Symptom prevalence, distress, and change over time in adults receiving treatment for lung cancer

Demographic Factors and their Relation to Fatigue and Mental Disorders in 12-Hour Petrochemical Shift Workers

BACKGROUND

Shift workers may be exposed to fatigue and mental disorders due to various work-related risk factors. This study evaluated the impact of demographic characteristics on fatigue and mental disorders among 12-hour shift workers in petrochemical industries.

METHODS

This study was conducted among 290 shift workers of Pardis Petrochemical Company in Iran. Data were collected using a general questionnaire for the demographic characteristic as well as multidimensional fatigue inventory (MFI-20) and general health questionnaire (GHQ-28).

RESULTS

Married workers were less likely to suffer from reduced activity levels (P< 0.027), depression (P< 0.032) and mental disorders (P< 0.040). Social dysfunction score (P< 0.029) and mental disorders (P< 0.048) decreased with shift work experience. Shift workers with non-academic education less likely to suffer from reduced activity levels (P< 0.000) and mental fatigue (P< 0.028).

CONCLUSION

Despite the significant difference between the variables, this study showed a weak effect of individual and occupational demographic characteristics on fatigue and mental disorders.

Supportive care needs and preferences of lung cancer patients: a semi-structured qualitative interview study

PURPOSE

Lung cancer patients report both high levels of unmet supportive care need and underutilisation of support services, but the existing literature offers limited understanding of their specific needs and preferences for help. This study aimed to address this research gap through qualitative exploration of the supportive care needs and preferences of lung cancer patients.

METHODS

Semi-structured interviews were conducted with ten lung cancer patients recruited from the Chest Clinic, Royal Adelaide Hospital (South Australia). Interviews particularly focussed on four key supportive care domains: medical information, physical symptoms, activities of daily living and emotional needs.

RESULTS

Participants reported low use of supportive care services and resources in all four domains. Verbal information from doctors was preferred over printed or online information, and upfront and honest communication was highly valued. Attitude was viewed as important for coping with physical symptoms. Participants demonstrated strong determination to manage activities of daily living independently and, when this was not possible, preferred to seek help from family over external organisations. Support groups and helplines were not utilised for a variety of reasons, although several benefits of connecting with fellow cancer patients were identified.

CONCLUSIONS

The reasons behind underutilisation of supportive care services by lung cancer patients are more complex than simple lack of awareness or availability of services. Information about patients' needs and preferences reveals opportunities for service improvement and alternative models of supportive care.

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

RATIONALE

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

RESULTS

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

CONCLUSIONS

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

Symptom distress in older adults following cancer surgery

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

IMPLICATIONS FOR PRACTICE

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

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

BACKGROUND

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

OBJECTIVE

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

INTERVENTIONS/METHODS

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

RESULTS

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

CONCLUSIONS

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

IMPLICATIONS FOR PRACTICE

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

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

PURPOSE OF THE RESEARCH

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

METHODS AND SAMPLE

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

FINDINGS

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

CONCLUSIONS

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

Identification of symptom clusters among patients with heart failure: an international observational study

BACKGROUND

Virtually all patients with heart failure experience multiple symptoms simultaneously, yet clinicians and researchers usually consider symptoms in isolation. Recognizing and responding early to escalating symptoms is essential to preventing hospitalizations in heart failure, yet patients have considerable difficulty recognizing symptoms. Identification of symptom clusters could improve symptom recognition, but cultural differences may be present that must be considered.

OBJECTIVES

To identify and compare symptom clusters in heart failure patients from the United States, Europe and Asia.

DESIGN

Cross-sectional, observational study.

SETTINGS

In- and out-patient settings in three regions of the world: Asia (i.e., China and Taiwan); Europe (i.e., the Netherlands and Sweden); and the United States.

PARTICIPANTS

A total of 720 patients with confirmed heart failure. Propensity scoring using New York Heart Association Classification was used to match participants from each of the three regions.

METHODS

Symptoms were identified using the Minnesota Living with Heart Failure Questionnaire. To identify symptom clusters we used cluster analysis with the hierarchical cluster agglomerative approach. We used the Euclidean distance to measure the similarity of variables. Proximity between groups of variables was measured using Ward's method. The resulting clusters were displayed with dendrograms, which show the proximity of variables to each other on the basis of semi-partial R-squared scores.

RESULTS

There was a core group of symptoms that formed two comparable clusters across the countries. Dyspnea, difficulty in walking or climbing, fatigue/increased need to rest, and fatigue/low energy were grouped into a cluster, which was labeled as a physical capacity symptom cluster. Worrying, feeling depressed, and cognitive problems were grouped into a cluster, which was labeled as an emotional/cognitive symptom cluster. The symptoms of edema and trouble sleeping were variable among the countries and fell into different clusters.

CONCLUSION

Despite the diversity in cultures studied, we found that symptoms clustered similarly among the cultural groups. Identification of similar symptoms clusters among patients with heart failure may improve symptom recognition in both patients and healthcare providers.

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

CONTEXT

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Functional impairments as symptoms in the symptom cluster analysis of patients newly diagnosed with advanced cancer

CONTEXT

Symptoms and subsequent functional impairment have been associated with the biological processes of disease, including the interaction between disease and treatment in a measurement model of symptoms. However, hitherto cluster analysis has primarily focused on symptoms.

OBJECTIVES

This study among patients within 100 days of diagnosis with advanced cancer explored whether self-reported physical symptoms and functional impairments formed clusters at the time of diagnosis.

METHODS

We applied cluster analysis to self-reported symptoms and activities of daily living of 111 patients newly diagnosed with advanced gastrointestinal (GI), gynecological, head and neck, and lung cancers. Based on content expert evaluations, the best techniques and variables were identified, yielding the best solution.

RESULTS

The best cluster solution used a K-means algorithm and cosine similarity and yielded five clusters of physical as well as emotional symptoms and functional impairments. Cancer site formed the predominant organizing principle of composition for each cluster. The top five symptoms and functional impairments in each cluster were Cluster 1 (GI): outlook, insomnia, appearance, concentration, and eating/feeding; Cluster 2 (GI): appetite, bowel, insomnia, eating/feeding, and appearance; Cluster 3 (gynecological): nausea, insomnia, eating/feeding, concentration, and pain; Cluster 4 (head and neck): dressing, eating/feeding, bathing, toileting, and walking; and Cluster 5 (lung): cough, walking, eating/feeding, breathing, and insomnia.

CONCLUSION

Functional impairments in patients newly diagnosed with late-stage cancers behave as symptoms during the diagnostic phase. Health care providers need to expand their assessments to include both symptoms and functional impairments. Early recognition of functional changes may accelerate diagnosis at an earlier cancer stage.

Symptom and quality of life benefit of afatinib in advanced non-small-cell lung cancer patients previously treated with erlotinib or gefitinib: results of a randomized phase IIb/III trial (LUX-Lung 1)

BACKGROUND

Patient-reported symptom and health-related quality of life (HRQoL) benefit of afatinib, a novel, irreversible, ErbB Family Blocker, was investigated in a double-blind, randomized, phase IIb/III trial (LUX-Lung 1).

METHODS

Five hundred and eighty-five patients with lung adenocarcinoma (stage IIIb/IV), who had progressed after chemotherapy (1-2 lines) and at least 12 weeks of erlotinib or gefitinib, were randomized (2:1) to receive either afatinib plus best supportive care (BSC) or placebo plus BSC. Symptom and HRQoL benefit were measured using the lung cancer-specific European Organisation for Research and Treatment of Cancer (QLQ-C30/LC13) and EuroQol (EQ-5D) questionnaires. Non-small-cell lung cancer-related symptoms (cough, dyspnea, and pain) were prespecified using three preplanned analyses (percentage of patients improved/worsened/stable, change in scores over time, and time to deterioration of scores).

RESULTS

Compared with patients on placebo, a significantly higher proportion of afatinib-treated patients showed an improvement in cough (p < 0.0001), dyspnea (p = 0.006), and pain (p < 0.0001). Afatinib also significantly improved the mean scores over time for cough (p < 0.0001), dyspnea (p = 0.0161), and pain (p = 0.0056); significantly delayed the time to deterioration for cough (p < 0.001); and showed a trend in delaying dyspnea (p = 0.170) and pain (p = 0.287). Consistent with the adverse-event profile of afatinib, a significantly (p < 0.05) higher proportion of afatinib-treated patients showed worsening of diarrhea, sore mouth, dysphagia, and appetite scores. However, compared with placebo, afatinib significantly (p < 0.05) improved QoL assessed with the EQ-5D questionnaire and global health status/QoL, physical functioning, and fatigue, which were assessed with the European Organisation for Research and Treatment of Cancer questionnaires.

CONCLUSION

In the LUX-Lung 1 trial, the addition of afatinib to BSC significantly improved non-small-cell lung cancer-related symptoms (cough, dyspnea, and pain), fatigue, physical functioning, and HRQoL and significantly delayed time to deterioration of cough.

Communicating advanced cancer patients' symptoms via the Internet: a pooled analysis of two randomized trials examining caregiver preparedness, physical burden, and negative mood

BACKGROUND

Using available communication technologies, clinicians may offer timely support to family caregivers in managing symptoms in patients with advanced cancer at home.

AIM

To assess the effects of an online symptom reporting system on caregiver preparedness, physical burden, and negative mood.

DESIGN

A pooled analysis of two randomized trials (NCT00214162 and NCT00365963) was conducted to compare caregiver outcomes at 6 and 12 months after intervention between two randomized, unblinded groups using General Linear Mixed Modeling. Caregivers in one group (Comprehensive Health Enhancement Support System-Only) were given access to an interactive cancer communication system, the Comprehensive Health Enhancement Support System. Those in the other group (Comprehensive Health Enhancement Support System + Clinician Report) received access to Comprehensive Health Enhancement Support System plus an online symptom reporting system called the Clinician Report. Clinicians of patients in the Comprehensive Health Enhancement Support System + Clinician Report group received e-mail alerts notifying them when a symptom distress was reported over a predetermined threshold.

SETTING/PARTICIPANTS

Dyads (n = 235) of advanced-stage lung, breast, and prostate cancer patients and their adult caregivers were recruited at five outpatient oncology clinics in the United States.

RESULTS

Caregivers in the Comprehensive Health Enhancement Support System + Clinician Report group reported less negative mood than those in the Comprehensive Health Enhancement Support System-Only group at both 6 months (p = 0.009) and 12 months (p = 0.004). Groups were not significantly different on caregiver preparedness or physical burden at either time point.

CONCLUSIONS

This study provides new evidence that by using an online symptom reporting system, caregivers may experience less emotional distress due to the Clinician Report's timely communication of caregiving needs in symptom management to clinicians.

Opioids in pain management of mesothelioma and lung cancer patients

BACKGROUND

Lung cancer and mesothelioma are malignant tumors with generally dismal prognosis and therefore palliative pain treatment constitutes a challenge for the clinician.

OBJECTIVES

The aim of this study was to compare the outcomes of pain treatment with opioids among mesothelioma and lung cancer patients treated for palliation and assess factors which confound to optimal treatment.

PATIENTS AND METHODS

A sub-cohort of 373 lung cancer and 22 mesothelioma patients was identified in multi-center European Pharmacogenetic Opioid Study (EPOS) cohort. A nested case-control (1:4) setting was designed to estimate the pain and other covariates distinguishing 22 mesothelioma- (= cases) and 88 lung cancer patients (controls), analyzed using univariate- and multivariate conditional (fixed-effects) logistic regression models.

RESULTS

The mean total daily dose of opioids varied from 30.0 to 960.0 mg (mean 275, median 160 mg, SD 293) in mesothelioma, and from 10 to 5072 mg (mean 414, median 175, SD 788) in lung cancer patients (p = 0.420). In both groups, pain was mostly experienced as moderate and severe and it was frequently accompanied by depression, poor sleep, anxiety and fatigue. Four mesothelioma patients (18%) and seven lung cancer patients (10%) experienced complete pain relief with opioids by self-assessment. Assessments of pain severity by the patients and their physicians deviated significantly in mesothelioma (p = 0.039 McNemar test), as well as in lung cancer (p = 0.0001). In conditional logistic regression, no significant differences were found in distribution of pain covariates between lung cancer and mesothelioma patients.

CONCLUSION

Pain perception by the patients was associated frequently with other symptoms and complete pain control with opioids was achieved only with minority of patients both with mesothelioma and advanced lung cancer. Adequate pain control requires continuous monitoring and tailoring the dose to patient's individual needs and tolerance, recognition of accompanying symptoms such as depression and poor sleep, and their management.

Prevalence, putative mechanisms, and current management of sleep problems during chemotherapy for cancer

Sleep problems are highly prevalent in cancer patients undergoing chemotherapy. This article reviews existing evidence on etiology, associated symptoms, and management of sleep problems associated with chemotherapy treatment during cancer. It also discusses limitations and methodological issues of current research. The existing literature suggests that subjectively and objectively measured sleep problems are the highest during the chemotherapy phase of cancer treatments. A possibly involved mechanism reviewed here includes the rise in the circulating proinflammatory cytokines and the associated disruption in circadian rhythm in the development and maintenance of sleep dysregulation in cancer patients during chemotherapy. Various approaches to the management of sleep problems during chemotherapy are discussed with behavioral intervention showing promise. Exercise, including yoga, also appear to be effective and safe at least for subclinical levels of sleep problems in cancer patients. Numerous challenges are associated with conducting research on sleep in cancer patients during chemotherapy treatments and they are discussed in this review. Dedicated intervention trials, methodologically sound and sufficiently powered, are needed to test current and novel treatments of sleep problems in cancer patients receiving chemotherapy. Optimal management of sleep problems in patients with cancer receiving treatment may improve not only the well-being of patients, but also their prognosis given the emerging experimental and clinical evidence suggesting that sleep disruption might adversely impact treatment and recovery from cancer.

Importance and relevance of pulmonary symptoms among patients receiving second- and third-line treatment for advanced non-small-cell lung cancer: support for the content validity of the 4-item Pulmonary Symptom Index

BACKGROUND

In advanced non-small-cell lung cancer (NSCLC), reducing symptoms can be a meaningful treatment outcome. This study characterizes the pulmonary symptoms of patients receiving second- and third-line systemic therapies for NSCLC and assesses the content validity of the 4-item Pulmonary Symptom Index (PSI) of the Functional Assessment of Cancer Therapy-Lung (FACT-L).

METHODS

Twenty patients with advanced NSCLC undergoing second- and third-line treatment ("qualitative sample") completed semistructured interviews regarding their NSCLC symptoms and the importance of pulmonary symptoms. Results were mapped to the PSI. In addition, existing PSI data from 912 patients with cancer ("validation sample") was analyzed to evaluate the scalability of the 4 PSI items.

RESULTS

In the qualitative sample, mean age was 62 years (range 30-79 years); 80% had nonsquamous histologic type, and 25% had comorbid chronic obstructive pulmonary disease (COPD). A core set of pulmonary symptoms emerged in the data-shortness of breath, cough, and chest tightness. These mapped to 3 PSI items. A quarter of the patients reported an absence of pulmonary symptoms, which supports the inclusion of the final PSI item, "breathing is easy." In the validation sample, for the shortness of breath/breathing ease item pair, weighted kappa representing chance-adjusted agreement ranged from 0.39 to 0.54 and percent agreement from 44% to 49% (both considered moderate), supporting a distinct contribution of each item.

CONCLUSION

The PSI captures the most important and relevant symptoms reported by patients with NSCLC receiving second- and third-line treatment. Our results suggest that the PSI may provide a clinically useful method to measure patient benefit from lung cancer therapies.

Qualitative research into the symptom experiences of adult cancer patients after treatments: a systematic review and meta-synthesis

PURPOSE

This review paper aimed to draw together the findings of qualitative research into the symptom experience of adult cancer patients in order to develop a better understanding of symptom experiences following cancer treatment.

METHODS

Systematic review and meta-synthesis techniques were used to identify, appraise and synthesise the relevant literature.

RESULTS

A thematic account of shared symptom experiences reported across papers is presented. Four main themes are discussed: interaction with health services, changing relationships, changing self and coping. In addition the range of symptoms reported across qualitative cancer research is highlighted.

CONCLUSIONS

Unexpected symptoms can have negative effects on patients who need to be better prepared for long-term symptom experiences. In addition, it is important to acknowledge that patients' symptom experiences do not happen in isolation and should be addressed holistically within the context of patients' lives.

The impact of lung cancer on patients and carers

This article aims to provide a brief review of the literature with regard to the impact of lung cancer on patients and their informal carers. Compared to other types of cancer, the distress associated with lung cancer has been found to be the most intense. Rather than focusing on symptoms in isolation recent emphasis regarding the symptom experience has been on symptoms clusters, as understanding these clusters may improve the management of ongoing and unrelieved symptoms. However, the disparities in methodology are significant barriers to producing comparable results, although recent efforts have been made to address these. Whilst research into symptoms has enormous potential for the management of symptom clusters, it needs to move away from the essentially reductionist stance which currently dominates and broaden its scope to one that acknowledges the complexity of the experience of symptom clusters from the perspective of the patient and their informal carer. Poor management of symptoms complicates patient care and potentially contributes to the heavy burden which often falls on family caregivers, especially as the disease progresses. The majority of studies focus on the experiences of primary care providers, most often the partner/spouse. Such studies have shown that spouses of patients with lung cancer exhibit significant distress and lower levels of quality of life than the general population. Research also indicates that significant others go through a transition process due to changes brought about by the diagnosis of lung cancer and struggle to endure and overcome difficulties and distress. Significant others were seen to suffer during this process of transition and experienced altered relationships. Clinicians working with patients suffering from lung cancer and their carers should intervene to enhance their quality of life from diagnosis, during the disease trajectory and during bereavement. Interventions need to be developed to support both patients and carers.

Functional status in older women following gynecological cancer surgery: can choice of measure influence evidence for clinical practice?

Although functional status serves as a major predictor of morbidity, researchers and clinicians use different terms and measures, limiting comparisons across studies. To demonstrate how differing measures may generate varied findings, we compared and contrasted data from the SF-12 Health Survey Physical Component Summary Scale (SF-12 PCS) and the Enforced Social Dependency Scale (ESDS). The sample consisted of 49 women aged 65 and older recovering from gynecological cancer surgery with data collection at baseline (postoperative period) and then at 3 and 6 months. Analysis of the relationship between SF-12 PCS and ESDS over time using generalized estimating equations (GEE) demonstrated the relationship was less than 1.0, signaling less than perfect agreement between measures (β = 0.16, P = .002). These findings suggest that that the 2 measures are not interchangeable and may produce conflicting evidence. This highlights the importance of researchers' and clinicians' careful conceptualization and operationalization of functional status before measure selection.

Age-related Differences in Symptoms and Their Interference with Quality of Life in 903 Cancer Patients Undergoing Radiation Therapy

OBJECTIVES: To evaluate the relationship of age with symptoms and interference with daily function and QOL during RT. DESIGN: A prospective observational study. SETTING: A university-based radiation oncology department. PARTICIPANTS: 903 cancer patients who received radiation therapy (RT). The mean age was 61 yrs (18-92) and 41% were ≥ 65 yrs. MEASUREMENTS: A symptom inventory was administered pre- and post-RT. Patients rated 10 symptoms and their interference with daily function and QOL on a Likert scale from 0 (not present) to 10 (as bad as possible). A total symptom score was calculated by adding the ratings of individual symptoms. T-tests, Pearson correlation coefficients, and mixed modeling were used to investigate relationships between symptoms and their interference with daily function and QOL. RESULTS: For older and younger patients, the total symptom score worsened during RT (p's < .001). There were no differences in the change in total symptom burden and interference with QOL between older and younger patients during RT. After RT, although younger patients reported significantly worse pain (p = .03), nausea (p <.01), and sleep disturbance (p <.01), symptom interference with walking was more severe in older patients (p = .01). Mixed modeling showed that older age (p=<.001), time of survey (after RT, p<.001), and age*time interaction (p<.001) increased the likelihood of reporting that symptoms interfered with walking. CONCLUSION: The prevalence of symptoms was similar for older and younger patients during RT. Older patients are more likely to report that symptoms interfere with walking after RT.

Natural course of insomnia comorbid with cancer: an 18-month longitudinal study

PURPOSE

This study aimed to assess the prevalence and natural course (incidence, persistence, remission, and relapse) of insomnia comorbid with cancer during an 18-month period.

PATIENTS AND METHODS

All patients scheduled to receive a curative surgery for a first diagnosis of nonmetastatic cancer were approached on the day of their preoperative visit to participate in the study. A total of 962 patients with cancer (mixed sites) completed an insomnia diagnostic interview at the perioperative phase (T1), as well as at 2 (T2), 6 (T3) 10 (T4), 14 (T5), and 18 (T6) months after surgery.

RESULTS

Findings revealed high rates of insomnia at baseline (59%), including 28% with an insomnia syndrome. The prevalence of insomnia generally declined over time but remained pervasive even at the end of the 18-month period (36%). Rates were greater in patients with breast (42% to 69%) and gynecologic (33% to 68%) cancer and lower in men with prostate cancer (25% to 39%) throughout the study. Nearly 15% of patients had a first incidence of insomnia during the study, and 19.5% experienced relapse. The evolution of symptoms varied according to sleep status. Remissions (patients becoming good sleepers) were much less likely for patients with an insomnia syndrome (10.8% to 14.9%) than for those with insomnia symptoms (42.0% to 51.3%). Most frequently (37.6%), patients with an insomnia syndrome at baseline kept that status throughout the 18-month period.

CONCLUSION

Insomnia is a frequent and enduring problem in patients with cancer, particularly at the syndrome level. Early intervention strategies, such as cognitive-behavioral therapy, could prevent the problem from becoming more severe and chronic.

Symptom Prevalence in Advanced Cancer

Age, gender, and performance status (PS) are important patient characteristics which might influence to cancer symptom profile. We conducted a secondary analysis of a symptom database to examine any interaction of these factors on symptom prevalence. 38 symptoms were assessed in 1000 consecutive patients with advanced cancer. The association of the three demographic factors with each symptom was examined using logistic regression analysis. Eight symptoms were associated with more than one of the three factors. Model-based estimates of symptom prevalence were calculated for 30 groups based on combinations of age, gender, and ECOG PS (0-4). Prevalence differences between various groups >10% were empirically classified as clinically relevant. The frequency of all eight symptoms (pain, constipation, sleep problems, nausea, anxiety, vomiting, sedation, and blackouts) was associated with more than one of the demographic characteristics of age, gender, and PS level. The prevalence of all eight decreased with older age. Females had more nausea, anxiety, and vomiting than males; males greater sleep problems. The prevalence of constipation, sedation, and blackouts was higher with worse PS, whereas pain and anxiety became less common with worse PS. Age, gender, and PS appeared to be associated with variations in the prevalence of eight gastrointestinal and neuropsychological symptoms in cancer patients. They should be included as important variables in clinical practice symptom research data.

A longitudinal qualitative analysis of the factors that influence patient distress within the lung cancer population

BACKGROUND

The literature consistently shows that lung cancer patients experience both greater number of symptoms and concerns about health and existential issues compared with patients from other cancer populations and that patient distress near diagnosis predicts survival in lung cancer patients. Also evidence suggests that symptom characteristics (e.g. symptom intensity and frequency) influence distress. The relationship between aspects of patients' symptom experiences can be complex and the mechanisms underpinning this association are not fully understood at present.

METHODS

Semi-structured interviews were conducted with 17 lung cancer patients and 15 primary caregivers at four time points: at the beginning of treatment and then subsequently at three, six, and twelve months, providing a total of 44 patient and 32 caregiver interviews. Interpretative Phenomenological Analysis was employed in the data analysis.

FINDINGS

The analysis presented here concentrates on two areas which was reported to influence distress in this population: (1) patients' perception of symptoms and symptom characteristics and their associated distress; and (2) the relationship between patients' causal reasoning and their distress.

CONCLUSION

The complexity of the issues involved in the development of symptom distress needs to be recognised by health care professionals in this poor prognosis group of patients. Better patient preparation about symptoms may alleviate some of the symptom distress in lung cancer patients.

Significant others' lived experiences following a lung cancer trajectory: from diagnosis through and after the death of a family member

PURPOSE

The purpose of this study was to illuminate the meanings of significant others' lived experiences of their situation from diagnosis through and after the death of a family member as a consequence of inoperable lung cancer.

METHODS

The data was collected through narrative interviews from eleven significant others and interpreted using a phenomenological hermeneutic approach. KEYRESULTS: Four themes emerged: being unbalanced, being transitional, being cared for, and moving forward.

CONCLUSION

The significant others' experiences can be viewed as a transition process, beginning with a sense of dislocation in life and continuing through struggling, enduring and conquering the consequences of the altered life situation until finally approaching a point characterized by a sense of stability. Different strategies of adjustment and adaptation to the new living conditions are considered. Furthermore, the results indicate the need to develop a framework for family-centered health care in order to enhance the wellbeing for the significant others both in the anticipatory grief phase and during the bereavement phase.

Symptoms experienced by cancer patients during the first year from diagnosis: patient and informal caregiver ratings and agreement

OBJECTIVE

The aim of this study was to explore the symptom experience of patients with cancer, identify changes in symptoms over time, and explore the congruence of symptom reports between patients and their informal caregivers.

METHOD

This was a prospective longitudinal evaluation of symptoms over 1 year from start of treatments (T1) using the Memorial Symptom Assessment Scale. Assessments and follow up took place at 3 months (T2), 6 months (T3) and 12 months (T4). A heterogeneous sample of 100 patients with cancer participated, providing 325 assessments over time. Furthermore, 82 caregivers also participated, providing 238 dyadic patient-caregiver assessments over the same time.

RESULTS

The most commonly occurring, and by far most distressing, symptom was "lack of energy." Common symptoms reported were lack of concentration, difficulties sleeping, shortness of breath, cough, pain, dry mouth, and feeling drowsy. Symptom occurrence and distress improved over time, particularly from T2 to T3 (p < 0.05), but the "chronicity" of some generic symptoms was notable. Caregivers tended to overestimate occurrence and distress compared to patients, particularly in symptoms of psychological nature; κ statistics had a highest coefficient of 0.45, suggesting moderate agreement between patients and caregivers at best.

SIGNIFICANCE OF RESULTS

More attention needs to be paid to the commonly reported symptoms by patients, as they have the potential of impacting on quality of life (QOL). As patient-caregiver reports had moderate agreement, effort should be directed to improving this agreement, as caregivers are often communicating patient symptoms to clinicians.

Combining extant datasets with differing outcome measures across studies of older adults after cancer surgery

Combining extant datasets with differing outcome measures, an economical method to generate evidence guiding older adults' cancer care, may introduce heterogeneity leading to invalid study results. We recently conducted a study combining extant datasets from five oncology nurse-directed clinical trials (parent studies) using norm-based scoring to standardize the differing outcome measures. The purpose of this article is to describe and analyze our methods in the recently completed study. Despite addressing and controlling for heterogeneity, our analysis found statistically significant heterogeneity (p < 0.0001) in temporal trends among the five parent studies. We concluded that assessing heterogeneity in combined extant datasets with differing outcome measures is important to ensure similar magnitude and direction of findings across parent studies. Future research should include investigating reasons for heterogeneity to generate hypotheses about subgroup differences or differing measurement domains that may have an impact on outcomes.

Factors affecting recovery of functional status in older adults after cancer surgery

OBJECTIVES

To explore factors influencing functional status over time after cancer surgery in adults aged 65 and older.

DESIGN

Secondary data analysis of combined data subsets.

SETTING

Five prospective, longitudinal oncology nurse-directed clinical studies conducted at three academic centers in the northwest and northeast United States.

PARTICIPANTS

Three hundred sixteen community-residing patients diagnosed with digestive system, thoracic, genitourinary, and gynecological cancers treated primarily with surgery.

MEASUREMENTS

Functional status, defined as performance of current life roles, was measured using the Enforced Social Dependency Scale and the Medical Outcomes Study 36-item Short-Form Survey (using physical component summary measures) after surgery (baseline) and again at 3 and 6 months. Number of symptoms, measured using the Symptom Distress Scale, quantified the effect of each additional common cancer symptom on functional status.

RESULTS

After controlling for cancer site and stage, comorbidities, symptoms, psychological status, treatment, and demographic variables, functional status was found to be significantly better at 3 and 6 months after surgery than at baseline. Factors associated with better functional status included higher income and better mental health. Factors associated with poorer average functional status were a greater number of symptoms and comorbidities. Persons reporting three or more symptoms experienced statistically significant and clinically meaningful poorer functional status than those without symptoms. Persons reporting three or more comorbidities were also found to have poorer functional status than those without comorbidities. No significant relationship existed between age and functional status in patients aged 65 and older.

CONCLUSION

Factors other than age affect recovery of functional status in older adults after cancer surgery.

Individual breathlessness trajectories do not match summary trajectories in advanced cancer and chronic obstructive pulmonary disease: results from a longitudinal study

Breathlessness is a distressing symptom in advanced disease. Little is known about the trajectories of this symptom over time and towards death. This study aimed to describe and compare the summary and individual trajectories of breathlessness and overall symptom burden over time and towards the end of life following patients with advanced cancer or severe chronic obstructive pulmonary disease (COPD) in inpatient and outpatient health care settings in Germany. The modified Borg Scale, Memorial Symptom Assessment Scale Short Form and Palliative Outcome Scale were used as outcome measures. Data were collected at baseline and then monthly over six months or until death. Forty-nine cancer and 60 COPD patients were included. Both groups had similar demographics. Thirty out of the 49 cancer and 6/60 COPD patients died, 7/49 cancer and 20/60 COPD patients dropped out due to physical deterioration or questionnaire fatigue. In cancer patients, breathlessness increased towards death. In COPD patients, breathlessness increased over time. Twenty-one cancer and 43 COPD patients provided data for individual breathlessness trajectories. These revealed wide individual variations with four different patterns: fluctuation, increasing, stable and decreasing breathlessness. Symptom trajectories on the population level reflecting the whole group mask individual variation, which is reflected in distinct symptom trajectories with different patterns.

A systematic review of the effectiveness of problem-solving approaches towards symptom management in cancer care

AIMS

To investigate the evidence of problem-solving approach interventions on symptom management in cancer care.

BACKGROUND

Symptom-related problems are a common challenge in cancer care. The problem-solving approach is one strategy of cognitive behavioural therapy used to help patients with cancer self-manage their symptoms. However, no systematic review has investigated the effectiveness of this approach.

DESIGN

Systematic review.

METHOD

A systematic search for intervention studies using randomised controlled designs, controlled clinical trial and quasi-experimental studies designs was conducted using the following electronic databases: EBSCO host, CINAHL (1991-2008), Medline (1975-2009), Electronic Periodical Services (Chinese) and Electronic Theses and Dissertations System (Taiwan).

RESULTS

Seven studies published in English between 1975-2009 were included in this systematic review. All studies were randomly assigned and almost all studies demonstrated the positive effects of a problem-solving approach in reducing symptomatic problems in the target participants. Varying protocols and qualities of methodological design (14% good, 43% fair and 43% poor) were found in this review.

CONCLUSIONS

This systematic review highlighted the potential of a problem-solving approach in the management of symptom problems in patients with cancer. However, more rigourous studies are needed and a better evaluation of the most effective problem-solving approach protocols is required.

RELEVANCE TO CLINICAL PRACTICE

Cancer care nurses should explore the use of problem-solving approach interventions in their practice as the evidence base suggests the value of this approach--but caution is needed in regard to the precise structure of the problem-solving approach protocol.

Symptoms, psychological distress, and supportive care needs in lung cancer patients

PURPOSE

The purpose of this study was to examine the level of symptoms, psychological distress, and supportive care needs and factors related to five unmet need domains in lung cancer patients.

METHODS

A cross-sectional study of 152 lung cancer patients at a medical center in Taiwan assessed their symptoms, psychological distress, and unmet supportive needs in five major care domains. Logistic regression was applied to examine the related factors of unmet supportive care needs.

RESULTS

In general, patients had mild-to-moderate levels of symptoms and high prevalence of psychological distress. Regardless of their treatment status, they reported high levels of supportive care needs. The top three need domains were: (1) health system and information, (2) psychological, and (3) patient care and support. Levels of symptoms, anxiety, and depression were the most significant factors in unmet supportive care needs.

CONCLUSION

The effect of symptoms and psychological distress on unmet supportive care needs is substantial. Therefore, a systematic assessment of patients' distress and care needs is important for clinical lung cancer care. Further intervention consisting of symptom management, continuing counseling, and preparation for transition from active treatment to the follow-up stages are essential in improving quality of care.

Depression may mediate the relationship between sense of coherence and quality of life in lung cancer patients

Lung cancer patients generally experience high levels of physical and psychological distress and decreased quality of life (QOL). Sense of coherence (SOC) has been conceptualized as a personality orientation reflecting the degree to which an individual perceives their world as comprehensible, manageable and meaningful. The present study investigated the associations of SOC with QOL in lung cancer. It also examined potential psychological mediators by which SOC may exert its influences on QOL. Fifty-six participants with non-small cell lung cancer were administered self-report assessments of SOC, QOL and psychological distress. Results revealed that SOC was positively associated with QOL and this relationship may be mediated by depressive symptoms. The current study supports the notion that SOC may be a protective factor with regard to psychological adjustment and QOL in cancer survivors.

Symptom clusters in men and women with heart failure and their impact on cardiac event-free survival

BACKGROUND

Because patients with heart failure (HF) experience multiple symptoms simultaneously, it is necessary to explore symptom clusters rather than individual symptoms to determine their impact on outcomes. Given gender differences in symptom experience, examination of potential gender differences in clusters is reasonable.

OBJECTIVE

The objective of the study was to compare symptom clusters between men and women with HF, differences in patient characteristics among symptom clusters, and the impact of symptom clusters on cardiac event-free survival.

METHODS

A total of 331 patients with HF recruited from HF clinics were included (35% were female and 62% were of New York Heart Association classes III/IV). Cluster analysis was used to identify symptom clusters between men and women based on ratings of distress related to 7 symptoms. Analysis of variance or chi test was used to compare characteristics of patient groups that were divided by the median split of total distress scores of each cluster. Cox proportional hazards regression was used to determine whether total scores of symptom distress in symptom clusters predicted time to first cardiac event.

RESULTS

Two identical symptom clusters were identified in men and women: a physical symptom cluster composed of dyspnea, fatigue/increased need to rest, fatigue/low energy, and sleep disturbances and an emotional/cognitive symptom cluster composed of worrying, feeling depressed, and cognitive problems. Patients with higher distress from the physical symptom cluster were primarily females and of New York Heart Association classes III and IV (P < .05). Patients with higher distress from the emotional/cognitive symptom cluster were younger than those with lower distress (P < .05). The total symptom distress score in the emotional/cognitive cluster, but not the physical cluster, was an independent predictor of cardiac event-free survival (hazard ratio, 1.18; 95% confidence interval, 1.03-1.37).

CONCLUSION

Although distress for individual symptoms may differ between men and women, they both experienced identical symptom clusters. Only the emotional/cognitive cluster predicted a higher risk for a cardiac event. These results suggested that interventions should be developed that consider symptom clusters. Targeting patients who have high distress from emotional/cognitive symptoms may be particularly important as they may be most vulnerable for adverse outcomes.

Equity of use of specialist palliative care by age: cross-sectional study of lung cancer patients

The equitable provision of care is a core principle of the National Health Service. Previous research has suggested that older cancer patients may be less likely to use specialist palliative care, but such research has been limited by retrospective design and the failure to measure clinical need. The objective of this study was to examine the extent to which the use of specialist palliative care in lung cancer patients varies by age, after accounting for need. A cross-sectional survey of patients and their carers attending four hospital lung cancer clinics in London was conducted between June 2006 and April 2007. Two hundred and fifty-two patients and 137 carers participated in the study. Thirty-nine percent of participants received specialist palliative care. Metastatic disease, global quality of life and the clinic where treatment was provided were associated with use of specialist palliative care. Age, gender, deprivation, living alone, current or most recent line of treatment, number of co-morbidities and carer stress were not associated with receipt of such services. This suggests that, for patients within the specialist cancer care system, access to specialist palliative care is offered on the basis of need.