Randomized Clinical Trial of the Effectiveness of a Self-Care Intervention to Improve Cancer Pain Management

Cancer pain: perspectives of a medical oncologist

Pain is highly prevalent in cancer patients and primarily managed by medical oncologists. This article reviews cancer pain syndromes related to cancer and sequelae of treatment. We discuss the assessment and treatment of cancer pain with pharmacotherapy and chemotherapy, and the role of pain specialists. There are numerous barriers to care, which arise from both the physician and patient. We review approaches that diminish these barriers to improve treatment of cancer pain.

Effect of a population-based educational intervention focusing on end-of-life home care, life-prolonging treatment and knowledge about palliative care

The effectiveness of population-based educational interventions in palliative care is unclear. We conducted an educational intervention study for the general public focusing on end-of-life home care, life-prolonging treatment and knowledge about palliative care and measured the change in perception about these issues. Participants were recruited from the 11 districts of Fukushima City, Japan. One-hour educational lectures were conducted in each district from April 2006 to March 2007. Meetings were held in a community centre or hall in each district. We asked participants to fill in a questionnaire before and after the educational lecture. Of 607 participants, 595 (98%) answered both pre- and post-intervention questionnaires. The feasibility of a home death changed from 9% before to 34% after the intervention (P < 0.001). In addition, preference for life-prolonging treatment and attitudes toward end-of-life care including symptom management at home, misconceptions about opioids, artificial hydration and communication issues between patient and medical practitioners were significantly improved after the intervention. Factors that were significantly associated with changing perceptions about the feasibility of a home death were male gender, change in beliefs regarding burden to family caregivers, anxiety regarding admission to the hospital with worsening physical condition and fear that pain would not be relieved at home. This population-based educational intervention was effective in changing beliefs regarding the feasibility of home care, preference for life-prolonging treatment and attitudes toward end-of-life care.

Western worms! Explication of aspects of health care behavior among Chamorro with HIV/AIDS

By means of critical ethnography with a focus on historical dimensions, this article delineates the ways Chamorro with HIV/AIDS negotiate interaction with Western health staff. This effort targets a largely unstudied and disenfranchised population of a U.S. territory (Guam) through qualitative methods. Results indicate that (a) foundational historical patterns inform covert behaviors, that is, the longstanding colonization of Chamorro culture has implications for communication, and (b) the residual influence of the investigation of lytico-bodig affects conceptualization and discussion of disease. At the same time, historically grounded forms such as the use of healers offer clients culturally sanctioned means of resistance to hegemonic medical structures. Findings have implications for nursing practice in the clinical setting.

Patient training in cancer pain management using integrated print and video materials: a multisite randomized controlled trial

Standard guidelines for cancer pain treatment routinely recommend training patients to reduce barriers to pain relief, use medications appropriately, and communicate their pain-related needs. Methods are needed to reduce professional time required while achieving sustained intervention effectiveness. In a multisite, randomized controlled trial, this study tested a pain training method versus a nutrition control. At six oncology clinics, physicians (N=22) and nurses (N=23) enrolled patients (N=93) who were over 18 years of age, with cancer diagnoses, pain, and a life expectancy of at least 6 months. Pain training and control interventions were matched for materials and method. Patients watched a video followed by about 20 min of manual-standardized training with an oncology nurse focused on reviewing the printed material and adapted to individual concerns of patients. A follow-up phone call after 72 h addressed individualized treatment content and pain communication. Assessments at baseline, one, three, and 6 months included barriers, the Brief Pain Inventory, opioid use, and physician and nurse ratings of their patients' pain. Trained versus control patients reported reduced barriers to pain relief (P<.001), lower usual pain (P=.03), and greater opioid use (P<.001). No pain training patients reported severe pain (>6 on a 0-10 scale) at 1-month outcomes (P=.03). Physician and nurse ratings were closer to patients' ratings of pain for trained versus nutrition groups (P=.04 and <.001, respectively). Training efficacy was not modified by patient characteristics. Using video and print materials, with brief individualized training, effectively improved pain management over time for cancer patients of varying diagnostic and demographic groups.

Overcoming barriers to cancer pain management: an institutional change model

The Agency for Health Care Policy and Research Pain Guidelines of 1994 recognized pain as a critical symptom that impacts quality of life (QOL). The barriers to optimum pain relief were classified into three categories: patient, professional, and system barriers. A prospective, longitudinal clinical trial is underway to test the effects of the "Passport to Comfort" innovative intervention on pain and fatigue management. This article reports on preintervention findings related to barriers to pain management. Cancer patients with a diagnosis of breast, lung, colon, or prostate cancer who reported a pain rating of >/=4 were accrued. Subjects completed questionnaires to assess subjective ratings of overall QOL, barriers to pain management, and pain knowledge at baseline and at one- and three-month evaluations. A chart audit was conducted at one month to document objective data related to pain management. The majority of subjects had moderate (4-6 on a 0-10 numeric rating scale) pain at the time of accrual. Patient barriers to pain management existed in attitudes and knowledge regarding addiction, tolerance, and not being able to control pain. Subjects who were currently receiving chemotherapy were reluctant to communicate their pain with health care professionals. Professional and system barriers were focused around screening, documentation, reassessment, and follow-up of pain. Lack of referrals to supportive care services for patients was also noted. Several well-described patient, professional, and system barriers continue to hinder efforts to provide optimal pain relief. Phase II of this initiative will attempt to eliminate these barriers using the "Passport" intervention to manage cancer pain.

Palliative care needs of cancer outpatients receiving chemotherapy: an audit of a clinical screening project

PURPOSE

Although more and more cancer patients are receiving chemotherapy in outpatient settings in their advanced stage and could have a broad range of palliative care needs, referral to the specialized palliative care service is often delayed. The primary aim of this study is to explore the usefulness of a combined intervention for cancer patients in identifying patients with under-recognized palliative care needs and referring them to the specialized palliative care service. The intervention consisted of (1) introducing the specialized palliative care service when starting chemotherapy, (2) using screening tools, and (3) providing on-demand specialized palliative care service.

MATERIALS AND METHODS

All cancer patients newly starting chemotherapy with primary tumor sites of the lung, gastrointestine, pancreas, bile duct, breast, ovary, and uterus were included. As routine practice, at the first instruction about chemotherapy, pharmacists provided information about the role of the specialized palliative care service using a pamphlet and handed out screening questionnaires. Screening questionnaires were distributed at every hospital visit. Treating physicians and/or nurses checked the questionnaire before examining the patients. The patients were referred to the palliative care team, if (1) the patients voluntarily wished for the specialized palliative care service or (2) the treating physicians clinically determined that, on the basis of the screening results, the patients had physical or psychological needs appropriate for referral to the specialized palliative care service. The screening questionnaire included an open-ended question about their greatest concerns, the severity of 11 physical symptoms, overall quality-of-life, the distress thermometer, help for information about the treatment and decision-making, economic problems, nutrition, daily activities, and wish for help from the specialized palliative care service.

RESULTS

Of 211 patients who newly started chemotherapy, 5 patients refused to complete the questionnaire (compliance rate, 98%). We obtained 1,000 questionnaires from 206 patients. The percentages of missing values ranged from 2.7% to 7.0%. Of 206 patients, 38 (18%) were referred to the palliative care team due to newly recognized problems, in addition to 10 patients with problems well-recognized by primary physicians. The total percentage of patients receiving specialized palliative care service was thus 23% of all patients. Frequently identified problems were oral problems (20%), insomnia (20%), help with information and decision-making (16%), psychological distress defined as the distress thermometer (14%), severe fatigue (9.0%), and severe appetite loss (8.8%). As a whole, problems were identified in half of all questionnaires.

CONCLUSION

The combined intervention of introducing the specialized palliative care service, using screening tools and providing on-demand specialized palliative care service, was feasible as part of the routine clinical practice for all cancer patients starting chemotherapy. It might be useful in identifying patients with under-recognized palliative care needs and referring them to the specialized palliative care service at the appropriate time.

Reducing medical costs and improving quality via self-management tools

The authors consider the advantages and limitations of self-management tools used for treating chronic illness.

The PRO-SELF® Pain Control Program Improves Patients' Knowledge of Cancer Pain Management

PURPOSE/OBJECTIVES

To evaluate the effectiveness of a psychoeducational program (i.e., PRO-SELF Pain Control Program) compared to standard care in increasing patients' knowledge regarding cancer pain management.

DESIGN

Randomized clinical trial.

SETTING

Seven outpatient settings in northern California.

SAMPLE

174 outpatients with cancer and pain from bone metastasis.

METHODS

Following randomization into either the PRO-SELF or standard care group, patients completed the Pain Experience Scale (PES) prior to and at the completion of the intervention.

MAIN RESEARCH VARIABLES

Total and individual item scores on the PES.

FINDINGS

Total PES knowledge scores increased significantly in the PRO-SELF group (21%) compared to the standard care group (0.5%). Significant improvements in knowledge scores for patients in the PRO-SELF group were found on five of the nine PES items when compared to baseline scores.

CONCLUSIONS

The PRO-SELF Pain Control Program was an effective approach to increase patients' knowledge of cancer pain management.

IMPLICATIONS FOR NURSING

The use of a structured paper-and-pencil questionnaire, such as the PES, as part of a psychoeducational intervention provides an effective foundation for patient education in cancer pain management. Oncology nurses can use patients' responses to this type of questionnaire to individualize the teaching and to spend more time on the identified knowledge deficits. This individualized approach to education about pain management may save staff time and improve patient outcomes.

The use of a responder analysis to identify differences in patient outcomes following a self-care intervention to improve cancer pain management

Previously, we demonstrated, in a randomized clinical trial, the effectiveness of a psychoeducational intervention to decrease pain intensity scores and increase patients' knowledge of cancer pain management with a sample of oncology patients with pain from bone metastasis. In the present study, we evaluated for changes in mood states (measured using the Profile of Mood States), quality of life (QOL; measured using the Medical Outcomes Study Short Form-36 (SF-36)), and pain's level of interference with function (measured using the Brief Pain Inventory (BPI)) from baseline to the end of the intervention first between the intervention and the standard care groups and then within the intervention group based on the patients' level of response to the intervention (i.e., patients were classified as non-responders, partial responders, or responders). No differences were found in any of these outcome measures between patients in the standard care and intervention groups. However, when patients in the intervention group were categorized using a responder analysis approach, significant differences in the various outcome measures were found among the three respondent groups. Differences in the physical and mental component summary scores on the SF-36 and the interference items on the BPI, among the three respondent groups, were not only statistically significant but also clinically significant. The use of responder analysis in analgesic trials may help to identify unique subgroups of patients and lead to the development of more effective psychoeducational interventions.

Interventions for improving older patients' involvement in primary care episodes

BACKGROUND

There is a growing expectation among patients that they should be involved in the delivery of medical care. Accumulating evidence from empirical studies shows that patients of average age who are encouraged to participate more actively in treatment decisions have more favourable health outcomes, in terms of both physiological and functional status, than those who do not. Interventions to encourage more active participation may be focused on different stages, including: the use of health care; preparation for contact with a care provider; contact with the care provider; or feedback about care. However, it is unclear whether the benefits of these interventions apply to the elderly as well.

OBJECTIVES

To assess the effects of interventions in primary medical care that improve the involvement of older patients (>=65 years) in their health care.

SEARCH STRATEGY

We searched: the Cochrane Consumers and Communication Review Group Specialised Register (May 2003); the Cochrane Central Register of Controlled Trials (CENTRAL), The Cochrane Library issue 1, 2004; MEDLINE (Ovid) (1966 to June 2004); EMBASE (1988 to June 2004); PsycINFO (1872 to June 2004); DARE, The Cochrane Library issue 1, 2004; ERIC (1966 to June 2004); CINAHL (1982 to June 2004); Sociological Abstracts (1963 to June 2004); Dissertation Abstracts International (1861 to June 2004); and reference lists of articles.

SELECTION CRITERIA

Randomised controlled trials or quasi-randomised trials of interventions to improve the involvement of older patients (>= 65 years) in single consultations or episodes of primary medical care.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. Results are presented narratively as meta-analysis was not possible.

MAIN RESULTS

We identified three studies involving 433 patients. Overall, the quality of studies was not high, and there was moderate to high risk of bias. Interventions of a pre-visit booklet and a pre-visit session (either combined or pre-visit session alone) led to more questioning behaviour and more self-reported active behaviour in the intervention group (3 studies). One study (booklet and pre-visit session) showed no difference in consultation length and time engaged in talk between the intervention and control groups. The booklet and pre-visit session in one study was associated with more satisfaction with interpersonal aspects of care for the intervention group although no difference in overall satisfaction between intervention and control. There was no long-term follow up to see if effects were sustained. No studies measured outcomes relating to the use of health care, health status and wellbeing, or health behaviour.

AUTHORS' CONCLUSIONS

Overall this review shows some positive effects of specific methods to improve the involvement of older people in primary care episodes. Because the evidence is limited, however, we can not recommend the use of the reviewed interventions in daily practice. There should be a balance between respecting patients' autonomy and stimulating their active participation in health care. Face-to-face coaching sessions, whether or not complemented with written materials, may be the way forward. As this is impractical for the whole population, it could be worthwhile to identify a subgroup of older patients who might benefit the most from enhanced involvement, ie. those who want to be involved, but lack the necessary skills. This group could be coached either individually or, more practically, in group sessions.

Differences in the prevalence and severity of side effects based on type of analgesic prescription in patients with chronic cancer pain

An understanding of the relationship between the type of analgesic prescription and the prevalence and severity of side effects is crucial in making appropriate treatment decisions. The purposes of this study were to determine if there were differences in the prevalence of side effects among four different types of analgesic prescriptions (i.e., no opioid, only an as needed (PRN) opioid, only an around-the-clock (ATC) opioid, or an ATC+PRN opioid); to determine if there were differences in the severity of side effects among the four prescription groups; and to determine the relationships between the total dose of opioid analgesic medication prescribed and taken and the severity of side effects. As part of a larger study, 174 cancer patients with bone metastasis reported their analgesic use and the prevalence and severity of 11 side effects. Significant differences (P<0.05) were found in prevalence rates for seven of the side effects among the four prescription groups. The highest prevalence rates were found in the only ATC and ATC+PRN groups. Significant differences were found in the severity scores for five of the side effects, with the highest severity scores reported by patients in the only ATC and ATC+PRN groups. Significant positive correlations were found between the severity of six of the side effects and the total dose of opioid prescribed and taken. Risk factors for analgesic-induced side effects are ATC and ATC+PRN prescription types and higher doses of opioid analgesics.

A review of literature about involving people affected by cancer in research, policy and planning and practice

OBJECTIVE

To systematically review the literature on involving people affected by cancer in healthcare research, policy and planning and practice.

METHODS

Database searches, cited author, and grey literature searches were conducted.

RESULTS

131 documents were included. Rationales for the agenda of involvement represent two polar characteristics of modernity: individualism and collectivism. In research, people acted as advocates, strategists, advisors, reviewers and as participatory researchers. In policy and planning, people were involved in one-off involvement exercises and in longer-term partnerships. Men, those with rare cancers, children, and people who are socially deprived have been rarely involved. There is little research evidence about the impact of involvement. Training and information, resources and a change in attitudes and roles are required to implement an agenda of involvement.

CONCLUSION

The USA, the UK, followed by Canada and Australia have promoted an agenda of involvement.

PRACTICE IMPLICATIONS

A dissemination strategy to share good practice; involvement of all types of people; an individualised and flexible approach; training, resources and a shift in thinking from paternalism towards partnership working are required. More research is needed about the impact of involvement and relationships between rationales for involvement and implementation.

The impact of conducting a regional palliative care clinical study

End-of-life care must be informed by methodologically rigorous, high-quality research, but well-documented barriers make the conduct of palliative care clinical trials difficult. With careful consideration to study design and procedures, these barriers are surmountable. This paper discusses the approach used in a large scale, randomised, controlled trial of service-based interventions in a regional palliative care service in South Australia, and the impact of this trial on palliative care research more broadly, the changes to the service in which it was conducted, and on health policy beyond palliative care. The Palliative Care Trial evaluated three interventions in a 2 x 2 x 2 factorial cluster randomised design: case conferences, general practitioner education, and patient education. Main outcomes were performance status, pain intensity, and resource utilisation. A total of 461 patients were enrolled in the study. Pre-study planning and piloting is crucial, and accurately estimated withdrawal and death rates in the study. Other study design elements that facilitated this research included assessment of three interventions at one time, a dedicated recruitment role, a single clinical triage point, embedding data collection into routine clinical assessments, and meaningful outcome measures. Recruitment and retention of participants is possible if barriers are systematically identified and addressed. This study challenged and developed the research culture within our clinical team and subsequently translated into further research.

Testing the effects of treatment complications on a cognitive-behavioral intervention for reducing symptom severity

Patients (n = 231) diagnosed with solid tumors and undergoing chemotherapy were randomly assigned to the experimental arm (n = 114) or to conventional care (n = 117). A symptom severity index based on summed severity scores across 15 symptoms was the primary outcome. Building on previously published work, an analysis was undertaken to determine the effects of patient characteristics and treatment complications on reductions in symptom severity achieved by a trial of a cognitive-behavioral intervention (CBI). The impact of the intervention on symptom severity differed by the occurrence of neutropenic events, chemotherapy dose delays or dose reductions, and number of comorbid conditions. Patients with more comorbid conditions, as well as those who did not experience neutropenia or dose delay/reduction, who received the intervention reported lower severity at 20 weeks compared to those who received conventional care. This research begins to specify the clinical conditions under which CBIs are effective in lowering symptom severity.

A multidimensional integrative medicine intervention to improve cardiovascular risk

BACKGROUND

Integrative medicine is an individualized, patient-centered approach to health, combining a whole-person model with evidence-based medicine. Interventions based in integrative medicine theory have not been tested as cardiovascular risk-reduction strategies. Our objective was to determine whether personalized health planning (PHP), an intervention based on the theories and principles underlying integrative medicine, reduces 10-year risk of coronary heart disease (CHD).

METHODS

We conducted a randomized, controlled trial among 154 outpatients age 45 or over, with 1 or more known cardiovascular risk factors. Subjects were enrolled from primary care practices near an academic medical center, and the intervention was delivered at a university Center for Integrative Medicine. Following a health risk assessment, each subject in the intervention arm worked with a health coach and a medical provider to construct a personalized health plan. The plan identified specific health behaviors important for each subject to modify; the choice of behaviors was driven both by cardiovascular risk reduction and the interests of each individual subject. The coach then assisted each subject in implementing her/his health plan. Techniques used in implementation included mindfulness meditation, relaxation training, stress management, motivational techniques, and health education and coaching. Subjects randomized to the comparison group received usual care (UC) without access to the intervention. Our primary outcome measure was 10-year risk of CHD, as measured by a standard Framingham risk score, and assessed at baseline, 5, and 10 months. Differences between arms were assessed by linear mixed effects modeling, with time and study arm as independent variables.

RESULTS

Baseline 10-year risk of CHD was 11.1% for subjects randomized to UC (n=77), and 9.3% for subjects randomized to PHP (n=77). Over 10 months of the intervention, CHD risk decreased to 9.8% for UC subjects and 7.8% for intervention subjects. Based on a linear mixed-effects model, there was a statistically significant difference in the rate of risk improvement between the 2 arms (P=.04). In secondary analyses, subjects in the PHP arm were found to have increased days of exercise per week compared with UC (3.7 vs 2.4, P=.002), and subjects who were overweight on entry into the study had greater weight loss in the PHP arm compared with UC (P=.06).

CONCLUSIONS

A multidimensional intervention based on integrative medicine principles reduced risk of CHD, possibly by increasing exercise and improving weight loss.

Patient-physician communication in the context of persistent pain: validation of a modified version of the patients' Perceived Involvement in Care Scale

The purpose of this study was to evaluate the psychometric properties of a modified version of the Perceived Involvement in Care Scale (M-PICS), a measure designed to assess pain patients' perceptions of patient health care provider communication during the medical consultation. Eighty-seven breast cancer outpatients with persistent pain completed a battery of questionnaires, including the M-PICS. A factor analysis supported four factors. Factor 1 reflected health care provider information behaviors; Factor 2, health care provider facilitation of patient involvement; Factor 3, patient information provision; and Factor 4, patient participation in decision making. The M-PICS total had an internal consistency of 0.87; alphas for subscales ranged from 0.80 to 0.90. M-PICS scores related to measures of patient characteristics and outcomes, including pain-related communication barriers, psychological status, quality of life, and health care satisfaction, in predicted ways. The M-PICS is a reliable and valid measure of perceived patient-provider communication in the context of persistent pain.

Utilising handheld computers to monitor and support patients receiving chemotherapy: results of a UK-based feasibility study

GOALS OF WORK

Recent changes in cancer service provision mean that many patients spend a limited time in hospital and therefore experience and must cope with and manage treatment-related side effects at home. Information technology can provide innovative solutions in promoting patient care through information provision, enhancing communication, monitoring treatment-related side effects and promoting self-care.

PATIENTS AND METHODS

The aim of this feasibility study was to evaluate the acceptability of using handheld computers as a symptom assessment and management tool for patients receiving chemotherapy for cancer. A convenience sample of patients (n = 18) and health professionals (n = 9) at one Scottish cancer centre was recruited. Patients used the handheld computer to record and send daily symptom reports to the cancer centre and receive instant, tailored symptom management advice during two treatment cycles. Both patients' and health professionals' perceptions of the handheld computer system were evaluated at baseline and at the end of the project.

MAIN RESULTS

Patients believed the handheld computer had improved their symptom management and felt comfortable in using it. The health professionals also found the handheld computer to be helpful in assessing and managing patients' symptoms.

CONCLUSIONS

This project suggests that a handheld-computer-based symptom management tool is feasible and acceptable to both patients and health professionals in complementing the care of patients receiving chemotherapy.

A pragmatic 2×2×2 factorial cluster randomized controlled trial of educational outreach visiting and case conferencing in palliative care—methodology of the Palliative Care Trial [ISRCTN 81117481]

The demand for palliative care is increasing, yet there are few data on the best models of care nor well-validated interventions that translate current evidence into clinical practice. Supporting multidisciplinary patient-centered palliative care while successfully conducting a large clinical trial is a challenge. The Palliative Care Trial (PCT) is a pragmatic 2 x 2 x 2 factorial cluster randomized controlled trial that tests the ability of educational outreach visiting and case conferencing to improve patient-based outcomes such as performance status and pain intensity. Four hundred sixty-one consenting patients and their general practitioners (GPs) were randomized to the following: (1) GP educational outreach visiting versus usual care, (2) Structured patient and caregiver educational outreach visiting versus usual care and (3) A coordinated palliative care model of case conferencing versus the standard model of palliative care in Adelaide, South Australia (3:1 randomization). Main outcome measures included patient functional status over time, pain intensity, and resource utilization. Participants were followed longitudinally until death or November 30, 2004. The interventions are aimed at translating current evidence into clinical practice and there was particular attention in the trial's design to addressing common pitfalls for clinical studies in palliative care. Given the need for evidence about optimal interventions and service delivery models that improve the care of people with life-limiting illness, the results of this rigorous, high quality clinical trial will inform practice. Initial results are expected in mid 2005.

Nurses' response to pain communication from patients: a post-test experimental study

BACKGROUND

Inadequate communication about pain can result in increased pain for patients.

OBJECTIVES

The purpose of the current pilot study was to test how nurses respond when patients use their own words, a pain intensity scale, or both to communicate pain.

DESIGN

A post-test only experimental design was used with three pain description conditions, personal and numeric; personal only; numeric only.

SETTING

The setting included six hospitals and one school of nursing located in the northeastern United States.

PARTICIPANTS

PARTICIPANTS included 122 registered medical surgical nurses.

METHODS

Nurses were randomly assigned to condition, and read a vignette about a trauma patient with moderately severe pain. The vignettes were identical except for the patient's pain description and age. The nurses then wrote how they would respond to the patient's pain. Two blind raters content analyzed the responses, giving nurses one point for including each of six a priori criteria derived from the Acute Pain Management Panel [1992. Acute Pain Management: operative or medical procedures and trauma. Clinical practice guideline (AHCPR Publication No. 92-0032)., Rockville, MD, USA] and the American Pain Society [2003. Principles of analgesic use in the treatment of acute pain and cancer pain, Glenville, IL, USA].

RESULTS

Nurses planned similar numbers of pain management strategies across the three conditions, with a mean of 2.1 (SD=1.14) strategies out of the recommended six.

CONCLUSIONS

Nurses did not respond with more pain management strategies when patients describe pain in their own words, or in their own words and a pain intensity scale. The relatively small number of pain management strategies planned by the nurses suggests that nurses use few strategies to respond to moderately severe pain problems.

Effect of neutropenia on the impact of a cognitive-behavioral intervention for symptom management

BACKGROUND

Trials of cognitive-behavioral interventions (CBI) designed to reduce symptom severity or improve dimensions of quality of life seldom consider how the side effects of treatment or the complications imposed by the disease or treatment may moderate the impact of the trial on the designated outcome. To address this issue, the moderating effect of neutropenia on the impact of a CBI for reducing symptom severity was evaluated among patients with cancer undergoing chemotherapy.

METHODS

The authors described the impact of a randomized trial of a 10-contact, 20-week CBI on symptom severity, as well as the moderating effect of a neutropenic episode on symptom severity at 20 weeks. Severity scores were based on sum scores (0-10) for 15 symptoms.

RESULTS

There was an effect for age (younger) and group on severity at 20 weeks and an interaction between neutropenia and group. Among patients with no evidence of neutropenia, those in the experimental arm had a 9-point lower severity score at 20 weeks. Among patients who experienced neutropenia, differences in symptom severity by arm of the trial were < 3 points. Further, fatigue, fever, and pain were more prevalent among patients with neutropenia.

CONCLUSIONS

Patients who experienced neutropenia did not benefit from a CBI to lower symptoms. The overall effect of this intervention came almost exclusively from patients without neutropenia.

Predictors of quality of life in oncology outpatients with pain from bone metastasis

The relationship between pain and quality of life (QOL) in cancer patients is complex due to the number and the diversity of factors that can influence pain and QOL. The aims of this study of oncology outpatients with pain from bone metastasis were: 1) to determine the extent to which pain characteristics (i.e., severity, duration, meaning of pain, and perceived availability and efficacy of pain relief), psychological distress (i.e., depression), physical functioning, social functioning and QOL are intercorrelated, and 2) to determine which of these variables are important predictors of QOL. A total of 157 oncology outpatients completed questionnaires that evaluated pain, QOL, depression, physical functioning, and social functioning at the time of enrollment into a randomized clinical trial that evaluated the effectiveness of a psychoeducational intervention to improve cancer pain management. Pearson product moment correlation coefficients were calculated to examine the relationships among the study variables. A blockwise, hierarchical multiple regression analysis was performed to determine which variables were the most important predictors of QOL. Meaning of pain was significantly correlated with all the other variables, in particular pain intensity and duration. The most important factors that predicted QOL were depression, social functioning, and physical functioning. Depression proved to be the most important predictor of QOL.

The impact of social deprivation on chronic back pain outcomes

Chronic low back pain is the commonest cause of disability for adults of working age. It is a complex problem frequently encapsulated as a bio-psychosocial issue, yet the social element has received less attention than it deserves, particularly for low-income and socially deprived patients. Rehabilitation programmes are often based on increasing function through cognitive and behavioural techniques, which, for many reasons, may be less effective for the socially disadvantaged. In this paper we discuss the potential barriers to successful rehabilitation in socially deprived groups and we look at possible factors that may need to be considered when designing interventions.

Categorizing the severity of cancer pain: further exploration of the establishment of cutpoints

Previous work by Serlin and colleagues [Serlin R C, Mendoza T R, Nakamura Y, Edwards K R, Cleeland C S. When is cancer pain mild, moderate, or severe? Grading pain severity by its interference with function. Pain 1995;61:277-84] established cutpoints for mild, moderate, and severe cancer pain based on the pain's level of interference with function. Recent work [Jensen M P, Smith D G, Ehde D M, Robinson L R. Pain site and the effects of amputation pain: further clarification of the meaning of mild, moderate, and severe pain. Pain 2001;91:317-22; Zelman D C, Hoffman D L, Seifeldin R, Dukes, E. Development of a metric for a day of manageable pain control: derivation of pain severity cutpoints for low back pain and osteoarthritis. Pain 2003;106(1/2):35-42]found differences in cutpoints for pain severity for different pain-related conditions. Reasons for these discrepancies may relate to the methods used to determine the cutpoints or to differences based on the type or the cause of the pain. The purposes of this study were to determine the optimal cutpoints for mild, moderate, and severe pain based on patients' ratings of average and worst pain severity, using a larger range of potential cutpoints, and to determine if those cutpoints distinguished among the three pain severity groups on several outcome measures. Results from a homogenous sample of oncology outpatients with pain from bone metastasis confirm a non-linear relationship between cancer pain severity and interference with function and also confirm that the boundary between a mild and a moderate level of cancer pain is at 4 on a 0-10 numeric rating scale. However, this analysis did not confirm the boundary between moderate and severe cancer pain previously described by Serlin and colleagues [Serlin R C, Mendoza T R, Nakamura Y, Edwards K R, Cleeland C S. When is cancer pain mild, moderate, or severe? Grading pain severity by its interference with function. Pain 1995;61:277-84]. In addition, these results were not consistent with the cutpoints that were found for back pain, phantom limb pain, pain 'in general', or osteoarthritis pain reported by Jensen and colleagues and Zelman and colleagues [Jensen M P, Smith D G, Ehde D M, Robinson L R. Pain site and the effects of amputation pain: further clarification of the meaning of mild, moderate, and severe pain. Pain 2001;91:317-22; Zelman D C, Hoffman D L, Seifeldin R, Dukes, E. Development of a metric for a day of manageable pain control: derivation of pain severity cutpoints for low back pain and osteoarthritis. Pain 2003;106(1/2):35-42]. Possible explanations for these differences are discussed, as well as implications for future research.

Qualitative research contribution to a randomized clinical trial

Qualitative research may be combined fruitfully with intervention studies, but few examples provide detailed methodological strategies for doing so. In this article, we describe the qualitative component of a randomized clinical trial (RCT) of the PRO-SELF(c) Pain Control Program, an intervention that provides individualized education, coaching, and support for cancer pain management. We conducted three qualitative analyses of verbatim transcripts of "real-time" audiotaped intervention sessions. As a result, we were better able to ascertain the nature of the individualized coaching component of the intervention, patient and family caregiver use of selected intervention tools, and reasons the intervention did not work for some patients. Study results were used to increase the specificity with which the coaching portion of the intervention is described in the intervention protocol.