Clinical Decision Support for Symptom Management in Lung Cancer Patients: A Group RCT

CONTEXT

Clinical guidelines are available to enhance symptom management during cancer treatment but often are not used in the practice setting. Clinical decision support can facilitate the implementation and adherence to clinical guidelines. and improve the quality of cancer care.

OBJECTIVES

Clinical decision support offers an innovative approach to integrate guideline-based symptom management into oncology care. This study evaluated the effect of clinical decision support-based recommendations on clinical management of symptoms and health-related quality of life (HR-QOL) among outpatients with lung cancer.

METHODS

Twenty providers and 179 patients were allotted in group randomization to attention control (AC) or Symptom Assessment and Management Intervention (SAMI) arms. SAMI entailed patient-report of symptoms and delivery of recommendations to manage pain, fatigue, dyspnea, depression, and anxiety; AC entailed symptom reporting prior to the visit. Outcomes were collected at baseline, two, four and six-months. Adherence to recommendations was assessed through masked chart review. HR-QOL was measured by the Functional Assessment of Cancer Therapy-Lung questionnaire. Descriptive statistics with linear and logistic regression accounting for the clustering structure of the design and a modified chi-square test were used for analyses.

RESULTS

Median age of patients was 63 years, 58% female, 88% white, and 32% ≤high school education. Significant differences in clinical management were evident in SAMI vs. AC for all target symptoms that passed threshold. Patients in SAMI were more likely to receive sustained-release opioids for constant pain, adjuvant medications for neuropathic pain, opioids for dyspnea, stimulants for fatigue and mental health referrals for anxiety. However, there were no statistically significant differences in HR-QOL at any time point.

CONCLUSION

SAMI improved clinical management for all target symptoms but did not improve patient outcomes. A larger study is warranted to evaluate effectiveness.

Cost-effectiveness analysis of home-based rehabilitation compared to usual care for people with inoperable lung cancer

OBJECTIVE

Few economic evaluations of lung cancer rehabilitation exist. The aim of this study was to assess the cost-effectiveness of providing home-based rehabilitation for inoperable lung cancer.

METHODS

A cost-utility analysis alongside a randomised controlled trial (RCT) of rehabilitation compared with usual care. The primary outcome was quality-adjusted life years (QALYs) gained. The incremental cost-effectiveness ratio [ICER (95% CI)] and the net monetary benefit are reported. Value of information (VOI) analysis assessed the need/value of more research.

RESULTS

Seventy participants (34 intervention and 36 usual care), average (SD) age 63.0 (12.0) years, 32 (45.7%) stage IV. The average intervention cost was AU$3421 (AU$5352 usual care), and effect (QALY) was 0.30 (0.31 usual care). The ICER was AU$228,197 (-1,173,194 to 1,101,450) per QALY gained. The net monetary benefit was AU$1508, favouring the intervention. The probability that the intervention was more cost-effective than usual care, at a willingness to pay threshold of AU$50,000, was 75%. VOI analysis showed that additional research to resolve decision uncertainty is potentially worthwhile.

CONCLUSION

A high degree of uncertainty exists regarding the cost-effectiveness of lung cancer rehabilitation. Further RCTs, powered for economic evaluations and utilising rehabilitation sensitive outcomes, are required to support translation of evidence into clinical practice.

Dimensions of Distress in Lung Cancer

OBJECTIVES

To (a) compare the domains of distress between patients who were distressed and patients who were not distressed and (b) examine the relationship between the National Comprehensive Cancer Network Distress Thermometer and Problem List for Patients (DT-PL) and the Hospital Anxiety and Depression Scale (HADS) in individuals with advanced lung cancer.

SAMPLE & SETTING

Individuals with advanced lung cancer receiving chemotherapy were recruited from a comprehensive cancer center in the southeastern United States.

METHODS & VARIABLES

A cross-sectional, descriptive, exploratory design was used. Individuals with lung cancer completed the DT-PL and the HADS. Data were analyzed using descriptive statistics, t tests, and chi-square analysis.

RESULTS

Significant differences were found between the nondistressed group and the clinically distressed group in three domains of distress.

IMPLICATIONS FOR NURSING

Distress in individuals with advanced lung cancer goes beyond psychological stressors and includes family problems and physical problems.

Maximizing quality of life remains an ultimate goal in the era of precision medicine: exemplified by lung cancer

An ultimate goal of precision medicine in lung cancer treatment is to restore patient health with maximized quality of life (QOL). Results from Mayo Clinic studies show that a significant improvement in fatigue, dyspnea, and pain scales could lead to better overall QOL. Although treatments and guidelines for clinical implementation to alleviate these key symptoms are available, few cancer patients receive adequate therapy, mostly because of limitations in current care delivery systems and unclear clinicians’ roles. For optimal care of lung cancer survivors in different subpopulations, three barriers must be overcome: physicians’ lack of knowledge, unwarranted practice variation, and uncertainty regarding care provider roles. Appropriate culturally adapted, tested and validated tools for QOL measures must be developed, rather than directly translating existing tools between different languages and across cultures or diverse subpopulations. Finally, lack of sensitive, adequate, and relevant tools in measuring health-related QOL (HRQOL) has long been an issue for effective data collection, demanding a global consensus on a set of core components that reflect the needs of all critical parties for the best cure and care, supporting patients to achieve optimal HRQOL.

Assessment and Management of Symptoms for Outpatients Newly Diagnosed With Lung Cancer

RATIONALE

Little is known about symptom assessment around the time of lung cancer diagnosis. The purpose of this pilot study was to assess symptoms within 2 months of diagnosis and the frequency with which clinicians addressed symptoms among a cohort of veterans (n = 20) newly diagnosed with lung cancer. We administered questionnaires and then reviewed medical records to identify symptom assessment and management provided by subspecialty clinics for 6 months following diagnosis.

RESULTS

Half (50%) of the patients were diagnosed with early-stage non-small-cell lung cancer (NSCLC), stage I or II. At baseline, 45% patients rated their overall symptoms as severe. There were no significant differences in symptoms among patients with early- or late-stage NSCLC or small-cell lung cancer. Of the 212 clinic visits over 6 months, 70.2% occurred in oncology. Clinicians most frequently addressed pain although assessment differed by clinic.

CONCLUSIONS

Veterans with newly diagnosed lung cancer report significant symptom burden. Despite ample opportunities to address patients' symptoms, variations in assessment exist among subspecialty services. Coordinated approaches to symptom assessment are likely needed among patients newly diagnosed with lung cancer.

Symptom distress in older adults following cancer surgery

BACKGROUND

Symptom distress remains a significant health problem among older adults with cancer following surgery. Understanding factors influencing older adults' symptom distress may lead to early identification and interventions, decreasing morbidity and improving outcomes.

OBJECTIVE

We conducted this study to identify factors associated with symptom distress following surgery among 326 community-residing patients 65 years or older with a diagnosis of thoracic, digestive, gynecologic, and genitourinary cancers.

METHODS

This secondary analysis used combined subsets of data from 5 nurse-directed intervention clinical trials targeting patients after surgery at academic cancer centers in northwest and northeastern United States. Symptom distress was assessed by the Symptom Distress Scale at baseline and at 3 and 6 months.

RESULTS

A multivariable analysis, using generalized estimating equations, showed that symptom distress was significantly less at 3 and 6 months (3 months: P < .001, 6 months: P = .002) than at baseline while controlling for demographic, biologic, psychological, treatment, and function covariates. Thoracic cancer, comorbidities, worse mental health, and decreased function were, on average, associated with increased symptom distress (all P < .05). Participants 75 years or older reported increased symptom distress over time compared with those aged 65 to 69 years (P < .05).

CONCLUSIONS

Age, type of cancer, comorbidities, mental health, and function may influence older adults' symptom distress following cancer surgery.

IMPLICATIONS FOR PRACTICE

Older adults generally experience decreasing symptom distress after thoracic, abdominal, or pelvic cancer surgery. Symptom management over time for those with thoracic cancer, comorbidities, those with worse mental health, those with decreased function, and those 75 years or older may prevent morbidity and improve outcomes of older adults following surgery.

Too sick not to exercise: using a 6-week, home-based exercise intervention for cancer-related fatigue self-management for postsurgical non-small cell lung cancer patients

BACKGROUND

Two prevalent unmet supportive care needs reported by the non-small cell lung cancer (NSCLC) population include the need to manage fatigue and attain adequate exercise to meet the physical demands of daily living. Yet, there are no guidelines for routine rehabilitative support to address fatigue and exercise for persons with NSCLC during the critical transition from hospital to home after thoracotomy.

OBJECTIVE

The objective of this study was to evaluate the feasibility, acceptability, safety, and changes in study end points of a home-based exercise intervention to enhance perceived self-efficacy for cancer-related fatigue (CRF) self-management for persons after thoracotomy for NSCLC transitioning from hospital to home.

INTERVENTIONS/METHODS

Guided by the principles of the Transitional Care Model and the Theory of Symptom Self-management, a single-arm design composed of 7 participants with early-stage NSCLC performed light-intensity walking and balance exercises in a virtual reality environment with the Nintendo Wii Fit Plus. Exercise started the first week after hospitalization for thoracotomy and continued for 6 weeks.

RESULTS

The intervention positively impacted end points such as CRF severity; perceived self-efficacy for fatigue self-management, walking, and balance; CRF self-management behaviors (walking and balance exercises); and functional performance (number of steps taken per day).

CONCLUSIONS

A home-based, light-intensity exercise intervention for patients after thoracotomy for NSCLC is feasible, safe, well tolerated, and highly acceptable showing positive changes in CRF self-management.

IMPLICATIONS FOR PRACTICE

Beginning evidence suggests that a light-intensity in-home walking and balance intervention after hospitalization for thoracotomy for NSCLC is a potentially effective rehabilitative CRF self-management intervention. Next steps include testing of this health-promoting self-management intervention in a larger-scale randomized controlled trial.

An Interpretative Phenomenological Analysis of the lived experience of multiple concurrent symptoms in patients with lung cancer: a contribution to the study of symptom clusters

PURPOSE OF THE RESEARCH

To explore the lived experience of multiple concurrent symptoms in people with advanced lung cancer to contribute to the understanding of the experience of symptom clusters.

METHODS AND SAMPLE

Purposive sampling recruited ten people with advanced lung cancer who were experiencing three or more concurrent symptoms, were at least 18 years of age and were able to provide written informed consent. The participants took part in two consecutive, in-depth interviews, 3-5 weeks apart. Interpretative Phenomenological Analysis was used to analyse the data.

FINDINGS

Participants experienced 4-11 concurrent symptoms with fatigue, cough, pain and breathlessness featuring prominently in their interviews. The participants commonly identified associations between the symptoms that they experienced, with the occurrence of one symptom often used to explain the occurrence of another. Reductions in physical and social functioning were often associated with the experience of multiple concurrent symptoms, particularly at times of high symptom severity. The participants' highlighted breathlessness and cough as being of particular salience, due to the association of these symptoms with fear of death and visibility and embarrassment in public.

CONCLUSIONS

People with lung cancer experience multiple concurrent symptoms and perceive relationships between the symptoms experienced. Within the experience of multiple symptoms, people with lung cancer highlight individual symptoms that are of particular importance, based on their concomitant meanings. Such findings provide vital information for the future development of meaning-based symptom cluster interventions.

Creating computable algorithms for symptom management in an outpatient thoracic oncology setting

CONTEXT

Adequate symptom management is essential to ensure quality cancer care, but symptom management is not always evidence based. Adapting and automating national guidelines for use at the point of care may enhance use by clinicians.

OBJECTIVES

This article reports on a process of adapting research evidence for use in a clinical decision support system that provided individualized symptom management recommendations to clinicians at the point of care.

METHODS

Using a modified ADAPTE process, panels of local experts adapted national guidelines and integrated research evidence to create computable algorithms with explicit recommendations for management of the most common symptoms (pain, fatigue, dyspnea, depression, and anxiety) associated with lung cancer.

RESULTS

Small multidisciplinary groups and a consensus panel, using a nominal group technique, modified and subsequently approved computable algorithms for fatigue, dyspnea, moderate pain, severe pain, depression, and anxiety. The approved algorithms represented the consensus of multidisciplinary clinicians on pharmacological and behavioral interventions tailored to the patient's age, comorbidities, laboratory values, current medications, and patient-reported symptom severity. Algorithms also were reconciled with one another to enable simultaneous management of several symptoms.

CONCLUSION

A modified ADAPTE process and nominal group technique enabled the development and approval of locally adapted computable algorithms for individualized symptom management in patients with lung cancer. The process was more complex and required more time and resources than initially anticipated, but it resulted in computable algorithms that represented the consensus of many experts.

Impact of symptom burden in post-surgical non-small cell lung cancer survivors

PURPOSE

Pain, fatigue, dyspnea, and distress are commonly reported cancer-related symptoms, but few studies have examined the effects of multiple concurrent symptoms in longer-term cancer survivors. We examined the impact of varying degrees of symptom burden on health-related quality of life (HRQOL) and performance status in surgically treated non-small cell lung cancer (NSCLC) survivors.

METHODS

A sample of 183 NSCLC survivors 1-6 years post-surgical treatment completed questionnaires assessing five specific symptoms (pain, fatigue, dyspnea, depression, and anxiety), HRQOL, and performance status. The number of concurrent clinically significant symptoms was calculated as an indicator of symptom burden.

RESULTS

Most survivors (79.8 %) had some degree of symptom burden, with 30.6 % reporting one clinically significant symptom, 27.9 % reporting two symptoms, and 21.3 % reporting three or more symptoms. Physical HRQOL significantly decreased as the degree of symptom burden increased, but mental HRQOL was only significantly decreased in those with three or more symptoms. Receiver-operating characteristic (ROC) curves showed that having multiple concurrent symptoms (two or more) was most likely associated with limitations in functioning (area under a ROC curve = 0.75, sensitivity = 0.81, specificity = 0.54).

CONCLUSIONS

Two or more clinically significant symptoms are identified as the "tipping point" for showing adverse effects on HRQOL and functioning. This highlights the need for incorporating multiple-symptom assessment into routine clinical practice. Comprehensive symptom management remains an important target of intervention for improved post-treatment HRQOL and functioning among lung cancer survivors.

Differences in symptom clusters identified using occurrence rates versus symptom severity ratings in patients at the end of radiation therapy

The purposes of this study were to identify the number and types of symptom clusters using yes/no responses from the Memorial Symptom Assessment Scale, identify the number and types of symptom clusters using severity scores from the Memorial Symptom Assessment Scale, compare the identified symptom clusters derived using severity scores to those derived using occurrence ratings, and evaluate for differences in symptom cluster severity scores between patients with breast and prostate cancer at the end of radiation therapy. Separate exploratory factor analyses were performed to determine the number of symptom clusters based on symptom occurrence rates and symptom severity ratings. Although specific symptoms within each symptom cluster were not identical, 3 very similar symptom clusters (ie, "mood-cognitive" symptom cluster, "sickness-behavior" symptom cluster, "treatment-related" symptom cluster) were identified regardless of whether occurrence rates or severity ratings were used to create the symptom clusters at the end of radiation therapy. However, the factor solution derived using the severity ratings fit the data better. Significant differences in severity scores for all 3 symptom clusters were found between patients with breast and prostate cancer. For all 3 symptom clusters, the patients with breast cancer had higher symptom cluster severity scores than the patients with prostate cancer.

The utility of screening in the design of trials for symptom management in cancer

Clinical trials that test interventions for symptom management must target patients whose symptoms are severe and can benefit from participation. Screening symptoms for their severity prior to trial entry may be an important element of trial design. This research describes the utility of screening for severity of symptoms prior to entry into clinical trials for symptom management in cancer. To accomplish this, 601 cancer patients undergoing chemotherapy were assessed at screening and at the initial intervention contact, using the 0-10 rating scale for severity of nine symptoms. Post-test probabilities and likelihood ratios (LRs) were estimated across cut-offs in screening severity scores. Areas under receiver operating characteristic curves for reaching threshold of four at the initial intervention contact were estimated by a nonparametric method. It was found that screening severity scores were good predictors for identifying patients who would not reach threshold but did not always accurately predict patients who would. The cut-offs between 2 and 4 on a 0-10 scale could be used to identify patients that might benefit from receipt of interventions. For all symptoms, the LRs were greater than one across possible screening cut-offs. The findings indicate that decision rules based on screening prior to entry into cancer symptom management trials can provide reasonable discriminative accuracy by differentiating among patients who are likely to reach higher levels of severity later in the trial from those who are not. Optimal severity cut-offs can be established based on LRs and desired sensitivity and specificity.

Symptoms and symptom distress in localized prostate cancer

For over a decade, symptom distress has been a key concept in several studies of cancer. However, the definition of symptom distress is still unclear, and there are few measures targeting symptom distress, in general, and specific cancers, in particular. Prostate cancer is the sixth most common cancer worldwide and the second leading cause of death in American men. Many men with clinically localized prostate cancer may experience unique and multidimensional symptoms that occur from diagnosis through treatment, and thereafter. These symptoms associated with the disease and its treatments are in the form of physical and psychological sequelae such as urinary and bowel problems and sexual dysfunction. The purposes of this article are to (1) systematically review literature on symptoms and symptom distress in localized prostate cancer and (2) synthesize evidence of symptom distress applications and measurement in this group. A comprehensive, systematic review was conducted to identify original, data-based studies of symptoms and symptom distress in localized prostate cancer. Clarification of symptom distress and more comprehensive information about symptoms and symptom distress will provide nurses with a better foundation for developing self-management interventions aimed at ameliorating symptom distress and, ultimately, enhancing the quality of life of patients with localized prostate cancer.

Symptom prevalence, intensity, and distress in patients with inoperable lung cancer in relation to time of death

PURPOSE

To examine symptom prevalence, intensity, and association with distress in patients with inoperable lung cancer (LC), using time to death as point of reference.

PATIENTS AND METHODS

A consecutive sample of 400 patients completed the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire C30 plus a 13-item LC-specific scale and the Thurstone Scale of Symptom Distress-Lung Cancer at six time points during the first year after diagnosis. Patients were divided into subgroups, using data from the time point closest to death (< 1; 1 to 2; > 2 to 3; > 3 to 6; > 6 to 12; and > 12 months before death) for analysis.

RESULTS

More than 50% of patients in all subgroups reported problems related to physical, role, and emotional functioning; fatigue; dyspnea; and cough. In general, functional levels were lower and symptoms higher in subgroups closer to death. Notably, clinically relevant differences were also found in role and social functioning and appetite loss between the two groups furthest from death. A consistent pattern was found among the six subgroups, with breathing, pain, and fatigue rated as the symptoms most associated with distress.

CONCLUSION

High prevalence of symptoms was found in all subgroups, with higher intensity in subgroups closer to death, indicating a need for prophylactic and proactive symptom management. Less concordance was found among symptom prevalence, intensity, and association with distress in subgroups further from death. Future studies should investigate longitudinal associations between symptoms with low intensity and high distress, and examine their clinical implications.

Relationships among pain, fatigue, insomnia, and gender in persons with lung cancer

PURPOSE/OBJECTIVES

To examine the relationships among pain, fatigue, insomnia, and gender while controlling for age, comorbidities, and stage of cancer in patients newly diagnosed with lung cancer within 56 days of receiving chemotherapy.

DESIGN

Secondary data analysis.

SETTING

Accrual from four sites: two clinical community oncology programs and two comprehensive cancer centers.

SAMPLE

80 patients newly diagnosed with lung cancer.

METHODS

Analysis from baseline observation of a randomized clinical intervention trial. Multinomial log-linear modeling was performed to explain the relationships among pain, fatigue, insomnia, and gender.

MAIN RESEARCH VARIABLES

Pain, fatigue, insomnia, and gender.

FINDINGS

For all people with lung cancer, fatigue (97%) and pain (69%) were the most frequently occurring symptoms; insomnia occurred 51% of the time. A model containing all main effects (two-way interactions of pain and fatigue, pain and insomnia, and insomnia and gender; and the three-way interaction of pain, fatigue, and insomnia, along with three covariates [age, comorbidities, and stage of cancer]) was a good fit to the data. Parameter estimates indicated that a statistically significant effect from the model was the three-way interaction of pain, fatigue, and insomnia. Gender did not make a difference. Age, comorbidities, and stage of cancer were not significant covariates.

CONCLUSIONS

For people newly diagnosed with lung cancer undergoing chemotherapy, multiple symptoms occur simultaneously rather than in isolation; a symptom cluster exists, consisting of pain, fatigue, and insomnia; and no relationship was found among gender, pain, fatigue, and insomnia.

IMPLICATIONS FOR NURSING

By understanding this symptom cluster, healthcare providers can target specific troublesome symptoms to optimize symptom management and achieve the delivery of high-quality cancer care.

Palliative Care Consultation, Quality-of-Life Measurements, and Bereavement for End-of-Life Care in Patients With Lung Cancer

OBJECTIVE

To develop clinical practice guidelines for application of palliative care consultation, quality-of-life measurements, and appropriate bereavement activities for patients with lung cancer.

METHODS

To review the pertinent medical literature on palliative care consultation, quality-of-life measurements, and bereavement for patients with lung cancer, developing multidisciplinary discussions with authorities in these areas, and evolving written guidelines for end-of-life care of these patients.

RESULTS

Palliative care consultation has developed into a new specialty with credentialing of experts in this field based on extensive experience with patients in end-of-life circumstances including those with lung cancer. Bereavement studies of the physical and emotional morbidity of family members and caregivers before, during, and after the death of a cancer patient have supported truthful communication, consideration of psychological problems, effective palliative care, understanding of the patient's spiritual and cultural background, and sufficient forewarning of impending death.

CONCLUSION

Multidisciplinary investigations and experiences, with emphasis on consultation and delivery of palliative care, timely use of quality-of-life measurements for morbidities of treatment modalities and prognosis, and an understanding of the multifaceted complexities of the bereavement process, have clarified additional responsibilities of the attending physician.

Symptom Clusters and Physical Function for Patients Receiving Chemotherapy

OBJECTIVES

To examine the literature on symptom clusters and the impact of co-occurring symptoms on the physical function of patients with cancer during treatment.

DATA SOURCES

Research and review articles.

CONCLUSION

Unmanaged symptoms occur in what are often called symptom clusters. A focus on known and frequently present co-occurring symptoms, such as pain, fatigue, and sleep disturbance, might be the most efficient and effective way to manage specific symptoms and improve patient functioning.

IMPLICATIONS FOR NURSING PRACTICE

Nurses should select assessments that identify multiple symptoms and define their co-occurrence.

Symptom Clusters Related to Specific Cancers

OBJECTIVES

To examine the current research related to symptom clusters in specific cancer diagnoses.

DATA SOURCES

Research studies, review articles.

CONCLUSION

Factors that can impact symptoms and their relationship include the stage of disease, treatment used, modification of treatment for the individual patient, patient co-morbidities as well as psychological, sociological, and cultural factors. Understanding is needed regarding which of these factors individually or in combination contribute to symptoms clustering together. The mechanism underlying symptom perception and interpretation need further exploration. Research focus should be on one type of cancer.

IMPLICATIONS FOR NURSING PRACTICE

Symptom cluster research offers little at this point to be helpful in patient diagnosis, assessment, monitoring, or management of disease.

Quality of Life and Meaning of Illness of Women With Lung Cancer

PURPOSE/OBJECTIVES

To describe the quality of life (QOL) of women with non-small cell lung cancer (NSCLC) and examine relationships of demographic, clinical, health status, and meaning of illness (MOI) characteristics to QOL.

DESIGN

Descriptive, cross-sectional survey.

SETTING

In-person interviews in homes or research offices.

SAMPLE

217 women with NSCLC (greater than 6 months and less than 5 years since diagnosis, mean = 2 years); 19% of the women had advanced disease. The mean age was 65 years.

METHODS

Assessments of QOL with cancer-specific (QOL Scale-Patient Version) and generic (Short Form-36) self-reports, health status (i.e., number and type of comorbid conditions, presence of depressed mood using the Center for Epidemiologic Studies Depression Scale, smoking status), and MOI (positive and negative perceptions).

MAIN RESEARCH VARIABLES

QOL, health status, MOI, and demographic and clinical characteristics.

FINDINGS

Serious disruptions in psychological and social aspects of QOL were common. Depressed mood, negative conceptualizations of MOI, and younger age explained 37% of the variance of global QOL and were correlated with poorer physical, psychological, and social dimensions of QOL. Thirty-six percent reported negative ascriptions of MOI; 35% experienced depressed mood; more than 75% reported distress with their diagnosis, family distress, and impact of sexual function as lowering their QOL; and 67% reported comorbid conditions, the most common being chronic obstructive pulmonary disease (31%).

CONCLUSIONS

Women with lung cancer experience a range of disruptions in QOL, and more than a third associate lung cancer with negative meaning. Younger age, depressed mood, and number of comorbid diseases are risk factors for negative QOL.

IMPLICATIONS FOR NURSING

These findings support the importance of assessing the QOL, MOI, and health status of women with lung cancer even after treatment is completed. Younger women may be at higher risk for disruptions.

The Effects of Spirituality on Well-Being of People With Lung Cancer

PURPOSE/OBJECTIVES

To examine the effects of spirituality on the sense of well-being of people with lung cancer.

DESIGN

Descriptive, correlational study.

SETTING

Urban and rural oncology and radiation centers.

SAMPLE

60 adults ranging from 33-83 years of age. Most participants had non-small cell lung cancer and were female, Caucasian, and older than 50.

METHODS

Participants completed a questionnaire composed of six survey instruments: Life Attitude Profile-Revised, Adapted Prayer Scale, Index of Well-Being, Symptom Distress Scale, a background information sheet, and a cancer characteristics questionnaire. Correlations among study concepts were examined, and multiple regression analysis was used to determine the effects of spirituality.

MAIN RESEARCH VARIABLES

Meaning in life, prayer activities and experiences, symptom distress, and psychological well-being.

FINDINGS

Higher meaning in life scores were associated with higher psychological well-being and lower symptom distress scores. Higher prayer scores were associated with higher psychological well-being scores. Regression analysis indicated that meaning in life mediated the relationship between functional status and physical responses to lung cancer and explained 9% of the variance in symptom distress. Prayer mediated the relationship between current physical health and psychological responses and explained 10% of the variance in psychological well-being.

CONCLUSIONS

Aspects of spirituality, meaning in life, and prayer have positive effects on psychological and physical responses in this group of people with lung cancer.

IMPLICATIONS FOR NURSING

This research provides knowledge about spirituality and sense of well-being to guide the care of people with lung cancer.

Promoting Enhanced Patient and Family Caregiver Congruence on Lung Cancer Symptom Experiences

PURPOSE/OBJECTIVES

To test the effects of different perspective-taking instructional sets, gender, caregivers' personal histories with cancer, and caregiving relationship factors on family caregiver and patient perceptual agreement of symptom experiences of patients with lung cancer.

DESIGN

Counterbalanced.

SETTING

Thoracic oncology outpatient clinical setting in Canada.

SAMPLE

98 dyads consisting of patients with lung cancer and their family caregivers.

METHODS

Data were collected on a one-time basis by employing an abbreviated version of the Memorial Symptom Assessment Scale targeting lack of energy and worrying. Caregivers were randomized to one of six counterbalanced conditions of perspective-taking instructions.

MAIN RESEARCH VARIABLES

Caregiver discrepancy scores, instructional sets (i.e., neutral, self-report, and imagine-self and imagine-patient perspective-taking), order effects, gender, caregivers' personal history with cancer, and caregiving relationship factors.

FINDINGS

No order effects were found for the instructional sets. Instructions to imagine the patient's perspective over imagining how the caregiver would feel if he or she had cancer were most effective in enhancing the caregiver's ability to estimate the patient's lack of energy and worrying. Gender had no significant effects. The amount of patient-caregiver communication had a positive impact on the accuracy of caregivers' perspectives.

CONCLUSIONS

The patient-oriented instructions had a limited impact on enhancing patient-caregiver congruence on patient symptoms. This likely is related to the study's convenience sample of caregivers who appear to naturally engage in empathic processes of patient-oriented perspective-taking when they assessed and reported on patient symptom conditions.

IMPLICATIONS FOR NURSING

Further exploratory work should identify interpersonal conditions that negatively hamper the effects of caregiver perspective-taking on their reasonable understanding of patient symptoms.

Distress screening in a multidisciplinary lung cancer clinic: prevalence and predictors of clinically significant distress

Screening for distress in cancer patients is recommended by the National Comprehensive Cancer Network, and a Distress Thermometer has previously been developed and empirically validated for this purpose. The present study sought to determine the rates and predictors of distress in a sample of patients being seen in a multidisciplinary lung cancer clinic. Consecutive patients (N=333) were recruited from an outpatient multidisciplinary lung cancer clinic to complete the Distress Thermometer, an associated Problem Symptom List, and two questions about interest in receiving help for symptoms. Over half (61.6%) of patients reported distress at a clinically significant level, and 22.5% of patients indicated interest in receiving help with their distress and/or symptoms. Problems in the areas of family relationships, emotional functioning, lack of information about diagnosis/treatment, physical functioning, and cognitive functioning were associated with higher reports of distress. Specific symptoms of depression, anxiety, pain and fatigue were most predictive of distress. Younger age was also associated with higher levels of distress. Distress was not associated with other clinical variables, including stage of illness or medical treatment approach. Similar results were obtained when individuals who had not yet received a definitive diagnosis of lung cancer (n=134) were excluded from analyses; however, family problems and anxiety were no longer predictive of distress. Screening for distress in a multidisciplinary lung cancer clinic is feasible and a significant number of patients can be expected to meet clinical criteria for distress. Results also highlight younger age and specific physical and psychosocial symptoms as predictive of clinically significant distress. Identification of the presence and predictors of distress are the first steps toward appropriate referral and treatment of symptoms and problems that contribute to cancer patients' distress.

Quality of life in newly diagnosed patients with lung cancer in a developing country: is it important?

There are no data regarding quality of life (QoL) assessments in lung cancer in developing countries like India. Quality of life was evaluated in 76 newly diagnosed lung cancer patients by using the World Health Organization Quality of Life questionnaire in Hindi (WHOQoL-Bref) (men 87%). The mean age was 55 years (SD = 10). Cough, dyspnoea, chest pain and haemoptysis were present in 83%, 72%, 66% and 43% of patients respectively. The median duration of symptoms was 5.9 months (range 1-13). Eighty-nine per cent had non-small cell lung cancer. The median pack-years smoked was 23 (range 0.5-88). Most patients (53%) had a Karnofsky's Performance Status (KPS) of 70 and 83% had stage III or IV disease. Quality of life did not correlate with age, gender, presence or duration of symptoms, histological type, stage of disease or degree of smoking. The physical and psychological domains of QoL correlated significantly with the KPS (P = 0.001 and P = 0.01 respectively). Patients with a KPS of 80 had better physical (P < 0.001), psychological (P < 0.01) and social (P < 0.05) QoL than those with a KPS of 70. In conclusion, patients with lung cancer in a developing country like India have an unsatisfactory QoL. The Karnofsky's Performance Scale is a simple and reliable surrogate marker for assessing QoL in these patients. Larger multi-centric studies may help in providing a more comprehensive evaluation of the effect of various demographic and clinical variables on QoL in this setting.

Validation of a Swedish version of the Cancer Dyspnea Scale

The Cancer Dyspnea Scale (CDS) is a multidimensional measure of dyspnea experience, with three subscales related to sense of effort, sense of anxiety and sense of discomfort, and a total score. In this study, we evaluated the validity and reliability of a Swedish version, the CDS-S, in 99 patients with advanced lung cancer who were not receiving curative or life-prolonging treatments. Criterion-related validity was demonstrated by significant group differences in CDS-S scores when patients were stratified by dyspnea intensity, as measured by a visual analogue scale (VAS-D). Correlations between the total CDS-S score and other dyspnea scales varied between 0.63 and 0.68. Convergent validity was shown by comparing the CDS-S subscales with conceptually related measures of physical and emotional function and discomfort, and correlations ranged from 0.34 to 0.57. The CDS-S captured the psychological dimension of dyspnea better than did the VAS-D. Internal consistency of the CDS-S scales was confirmed by Cronbach's alpha coefficients ranging from 0.81 to 0.90. The CDS-S was well received by the patients and completed in 2 minutes. This study supports the CDS as a valid and reliable instrument to measure dyspnea experience in a palliative setting, well suited for use in research as well as in clinical practice.

The Relationship Between Meaning of Illness, Social Support, Coping Strategies, and Quality of Life for Lung Cancer Patients and Their Family Members

This article explores the relationship between meaning of illness, perceived social support resources, coping strategies used, and quality of life (QOL) by patients with lung cancer and their family members. The study was cross-sectional using interview data from 85 patients and associated family members. Regression results showed that total QOL in patients with lung cancer is predicted most by meaning of illness, specifically, the illness being perceived as manageable. QOL in family members is predicted most by meaning of illness, specifically, less adverse impact. Interestingly, the overall meaning of illness, coping strategies used, and social support were similar in the 2 groups. The results of the study emphasize the importance of acknowledging the circumstances of people's lives, both patients surviving lung cancer and their family members, which contribute to QOL.

A study to assess the existence of the symptom cluster of breathlessness, fatigue and anxiety in patients with advanced lung cancer

The purpose of this small-scale study was to assess the existence of a symptom cluster involving breathlessness, fatigue and anxiety in patients with advanced lung cancer undergoing palliative radiation. A convenience sample of 27 patients were asked to complete a set of 100mm horizontal visual analogue scales (VAS) measuring the intensity of anxiety, breathlessness and fatigue at 3 points in time: 1 day prior to palliative radiotherapy (RT) (baseline, T0), and at week 3 (T1) and week 6 (T2) after the commencement of the RT. The prevalence of the 3 symptoms ranged from 59% to 96%. At baseline the median intensity of symptoms was mild, becoming progressively worse at T1 and T2. The correlations between the 3 symptoms were moderately strong at T1 and T2 (r=0.49-0.75). The proposed symptom cluster had high internal consistency across T0-T2. These data support the notion that the symptoms--breathlessness, fatigue, and anxiety--may be viewed as a symptom cluster. The high prevalence and moderate intensity of the symptom cluster demonstrates a need for an intervention to manage these symptoms simultaneously.

Discrepancies and similarities in how patients with lung cancer and their professional and family caregivers assess symptom occurrence and symptom distress

Historically, conceptual distinctions have not been made between the components of symptom experience--symptom distress and symptom occurrence--nor has the question of how distressing patients perceive different symptoms to be, irrespective of their current occurrence, been addressed. The aim of this study was to explore the hypothesis that there may be different patterns in discrepancies between how lung cancer patients and their caregivers assess symptom distress and in how they assess symptom occurrence. Thirty-three patient-nurse dyads and 54 patient-family caregiver dyads assessed patients' symptom distress and symptom occurrence. Discrepancies with regard to how patients, nurses, and family caregivers assessed symptom distress and symptom occurrence were identified. Patients and caregivers were more in agreement about which symptoms might cause distress than about current symptom occurrence. Caregivers rated symptom occurrence as greater than patients. The findings highlight the need to further explore what symptom characteristics caregivers address when assessing patients' symptom experiences.

Psychosocial aspects of lung cancer

BACKGROUND

Lung cancer is one of the commonest cancers in the industrialised world, and persons with this grave disease must deal not only with the physical effects but also with the psychosocial aspects.

METHODS

This review is based on an examination of intervention, prospective and case-control studies with more than 50 participants published between 1966 and 2003.

RESULTS

The studies show that on average one out of four persons with lung cancer experience periods of depression or other psychosocial problems during their illness. Persons who are not offered treatment for their cancer and persons with small-cell lung cancer have a higher risk compared to other groups of lung cancer patients. The degree of depression can be reduced by psychosocial interventions.

CONCLUSIONS

We suggest that psychosocial screening of persons with lung cancer could prevent depression and might result in improved quality of care.

Symptom experience in Korean adults with lung cancer

This study aimed to examine how symptoms vary in relation to demographic characteristics (age and sex), stage of disease, histology of lung cancer, and treatment type in Korean adults with lung cancer. Symptoms were measured with the Symptom Distress Scale. A total 106 patients with a mean age of 60.9 (SD = 10.38) years participated. The results indicated that 1) overall symptom distress was more severe (mean 32.74, SD 10.75) compared to the studies reported in Western countries, and 2) among the variables, only the stage of lung cancer showed a significant relationship with total symptom distress (P < 0.05). In analyses of the individual symptoms, bowel-related symptoms showed significant relationships with sex, age, and type of treatment. The results highlight the importance of symptom management as well as the need to tailor clinical interventions according to related factors in order to maximize effective symptom management in Korean patients with lung cancer.

Impact of respiratory symptoms and pulmonary function on quality of life of long-term survivors of non-small cell lung cancer

PURPOSE

To describe respiratory symptoms and pulmonary function among long-term survivors of non-small cell lung cancer (NSCLC), and their relationship to quality of life (QOL).

METHODS

Cross-sectional survey of disease-free, 5-year minimum survivors of NSCLC (n = 142; 54% women; average age, 71 years); the majority (74%) had received a lobectomy. Analysis included frequency of self-reported respiratory symptoms (cough, phlegm, wheezing, breathlessness) as measured by the American Thoracic Society questionnaire, pulmonary function findings from hand-held spirometry, and QOL (Short Form-36).

RESULTS

Two thirds of survivors reported at least one respiratory symptom (mean, 1.3; SD, 1.2): 25% cough, 28% phlegm, 31% wheezing, and 39% dyspnea. Twenty-one percent reported that they spent most of the day in bed in the past 12 months because of respiratory symptoms. Average FEV(1) percentage predicted was 68% (SD, 23); 21% had < 50% predicted FEV(1). Based on spirometry results, 36% had a moderate/severe obstructive and/or restrictive ventilatory disorder. Survivors exposed to second-hand smoke (28%) were more than three times as likely to report respiratory symptoms. Respiratory symptom burden contributed to diminished QOL in several domains.

CONCLUSIONS

The majority of these survivors experienced respiratory symptoms, and more than one third reported dyspnea, including one of five patients with seriously diminished pulmonary function. Symptom burden, rather than ventilatory impairment, contributed to diminished QOL. Further study is needed to determine the patterns and effective management of posttreatment respiratory symptoms on survivors of lung cancer.

Distress, psychiatric morbidity, and prescriptions for psychotropic medication in a breast cancer waiting room sample

We examined relationships among psychiatric screening, the prevalence of psychiatric morbidity, and prescription rates for psychotropic medication in a waiting room sample of breast cancer patients (N=113). Rates of distress (29%), major depressive disorder (MDD; 9%), and generalized anxiety disorder (GAD; 6%) were low and similar to those found in primary care settings. A substantial proportion of patients (52%) had received psychotropic medication during treatment, including almost half (48%) of those without a current psychiatric diagnosis. Most individuals with MDD received pharmacotherapy during cancer treatment (80%), although only half of those with GAD were treated. Overall high rates psychotropic medication negatively impacted the efficiency of screening, and individuals with elevated distress were about 6 times less likely to represent a case of untreated psychiatric morbidity than to be a new case. We conclude that the risk of psychiatric morbidity attributable to breast cancer may be lower and treatment rates for psychiatric morbidity higher than previously believed and that screening is unlikely to provide efficient identification of untreated psychiatric morbidity. Adequacy of follow-up care is unclear and medication may be prescribed nonspecifically. The low rate of untreated psychiatric morbidity may signal a need for multisite collaborations to generate adequate numbers of participants in clinical trials.

Effect of a cognitive behavioral intervention on reducing symptom severity during chemotherapy

PURPOSE

To describe a randomized trial of a cognitive behavioral intervention on reducing symptom severity among patients diagnosed with solid tumors and undergoing a first course of chemotherapy and to determine whether the intervention had an additive or interactive effect on symptom severity in the presence of supportive care medications.

PATIENTS AND METHODS

Patients (N = 237) were accrued from comprehensive and community cancer centers, interviewed, and randomly assigned to either the experimental intervention (n = 118) or conventional care (n = 119). A symptom severity index, based on summed severity scores across 15 symptoms, was the primary outcome. Each patient's site of cancer, stage at diagnosis, chemotherapy protocols, and use of supportive medications were learned from medical records.

RESULTS

Groups were equivalent at baseline, and attrition by characteristics by group was not different. The proportion of patients not receiving chemotherapy at 10 and 20 weeks did not differ by group. At the 10- and 20-week observations, there was a significant interaction between the experimental group and baseline symptom severity. Patients in the experimental group who entered the trial with higher symptom severity reported significantly lower severity at 10 and 20 weeks. Controlling for chemotherapy treatment status at follow-up and supportive care medications did not alter the effect of the experimental intervention.

CONCLUSION

Compared with conventional care alone, the experimental intervention was effective among patients who entered the trial with higher levels of symptom severity. Age, sex, site or stage of cancer, and supportive medications did not modify the effect of this cognitive behavioral intervention on symptom severity.

A cluster of symptoms over time in patients with lung cancer

BACKGROUND

Patients with lung cancer present late in the disease and have multiple symptoms. Previous research has shown the symptom cluster of fatigue, weakness, weight loss, appetite loss, nausea, vomiting, and altered taste to be present at time of lung cancer diagnosis.

OBJECTIVES

The study determined whether the symptom cluster identified at the time of diagnosis remained 3 and 6 months later, and whether there was a difference in the mean number of symptoms and the mean level of symptom severity over time. The relation of the severity rating for individual symptoms at the time of diagnosis and at 3 and 6 months after diagnosis was examined. Predictors for the number of symptoms and whether the symptom cluster was predictive of death were determined.

METHODS

Secondary analysis of an existing data set for 112 patients with newly diagnosed lung cancer assessed at diagnosis and at 3 and 6 months was performed and determined whether they were alive or dead 19 months after diagnosis.

RESULTS

The cluster of seven symptoms had internal consistency that remained at 3 and 6 months. The mean symptom severity and the number of symptoms at diagnosis were correlated with later ratings, but decreased in severity over time. A similar decrease in severity rating was seen for the individual symptoms in the cluster. The stage of cancer at diagnosis was the most predictive of the number of cluster symptoms reported. Death 6 to 19 months after diagnosis was predicted by age, stage of cancer at diagnosis, and symptom severity at 6 months.

CONCLUSIONS

The symptom cluster remains over the course of lung cancer and is an independent predictor of the patient's death. Symptom severity, the number of symptoms reported, and the severity of the individual symptoms decreased over time. The stage of cancer at diagnosis is the best predictor of symptoms later in the disease.