Exploring Inflammation and Stress as Biological Correlates of Symptoms in Children With Advanced Cancer: A Longitudinal Feasibility Study

Background: Few studies have examined biomarkers of stress and inflammation as underlying mechanisms of symptoms in adolescents and young adults with cancer. This study determined the feasibility of collecting blood and saliva samples across time, described the range and distribution of biomarkers, and explored the association of biomarkers with symptom adverse events (AEs). Method: This longitudinal, prospective repeated-measures single-site feasibility study recruited N  =  10 children (M = 12.5 years) receiving treatment for advanced cancer. Symptom AE data and inflammation (cytokines and C-reactive protein) and physiologic response to stress (salivary cortisol and salivary alpha-amylase) biomarker levels were collected at three time points. Descriptive statistics were used to examine feasibility and acceptability and to summarize symptom AE, stress, and inflammatory biomarker data. A linear regression model was used to determine cortisol diurnal slopes. The relationship between symptom and inflammatory biomarker data was explored and Hedges's g statistic was used to determine its effect size. Results: Participants provided 83% of saliva samples (n  =  199/240) and 185 samples were sufficient to be analyzed. Nurses collected 97% (n  =  29/30) of blood samples. Participants reported the saliva collection instructions, kits, and reminders were clear and helpful. Insomnia, pain, fatigue, and anxiety demonstrated the most medium and large negative effects with inflammatory markers. Symptom AEs demonstrated the highest number of medium and large negative effects with interleukin-8 and tumor necrosis factor-alpha (-0.53 to -2.00). Discussion: The results indicate longitudinal concurrent collection of symptom and biomarker data is feasible and inflammatory and stress biomarkers merit consideration for inclusion in future studies.

"There is no expiration date": a qualitative analysis using the Social Cognitive Theory to identify factors influencing physical activity among adults living with advanced cancer

PURPOSE

To identify cognitive, behavioral, environmental, and other factors that influence physical activity in adults with advanced cancer using qualitative, semi-structured interviews.

METHODS

Eighteen semi-structured interviews were conducted with adults living with stage IV breast, prostate, or colorectal cancer; or multiple myeloma recruited from the University of Wisconsin Carbone Cancer Center. We used the Social Cognitive Theory to design the interview guide and a reflexive thematic approach for analysis.

RESULTS

Participants were 62 years old on average and currently receiving treatment. Despite reporting numerous barriers to physical activity, most participants discussed engaging in some physical activity. Participants reported difficulties coping with changes in physical functioning especially due to fatigue, weakness, neuropathy, and pain. While cold weather was seen as a deterrent for activity, access to sidewalks was a commonly reported feature of neighborhood conduciveness for physical activity. Regardless of current activity levels, adults with advanced cancer were interested in engaging in activities to meet their goals of gaining strength and maintaining independence. Having a conversation with a provider from their cancer care team about physical activity was seen as encouraging for pursuing some activity.

CONCLUSIONS

Adults living with advanced cancer are interested in pursuing activity to gain strength and maintain independence despite reported barriers to physical activity. To ensure patients are encouraged to be active, accessible resources, targeted referrals, and interventions designed to address their goals are critical next steps.

RELEVANCE

Integrating conversations about physical activity into oncology care for adults living with advanced cancer is an important next step to encourage patients to remain active and help them improve strength and maintain quality of life and independence.

A Systematic Review of the Characteristics and Effects of Physical Activity Interventions on Physical Activity Engagement, Long-Term and Late Effects, and Quality of Life in Adolescent and Young Adult Cancer Survivors

Physical activity (PA) may minimize long-term and late effects experienced by cancer survivors. However, the efficacy of PA interventions in increasing PA engagement among adolescent and young adult (AYA) cancer survivors diagnosed between 15 and 39 is not well understood. This systematic review aimed to examine the effects of moderate- to high-intensity or strength training PA interventions on PA engagement in AYA cancer survivors. Secondary aims included describing intervention components unique to efficacious interventions, identifying symptom management in PA interventions, and evaluating intervention effects on quality of life (QoL), and long-term or late effects of cancer. We searched PubMed, CINAHL, PsycINFO, SportDiscus, Cochrane Library, and Scopus databases from inception to August 2022 and identified 12 articles, including 8 randomized controlled trials and 4 quasi-experimental studies. The effect of PA interventions on PA engagement was mixed, with four studies reporting increases in PA engagement ranging from 18.4 to 113.8 min/week postintervention. There was great diversity in PA intervention components. Motivational interviewing, supervised and unsupervised PA sessions together, moderate-intensity PA only, and mindful meditation were components unique to efficacious interventions. No intervention incorporated symptom management components. Studies provided some evidence of PA interventions on potential long-term effects of cancer, with positive impact on fatigue, and some evidence of improved anxiety, sleep, and QoL. Given limited research with AYA cancer survivors, additional research is needed to identify effective intervention components, integrate symptom management strategies into PA interventions, and track effects of PA interventions on late and long-term effects of cancer in this population.

A Midwest Stakeholder Evaluation of an Adolescent and Young Adult Cancer Survivor Needs Assessment Survey

Purpose: Over 87,000 adolescents and young adults (AYAs) are diagnosed with cancer in the United States each year. Improvement in outcomes in the AYA population has lagged that of both younger and older patients. This decrement may be attributable to several factors, including insufficient supportive care services. Our team modified the Needs Assessment & Service Bridge (NA-SB) tool, utilizing an iterative approach with patient and clinician stakeholders to meet the needs of the AYA population at a large Midwestern Cancer Center. Methods: We recruited a 10-member AYA Advisory Board (AB) from our Cancer Center patients, and met five times over 9 months to discuss supportive care and the NA-SB. We recruited a multidisciplinary group of oncology clinicians to assess content validity and conducted interviews with nine clinician stakeholders to discuss implementation. Results: The AB generated a 59-item-modified NA-SB, retaining most of the original NA-SB items and adding several more. Five items with concerns for relevance and/or clarity were revised to create the final 58-item-modified NA-SB. Priorities for implementation were identified by AB and clinician stakeholders. Conclusions: The modified NA-SB thoroughly reflects supportive care needs of our Midwestern AYA cancer survivors. When implemented, the tool may facilitate patient-care team communication and provide data to prioritize development of new supportive care resources. AYA cancer survivors have unique supportive care needs that are insufficiently addressed by current care models; using the modified NA-SB may help address those needs, leading to improved AYA outcomes.

Change in alcohol consumption during the Covid-19 pandemic and associations with mental health and financial hardship: results from a survey of Wisconsin patients with cancer

PURPOSE

Alcohol consumption increases health risks for patients with cancer. The Covid-19 pandemic may have affected drinking habits for these individuals. We surveyed patients with cancer to examine whether changes in drinking habits were related to mental health or financial effects of the pandemic.

METHODS

From October 2020 to April 2021, adult patients (age 18-80 years at diagnosis) treated for cancer in southcentral Wisconsin were invited to complete a survey. Age-adjusted percentages for history of anxiety or depression, emotional distress, and financial impacts of Covid-19 overall and by change in alcohol consumption (non-drinker, stable, decreased, or increased) were obtained via logistic regression.

RESULTS

In total, 1,875 patients were included in the analysis (median age 64, range 19-87 years), including 9% who increased and 23% who decreased drinking. Compared to stable drinkers (32% of sample), a higher proportion of participants who increased drinking alcohol also reported anxiety or depression (45% vs. 26%), moderate to severe emotional distress (61% vs. 37%) and viewing Covid-19 as a threat to their community (67% vs. 55%). Decreased (vs. stable) drinking was associated with higher prevalence of depression or anxiety diagnosis, emotional distress, and negative financial impacts of the pandemic. Compared to non-drinkers (36% of sample), participants who increased drinking were more likely to report emotional distress (61% vs. 48%).

CONCLUSIONS

Patients with cancer from Wisconsin who changed their alcohol consumption during the Covid-19 pandemic were more likely to report poor mental health including anxiety, depression, and emotional distress than persons whose alcohol consumption was stable.

IMPLICATIONS FOR CANCER SURVIVORS

Clinicians working with cancer survivors should be aware of the link between poor mental health and increased alcohol consumption and be prepared to offer guidance or referrals to counseling, as needed.

Cancer-Related Symptom Frameworks Using a Biopsychosocial-Spiritual Perspective: A Scoping Review

BACKGROUND

Research to understand and manage cancer-related symptoms continues to advance, yet work that more fully adopts a biopsychosocial-spiritual view of symptoms is needed.

OBJECTIVE

The purpose of this article is to review existing frameworks that have the potential to guide research on cancer-related symptoms, to explore the characteristics of each framework, and to appraise each using a biopsychosocial-spiritual lens.

METHODS

A scoping review was conducted to identify available frameworks that could be applied to guide cancer-related symptom research and to assess their characteristics. Research questions and criteria were formulated at the outset, followed by identifying relevant publications detailing novel frameworks, charting data, and collating results. Upon identification of available frameworks, each was appraised for alignment with a standard definition of "biopsychosocial-spiritual."

RESULTS

Eleven frameworks were identified to guide cancer-related symptom research. All were developed in the United States, led by nurse scientists, including symptom experiences as well as their antecedents and outcomes, and could be applied to one or more concurrent cancer-related symptoms. While all 11 frameworks included biopsychosocial dimensions, only 4 included spirituality.

CONCLUSIONS

Four biopsychosocial-spiritual frameworks offer unique insight to support advancement of cancer-related symptom research and practice from a holistic perspective. This foundational work could lead to development and validation of new frameworks and modification of existing frameworks to more closely align with a biopsychosocial-spiritual view of cancer-related symptoms. This review offers a starting point to carefully and explicitly adopt frameworks in research and practice with increased emphasis on considering spiritual dimensions of symptoms.

PSYCHONEUROLOGICAL SYMPTOMS IN CANCER SURVIVORS AND THEIR CAREGIVERS: A LONGITUDINAL PILOT STUDY

In cancer patients, stress is associated with a psychoneurologic symptom cluster of depressed mood, anxiety, pain, fatigue, and sleep disturbance. The stress of caregiving may trigger similar symptoms among caregivers and warrants investigation. The purpose of this analysis was to characterize correlates of psychoneurologic symptoms in cancer caregivers. Cancer survivor-caregiver dyads (n=29) provided eight weekly symptom reports using a web-based assessment system. Symptom burden was calculated as the sum of symptom severity (mean=7.5, SD=8.1, range=0-41). Primary and secondary stressors of caregiving were also assessed. Mixed modeling was used, accounting for repeated measures. Models controlled for person-mean of time varying covariates, as well as sociodemographic, clinical, and care-related covariates. A secondary analysis assessed interdependence in survivor and caregiver symptoms using Actor-Partner Interdependence Models. In descriptive analyses, caregivers most frequently reported feeling anxious (44% on average across timepoints), sleep problems (31%), fatigue (25%), depressed mood (24%), and feeling irritable/angry (24%). Within caregivers, greater hours of care (beta=0.11, p<.01) and more patient symptoms (beta=0.10, p<.01) were associated with greater symptom burden. Between caregivers, higher baseline perceived stress was associated with greater symptom burden (beta=0.38, p=.04) and coresidence with the survivor was associated with lower symptom burden (beta=-12.8, p<.01). Caregivers experienced higher symptoms when patients specifically reported anxiety, lack of appetite, or pain (beta=1.4, 2,4, and 3.0, p<.05). Cross-lagged Actor-Partner Interdependence Models indicated interdependence among survivor and caregiver symptom burden. The findings provide preliminary evidence of the interrelationship of psychoneurologic symptoms in survivors and patients, with implications for symptom management and supportive care practice.

Revisiting patient-related barriers to cancer pain management in the context of the US opioid crisis

ABSTRACT

Patient fear of addiction is a well-documented barrier to the use of analgesic medications for cancer pain control. Over the past 2 decades in the United States, an "opioid crisis" has arisen, accompanied by risk messages delivered through news outlets, public health education, and patient-provider communication. The purpose of this study was to determine if patient-related barriers to cancer pain management-specifically, fears of addiction-and related pain outcomes (pain severity, pain interference with daily life, and adequacy of pain management) have worsened over the last 20 years. A sample of 157 outpatients with active recurrent or active metastatic cancer completed the Barriers Questionnaire-II (BQ-II) and measures of pain and analgesic use. We identified 7 comparison studies published between 2002 and 2020 that reported patient-related barriers using the BQ-II. Significant linear relationships were found between later year of publication and greater fear of addiction (harmful effect subscale score, B = 0.0350, R2 = 0.0347, F1,637 = 23.19, P < 0.0001) and between year of publication and more pain management barriers overall (total BQ-II score, B = 0.039, R2 = 0.065, F1,923 = 73.79, P < 0.0001). Relationships between BQ-II scores (harmful effect and total) and pain outcomes did not change over time. Despite worsening in patient-related barriers, the proportion of patients with adequate vs inadequate analgesic use did not differ over time. Notably, 40% of participants reported inadequate analgesic use, a statistic that has not improved in 20 years. Additional research is necessary to clarify factors contributing to changing beliefs. Findings indicate a continuing need for clinical and possibly system/policy-level interventions to support adequate cancer pain management.

Randomized controlled trial of a brief cognitive-behavioral strategies intervention for the pain, fatigue, and sleep disturbance symptom cluster in advanced cancer

OBJECTIVE

Patients receiving treatment for advanced cancer suffer significant symptom burden, including co-occurring pain, fatigue, and sleep disturbance. There is limited evidence for effective interventions targeting this common symptom cluster.

METHODS

A randomized controlled trial of a brief cognitive-behavioral strategies (CBS) intervention was conducted. A sample of 164 patients with advanced cancer receiving chemotherapy practiced imagery, relaxation, and distraction exercises or listened to cancer education recordings (attention-control) to manage co-occurring pain, fatigue, and sleep disturbance over a 9-week period. Symptom cluster severity, distress, and interference with daily life were measured at baseline and 3, 6, and 9 weeks. We also evaluated the moderating influence of imaging ability and number of concurrent symptoms, and mediating effects of changes in stress, anxiety, outcome expectancy, and perceived control over symptoms.

RESULTS

Compared with the cancer education condition, participants receiving the CBS intervention reported less symptom cluster distress at week 6 (M = 1.82 vs 2.15 on a 0-4 scale, P < .05). No other group differences were statistically significant. The number of concurrent symptoms moderated the intervention effect on symptom cluster interference. Changes in stress, outcome expectancy, and perceived control mediated the extent of intervention effects on symptom outcomes, primarily at weeks 6 and 9.

CONCLUSIONS

The brief CBS intervention had limited effects in this trial. However, findings regarding potential mediators affirm hypothesized mechanisms and provide insight into ways to strengthen future interventions to reduce the suffering associated with co-occurring pain, fatigue, and sleep disturbance.

Prevalence, Duration, Severity, and Distress of Chemotherapy-Related Gastrointestinal Symptoms in Patients With a Hematologic Malignancy

PURPOSE/OBJECTIVES

To describe prevalence, duration, severity, and distress of chemotherapy-related gastrointestinal (GI) symptoms, and evaluate inclusion of clinically relevant GI symptom items on cancer symptom questionnaires.
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DESIGN

Longitudinal descriptive design.
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SETTING

Inpatient and outpatient hematology settings.
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SAMPLE

105 adults with a hematologic malignancy receiving their third or subsequent cycle of chemotherapy. 
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METHODS

Participants completed weekly assessments of 19 GI symptoms during a three-week period of chemotherapy. Descriptive statistics were calculated to summarize GI symptom prevalence, duration, severity, and distress ratings at each week. Findings were compared to item content of 12 cancer multisymptom questionnaires identified in the literature.
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MAIN RESEARCH VARIABLES

GI symptom prevalence, duration, severity, and distress.
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FINDINGS

Participants reported an average of three to five GI symptoms at each time point that were typically experienced as mild to moderate in duration, severity, and distress. Only 3 of 11 clinically relevant GI symptoms were included on more than half of the cancer symptom questionnaires. 
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CONCLUSIONS

Patients receiving chemotherapy experience a moderate GI symptom burden across a wide range of potential GI symptoms.
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IMPLICATIONS FOR NURSING

Future research should include measures of clinically relevant GI symptoms that may be emerging with new cancer therapies and toxicity prevention protocols.

Use of Art-Making Intervention for Pain and Quality of Life Among Cancer Patients: A Systematic Review

BACKGROUND

Although pain is one of the most prevalent symptoms among cancer patients, medications do not always result in sufficient pain relief. Furthermore, these medications only address the physical component of pain. Art making, a holistic approach, may distract the user's attention from pain and allow expression of the nonphysical (e.g., psychological, spiritual) components of pain. The purpose of this systematic review was to evaluate evidence for the efficacy of art-making interventions in reducing pain and improving health-related quality of life (QoL) among cancer patients.

METHOD

PubMed, Academic Search Premier, ProQuest, and CINAHL were searched from database inception to September 2016 using the following search terms: neoplasm, cancer, tumor, pain, pain management, quality of life (QoL), well-being, art therapy, painting, and drawing.

RESULTS

Fourteen articles reporting 13 studies were reviewed. Some studies reported beneficial effects of art making on pain and QoL, but the evidence was weakened by poor study quality ratings, heterogeneity in art-making interventions and outcome measures, interventions including non-art-making components, and few randomized controlled studies.

CONCLUSION

More rigorous research is needed to demonstrate the efficacy of art making in relieving cancer-related pain and improving QoL.

A Community Needs Assessment for Palliative Care Services from a Hospice Organization

BACKGROUND

Palliative care is described as comprehensive care focused on preventing or relieving physical, emotional, psychological, and spiritual suffering in patients with life-threatening illnesses. As national interest in increasing access to palliative care grows, hospice organizations may consider expanding their missions to provide palliative care to individuals with chronic and life-limiting illnesses who do not meet traditional hospice criteria. Before expanding operations, hospice organizations must know if there is need and support within the communities they serve.

OBJECTIVE

The purpose of this study was to assess perceived need for palliative care services in a small metropolitan area in the Midwest served by a nonprofit community-based hospice organization.

DESIGN

A survey approach was used.

SETTINGS/SUBJECTS

Surveys were distributed to health care professionals and lay individuals in the community by mail or in person. A total of 576 surveys were distributed; 195 were completed and returned.

RESULTS

While the majority of professionals reported being comfortable providing palliative care, services were not perceived as widely available. Both health care professional and lay respondents knew someone who could benefit from palliative care services and believed it would be helpful to develop or increase palliative care for persons with chronic illnesses who are not yet terminally ill. A majority of professionals reported they were willing to refer patients for services, but were concerned that patients would be hesitant to accept such care from a hospice organization. Lay individuals indicated they would be willing to accept such services, particularly if insurance covered the cost.

CONCLUSIONS

Several issues need further exploration before hospice organizations expand their missions.

Imaging ability and effective use of guided imagery

Imaging ability, the ability to generate mental images and become absorbed in them as if they were real, is proposed as a moderator in the relationship between guided imagery and symptom relief. Two existing measures of image generation, Marks's (1973) Vividness of Visual Imagery Questionnaire and Betts's (1909) shortened Questionnaire Upon Mental Imagery (Sheehan, 1967), and one measure of absorption, Tellegen's Absorption scale (1993; TAS) were completed by 60 graduate students prior to listening to a guided imagery intervention to relieve anxiety associated with an upcoming stressful task. Analyses were conducted using data from 30 participants (7 men and 23 women) who reported an increase in anxiety level after learning of the stressful task. Participants were divided into two groups, successful (n=21) and unsuccessful (n=9) users of imagery, based on change in anxiety scores after listening to the guided imagery intervention. Absorption (TAS) scores were significantly higher for persons in the successful group; there were no differences in image generation scores. Two TAS items were identified as potential predictors of success with guided imagery. Findings may be helpful in developing a clinically useful instrument to predict likelihood of success with guided imagery in relieving cancer pain and its distress.

Postmastectomy pain syndromes

Pain associated with cancer and its treatment continues to be a significant concern for those persons diagnosed with the illness. This article will focus on pain syndromes associated with surgical interventions for women with breast cancer. Postmastectomy pain syndromes including postaxillary dissection pain and phantom breast pain will be described in terms of their nature, incidence, and temporal course based on current literature findings. Treatment strategies and implications for nursing interventions employed in caring for these women will also be discussed. Nurses can use information about postmastectomy pain syndromes to educate their patients, to cooperate in successfully managing effects of the disease and treatment, and to help women cope after breast cancer surgery.