The origins and management of erotic countertrasference and its impact on the therapeutic alliance : a critical investigation of the psychoanalytic literature.

In certain instances both male and female analysts may develop an erotic countertransference during the course of analysis. This theoretical research project sought to explore the meaning and manifestation of erotic countertransference in psychoanalytic treatment. Information was gathered from a variety of psychoanalytic literature sources in order to include a broad coverage of psychoanalytic approaches to issues concerning the origins and handling of erotic countertransference within the therapeutic setting. Analysts may experience both idealising, sexual, and loving feelings, as well as feelings of hostility and hate in the erotic countertransference response. Erotic countertransference feelings were found to originate from various psychosexual developmental stages, internal objects relations and may also be experienced due to projective identification, narcissistic tendencies in analysts as well as being influenced by the genders of patient and analyst in the dyad. However, it was noted that a complicating factor in identifying why an erotic countertransference occurs is the mutual influence of unconscious dynamics of both patient and analyst. This has implications for how the erotic countertransference may be most effectively and ethically handled. A specific debate concerning self-disclosure of analysts’ sexual feelings from a relational psychoanalytic perspective versus maintaining analytic abstinence was included and it was found that self-disclosure of analysts’ sexual feelings is a problematic technique in the psychoanalytic therapeutic context. The findings of this research report may provide some containment for analysts who experience sexual feelings for patients by offering an explanation of the complexity of erotic countertransference and recommendations on how it may be managed

Appropriateness of the 30-day expected mortality metric in palliative radiation treatment: a narrative review

BACKGROUND AND OBJECTIVE The 30-day expected mortality rate is frequently used as a metric to determine which patients benefit from palliative radiation treatment (RT). We conducted a narrative review to examine whether its use as a metric might be appropriate for patient selection. METHODS A literature review was conducted to identify relevant studies that highlight the benefits of palliative RT in timely symptom management among patients with a poor performance status, the accuracy of predicting survival near the end of life and ways to speed up the process of RT administration through rapid response clinics. KEY CONTENT AND FINDINGS Several trials have demonstrated substantial response rates for pain and/or bleeding by four weeks and sometimes within the first two weeks after RT. Models of patient survival have limited accuracy, particularly for predicting whether patients will die within the next 30 days. Dedicated Rapid Access Palliative RT (RAPRT) clinics, in which patients are assessed, simulated and treated on the same day, reduce the number of patient visits to the radiation oncology department and hence the burden on the patient as well as costs. CONCLUSIONS Single-fraction palliative RT should be offered to eligible patients if they are able to attend treatment and could potentially benefit from symptom palliation, irrespective of predicted life expectancy. We discourage the routine use of the 30-day mortality as the only metric to decide whether to offer RT. More common implementation of RAPRT clinics could result in a significant benefit for patients of all life expectancies, but particularly those having short ones

Randomized Phase II Study Comparing Prophylactic Cranial Irradiation Alone to Prophylactic Cranial Irradiation and Consolidative Extracranial Irradiation for Extensive-Disease Small Cell Lung Cancer (ED SCLC): NRG Oncology RTOG 0937

Introduction—RTOG-0937 is a randomized phase-II trial evaluating 1-year OS with PCI or PCI plus consolidative radiation therapy (cRT) to intra-thoracic disease and extracranial metastases for ED-SCLC. Methods—Patients with 1–4 extracranial metastases were eligible after CR or PR to chemotherapy. Randomization was to PCI or PCI+cRT to the thorax and metastases. Original stratification included PR vs CR after chemotherapy and 1 vs 2–4 metastases; age \u3c 65 vs ≥ 65 was added after an observed imbalance. PCI was 25GY/10 fractions. cRT was 45GY/15 fractions. To detect an OS improvement from 30% to 45% with a 34% hazard reduction (HR=0·66) under a 0.1 type-1 error (1-sided) and 80% power, 154 patients were required. Results—Ninety-seven patients were randomized between March, 2010 and February, 2015. Eleven patients were ineligible (nine PCI, two PCI+cRT), leaving 42 randomized to PCI and 44 to PCI+cRT. At planned interim analysis the study crossed the futility boundary for OS and was closed prior to meeting accrual target. Median follow-up was 9 months. One-year OS was not different between the groups: 60.1% [95% CI: 41.2–74.7%] for PCI and 50.8% [95% CI:34.0–65.3%] for PCI+cRT (p=0.21). Three and 12-month rates of progression were 53.3% and 79.6% for PCI, and 14.5% and 75% for PCI+cRT. Time to progression favored PCI+cRT, HR=0.53 (95% CI: 0.32–0.87, p=0.01). One-patient in each arm had Grade-4 therapy related toxicity and one had Grade-5 therapy related pneumonitis with PCI+cRT. Conclusions—OS exceeded predictions for both arms. Consolidative RT delayed progression but did not improve 1-year OS

The role of radiation therapy in the management of primary thymic epithelial neoplasms

Therapeutic radiation plays an important role in the management of thymoma and thymic carcinoma. These two tumor types differ substantially in their aggressiveness and prognosis. The most pressing issue in radiotherapy is which thymoma and thymic carcinoma patients need radiation. Given that these are rare cancers, few randomized trials have been published. Controversy remains regarding which patients benefit from adjuvant radiation therapy. Existing literature spans patients treated over nearly 50 years, during which time radiation therapy has evolved from rudimentary 2-dimensional based planning to conformal 3-dimensional planning to yet more conformal dose painting techniques such as intensity-modulated radiation therapy and proton therapy. If the effect of radiation is small and the natural history of a disease long, as is the case for stage I favorable histology thymoma, then differences in techniques and toxicities may have as much of an impact as whether radiation was given or not

The influence of breast cancer subtype on survival after palliative radiation for osseous metastases

Background Among patients with osseous metastases, breast cancer (BC) patients typically have the best prognosis. In the palliative setting, BC is often considered a single disease, but based on receptor status there are four distinct subtypes: luminal A (LA), luminal B (LB), triple negative (TN), and HER2-enriched (HER2). We hypothesize that survival and palliative outcomes following palliative RT for osseous metastases correlate with breast cancer subtype (BCS). Methods We identified 3,895 BC patients with known receptor status who received palliative RT for osseous metastases from 2004-2013 in the National Cancer Database. Kaplan-Meier method with log-rank testing and univariate/multivariate Cox-regression was used to identify survival factors. Incomplete radiation courses, 30-day mortality rate, and percentage remaining life spent receiving RT (PRLSRT) were calculated. Results Subtypes were 54% LA, 33% LB, 8% TN, and 5% HER2 with median survival of 34.1, 28.2, 5.3, and 15.7 months, respectively (p = 10 fractions. Although BCS had limited effect on radiation regimens, TN received nearly twice as many single or hypofractionated (<= 5 fractions) treatments, but the overall rate of these fraction schemes was low at 3.7 and 13.7%, respectively. Compared to LA and LB, TN and HER2 patients had worse palliative outcomes; higher rates of incomplete courses at 18.8% and 18.3% versus 12.7%-14.4%; higher 30-day mortality post-radiotherapy at 21.5% and 16.0% versus 6.3%-7.9%, and higher median PRLSRT of 7.7% and 3.7% versus 2.2%-2.4% for LA and LB. On multivariate analysis, BCS was associated with overall survival with TN (HR 3.7), HER2 (HR 1.75), and LB (HR 1.28) fairing worse than LA (p < 0.001). Conclusions BCS correlated with survival and palliative outcome following radiation to osseous metastases. BCS should be considered by physicians when planning palliative RT to maximize quality-of-life, avoid unnecessary treatment, and ensure palliative benefits.Open access journalThis item from the UA Faculty Publications collection is made available by the University of Arizona with support from the University of Arizona Libraries. If you have questions, please contact us at [email protected]