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Holch P, Absolom KL, Henry AM, Walker K, Gibson A, Hudson E, Rogers Z, Holmes M, Peacock R, Pini S, Gilbert A, Davidson S, Routledge J, Murphy A, Franks K, Hulme C, Hewison J, Morris C, McParland L, Brown J, Velikova G. Online Symptom Monitoring During Pelvic Radiation Therapy: Randomized Pilot Trial of the eRAPID Intervention. Int J Radiat Oncol Biol Phys 2023; 115:664-676. [PMID: 36241128 DOI: 10.1016/j.ijrobp.2022.09.078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 09/21/2022] [Accepted: 09/24/2022] [Indexed: 11/06/2022]
Abstract
PURPOSE Radiation therapy (RT) and chemoRT for pelvic cancers increase survival but are associated with serious treatment-related symptoms. Electronic-patient self-Reporting of Adverse-events: Patient Information and aDvice (eRAPID) is a secure online system for patients to self-report symptoms, generating immediate advice for hospital contact or self-management. This pilot study aimed to establish feasibility and acceptability of the system. METHODS AND MATERIALS In a prospective 2-center randomized parallel-group pilot study, patients undergoing radical pelvic RT for prostate cancer (prostateRT) or chemoRT for lower gastrointestinal and gynecological cancers were randomized to usual care (UC) or eRAPID (weekly online symptom reporting for 12, 18, and 24 weeks). Primary outcomes were recruitment/attrition, study completion, and patient adherence. Secondary outcomes were effect on hospital services and performance of patient outcome measures. Missing data, floor/ceiling effects, and mean change scores were examined for Functional Assessment of Cancer Therapy (FACT-G), European Organisation for Research and Treatment of Cancer, Quality of Life (EORTC QLQ C-30), self-efficacy, and EuroQol (EQ5D). RESULTS From 228 patients approached, 167 (73.2%) were consented and randomized (83, eRAPID; 84, UC; 87, prostateRT; 80, chemoRT); 150 of 167 completed 24 study weeks. Only 16 patients (9.6%) withdrew (10, eRAPID; 6, UC). In the eRAPID arm, completion rates were higher in patients treated with prostateRT compared with chemoRT (week 1, 93% vs 69%; week 2, 93% vs 68%; week 12, 69% vs 55%). Overall, over 50% of online reports triggered self-management advice for milder adverse events. Unscheduled hospital contact was low, with no difference between eRAPID and UC. Return rates for outcome measures were excellent in prostateRT (97%-91%; 6-24 weeks) but lower in chemoRT (95%-55%; 6-24 weeks). Missing data were low (1%-4.1%), ceiling effects were evident in EQ5D-5L, self-efficacy-scale, and FACT-Physical Wellbeing. At 6 weeks, the chemoRT-eRAPID group showed less deterioration in FACT-G, EORTC QLQ-C30, and EQ5D-Visual Analogue Scale than UC, after baseline adjustment. CONCLUSIONS eRAPID was successfully added to UC at 2 cancer centers in different patient populations. Acceptability and feasibility were confirmed with excellent adherence by prostate patients, but lower by those undergoing chemoRT for gynecological cancers.
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Affiliation(s)
- Patricia Holch
- Department of Psychology, School of Social Sciences, Leeds Beckett University, Leeds, United Kingdom; Leeds Institute of Medical Research at St James's and.
| | - Kate L Absolom
- Leeds Institute of Medical Research at St James's and; Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | - Ann M Henry
- Leeds Institute of Medical Research at St James's and; Leeds Teaching Hospitals NHS Trust, Leeds Cancer Centre, Leeds, United Kingdom
| | - Katrina Walker
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | - Andrea Gibson
- Leeds Institute of Medical Research at St James's and; Leeds Teaching Hospitals NHS Trust, Leeds Cancer Centre, Leeds, United Kingdom
| | - Eleanor Hudson
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | - Zoe Rogers
- Leeds Institute of Medical Research at St James's and
| | - Marie Holmes
- Leeds Institute of Medical Research at St James's and
| | | | - Simon Pini
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | - Alexandra Gilbert
- Leeds Institute of Medical Research at St James's and; Leeds Teaching Hospitals NHS Trust, Leeds Cancer Centre, Leeds, United Kingdom; Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | - Susan Davidson
- Christie NHS Foundation Trust, Manchester, United Kingdom
| | | | - Anthony Murphy
- Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Kevin Franks
- Leeds Teaching Hospitals NHS Trust, Leeds Cancer Centre, Leeds, United Kingdom
| | | | - Jenny Hewison
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | | | | | - Julia Brown
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | - Galina Velikova
- Leeds Institute of Medical Research at St James's and; Leeds Teaching Hospitals NHS Trust, Leeds Cancer Centre, Leeds, United Kingdom
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Postprostatectomy Incontinence and Self-management for Urinary Incontinence After Laparoscopic Radical Prostatectomy: A Cross-sectional Study. J Wound Ostomy Continence Nurs 2021; 48:440-446. [PMID: 34495936 DOI: 10.1097/won.0000000000000793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE The purpose of this study was to describe postprostatectomy incontinence (PPI) after laparoscopic radical prostatectomy (LRP), self-management strategies for managing incontinence, and factors influencing self-management. DESIGN A descriptive, cross-sectional study. SUBJECTS AND SETTING The sample comprising 37 males with prostate cancer who underwent LRP was recruited within first 2 years. The study setting was a tertiary care hospital in Beijing, China. An additional 78 individuals who responded to a mailed invitation sent from September 2015 to October 2016 participated in the study. METHODS Participants completed a questionnaire that queried demographic and pertinent clinical data. The questionnaire also included 2 validated instruments. The International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF) was used to assess urinary incontinence (UI) following radical prostatectomy and its severity. The Strategy and Effectiveness of Symptom Self-Management questionnaire of Postprostatectomy Incontinence (SESSM-PPI) was used to evaluate self-management of UI, including strategies used and their perceived effectiveness. RESULTS Data analysis was based on 115 respondents who completed all components of the questionnaire; 95 (82.6%) indicated having UI. Forty-one patients (43.2%) indicated mild UI, 47 (49.5%) indicated moderate UI, and 7 (7.4%) indicated severe UI. The mean score of the SESSM-PPI was 14.04 ± 7.92, indicating a low level of self-management.The top 5 strategies with moderate effectiveness were in the following order: "use pads or adult diapers"; "pelvic floor muscle training"; "avoid extracting heavy objects"; "avoid drinking"; and "eat more fruit to prevent constipation." The Spearman correlation analysis revealed a positive correlation between the frequency of use of self-management strategies and incontinence severity. CONCLUSIONS Urinary incontinence is prevalent among males with prostate cancer managed by radical prostatectomy. Respondents tended to report mild to moderate UI severity. Self-management of UI among respondents is low.
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Patient experiences of self-care management after radical prostatectomy. Eur J Oncol Nurs 2021; 50:101894. [PMID: 33529792 DOI: 10.1016/j.ejon.2020.101894] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 12/22/2020] [Accepted: 12/29/2020] [Indexed: 12/24/2022]
Abstract
PURPOSE Prostate cancer is the most common cancer form in Sweden and side effects of the leading treatment, radical prostatectomy, include urinary leakage and erectile dysfunction. Patients are recommended to perform self-care to reduce side effects, but their experiences of performing self-care management after radical prostatectomy are largely unexplored. The aim of this study was to deepen the understanding about patient experiences of support for managing self-care during the first six months after radical prostatectomy. METHODS Eighteen patients were consecutively recruited six months after surgery and individual interviews were conducted. The study had a descriptive qualitative approach and inductive content analysis was used. RESULTS Patients described self-care management during the first half-year after surgery as a progression with growth in self-management skills through interconnected phases, from initially striving to get a grasp of the situation and find supportive relationships, to getting grounded in the new situation and taking command of the situation. At six months after surgery, patients had reached a point where they needed to maneuver feelings about long-term consequences. CONCLUSIONS Standardized routines ensure a certain level of care, but are sparsely adjustable to patients' progression in self-care management. For sustained self-care behaviors, tailored and interactive support is required from multiple disciplines and peers, in order for a patient to get grounded in and take command of the situation.
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An exploration of symptom burden and its management, in Saudi Arabian patients receiving haemodialysis, and their caregivers: a mixed methods study protocol. BMC Nephrol 2019; 20:250. [PMID: 31288747 PMCID: PMC6617670 DOI: 10.1186/s12882-019-1424-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 06/20/2019] [Indexed: 11/13/2022] Open
Abstract
Background Globally 10% of the population worldwide are affected by chronic kidney disease (CKD), making it one of the most prevalent chronic diseases. Several studies have highlighted that the symptoms of CKD have a significant impact on patients. A number of symptoms, including fatigue and depression, are associated with poor patient health, increased risk of hospitalisation and mortality. Physical and emotional symptoms often remain under-recognised and largely untreated; however, patients often create a variety of self-management strategies to meet the challenges of these symptoms. There is a lack of knowledge regarding symptom burden and the experiences of patients receiving haemodialysis (HD) and their caregivers, particularly in Saudi Arabia, therefore, this study aims to explore symptom burden and its management amongst patients receiving HD in addition to caregiver burden. Method A mixed methods, sequential, explanatory design consisting of two phases: phase 1 involves a cross-sectional study design with a planned convenience sample size of 141 patients who will be recruited from King Khaled hospital, Saudi Arabia. Thirty-two physical and psychological symptoms will be measured using the Chronic Kidney Disease-Symptom Burden Index (CKD-SBI). Additionally, 130 caregivers will complete the Arabic version of the Zarit Burden Interview (ZBI-22) to identify the level of burden in the caregivers of patients on maintenance HD. Phase 2 of the study is a qualitative descriptive design involving semi-structural interviews with 15 eligible patients currently receiving HD. The selection of participants for interviews will be based on the patients’ total CKD-SBI scores with five individuals recruited from the lowest, median and highest percentiles. Additionally, 15 caregivers of the patients to be interviewed, will also be recruited and interviewed. Discussion This study focuses on a wide number of physical and psychological symptoms experienced by patients receiving HD. It will also focus on the effective management strategies patients employ to help reduce their perceived symptoms. Burden in caregivers of patients receiving HD will also be explored. Furthermore, the association between symptom burden and caregiver burden will be investigated. Findings from this study will provide evidence to help health care providers to develop effective interventions to assess and manage symptoms in patients receiving HD.
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Bowler M, Dehek R, Thomas E, Ngo K, Grose L. Evaluating the Impact of Post-Treatment Self-Management Guidelines for Prostate Cancer Survivors. J Med Imaging Radiat Sci 2019; 50:398-407. [PMID: 31178381 DOI: 10.1016/j.jmir.2019.03.182] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 03/30/2019] [Accepted: 03/30/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND With a rising number of prostate cancer survivors, transitioning patients to follow-up care has become more relevant in the current Albertan cancer care landscape and has led to a need for better patient education resources surrounding this topic. In response, the Alberta Provincial Genitourinary Tumour Team and Cancer Control Alberta have developed self-management guidelines to aid patients with prostate cancer during this transition. This study aimed to evaluate the effectiveness and impact of the new provincial self-management guidelines in facilitating transition from active curative external beam radiation treatment to primary community care. METHODS This prospective study used convenience sampling to recruit 18 patients with prostate cancer from two major cancer centers in Alberta: Calgary and Edmonton. Participants were given the self-management guidelines within their final week of external beam radiation treatment and a follow-up phone questionnaire 4 weeks later. Participants answered standardized questions regarding the self-management document based on the themes of timeliness, patient-centeredness, safety, effectiveness, and comprehensiveness. RESULTS AND DISCUSSION A thematic analysis of the results suggested that the majority of patients were satisfied with the document in all domains, but some expressed concern with the clarity of the document. They suggested improvements such as adding a side effect timeline, adding an appendix or symptom index, further simplifying the language, and coordinating delivery of the guidelines with an in-person education session. CONCLUSION Overall, our findings supported the effectiveness of the guidelines in providing self-management information. If implemented into practice, these guidelines could have a positive impact on the perception of patients with prostate cancer regarding transitioning to follow-up care.
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Affiliation(s)
- Miranda Bowler
- Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - Rebecca Dehek
- Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - Elizabeth Thomas
- Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - Kristi Ngo
- Department of Oncology, University of Alberta, Edmonton, Alberta, Canada.
| | - Laura Grose
- Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
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An ecological momentary assessment of self-management in prostate cancer survivors. J Cancer Surviv 2019; 13:364-373. [PMID: 31115766 DOI: 10.1007/s11764-019-00758-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 04/05/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE To assess the 'real-time' self-management strategies employed by prostate cancer survivors to inform personalised supportive care interventions in the future. METHOD A purposive sampling framework was used to recruit men with different stages of cancer and treatment to an ecological momentary assessment (capturing experiences in real time) study. Each participant was prompted by an audio alert to complete self-report questionnaires three times per day (93 data entries in total) for a total duration of 31 days. The personal digital assistant (PDA) and pocket interview software were used. RESULTS Prostate cancer survivors experienced a wide range of after-effects of therapy for which they used various self-management strategies. Many of the men experienced sexual dysfunction but did not perform any self-management. CONCLUSION Our findings reinforce the importance of having access to tailored, timely and person-centred supported self-management care plans. Real-time monitoring data can provide helpful information to facilitate tailored recommendations for self-management. IMPLICATIONS FOR CANCER SURVIVORS Prostate cancer survivors can experience unmet supportive care needs which may increase men's demands to perform self-management of their condition. Future clinical intervention studies aimed at utilising the remote exchange of real-time data serves to optimise tailored supported self-management.
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King-Okoye M, Arber A, Faithfull S. Beliefs that contribute to delays in diagnosis of prostate cancer among Afro-Caribbean men in Trinidad and Tobago. Psychooncology 2019; 28:1321-1327. [PMID: 30953381 PMCID: PMC6617795 DOI: 10.1002/pon.5085] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 02/21/2019] [Accepted: 03/13/2019] [Indexed: 12/30/2022]
Abstract
OBJECTIVE The aim of this study was to explore Trinidad and Tobago (TT) men's prediagnosis experiences of prostate cancer (PCa). This study is part of a wider project that examined men and their partners' experiences of routes to diagnosis for PCa in TT. METHODS Men (n = 51) were voluntarily recruited to semi-structured interviews from four centres. Data were analysed following principles of grounded theory. RESULTS Major barriers to medical help seeking were highlighted as lack of knowledge and awareness of the prostate gland and symptoms of PCa, the digital rectal exam (DRE), prostate-specific antigen (PSA), cultural and religious beliefs, and hegemonic masculinity norms and nonreporting of bodily changes to GPs. Fear of DRE, distrust in providers, and misinterpretation of bodily changes as related to ageing and diabetes mellitus also contributed to delays towards seeking medical help. Men's interactions with pharmacists and traditional healers lengthened the time taken to consult with health care providers for prostate concerns. CONCLUSIONS TT men's PCa prediagnosis experiences are important to unearth barriers and facilitators to care along routes to diagnosis for this disease. This can help target specific health promotion strategies to motivate men to seek medical care for symptoms in a timely manner.
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Affiliation(s)
| | - Anne Arber
- Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Sara Faithfull
- Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
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Blakeman JR. An integrative review of the theory of unpleasant symptoms. J Adv Nurs 2018; 75:946-961. [PMID: 30397941 DOI: 10.1111/jan.13906] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 09/07/2018] [Accepted: 10/08/2018] [Indexed: 01/04/2023]
Abstract
AIMS The aim of this study was to explore how the theory of unpleasant symptoms (TOUS) has been used in the methodological design and analysis of symptom research. DESIGN An integrative review, using Whittemore and Knafl's approach. DATA SOURCES Searches were conducted between 26 January-10 February 2018. Databases included CINAHL Complete, PubMed, Proquest Nursing and Allied Health Source, Health Source: Nursing/Academic Edition, Academic Search Complete and Google Scholar. REVIEW METHODS A systematic approach to searching, screening and analysing the literature was applied. The matrix method, content analysis, constant comparison, counting and clustering were used. RESULTS Sixty-four records were included. Most studies were quantitative, cross-sectional, instrument-based and conducted in the USA. Various symptoms and patient populations were represented and each of the TOUS concepts were explored. CONCLUSION Although the theory has a role to play in furthering symptom science, attention should be paid to the areas of the model and of symptom research that have received less attention. More complex statistical approaches and big data will help to illuminate symptom experiences. Additional focus on intervention studies and all symptom dimensions will help to advance symptom science research. IMPACT This review is the first to provide a comprehensive, systematic summary of the uses of the TOUS across the research literature to date. This theory is a diverse, holistic middle-range theory capable of being applied to multiple symptoms and populations. Researchers should consider using the theory as a conceptual framework for studies to advance symptom science and explore symptoms holistically.
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Affiliation(s)
- John R Blakeman
- Mennonite College of Nursing, Illinois State University, Normal, Illinois.,School of Nursing, Millikin University, Decatur, Illinois
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Hayama Y, Doi H, Hasegawa T, Minami Y, Ichimura N, Koike M, Shiomi H, Oh RJ, Oishi F. Lower urinary tract symptoms in patients with prostate cancer under and after intensity-modulated radiation therapy. Low Urin Tract Symptoms 2018; 11:O127-O134. [PMID: 30010254 DOI: 10.1111/luts.12230] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 05/09/2018] [Accepted: 05/24/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The aim of the present study was to collect data on the characteristics, degree, and natural course of urinary complications, as well as self-care for such complications, in patients during and after prostate intensity-modulated radiation therapy (IMRT). METHODS Quality of life data were collected retrospectively for all eligible patients who underwent IMRT. In all eligible patients, urinary symptoms were evaluated using questionnaires and face-to-face interview. Participants were asked to respond to a self-administered questionnaire concerning the core lower urinary tract symptom score during the course of IMRT and up to 12 months after the completion of IMRT. RESULTS In all, 29 eligible patients were included in the study. The frequency of urinary symptoms increased over of the course of IMRT, decreased at ≥3 months after completion of IMRT, and disappeared 6 months after IMRT. Responses to the questionnaire revealed a variety of approaches to self-care and adaptations by patients to manage urinary symptoms. CONCLUSIONS During and after IMRT for localized prostate cancer, patients often developed more frequent urination and urgency than at the start of IMRT, and recovered 3-6 months after the completion of IMRT. Based on the present study, clinicians and nurses could help convey this information to patients and thus offer better support.
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Affiliation(s)
- Yuka Hayama
- Department of Nursing, Faculty of Nursing, Doshisha Women's College of Liberal Arts, Kyoto, Japan.,Miyakojima IGRT Clinic, Osaka, Japan
| | - Hiroshi Doi
- Miyakojima IGRT Clinic, Osaka, Japan.,Department of Radiation Oncology, Kindai University Faculty of Medicine, Osaka, Japan
| | | | - Yumi Minami
- Department of Nursing, Faculty of Nursing and Rehabilitation, Mukogawa Women's University, Nishinomiya, Japan
| | | | | | | | | | - Fumiko Oishi
- Department of Nursing, Faculty of Nursing, Seirei Christopher University, Shizuoka, Japan
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Wochna Loerzel V. Symptom Self-Management: Strategies Used by Older Adults Receiving Treatment for Cancer. Clin J Oncol Nurs 2018; 22:83-90. [DOI: 10.1188/18.cjon.83-90] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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White L, Cohen M, Berger A, Kupzyk K, Swore-Fletcher B, Bierman P. Perceived Self-Efficacy: A Concept Analysis for Symptom Management in Patients With Cancer. Clin J Oncol Nurs 2017; 21:E272-E279. [DOI: 10.1188/17.cjon.e272-e279] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Langius-Eklöf A, Christiansen M, Lindström V, Blomberg K, Hälleberg Nyman M, Wengström Y, Sundberg K. Adherence to Report and Patient Perception of an Interactive App for Managing Symptoms During Radiotherapy for Prostate Cancer: Descriptive Study of Logged and Interview Data. JMIR Cancer 2017; 3:e18. [PMID: 29089290 PMCID: PMC5686419 DOI: 10.2196/cancer.7599] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 06/05/2017] [Accepted: 09/20/2017] [Indexed: 02/06/2023] Open
Abstract
Background Patients undergoing radiotherapy for prostate cancer experience symptoms related to both the cancer itself and its treatment, and it is evident that patients with prostate cancer have unmet supportive care needs related to their disease. Over the past decade, there has been an increase in the amount of research within the field of mobile health and the use of apps as tools for managing illness. The main challenge is to develop a mobile technology to its full potential of being interactive in real time. The interactive app Interaktor, which aims to identify and manage symptoms in real time includes (1) a function for patients’ assessment of the occurrence, frequency, and distress of symptoms; (2) a connection to a monitoring Web interface; (3) a risk assessment model that sends alerts via text message to health care providers; (4) continuous access to evidence-based self-care advice and links to relevant websites for more information; and (5) graphs for the patients and health care providers to view the history of symptom reporting. Objective The aim of the study was to investigate user behavior, adherence to reporting, and the patients’ experiences of using Interaktor during radiotherapy for localized advanced prostate cancer. Methods The patients were instructed to report daily during the time of treatment and then for an additional 3 weeks. Logged data from patients’ use of the app were analyzed with descriptive statistics. Interview data about experiences of using the app were analyzed with content analysis. Results A total of 66 patients participated in the study. Logged data showed that adherence to daily reporting of symptoms was high (87%). The patients used all the symptoms included in the app. Of the reports, 15.6% generated alerts to the health care providers. Overall, the patients found that it was easy and not particularly time-consuming to send a daily report, and many described it as becoming a routine. Reporting symptoms facilitated reflection on their symptoms and gave them a sense of security. Few technological problems were reported. Conclusions The use of Interaktor increased patients’ sense of security and their reflections on their own well-being and thereby served as a supportive tool for the self-management of symptoms during treatment of prostate cancer. Some further development of the app’s content might be beneficial for future use.
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Affiliation(s)
- Ann Langius-Eklöf
- Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden
| | - Mats Christiansen
- Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden
| | - Veronica Lindström
- Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden
| | - Karin Blomberg
- School of Health Sciences, Örebro University, Örebro, Sweden
| | | | - Yvonne Wengström
- Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden
| | - Kay Sundberg
- Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden
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Langius-Eklöf A, Crafoord MT, Christiansen M, Fjell M, Sundberg K. Effects of an interactive mHealth innovation for early detection of patient-reported symptom distress with focus on participatory care: protocol for a study based on prospective, randomised, controlled trials in patients with prostate and breast cancer. BMC Cancer 2017; 17:466. [PMID: 28676102 PMCID: PMC5496395 DOI: 10.1186/s12885-017-3450-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 06/26/2017] [Indexed: 11/12/2022] Open
Abstract
Background Cancer patients are predominantly treated as out-patients and as they often experience difficult symptoms and side effects it is important to facilitate and improve patient-clinician communication to support symptom management and self-care. Although the number of projects within supportive cancer care evaluating mobile health is increasing, few evidence-based interventions are described in the literature and thus there is a need for good quality clinical studies with a randomised design and sufficient power to guide future implementations. An interactive information and communications technology platform, including a smartphone/computer tablet app for reporting symptoms during cancer treatment was created in collaboration with a company specialising in health care management. The aim of this paper is to evaluate the effects of using the platform for patients with breast cancer during neo adjuvant chemotherapy treatment and patients with locally advanced prostate cancer during curative radiotherapy treatment. The main hypothesis is that the use of the platform will improve clinical management, reduce costs, and promote safe and participatory care. Method The study is a prospective, randomised, controlled trial for each patient group and it is based on repeated measurements. Patients are consecutively included and randomised. The intervention groups report symptoms via the app daily, during treatment and up to three weeks after end of treatment, as a complement to standard care. Patients in the control groups receive standard care alone. Outcomes targeted are symptom burden, quality of life, health literacy (capacity to understand and communicate health needs and promote healthy behaviours), disease progress and health care costs. Data will be collected before and after treatment by questionnaires, registers, medical records and biomarkers. Lastly, participants will be interviewed about participatory and meaningful care. Discussion Results will generate knowledge to enhance understanding about how to develop person-centred care using mobile technology. Supporting patients’ involvement in their care to identify problems early, promotes more timely initiation of necessary treatment. This can benefit patients treated outside the hospital setting in regard to maintaining their safety. Clinical trial registration June 12 2015 NCT02477137 (Prostate cancer) and June 12 2015 NCT02479607 (Breast cancer).
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Affiliation(s)
- Ann Langius-Eklöf
- Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet, 141 83 Huddinge, Stockholm, Sweden.
| | - Marie-Therése Crafoord
- Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet, 141 83 Huddinge, Stockholm, Sweden
| | - Mats Christiansen
- Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet, 141 83 Huddinge, Stockholm, Sweden
| | - Maria Fjell
- Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet, 141 83 Huddinge, Stockholm, Sweden
| | - Kay Sundberg
- Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet, 141 83 Huddinge, Stockholm, Sweden
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Sundberg K, Wengström Y, Blomberg K, Hälleberg-Nyman M, Frank C, Langius-Eklöf A. Early detection and management of symptoms using an interactive smartphone application (Interaktor) during radiotherapy for prostate cancer. Support Care Cancer 2017; 25:2195-2204. [PMID: 28236145 PMCID: PMC5445148 DOI: 10.1007/s00520-017-3625-8] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 02/06/2017] [Indexed: 12/22/2022]
Abstract
Purpose Patients undergoing radiotherapy for prostate cancer suffer from a variety of symptoms which influence health-related quality of life. We have developed an application (Interaktor) for smartphones and tablets for early detection, reporting and management of symptoms, and concerns during treatment for prostate cancer. The study evaluates the effect on symptom burden and quality of life when using the application for real-time symptom assessment and management during radiotherapy for localized prostate cancer. Methods A non-randomized controlled study was used at two university hospitals in Sweden where 64 patients constituted a control group and 66 patients made up an intervention group. The intervention group was asked to report symptoms via the application daily during the treatment as well as 3 weeks after. The EORTC QLQ-C30 and its module PR25 and the Sense of Coherence questionnaire were administered at three time points in both groups. Results The intervention group rated significantly lower levels of fatigue and nausea at the end of radiotherapy. Moreover, they had significantly less burden in emotional functioning, insomnia, and urinary-related symptoms at the end of treatment as well as 3 months later compared with the control group. In the multivariate analyses, with education and sense of coherence as covariates, the intervention group still significantly rated emotional functioning (p = 0.007), insomnia (p = 0.017), and urinary-related symptoms (p = 0.008) as better than the control group at T2. Conclusion Study findings suggest that Interaktor could be an efficient mHealth tool for facilitating supportive care needs during cancer treatment.
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Affiliation(s)
- Kay Sundberg
- Department of NVS, Division of Nursing, Karolinska Institutet, 23 300, Huddinge, 14183, Stockholm, Sweden. .,Radiumhemmet, Karolinska University Hospital, Stockholm, Sweden.
| | - Yvonne Wengström
- Department of NVS, Division of Nursing, Karolinska Institutet, 23 300, Huddinge, 14183, Stockholm, Sweden.,Radiumhemmet, Karolinska University Hospital, Stockholm, Sweden
| | - Karin Blomberg
- Faculty of Medicine and Health, School of Health Sciences, Örebro University, Örebro, Sweden
| | - Maria Hälleberg-Nyman
- Faculty of Medicine and Health, School of Health Sciences, Örebro University, Örebro, Sweden
| | - Catharina Frank
- Department of NVS, Division of Nursing, Karolinska Institutet, 23 300, Huddinge, 14183, Stockholm, Sweden
| | - Ann Langius-Eklöf
- Department of NVS, Division of Nursing, Karolinska Institutet, 23 300, Huddinge, 14183, Stockholm, Sweden
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15
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Lee SE, Vincent C, Finnegan L. An Analysis and Evaluation of the Theory of Unpleasant Symptoms. ANS Adv Nurs Sci 2017; 40:E16-E39. [PMID: 27525959 DOI: 10.1097/ans.0000000000000141] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The Theory of Unpleasant Symptoms was developed to enhance understanding of relationships among multiple symptoms and symptom experiences. Although the theory has been used to guide research, no formal critique of the theory has been published since 2000. This article comprehensively analyzes and evaluates the theory using Fawcett and DeSanto-Madeya's framework. Although its semantic clarity, semantic and structural consistency, and parsimony could be improved, the theory demonstrates good social and theoretical significance, testability, and empirical and pragmatic adequacy. Understanding multiple patient symptoms is essential, and the theory demonstrates that nurses should focus on multiple rather than individual symptoms.
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16
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Zanchetta MS, Cognet M, Lam-Kin-Teng MR, Dumitriu ME, Renaud L, Rhéaume J. From early detection to rehabilitation in the community: reading beyond the blog testimonies of survivors' quality of life and prostate cancer representation. Health Qual Life Outcomes 2016; 14:171. [PMID: 27986091 PMCID: PMC5162078 DOI: 10.1186/s12955-016-0568-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 11/29/2016] [Indexed: 11/20/2022] Open
Abstract
Background Survivors’ testimonies can reveal much about men’s experiences of prostate cancer and impacts on their quality of life (QOL) during the clinical trajectory of the disease. These survivors’ shared thoughts and views were hypothesized to reflect salient features of their lived social representation of prostate cancer. Context We explored the content of testimonies posted by men to a public blog hosted by a French national prostate cancer patients’ association. The study question, “What do French bloggers’ testimonies reveal about their lived experiences with prostate cancer, especially regarding their quality of life in community settings, that underpin their social representation of prostate cancer?” guided the exploration and analysis of the textual data. The aims were to better understand men’s experiences and predominant thoughts and views, to elucidate patients’ behaviours, and to enlighten medical policy and practice. Purpose Explore issues of QOL as reported by French prostate cancer survivors in a public blog by: (a) identifying the salient aspects and issues of the experience of living with prostate cancer from the perspective of survivors; and (b) analyzing the content in the posted testimonies regarding perceived and lived impacts of prostate cancer on QOL. Methods A critical ethnographic study guided the selection of textual data from 196 male bloggers’ testimonies about prostate cancer posted in the period from 2008 to 2013. Media content analysis method was undertaken on blog testimonies, framed by a multidimensional conceptual framework of QOL. Results Testimonies focused mainly on medical care and rehabilitation, recovery, health education and self-care, as well as on a global vision of prostate cancer and its impacts on personal views of manhood and masculinity. The language used indicated that political, educative and compassionate discourses were intertwined to create a complex representation of the experience and effects of prostate cancer; this multi-faceted representation can inform the public and professional debate about men’s capacity to provide emotional support and problem-solve within a community of interest. Conclusion Findings, while based on data limited to mostly one-time entries to a French blog, contribute to understanding a unique, collective expression of men’s lived experiences of prostate cancer. These anonymous survivors shared their varied reactions, ways of coping, and thoughts on needed change.
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Affiliation(s)
- Margareth Santos Zanchetta
- Ryerson University- Faculty of Community Services, Daphne Cockwell School of Nursing, 350 Victoria St. office POD 470C, Toronto, ON, M5B 2K3, Canada.
| | - Marguerite Cognet
- Université Denis Diderot- UFR Sciences sociales, Unité de recherche Migrations et Sociétés, Paris, France
| | - Mary Rachel Lam-Kin-Teng
- Ryerson University- Faculty of Community Services, Daphne Cockwell School of Nursing, 350 Victoria St. office POD 470C, Toronto, ON, M5B 2K3, Canada
| | - Marie Elisabeth Dumitriu
- Ryerson University- Faculty of Community Services, Daphne Cockwell School of Nursing, 350 Victoria St. office POD 470C, Toronto, ON, M5B 2K3, Canada
| | - Lise Renaud
- Université du Québec à Montréal, CSSS de la Montagne, Ministère de la santé et des services sociaux du Québec, Montréal, Québec, Canada
| | - Jacques Rhéaume
- CSSS de la Montagne, Ministère de la santé et des services sociaux du Québec, Montréal, Québec, Canada
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17
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Blomberg K, Wengström Y, Sundberg K, Browall M, Isaksson AK, Nyman MH, Langius-Eklöf A. Symptoms and self-care strategies during and six months after radiotherapy for prostate cancer - Scoping the perspectives of patients, professionals and literature. Eur J Oncol Nurs 2015; 21:139-45. [PMID: 26482003 DOI: 10.1016/j.ejon.2015.09.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Revised: 08/05/2015] [Accepted: 09/22/2015] [Indexed: 11/25/2022]
Abstract
PURPOSE Under-diagnosed and uncontrolled symptoms in patients with prostate cancer during radiotherapy can have a negative impact on the individual's quality of life. An opportunity for patients to report their symptoms systematically, communicate these symptoms to cancer nurses and to receive self-care advice via an application in an Information and Communication Technology-platform could overcome this risk. The content in the application must precisely capture symptoms that are significant to both patients and health care professionals. Therefore, the aim of the study was to map and describe symptoms and self-care strategies identified by patients with prostate cancer undergoing radiotherapy, by health care professionals caring for these patients, and in the literature. METHODS The study combines data from interviews with patients (n = 8) and health care professionals (n = 10) and a scoping review of the literature (n = 26) focusing on the period during and up to 6 months after radiotherapy. RESULTS There was a concordance between the patients, health care professionals, and the literature on symptoms during and after radiotherapy. Urinary symptoms, bowel problems, pain, sexual problems, fatigue, anxiety, depression, cognitive impairment and irregular symptoms were commonly described during the initial treatment period. Self-care strategies were rarely described in all three of the sources. CONCLUSIONS The results show which symptoms to regularly assess using an Information and Communication Technology-platform for patients with newly-diagnosed prostate cancer during radiotherapy. The next step is to evaluate the efficacy of using the platform and the accuracy of the selected symptoms and self-care advice included in a smartphone application.
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Affiliation(s)
- Karin Blomberg
- Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, S-70182 Örebro, Sweden.
| | - Yvonne Wengström
- Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, S-70182 Örebro, Sweden; Department NVS, Section for Nursing, Karolinska Institutet, Stockholm, Sweden
| | - Kay Sundberg
- Department NVS, Section for Nursing, Karolinska Institutet, Stockholm, Sweden
| | - Maria Browall
- Department NVS, Section for Nursing, Karolinska Institutet, Stockholm, Sweden; School of Life Sciences, University of Skövde, Skövde, Sweden
| | - Ann-Kristin Isaksson
- Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, S-70182 Örebro, Sweden
| | - Maria Hälleberg Nyman
- Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, S-70182 Örebro, Sweden
| | - Ann Langius-Eklöf
- Department NVS, Section for Nursing, Karolinska Institutet, Stockholm, Sweden
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18
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Paterson C, Alashkham A, Windsor P, Nabi G. Management and treatment of men affected by metastatic prostate cancer: evidence-based recommendations for practice. INTERNATIONAL JOURNAL OF UROLOGICAL NURSING 2015. [DOI: 10.1111/ijun.12093] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Catherine Paterson
- Research Fellow in Cancer Care, Academic section of Urology, Medical Research Institute, School of Medicine; University of Dundee; UK
| | - Abduelmenem Alashkham
- Academic section of Urology, Medical Research Institute, School of Medicine; University of Dundee; UK
| | - Phyllis Windsor
- OBE-Consultant Clinical Oncologist; Ninewells Hospital; Dundee UK
| | - Ghulam Nabi
- [Urol]-Reader in Surgical Uro-Oncology, Hon. Consultant Urological Surgeon; University of Dundee; UK
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19
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Halverson JL, Martinez-Donate AP, Palta M, Leal T, Lubner S, Walsh MC, Strickland JS, Smith PD, Trentham-Dietz A. Health Literacy and Health-Related Quality of Life Among a Population-Based Sample of Cancer Patients. JOURNAL OF HEALTH COMMUNICATION 2015; 20:1320-9. [PMID: 26161549 PMCID: PMC4751057 DOI: 10.1080/10810730.2015.1018638] [Citation(s) in RCA: 89] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Health-related quality of life is an important outcome in cancer care. A few studies indicate that health literacy influences cancer patients' health-related quality of life, but additional investigation is needed. The authors examined the relation between health literacy and health-related quality of life among cancer patients. A cross-sectional survey was conducted with cancer patients in Wisconsin during 2006-2007. Data on sociodemographics, clinical characteristics, health-related quality of life, and health literacy were obtained from the state's cancer registry and a mailed questionnaire. Regression analyses were used to characterize the association between health-related quality of life and health literacy. The study sample included 1,841 adults, newly diagnosed with lung, breast, colorectal, or prostate cancer in 2004 (response rate = 68%). Health-related quality of life was measured with the Functional Assessment of Cancer Therapy-General. Adjusting for confounders, higher health literacy was associated with greater health-related quality of life (p < .0001). Controlling for covariates, we found significant differences between those in the highest and lowest health literacy categories (p < .0001) and in the physical (p < .0001), functional (p < .0001), emotional (p < .0001), and social (p = .0007) well-being subscales. These associations exceeded the minimally important difference threshold for overall health-related quality of life and functional well-being. Health literacy is positively and independently associated with health-related quality of life among cancer patients. These findings support adoption of health literacy best practices by cancer care systems.
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Affiliation(s)
- Julie L. Halverson
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Ana P. Martinez-Donate
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Mari Palta
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Ticiana Leal
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Sam Lubner
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Matthew C. Walsh
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | | | - Paul D. Smith
- Department of Family Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Amy Trentham-Dietz
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
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20
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Levesque JV, Lambert SD, Girgis A, Turner J, McElduff P, Kayser K. Do men with prostate cancer and their partners receive the information they need for optimal illness self-management in the immediate post-diagnostic phase? Asia Pac J Oncol Nurs 2015; 2:169-175. [PMID: 27981111 PMCID: PMC5123470 DOI: 10.4103/2347-5625.160969] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Accepted: 05/11/2015] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To (a) determine whether the information provided to men with prostate cancer and their partners in the immediate postdiagnostic phase met their needs; and (b) examine patient and partner satisfaction with the information received. METHODS Pre-intervention survey data from a pilot randomized controlled trial of a self-directed coping skills intervention involving 42 patients with prostate cancer, and their partners were collected to examine their psychosocial concerns/needs. RESULTS The main concerns for patients and partners were psychosocial in nature such as managing emotions, concern about the future, and losing control. Overall, patients and partners received most information about tests and treatment options. Partners reported receiving significantly less information about support services (P = 0.03) and self-care strategies (P = 0.03) compared to patients. Partners also reported being significantly less satisfied with the information they received (P = 0.007). CONCLUSIONS Whereas medical information is routinely given, patients and partners may benefit from greater information about psychosocial issues arising from cancer. Despite increased recognition of partner's information needs these still remain unmet.
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Affiliation(s)
- Janelle V. Levesque
- Centre for Oncology Education and Research Translation (CONCERT), Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, UNSW Medicine, UNSW Sydney, Australia
| | | | - Afaf Girgis
- Centre for Oncology Education and Research Translation (CONCERT), Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, UNSW Medicine, UNSW Sydney, Australia
| | - Jane Turner
- School of Medicine, University of Queensland, Queensland, Australia
| | - Patrick McElduff
- School of Medicine and Public Health, John Hunter Hospital, The University of Newcastle, New South Wales, Australia
| | - Karen Kayser
- Kent School of Social Work, University of Louisville, Louisville, USA
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21
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Sundberg K, Eklöf AL, Blomberg K, Isaksson AK, Wengström Y. Feasibility of an interactive ICT-platform for early assessment and management of patient-reported symptoms during radiotherapy for prostate cancer. Eur J Oncol Nurs 2015; 19:523-8. [PMID: 25813529 DOI: 10.1016/j.ejon.2015.02.013] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Revised: 02/08/2015] [Accepted: 02/23/2015] [Indexed: 12/18/2022]
Abstract
PURPOSE The aim of this study was to test the feasibility and acceptability of an Information and Communication Technology platform for assessing and managing patient reported symptoms during radiotherapy for prostate cancer. METHODS In cooperation with a health management company, using a patient experience co-design, we developed the platform operated by an interactive application for reporting and managing symptoms in real time. Nine patients diagnosed with prostate cancer and receiving radiotherapy were recruited from two university hospitals in Sweden. Evidence-based symptoms and related self-care advice specific to prostate cancer were implemented in the application based on a literature review and interviews with patients and health care professionals. In the test of the platform the patients reported symptoms, via a mobile phone, daily for two weeks and were afterwards interviewed about their experiences. RESULTS Overall, the patients found the symptom questionnaire and the self-care advice relevant and the application user friendly. The alert system was activated on several occasions when the symptoms were severe leading to a nurse contact and support so the patients felt safe and well cared for. CONCLUSIONS The platform enabled increased patient involvement and facilitated symptom assessment and communication between the patient and the health care provider. The study's results support further development of the platform, as well as tests in full-scale studies and in other populations.
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Affiliation(s)
- Kay Sundberg
- Department of NVS, Division of Nursing, Karolinska Institutet, Stockholm, Sweden.
| | - Ann Langius Eklöf
- Department of NVS, Division of Nursing, Karolinska Institutet, Stockholm, Sweden
| | - Karin Blomberg
- School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | | | - Yvonne Wengström
- School of Health and Medical Sciences, Örebro University, Örebro, Sweden
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