Feasibility of implementing acupuncture in medically underserved breast cancer survivors (FAB): A protocol

Nearly 94% of breast cancer survivors experience one or more symptoms or side effects during or after endocrine therapy. Joint pain, hot flashes, sleep disturbance, fatigue, depression, and anxiety are the most common concurrent symptoms, some of which can persist for 5 to 10 years. Acupuncture is a holistic modality that addresses multiple symptoms and side effects in a single therapy. Acupuncture has not yet been investigated for its effectiveness in treating the multiple symptoms experienced by breast cancer survivors receiving endocrine therapy. Medically underserved breast cancer survivors typically have limited access to acupuncture. The barriers limiting access to acupuncture need to be removed to enable equal access to breast cancer survivors for this evidence-based treatment. Thus, we developed a randomized controlled trial with a 5-week acupuncture intervention versus usual care for medically underserved breast cancer survivors. Mixed methods (semi-structured interviews, surveys, study notes) will be used to obtain in-depth understanding of barriers and facilitators for eventual implementation of the acupuncture intervention. This study will facilitate the widespread implementation, dissemination, and sustained utilization of acupuncture for symptom management among medically underserved breast cancer survivors receiving endocrine therapy.

Predictors of the multidimensional symptom experience of lung cancer patients receiving chemotherapy

PURPOSE

Few studies have examined interindividual variability in the symptom experience of lung cancer patients. We aimed to identify the most prevalent, severe, and distressing symptoms, and risk factors associated with increased symptom burden.

METHODS

Lung cancer patients (n = 145) reported occurrence, severity, and distress for 38 symptoms on the Memorial Symptom Assessment Scale 1 week after chemotherapy. Using multidimensional subscales, risk factors for higher global distress, physical, and psychological symptoms were evaluated using simultaneous linear regression.

RESULTS

Mean age was 64.0 years and 56.6% were female. Mean Karnofsky Performance Status score was 79.1 (SD 14.6) and mean Self-Administered Comorbidity Questionnaire score was 7.3 (SD 3.9). The most distressing and prevalent symptom was fatigue. Problems with sexual interest/activity had the highest mean severity rating. Patients with lower functional status (p = 0.001) and higher comorbidity (p = 0.02) reported higher global distress. Similarly, lower functional status (p = 0.003) and higher comorbidity (p = 0.04) were associated with a higher physical symptom burden along with lower body mass index (p = 0.02). Higher psychology symptom burden was associated with lower functional status (p = 0.01), younger age (p = 0.02), non-metastatic disease (p = 0.03), higher number of prior treatments (p = 0.04), and income (p = 0.03).

CONCLUSIONS

Fatigue was the most distressing and prevalent symptom among lung cancer patients receiving chemotherapy. Lower functional status was associated with a higher burden of global distress, physical, and psychological symptoms. Younger age and non-metastatic disease were additional risk factors for increased psychological symptoms. Together, these risk factors can help clinicians identify lung cancer patients at increased need for aggressive symptom management.

No Differences in Symptom Burden Between Colorectal Cancer Patients Receiving Curative Versus Palliative Chemotherapy

CONTEXT

Colorectal cancer (CRC) is one of the most common cancers worldwide. Patients with CRC may have multiple cooccurring symptoms as a result of their disease or its treatment. Little is known about potential differences in symptom burden in CRC patients scheduled to receive curative versus palliative chemotherapy (CTX).

OBJECTIVES

The purposes of this study were to investigate the overall symptom burden of patients with CRC before their first CTX treatment or before the initiation of a new CTX regimen and to evaluate for differences in symptom occurrence, severity, and distress between patients with CRC who were scheduled to receive curative versus palliative CTX.

METHODS

Consecutive patients with CRC were recruited (n = 120), and symptoms were assessed using the Memorial Symptom Assessment Scale before the initiation of the CTX. The most common symptoms that occurred in ≥30% of the patients were evaluated. Differences in occurrence rates and severity and distress scores between the curative (n = 68) and palliative (n = 52) patient groups were evaluated using binary logistic regression and ordinal logistic regression analyses, respectively.

RESULTS

In both groups, patients reported an average of 10 cooccurring symptoms. Worrying (65%), lack of energy (59%), feeling drowsy (54%), feeling bloated (53%), pain (51%), and difficulty sleeping (50%) were the most prevalent symptoms. Problems with sexual interest had the highest severity and distress scores in both groups. For the 13 most common symptoms, no significant differences were found between the two patient groups on any of the Memorial Symptom Assessment Scale dimensions (i.e., occurrence, severity, distress).

CONCLUSION

Regardless of the reason for CTX, CRC patients experience a large number of cooccurring symptoms.

Clinicians' Perspectives on Managing Symptom Clusters in Advanced Cancer: A Semistructured Interview Study

CONTEXT

Managing symptom clusters or multiple concurrent symptoms in patients with advanced cancer remains a clinical challenge. The optimal processes constituting effective management of symptom clusters remain uncertain.

OBJECTIVES

To describe the attitudes and strategies of clinicians in managing multiple co-occurring symptoms in patients with advanced cancer.

METHODS

Semistructured interviews were conducted with 48 clinicians (palliative care physicians [n = 10], oncologists [n = 6], general practitioners [n = 6], nurses [n = 12], and allied health providers [n = 14]), purposively recruited from two acute hospitals, two palliative care centers, and four community general practices in Sydney, Australia. Transcripts were analyzed using thematic analysis and adapted grounded theory.

RESULTS

Six themes were identified: uncertainty in decision making (inadequacy of scientific evidence, relying on experiential knowledge, and pressure to optimize care); attunement to patient and family (sensitivity to multiple cues, prioritizing individual preferences, addressing psychosocial and physical interactions, and opening Pandora's box); deciphering cause to guide intervention (disaggregating symptoms and interactions, flexibility in assessment, and curtailing investigative intrusiveness); balancing complexities in medical management (trading off side effects, minimizing mismatched goals, and urgency in resolving severe symptoms); fostering hope and empowerment (allaying fear of the unknown, encouraging meaning making, championing patient empowerment, and truth telling); and depending on multidisciplinary expertise (maximizing knowledge exchange, sharing management responsibility, contending with hierarchical tensions, and isolation and discontinuity of care).

CONCLUSION

Management of symptom clusters, as both an art and a science, is currently fraught with uncertainty in decision making. Strengthening multidisciplinary collaboration, continuity of care, more pragmatic planning of clinical trials to address more than one symptom, and training in symptom cluster management are required.

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.