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Dealing with Loss in Multiple Pregnancies

TO THE EDITOR: This letter was written in reaction to the "Diary from a Week in Practice" feature published in the May 1, 1998, issue of American Family Physician.¹ It was with a mixture of surprise, pleasure, anxiety and grief that I read the news that Dr. Frisbie is expecting twins. I have followed "Diary" closely since I learned in September 1996 that I was pregnant with twins. Although I felt overwhelmed by the news at the time, I took some comfort in knowing that Dr. Shupe had successfully completed a twin pregnancy and seemed to have achieved a healthy balance between her family responsibilities and an active, interesting practice. Her associates seem to be uncommonly supportive, and I'm fortunate to be affiliated with a similarly understanding group of family physicians. I'm sure Dr. Frisbie will enjoy the same support, professionally and personally, that Dr. Shupe was privileged to have.

My own story took a tragic turn with the intrauterine demise of my son Bryan. His death was discovered during a routine prenatal visit, and his surviving identical twin, Jared, was urgently delivered that day at 33 weeks' gestation. I am grateful that my now 15-month-old survivor is doing well. My sorrow for the brother he and I will never know leaves me with ambivalent feelings when I read about other multiple pregnancies, such as the well-publicized McCaughey septuplets.

I wish to remind my colleagues that multiple pregnancies carry a significantly higher risk of morbidity and mortality for both the mother and the infants, and that issues in grieving the loss of pregnancy in multiple gestations are misunderstood. With the rising number of twin pregnancies, as noted in "Diary," it is important that physicians not minimize the grief process that parents undergo when either a "selective reduction" procedure is undertaken or an accidental loss occurs early or late in a multiple pregnancy. In particular, attempts to reassure parents that they "at least" have one or more survivors from the pregnancy will damage the physician's relationship with them.

Properly grieving the loss of the equally desired child promotes healthy development of surviving children from the same pregnancy, in addition to children who were born previously or subsequently. Parents want and need to hear that their physician is concerned about their adjustment to such a loss. Simple gestures, such as asking how they're coping when they bring surviving children to the physician's office for well-child examinations or mentioning the deceased child by name at a well-woman examination after delivery or even a year or two later, will greatly enhance the quality of your professional relationship with these families.

Support networks are available for families facing these complex situations. Centers for Loss in Multiple Birth (CLIMB), Inc. (P.O. Box 1064, Palmer, AK 99645; telephone: 907-746-6123; e-mail: climb@pobox.alaska.net) has helpful materials for both parents and professionals dealing with the loss of one, more or all of the children in a multiple pregnancy, including prenatal loss, loss by selective reduction or loss later during childhood.

Second, an organization is available to help surviving twins whose loss occurred at any time from before birth through adulthood. This organization provides information and support for both the surviving twins and the people who are close to them: Twinless Twins (c/o Dr. Raymond Brandt, 11220 St. Joe Road, Fort Wayne, IN 46835; telephone: 219-627-5414; e-mail: brandt@fwi.com; Web site: http://www.twinlesstwins.org/). I have no connection with these organizations other than as a mother who has received valuable support from them.

I wish Dr. Frisbie the best of health during her pregnancy and a happy, successful delivery with minimal discomfort or disability preceding it. I'm sure Dr. Shupe will adequately prepare her for the inevitable questions from patients about whether twins run in her family or if she used fertility drugs. Part of the art of family practice is learning how to disclose an appropriate amount of personal information while keeping the encounter focused on the needs of the patient. I wish Dr. Frisbie good luck in her own journey through this territory. My patients were among my greatest supporters during my emotional recovery process, and by sharing my story, I've been able to empathetically assist other patients who have experienced their own unfortunate losses of pregnancy.

ELIZABETH A. PECTOR, M.D.
DuPage Family Medicine
636 Raymond Dr.
Suite 300
Naperville, IL 60563

REFERENCE

1. Larimore WL, Hartman JR, Shupe TB, Frisbie SE, Ries JS, Griffin CA. Diary from a week in practice. Am Fam Physician 1998;57:2116-20.

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Pseudoneurologic Symptoms in Post-traumatic Stress Disorder

TO THE EDITOR: The recent article by Drs. Shaibani and Sabbagh¹ focuses on "nonorganic" neurologic symptoms. The article describes individuals with symptoms such as paresthesias/hypesthesias, pseudoseizures, dizziness/ vertigo, weakness, tremors, ataxia, bowel/bladder dysfunction, cognitive dysfunction and chronic pain syndromes. On the basis of normal findings on neurologic examination, laboratory testing, imaging and other standard testing, the symptoms ultimately are seen as pseudoneurologic or psychogenic in etiology.

The implication is that neurophysiologic dysfunction is not present in these individuals--that is, the problem is in their minds. It is interesting to note that the authors did not mention post-traumatic stress disorder when they discussed mental health concerns or psychiatric diagnoses in the individuals described in the article. We believe that the literature on post-traumatic stress disorder offers some relevant and useful information when considering the possibility of "pseudoneurologic syndromes."

Post-traumatic stress disorder is a complex psychobiologic syndrome that results from profound psychoemotional trauma. Manifestations include disturbances in the psychologic, emotional, psychosocial and physiologic functioning of affected individuals.² Physical symptomatology, including neurologic symptoms, is frequently seen in individuals with post-traumatic stress disorder.³ Individuals with pseudoseizures have a prevalence of post-traumatic stress disorder of 49 percent,⁴ and 84 percent have a history of psychoemotional trauma.⁵

Associations have been noted between a history of sexual abuse and chronic pelvic pain, as well as between a history of physical abuse and headaches.⁶ Histories of trauma are so common among individuals with medically unexplained symptoms that a proposal has been made to consider such symptoms as diagnostic of "atypical post-traumatic stress disorder" (i.e., post-traumatic stress disorder manifested by physical symptoms only).⁷

In certain cases involving "pseudoneurologic" symptomatology, particularly in patients with a history of psychoemotional trauma, the discrimination between what is neurologic and what is "nonorganic" may be more complex than the article by Drs. Shaibani and Sabbagh implies. For the clinician, the distinction may be less significant and relevant than is our capacity to approach our patients in a circumspect and integrated fashion. Physicians are encouraged to appreciate the inextricably linked phenomena of behavior and physiology, environment and organism, mind and body.

STEPHEN C. HUNT, M.D.
RALPH D. RICHARDSON, PH.D.
Persian Gulf Veterans' Clinic
VA Puget Sound Health Care System
1660 S. Columbian Way
Seattle, WA 98108-1597

REFERENCES

1. Shaibani A, Sabbagh MN. Pseudoneurologic syndromes: recognition and diagnosis. Am Fam Physician 1998;57:2485-94.
2. Friedman MJ, Charney DS, Deutch AY. Neurobiological and clinical consequences of stress: from normal adaptation to post-traumatic stress disorder. Philadelphia: Lippincott-Raven, 1995.
3. McFarlane AC, Atchison M, Rafalowicz E, Papay P. Physical symptoms in post-traumatic stress disorder. J Psychosom Res 1994; 38:715-26.
4. Bowman ES, Markand ON. Psychodynamics and psychiatric diagnoses of pseudoseizure subjects. Am J Psychiatry 1996;153:57-63.
5. Harden CL. Pseudoseizures and dissociative disorders: a common mechanism involving traumatic experiences. Seizure 1997;6:151-5.
6. Walling MK, Reiter RC, O'Hara MW, Milburn AK, Lilly G, Vincent SD. Abuse history and chronic pain in women: I. Prevalences of sexual abuse and physical abuse. Obstet Gynecol 1994;84:193-9.
7. Schottenfeld RS, Cullen MR. Occupation-induced posttraumatic stress disorders. Am J Psychiatry 1985;142:198-202.

IN REPLY: I would like to thank Drs. Hunt and Richardson for their very interesting letter regarding the psychobiology and prevalence of post-traumatic stress disorder. They are correct that we did not mention post-traumatic stress disorder in our article, and this is regrettable. Unfortunately, we were constrained by space and editorial parameters established by American Family Physician. Therefore, much of the discussion regarding the psychologic issues in the somatoform disorders was beyond the scope of our review.

Our review focused on enlightening the primary care physician about the use of bedside techniques to differentiate between the structural/organic causes of disease and the nonstructural/psychologic causes of disease. It was, therefore, impossible to include a discussion about post-traumatic stress disorder.

MARWAN N. SABBAGH, M.D.
University of California, San Diego
Department of Neurology
Mail Code 9127
San Diego VA Medical Center
3350 La Jolla Village Dr.
San Diego, CA 92161

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Radical Prostatectomy in the Treatment of Prostate Cancer

TO THE EDITOR: I am writing to express my deep concern and disagreement in relation to the article on prostate cancer written by Dr. Naitoh and colleagues.¹ This article was obviously written with a strong urologist bias and does not accurately describe the diagnosis and treatment of prostate cancer from the aspects that should be delivered by a family physician practicing in the United States.

I feel that Dr. Naitoh's article is grossly biased toward radical prostatectomy. An article on the complications of external beam radiotherapy is cited in Table 5.² This article was published in 1994; since then, major advancements in brachytherapy have changed this management extensively. A highly respected meta-analysis by Coley and colleagues^3,4 points to the questionable outcomes of radical prostatectomy. The results of this analysis indicate that, as with using favorable assumptions, earlier studies show an increase in life expectancy of only two weeks after radical prostatectomy. This information is not brought out in Dr. Naitoh's article, and it is inappropriate for this article to be published today with what is known about the advancements in the management of prostate cancer.

The information that is cited in Tables 3 and 4 on complications after radical prostatectomy is also extremely misleading.¹ Table 3 states that rates of urinary incontinence are low with the procedure. Rates vary with the institution and the surgeon who performs the procedure. The most misleading part of the article is Table 4, which states that, after radical prostatectomy, patients 40 to 50 years of age have potency rates of 100 percent and patients 61 to 70 years of age have potency rates that are 43 percent higher than preoperative rates of sexual function. I think these rates vastly underestimate the actual occurrence of impotency as a complication of radical prostatectomy. I am disappointed that a more balanced discussion was not presented on this extremely important topic.

WILLIAM J. EPPERSON, M.D.
Inlet Medical Associates
912 Inlet Square Dr.
P.O. Box 545
Murrells Inlet, SC 29576

REFERENCES

1. Naitoh J, Zeiner RL, Dekernion JB. Diagnosis and treatment of prostate cancer. Am Fam Physician 1998;57:1531-9.
2. Shipley WU, Zietman AL, Hanks GE, Coen JJ, Caplan RJ, Won M, et al. Treatment related sequelae following external beam radiation for prostate cancer: a review with an update in patients with stages T1 and T2 tumor. J Urol 1994;152(5 Pt 2):1799-805.
3. Coley CM, Barry MJ, Fleming C, Mulley AG. Early detection of prostate cancer. Part I: Prior probability and effectiveness of tests. Ann Intern Med 1997;126:394-406.
4. Coley CM, Barry MJ, Fleming C, Fahs MC, Mulley AG. Early detection of prostate cancer. Part II: Estimating the risks, benefits, and costs. Ann Intern Med 1997;126:468-79.

IN REPLY: We appreciate Dr. Epperson's comments, and we want to make it clear that we did not intend to write a review article that was weighted toward radical prostatectomy. Recent evidence suggests that radical prostatectomy offers a slight long-term advantage over radiotherapy in terms of cancer control, although one must also remember that radical prostatectomy is associated with a higher complication rate.¹

While Dr. Epperson criticized our article because we referenced data on the complications of radiotherapy published in 1994, more recent studies have not reported complication rates that are markedly different.² Countless variations in the delivery of external beam radiotherapy (such as 2-D or 3-D conformal techniques, blocking, neoadjuvant prostate downsizing using antiandrogens, dose escalation and proton-based regimens) have made radiotherapy a "moving target." Because of this, the data on complications of radiotherapy are difficult to interpret and compare.³ Furthermore, since many of the complications related to radiation (impotence, radiation cystitis) can take a few years to become evident, and since validated survey instruments that measure complications and outcomes have rarely been used in the radiotherapy literature, the true impact of modern external beam radiotherapy on patient quality of life remains undefined.

While Dr. Epperson commented on our failure to discuss the "major advances in brachytherapy," we felt that more study was needed before we could recommend brachytherapy for the average patient who has a tumor confined to the prostate. While we agree that brachytherapy represents a potential advancement in the treatment of localized prostate cancer, we deliberately avoided discussion of this modality even though we perform this technique in our own practice.

We chose to avoid discussion of brachytherapy (as well as discussion of other novel techniques for the treatment of prostate cancer, which include cryosurgery, proton beam therapy and thermotherapy), because (1) the data on the recurrence of prostate-specific antigen are not mature enough to make any long-term conclusions about the ability of this modality to cure prostate cancer; (2) to date, the long-term complication rates (such as impotence) have not been adequately studied using validated survey instruments in a prospective manner; and (3) the quality of implant placement, the use of post-treatment dosimetry, the use of palladium versus the use of iodine seeds, the use of seeds in combination with androgen ablation or external beam radiotherapy and the role of high-dose-rate brachytherapy make the subject much more complex and controversial than what could be covered in the limited scope of our review article. We do, however, feel that brachytherapy should be explored as a treatment for low-stage, low-volume, low-grade prostate cancer.

Finally, Dr. Epperson criticized the complication rates that we reported, especially since rates reported in the literature vary widely. However, the existence of variation in reported complication rates should not be a reason to dismiss the value of a therapy; it is simply an indication that more studies are needed to determine why there is variation and how complication rates can be minimized. At this time, the reasons for variation of continence and potency rates among different institutions are unknown. While the variation could be attributed to differences in the "institution and surgeon," the other factors that must be considered include (1) the definitions of incontinence and impotence that were used, (2) the methods that were used to measure incontinence and impotence, and (3) the case-mix adjusters such as age, co-morbidity, baseline functioning and factors related to the tumors.

While studies are currently ongoing to determine which quality measures are important following the treatment of prostate cancer, it cannot be said with certainty that the skill of the surgeon alone determines the outcome, just as it cannot be said that variations in the delivery of radiotherapy alone result in the variation of the bladder irritation and impotence rates that have been reported in the radiotherapy literature.⁴

In summary, we believe that the following statements reflect state-of-the-art treatment of localized prostate cancer: (1) over the long term (more than 10 to 15 years), surgery provides a slight advantage over radiotherapy in terms of disease-free survival; (2) there is a low, but real, risk of severe incontinence following radical prostatectomy; (3) external beam radiotherapy does not cause incontinence; (4) both treatments may result in impotence; (5) brachytherapy appears to work well in the treatment of low-stage, low-grade tumors, although there is not enough long-term data to make any definitive statements regarding its efficacy or side effects; and (6) watchful waiting is best applied in older men who have low-grade cancers (Gleason <6), and who have a life expectancy of fewer than 10 years.

JOHN NAITOH, M.D.
Coast Urology Medical Group
9850 Genesee Ave. #440
La Jolla, CA 92037

REBECCA L. ZEINER, M.D.
Southern California Permanente Medical Group
San Diego, CA

JEAN B. DEKERNION, M.D.
UCLA School of Medicine
Los Angeles, CA

REFERENCES

1. Polascik TJ, Pound CR, DeWeese TL, Walsh PC. Comparison of radical prostatectomy and iodine 125 interstitial radiotherapy for the treatment of clinically localized prostate cancer: a 7-year biochemical (PSA) progression analysis. Urology 1998;51:884-9.
2. Beard CJ, Lamb C, Buswell L, Schneider L, Propert KJ, Gladstone D, et al. Radiation-associated morbidity in patients undergoing small-field external beam irradiation for prostate cancer. Int J Radiat Oncol Biol Phys 1998;41:257-62.
3. Nguyen LN, Pollack A, Zagars GK. Late effects after radiotherapy for prostate cancer in a randomized dose-response study: results of a self-assessment questionnaire. Urology 1998;51:991-7.
4. Talcott JA, Rieker P, Clark JA, Propert KJ, Weeks JC, Beard CJ, et al. Patient-reported symptoms after primary therapy for early prostate cancer: results of a prospective cohort study. J Clin Oncol 1998; 16:275-83.

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Send letters to Jay Siwek, M.D., Editor, American Family Physician, 8880 Ward Pkwy., Kansas City, MO 64114; fax: 816-333-0303; e-mail: afplet@aafp.org. Please include your complete address, telephone number and fax number. Letters should be double-spaced, fewer than 500 words and limited to one table or figure and six references. Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter constitutes transfer of copyright to the American Academy of Family Physicians. The editors may edit letters to meet style and space requirements.

Copyright © 1998 by the American Academy of Family Physicians.
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