Testing the differential effects of symptom management interventions in cancer

A Sequential Multiple Assignment Randomized Trial of Symptom Management After Chemotherapy

CONTEXT

Many cancer survivors experience a lingering symptom burden after chemotherapy.

OBJECTIVES

In this sequential multiple assignment randomized trial, we tested optimal sequencing of two evidence-based interventions for symptom management.

METHODS

Survivors of solid tumors (N = 451) were interviewed at baseline and stratified as high or low need for symptom management based on comorbidity and depressive symptoms. High need survivors were randomized initially to the 12-week Symptom Management and Survivorship Handbook (SMSH, N = 282) or 12-week SMSH with eight weeks of Telephone Interpersonal Counseling (TIPC, N = 93) added during weeks one to eight. After four weeks of the SMSH alone, non-responders on depression were re-randomized to continue with SMSH alone (N = 30) or add TIPC (N = 31). Severity of depression and summed severity index of 17 other symptoms over weeks one to13 were compared between randomized groups and among three dynamic treatment regimes (DTRs): 1) SMSH for 12 weeks; 2) SMSH for 12 weeks with eight weeks of TIPC from week one; 3) SMSH for four weeks followed by SMSH+TIPC for eight weeks if no response to the SMSH alone on depression at week four.

RESULTS

There were no main effects for randomized arms or DTRs, but there was a significant interaction of trial arm with baseline depression favoring SMSH alone during weeks one to four in the first randomization and SMSH+TIPC in the second randomization.

CONCLUSION

The SMSH may represent a simple effective option for symptom management, adding TIPC only when there is no response to SMSH alone for people with elevated depression and multiple co-morbidities.

Only the Lonely: Expression of Proinflammatory Genes Through Family Cancer Caregiving Experiences

OBJECTIVE

The experience of cancer elicits not only turmoil but also resilience in the family, which has been related to psychological adjustment and physical health of family caregivers. The biological pathways linking family cancer caregiving to health, however, remain poorly understood. This study examined the extent to which psychological risk and resilience factors related to a proinflammatory gene expression profile (conserved transcriptional response to adversity, or CTRA) among caregivers during the first-year postdiagnosis of a patient with colorectal cancer.

METHODS

A total of 41 caregivers (mean age = 54 years, 74% female, 40% Hispanic) provided psychological data and peripheral blood samples around 4 and 12 months after diagnosis. Mixed regression models controlling for demographic and biometric factors were used to test the associations of caregiver CTRA gene expression with caregiving stress, loneliness, and lack of social support (risk factors), as well as benefit finding and meaning (resilience factors).

RESULTS

When individually tested, all but benefit finding were significantly related to CTRA (R2 ≥ 0.112, p < .045). When adjusted for other factors in either the risk or resilience group, loneliness, social support, and meaning effects remained significant (R2 ≥ 0.120, p < .041). When all study factors were simultaneously adjusted (R2 = 0.139), only loneliness remained significant (p = .034).

CONCLUSIONS

Findings suggest that caregiving-related transcriptional effects seem to be most pronounced when caregivers experience low social support and loneliness, as well as little meaning or purpose in their caregiving. These findings suggest that the development of new intervention strategies that prioritize reductions in caregiver loneliness may favorably impact biological mechanisms related to caregiver health.

Impact of advanced nursing practice through nurse-led clinics in the care of cancer patients: A scoping review

OBJECTIVE

This scoping review aims at exploring the effectiveness of nurse-led advanced practice for patients with cancer.

METHODS

This review followed the PRISMA extension for scoping reviews. Randomised controlled trials on cancer nurse-led clinics for patient outcomes, costs, service utilisation and other outcomes were included. Databases such as MEDLINE, CENTRAL, CINAHL, EMBASE and PsychINFO were searched based on MeSH terms. Thematic analysis was used to synthesise results of the included studies.

RESULTS

Seventeen articles were included, published between 2001 and 2019. There were methodological shortcomings with a number of the studies reviewed. Five themes were identified including (1) rationale for developing nurse-led clinics, (2) mode of delivery of nurse-led clinics, (3) the content of nurse-led clinics, (4) exploring patient outcomes and (5) satisfaction with nurse-led clinics.

CONCLUSIONS

The results support the effectiveness of nurse-led clinics in improving self-reported responses such as distress levels, satisfaction, quality of life, depressive symptoms, concerns and vomiting among cancer patients. Following a sound protocol for both the study and the reporting is recommended, and future studies should focus more on costs and effectiveness of different models of care administered by advanced practice nurses. Effectiveness of nurse-led clinics needs further evaluation with stronger trials and wider focus on nursing-sensitive clinical outcomes and costs.

"Just Living With Them": Symptom Management Experiences of Rural Residents With Advanced Cancer

PURPOSE

To understand how rural residents with advanced cancer experience and manage their symptoms.

PARTICIPANTS & SETTING

16 adult patients with a diagnosis of advanced cancer, who were receiving antineoplastic treatment and living in rural areas of southeastern Iowa, participated in the study.

METHODOLOGIC APPROACH

Data were collected through semistructured, audio-recorded interviews using open-ended questions. Data were analyzed using content and dimensional analyses.

FINDINGS

Four themes were developed from the completed interviews, including (a) barriers and challenges associated with rural cancer care, (b) physical symptoms experienced from the time of diagnosis through the cancer trajectory, (c) symptom management strategies used to control physical symptoms, and (d) perceptions of having cancer and the use of technology in managing symptoms.

IMPLICATIONS FOR NURSING

Rural residents with advanced cancer experience a wide range of physical symptoms that may affect their quality of life. Although residents may develop self-management strategies to cope with symptoms, additional guidance on and interventions for how best to manage physical symptoms are needed.

Using SMART design to improve symptom management among cancer patients: A study protocol

In this in-progress sequential multiple assignment randomized trial (SMART), dyads of solid tumor cancer patients and their caregivers are initially randomized to 4 weeks of reflexology or meditative (mindfulness) practices provided by/with their caregiver in the patient's home or to a control group. After 4 weeks, intervention group dyads in which patients do not show improvement in fatigue (non-responders) are re-randomized to either receive additional time with the same therapy during weeks 5-8 or to add the other therapy. The aims are (1) to compare reflexology and meditative practices groups during weeks 1-4 on patients' fatigue severity, summed symptom inventory score, depressive symptoms, and anxiety, so as to determine the relative effectiveness of these therapies and the characteristics of responders and non-responders to each therapy. (2) Among reflexology non-responders based on fatigue score at week 4, to determine patient symptom outcomes when meditative practices are added during weeks 5-8, versus continuing with reflexology alone. (3) Among meditative practices non-responders based on fatigue score at week 4, to determine patient symptom outcomes when reflexology is added during weeks 5-8, versus continuing with meditative practices alone. (4) To compare improvements in patient symptom outcomes among the three groups created by the first randomization. (5) To explore which dyadic characteristics are associated with optimal patient symptom outcomes, to determine tailoring variables for decision rules of future interventions. The trial has a target of 331 dyads post-attrition and has 150 dyads enrolled. We are overcoming challenges with dyadic recruitment and retention while maintaining fidelity.

Self-management education interventions for patients with cancer: a systematic review

PURPOSE

This systematic review was intended to identify the effectiveness and inclusion of essential components of self-management education interventions to support patients with cancer in developing the skills needed for effective self-management of their disease and the acute or immediate, long-term, and late harmful effects of treatments.

METHODS

Self-management education interventions were included if they were randomized controlled trials (RCTs) containing at least one of the eight core elements outlined by the research team. A systematic search was conducted in Ovid MEDLINE (2005 through April 2015), Embase (2005 to 2015, week 15), the Cochrane Database of Systematic Reviews (Issue 4, April 2015), CINAHL (2005 to 2015) and PsychINFO (2005 to 2015). Keywords searched include 'self-management patient education' or 'patient education'.

RESULTS

Forty-two RCTs examining self-management education interventions for patients with cancer were identified. Heterogeneity of interventions precluded meta-analysis, but narrative qualitative synthesis suggested that self-management education interventions improve symptoms of fatigue, pain, depression, anxiety, emotional distress and quality of life. Results for specific combinations of core elements were inconclusive. Very few studies used the same combinations of core elements, and among those that did, results were conflicting. Thus, conclusions as to the components or elements of self-management education interventions associated with the strength of the effects could not be assessed by this review.

CONCLUSION

Defining the core components of cancer self-management education and the fundamental elements for inclusion in supporting effective self-management will be critical to ensure consistent and effective provision of self-management support in the cancer system.

Automated telephone communication systems for preventive healthcare and management of long-term conditions

BACKGROUND

Automated telephone communication systems (ATCS) can deliver voice messages and collect health-related information from patients using either their telephone's touch-tone keypad or voice recognition software. ATCS can supplement or replace telephone contact between health professionals and patients. There are four different types of ATCS: unidirectional (one-way, non-interactive voice communication), interactive voice response (IVR) systems, ATCS with additional functions such as access to an expert to request advice (ATCS Plus) and multimodal ATCS, where the calls are delivered as part of a multicomponent intervention.

OBJECTIVES

To assess the effects of ATCS for preventing disease and managing long-term conditions on behavioural change, clinical, process, cognitive, patient-centred and adverse outcomes.

SEARCH METHODS

We searched 10 electronic databases (the Cochrane Central Register of Controlled Trials; MEDLINE; Embase; PsycINFO; CINAHL; Global Health; WHOLIS; LILACS; Web of Science; and ASSIA); three grey literature sources (Dissertation Abstracts, Index to Theses, Australasian Digital Theses); and two trial registries (www.controlled-trials.com; www.clinicaltrials.gov) for papers published between 1980 and June 2015.

SELECTION CRITERIA

Randomised, cluster- and quasi-randomised trials, interrupted time series and controlled before-and-after studies comparing ATCS interventions, with any control or another ATCS type were eligible for inclusion. Studies in all settings, for all consumers/carers, in any preventive healthcare or long term condition management role were eligible.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods to select and extract data and to appraise eligible studies.

MAIN RESULTS

We included 132 trials (N = 4,669,689). Studies spanned across several clinical areas, assessing many comparisons based on evaluation of different ATCS types and variable comparison groups. Forty-one studies evaluated ATCS for delivering preventive healthcare, 84 for managing long-term conditions, and seven studies for appointment reminders. We downgraded our certainty in the evidence primarily because of the risk of bias for many outcomes. We judged the risk of bias arising from allocation processes to be low for just over half the studies and unclear for the remainder. We considered most studies to be at unclear risk of performance or detection bias due to blinding, while only 16% of studies were at low risk. We generally judged the risk of bias due to missing data and selective outcome reporting to be unclear.For preventive healthcare, ATCS (ATCS Plus, IVR, unidirectional) probably increase immunisation uptake in children (risk ratio (RR) 1.25, 95% confidence interval (CI) 1.18 to 1.32; 5 studies, N = 10,454; moderate certainty) and to a lesser extent in adolescents (RR 1.06, 95% CI 1.02 to 1.11; 2 studies, N = 5725; moderate certainty). The effects of ATCS in adults are unclear (RR 2.18, 95% CI 0.53 to 9.02; 2 studies, N = 1743; very low certainty).For screening, multimodal ATCS increase uptake of screening for breast cancer (RR 2.17, 95% CI 1.55 to 3.04; 2 studies, N = 462; high certainty) and colorectal cancer (CRC) (RR 2.19, 95% CI 1.88 to 2.55; 3 studies, N = 1013; high certainty) versus usual care. It may also increase osteoporosis screening. ATCS Plus interventions probably slightly increase cervical cancer screening (moderate certainty), but effects on osteoporosis screening are uncertain. IVR systems probably increase CRC screening at 6 months (RR 1.36, 95% CI 1.25 to 1.48; 2 studies, N = 16,915; moderate certainty) but not at 9 to 12 months, with probably little or no effect of IVR (RR 1.05, 95% CI 0.99, 1.11; 2 studies, 2599 participants; moderate certainty) or unidirectional ATCS on breast cancer screening.Appointment reminders delivered through IVR or unidirectional ATCS may improve attendance rates compared with no calls (low certainty). For long-term management, medication or laboratory test adherence provided the most general evidence across conditions (25 studies, data not combined). Multimodal ATCS versus usual care showed conflicting effects (positive and uncertain) on medication adherence. ATCS Plus probably slightly (versus control; moderate certainty) or probably (versus usual care; moderate certainty) improves medication adherence but may have little effect on adherence to tests (versus control). IVR probably slightly improves medication adherence versus control (moderate certainty). Compared with usual care, IVR probably improves test adherence and slightly increases medication adherence up to six months but has little or no effect at longer time points (moderate certainty). Unidirectional ATCS, compared with control, may have little effect or slightly improve medication adherence (low certainty). The evidence suggested little or no consistent effect of any ATCS type on clinical outcomes (blood pressure control, blood lipids, asthma control, therapeutic coverage) related to adherence, but only a small number of studies contributed clinical outcome data.The above results focus on areas with the most general findings across conditions. In condition-specific areas, the effects of ATCS varied, including by the type of ATCS intervention in use.Multimodal ATCS probably decrease both cancer pain and chronic pain as well as depression (moderate certainty), but other ATCS types were less effective. Depending on the type of intervention, ATCS may have small effects on outcomes for physical activity, weight management, alcohol consumption, and diabetes mellitus. ATCS have little or no effect on outcomes related to heart failure, hypertension, mental health or smoking cessation, and there is insufficient evidence to determine their effects for preventing alcohol/substance misuse or managing illicit drug addiction, asthma, chronic obstructive pulmonary disease, HIV/AIDS, hypercholesterolaemia, obstructive sleep apnoea, spinal cord dysfunction or psychological stress in carers.Only four trials (3%) reported adverse events, and it was unclear whether these were related to the interventions.

AUTHORS' CONCLUSIONS

ATCS interventions can change patients' health behaviours, improve clinical outcomes and increase healthcare uptake with positive effects in several important areas including immunisation, screening, appointment attendance, and adherence to medications or tests. The decision to integrate ATCS interventions in routine healthcare delivery should reflect variations in the certainty of the evidence available and the size of effects across different conditions, together with the varied nature of ATCS interventions assessed. Future research should investigate both the content of ATCS interventions and the mode of delivery; users' experiences, particularly with regard to acceptability; and clarify which ATCS types are most effective and cost-effective.

Lower Patient Ratings of Physician Communication Are Associated With Unmet Need for Symptom Management in Patients With Lung and Colorectal Cancer

PURPOSE

Little is known about factors associated with unmet needs for symptom management in patients with cancer.

METHODS

Patients with a new diagnosis of lung and colorectal cancer from the diverse nationally representative Cancer Care Outcomes Research and Surveillance cohort completed a survey approximately 5 months after diagnosis (N = 5,422). We estimated the prevalence of unmet need for symptom management, defined as patients who report that they wanted help for at least one common symptom (pain, fatigue, depression, nausea/vomiting, cough, dyspnea, diarrhea) during the 4 weeks before the survey but did not receive it. We identified patient factors associated with unmet need by using logistic regression with random effects to account for clustering within study sites.

RESULTS

Overall, 15% (791 of 5,422) of patients had at least one unmet need for symptom management. Adjusting for sociodemographic and clinical factors, African American race, being uninsured or poor, having early-stage lung cancer, and the presence of moderate to severe symptoms were associated with unmet need (all P < .05). Furthermore, patients who rated their physician's communication score < 80 (on a 0 to 100 scale) had adjusted rates of an unmet need for symptom management that were more than twice as high as patients who rated their physicians with a perfect communication score (23.1% v 10.0%; P < .001).

CONCLUSION

A significant minority of patients with newly diagnosed lung and colorectal cancer report unmet needs for symptom management. Interventions to improve symptom management should consider the importance of physician communication to the patient's experience of disease.

Achieving a High-Quality Cancer Care Delivery System for Older Adults: Innovative Models of Care

OBJECTIVES

To examine innovative models and other research-based interventions that hold potential to assure high-quality care for the growing older adult population living with cancer as one of multiple chronic conditions. Evidence from these care delivery approaches provides a roadmap for the development of future care models.

DATA SOURCES

Published peer-reviewed literature, policy analyses, and web-based resources.

CONCLUSION

Available evidence suggests the need for models that engage patients and their family caregivers, focus on patient's functional capacities, emphasize palliative care, and maximize the contributions of all team members.

IMPLICATIONS FOR NURSING PRACTICE

Nurses are uniquely positioned to lead or play a major role in the evolution and implementation of care models targeting older adults with cancer, but must increase their knowledge and skills related to both oncology and geriatrics to maximize their contributions.

Challenges in Cancer Self-management of Patients with Limited English Proficiency

Objective:

This paper summarizes the barriers and challenges in cancer care reported from a validation project of a self-management intervention handbook from Chinese-American cancer patients with limited English proficiency (LEP).

Methods:

Seven health-care providers (HCPs) and 16 Chinese-American cancer survivors with LEP were invited to validate a self-management intervention handbook through networking sampling method. Bilingual versions were developed and validated using the repeated translation process. Online and paper-based survey and interview were conducted to collect information on the perception of barriers and experiences on cancer care. Data were analyzed by the content analysis method.

Results:

The HCPs reported a bilingual self-management handbook which is useful and feasible for patient self-management. The challenges in giving cancer care to LEP patients included: patients do not engage in discussion, different cultural health beliefs, unable to speak to patients in their primary language, and patients are less likely to discuss emotional and social challenges during treatments. The common barriers and experiences during cancer care included: limited understanding about treatment/medication and side effects, language barriers such as unable to communicate to make the decision, unable to understand information related to resources and do not know what questions to ask, and do not know what to expect during their cancer treatment.

Conclusions:

The current findings highlight the need of cancer self-management support for culturally diverse LEP cancer patients. Further research can include applying the supportive intervention to all LEP cancer patients.

Putting evidence into practice: an update of evidence-based interventions for cancer-related fatigue during and following treatment

Cancer-related fatigue (CRF) has deleterious effects on physical, social, cognitive, and vocational functioning, and causes emotional and spiritual distress for patients and their families; however, it remains under-recognized and undertreated. This article critically reviews and integrates the available empirical evidence supporting the efficacy of pharmacologic and nonpharmacologic treatment approaches to CRF, highlighting new evidence since 2007 and 2009 Putting Evidence Into Practice publications. Interventions that are recommended for practice or likely to be effective in improving fatigue outcomes include exercise; screening for treatable risk factors; management of concurrent symptoms; yoga; structured rehabilitation; Wisconsin ginseng; cognitive-behavioral therapies for insomnia, pain, and depression; mindfulness-based stress reduction; and psychoeducational interventions such as anticipatory guidance, psychosocial support, and energy conservation and activity management. This information can be applied to improve the management of CRF, inform health policy and program development, shape the design of clinical trials of new therapies for CRF, and drive basic and translational research.

Treatment with oral anticancer agents: symptom severity and attribution, and interference with comorbidity management

PURPOSE/OBJECTIVES

To evaluate the prevalence, severity, and attribution of symptoms, as well as the interference with management of comorbidities, in patients who have been prescribed oral anticancer agents (OAs).

DESIGN

Descriptive exploratory study.

SETTING

A comprehensive cancer center and two community-based oncology programs in the midwestern United States.

SAMPLE

30 adults undergoing OA treatment.

METHODS

Five phone interviews were conducted during eight weeks. Linear mixed effects and generalized estimating equations were used to examine symptoms and interference over time.

MAIN RESEARCH VARIABLES

Symptoms and comorbid conditions.

FINDINGS

The mean age of participants was 65.1 years. Fifteen participants were female, 25 were Caucasian, and 23 had comorbidities. Twenty-one patients had late-stage cancer, and rates of adherence were 90%. Fatigue, sleep disturbance, and numbness or tingling in hands and feet were highly prevalent symptoms. Younger age was associated with higher symptom severity (p < 0.01) and interference (p = 0.01). Patients with more comorbidities tended to report higher symptom severity. Simultaneous IV chemotherapy was not a predictor of symptom severity or interference over age and comorbidity. Symptoms were most frequently attributed to cancer and its treatment. Patients with a greater number of comorbidities were more likely to include comorbidities in symptom attribution and reported interference from the OA with managing comorbid conditions.

CONCLUSIONS

Symptoms may be more severe in patients prescribed OAs who are younger and have comorbid conditions. More comorbidities and absence of simultaneous IV chemotherapy increased the likelihood of inclusion of chronic conditions in symptom attribution. Patients reported that OA treatment interfered with comorbidity management.

IMPLICATIONS FOR NURSING

Nurses need to take comorbidities into account when caring for patients prescribed OAs because the chronic conditions may influence symptom severity and the ability to manage symptoms.