From evidence to practice: factors affecting the specialist breast nurse's detection of psychological morbidity in women with breast cancer

Primary breast cancer and health related quality of life in Spanish women: The EpiGEICAM case-control study

This study evaluates the impact of breast cancer (BC) in health related quality of life (HRQL) and in psychological distress (PD) during the initial phases of the disease and looks for contributing factors. A multicentric case-control study, EpiGEICAM, was carried out. Incident BC cases and age- and residence- matched controls were included. Clinical, epidemiological, HRQL (SF-36) and PD information (GHQ-28) was collected. We used multivariable logistic regression models to estimate OR of low HRQL and of PD in cases compared to controls, and to identify factors associated with low HRQL and with PD. Among 896 BC cases and 890 control women, cases had poorer scores than both, the reference population and the control group, in all SF-36 scales. BC women with lower education, younger, active workers, never smokers, those with comorbidities, in stage IV and with surgical treatment had lower physical HRQL; factors associated with low mental HRQL were dissatisfaction with social support, being current smoker and having children. Cases had a fivefold increased odds of PD compared to controls. Managing comorbidities and trying to promote social support, especially in younger and less educated women, could improve well-being of BC patients.

Early screening in patients with head and neck cancer identified high levels of pain and distress

PURPOSE

Pain and distress are recognized as the fifth and sixth vital signs in cancer care, respectively, as debilitating symptoms that are frequently under-recognized. The aim of this study was to document, using touch-screen technology, levels of pain and distress in patients with head and neck cancer before their assessment at a head and neck multidisciplinary referral clinic.

MATERIALS AND METHODS

A cross-sectional study over a 4-year period (2008 through 2011) was conducted for patients attending a head and neck oncology multidisciplinary team clinic in the Hunter New England referral district of Australia. Predictor variables were cancer stage and site. Cancer sites divided into 8 different regions, with distinction made for cutaneous versus noncutaneous sites. Outcome variables consisted of pain and distress levels. Pain was assessed using a Numerical Rating Scale of 0 to 10, and distress was assessed using the Distress Thermometer and PSYCH-6 scales. In the context of a screening study and for statistically comparing pain with other variables, pain was regarded as any score higher than 0. Clinically significant distress represented a Distress Thermometer score higher than 3 and a PSYCH-6 score of at least 3. Data analysis consisted of descriptive statistics, variance contrasts, and 2-tailed Pearson correlations.

RESULTS

Four hundred thirty-six patients were included in the study, with an equal number of cutaneous and noncutaneous cancer sites. Thirty-four percent of patients reported having pain, and 13% had clinically significant distress. Tumor stage did not significantly affect pain or distress scores.

CONCLUSIONS

There is a high level of pain and distress reported by patients with head and neck cancer before their assessment and management is discussed.

Complementary and alternative medicine use of women with breast cancer: self-help CAM attracts other women than guided CAM therapies

OBJECTIVE

Examine stability of use of complementary and alternative medicine (CAM) of breast cancer patients, reasons for CAM use, and sociodemographic, clinical, and psychological predictors of CAM use.

METHODS

CAM use was assessed after adjuvant therapy and six months later. Following the CAM Healthcare Model, CAM use was divided into use of provider-directed (guided) and self-directed (self-help) CAM. Stability and reasons for CAM use were examined with McNemar's tests and descriptive statistics. Cross-sectional and longitudinal associations between predictors and CAM use were examined with univariate and multivariate logistical analyses.

RESULTS

Use of provider-directed and self-directed CAM was stable over time (N=176). Self-directed CAM was more often used to influence the course of cancer than provider-directed CAM. Both were used to influence well-being. Openness to experience predicted use of provider-directed CAM, while clinical distress predicted use of self-directed CAM, after adjusting for other predictors. Perceived control did not predict CAM use.

CONCLUSION

CAM use is stable over time. It is meaningful to distinguish provider-directed from self-directed CAM.

PRACTICE IMPLICATIONS

Providers are advised to plan a 'CAM-talk' before adjuvant therapy, and discuss patients' expectations about influence of CAM on the course of cancer. Distressed patients most likely need information about self-directed CAM.

Identification of patient-reported distress by clinical nurse specialists in routine oncology practice: a multicentre UK study

BACKGROUND

There is uncertainty regarding how well clinical nurse specialists are able to identify distress in cancer settings.

METHODS

We examined recognition of patient-reported distress by nurse specialists across three sites in the East Midlands (UK). Clinicians were asked to report on their clinical opinion regarding the presence of distress or any mental health complication after routine assessment of 401 mixed cancer patients. Patient-reported distress was defined by the distress thermometer at a cut-off of 4 or higher.

RESULTS

We found that the prevalence of patient-reported distress was 45.4%. The rates for mild, moderate and severe distress were: 23.4, 13.7 and 8.2, respectively. When looking for distress (or any mental health complication) nurse practitioners had a detection sensitivity of 50.5% and specificity 80.0%. Cohen's kappa suggested fair agreement between staff and patients. Examining predictors of distress, clinicians were better able to recognise higher severities of distress (adjusted R(2) =0.87 P=0.001). There was lower sensitivity in palliative stages but no differences according to the type of cancer. There was also higher sensitivity but lower specificity in those clinicians with high self-rated confidence.

CONCLUSIONS

Nurses working in cancer settings have difficulty identifying distress using their routine clinical judgement and tend to make more false-negative than false-positive errors. Evidence-based strategies that improve detection of mild and moderate distress are required in routine cancer care.

Ability of nurses to identify depression in primary care, secondary care and nursing homes--a meta-analysis of routine clinical accuracy

PURPOSE

To clarify the ability of nurses and nursing assistants working in primary care, secondary care and nursing homes to identify depressed individuals using their clinical skills using meta-analysis of published studies.

METHODS

Literature search, appraisal and meta-analysis. We located 22 studies reporting on the detection of depression, 4 involving primary care or community nurses; 7 involving hospital nurses and 11 from nursing homes.17 of 22 studies had specificity data.

RESULTS

Across all 22 studies involving 7061 individuals, and a prevalence of 28.1% (95% CI=22.6-33.9%), practice and community nurses correctly identified 26.3% (95% CI=16.2-37.8%) of people with depression. They also correctly identified 94.8% (95% CI=91.3-97.4%) of the non-depressed. Nurses working in hospital settings correctly identified 43.1% (95% CI=31.9-54.8%) of people with depression and 79.6% (95% CI=71.5-86.7%) of the non-depressed. Those working in nursing homes correctly identified 45.8% (95% CI=38.1-53.6%) of people with depression and 80.0% (95% CI=68.6-88.7%) of the non-depressed.

CONCLUSIONS

Nurses have considerable difficulty accurately identifying depression but are probably at least as accurate as medical staff.

Breast cancer follow up: a randomised controlled trial comparing point of need access versus routine 6-monthly clinical review

AIM

To examine a model of care for breast cancer patients based on the concept of point of need access and investigate the effectiveness of this model compared to routine 6-monthly clinical reviews.

DESIGN

A parallel randomised controlled trial was used to examine point of need access to specialist care via the nurse specialist, compared to routine hospital based 6-monthly clinical review at year two post breast cancer diagnosis. A total of 237 patients were recruited to the study.

METHODS

Outcome measures at baseline, 9 and 18 months included psychological morbidity using the GHQ12 questionnaire, quality of life using the FACT-B plus endocrine subscale, fear and isolation. An analysis of covariance was used to detect changes over time. Recurrences and methods of detection were recorded as secondary outcome measures.

RESULTS

Two hundred and fourteen patients completed the study. Overall patients were not exposed to risks of increased psychological morbidity (p=0.767) or decline of quality of life (p=0.282) when routine review was discontinued and no significant differences were detected during an 18-month period. Patients not receiving regular review did not feel isolated, and at the end of 18 months did not wish to return to 6-monthly clinical reviews. The presentation of recurrences and short symptom history demonstrate that the recurrences observed were unlikely to have been detected at a routine visit.

CONCLUSIONS

Point of need access is acceptable to the majority of patients. Although a third of patients may wish to maintain a regular review, patient choice is important. Findings suggest that after 2 years following the diagnosis of breast cancer there is no evidence to support the view that regular clinical review improves psychological morbidity or quality of life. Patients do not appear to be compromised in terms of early detection of recurrence. Point of need access can be provided by suitably trained specialist nurses and provides a fast, responsive management system at a time when patients really need it.

Breast cancer follow-up: Literature review and discussion

This paper presents a review of the evidence for long-term breast cancer follow up to determine if routine clinical review post treatment for breast cancer has benefits for patients. There is little evidence that clinical review of patients beyond 3 years post-diagnosis leads to improved patient survival. Separate to survival there is a dearth of inquiry relating to the value of long-term clinical review of patient in terms of psychological outcomes, quality of life, patient satisfaction, access to specialist advice regarding management of symptoms, and reassurance. Regardless of supporting evidence, most breast units in the UK continue to undertake routine six monthly clinical reviews of patients up to a minimum of 5 years. A literature search for the period 1989 to January 2006 was undertaken using the CINAHL, MEDLINE, and PsychINFO databases. Keywords such as 'cancer follow-up', 'cancer survivorship', and 'psychological outcomes of cancer' were utilised. Hand searching was also undertaken. Overall a paucity of evidence was found in relation to the long-term needs of breast cancer survivors. Alternatives to hospital-based follow-up are reported such as GP or nurse-led follow-up, but the fundamental question of the importance of follow-up in relation to psychological morbidity and quality of life still remains unanswered. Further research is needed to investigate the importance of follow-up to patient survivorship. Research to explore the concept of point of need access, as well as the qualitative experiences of patients post-discharge, informational needs at discharge and on-going psychosocial support is suggested. Ultimately this paper argues for a greater choice and involvement of patients in determining their future follow up needs, providing the patient with a personalised package of care based on risk assessment and subsequent education programmes to empower patients towards self-management following discharge.

Mapping the quality of life and unmet needs of urban women with metastatic breast cancer

Enhancing quality of life and reducing the unmet needs of women are central to the successful management of advanced breast cancer. The objective of this study was to investigate the quality of life and support and information needs of urban women with advanced breast cancer. This study was conducted at four large urban hospitals in Melbourne, Australia. A consecutive sample of 105 women with advanced breast cancer completed a questionnaire that contained the European Organization of Research and Treatment of Cancer Quality of Life Q-C30 and the Supportive Care Needs Survey. Between one quarter and a third of the women reported difficulties with their physical, role and social functioning, and a little over a quarter of the women reported poor global health status. Fatigue was a problem for most women. The highest unmet needs were in the psychological and health information domains. Almost no differences in unmet needs were detected when comparing different demographic and disease characteristics of women. Health care providers should routinely monitor the quality of life and needs of women with advanced breast cancer to ensure that appropriate treatment, information or supportive services are made available.

The use of denial in an ethnically diverse British cancer population: a cross-sectional study

A total of 82 Asian and 117 randomly selected white Caucasian patients at the Leicestershire Cancer Centre were assessed using measures of coping and adaption to cancer. On the Mental Adjustment to Cancer (MAC) scale, Asian patients were more fatalistic (P<0.0001) and had more significant hopeless/helpless scores (P=0.007). The two ethnic groups answered the three questions thought to assess denial differently. Caucasians were more likely not to dwell on their illness (73 vs 55.5%, P<0.0001) and agree with the statement ‘I have difficulty believing this is happening to me’ (73 vs 60.5%, P<0.0001). However, Asian patients were more likely to agree with the statement ‘I don't really believe I have cancer’ (48.2 vs 31.3%, P=0.019). Within both groups there was an association with denial and anxious preoccupation (P<0.001). On the Hospital Anxiety and Depression (HAD) scale, there was no difference in anxiety scores between either sexes or between the Asian and Caucasian groups. However, Asian patients were more depressed (P=0.001). Although denial was significantly related to the presence of both depression (P<0.0001) and anxiety (P=0.001) in the entire patient population, there were different predictors of denial in each subgroup. On multiple regression analysis depression was linked with denial in Caucasians, whereas Fighting Spirit (minus helplessness/hopelessness) was linked with denial in Asian patients. There are definite differences in coping styles in British cancer patients according to ethnicity. While significant numbers in both groups employ denial in some form, Caucasian patients appear to adapt to the psychological pressures of cancer more successfully than Asian patients at a particular point in time. Further work is required to elucidate longitudinal relationships between denial and adaption to cancer.

Nurse-led models of chemotherapy care: mixed economy or nurse-doctor substitution?

AIM

This paper reports a study exploring the perspectives of people affected by cancer (service users) and health care professionals' about current medical consultant-led services and the acceptability of a proposed nurse-led ambulatory chemotherapy service.

BACKGROUND

A number of studies have evaluated a nurse-led model of cancer care delivery but little work has been undertaken in chemotherapy settings. Furthermore, many of these studies give little information on how the perspective of users was incorporated in the design and evaluation of these services.

METHODS

Service users (n = 26) and health care professionals (n = 22) were recruited across the South East of England. A qualitative study was undertaken... Using a semi-structured interview schedule, participants were asked to give their perceptions of current chemotherapy services and the potential of a nurse-led service. A thematic analysis of data was undertaken.

FINDINGS

This paper focuses on the theme of the current and future context of a chemotherapy service. Three sub-themes were identified: contextualizing roles, defining therapeutic outcomes, and demonstrating effectiveness. All interviewees saw this role as different but complementary to the role of medical staff. There were mixed opinions from service users and professionals on the acceptability of nurse-led chemotherapy provision. In defining potential outcomes of nurse-led care, service users described benefits in terms of service and economic outcomes. Professionals saw additional benefits in terms of patient-based outcomes. Professionals and service users expressed the need for appropriate education of nurses for this role and rigorous evaluation of any new service before widespread implementation.

CONCLUSIONS

Understanding the perspective of users is imperative when re-designing cancer nursing services. Implementation of nurse-led models in chemotherapy services should be preceded by staff education and followed by systematic evaluation.

Screening for depression in women with metastatic breast cancer: a comparison of the Beck Depression Inventory Short Form and the Hospital Anxiety and Depression Scale

OBJECTIVE

To compare two self-report questionnaires for identifying possible depression in women with metastatic breast cancer.

METHOD

We conducted structured psychiatric interviews and administered the Beck Depression Inventory Short Form (BDI-SF) and Hospital Anxiety and Depression Scale (HADS) to 227 women with stage IV breast cancer. The accuracy for identifying DSM-IV-defined major and minor depression was examined. Sensitivity, specificity, positive (PPV) and negative (NPV) predictive values were calculated and receiver operating characteristic curves plotted.

RESULTS

Seventy-four (32.6%) patients satisfied DSM-IV criteria for a depressive disorder. With a cut-off of 4, the BDI-SF had a sensitivity of 0.84, specificity of 0.63, and PPV of 0.52. A cut-off of 11 on the HADS-Depression scale (HADS-D) resulted in sensitivity, specificity, and PPV of 0.16, 0.97, and 0.75, respectively. For major depression alone, the BDI-SF with a cut-off of 5 had excellent sensitivity but poor PPV; the HADS, with a cut-off of 7, had weak sensitivity and PPV.

CONCLUSIONS

Overall, the two scales perform similarly in identifying major depression, while the BDI-SF is the more useful in screening for DSM-IV major or minor depression categories in this clinical group.

Improving supportive care for women with breast cancer in Australia: the challenge of modifying health systems

Although the benefits of many psychosocial support strategies in improving well being in women with breast cancer have been demonstrated, few women receive these programs as part of routine care. This paper provides some recommendations, based on experience in Australia, about how access to evidence-based supportive care strategies might be improved through modification of health systems. It demonstrates the paucity of research about the costs and health service implications of psychosocial support strategies, which is vital to health planning and service delivery change. It outlines the systematic approach taken in Australia to improving psychosocial support nationally by: the development of research reviews; preparation of guidelines about supportive care; implementation of programs to foster the adoption of guidelines through modification of policy, health service delivery and clinician training; and monitoring programs. Coalitions of government, health care professionals and consumers are key to effective lobbying for change. If all women with breast cancer are to receive better supportive care, there is a need for approaches which: refocus the research effort in psycho-oncology; develop more strategic approaches to generating change in health systems and health policy and foster partnerships to advocate for improved resources.

An evidence-based specialist breast nurse role in practice: a multicentre implementation study

The objective of this study was to examine the feasibility, implementation, acceptability and impact of an evidence-based specialist breast care nurse (SBN) model of care in Australia. Primary data were collected from four diverse Australian breast cancer treatment centres over a 12-month period. The design was a multicentre demonstration project. Information about the provision of care and patient needs was collected through prospective logs. Structured interviews were conducted with women who received the SBN intervention (N = 167) and with a control group of women treated prior to the intervention period (N = 133). Health professionals (N = 47) were interviewed about their experience of the SBN. Almost all women had contact with an SBN at five scheduled consultations and 67% of women in the intervention group requested at least one additional consultation with the SBN. Women in the intervention group were more likely to receive hospital fact sheets and to be told about and participate in clinical trials. Ninety-eight per cent of women reported that the availability of an SBN would affect their choice of hospital, with 48% indicating that they would recommend only a hospital with a SBN available. Health professionals reported that SBNs improved continuity of care, information and support for the women, and resulted in more appropriate referrals and use of the time of other members of the team. In conclusion, the SBN model is feasible and acceptable within diverse Australian treatment centres; there is evidence that some aspects of care were improved by the SBN.

Changes in family relationships affect the development of chemotherapy-related nausea symptoms

This study examined the effect of changes in family relationships (cohesion, expression, and conflict) on patients' physical adjustment to chemotherapy and whether the effect would differ depending on the patient's age and gender. Two hundred thirty-three married cancer patients completed questionnaires consisting of measures of family relationships and chemotherapy-related nausea symptoms, at two assessments. Results revealed that the prevalence of nausea symptoms was related to the degree of conflict in the family, depending on the patient's age and gender. An increase in family conflict was associated with an increased duration of post-treatment nausea and greater severity of anticipatory nausea for younger adult patients but not for older adult patients. An increase in family conflict was also associated with a greater severity of anticipatory nausea for female patients but not for male patients. These findings suggest that intervention programs to help reduce family conflict may be especially beneficial for younger adult and female patients.