Outpatient Pain Medication Use: An Electronic Daily Diary Study in Metastatic Breast Cancer

Uncovering the Daily Experiences of People Living With Advanced Cancer Using an Experience Sampling Method Questionnaire: Development, Content Validation, and Optimization Study

BACKGROUND

The experience sampling method (ESM), a self-report method that typically uses multiple assessments per day, can provide detailed knowledge of the daily experiences of people with cancer, potentially informing oncological care. The use of the ESM among people with advanced cancer is limited, and no validated ESM questionnaires have been developed specifically for oncology.

OBJECTIVE

This study aims to develop, content validate, and optimize the digital Experience Sampling Method for People Living With Advanced Cancer (ESM-AC) questionnaire, covering multidimensional domains and contextual factors.

METHODS

A 3-round mixed methods study was designed in accordance with the Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) and the European Organization for Research and Treatment of Cancer guidelines. The study included semistructured interviews with 43 people with stage IV breast cancer or stage III to IV lung cancer and 8 health care professionals. Round 1 assessed the appropriateness, relative importance, relevance, and comprehensiveness of an initial set of ESM items that were developed based on the existing questionnaires. Round 2 tested the comprehensibility of ESM items. Round 3 tested the usability of the digital ESM-AC questionnaire using the m-Path app. Analyses included descriptive statistics and qualitative content analysis.

RESULTS

Following the first round, we developed an initial core set of 68 items (to be used with all patients) and a supplementary set (optional; patients select items), both covering physical, psychological, social, spiritual-existential, and global well-being domains and concurrent contexts in which experiences occur. We categorized items to be assessed multiple times per day as momentary items (eg, "At this moment, I feel tired"), once a day in the morning as morning items (eg, "Last night, I slept well"), or once a day in the evening as evening items (eg, "Today, I felt hopeful"). We used participants' evaluations to optimize the questionnaire items, the digital app, and its onboarding manual. This resulted in the ESM-AC questionnaire, which comprised a digital core questionnaire containing 31 momentary items, 2 morning items, and 7 evening items and a supplementary set containing 39 items. Participants largely rated the digital questionnaire as "easy to use," with an average score of 4.5 (SD 0.5) on a scale from 1 ("completely disagree") to 5 ("completely agree").

CONCLUSIONS

We developed the ESM-AC questionnaire, a content-validated digital questionnaire for people with advanced breast or lung cancer. It showed good usability when administered on smartphone devices. Future research should evaluate the potential of this ESM tool to uncover daily experiences of people with advanced breast or lung cancer, explore its clinical utility, and extend its validation to other populations with advanced diseases.

Characterization of chronic pain, pain interference, and daily pain experiences in adult survivors of childhood cancer: a report from the Childhood Cancer Survivor Study

ABSTRACT

Although survivors of childhood cancer are at an increased risk, little is known about the prevalence of chronic pain, associated interference, and daily pain experiences. Survivors (N = 233; mean age = 40.8 years, range 22-64 years; mean time since diagnosis = 32.7 years) from the Childhood Cancer Survivor Study completed pain and psychosocial measures. Survivors with chronic pain completed 2-week, daily measures assessing pain and psychological symptoms using mHealth-based ecological momentary assessment. Multivariable-modified Poisson and linear regression models estimated prevalence ratio estimates (PR) and mean effects with 95% confidence intervals (CI) for associations of key risk factors with chronic pain and pain interference, respectively. Multilevel mixed models examined outcomes of daily pain and pain interference with prior day symptoms. Ninety-six survivors (41%) reported chronic pain, of whom 23 (24%) had severe interference. Chronic pain was associated with previous intravenous methotrexate treatment (PR = 1.6, 95% CI 1.1-2.3), respiratory (PR = 1.8, 95% CI 1.2-2.5), gastrointestinal (PR = 1.6, 95% CI 11.0-2.3), and neurological (PR = 1.5, 95% CI 1.0-2.1) chronic health conditions, unemployment (PR = 1.4, 95% CI 1.0-1.9) and clinically significant depression and anxiety (PR = 2.9, 95% CI 2.0-4.2), as well as a diagnosis of childhood Ewing sarcoma or osteosarcoma (PR = 1.9, 95% CI 1.0-3.5). Higher pain interference was associated with cardiovascular and neurological conditions, unemployment and clinical levels of depression and/or anxiety, and fear of cancer recurrence. For male, but not female survivors, low sleep quality, elevated anxiety, and elevated depression predicted high pain intensity and interference the next day. A substantial proportion of childhood cancer survivors experience chronic pain and significant associated interference. Chronic pain should be routinely evaluated, and interventions are needed.

Intensive Longitudinal Methods Among Adults With Breast or Lung Cancer: Scoping Review

BACKGROUND

Intensive longitudinal methods offer a powerful tool for capturing daily experiences of individuals. However, its feasibility, effectiveness, and optimal methodological approaches for studying or monitoring experiences of oncology patients remain uncertain.

OBJECTIVE

This scoping review aims to describe to what extent intensive longitudinal methods with daily electronic assessments have been used among patients with breast or lung cancer and with which methodologies, associated outcomes, and influencing factors.

METHODS

We searched the electronic databases (PubMed, Embase, and PsycINFO) up to January 2024 and included studies reporting on the use of these methods among adults with breast or lung cancer. Data were extracted on population characteristics, intensive monitoring methodologies used, study findings, and factors influencing the implementation of these methods in research and clinical practice.

RESULTS

We identified 1311 articles and included 52 articles reporting on 41 studies. Study aims and intensive monitoring methodologies varied widely, but most studies focused on measuring physical and psychological symptom constructs, such as pain, anxiety, or depression. Compliance and attrition rates seemed acceptable for most studies, although complete methodological reporting was often lacking. Few studies specifically examined these methods among patients with advanced cancer. Factors influencing implementation were linked to both patient (eg, confidence with intensive monitoring system) and methodology (eg, option to use personal devices).

CONCLUSIONS

Intensive longitudinal methods with daily electronic assessments hold promise to provide unique insights into the daily lives of patients with cancer. Intensive longitudinal methods may be feasible among people with breast or lung cancer. Our findings encourage further research to determine optimal conditions for intensive monitoring, specifically in more advanced disease stages.

Testing the feasibility of mobile ecological momentary assessment for symptom burden and management among metastatic cancer patients

Background

Individuals who have metastatic cancer experience substantial physical and psychological distress (e.g., pain, depression, anxiety) from their disease and its treatment compared to patients with less advanced disease. As the burden of symptoms varies over time, ecological momentary assessment (EMA) may be used to better understand patients' symptom trajectories, complimenting traditional longitudinal data collection methods. However, few have used EMA in patients with metastatic disease. The current study adds to the existing literature by exploring interrelated, common cancer-related symptoms of pain, anxiety, and depression and use of cannabis-based products, opioid medications, other (nonopioid) pain medications, and medications for anxiety or depression.

Methods

An eight-day prospective observational feasibility study was conducted among 50 patients with metastatic cancer recruited from seven solid cancer clinics at The Ohio State University Comprehensive Cancer Center. Participants completed a week of interval-contingent mobile EMA, administered daily at 9 a.m., 3 p.m., and 8 p.m., and a comprehensive interviewer-administered questionnaire on Day 8. Participants were queried on their symptom burden and management strategies (i.e., use of medications and cannabis). We considered EMA to be feasible if a priori retention (80%) and adherence goals (75%) were met.

Results

Seventy-nine percent of eligible patients contacted enrolled in the study (n = 50 of 63). Among those enrolled, 92% were retained through Day 8 and 80% completed >90% of EMAs, exceeding a priori objectives. Participants' average pain, anxiety, and depressive symptoms across the week of EMA ranged from 1.7 to 1.8 (1 to 5 scale). Symptoms varied little by day or time of administration. On Day 8, significant proportions of participants reported past-week use of medications and cannabis for symptom management.

Conclusions

Participants exceeded a priori adherence and retention objectives, indicating that mobile EMA is feasible among metastatic cancer patients, addressing a gap in the existing literature and informing future research. Restricting eligibility to participants with a minimum cutoff of symptom burden may be warranted to increase observations of symptom variability and provide opportunities for future health interventions. Future research is needed to test the acceptability and quality of data over a longer study period in this patient population.

Current Landscape of Ecological Momentary Assessment (Real-Time Data) Methodology in Cancer Research: A Systematic Review

OBJECTIVE

To critically synthesize and describe the use and methods of ecological momentary assessment (EMA) in cancer research.

DATA SOURCES

A systematic review was conducted and has been reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) Guideline. Electronic databases (APA PsycINFO, CINAHL, Cochrane Central Register of Controlled Trials, MEDLINE, Scopus, and Web of Science Core Collection) were searched using a variety of keywords and subject headings by an expert systematic review librarian. All publications were double screened by two reviewers using predetermined exclusion and inclusion criteria throughout the full review process. The review used Covidence Systematic Review Software. Methodological quality assessment and data extraction were performed. A narrative synthesis was conducted to examine the aim for EMA, the characteristics of the study samples, the EMA sampling procedures, EMA completion rates, outcome measures, and any implications of findings for survivorship care.

CONCLUSION

A total of 42 EMA studies in cancer were included. Most studies used an electronic mobile device to capture EMA data apart from several that used paper diaries. Existing studies were found to have significant heterogeneity in methods and widely varying approaches to design and self-report measurements. While EMA in cancer research holds significant promise to advance cancer care research into the future by increasing ecological validity and reducing retrospective bias and can capture the unique idiographic within-person change over time, in real-time, further research is needed to develop standardized EMA self-report questionnaires.

IMPLICATIONS FOR NURSING PRACTICE

This is the first comprehensive systematic review to describe the use and methods of EMA in cancer research. There is significant heterogeneity in methods and widely varying approaches to design and self-report measurements in EMA cancer research. People affected by cancer found taking part in EMA studies reported benefit from the experience. However, researchers must engage with cancer survivors in the development and co-design of future EMA questionnaires to ensure relevant and acceptability of EMA data collection protocols.

AYAs' online information and eHealth needs: A comparison with healthcare professionals' perceptions

BACKGROUND

Adolescents and young adults (AYAs) diagnosed with cancer fulfill their cancer-related information needs often via the Internet. Healthcare professionals (HCPs) have a crucial role in guiding patients in finding appropriate online information and eHealth sources, a role that is often overlooked. Misperceptions of AYAs' needs by HCPs may lead to suboptimal guidance. We aimed to examine the extent to which AYAs' online information and eHealth needs corresponded with HCPs' perceptions of these needs.

METHODS

Two cross-sectional online surveys (AYAs, n = 299; HCP, n = 80) on online information and eHealth needs were conducted. HCPs provided indications of their perceptions of AYA's needs.

RESULTS

AYAs reported significantly more online information needs compared with HCPs' perceptions regarding: survival rates (AYA = 69%, HCP = 35%, p < 0.001), treatment guidelines (AYA = 65%, HCP = 41%, p < 0.001), return of cancer (AYA = 76%, HCP = 59%, p = 0.004), "what can I do myself" (AYA = 68%, HCP = 54%, p = 0.029), and metastases (AYA = 64%, HCP = 50%, p = 0.040). Significantly more unmet eHealth needs were reported by AYAs compared with HCPs relating to access to own test results (AYA = 25, HCP = 0%, p < 0.001), request tests (AYA = 30%, HCP = 7%, p < 0.001), medical information (AYA = 22%, HCP = 0%, p = 0.001), e-consult with nurses (AYA = 30%, HCP = 10%, p < 0.001), e-consult with physicians (AYA = 38%, HCP = 13%, p = 0.001), and request prescriptions (AYA = 33%, HCP = 21%, p = 0.009).

CONCLUSION

AYAs' online information and eHealth needs are partially discrepant with the impression HCPs have, which could result in insufficient guidance related to AYAs' needs. AYAs and HCPs should get guidance regarding where to find optimal information in a language they understand. This may contribute to AYAs' access, understanding, and satisfaction regarding online information and eHealth.

Are Physical Activity and Sedentary Behavior Associated With Cancer-Related Symptoms in Real Time?: A Daily Diary Study

BACKGROUND

Few studies have examined the real-time and dynamic relationship between lifestyle behaviors and treatment-related symptoms.

OBJECTIVE

The aim of this study was to examine the associations of daily physical activity and sedentary behavior with symptom burden, pain interference, and fatigue among patients who were undergoing active cancer treatment.

METHODS

A total of 22 (mean age = 57 years; 73% women; 55% Black) cancer patients were recruited from a local hospital and reported a daily diary of physical activity, sedentary behavior, symptom burden, pain interference, and fatigue over 10 days. Adjusted mixed-effects models were used to examine all associations.

RESULTS

Body mass index moderated the relationship between physical activity and symptom burden (γ = 0.06, P < .01) and physical activity and fatigue (γ = 0.09, P < .05). On days where physical activity was higher than average, symptom burden and fatigue scores were lower among patients who had lower body mass index values. Also, age moderated the relationship between sedentary behavior and symptom burden (γ = -0.04, P < .05); on days where patients sat more, symptom burden was lower among patients who were younger than the average age.

CONCLUSIONS

Overall, these data indicate that treatment-related symptoms vary daily within cancer patients and that physical activity may alleviate treatment-related symptoms for leaner patients. Larger samples and objective assessments of physical activity and sedentary behavior are needed to validate our results.

IMPLICATIONS FOR PRACTICE

Oncology nurses may be in the best position to promote physical activity during treatment as a strategy to manage symptom burden.

Ecological momentary assessments among patients with cancer: A scoping review

INTRODUCTION

Ecological momentary assessment (EMA) is an emerging method to assess an individual's current thoughts, affect, behaviour, physical states and contextual factors as they occur in real-time and in their natural environment. Whereas EMA is frequently used in mental health, little is known about the added value of EMA in oncology research. This review aimed to synthesise methodological information and results of studies that applied EMA among patients with cancer to inform future researchers about the opportunities and challenges.

METHODS

We included full-text articles on studies that: (a) were conducted among adult cancer patients; and (b) examined cancer and treatment-related experiences by EMA. Information from selected studies was synthesised: study designs, EMA data collection methods, response-related results and main findings.

RESULTS

Twelve studies were included, which all applied an observational design. The EMA data collection methods varied considerably and the reporting of response-related results were poor. Nevertheless, EMA was found feasible as no systematic patterns of problems were reported and reported response-related results were acceptable. Furthermore, EMA was found useful as it facilitated examination of real-time experiences and behaviour.

CONCLUSION

Ecological momentary assessment is useful and feasible in oncology research. Future studies would benefit from guidelines for designing and reporting EMA studies.