Components That Influence Assessment and Management of Cancer-Related Symptoms: An Interdisciplinary Perspective

Fatigue and related variables in bladder cancer treatment - Longitudinal pilot study

Fatigue is a significant problem in patients with bladder cancer treated by radical cystectomy. This pilot study evaluated fatigue and related variables during a treatment period. Four measurements were made, the first 1 month after the cystectomy, and the next three at an interval of about 3 months each (at 4 months, 7 months, and 10 months after the surgery). In addition to the author's questionnaire (sociodemographic variables and a question about the impact of the disease on the patient's life), the FACIT-F Fatigue (to measure fatigue), NCCN/FACT FBISI-18, version 2 (symptoms, general condition of the patient), HADS (depression, anxiety, and irritability) measures were used. In this study, 21 patients participated in all four measurement periods. The fatigue intensity increased significantly between the first and second measurements and gradually decreased between the third and fourth measurements. As the severity of fatigue increases, can be observed an increase in the sense of the impact of the disease on the patient's life in all except the first measurement. The study revealed statistically significant correlations between fatigue and experiencing symptoms of cancer and treatment at each stage of the study, with the strongest correlations in the second and fourth measurements regarding symptoms of cancer and a stronger correlation in the second compared to the first measurement regarding side effects. At each stage of measurement, the experience of dizziness, lack of appetite, feeling of being sick, and feeling of annoyance from treatment side effects were statistically significantly correlated with fatigue. The intensity of fatigue correlated with the feeling of experiencing difficulties in meeting the needs of the family due to the physical condition in the first measurement (Rho = 0.76), a sense of weakness (Rho = 0.92) and sleepiness (Rho = 0.72) in the second measurement, pain in the third (Rho = 0.77). The greatest number of correlates of fatigue were described in the fourth measurement (all symptoms of cancer and side effects except losing weight). Stress, anxiety, depression and irritability were correlated with fatigue at each of the stages of research except the first one (without differences between the correlation coefficients in the second, third and fourth measurements). Significantly lower levels of fatigue characterised patients who survived over 6 months after the end of the study compared to the first three measurements.

Self-rated health over a two-year period after breast cancer surgery: prospective ratings and retrospective rating by means of a health-line

BACKGROUND

There are difficulties in clinical assessment of patients' health, and there is a need for evaluating instruments that measures self-rated health over time and that are based on the patient's own experiences of their health situation.

AIM

To describe the trajectory of self-rated health given in a retrospective health-line and its correspondence with the ratings of health given at six different time points during 2 years following a first breast cancer surgery.

DESIGNS AND METHODS

An explorative prospective cohort study presented according to the STROBE guideline. At six time points, 459 women (26-63 years) completed assessments of self-rated health during 2 years following a first breast cancer surgery. Subsequently, the women retrospectively rated health month by month over the two years by means of a health-line. The women were included consecutively in 2007-2009, last data collection was performed in 2012. Statistical analyses were used to compare the health-line with previous ratings.

RESULTS

Most women (74-88%) rated their health as good, very good or excellent at all six time points. Health-line ratings were somewhat lower than the ratings made at the actual time-point; however, the illustrated trajectories back in time followed the same patterns as the women had reported during the two years. The lowest ratings of self-rated health were reported at four months after surgery. The retrospective illustrations varied greatly, and poorer health was reported by women undergoing chemotherapy, with lower education and who reported more life events.

CONCLUSIONS

Even if the retrospective ratings by the health-line were somewhat lower than the ratings at the actual time-point, the health-line captures the health trajectory. The individual graphic illustration by means of a health-line may serve as a basis for assessment and support patient health narratives. The findings indicate that life event, lower education and chemotherapy influence concurrent and retrospective self-assessment of health.

Exploring symptom meaning: perspectives of palliative care physicians

CONTEXT

Understanding patients' symptom experiences is essential to providing effective clinical care. The discussion between patients and physicians of symptom meaning and its significance, however, is ill understood.

OBJECTIVES

To investigate palliative care physicians' understanding of symptom meaning, and their experiences of and attitudes towards the discussion of symptom meaning with patients.

METHODS

Semi-structured interviews were conducted (N = 17) across Sydney, Australia. Transcripts were analysed using framework analysis.

RESULTS

Six key themes were identified: (1) definitions of symptom meaning (causal meanings, functional impact, existential impact, and cascade of meanings); (2) meanings are personal (demographic, culture, spiritual, and family differences); (3) eliciting meanings requires subtlety and trust (following the patient's cues); discussing meaning can be (4) hard (for the patient and health professional); (5) therapeutic (assuaging fears, feeling listened to and valued, increased sense of control, and reduced symptom distress); and (6) enhances clinicians' practice and work satisfaction (provision of more tailored care, reassurance through the provision of information, and strengthening of doctor-patient relationship).

CONCLUSIONS

Exploring symptom meaning can serve to provide information, alleviate anxiety, and facilitate individualised care, but only when patients present cues or are open to discuss symptom-related concerns. However, various barriers hinder such dialogue in consultations. Greater awareness of symptom meaning and its influence may facilitate physicians exploring symptom meaning more with patients in the future.

Implementation and Use of a Patient Symptom Diary During Chemotherapy: A Mixed-Methods Evaluation of the Nurse Perspective

PURPOSE/OBJECTIVES

To gain a deeper understanding of nurses' experience working with a patient diary for tracking and treating side effects during chemotherapy.
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DESIGN

A mixed-methods design was used to learn about oncology nurses' use and perceptions of a symptom diary. 
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SETTING

Six oncology wards and two outpatient clinics at the University Hospitals Leuven, Belgium.
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SAMPLE

79 nurses completed a survey, and 14 nurses participated in focus group discussions.
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METHODS

First, a survey sampled nurses' use and perceptions of the diary. Next, focus group discussions were held with the aim of arriving at a deeper understanding of the survey results.
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MAIN RESEARCH VARIABLES

Use and perceptions of a symptom diary.
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FINDINGS

Most nurses reported performing diary-related behavior to some extent. The survey and focus groups indicated that many nurses strongly believed in the value of the diary, but some were still hesitant or had concerns about patients' perceptions of the diary. The focus group results showed that nurses' use of the diary in daily practice was influenced by their personal beliefs about the value of the diary, the team's, and those of their patients.
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CONCLUSIONS

Although a positive trend was noted, nurses' use of the symptom diary was suboptimal six months after its implementation.
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IMPLICATIONS FOR NURSING

This study highlights important issues that need to be addressed to advance the successful implementation of the symptom diary.

Clinicians' Perspectives on Managing Symptom Clusters in Advanced Cancer: A Semistructured Interview Study

CONTEXT

Managing symptom clusters or multiple concurrent symptoms in patients with advanced cancer remains a clinical challenge. The optimal processes constituting effective management of symptom clusters remain uncertain.

OBJECTIVES

To describe the attitudes and strategies of clinicians in managing multiple co-occurring symptoms in patients with advanced cancer.

METHODS

Semistructured interviews were conducted with 48 clinicians (palliative care physicians [n = 10], oncologists [n = 6], general practitioners [n = 6], nurses [n = 12], and allied health providers [n = 14]), purposively recruited from two acute hospitals, two palliative care centers, and four community general practices in Sydney, Australia. Transcripts were analyzed using thematic analysis and adapted grounded theory.

RESULTS

Six themes were identified: uncertainty in decision making (inadequacy of scientific evidence, relying on experiential knowledge, and pressure to optimize care); attunement to patient and family (sensitivity to multiple cues, prioritizing individual preferences, addressing psychosocial and physical interactions, and opening Pandora's box); deciphering cause to guide intervention (disaggregating symptoms and interactions, flexibility in assessment, and curtailing investigative intrusiveness); balancing complexities in medical management (trading off side effects, minimizing mismatched goals, and urgency in resolving severe symptoms); fostering hope and empowerment (allaying fear of the unknown, encouraging meaning making, championing patient empowerment, and truth telling); and depending on multidisciplinary expertise (maximizing knowledge exchange, sharing management responsibility, contending with hierarchical tensions, and isolation and discontinuity of care).

CONCLUSION

Management of symptom clusters, as both an art and a science, is currently fraught with uncertainty in decision making. Strengthening multidisciplinary collaboration, continuity of care, more pragmatic planning of clinical trials to address more than one symptom, and training in symptom cluster management are required.

Caregivers' quality of life and quality of services for children with cancer: a review from iran

Objective:

Caregivers of cancer patients are exposed to different types of psychosocial stress which influence their quality of life. The purposes of this study were to assess quality of life in caregivers of children with cancer and to investigate the relationship between the caregivers’ quality of life and quality of services in the social work section.

Method:

125 caregivers were recruited. Quality of life was measured by the Iranian version of the WHOQOL-BREF questionnaire and data concerning service quality were obtained from the Iranian version of the SERVQUAL questionnaire.

Findings:

Scores in physical health, psychological status and environmental conditions for caregivers of children with cancer were significantly lower than the general population. There was a negative correlation between the tangible domain of SERVQUAL and the psychological status and environmental conditions of quality of life. The tangible dimension was the only aspect of service quality to predict caregivers’ quality of life regarding psychological status and environmental conditions.

Conclusion:

Caregivers of children with a disease are care consumers and, like all consumers, they expect good service. Delivering high quality services consistently is difficult but profitable for a service organization. In other words, trying to deliver more appropriate services than patients expect to receive from their social work care is one of the most reliable ways to promote caregivers’ satisfaction and quality of life.

How can we improve cancer care? A review of interprofessional collaboration models and their use in clinical management

BACKGROUND

Multimodal cancer care requires collaboration among different professionals in various settings. Practice guidelines provide little direction on how this can best be achieved. Research shows that collaborative cancer management is limited, and challenged by numerous issues. The purpose of this research was to describe conceptual models of collaboration, and analyze how they have been applied in the clinical management of cancer patients.

METHODS

A review of the literature was performed using a two-phase meta-narrative approach. The first phase involved searching for conceptual models of collaboration. Their components and limitations were summarized. The second phase involved targeted searching for empirical research on evaluation of these concepts in the clinical management of cancer patients. Data on study objective, design, and findings were tabulated, and then summarized according to collaborative model and phase of clinical care to identify topics warranting further research.

RESULTS

Conceptual models for teamwork, interprofessional collaboration, integrated care delivery, interorganizational collaboration, continuity of care, and case management were described. All concepts involve two or more health care professionals that share patient care goals and interact on a continuum from consultative to integrative, varying according to extent and nature of interaction, degree to which decision making is shared, and the scope of patient management (medical versus holistic). Determinants of positive objective and subjective patient, team and organizational outcomes common across models included system or organizational support, team structure and traits, and team processes. Twenty-two studies conducted in ten countries examining these concepts for cancer care were identified. Two were based on an explicit model of collaboration. Many health professionals function through parallel or consultative models of care and are not well integrated. Few interventions or strategies have been applied to promote models that support collaboration.

CONCLUSIONS

Ongoing development, implementation and evaluation of collaborative cancer management, in the context of both practice and research, would benefit from systematic planning and operationalization. Such an approach is likely to improve patient, professional and organizational outcomes, and contribute to a collective understanding of collaborative cancer care.

Reconsidering the team concept: educational implications for patient-centered cancer care

Patient-centered cancer care has become a priority in the oncology field. Increasing efforts to train oncologists in communication skills have led to a growing literature on patient-centered cancer education. In addition, systems approaches have led to an increased emphasis on the concept of teams as an organizing framework for cancer care. In this essay, we examine issues involved in educating teams to provide patient-centered cancer care. In the process, we question the applicability of a tightly coordinated 'team' concept, and suggest the concept of a 'care community' as a more achievable ideal for the way that cancer care is commonly delivered. We discuss the implications that this has for cancer communication education, and propose three principles to guide the development of educational interventions aimed at increasing patient-centeredness in cancer care delivery systems.

A model of treatment decision making when patients have advanced cancer: how do cancer treatment doctors and nurses contribute to the process?

This qualitative study describes how doctors and nurses report their contribution to treatment decision-making processes when patients have advanced cancer. Thirteen nurses and eight doctors involved in cancer treatment and palliation in one geographical location in New Zealand participated in the study. Data were collected using qualitative in-depth, face-to-face interviews. Content analysis revealed a complex context of decision making influenced by doctors and nurses as well as the patient and other factors. A model of clinician and patient decision making emerged with a distinct and cyclical process as advanced cancer remits and progresses. When patients have advanced cancer, nurses and doctors describe a predictable model of decision making in which they both contribute and that cycles through short- and long-term remissions; often nowadays to the point of the patient dying. In conclusion, the findings suggest doctors and nurses have different but complementary roles in what, when and how treatment choices are negotiated with patients, nevertheless within a distinct model of decision making.

Cancer-Related Fatigue: A Review and a Conceptual Framework to Guide Therapists' Understanding

Cancer-related fatigue is reported as the most common and distressing symptom experienced by people with cancer. There is limited research published to guide occupational therapists working with people with cancer to help address this distressing symptom. This article reviews literature on cancer-related fatigue and identifies several factors associated with the development of fatigue, including underlying medical factors and other factors.

The underlying medical factors reported in the literature include biomedical mechanisms, such as anaemia, proinflammatory cytokines and specific cellular processes; disease-related factors; treatment-related factors; and comorbid conditions. Other factors reviewed include physical or behavioural factors, such as poor nutrition, decreased activity, sleep disturbance and pain; psychological factors, including anxiety and depression; and sociodemographic factors, such as social support, employment and education.

The review identified a variety of factors associated with cancer-related fatigue, which must be considered by occupational therapists working with people with cancer. This presents a challenge to the clinical reasoning of occupational therapists attempting to treat such people. A framework of factors contributing to cancer-related fatigue is proposed in order to guide both the practice of occupational therapists working with adults with cancer and future research in this area.

To be involved or not: factors that influence nurses' involvement in providing treatment decisional support in advanced cancer

Decisional support is a multifaceted process of facilitating patients' decision making regarding treatment choices. Effective decisional support practices of nurses in relation to the use of anticancer therapies in patients with advanced disease are central to quality cancer care. A recent qualitative descriptive study (n=21) exploring the decision making practices of doctors and nurses in one tertiary cancer centre in New Zealand identified many complexities associated with nurses and their participation in decisional support. The study revealed that cancer nurses had varied opinions about the meaning and importance of their roles in treatment related decision making. This variation was significant and led the researchers to undertake a detailed secondary exploration of factors that impacted on the nurses' involvement in the provision of decisional support. Four key groups of factors were identified. These were factors relating to degree of knowledge, level of experience, beliefs and understandings about nursing roles and cancer therapies, and structural interfaces in the work setting. Understanding these factors is important because it allows modification of the conditions which impact on the ability to provide effective decisional care. It also provides some understanding of clinical drivers associated with nurses' decisional support work with patients who have advanced cancer.