatic disease includes liver monitoring
semi-annually for 5 years.
Procedure
The patients were informed verbally and in writing
about the study. Informed consent was obtained
verbally. The patients were asked to complete
questionnaires on three occasions. At the first visit to
St Erik's Eye Hospital, before diagnosis was confirmed
and appropriate management was decided, the patients
received a questionnaire concerning anxiety and
depression. Two months (range 1-3 months) after
treatment the patients were interviewed by 'phone by a
psychologist and asked to complete mailed
questionnaires measuring quality of life, anxiety,
depressive symptoms and subjective stress responses. A
similar set of questionnaires, including an additional
questionnaire regarding eye-specific symptoms, was
mailed to patients 1 year after surgery.
The aim of the study was to prospectively investigate
psychological reactions and the quality of life in patients
with uveal melanoma at the time of diagnosis and 2 and
12 months after treatment.
Materials and methods
Patients
All patients referred for posterior uveal melanoma to the
Ophthalmic Pathology and Oncology Service, St Erik's
Eye Hospital, Stockholm and primarily managed
1995-1996 with enucleation (E) or ruthenium plaque
radiotherapy (R) were eligible for inclusion in the present
study.
e instruments
Following clinical examination and relevant
diagnostic procedures, patients were informed of the
clinical diagnosis and given the benefits and
The Hospital Anxiety and Depression (HAD) Scale was
developed to measure anxiety and depressive symptoms
among patients with somatic diseasesY It consists of 14
items - 7 for anxiety and 7 for depressive symptoms -
assessing problems during the previous week in one of
four categories (scored 0 to 3). The sum of scores was
calculated for each scale (maximum 21).
The reliability and validity of the HAD scale have
been tested in a number of international studies.14 Two
cut-off scores have been recommended: 7/8 for possible
and 10/11 for probable clinical levels of anxiety and
depression.13 The HAD scale was translated into
disadvantages associated with any potential treatment
(usually plaque radiotherapy or enucleation) according
to the procedures described by Damato.12 The individual
patient was then recommended a particular treatment
and, briefly, patients with tumours < 7 mm in height and
< 18 mm in diameter were advised to have plaque
radiotherapy, whereas larger tumours were managed by
enucleation. However, the actual choice was made jointly
by the patient and ophthalmologist based upon the
information available and the patient's preferences.
In general, patients selected for enucleation had larger
tumours (median diameter 14 mm; range 6-25 mm) than
patients receiving plaque radiotherapy (median diameter
8 mm; range 4-16 mm). Similarly, patients with
enucleation had thicker tumours (median thickness
9 mm; range 2-20 mm) than patients with tumours
managed with brachytherapy (median thickness 4 mm;
range 2-8 mm). While 5 patients with ciliary body
melanomas decided to have the eye removed, only 1
patient with a ciliary body tumour had plaque
radiotherapy.
Before treatment was initiated, a liver ultrasound scan
was performed and liver enzymes checked for signs of
metastatic disease. Enucleation was conducted at a
hospital near the patient's home, and at the time of the
study, follow-up was based on local routines. Patients
enucleated at St Erik's Eye Hospital had at least one
follow-up examination 1 month after enucleation, at
which time additional follow-up was planned depending
on the patient's choice. All the study patients receiving
plaque radiotherapy were treated at St Erik's Eye
Hospital. These patients had four follow-up
Swedish and validated by Marianne Sullivan.
IS
The European Organisation for Research and Treatment of
Cancer (EORTC) QLQ-C30 (+3) questionnaire has been
developed by the EORTC Quality of Life Group for the
measurement of quality of life in cancer patients in
clinical trials.16 It consists of 33 items, incorporating nine
multi-item scales: five functional scales (physical, role,
cognitive, emotional and social); three symptom scales
(fatigue, pain and nausea/vomiting); and three global
health and quality of life scales. For each item, the
respondent is asked to indicate on a four-point scale from
1 (Not at all) to 4 (Very much) the extent to which he or
she has experienced the problem during the past week. A
number of single-item scales are also included.
The Impact of Event Scale (IES) was included in order to
measure the post-traumatic stress responses to the
diagnosis of ocular melanoma and the eye operation. e
IES was developed by Horowitz and co-workersI? in
order to measure the degree of subjective stress
experienced as a result of a specific event.IS The IES
consists of 15 items, and taps two dimensions paralleling
the definition of the DSM-III 'Post Traumatic Stress
Disorder,.19 'Avoidance responses' (8 items) includes
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