Smoking cessation is challenging even after lung cancer surgery

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Background: It is recommended that patients undergoing lung cancer surgery quit smoking pre-operatively to reduce peri- operative complications. Smoking cessation after diagnosis is associated with improved clinical outcomes. Few studies have examined the behavior of surgical lung cancer patients who are smokers. We sought to 1) determine the smoking prevalence rate at diagnosis; 2) identify readiness to quit and cessation strategies, 3) describe patterns of smoking overtime, and 4) identify factors (demographic, tobacco-related, and health status) correlating with smoking relapse and/or continued smoking (SR) after surgery. Methods: Ninety-four patients were enrolled in a descriptive study. Data were collected through chart review and standardized tobacco and health status questionnaires. Smoking status was assessed through self-report and measurement of urinary cotinine. The primary endpoints were smoking status at 1, 2, and 4 months after surgery. Frequencies, t-tests, and chi-square were used for analysis. Results: Eighty-four patients (89%) were ever-smokers and 35 (42%) reported smoking at diagnosis. Twenty-nine (83%) current smokers attempted cessation at diagnosis and 18 (51%) received assistance with pharmacotherapy being the most common strategy. One month post-operatively, 20 (56%) self-reported smokers planned to quit within the following month. Fifty (60%) ever-smokers remained abstinent, 13 (15%) continued smoking, and 21 (25%) relapsed. Ten (48%) of those who relapsed were former smokers and had not smoked for at least a year before diagnosis. Factors significantly associated with SR included younger age, lower education and pain. Those who relapsed were on average 7 years younger (p=0.01). Those without high school education (HS) had a significantly higher rate of relapse as compared to those with at least HS (83% vs. 48%, p=0.04). Those with pain had a higher rate of relapse as compared to those who did not have pain (73% vs. 33%, p=0.03). Conclusions: Smoking relapse rates are high after lung cancer surgery even among those who previously quit. Former and current smokers are at high risk for relapse and will require smoking cessation programs incorporating symptom management and relapse prevention.

No significant financial relationships to disclose.

The silent epidemic: tobacco and the evolution of lung cancer and its treatment

Considered a rare disease during the 19th century, lung cancer became the most virulent and lethal cause of cancer mortality by the end of the 20th century. In this paper, lung cancer and its treatment are addressed within the social, cultural, economic, and political context of the last century. Because lung cancer is related to the consumption of cigarettes, the battles over tobacco control are highlighted. Four time periods are addressed: the early years (1900-1930), beginning of the epidemic (1930-1960), defining the problem (1960-1980), and expanding options (1980-1990s). Although improvements have been made in science and technology, attempts at finding curative treatments have met with little success. Smoking cessation and efforts to control tobacco (especially among children and adolescents) remain the most important factors if the incidence of lung cancer is to be curtailed in the future. Providing care to individuals with the illness is a current challenge. Research examining the efficacy of treatments and their effect on survival, health-related quality of life, and cost outcomes is essential and can be best achieved through the efforts of multidisciplinary teams.

A specialized home care intervention improves survival among older post-surgical cancer patients

CONTEXT

Changes in the healthcare system have resulted in shortened hospital stays, moving the focus of care from the hospital to the home. Patients are discharged post-operatively with ongoing needs, and whether they receive nursing care post-hospitalization can influence their recovery and survival. Little information is available about the factors that influence outcomes, including the survival of older cancer patients after cancer surgery.

OBJECTIVE

To compare the length of survival of older post-surgical cancer patients who received a specialized home care intervention provided by advanced practice nurses (APNs) with that of patients who received usual follow-up care in an ambulatory setting. We also assessed potential predictors of survival in terms of depressive symptoms, symptom distress, functional status, comorbidities, length of hospital stay, age of patient, and stage of disease.

DESIGN

A randomized controlled intervention study.

SETTING

Discharged older cancer patients after surgery at a Comprehensive Cancer Center in southeastern Pennsylvania.

PATIENTS

Three hundred seventy-five patients aged 60 to 92, newly diagnosed with solid cancers, were treated surgically between February 1993 and December 1995. One hundred ninety patients were randomized to the intervention groups and 185 to the usual care group.

INTERVENTION

The intervention was a standardized protocol that consisted of standard assessment and management post-surgical guidelines, doses of instructional content, and schedules of contacts. The intervention lasted 4 weeks and consisted of three home visits and five telephone contacts provided by APNs. Both the patients and their family caregivers received comprehensive clinical assessments, monitoring, and teaching, including skills training.

MAIN OUTCOME MEASURE

Time from enrollment of patients into the study until death or last date known alive at the end of November 1996.

RESULTS

During the 44-month follow-up period, 93 (24.8%) of 375 patients died. Forty-one (22%) of those who died were patients in the specialized home care intervention group, compared with 52 (28%) in the usual care group. Stage of disease at diagnosis differed between the two groups at baseline (38% late stage patients in the intervention group compared with 26% in the control group, P = .01), so stratified analysis was performed. Overall, the specialized home care intervention group was found to have increased survival (P = .002 using stratified log-rank test). Among early stage patients only, there was no difference in survival between the intervention and control groups. Among late stage patients, there was improved survival in the intervention group. For example, 2-year survival among late stage intervention group cases was 67% compared with 40% among control cases. When Cox's proportional hazard model was used to adjust for significant baseline covariates, the relative hazard of death in the usual care group was 2.04 (CI: 1.33 to 3.12; P = .001) after adjusting for stage of disease and surgical hospitalization length of stay.

CONCLUSIONS

This is the first empirical study of post-surgical cancer patients to link a specialized home care intervention by advanced practice nurses with improved survival. Additional research is needed to test home care interventions aimed at maintaining quality of life outcomes and their effects on survival of post-surgical cancer patients.

Symptoms in adults with lung cancer. A systematic research review

Health care providers play a key role in providing adequate symptom management and promoting quality of life during chronic illness. Several studies have noted that adults with lung cancer experience more symptom distress than patients with other types of cancer. Therefore, symptom management in this group of patients is particularly important. An understanding of the research conducted in this area is important for further knowledge development and for potentially improving symptom management. This paper presents a systematic review of empirical studies examining symptoms in adults with lung cancer. The results of this systematic review revealed that although major strides have been made in understanding symptoms associated with lung cancer, further progress is needed to decrease the morbidity associated with uncontrolled symptoms. Theoretical, conceptual, and/or methodological issues identified through this review must be addressed in future research. In particular, the researcher should provide information about the theoretical or empirical framework guiding the study, give an explicit definition about the dimensions of the symptom experience being studied, report refusal rates and attrition, and use instruments that are reliable and valid.

Analysis and evaluation of the Trajectory Theory of Chronic Illness Management

The development and testing of theories for use in nursing research and practice is essential for advancement of the profession. The Trajectory Theory of Chronic Illness Management is a middle-range nursing theory that has been proposed by Corbin and Strauss (1991a). Analysis and evaluation of this theory was performed using Fawcett and Downs's (1992) guidelines. Theory analysis and evaluation are important first steps before using a theory for practical purposes. Theory analysis makes a theory more understandable and helps to identify the strengths and weaknesses of the theory. Evaluation extends the analysis process by making judgments about the potential contribution of the theory based on published data. Results of the theory analysis and evaluation suggest that the Trajectory Theory has theoretical and social significance but that further theoretical work is necessary to enhance the internal consistency and parsimony of the theory. Although several authors have suggested that the theory has pragmatic adequacy, evidence for empirical adequacy of the theory is needed. Before more empirical studies are conducted, further theoretical work is recommended.

Testing a theory for health-related quality of life in cancer patients: a structural equation approach

The purpose of this study was to test a Roy Adaptation Model-based theory of health-related quality of life in patients with newly diagnosed cancer. Using a structural equation model, health-related quality of life (HRQOL) was regarded as a latent variable measured by 4 empirical indicators representing the 4 biopsychosocial response modes of the Roy Adaptation Model (RAM). The response modes are physiologic, self-concept, interdependence, and role function. These were empirically represented by physical symptoms, affective status, social support, and functional support, respectively. In this secondary analysis, 3 RAM propositions were tested in a sample of 375 newly diagnosed postsurgical cancer patients 60 years and over. These were: (a) that the 4 response modes are interrelated; (b) that environmental stimuli of gender, race, age, income, marital status, cancer treatment, and severity of illness influence the biopsychosocial response modes; and (c) that the biopsychosocial responses soon after diagnosis predict biopsychosocial responses 3 months later. The analyses did not support the proposition that all 4 response modes were interrelated. The results, however, revealed that severity of illness and adjuvant cancer treatment had the strongest association with the biopsychosocial responses and should be considered the focal environmental stimuli. The remaining environmental stimuli can be considered contextual. Also, the proposition that initial biopsychosocial responses predicted later responses was supported.

Cultural assessment of black American men treated for prostate cancer: clinical case studies

PURPOSE/OBJECTIVES

To describe aspects of culturally competent care. Two case studies of black American men who received treatment for prostate cancer are presented to illustrate the use of the explanatory model of illness as a guide for conducting a cultural assessment.

DATA SOURCES

Published articles, abstracts, and books; case studies developed from interviews of black American men who received treatment for prostate cancer.

DATA SYNTHESIS

The explanatory model of illness provides a vehicle for healthcare providers to examine the cultural values and health beliefs of the individual seeking professional healthcare. Knowledge about cultural values and beliefs is essential in order to provide culturally competent care. Beliefs about health and illness, use of a lay referral system, use of folk treatments, and the importance of family, community, and spiritual support are some of the cultural concepts that must be considered.

CONCLUSIONS

Culture exerts an important influence on the illness experience of individuals seeking health care. However, culture has not received the same attention as biopsychosocial factors in nursing care. Given the increasing racial and ethnic diversity of the U.S. population, cultural competence must assume a more central role in healthcare delivery. Knowledge and mutual respect for cultural differences are necessary for culturally competent care to become a reality in a changing healthcare environment.

IMPLICATIONS FOR NURSING PRACTICE

Oncology nurses need to increase their awareness of cultural variations and include them in the patient's plan of care.

Quality of life in persons with non-small cell lung cancer: a concept analysis

Quality of life, as a concept, has received increased attention in recent years. In fact, issues related to quality of life have been identified as among the top three priorities for research by the Oncology Nursing Society. Several nurse investigators have underscored the importance of quality of life research as an outcome measure to evaluate the effectiveness of nursing interventions. Given its significance in contemporary nursing practice, a clear understanding of the definition and dimensions of quality of life is essential for future development of an empirical knowledge base for practice. This article presents a concept analysis of quality of life as it relates to the health care of individuals with non-small cell lung cancer. An evolutionary method of concept analysis is used as a guide for examining the historical context of the concept, defining the concept, identifying antecedents, recognizing consequences, and distinguishing related concepts. A theoretical model of health-related quality of life is proposed on the basis of this analysis, and future directions for research in this population are discussed.

Palliative care: past, present, and future perspectives

OBJECTIVES

To provide a review of the development and impact of palliative care; to discuss quality of lie as a framework for guiding clinical practice and research in palliative care; and to identify future trends that are likely to affect palliative care services.

DATA SOURCES

Research studies, review articles, and book chapters.

CONCLUSIONS

Palliative care is in the process of dynamic change. Advocates of palliative care are suggesting that cost-effective holistic care strategies should be available to patients and families throughout the illness trajectory, not just reserved for end of life care.

IMPLICATIONS FOR NURSING PRACTICE

Incorporation of palliative care principles across the cancer illness trajectory requires an attitude shift by all members of the multidisciplinary team.

Lung cancer in African Americans. A call for action

PURPOSE

The authors present information about current trends in the incidence, risk factors, types, presentation, and treatment for lung cancer common to all Americans and highlight factors that are unique to African Americans. Barriers to effective care and strategies for implementing culturally competent programs for lung cancer are outlined.

OVERVIEW

Disparity in the incidence and mortality rates of cancer between African Americans and white Americans has been increasing at an alarming rate since 1950. For African-American men and women, lung cancer accounted for the largest increase in the incidence of cancer between 1988 and 1992: African-American men experienced an increase of 170%, and African-American women had a dramatic increase of 464%. Lung cancer is by far the most common cause of cancer death in this population, accounting for 32% of the mortality rate in men and 20% in women. Unfortunately, lung cancer in African Americans has received little attention, and culturally competent programs are needed urgently to promote lung cancer prevention, early detection, and treatment in this population.

CLINICAL IMPLICATIONS

Healthcare providers' lack of knowledge about cultural influences on care is a barrier to providing adequate healthcare to individuals of different ethnic groups. Knowledge about cultural differences, respect for individual opinions about health and illness, and ability to negotiate differences are essential qualities for health professionals who serve culturally diverse populations. Because of the morbidity and mortality rates associated with lung cancer in the African-American population, prevention, early detection, and treatment programs are needed urgently. However, for these programs to succeed, the multidisciplinary cancer care team (nurses, physicians, social workers, psychologists, health educators, clergy) must provide information and care in culturally appropriate ways. Partnerships with family, extended kin networks, and religious and community leaders are essential. Finally, to minimize morbidity and maximize quality of life during the illness trajectory, comprehensive education and supportive care services are needed for those who have been diagnosed with lung cancer.

A test of the fit between the Corbin and Strauss Trajectory Model and care provided to older patients after cancer surgery

The Corbin and Strauss Trajectory Model proposed that nursing care should differ along a trajectory of eight phases to meet patients' and families' needs. Seventy-nine patients with breast, prostate, or gastrointestinal cancer were determined to be in either the stable or the unstable phase of their illness. Contrary to expectations, documented nursing interventions did not significantly differ between stable and unstable trajectory phases, although significant differences were found when comparisons were made across cancer sites. These findings suggest that the trajectory framework may require modification for use with oncology patients.

Development and testing of the symptom experience scale

The Symptom Experience Scale (SES) was designed to measure women's experience of symptoms associated with treatment for breast cancer. The SES, a modification of McCorkle's Symptom Distress Scale, was developed and tested in a sample of 252 women with breast cancer. Exploratory factor analysis yielded six factors, which used all 24 SES items and accounted for 83.2% of the variance. The factors were nausea and appetite, fatigue and sleep, concentration, appearance, bowel pattern, and pain. Cronbach's alpha internal consistency reliability coefficients ranged from 0.92 to 0.96; the alpha for the total SES was 0.94. Subscale to subscale correlations ranged from 0.21 to 0.56. Additional research is recommended with samples large enough to permit confirmatory factor analysis and determine the stability of the factor structure identified in the present study. Additional research also is recommended to determine the applicability of the SES for men and women of diverse ethnic groups with various types of cancer and other chronic illnesses.

Patient literacy and the readability of written cancer educational materials

PURPOSE/OBJECTIVES

The purpose of this study was to determine whether the reading level of educational materials for patients with cancer corresponds to the reading abilities of a sample of patients. A secondary aim was to describe what type of educational materials patients with cancer report as most helpful.

DESIGN

Descriptive, cross-sectional.

SETTING

Outpatient oncology clinics at an urban Veterans Affairs Medical Center.

SAMPLE

A convenience sample of 63 outpatients with cancer.

METHODS

Investigators used the Word Recognition Achievement Test-Revised Level (WRAT-R2) to measure patients' reading levels. They used the Flesch Index to analyze the reading levels of the booklets that the patients used (14 booklets developed by the American Cancer Society and 16 developed by the National Cancer Institute). Data were analyzed through descriptive statistics and a Wilcoxon signed rank test.

MAIN RESEARCH VARIABLES

Patient and booklet reading levels.

FINDINGS

The reading level of 27% of the sample was less than that of all 30 pamphlets (less than a sixth-grade reading level). Seventeen percent of the patients had a reading level between sixth and eighth grades (representing 47% of the pamphlets). Twenty-nine percent of the sample had WRAT scores between 9th and 12th grades (representing 80% of the pamphlets). Only 27% had WRAT scores of the 13th grade and above. Twenty-six percent of the patients preferred written educational materials alone, while 57% of patients desired more than one method of instruction.

CONCLUSION

Written materials for the education of patients with cancer must be carefully matched to patient reading levels. Written materials may not be the only desirable mode of instruction.

IMPLICATIONS FOR NURSING PRACTICE

Given the increasing complexity of cancer care, shorter hospital stays, and a shift toward busy ambulatory care centers, nurses need to develop creative, innovative, and comprehensive patient education programs that are understandable to patients and that use multiple types of instruction.

Alpha-2 adrenergic receptors in the bovine retina. Presence of only the alpha-2D subtype

PURPOSE

To identify and characterize the alpha-2 adrenergic receptor subtypes present in the bovine neurosensory retina.

METHODS

Radioligand saturation and inhibition binding assays were performed with the antagonist radioligands [3H]RX821002 and [3H]rauwolscine.

RESULTS

[3H]RX821002 bound to a single class of receptors with the characteristics of an alpha-2 adrenergic receptor with an affinity (KD) of 0.16 nM and a receptor density (Bmax) of 1500 fmol/mg protein. Correlation of the affinities (pKi values) for nine antagonists in the bovine neurosensory retina with the alpha-2D receptor of the bovine pineal gave a correlation coefficient of 0.99. The correlation coefficients for the alpha-2A (0.84), alpha-2B (0.36), and alpha-2C (0.39) subtypes were much lower. The presence of a minor population of alpha-2B or alpha-2C receptors was excluded.

CONCLUSIONS

A high density of alpha-2D adrenergic receptors is present in the bovine neurosensory retina. Neither the alpha-2B nor the alpha-2C subtype is detectable.

A pain syndrome associated with large adrenal metastases in patients with lung cancer

We report two cases of a pain syndrome caused by large adrenal metastases in patients with lung cancer. A review of the literature identified 23 previously reported patients with primary lung cancers who appear to have had a similar syndrome, although in none of these cases were other likely causes of the pain syndrome carefully excluded. The syndrome characteristically includes unilateral flank pain but may have abdominal components as well, and has only been reported in patients with large metastases (> or = 5 cm in largest diameter). Although the mechanism by which large adrenal metastases cause the pain syndrome is not clear, we suggest that treatment that includes local anesthetic agents or steroids may be effective. The pain syndrome caused by large adrenal metastases is not included in reviews of cancer pain syndromes but needs to be considered in the differential diagnosis of patients with lung cancer and flank or abdominal pain.

The ambulatory oncology nurse's role

The increasing complexity of cancer care in the ambulatory setting results in the role of the ambulatory oncology nurse being pivotal to ensuring quality health care. Nurses have created a variety of multifaceted roles that include the staff nurse, advanced practice nurse, clinical trials nurse, office nurse, and the head nurse or nurse manager. Common issues encountered by the ambulatory oncology nurse are telephone triage, limitation of time, and transition of care.

Cisplatin: a clinical review. Part II--Nursing assessment and management of side effects of cisplatin

Cisplatin is one of the most active cancer treatment agents available. Unfortunately, however, cisplatin causes many untoward side effects. Nurses play a major role in administering cisplatin and in preventing and managing the adverse effects associated with this drug. In order to maximize the quality of life of patients undergoing cisplatin treatment, nurses need a thorough knowledge of its uses, administration, and side effects. This article is the second of a two-part series about cisplatin. Part I provided a review of the mechanism of action, current uses, and administration guidelines. Part II discusses the most common side effects of cisplatin and the appropriate nursing assessment and management of patients undergoing treatment with this agent. In addition, future directions for the use of cisplatin and the use of alternative agents will be discussed.

Cisplatin: a clinical review. Part I--Current uses of cisplatin and administration guidelines

Cisplatin is one of the most active cancer treatment agents available. Unfortunately, however, cisplatin causes many untoward side effects. Nurses play a major role in administering cisplatin and in preventing and managing the adverse effects associated with this drug. In order to maximize the quality of life of patients undergoing cisplatin treatment, nurses need a thorough knowledge of its uses, administration, and side effects. This article is the first of a two-part series about cisplatin. Part I will provide a review of the mechanism of action, current uses, and administration guidelines. Part II will discuss the most common side effects of cisplatin and the appropriate nursing assessment and management of patients undergoing treatment with this agent. In addition, future directions for the use of cisplatin and the use of alternative agents will be discussed.

Bereavement care. A role for nurses

Bereavement care is an important, yet often forgotten, area of care. Evidence suggests that early and prompt interventions for high-risk individuals can facilitate grief and can minimize the adverse consequences of grief. Nurses can play a pivotal role in providing care to bereaved individuals. However, it is essential to have a thorough knowledge of the normal grief response, and a framework for assessment and management. This article provides fundamental information about the manifestations of grief, and offers information about appropriate nursing assessment and management for bereaved individuals.

Skin colonization with antibiotic-resistant (JK group) and antibiotic-sensitive lipophilic diphtheroids in hospitalized and normal adults

A strict nutritional requirement for lipid and similar components of cell wall fatty acids and sugars are features common to both JK coryneforms (JK) that are resistant to multiple antibiotics and to lipophilic diphtheroids (LD) that are sensitive to antibiotics. We surveyed 123 subjects for LD and JK. Twenty-eight patients with leukemia (776 samples) were cultured longitudinally during 42 hospitalizations; 15 other patients hospitalized for at least two weeks and 80 controls were sampled once. JK were isolated from at least one of four skin sites in 82.1% of the leukemic patients, 73.3% of other patients, and 15.7% of controls. There was an inverse correlation between the density of LDs and JKs in all groups (P = .03). The perineum was the most frequent, and usually the first, site of JK colonization. Once present, colonization persisted for as long as follow-up continued. Systemic vancomycin did not eliminate or prevent skin colonization with JK. Leukemic patients may have a greater risk of JK infection but probably no increased risk of skin colonization.