Treatment-Related Symptom Clusters

Symptom Clusters, Psychological Distress, and Quality of Life in Patients with Atrial Fibrillation

Background: Patients with atrial fibrillation (AF) experience diverse symptoms such as palpitations, dizziness, and fainting that lead to depression, anxiety, and poor quality of life. Management of symptoms is fundamental for AF, and with the increasing prevalence of AF, studies on management of symptoms in patients with AF are needed. Objectives: This study aimed to assess symptom clusters according to symptom severity in patients with atrial fibrillation and evaluate the relationships between symptom cluster groups and the psychological distress and quality of life of these patients. Design: A descriptive survey was used in this study. Methods: A total of 175 patients were included in this study. Data regarding symptoms, psychological distress, and quality of life were obtained using structured questionnaires and analyzed using frequency and percentage, mean and standard deviation, cluster analysis, t-testing, Chi-square testing, Pearson's correlation coefficient, and multiple regression analysis. The Euclidean distance square of the hierarchical cluster was used to form symptom cluster groups. Results: Two groups of symptom clusters were formed based on the seven most common symptoms (i.e., chest palpitations, fatigue/tiredness, dizziness, lack of energy, pulse skipping, insomnia, and heavy breathing) of atrial fibrillation patients. Psychological distress and quality of life showed significant correlations with the symptom cluster groups (p < 0.001). Conclusion: Symptoms of atrial fibrillation increased patients' depression and anxiety, and further affected their quality of life. Therefore, management of symptoms is critical to maintaining a high quality of life. Nursing interventions based on the characteristics of symptom cluster groups must be developed and attempted.

Nurse-Delivered Telephone Intervention to Reduce Oral Mucositis and Prevent Dehydration

PROBLEM STATEMENT

This study evaluates the feasibility of a nurse-delivered telephone intervention to reduce oral mucositis severity and prevent dehydration in patients with lung or head and neck cancer undergoing chemotherapy and radiation therapy.

DESIGN

This study used a two-phase, qualitatively driven, mixed-methods descriptive design.

DATA SOURCES

11 participants were recruited from an academic cancer center in southern Florida. Participants received symptom management education followed by twice-weekly tailored nurse coaching telephone calls.

ANALYSIS

Questionnaires measuring symptom severity, health-related quality of life, perceived self-efficacy, and symptom self-management were administered at four data points. Data on unscheduled medical visits were collected. Guided interviews were conducted four weeks post-treatment and analyzed qualitatively using content analysis.

FINDINGS

Participants found the intervention to be acceptable. Oral mucositis symptom severity was minimized, and dehydration was avoided. The intervention enabled symptom self-management and improved perceived self-efficacy.

IMPLICATIONS FOR PRACTICE

Emotional support provided by the nurse was crucial, exemplifying improvement over an automated system.

Validity and Reliability Assessment of the Persian Version of Therapy-Related Symptom Checklist

Therapy-related symptom checklist for children (TRSC-C) was developed as a symptom assessment tool in children receiving chemotherapy. The objective of the present study was to evaluate the validity and reliability of the Persian version of TRSC-C. This cross-sectional study was conducted in 2013-2014 in Tehran, Iran. TRSC-C was translated using backward-forward approach. The content validity, face validity, and comprehensiveness were investigated based on the opinion of experts. The item content validity index (I-CVI) and scale content validity index (S-CVI) were calculated by the mean approach and inter-rater agreement. The scale was revised based on the comments from a team of five experts, after which it was evaluated by an additional group of four experts. To assess the inter-rater reliability, two raters filled the scale with 29 and 30 patients in the outpatient clinic of Hazrat-e Ali Asghar Hospital. The Cronbach's alpha was calculated and factor analysis was performed. The scores of content validity were analyzed in Excel. Other statistical analyses were performed using the SPSS software version 20.0. Based on the initial assessment, the S-CVI with less conservative approach was 60% for clarity, 33% for relevancy, and 60% for simplicity. After revising the scale, the S-CVI reached 100%. The comprehensiveness and face validity of the scale were appropriate. The scale was inter-rater reliable and the Cronbach's alpha was 0.803. Eleven subscales were found in the TRSC-C. It is concluded that the Persian TRSC-C is a valid and reliable tool for measuring children symptoms. Availability of a valid and reliable checklist is a fundamental step in monitoring the symptoms of patients while receiving chemotherapy.

Symptom Clusters and Quality of Life According to the Survivorship Stage in Ovarian Cancer Survivors

This cross-sectional study evaluated a convenience sample comprising 182 ovarian cancer survivors to identify symptom clusters according to the cancer survivorship stage and to determine their effects on quality of life using the European Organization for Research and Treatment of Cancer Quality of Life-C30 and -OV28 questionnaires. Factor and multiple regression analyses were performed to identify symptom clusters according to the cancer survivorship stage and the symptom clusters that affected the quality of life in each cancer survivorship stage, respectively. Participants in the acute, extended, and permanent survival stages accounted for 33%, 36.3%, and 30.7% of subjects, respectively. Overall, the most common symptom cluster was fatigue-diarrhea, and the symptom clusters affecting the quality of life differed according to the cancer survivorship stage. Thus, to improve the quality of life of ovarian cancer survivors, the main symptom clusters of each cancer survivorship stage must be identified, and management strategies for the related symptoms must be designed.

Evaluation of the symptoms and treatment prescribed to hospitalized patients

OBJECTIVE

Evaluation of the presence of symptoms and suitability in the treatment of patients admitted to medical wards at HU-UFSC. Identification of patients eligible for palliative care (PC).

METHOD

A prospective cohort study, which evaluated patients in the first 48 hours of hospitalization (D1) and after 48 hours (D2). On D1, palliative performance and symptom assessment scales were applied (PPS/ESAS). The treatment established for the control of detected symptoms was also identified. On D2, the ESAS scale was applied again, and the medical prescription reviewed. When the presence of severe symptoms was found, the attending physician was informed. Patients who presented PPS≤60 were eligible for PC prioritization. For statistical analysis Student's t and χ2 tests were used.

RESULTS

168 patients were studied. Of these, 26.8% had PPS≤60. PC was described in one medical chart. Patients with mild symptoms reported significant worsening in the second evaluation, especially worsening in pain (32.3%) and well-being (49.3%). Symptoms considered severe showed significant improvement. There was no control of pain reported as moderate. Prescriptions for pain control were predominantly "if necessary", prevailing the use of non-opioid analgesics and weak opioids. The attending physician was informed of 116 (69%) patients with ESAS score≥4.

CONCLUSION

The control of symptoms, especially those considered mild, was unsatisfactory. Drug prescription was inadequate to control pain, and non-existent for some reported symptoms. There was no adequate prioritization of PC. There is a need for optimization and dissemination of PC among health professionals.

Measures and Methods for Symptom and Symptom Cluster Assessment in Adolescents and Young Adults with Cancer

OBJECTIVES

To provide an overview of resources for measuring symptoms and symptom clusters in adolescents and young adults (AYAs) with cancer and to examine methodological strategies for evaluating symptom clusters.

DATA SOURCES

Published research articles and clinical experience.

CONCLUSION

Limited research has addressed symptoms and symptom clusters in AYAs with cancer. Reliable, valid, and developmentally appropriate measures are needed to advance this area of research.

IMPLICATIONS FOR NURSING PRACTICE

Use of mobile technology and mixed qualitative and quantitative methods to understand AYAs' experience of symptoms and symptom clusters could enhance symptom awareness and the evidence base for practice.

A longitudinal analysis of symptom clusters in cancer patients and their sociodemographic predictors

CONTEXT

Exploring the relationships between concurrent symptoms or "symptom clusters" (SCs) longitudinally may complement the knowledge gained from the traditional approach of examining individual symptoms or SCs crosssectionally.

OBJECTIVES

To identify consistent SCs over the course of one year and determine the possible associations between SCs and demographic and medical characteristics, and between SCs and emotional distress.

METHODS

This study was an exploratory longitudinal analysis of SCs in a large sample of newly diagnosed cancer patients. Patients provided symptom assessment data at baseline, three, six, and 12 months. A factor analysis was conducted (controlling for the patient over time) on pain, fatigue, anxiety, depression, sleep, weight change, and food intake items to identify clusters. A panel regression on each cluster explored associations with demographic and medical characteristics and distress.

RESULTS

In total, 877 patients provided baseline data, with 505 retained at 12 months. Three SCs explained 71% of the variance. The somatic cluster included pain, fatigue, and sleep; the psychological cluster included anxiety and depression; and the nutrition cluster consisted of weight and food intake. Low income and treatment with radiation or chemotherapy predicted higher somatic symptom burden. Younger age, being female, low income, and treatment with surgery predicted more psychological symptomatology. Older age and treatment with surgery predicted higher nutritional burden. Patients with higher somatic, psychological, and nutritional symptom burden reported higher distress.

CONCLUSION

The presence of SCs across the first year of diagnosis supports the need for routine and ongoing screening for the range of symptoms that may be experienced by patients. Further work is needed to develop interventions that better target individual symptoms that cluster, as well as the entire cluster itself.

Symptoms, clusters and quality of life prior to surgery for breast cancer

AIMS AND OBJECTIVES

To examine the pretreatment symptoms and symptom clusters that women awaiting breast cancer surgery are experiencing and the impact of these symptoms on their quality of life.

BACKGROUND

Most women diagnosed with breast cancer will have surgery as a first-line treatment. The presence of presurgery symptoms may be significant in contributing to distress and impaired quality of life. While it seems that women with breast cancer may experience the symptoms of fatigue, pain, depression and sleep disturbance as a cluster, this has not yet been confirmed by empirical research in the presurgery time period.

DESIGN

A multiple-point prospective longitudinal cohort panel design is used.

METHODS

Presurgery symptoms and quality of life were assessed using the Hospital Anxiety and Depression Scale, Insomnia Severity Index, Functional Assessment of Cancer Therapy-Fatigue, Brief Pain Inventory and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30(3).

RESULTS

Participants (n = 94, age range 30-92) experienced symptoms prior to surgery, with pain being a more prevalent symptom (35%) than fatigue (32%), sleep disturbances (25·5%) or depression (11%). global quality of life was significantly impacted on by fatigue and showed a moderate correlation with emotional functioning and a weak correlation with physical and social functioning. Hierarchical cluster analysis identified the presence of five clusters with symptoms present in differing intensities in each cluster.

CONCLUSION

In this cohort of women, healthy other than having a diagnosis of breast cancer, symptoms were impacting on quality of life. It is evident that clusters of symptoms are present presurgery that must be assessed and managed.

RELEVANCE TO PRACTICE

Healthcare delivery systems must ensure that early symptoms are addressed effectively in the presurgery period to improve quality of life and reduce adverse outcomes postsurgery.

Ten Weeks of Home-Based Exercise Attenuates Symptoms of Chemotherapy-Induced Peripheral Neuropathy in Breast Cancer Patients

The purpose of this investigation was to determine if a structured, home-based exercise program was beneficial to reduce symptoms of chemotherapy-induced peripheral neuropathy and improve quality of life (QOL). A total of 50 women who are breast cancer survivors and are listed in the Breast Cancer Registry of Greater Cincinnati database were recruited by mail. Participants were initially asked to complete the McGill QOL questionnaire and the Leeds Assessment of Neuropathic Symptoms and Signs, before beginning a 10-week home-based exercise program. At the completion of the exercise program, subjects were asked again to complete the same two questionnaires. Pre- and post-intervention data were analyzed using a repeated measures ANOVA, at a significance level of α<0.05. Six individuals completed the investigation. Prior to the 10-week exercise program, participants described their pain as unpleasant skin sensations (Pre-HBEx, N=6), abnormally sensitive to touch (Pre-HBEx, N=6), and coming on suddenly in bursts for no apparent reason (Pre-HBEx, N=5). Following 10-weeks of exercise, participants reported experiencing less of these symptoms (Post-HBEx, N=3, 1, and 4 respectively; P=0.05). It was also determined that troublesome symptoms were significantly reduced after 10-weeks of home-based exercise (P=0.05).

Mimic of manganese superoxide dismutase induces apoptosis in human acute myeloid leukemia cells

Abstract Increasing manganese superoxide dismutase (MnSOD) expression can suppress the malignant phenotype in various cancer cell lines and suppress tumor formation in xenograft and transgenic mouse models. A mimic of manganese superoxide dismutase (MnSODm), synthesized by a chemical method, has been shown to possess antitumor properties. However, the anticancer activity of MnSODm in acute myeloid leukemia (AML) is still obscure. In this study, we investigated the effects of MnSODm on the apoptosis of human leukemia HL-60 cells. Results showed that MnSODm significantly reduced the proliferation of HL-60 cells in a concentration- and time-dependent manner. By flow cytometric analysis, we found that MnSODm treatment resulted in increased apoptosis in HL-60 cells. Further analysis demonstrated involvement of activation of the caspase cascade, cleavage of poly(ADP-ribose) polymerase (PARP) and release of cytochrome c in MnSODm-induced apoptosis. The results also showed that the expression of anti-apoptotic Bcl-2 and Bid were dose-dependently decreased, whereas the expression of pro-apoptotic Bax protein was increased. Thus, MnSODm induced apoptosis in HL-60 cells via mitochondria-mediated, caspase-dependent pathways. MnSODm inhibition of Akt phosphorylation may contribute to MnSODm-mediated acute myeloid leukemia cell growth inhibition and apoptosis induction.

Evolution of cancer-related symptoms over an 18-month period

CONTEXT

Previous studies have revealed inconsistent findings about the longitudinal evolution of cancer-related symptoms. In addition, the contribution of medical factors (e.g., cancer site, and treatments) in explaining the changes in these symptoms is yet to be established.

OBJECTIVES

This prospective study investigated longitudinal changes of five symptoms (i.e., depression, anxiety, insomnia, fatigue, and pain) in patients scheduled to undergo surgery for cancer (N=828).

METHODS

The patients completed the Hospital Anxiety and Depression Scale, the Insomnia Severity Index, the Multidimensional Fatigue Inventory, and a pain questionnaire at baseline and after 2, 6, 10, 14 and 18 months.

RESULTS

Several time changes were statistically significant but effect sizes only revealed one change of a medium magnitude, that is, a reduction of anxiety from T1 to T2 (d=-0.58). Women with breast or gynecological cancer were the only subgroups to exhibit significant changes (i.e., reduction of a small magnitude of anxiety symptoms from T1 to T2; ds=-0.27 and -0.30, respectively). However, numerous differences were found across adjuvant treatments, including greater variations in depression and insomnia scores in the chemotherapy group (ds=-0.71 to 0.20) and a transient increase in fatigue symptoms in patients receiving "all" adjuvant treatments (ds=-0.24 to 0.37).

CONCLUSION

The severity of cancer-related symptoms varies during the cancer care trajectory, especially anxiety scores, which importantly decrease during the first few months after the surgery. This study also suggests that treatment regimens better account for individual differences than cancer site in the evolution of symptoms.

Symptom clusters in patients with metastatic cancer: a literature review

This article reviews the literature reporting empirically determined symptom clusters in patients with metastatic cancer. A literature search was conducted on symptom clusters within heterogeneous metastatic cancer patient populations using MEDLINE, EMBASE, and CINAHL. Studies examining predetermined symptom clusters were excluded. A total of eight relevant studies published between 2005 and 2011 were identified. The number of symptom clusters extracted varied from two to eight clusters per study, comprising of two to eight symptoms per cluster. There were no clusters consistently identified within all eight studies. Notable differences in symptoms assessed, assessment tools, statistical analysis, patient demographics were observed between the studies. The lack of consensus among the inter-study symptom clusters are likely due to the differences in patient population as well as study methodology. Further exploration in metastatic symptom cluster research will ideally improve patient outcomes by facilitating improved symptom management in future clinical practice.

Subgroups of advanced cancer patients clustered by their symptom profiles: quality-of-life outcomes

BACKGROUND

Symptom cluster analysis is a new frontier of research in symptom management. This study clustered patients by their symptom profiles to identify subgroups that may be at higher risk for poor quality of life (QOL) and that may, therefore, benefit most from targeted interventions.

METHODS

Longitudinal study of metastatic cancer patients using the Edmonton Symptom Assessment Scale (ESAS). We generated two-, three-, and four-cluster subgroups and examined the relationship of cluster membership with patient outcomes. To address the problem of missing longitudinal data, we developed a novel outcome variable (QualTime) that measures both QOL and time in study.

RESULTS

Two hundred and twenty-one patients with a mean Palliative Performance Scale (PPS) of 59.1 were enrolled. The three-cluster model was chosen for further analysis. The low-burden subgroup had all low severity symptom scores. The intermediate subgroup separates from the low-burden group on the "debility" profile of fatigue, drowsiness, appetite, and well-being. The high-burden group separates from the intermediate-burden group on pain, depression, and anxiety. At baseline, PPS (p=0.0003) and cluster membership (p<0.0001) contributed significantly to global QOL. In univariate analysis, cluster membership was related to the longitudinal outcome, QualTime. In a multivariate model, the relationship of PPS to QualTime was still significant (p=0.0002), but subgroup membership was no longer significant (p=0.1009).

CONCLUSION

PPS is a stronger predictor of the longitudinal variable than cluster subgroups; however, cluster subgroups provide a target for clinical interventions that may improve QOL.

Feasibility of a patient-controlled cognitive-behavioral intervention for pain, fatigue, and sleep disturbance in cancer

PURPOSE/OBJECTIVES

To evaluate the feasibility of a patient-controlled cognitive-behavioral intervention for pain, fatigue, and sleep disturbance during treatment for advanced cancer and to assess initial efficacy of the intervention.

DESIGN

One group pre- and post-test design.

SETTING

Outpatient oncology clinics at a comprehensive cancer center in the midwestern United States.

SAMPLE

30 adults with advanced (recurrent or metastatic) colorectal, lung, prostate, or gynecologic cancer receiving chemotherapy or radiotherapy.

METHODS

Participants completed baseline measures (e.g., demographics, symptom inventory) and received education and training to use an MP3 player loaded with 12 cognitive-behavioral strategies (e.g., relaxation exercises, guided imagery, nature sound recordings). Participants used the strategies as needed for symptom management for two weeks, keeping a log of symptom ratings with each use. Following the two-week intervention, participants completed a second symptom inventory and an evaluation of the intervention.

MAIN RESEARCH VARIABLES

Feasibility, patient-controlled cognitive-behavioral intervention, pain, fatigue, and sleep disturbance.

FINDINGS

Thirty of 43 eligible patients (73%) agreed to participate; of them, 27 (90%) completed the study. Most reported that they enjoyed the intervention, had learned useful skills, and perceived improvement in their symptoms. Symptom scores at two weeks did not differ significantly from baseline; however, significant reductions in pain, fatigue, and sleep disturbance severity were found in ratings made immediately before and after use of a cognitive-behavioral strategy.

CONCLUSIONS

The patient-controlled cognitive-behavioral intervention appears to be feasible for additional study and could reduce day-to-day severity of co-occurring pain, fatigue, and sleep disturbance.

IMPLICATIONS FOR NURSING

A randomized, controlled trial is needed to test efficacy of the intervention for co-occurring pain, fatigue, and sleep disturbance. Meanwhile, based on previous efficacy studies, cognitive-behavioral strategies can be recommended for certain individual symptoms.

Sustaining self: the lived experience of transition to long-term ventilation

Long-term mechanical ventilation (LTMV) is used to support growing numbers of children and adults who develop chronic respiratory failure. The purpose of this hermeneutic phenomenological study was to explore the subjective meaning of the experience of transition from spontaneous breathing to reliance on LTMV. In-depth, audiorecorded interviews of 11 ventilated individuals living in a western Canadian province were transcribed and analyzed. The transition journey was revealed to be a time of psychological, physical, and spiritual challenge. "Sustaining self " was revealed as the essence of ventilator users' transition experience. Findings underscore the complex nature of transition to technological reliance, illuminating the need for increased health professional knowledge and understanding of the symptom experience and management options for individuals living with chronic respiratory failure. Strategies to support individuals' sense of self as they journey to a life reliant on LTMV are required.

Mind-body treatments for the pain-fatigue-sleep disturbance symptom cluster in persons with cancer

CONTEXT

Co-occurring pain, fatigue, and sleep disturbance comprise a common symptom cluster in patients with cancer. Treatment approaches that target the cluster of symptoms rather than just a single symptom need to be identified and tested.

OBJECTIVES

To synthesize evidence regarding mind-body interventions that have shown efficacy in treating two or more symptoms in the pain-fatigue-sleep disturbance cancer symptom cluster.

METHODS

A literature search was conducted using CINAHL, Medline, and PsychInfo databases through March 2009. Studies were categorized based on the type of mind-body intervention (relaxation, imagery/hypnosis, cognitive-behavioral therapy/coping skills training [CBT/CST], meditation, music, and virtual reality), and a preliminary review was conducted with respect to efficacy for pain, fatigue, and sleep disturbance. Mind-body interventions were selected for review if there was evidence of efficacy for at least two of the three symptoms. Forty-three studies addressing five types of mind-body interventions met criteria and are summarized in this review.

RESULTS

Imagery/hypnosis and CBT/CST interventions have produced improvement in all the three cancer-related symptoms individually: pain, fatigue, and sleep disturbance. Relaxation has resulted in improvements in pain and sleep disturbance. Meditation interventions have demonstrated beneficial effects on fatigue and sleep disturbance. Music interventions have demonstrated efficacy for pain and fatigue. No trials were found that tested the mind-body interventions specifically for the pain-fatigue-sleep disturbance symptom cluster.

CONCLUSION

Efficacy studies are needed to test the impact of relaxation, imagery/hypnosis, CBT/CST, meditation, and music interventions in persons with cancer experiencing concurrent pain, fatigue, and sleep disturbance. These mind-body interventions could help patients manage all the symptoms in the cluster with a single treatment strategy.

Taste and smell changes in patients receiving cancer chemotherapy: distress, impact on daily life, and self-care strategies

Few studies have described how patients receiving chemotherapy experience taste/smell changes (TSCs). Food and meal situations have important meaning beyond nutrition, so these common symptoms may affect daily lives. This study aims to investigate distress and impact on daily life from TSCs in patients receiving cancer chemotherapy, analyze reported levels of distress and impact on daily life from TSCs with regard to sociodemographic and clinical factors, and explore patients' reports of self-care strategies and communication with staff. The 340 patients reporting TSCs on a multicenter survey (n = 518) were grouped into subsets by level of TSC-related distress and impact on daily life, which served as the basis for statistical comparison. Written comments were analyzed inductively using content analysis. Nearly one-third of participating patients reported both high levels of distress and impact on daily life (high distress and high impact on daily life [HDHI]) from TSCs. The HDHI subset reported other symptoms more often than others did (P = .01) and also more often responded to open questions about distress, impact, and self-care strategies (P = .01). Taste/smell changes were not always reported to staff, even in the HDHI subset. The specific aspects of TSCs resulting in distress and impact on daily life varied greatly, affecting both psychological and somatic aspects, with little consensus and great individual differences described in self-care strategies. The variety of distress, impact, and strategies used to alleviate TSCs clarifies the importance of situational meaning.

Symptom management issues in oncology nursing

Symptoms experienced by patients with cancer can occur as a direct effect of the disease process and be related to side effects of treatment. Many patients with cancer also are older in age and have comorbidities, such as diabetes and heart disease. Comorbid conditions also produce disease and treatment-related symptoms that may have an independent or compounding effect on cancer-related symptoms.

A review of patient self-report tools for chemotherapy-induced nausea and vomiting

GOALS OF WORK

The assessment of chemotherapy-induced nausea, vomiting and retching (CINVR) is important and to date no review has comprehensively assessed available patient self-report tools. The aim was to undertake a review of their utility, content and psychometric properties.

MATERIALS AND METHODS

One thousand three hundred and forty-seven citations were identified by electronic and hand searches resulting in 24 non-duplicate abstracts, 15 articles for analysis, and six articles, which fitted the inclusion criteria. E-mail investigations discovered a further scale, resulting in seven measures.

RESULTS

The review highlighted the strengths and weaknesses of current tools. The multiple domains, phases and aspects of CINVR signify that the assessment tools varied markedly. The diverse requirements of research and clinicians also contribute to the variation. There was a notable disparity in the quality of scales and paucity in terms of their development and psychometric evaluation. We found that several self-assessment scales currently perceived as well-validated tools have problems in terms of their validity, reliability and appropriateness.

CONCLUSIONS

The constituents of a scale relevant for both clinical and research use were assessed and it was recommended that a modular tool focusing on two domains (nausea and vomiting); two phases (acute and delayed); measuring the aspects of occurrence, frequency, intensity alongside duration and functional interference; and antiemetic use and adverse events should be developed. Based on these recommendations, further research into an appropriate scale would minimise conceptual confusion, increase clinicians' understanding and control of CINVR, decrease patient distress and could have equal utility in both a clinical and a research setting.