A New Framework for Co-Creating Telehealth for Cancer Care with the Patient Community

The increased use of telehealth in cancer care during the coronavirus disease 2019 pandemic has added to our knowledge and experience of the modality with benefits in terms of efficacy, cost, and patient and healthcare professional experience reported. However, telehealth has also been found not to be universally available to all patients with cancer, nor to be appropriate for every healthcare interaction; additionally, not all patients prefer it. Now that coronavirus disease restrictions have essentially ended and an opportunity to re-assess telehealth provision in cancer care presents, we offer a framework that aims to ensure that the needs and preferences of the patient community are included in the development of telehealth provision. Stakeholders in this process include patients, patient advocates, healthcare providers, healthcare services commissioners, managers, and policy makers. The framework outlines how patient advocates can work with other stakeholders as equal partners at all stages of telehealth service development. The patient advocate community has a unique understanding of the patient perspective as well as expertise in healthcare design and delivery. This enables advocates to contribute to shaping telehealth provision, from policy and guideline formulation to patient navigation. Appropriate resources, education and training may be needed for all stakeholders to support the development of an effective telehealth system. Together with other stakeholders, patient advocates can make an important contribution to optimizing appropriate patient-centred telehealth provision in cancer care.

Including the patient voice in the development and implementation of patient-reported outcomes in cancer clinical trials

CONTEXT

Patient-reported outcomes (PROs) are used in parallel with clinical evidence to inform decisions made by industry, clinicians, regulators, health technology assessment bodies and other health-care decision-makers. In addition, PRO data can also guide shared decision making and individual patient choice. Yet, the quality of many PROs in cancer clinical trials is suboptimal and requires improvement to add value to health care and policy decision making.

OBJECTIVE

To show how the integration of the patient and/or patient advocate at all stages of PRO development can help to realize the full potential of PROs.

METHODS

We examined the literature to show that the patient voice is often absent from the planning and implementation of PROs in cancer clinical trials. Good practice examples from the literature were combined with guideline recommendations, training or educational resources, and our own experience to create detailed practical steps for the inclusion of patients and/or patient advocates throughout PRO development.

RESULTS

Patient or patient advocates can play an active role in shaping PROs that are meaningful to the patient. They can contribute to content, choice of medium and implementation in a way that may support PRO completion and minimize missing data. Patients and their advocates can work to ensure PRO findings are disseminated appropriately in a way that is accessible to patients.

CONCLUSION

This practical guidance aims to optimize PRO development and implementation in clinical trials, resulting in robust, relevant data that reflect the patient experience and that support decisions made by all stakeholders involved in research and health care.

A randomized trial to reduce smoking among American Indians in South Dakota: The walking forward study

BACKGROUND

Lung cancer is an important public health issue, particularly among American Indians (AIs). The reported decline in tobacco use for most racial/ethnic groups is not observed among AIs. This project was designed to address the research question, "Why don't more Northern Plains American Indians alter tobacco use behaviors known to increase the risk of cancer?"

METHODS

Guided by the Theory of Planned Behavior, a multi-component intervention study was implemented. Adult AIs, age 18 years or older and currently smoking, were enrolled. Eligible subjects were randomized to one of 15 groups and exposed to either a MINIMAL or an INTENSE level of 4 intervention components. The intervention was delivered face-to-face or via telephone by Patient Navigators (PN). The primary outcome was self-reported abstinence from smoking verified by carbon monoxide measurement.

RESULTS

At 18 months post-quit date, 88% of those who were still in the study were abstinent. This included 6% of all participants who enrolled in the study (14/254) and 13% of those who made it to the quit date (14/108). No intervention groups were found to have significant proportions of participants who were abstinent from smoking at the quit date (visit 5) or primary outcome visit (18 months post-quit date, visit 11), but use of pharmacologic support for abstinence was found to be an effective strategy for individuals who continued participation throughout the study. Those who remained in the study received more visits and were more likely to be abstinent.

CONCLUSIONS

Use of NRT increased the odds of not smoking, as assessed at the 18-month follow-up visit, but no other interventions were found to significantly contribute to abstinence from smoking. Although the intervention protocol included numerous points of contact between CRRs and participants (11 visits) loss to follow-up was extensive with only 16/254 remaining enrolled. Additional research is needed to improve understanding of factors that influence enrollment and retention in smoking cessation interventions for AI and other populations.

Findings from American Indian Needs Assessments

Because of decreased access and dismal survival rates, strategies need to be developed to increase cancer awareness and facilitate cancer prevention, early detection, and screening activities within American Indian (AI) populations. The purpose of this study was to develop a locally tailored needs assessment to collect cancer prevention, control, and risk factor information and knowledge, attitude, and perceived behavior (hereafter referred to as "needs assessment") data from 500 community members living in 3 geographically diverse settings: the Southeastern USA, the Rocky Mountain region, and the Northern Plains. Needs assessment data helped identify local health priorities and create a pilot cancer prevention and early detection education intervention. There were two versions of common items of the instrument: short (~35 items) and long (55 items), and each partner added items that were recommended by their local AI Advisory Committee. Each partner collaborated with local AI organizations to identify and recruit participants at community venues. During the sessions, facilitators used Power Point® slides and ARS equipment and software to anonymously collect participants' responses. The partners collected needs assessment data from 677 community members over a 4-year period. Cancer education knowledge was low, barriers to accessing timely cancer screening and care services were excessive, tobacco use was excessive, and daily physical activity was insufficient for most participants. ARS was an effective way to collect needs assessment information. During discussions following the data collection, community members requested more cancer education opportunities, access to patient navigation services, and cultural competency training for healthcare providers.

Lessons Learned While Developing “Clinical Trials Education for Native Americans” Curriculum

This paper highlights lessons learned while developing the Clinical Trials Education for Native Americans (CTENA) curriculum. The CTENA is a culturally specific clinical trials education curriculum that evolved from another ongoing NCI-supported project, Clinical Trials Education for Colorado Providers. The multicultural team learned many lessons while developing, pretesting, and revising this curriculum. These include allocating sufficient time and resources to tailor presentations for diverse tribal settings and workshop participants, addressing barriers to participation in clinical trials through culturally appropriate strategies, providing information to foster informed decision making related to participation, and writing as a team to increase cultural breadth of examples and interactive experiences. There are multiple challenges to developing and implementing a culturally acceptable curriculum on clinical trials within medically underserved communities. Both the multicultural team and the curriculum benefited from the collaborative process, resulting in a culturally relevant clinical trials curriculum that will assist Native Americans to make informed choices about clinical trials participation. The lessons shared here, which may need to be modified to be culturally relevant to other underrepresented communities, may be beneficial to others developing similar curricula for other medically underserved populations.

Reality Versus Grant Application Research "Plans"

This article describes the implementation of the American Indian mHealth Smoking Dependence Study focusing on the differences between what was written in the grant application compared to what happened in reality. The study was designed to evaluate a multicomponent intervention involving 256 participants randomly assigned to one of 15 groups. Participants received either a minimal or an intense level of four intervention components: (1) nicotine replacement therapy, (2) precessation counseling, (3) cessation counseling, and (4) mHealth text messaging. The project team met via biweekly webinars as well as one to two in-person meetings per year throughout the study. The project team openly shared progress and challenges and collaborated to find proactive solutions to address challenges as compared to what was planned in the original grant application. The project team used multiple strategies to overcome unanticipated intervention issues: (1) cell phone challenges, (2) making difficult staffing decisions, (3) survey lessons, (4) nicotine replacement therapy, (5) mHealth text messages, (6) motivational interviewing counseling sessions, and (7) use of e-cigarettes. Smoking cessation studies should be designed based on the grant plans. However, on the ground reality issues needed to be addressed to assure the scientific rigor and innovativeness of this study.

Abstract IA10: Challenges in addressing cancer health disparities in Native American communities

Brief Overview of Demographics and Risk Factors: There are more than 760 federally and state-recognized American Indians/Alaska Natives (AI/ANs) tribes in the US.1 Of those AI/ANs responding to the 2010 Census, 41% lived in the West and the majority (78%) lived in urban and rural areas or in states that do not have a federal Reservation.2 AI/ANs have daily behaviors and co-morbidities that increase their risks for cancer. They are more likely to be obese, use commercial tobacco, and have diabetes or high blood pressure. They also have long experienced lower health status in comparison with other US populations. AI/ANs born in 2011 have a lower life expectancy than all US populations (72.6 years vs. 77.8 years).2 Their poverty level is nearly twice that of the overall US population; only half as many having health insurance. When compared to other populations, AI/ANs are more likely to have a lower socioeconomic status and live in poverty, leading to less access to cancer prevention and screening services. Additionally, 20% of AI/ANs have not completed high school as opposed to only 8% of non-Hispanic Whites. Not completing high school has been associated with unhealthy and risk taking behaviors.3 The Indian Health Service (IHS) reported that cancer screening rates for AI/ANs were significantly lower in comparison to the overall US population with only 59% receiving cervical screening, 45% breast screening and 33% receiving colorectal screening, leading to increased risk of late diagnosis and decreased survival from cancer.2

Excerpts from “Native American Cancer Education for Survivors” (NACES): Native American Cancer Education for Survivors” (NACES) is the largest AI cancer survivorship database, education and support program in the US, with almost 900 survivors. NACES is a cancer education intervention designed to improve the Quality of Life (QOL) of cancer survivors by increasing knowledge and informed choice using innovative, tailored, web-based technology. The website includes a QOL survey, culturally appropriate and scientifically accurate content based on the Medicine Wheel (physical, mental-emotional, social and spiritual health), video excerpts from almost 90 AI survivors, sample questions to ask providers, and other interactive information. It is organized as a QOL Tree with information written at reading grade levels 5-7, and is based on AI survivors sharing their cancer-related stories throughout the education materials. Native Patient Navigators (NPNs) assist cancer survivors to effectively use the website and complete a QOL survey. This survey was adapted and culturally tailored from Ferrell's QOL survey initiated at the City of Hope. In 2013, 75 items, mostly NIH PROMIS® items, were added. As of September 2014, 890 AI cancer survivors completed the survey. Findings include: Most (n=710; 79.8%) are female, 46% have high school or less education, more than half (54.6%) are full-bloods, and almost half (47.6%) were diagnosed with cancer prior to age 50. About 1/3 (35.7%) travel 200 or more miles one way to access cancer care and because of rural road conditions and other geographic issues, almost half (48.1%) travel more than 2 hours one way to access such care. More than 1/3 (37.4%) had difficulties getting into cancer treatment. These data differ greatly from NCI published findings of older age at diagnosis, living within a reasonable distance from cancer care services and access to treatment.4 5

Affordable Care Act (ACA): IHS offers basic clinic services until there is a cancer diagnosis. Then patients are referred through Contract Health Services (CHS) out of the IHS system to private health providers. When there are not enough CHS funds available in a contract year, patients cannot be referred until the next year begins. The current system typically results in people returning to their home reservation for 3-6 months to re-establish “residency”, then they are placed on the CHS priority / waiting list to be referred elsewhere for cancer care. This means that AIs must return to the reservation to seek care. However, the ACA, should eliminate such obstacles to accessing timely cancer services.

Those AIs who have health insurance receive care in sites determined by their healthcare plans. Those without health insurance and not living near an IHS clinic access health care the same as others in poverty, often not receiving healthcare until an emergency. For many reasons, few receive health care at public institutions. Contrary to popular belief, AIs living in urban areas do not have easier access to healthcare services in comparison to Reservation-based AIs. While almost 2/3 of AIs live in urban areas, only 2% of the total IHS budget is allocated to urban AI clinics, affecting access to cancer screening and early detection programs. Those who seek public screening services often experience fragmented care due to lack of a primary care provider, delayed or lost results reporting or insufficient or delayed follow-up care of suspicious findings.

Because the ACA allows AIs the option for exemption from obtaining health insurance, many will rely solely on care through IHS. However, due to major reductions in the IHS budget, tribes and Indian organizations are referring AIs for private insurance through the ACA to assure that they receive healthcare. Because private health insurance is not the norm for AIs, many are unfamiliar with how to use it and are unclear how to access health services such as routine cancer screenings.

Access to Technology: In 2012, NACR and its collaborators (Muscogee (Creek) Nation, Rapid City Regional Hospital's Walking Forward Program, Intertribal Council of Michigan) had their Native Patient Navigators (NPNs) administer a short survey on access to and use of technology to AIs (n= 306). Two thirds of respondents were female, 64% were between 31 and 64 years of age and 68.9% had less than a college education. About 2/3 had positive responses to the use of cell phones, with 76% having a cell phone, 66.6% currently using text messaging and 74.8% willing to receive and respond to about 4-6 health-related texts per day. Many of the elders used Facebook to stay in contact with their grandchildren. Cell phone towers on Reservations are increasing; in 2014, 85% of Reservations have cell phone coverage. Although the majority of AIs now have cell phones, many do not know how to use common features.

The need for “cultural” Native Patient Navigators: AIs experience barriers to accessing health care due to socioeconomic and cultural issues as well as historical trauma, even when it is second and third generation.6 7 NPNs help patients understand healthcare information by translating it into terms that are more comfortable and easily understood. They know how to address historical issues unique to tribal members, varying communication patterns and spirituality practices that may impact contemporary medical practices. They provide support and referrals to education programs, resources and cancer screenings and improve and enhance AI patient outcomes through recognizing and integrating culture in overall healthcare.

References:

1 US Census Bureau, (2012). The American Indian and Alaska Native Population: 2010 (based on the 2010 Census Redistricting Data (Public Law 94-171) Summary File). In: Commerce USDo, editor. Washington, DC.

2 Indian Health Service DHHS. (2012). Indian Health Service. IHS Fact Sheets. In: http://www.ihs.gov/publicaffairs/ihsbrochure/disparities.asp.

3 DHHS, Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, CDC Health Disparities and Inequalities Report—United States, 2013, Supplement, volume 62, number 3, November 22, 2013, page 9

4 Howlader N, Noone A, Krapcho M, Neyman N, Aminou R, Waldron W, et al. (eds). SEER Cancer Statistics Review, 1975–2009 (Vintage 2009 Populations), National Cancer Institute; Bethesda, MD, http://seer.cancer.gov/csr/1975_2009_pops09/, based on November 2011 SEER data submission, posted to the SEER web site, April 2012.

5 de Moor JS, Mariotto AB, Parry C, Alfano CM, Padgett L, Kent EE, Forsythe L, Scoppa S, Hachey M, and Rowland JH. Cancer Survivors in the United States: Prevalence across the Survivorship Trajectory and Implications for Care. Cancer Epidemiol Biomarkers Prev. 2013 Apr;22(4):561-70.

6 Harjo, Lisa, Burhansstipanov, Linda, Lindstrom, Denise, Rationale for “Cultural” Native Patient Navigators in Indian Country. Journal of Cancer Education. (online June 2014, in print summer 2014) Doi 10.1007/s13187-014-0684-0

7 Cutler M (n.d.) Multigenerational trauma: behavior patterns in cultures. Retrieved from http://edweb.boisestate.edu/instituteforthestudyofaddiction/pp/Historical_Trauma_and_Grief.ppt on July 2014

Citation Format: Linda Burhansstipanov, Linda U. Krebs, Lisa D. Harjo. Challenges in addressing cancer health disparities in Native American communities. [abstract]. In: Proceedings of the Seventh AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 9-12, 2014; San Antonio, TX. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2015;24(10 Suppl):Abstract nr IA10.

Findings from the native navigators and the Cancer Continuum (NNACC) study

Native Navigators and the Cancer Continuum (NNACC) was a community based participatory research study among Native American Cancer Research Corporation, CO; Inter-Tribal Council of Michigan, MI; Rapid City Regional Hospital's Walking Forward, SD; Great Plains Tribal Chairman's' Health Board, SD; and Muscogee (Creek) Nation, OK. The project goal was to collaborate, refine, expand, and adapt navigator/community education programs to address American Indian communities' and patients' needs across the continuum of cancer care (prevention through end-of-life). The intervention consisted of four to six site-specific education workshop series at all five sites. Each series encompassed 24 h of community education. The Social Ecology Theory guided intervention development; community members from each site helped refine education materials. Following extensive education, Native Patient Navigators (NPNs) implemented the workshops, referred participants to cancer screenings, helped participants access local programs and resources, and assisted those with cancer to access quality cancer care in a timely manner. The intervention was highly successful; 1,964 community participants took part. Participants were primarily American Indians (83 %), female (70 %) and between 18 and 95 years of age. The education programs increased community knowledge by 28 %, facilitated referral to local services, and, through site-specific navigation services, improved access to care for 77 participants diagnosed with cancer during the intervention. Approximately, 90 % of participants evaluated workshop content as useful and 92.3 % said they would recommend the workshop to others. The intervention successfully increased community members' knowledge and raised the visibility of the NPNs in all five sites.

Providing community education: lessons learned from Native Patient Navigators

Native Navigators and the Cancer Continuum (NNACC) was a community-based participatory research study among five American Indian organizations. The intervention required lay Native Patient Navigators (NPNs) to implement and evaluate community education workshops in their local settings. Community education was a new role for the NPNs and resulted in many lessons learned. NPNs met quarterly from 2008 through 2013 and shared lessons learned with one another and with the administrative team. In July 2012, the NPNs prioritized lessons learned throughout the study that were specific to implementing the education intervention. These were shared to help other navigators who may be including community education within their scope of work. The NPNs identified eight lessons learned that can be divided into three categories: NPN education and training, workshop content and presentation, and workshop logistics and problem-solving. A ninth overarching lesson for the entire NNACC study identified meeting community needs as an avenue for success. This project was successful due to the diligence of the NPNs in understanding their communities' needs and striving to meet them through education workshops. Nine lessons were identified by the NPNs who provided community education through the NNACC project. Most are relevant to all patient navigators, regardless of patient population, who are incorporating public education into navigation services. Due to their intervention and budget implications, many of these lessons also are relevant to those who are developing navigation research.

Navigation as an intervention to eliminate disparities in American Indian communities

OBJECTIVES

To identify the role of patient navigation in decreasing health care disparities through an exemplar of a successful patient navigation program for American Indian populations living in the Northern and Southern Plains of the United States.

DATA SOURCES

Published literature and data from the Native Navigators and the Cancer Continuum study.

CONCLUSION

Native Patient Navigators successfully collaborated with local American Indian organizations to provide cancer education through a series of 24-hour workshops. These workshops increased community knowledge about cancer, influenced cancer screening behaviors, and increased the visibility and availability of the navigators to provide navigation services.

IMPLICATIONS FOR NURSING PRACTICE

Reaching those with health care disparities requires multiple strategies. Collaborating with patient navigators who are embedded within and trusted by their communities helps to bridge the gap between patients and providers, increases adherence to care recommendations, and improves quality of life and survival.

Toward an mHealth Intervention for Smoking Cessation

The prevalence of tobacco dependence in the United States (US) remains alarming. Invariably, smoke-related health problems are the leading preventable causes of death in the US. Research has shown that a culturally tailored cessation counseling program can help reduce smoking and other tobacco usage. In this paper, we present a mobile health (mHealth) solution that leverages the Short Message Service (SMS) or text messaging feature of mobile devices to motivate behavior change among tobacco users. Our approach implements the Theory of Planned Behavior (TPB) and a phase-based framework. We make contributions to improving previous mHealth intervention approaches by delivering personalized and evidence-based motivational SMS messages to participants. Our proposed solution implements machine learning algorithms that take the participant's demographic profile and previous smoking behavior into account. We discuss our preliminary evaluation of the system against a couple of pseudo-scenarios and our observation of the system's performance.

Comparison of quality of life between Native and non-Native cancer survivors: Native and non-Native cancer survivors' QOL

This paper compares quality of life (QOL) outcomes between Native American and non-Native cancer survivors. Native Patient Navigators helped Native cancer patients complete a 114-item QOL survey and access survivorship information available on the NACES website. The survey was modified from Ferrell et. al’s QOL measure and assessed the four domains of cancer survivorship: physical, psychological, social, and spiritual. Findings from Native survivors were compared to Ferrell’s findings. This is the first time that QOL outcomes have been compared between Native and Non-Native cancer survivors. Natives scored lower for physical and social QOL, the same for psychological QOL, and higher for spiritual QOL in comparison to non-Natives. Overall QOL scores were the same. Although this is the largest sample of Native cancer survivors reported in peer-reviewed manuscripts, these Native survivorship data are based on a self-selected group and it is unknown if the findings are generalizable to others.

Online evaluation programs: benefits and limitations

Patient navigation programs are increasing throughout the USA, yet some evaluation measures are too vague to determine what and how navigation functions. Through collaborative efforts an online evaluation program was developed. The goal of this evaluation program is to make data entry accurate, simple, and efficient. This comprehensive program includes major components on staff, mentoring, committees, partnerships, grants/studies, products, dissemination, patient navigation, and reports. Pull down menus, radio buttons, and check boxes are incorporated whenever possible. Although the program has limitations, the benefits of having access to current, up-to-date program data 24/7 are worth overcoming the challenges. Of major benefit is the ability of the staff to tailor summary reports to provide anonymous feedback in a timely manner to community partners and participants. The tailored data are useful for the partners to generate summaries for inclusion in new grant applications.

Preliminary lessons learned from the "Native Navigators and the Cancer Continuum" (NNACC)

This community-based participatory research (CBPR) study was based on patient navigation (Navigator) among three original sites: Colorado, Michigan, and South Dakota. During 2010, the study added two sites: the Comanche Nation and the Muscogee (Creek) Nation (Oklahoma). The intervention includes 24-h of a Navigator-implemented cancer education program that addresses the full continuum of cancer care. The partners include agreements with up to two local Native American organizations each year, called Memorandum Native Organizations, who have strong relationships with local American Indians. Family fun events are used to initiate the series of workshops and to collect baseline data and also to wrap up and evaluate the series 3 months following the completion of the workshop series. Evaluation data are collected using an audience response system (ARS) and stored using an online evaluation program. Among the lessons learned to date are: the Institutional Review Board processes required both regional and national approvals and took more than 9 months. All of the workshop slides were missing some components and needed refinements. The specifics for the Memorandum Native Organization deliverables needed more details. The ARS required additional training sessions, but once learned the Navigator use the ARS well. Use of the NACR website for a password-protected page to store all NNACC workshop and training materials was easier to manage than use of other online storage programs. The community interest in taking part in the workshops was greater than what was anticipated. All of the Navigators' skills are improving and all are enjoying working with the community.

Breast screening navigator programs within three settings that assist underserved women

Medically underserved women in the Greater Denver Metropolitan Area had low rates of routine repeat mammograms in the latter 1990s. "Increasing Mammography Adherence among Medically Underserved Women" was designed to increase annual rescreening among medically underserved populations living in this area. Four community-based organizations collaborated to implement this 5-year study. A culturally modified navigator model including both face-to-face and telephone formats was used to facilitate mammography for African Americans, Latinas, Native Americans, and poor White women who had not been rescreened in more than 18 months. The navigator-implemented intervention was statistically significant at the 0.05 level for increasing rescreening.

Native American breast cancer survivors' physical conditions and quality of life

BACKGROUND

Based on Survivors' Guidance, an interactive, Web-based, culturally relevant Native American cancer survivorship program, Native American Cancer Education for Survivors (NACES), was developed. The focus of the program is to improve quality of life (QOL) for Native American breast cancer survivors.

METHODS

NACES is a community-driven research and education project, based on the Social Cognitive Theoretical Model. Participants complete a QOL survey that includes physical, psychosocial, spiritual, and social components. This publication focuses on the physical component of the survey collected by trained Native American patient advocates, and compares physical conditions among Native American breast cancer survivors who were diagnosed within 1 year, those diagnosed between 1 and 4 years, and those who are long-term survivors (diagnosed > or = 5 years ago).

RESULTS

For the first time, survivorship issues are reported specifically for Native American breast cancer patients (n = 266). Selected access issues document situations that contribute to disparities. Comorbidities such as high blood pressure and arthritis are common in the survivors, with more than a third having diabetes, in addition to breast cancer. Numerous side effects from cancer treatments are experienced by these survivors.

CONCLUSIONS

These data describe what Native American breast cancer patients are experiencing based on self-reported information. Clearly there is need for much more work and long-term tracking of Native American patients to begin to document if or how the severity of physical symptoms lessens over time and if their experiences are significantly different from non-Native Americans.

Sexual assessment in cancer care: concepts, methods, and strategies for success

OBJECTIVES

To review the literature and provide specific suggestions for assessing and addressing sexual concerns seen in those diagnosed with cancer.

DATA SOURCES

Review and research articles, abstracts, books, electronic databases.

CONCLUSION

Sexuality and sexual health are integral components of overall health and essential for quality of life. Patients should have the opportunity to discuss their sexual issues and concerns with a qualified health care professional. Knowledgeable, skilled nurses are well-qualified to conduct sexual assessments and to provide options for interventions and referrals.

IMPLICATIONS FOR NURSING PRACTICE

To provide quality cancer care, nurses need to be educated about sexual health and to learn the knowledge and skills requisite to a basic discussion and assessment of potential or actual sexual dysfunction in their patients.

Quality of life in long-term cervical cancer survivors

OBJECTIVES

To describe the quality of life (QOL) and long-term psychosocial sequelae of women of childbearing age diagnosed with cervical cancer 5-10 years earlier.

METHODS

Utilizing a cross-sectional descriptive design, 51 cervical cancer survivors and 50 age-matched controls completed a comprehensive QOL interview.

RESULTS

Participants were predominantly married, non-Hispanic White, with a mean age at diagnosis of 37 years and a mean age at interview of 45 years. This disease-free sample enjoys a good QOL, with physical, social, and emotional functioning comparable to or better than comparative norms. However, certain psychological survivorship sequelae and reproductive concerns persist. Participants reporting good QOL were less likely to report ongoing coping efforts related to having had this illness and were more likely to report greater social support, greater sexual pleasure, and less cervical cancer-specific distress. In a multiple-regression model, cancer-specific distress, spiritual well-being, maladaptive coping, and reproductive concerns accounted for 72% of the variance in QOL scores. Fifty-nine percent of respondents expressed that they would likely participate in a counseling program today to discuss psychosocial issues raised by having had cervical cancer, and 69% stated that they would have attended a support group program during the initial treatment if it had been offered.

CONCLUSIONS

This information provides insight into the complex survivorship relationships between QOL and sequelae of cervical cancer for women diagnosed during childbearing years. Therefore, it is important for health care professionals to recognize that aspects of cancer survivorship continue to require attention and possible follow-up care.

A review of effective strategies for native women's breast health outreach and education

BACKGROUND

This commentary provides a summary of a pilot study designed to assist the American Cancer Society in revising the Circle of Life breast health program for American Indians and Alaska Natives (AIANs).

METHODS

Included are analyses of a literature review focusing on breast health outreach strategies among AIANs and in-depth interviews with breast health focus group facilitators. Over 70 AIAN breast or cervix cancer screening articles were reviewed, and approximately 20 focus group facilitators were interviewed.

RESULTS AND CONCLUSIONS

A primary finding was that AIAN breast cancer outreach, education, and screening programs are most effective when community-driven and culturally relevant to local tribal nations and geographic regions.

The use of an electronic audience response system for data collection

BACKGROUND

Gathering complete and accurate data from community groups, particularly medically underserved populations, is challenging.

METHODS

An electronic audience response system (ARS) is a novel method for the efficient collection of data while maintaining participant confidentiality in group settings.

RESULTS

Because data are captured electronically, an ARS eliminates the need to transfer data from paper forms, reducing errors and the amount of time required for data management.

CONCLUSIONS

ARS is a useful data collection tool that works well with diverse populations and greatly increases data accuracy and completeness while maintaining participant confidentiality.

Understanding cancer-understanding the stories of life and living

BACKGROUND

Storytelling is an effective and efficient educational methodology for American Indians/Alaska Natives (AIs/ANs). It has been used for hundreds of years, is well respected, and has significant implications in the oncology setting. Storytelling not only values the individual sharing the story but also offers educational information and emotional support to those who hear it.

METHODS

Content analysis of transcripts from an educational session in which AIs/ANs were encouraged to share stories of living with/surviving cancer identified 12 themes that revealed the essence of their cancer experiences.

RESULTS

The themes identified were: cancer journey, responsibility to self and community, getting beyond the diagnosis, cancer lessons-cancer gifts, the strength of our stories, being connected, prospering through cancer, pain is more than a word, survival is an attitude, spirituality and cancer, specific cancer issues and understanding our ways.

CONCLUSIONS

These themes are a reminder for health care professionals to spend time looking at, listening to and trying to understand how cancer and its treatments affect the everyday lives of people and families we treat and how this should guide our overall management plan. They teach us the importance of taking time to listen to the stories, responding to the cultural needs of every patient and family member and honoring teach the cancer journeys of all people.

From survivorship to thrivership: native peoples weaving a healthy life from cancer

BACKGROUND

In this commentary, we describe culturally specific cancer support and education programs that have been successfully adapted for use with both urban and reservation-based California Indian communities.

METHODS

The Native American Cancer Survivor Support Circles were initiated in Los Angeles County in 2000 and were tailored for specific use with reservation-based communities in 2002. Support circles include culturally respectful ground rules, prayers, and culturally specific education topics (spirituality, coping with chemotherapy) and psychosocial support as well.

RESULTS AND CONCLUSIONS

Evaluation showed that both Native men and women had greater confidence in their abilities to cope with their healing and recovery from cancer following participation.

An innovative path to improving cancer care in Indian country

The Native American Cancer Survivors' Support Network is an innovative public health program designed to improve survival from cancer and the quality of life after a cancer diagnosis for American Indians, Alaska Natives, and Canadian Aboriginal patients and their loved ones. The Network, initiated in 1999, now has more than 300 survivors enrolled as members. This article briefly describes the process that led to its formation and preliminary findings, primarily for breast cancer survivors, of ongoing qualitative and quantitative research. Network data show patterns of cancer care that are partially responsible for poor survivorship outcomes.

The nurse's role in the informed consent process

OBJECTIVES

To review the informed consent process in relation to oncology nursing roles and responsibilities, patient comprehension, cultural sensitivity, and qualitative methodologies.

DATA SOURCES

Scientific and review articles, regulatory documents, and texts relating to informed consent.

CONCLUSIONS

Nursing is involved in almost every aspect of the informed consent process. To be effective, nurses must be knowledgeable about fundamental concepts associated with informed consent and corresponding responsibilities and willing to address the complexities of the informed consent process.

IMPLICATIONS FOR NURSING PRACTICE

Situations related to informed consent provide challenges and opportunities for professional growth. Keeping abreast of the evolving standards and concepts of informed consent enhances the essential roles that nurses play in clinically based research.

Promoting nurses' positive attitudes toward cancer prevention/screening

BACKGROUND

From 1991 to 1994, a special projects grant to teach nurses cancer prevention/screening theory and clinical skills was developed, implemented, and evaluated. Approximately 60 nurses in Colorado rural settings attended five two-day training sessions over a 20-month period. Attitudes, constructive or destructive, regarding specific behaviors lead to intentions to perform those behaviors and have an important impact on cancer-related nursing practice.

METHODS

Two cancer-related attitude scales, Cancer Prevention/Early Detection Attitude Inventory and Fanslow Cancer Attitudes Scale, were administered prior to the first training session, following the final session, and at six-month follow-up. Data reflecting program impact on nursing practice were obtained from follow-up self-assessment of confidence in implementing new knowledge and skills.

RESULTS

Significant differences in pre- and post-training attitude scores and fairly high-level confidence ratings suggest that these nurses will continue to use their cancer prevention and detection skills in practice.

CONCLUSION

Documentation of practice activities to date has been impressive.

An innovative curriculum plan for advanced practice in oncology nursing

BACKGROUND

The Advanced Practice in Oncology Nursing Program was designed to prepare graduates to manage the cancer experience through the delivery of comprehensive, holistic, oncology-focused care to individuals, families, and communities in a variety of settings.

METHODS

Theoretical course work and clinical practicum are required to complete the degree plan. Students are actively recruited from urban, rural, and underserved population settings. The program is committed to fostering a teaching-learning paradigm that facilitates self-directed learning. The program's basic tenet is that all course offerings will be designed in a distributed learning/distance learning method. Clinical experiences are accomplished in or near the student's home community.

RESULTS

Development and implementation of the program are in process. Shaping a curriculum and learning environment to be consonant with a health care system in a constant state of reform flux is a challenging task.

CONCLUSION

This program's long-term challenge is to remain flexible, collaborative, and futuristic while promoting the expansion of advanced practice in oncology nursing.

The oncology nursing image: lifting the mist

PURPOSE/OBJECTIVES

To examine oncology nurses' perceptions of their professional image and describe implications and strategies for practice.

DATA SOURCES

Individuals in 28 Oncology Nursing Society (ONS) image focus groups and 13 validation focus groups in local ONS chapters throughout the United States.

DATA SYNTHESIS

Although they used both negative and positive descriptors, participants believed the primary perceptions of physicians, administrators, and other nurses regarding oncology nurses were negative, whereas the perceptions of patients and families generally were more positive. Participants believed a lack of understanding exists about oncology nurses, their duties, and the impact of their specialized skills and knowledge on patient-care outcomes. They also believed that the current image of oncology nursing was not one they desired.

CONCLUSIONS

Oncology nurses were concerned about their image and believed their external publics (e.g., physicians, administrators, nononcology nurses, patients, families) did not have a clear picture of who they are and what they do. They felt this lack of understanding led to diminished relationships with colleagues and patients/families and a lack of recognition of the oncology nurse as a valued member of the healthcare team. Participants felt this image could be changed and identified strategies to achieve their desired image through activities related to research, education, professionalism, communication, and influence.

IMPLICATIONS FOR NURSING PRACTICE

Understanding the possible barriers to collaborative relationships, cost-effective care, disparate feelings of colleagues and external publics, and negative stereotypes will foster strategies to enhance relationships and improve care.

Placebo-blinded study of morphine sulfate sustained-release tablets and immediate-release morphine sulfate solution in outpatients with chronic pain due to advanced cancer

PURPOSE

This study was conducted to compare the relative analgesic efficacy and safety of an every-4-hour immediate-release oral morphine (IRM) solution with that of an every-12-hour sustained-release oral morphine (SRM) formulation.

PATIENTS AND METHODS

This was a double-blind, placebo-blinded, crossover study in 34 adult male and female outpatients with pain due to advanced cancer. Baseline data were collected on day 1. On days 2 and 3, randomly assigned patients received either placebo plus IRM (Roxanol; Roxane Laboratories, Inc, Columbus, OH; 20 mg/mL) at 2, 6, and 10 am, and 2, 6, and 10 pm, or alternatively SRM (Oramorph SR; Roxane Laboratories, Inc; 30 mg) at 10 AM and 10 PM. Patients were then crossed over to the alternate treatment for days 4 through 6. Pain relief was measured using a conventional 100-mm visual analog scale (VAS) and by recording the incidence of breakthrough pain. Information on side effects was obtained from VAS scores for sedation, nausea, anxiety, and depression; by directly questioning the patient as to mental confusion, bowel movements, and laxative use; and from Karnofsky performance status scores. VAS data were analyzed using a linear statistical model. Breakthrough pain data were analyzed using analysis of variance (ANOVA).

RESULTS

There were no statistically significant differences between IRM and SRM treatments with respect to VAS pain scores, side effect scores, or incidence of breakthrough pain data. Karnofsky performance scores remained stable for all patients throughout the study.

CONCLUSION

It was concluded that every-12-hour administration of SRM and every-4-hour administration of IRM provide similar analgesic effectiveness and side effect profiles in the treatment of chronic pain in cancer patients.

Malignant melanoma--profile of an epidemic

Cutaneous malignant melanoma is occurring in epidemic proportions in the United States. To provide a profile of persons at risk and the epidemiologic features of malignant melanoma, we reviewed the records of 325 patients with cutaneous malignant melanoma seen at the University of Colorado Health Sciences Center between 1973 and 1983. Most patients had fair skin, brown or blonde hair, blue or green eyes, and had difficulty in suntanning. The majority of melanomas (72%) developed in preexisting nevi. In women, melanomas were most common on the extremities, and in men they occurred most frequently on the trunk, head or neck. The most frequently noted depth of invasion was Clark's level IV. At diagnosis, most of the patients (77%) were at stage I. We conclude that malignant melanoma constitutes a major disease problem in the western United States that is largely preventable with appropriate physician and patient education.