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

Interactive Health Literacy and Symptom Self-management in Patients With Lung Cancer: A Critical Realist Analysis

BACKGROUND

Patients with lung cancer experience multiple symptoms requiring self-management. Little is known about how self-management is influenced by interactive health literacy, defined as communicating with healthcare providers to obtain and process information.

OBJECTIVE

This study explored how interactive health literacy relates to symptom self-management among patients with lung cancer. A second aim explored how interactive health literacy might be integrated into the Individual and Family Self-management Theory.

METHODS

This study used a cross-sectional mixed-methods design. Quantitative data included demographics, the All Aspects of Health Literacy Scale, and the Memorial Symptom Assessment-Short Form. Qualitative data were collected using semistructured interviews. Data analysis followed a critical realist model.

RESULTS

Twelve adults who recently received treatment for lung cancer reported an average of 14 symptoms that caused moderate distress. Average interactive health literacy of the sample was in the moderate range. Participants' experiences of self-management differed based on their interactive health literacy. A generative mechanism proposes that those with higher interactive health literacy who accessed online information used this information as a basis for engaging with providers regarding potential symptom self-management strategies.

CONCLUSIONS

Interactive health literacy skills may play a role in patients' ability and confidence in symptom self-management through interactions with oncology providers. Further research should clarify the relationship between interactive health literacy, self-efficacy, and collaboration with oncology providers.

IMPLICATIONS FOR PRACTICE

The patient-provider relationship is a key factor influencing how patients obtain and process symptom self-management information. Oncology providers should implement patient-centered strategies to engage patients in symptom self-management.

Applying the Multicultural Orientation in Cancer Care for Sexual and Gender Minority Cancer Survivors: A Cross-Sectional Correlational Study

Purpose: Sexual and gender minority (SGM) cancer survivors report unique needs that are not met by some providers. The multicultural orientation (MCO) holds promise for creating a paradigm shift in providing affirmative cancer care, yet has not been tested empirically. This study examines the predictive strength of MCO's tenets of cultural humility and cultural opportunities for SGM cancer patient-provider relationships. Methods: In this cross-sectional study, 108 SGM cancer survivors completed surveys on perceptions of their oncology providers' cultural humility and actualization of cultural opportunities as predictors of survivors' treatment adherence and the patient-provider alliance. Hierarchical regression analyses were conducted. Results: Average participant age was 50 years (standard deviation = 15 years). Over 10 cancer types were represented and 69% of participants were in active treatment, with the remaining 31% receiving follow-up care. Age at diagnosis and not being in active treatment positively correlated with perceptions of providers' cultural humility, patient-provider alliance, and treatment adherence. Regression models explained 38% and 61%, respectively, of the variance in treatment adherence and patient-provider alliance, with cultural humility remaining a significant predictor in both models after accounting for all other variables. Conclusion: Providers' cultural humility and navigation of cultural opportunities in incorporating their patients' salient cultural identities into cancer care are strongly associated with how supported SGM cancer survivors feel by their oncology providers. The MCO is a useful framework for identifying important dimensions in SGM affirmative cancer care.

Cultivating Relationship-Centered Care: Patient, Caregiver, and Provider Communication Preferences for and Experiences with Prognostic Conversations

Prognostic conversations present many challenges for patients, caregivers, and providers alike. Most research examining the context of prognostic conversations have used a more siloed approach to gather the range of perspectives of those involved, typically through the lens of patient-centered care. However, the mutual influence evident in prognostic conversations suggests a relationship-centered care model may be useful in cancer communication research. Similarities and differences in preferences for and experiences with prognostic conversations among oncology patients, caregivers, and providers (N = 32) were explored. Identified themes were then mapped to the principles of the relationship-centered care framework to extend our understanding of prognostic conversations and contribute to a new direction in the application of relationship-centered care. Findings suggest fewer similarities than differences, point to important discrepancies among participant perspectives, and reinforce the utility of relationship-centered care in identifying communication practices that enhance the prognostic conversation experience.

Perceived communication efficacy and unmet needs for chemotherapy-associated symptom management in patients with lung and colorectal cancer: a cross-sectional study

BACKGROUND

Understanding cancer patients' unmet needs for chemotherapy-related symptom management will assist clinicians in developing tailored intervention programs. Little is known about the association between perceived communication efficacy and unmet care needs for symptom management in patients with lung and colorectal cancer.

OBJECTIVES

To examine the unmet care needs for symptom management of patients with lung and colorectal cancer and their association with perceived communication efficacy.

METHODS

A cross-sectional survey was conducted in a tertiary hospital in China from July to November 2020. A convenience sample of 203 patients with lung and colorectal cancer undergoing chemotherapy completed survey questionnaires, including the MD Anderson Symptom Inventory Scale and the Perceived Efficacy in Patient‒Physician Interactions Scale.

RESULTS

Approximately 43% of participants had at least one symptom with unmet needs. Fatigue was reported as the symptom with the highest occurrence (66%), the highest demand for supportive care (36%), and the highest prevalence of unmet needs (19%). Low levels of perceived communication efficacy independently predicted participants' unmet needs for symptom management (β=-0.13, p = 0.011).

CONCLUSIONS

This study highlights the necessity of introducing clinical assessment tools and guidelines to address fatigue and other chemotherapy-induced symptoms in patients with lung and colorectal cancer. Clinical programs designed to actively engage cancer patients to voice their needs and strengthen their communication efficacy are also warranted.

Determinants of Cancer-Related Fatigue among Cancer Patients: A Systematic Review

Objectives: This systematic review aims to assess and explore various determinants of cancer- related fatigue. Methods: A systematic search of various determinants of Cancer-related fatigue (CRF) was performed in different databases like PubMed, Google Scholar, Science Direct and Clinical Key dating from 1990 to September 2020. Results: A total of 6115 studies were screened and 95 articles related to determinants of fatigue were retained. Various modifiable and non-modifiable determinants including socio-demographic, clinical, treatment related, plasma biomarker related, genetic, behavioural, concurrent symptoms related and psychological determinants were identified. Depression was one of the significant factors reported in 28% of studies, followed by pain, (17%), performance status (16%), chemotherapy and anxiety (15%). Conclusion: It is recommended that nurses and clinicians should anticipate, identify and take appropriate interventions to manage those modifiable factors. Ultimately, managing the modifiable factors helps in the comprehensive care of cancer patients.

Using Patient-Reported Outcomes Measurement Information System® (PROMIS) to Identify Physical and Psychosocial Quality of Life Issues in Lung Cancer Survivors

Background: Lung cancer survivors (LCS) are living longer due to improved screening and treatment but often experience long-term treatment effects. Due to a traditionally poor prognosis, research related to LCS symptomology and associated quality of life (QOL) is lacking. Objective: The objective of this study was to develop a process for identifying symptomology and unmet needs affecting QOL in LCS. Methods: A literature review identified recommended methods of implementing a QOL screening program in LCS. Training guidelines using the best evidence were presented to the survivorship clinic (SC) staff. The Patient-Reported Outcomes Measurement Information System® (PROMIS-29) profile was used to collect data from LCS. The experience of the SC staff (N = 2) and providers (N = 2) in implementing the QOL screening program in LCS was assessed. Results: A 100% compliance rate in completing the PROMIS-29 profile was achieved. Physical function and pain interference were the most impacted QOL domains identified by LCS, while depression was the least. No challenges were identified in assisting LCS with profile completion. Providers agreed that the PROMIS-29 was instrumental in identifying QOL issues. Conclusion: A QOL screening program tailored to LCS-improved compliance and reliability in identifying QOL issues. Implications for Nursing: A QOL screening program using the PROMIS-29 may improve patient-provider interactions and value-based oncology care.

The potential impact of proxy reports for symptom experience and care quality and experience in advanced cancer

OBJECTIVES

As the US tests models of care for the seriously ill, patient perceptions of the quality of care are important. Proxies are often needed for this group. We sought to understand the potential impact of proxy reports for the assessment of care quality and experience in cancer.

METHODS

Secondary data analysis of a deidentified prospective study that included surveys of perceived care quality, including symptom management, from patients with advanced cancer receiving chemotherapy and their caregivers. Surveys were administered at diagnosis (time 1) and treatment (time 2), with top-box scoring used for analysis. Overall concordance was assessed using metrics including Gwet's AC1. The proportion of the highest scores by respondent type within 2 subgroups were examined: (1) symptom burden and (2) practice setting.

RESULTS

Data from 83 dyads were analyzed. Proxies and patients frequently reported the highest scores for quality (time 1: proxies: 77% and patients: 80%). At time 1, 14% of proxies and 10% of patients reported an unmet need for symptom palliation. Most patients reporting an unmet need gave the top score for quality (75%), but fewer proxies did so (45%). Proxy and patient reports were similar within practice settings. Concordance was at least moderate (nearly all outcomes >0.5 and some >0.8) by Gwet's AC1.

SIGNIFICANCE OF RESULTS

Findings of at least moderate concordance and similar experience outcomes within subgroups suggest the use of proxies may not change estimates substantially. However, consideration should be taken when evaluating symptom management, particularly if such evaluations inform assessment of provider performance.

Characterizing unique supportive care needs among women living with metastatic breast cancer: A qualitative study

Background

Women with metastatic breast cancer face unique challenges as they cope with life-limiting prognoses and arduous treatments. However, the vast majority of research has focused on optimizing quality of life in women with early-stage, non-metastatic breast cancer and little is known about supportive care needs among women living with metastatic cancer. As part of a larger project that sought to inform the development of a psychosocial intervention, the aim of this study was to characterize supportive care needs among women with metastatic breast cancer and elucidate challenges unique to living with a life-limiting prognosis.

Methods

Four, two-hour focus groups with 22 women were audio-recorded, transcribed verbatim, and analyzed in Dedoose using a general inductive approach to code categories and extract themes.

Results

A total of 16 codes emerged from 201 participant comments regarding supportive care needs. Codes were collapsed into four supportive care need domains: 1. psychosocial, 2. physical and functional, 3. health system and information, and 4. sexuality and fertility needs. The most prevalent needs were breast cancer-related symptom burden (17.4%), lack of social support (14.9%), uncertainty (10.0%), stress management (9.0%), patient-centered care (7.5%), and sexual functioning (7.5%). More than half of needs (56.2%) were in the psychosocial domain and more than two-thirds of needs (76.8%) were in the psychosocial and physical and functional domains. Supportive care needs unique to living with metastatic breast cancer included the cumulative effects of continuously undergoing cancer treatment on symptom burden, worry from scan-to-scan regarding response to cancer treatments, diagnosis-related stigma and social isolation, end-of-life concerns, and misconceptions regarding metastatic breast cancer.

Conclusions

Findings suggest that women with metastatic breast cancer have unique supportive care needs compared to women with early-stage breast cancer that are specific to living with a life-limiting prognosis and are not typically captured in existing self-report measures of supportive care needs. Results also highlight the importance of addressing psychosocial concerns and breast cancer-related symptoms. Women with metastatic breast cancer may benefit from early access to evidence-based interventions and resources that specifically address their supportive care needs and optimize quality of life and wellbeing.

Healthcare Providers' Perceptions of the Cancer Pain Management Barriers at a Hospital in Zambia: A Qualitative Study

Introduction

Cancer incidence and mortality are increasing worldwide, and pain is the most common symptom patients experience. Despite developments in cancer pain management and guidelines, the pain often remains undertreated. Effective pain management ultimately involves overcoming several complex institutional, patient, and healthcare provider-related barriers.

Objective

The objective of the study was to explore and describe healthcare providers' perceptions of the cancer pain management barriers at a hospital in Zambia.

Method

A descriptive qualitative study was conducted. Data were collected from 10 purposively sampled medical doctors and registered nurses using prepiloted semistructured individual interviews. Interviews were audio recorded and transcribed verbatim. Thematic analysis was done, and trustworthiness was enhanced based on the criteria described by Lincoln and Guba. Ethical principles, as outlined in the Declaration of Helsinki, were adhered to.

Results

Three themes emerged, namely patient-related barriers (biographic characteristics, patient knowledge and perceptions), healthcare provider-related barriers (knowledge and perceptions and language barriers), and institution-related barriers (resource limitations and lack of standards and guidelines). Healthcare providers' views that cultural beliefs about cancer being caused by witchcraft and the use of traditional medicine and services are barriers to cancer pain management were unique to this study.

Conclusion

Cancer pain management requires a total pain management approach that addresses the barriers to pain management strategies from a patient, healthcare provider, and institutional perspective. The knowledge deficit among patients and healthcare providers is a barrier to cancer pain management and one of the most common challenges reported in the literature. This study further points toward a need to develop culturally competent healthcare providers.

Antiracist symptom science: A call to action and path forward

Nurse scientists recognize the experience of racism as a driving force behind health. However, symptom science, a pillar of nursing, has rarely considered contributions of racism. Our objective is to describe findings within symptom science research related to racial disparities and/or experiences of racism and to promote antiracist symptom science within nursing research. In this manuscript, we use an antiracist lens to review a predominant symptom science theory and literature in three areas of symptom science research-oncology, mental health, and perinatal health. Finally, we make recommendations for increasing antiracist research in symptom science by altering (a) research questions, (b) recruitment methods, (c) study design, (d) data analysis, and (e) dissemination of findings. Traditionally, symptom science focuses on individual level factors rather than broader contexts driving symptom experience and management. We urge symptom science researchers to embrace antiracism by designing research with the specific intent of dismantling racism at multiple levels.

Disparities in Supportive Care Needs Over Time Between Racial and Ethnic Minority and Non-Minority Patients With Advanced Lung Cancer

CONTEXT

Little is known about inequities in supportive care needs among diverse patients with advanced lung cancer.

OBJECTIVES

We aimed to examine differences in supportive care needs between racial/ethnic minority and non-minority patients with lung cancer and identify how these needs change over time.

METHODS

We performed a prospective cohort study of patients newly diagnosed with advanced lung cancer (stage III and IV). Patients completed a validated survey at baseline, 4-, 8- and 12-months post-diagnosis, assessing supportive care needs: medical communication/information, psychological/emotional support, daily living, financial concerns, physical symptoms, and spiritual and social needs. Univariable and multivariable regression analyses compared differences in supportive care needs between minority (Black and Latinx) and non-minority patients. A mixed effect model with minority status, follow-up time and the interaction between minority status and time assessed the association between each need and minority status with changes over time.

RESULTS

We enrolled 99 patients; 55 (56%) were minorities and 44 (44%) were non-minorities. At baseline, minorities reported significantly higher needs across each domain except medical communication/information. Over time, these reported differences remained consistent except for medical communication. After adjustment, the needs of both minorities and non-minorities increased significantly in the psychological/emotional, daily living and physical symptom domains.

CONCLUSION

Minority patients with advanced lung cancer are more likely to have higher baseline and persistent supportive care needs relatives to non-minority patients. Clinicians caring for minority patients with lung cancer should provide targeted supportive care evaluation and treatment to ensure health equity.

Physical Activity: A Systematic Review to Inform Nurse Recommendations During Treatment for Colorectal Cancer

Colorectal cancer (CRC) is the third most common cancer in the world (American Cancer Society [ACS], 2021). Because of increasing survival rates, there is a need improve survivors' quality of life (QOL), physical functioning, recurrence risk, and comorbidity prevalence (ACS, 2020). Many patients with CRC have poor QOL during and after treatment; other common side effects include fatigue, depression, anxiety, and decreased sleep quality (Bourke et al., 2014; Cramer et al., 2014; Gao et al., 2020). Focusing on the treatment period is important because physical activity (PA) may decrease side effects and prevent PA decline and functional decline, both of which can become significant barriers to PA following treatment. In addition, patients with CRC have a higher rate of comorbidities than patients without cancer, making lifestyle changes pre- and post-treatment particularly important for their continued survival and QOL (ACS, 2020).

Patient-reported symptom burden in routine oncology care: Examining racial and ethnic disparities

Background

Racial and ethnic disparities are well‐documented in cancer outcomes such as disease progression and survival, but less is known regarding potential disparities in symptom burden.

Aims

The goal of this retrospective study was to examine differences in symptom burden by race and ethnicity in a large sample of cancer patients. We hypothesized that racial and ethnic minority patients would report greater symptom burden than non‐Hispanic and White patients.

Methods and results

A total of 5798 cancer patients completed the Edmonton Symptom Assessment Scale—revised (ESAS‐r‐CSS) at least once as part of clinical care. Two indicators of symptom burden were evaluated: (1) total ESAS‐r‐CSS score (i.e., overall symptom burden) and (2) number of severe symptoms (i.e., severe symptomatology). For patients completing the ESAS‐r‐CSS on multiple occasions, the highest score for each indicator was used. Zero‐inflated negative binomial regression analyses were conducted, adjusting for other sociodemographic and clinical characteristics. Symptomology varied across race. Patients who self‐identified as Black reported higher symptom burden (p = .016) and were more likely to report severe symptoms (p < .001) than self‐identified White patients. Patients with “other” race were also more likely to report severe symptoms than White patients (p = .032), but reported similar total symptom burden (p = .315). Asian and Hispanic patients did not differ from White or non‐Hispanic patients on symptom burden (ps > .05).

Conclusion

This study describes racial disparities in patient‐reported symptom burden during routine oncology care, primarily observed in Black patients. Clinic‐based electronic symptom monitoring may be useful to detect high symptom burden, particularly in patients who self‐identify their race as Black or other. Future research is needed to reduce symptom burden in racially diverse cancer populations.

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.

Improving symptom-related communication skills among cancer patients in an oncology ward: a best practice implementation project

INTRODUCTION AND AIMS

As a symptom is a subjective perception of patients, good symptom management requires the patients to actively talk to clinicians about their symptom experience and to effectively express concerns about treatment. It has been found that the patients displayed poor communication behaviors and lacked communication knowledge and skills in the oncology ward of a tertiary hospital in PR China, indicating the need for improvement. This project aimed to promote the cancer patients' symptom-related communication with clinicians in this hospital setting.

METHOD

A baseline audit against six evidence-based audit criteria derived from best practice recommendations was conducted, utilizing the JBI Practical Application of Clinical Evidence System tool. Identification of facilitators and barriers to best practice was then carried out and strategies were implemented to overcome identified barriers. A postimplementation audit was undertaken to assess any improvement in practice.

RESULTS

The baseline audit showed that the nurses' compliance with best practice recommendations was unsatisfactory, with five out of six criteria recording 0% compliance. Strategies including nurse education, patient symptom assessment, patient education and use of communication tools were implemented. The postimplementation audit showed significantly improved compliance in the nurses' practice with all best practice recommendations, with all audit criteria achieving at least 69% compliance.

CONCLUSION

The project achieved improved practice in patient communication promotion across all six audit criteria. However, further effort is needed to strengthen and maintain best practice. Patient symptom-related communication behavior should be measured in the future.

Unmet needs of symptom management and associated factors among the HIV-positive population in Shanghai, China: A cross-sectional study

BACKGROUND

People living with HIV/AIDS (PLWHA) are a vulnerable group who experience multiple physiological and psychological symptoms. A better understanding of unmet symptom management needs will allow researchers to design interventions that are more reflective of deficits in care and more effective at improving patient care. Few studies have focused on unmet needs for symptom management in PLWHA particularly in China. Factors influencing Chinese PLWHA symptom management needs are rarely discussed.

AIM

The purpose of this study was to investigate the unmet needs for symptom management of PLWHA and how their symptom burden, HIV perceived stigma, and self-management capacity contributes to HIV-related self-management practices in Shanghai, China.

DESIGN

Study participants were recruited from the outpatient and inpatient HIV/AIDS wards in an infectious hospital in Shanghai, China. Self-administered questionnaires were implemented and medical charts were reviewed.

RESULTS

A total of 367 participants was recruited from April to September 2017. The results show that 53.1% (195 of 367) of participants presented at least one unmet symptom management need and that symptom burden, as well as perceived stigma, reduced self-management capacity, and no employment significantly affected unmet symptom management needs.

CONCLUSION

The findings indicate that there is room for improvement in symptom management for Chinese PLWHA. Culturally appropriate interventions focusing on improving symptom burden, decreasing HIV perceived stigma, and enhancing self-management capacity can enhance symptom management in this population.

Urban and Rural Differences: Unmet Needs for Symptom Management in People Living With HIV in China

Access to HIV care has increased in China, but regional disparities for the unmet symptom management needs of people living with HIV remain. Little attention has been paid to these disparities, especially in rural areas. We describe unmet symptom management needs in 1,214 people living with HIV from five HIV hospitals in the eastern coast, middle, and southern regions of China. Insomnia, abnormal dreams, and fatigue were the most common unmet needs of patients in urban China, whereas cognitive problems and blurry vision were the most common in rural China. Self-management capacity, discrimination, and symptom severity predicted more unmet symptom management needs for patients in urban areas. Medication adherence, basic function, and symptom severity predicted more unmet needs among patients in rural areas. Our results have implications for nurses in HIV care and HIV policymakers. Separate interventions targeting the urban and rural areas must be implemented to meet patient symptom management needs.

What the HEC? Clinician Adherence to Evidence-Based Antiemetic Prophylaxis for Highly Emetogenic Chemotherapy

Background: Clinician adherence to antiemetic guidelines for preventing chemotherapy-induced nausea and vomiting (CINV) caused by highly emetogenic chemotherapy (HEC) remains poorly characterized. The primary aim of this study was to evaluate individual clinician adherence to HEC antiemetic guidelines. Patients and Methods: A retrospective analysis of patients receiving HEC was conducted using the IBM Watson Explorys Electronic Health Record Database (2012–2018). HEC antiemetic guideline adherence was defined as prescription of triple prophylaxis (neurokinin-1 receptor antagonist [NK1 RA], serotonin type-3 receptor antagonist, dexamethasone) at initiation of cisplatin or anthracycline + cyclophosphamide (AC). Clinicians who prescribed ≥5 HEC courses were included and individual guideline adherence was assessed, noting the number of prescribing clinicians with >90% adherence. Results: A total of 217 clinicians were identified who prescribed 2,543 cisplatin and 1,490 AC courses. Patients (N=4,033) were primarily women (63.3%) and chemotherapy-naïve (92%) with a mean age of 58.6 years. Breast (36%) and thoracic (19%) cancers were the most common tumor types. Guideline adherence rates of >90% were achieved by 35% and 58% of clinicians using cisplatin or AC, respectively. Omission of an NK1 RA was the most common practice of nonadherence. Variation in prophylaxis guideline adherence was considerable for cisplatin (mean, 71%; SD, 29%; coefficient of variation [CV], 0.40) and AC (mean, 84%; SD, 26%; CV, 0.31). Conclusions: Findings showed substantial gaps in clinician adherence to HEC CINV guidelines, including a high variability across clinicians. Clinicians should review their individual clinical practices and ensure adherence to evidence-based CINV guidelines to optimize patient care.

Prevalence and risk factors associated with the comprehensive needs of cancer patients in China

Background

The incidence and mortality rates of cancer have been increasing in developing countries, particularly in Asia. Therefore to provide optimal comprehensive care to the cancer patients, the care plan must focus on the comprehensive needs of cancer patients. The purpose of this study was to investigate the comprehensive needs of cancer patients, and explore the associated factors.

Methods

In a cross-sectional questionnaire study, a total of 200 cancer patient-caregiver dyads were selected and interviewed in Mainland China by convenient sampling method. Patients’ comprehensive needs were assessed with Comprehensive Needs Assessment Tool in cancer for Patients (CNAT), including seven domains (Information, Psychological Problems, Health Care Staffs, Physical Symptoms, Hospital Facilities and Services, Social/Religious/Spiritual Support and Practical Support). Both cancer patients and caregivers completed the sociodemographic survey. The mean differences in domain scores for different characteristics groups were compared by one-way ANOVA or non-parametric analyses, and influencing factors defined with multivariate regression analysis.

Results

The cancer patients’ need for Health Care Staffs (78.35 ± 13.08) was the highest among the seven domains, followed by the need for Information (71.18 ± 17.39) and the need for Hospital Facilities and Services (52.65 ± 13.35). The lowest score was the need for Physical Symptoms (35.12 ± 16.68). Patients who were female, with low family monthly income, at their own expense, and with highly educated caregivers had higher score of CNAT. Also sociodemographic characteristics were associated with each domain need of cancer patients.

Conclusion

This study shows that cancer patients experience high levels of needs for health-care staff and information, and the different needs are closely related to their sociological characteristics. The provision of health care can be adapted to meet the different needs of cancer patients of different epidemiological characteristics at different times during the course of treatment.

Information visualizations of symptom information for patients and providers: a systematic review

Objective

To systematically synthesize the literature on information visualizations of symptoms included as National Institute of Nursing Research common data elements and designed for use by patients and/or healthcare providers.

Methods

We searched CINAHL, Engineering Village, PsycINFO, PubMed, ACM Digital Library, and IEEE Explore Digital Library to identify peer-reviewed studies published between 2007 and 2017. We evaluated the studies using the Mixed Methods Appraisal Tool (MMAT) and a visualization quality score, and organized evaluation findings according to the Health Information Technology Usability Evaluation Model.

Results

Eighteen studies met inclusion criteria. Ten of these addressed all MMAT items; 13 addressed all visualization quality items. Symptom visualizations focused on pain, fatigue, and sleep and were represented as graphs (n = 14), icons (n = 4), and virtual body maps (n = 2). Studies evaluated perceived ease of use (n = 13), perceived usefulness (n = 12), efficiency (n = 9), effectiveness (n = 5), preference (n = 6), and intent to use (n = 3). Few studies reported race/ethnicity or education level.

Conclusion

The small number of studies for each type of information visualization limit generalizable conclusions about optimal visualization approaches. User-centered participatory approaches for information visualization design and more sophisticated evaluation designs are needed to assess which visualization elements work best for which populations in which contexts.

The relationship between household income and patient-reported symptom distress and quality of life in children with advanced cancer: A report from the PediQUEST study

BACKGROUND

Children with advanced cancer experience high symptom distress, which negatively impacts their health-related quality of life (HRQOL). To the authors' knowledge, the relationship between income and symptom distress and HRQOL is not well described.

METHODS

The Pediatric Quality of Life and Symptoms Technology (PediQUEST) multisite clinical trial evaluated an electronic patient-reported outcome system to describe symptom distress and HRQOL in children with advanced cancer via repeated surveys. The authors performed a secondary analysis of PediQUEST data for those children with available parent-reported household income (dichotomized at 200% of the Federal Poverty Level and categorized as low income [<$50,000/year] or high income [≥$50,000/year]). The prevalence of the 5 most commonly reported physical and psychological symptoms was compared between groups. Multivariable generalized estimating equation models were used to test the association between household income and symptom distress and HRQOL.

RESULTS

A total of 78 children were included in the analyses: 56 (72%) in the high-income group and 22 (28%) in the low-income group. Low-income children were more likely to report pain than high-income children (64% vs 42%; P=.02). In multivariable models, children from low-income families demonstrated a uniform trend toward higher total (β_low-high =3.1; 95% confidence interval [95% CI], -0.08 to 6.2 [P=.06]), physical (β=3.8; 95% CI, -0.4 to 8.0 [P=.09]), and psychological (β=3.46; 95% CI, -1.91 to 8.84 [P=.21]) symptom distress compared with children from high-income families. Low income was associated with a uniform trend toward lower total (β=-7.9; 95% CI, -14.8, to -1.1 [P=.03]), physical (β=-11.2; 95% CI, -21.2 to -1.2 [P=.04]), emotional (β=-5.8; 95% CI, -13.6 to 2.0 [P=.15]), social (β=-2.52; 95% CI, -9.27 to 4.24 [P=.47]), and school (β=-9.8; 95% CI, -17.8 to -1.8 [P=.03]) HRQOL.

CONCLUSIONS

In this cohort of children with advanced cancer, children from low-income families were found to experience higher symptom burden and worse QOL.

Social Inequalities in Palliative Care for Cancer Patients in the United States: A Structured Review

OBJECTIVES

To identify patterns of access to and use or provision of palliative care services in medically underserved and vulnerable groups diagnosed with cancer.

DATA SOURCES

Google Scholar, PubMed, MEDLINE, and Web of Science were searched to identify peer-reviewed studies that described palliative care in medically underserved or vulnerable populations diagnosed with cancer.

CONCLUSION

Disparities in both access and referral to palliative care are evident in many underserved groups. There is evidence that some groups received poorer quality of such care.

IMPLICATIONS FOR NURSING PRACTICE

Achieving health equity in access to and receipt of quality palliative care requires prioritization of this area in clinical practice and in research funding.

Unmet supportive care needs in Hispanic/Latino cancer survivors: prevalence and associations with patient-provider communication, satisfaction with cancer care, and symptom burden

PURPOSE

The aim of this study was to elucidate the prevalence of unmet supportive care needs in Hispanic/Latino cancer survivors and examine the association between unmet needs and patient-provider communication, satisfaction with cancer care, and cancer-specific symptom burden.

METHODS

Hispanics/Latinos diagnosed with breast, prostate, or colorectal cancer within 15 months of treatment completion (n = 288) completed questionnaires as part of an NCI-funded project.

RESULTS

Hispanic/Latino cancer survivors reported greater unmet needs compared to previously published norms in primarily non-Hispanic/Latino white samples. Across the three cancer types, the two most common unmet needs were in the psychological domain: fear of metastasis (32.6%) and concern for close others (31.3%). However, unmet needs varied by cancer type. Factors associated with greater unmet needs included more recent cancer diagnosis (OR .98 [.96-.99]), younger age (OR .96-.97 [.93-.99]), female gender (OR 2.53-3.75 [1.53-7.36]), and being single (OR 1.82 [1.11-2.97]). Breast cancer survivors reported greater unmet needs than both prostate and colorectal cancer survivors (OR 2.33-5.86 [1.27-14.01]). Adjusting for sociodemographic and medical covariates, unmet needs were associated with lower patient-provider communication self-efficacy (B = - .18-- .22, p's < .01) and satisfaction with cancer care (B = - 3.57-- 3.81, p's < .05), and greater breast (B = - 4.18-- 8.30, p's < .01) and prostate (B = - 6.01-- 8.13, p's < .01) cancer-specific symptom burden.

CONCLUSIONS

Findings document unmet supportive care needs in Hispanic/Latino cancer survivors and suggest that reducing unmet needs in Hispanic/Latino cancer survivors may improve not only satisfaction with care, but also health-related quality of life.

Understanding racial/ethnic differences in breast cancer-related physical well-being: the role of patient-provider interactions

PURPOSE

Racial/ethnic differences in cancer symptom burden are well documented, but limited research has evaluated modifiable factors underlying these differences. Our objective was to examine the role of patient-provider interactions to help explain the relationship between race/ethnicity and cancer-specific physical well-being (PWB) among women with breast cancer.

METHODS

The Pathways Study is a prospective cohort study of 4505 women diagnosed with breast cancer at Kaiser Permanente Northern California between 2006 and 2013. Our analysis included white, black, Hispanic, and Asian participants who completed baseline assessments of PWB, measured using the Functional Assessment of Cancer Therapy for Breast Cancer, and patient-provider interactions, measured by the Interpersonal Processes of Care Survey (IPC) (N = 4002). Using step-wise linear regression, we examined associations of race/ethnicity with PWB, and changes in associations when IPC domains were added.

RESULTS

We observed racial/ethnic differences in PWB, with minorities reporting lower scores than whites (beta, black: - 1.79; beta, Hispanic: - 1.92; beta, Asian: - 1.68; p < 0.0001 for all comparisons). With the addition of health and demographic covariates to the model, associations between race/ethnicity and PWB score became attenuated for blacks and Asians (beta: - 0.63, p = 0.06; beta: - 0.68, p = 0.02, respectively) and, to a lesser extent, for Hispanic women (beta: - 1.06, p = 0.0003). Adjusting for IPC domains did not affect Hispanic-white differences (beta: - 1.08, p = 0.0002), and slightly attenuated black-white differences (beta: - 0.51, p = 0.14). Asian-white differences narrowed substantially (beta: - 0.31, p = 0.28).

CONCLUSIONS

IPC domains, including those capturing perceived discrimination, respect, and clarity of communication, appeared to partly explain PWB differences for black and Asian women. Results highlight opportunities to improve providers' interactions with minority patients, and communication with minority patients about their supportive care needs.

Cancer care coordination: opportunities for healthcare delivery research

In this commentary, we discuss opportunities to explore issues related to care coordination at three points on the cancer care continuum: (1) screening, particularly coordinating follow-up for abnormal findings, (2) active treatment, particularly challenges for patients with multiple chronic conditions, and (3) survivorship, particularly issues related to facilitating shared care between oncology and primary care. For each point on the continuum, we briefly summarize some of the important coordination issues and discuss potential avenues for future research in the context of existing evidence.

Racial differences in symptom management experiences during breast cancer treatment

PURPOSE

Racial disparities in cancer treatment-related symptom burden are well documented and linked to worse treatment outcomes. Yet, little is known about racial differences in patients' treatment-related symptom management experiences. Such understanding can help identify modifiable drivers of symptom burden inequities. As part of the Cancer Health Accountability for Managing Pain and Symptoms (CHAMPS) study, we examined racial differences in symptom management experiences among Black and White breast cancer survivors (BCS).

METHODS

We conducted six focus groups (n = 3 Black BCS groups; n = 3 White BCS groups) with 22 stages I-IV BCS at two cancer centers. Focus groups were audio-recorded and transcribed verbatim. Based on key community-based participatory research principles, our community/academic/medical partner team facilitated focus groups and conducted qualitative analyses.

RESULTS

All BCS described positive symptom management experiences, including clinician attentiveness to symptom concerns and clinician recommendations for pre-emptively managing symptoms. Black BCS commonly reported having to advocate for themselves to get information about treatment-related symptoms, and indicated dissatisfaction regarding clinicians' failure to disclose potential treatment-related symptoms or provide medications to address symptoms. White BCS often described dissatisfaction regarding inadequate information on symptom origins and clinicians' failure to offer reassurance.

CONCLUSIONS

This study elucidates opportunities for future research aimed at improving equity for cancer treatment-related symptom management. For Black women, warnings about anticipated symptoms and treatment for ongoing symptoms were particular areas of concern. Routine symptom assessment for all women, as well as clinicians' management of symptoms for racially diverse cancer patients, need to be more thoroughly studied and addressed.

Reducing Symptom Distress in Patients With Advanced Cancer Using an e-Alert System for Caregivers: Pooled Analysis of Two Randomized Clinical Trials

Background

Symptom distress in patients toward the end of life can change rapidly. Family caregivers have the potential to help patients manage those symptoms, as well as their own stress, if they are equipped with the proper resources. Electronic health (eHealth) systems may be able to provide those resources. Very sick patients may not be able to use such systems themselves to report their symptoms but family caregivers could.

Objective

The aim of this paper was to assess the effects on cancer patient symptom distress of an eHealth system that alerts clinicians to significant changes in the patient’s symptoms, as reported by a family caregiver.

Methods

A pooled analysis from two randomized clinical trials (NCT00214162 and NCT00365963) compared outcomes at 12 months for two unblinded groups: a control group (Comprehensive Health Enhancement Support System [CHESS]-Only) that gave caregivers access to CHESS, an online support system, and an experimental group (CHESS+CR [Clinician Report]), which also had CHESS but with a CR that automatically alerted clinicians if symptoms exceeded a predetermined threshold of severity. Participants were dyads (n=235) of patients with advanced lung, breast, or prostate cancer and their respective family caregivers from 5 oncology clinics in the United States of America. The proportion of improved patient threshold symptoms was compared between groups using area-under-the-curve analysis and binomial proportion tests. The proportion of threshold symptoms out of all reported symptoms was also examined.

Results

When severe caregiver-reported symptoms were shared with clinicians, the symptoms were more likely to be subsequently reported as improved than when the symptoms were not shared with clinicians (P<.001). Fewer symptom reports were completed in the group of caregivers whose reports went to clinicians than in the CHESS-Only group (P<.001), perhaps because caregivers, knowing their reports might be sent to a doctor, feared they might be bothering the clinician.

Conclusions

This study suggests that an eHealth system designed for caregivers that alerts clinicians to worrisome changes in patient health status may lead to reduced patient distress.

Trial Registration

Clinicaltrials.gov NCT00214162; https://clinicaltrials.gov/ct2/show/NCT00214162 (Archived by WebCite at http://www.webcitation.org/6nmgdGfuD) and Clinicaltrials.gov NCT00365963; https://clinicaltrials.gov/ct2/show/NCT00365963 (Archived by WebCite at http://www.webcitation.org/6nmh0U8VP)

Concussion As a Multi-Scale Complex System: An Interdisciplinary Synthesis of Current Knowledge

Traumatic brain injury (TBI) has been called "the most complicated disease of the most complex organ of the body" and is an increasingly high-profile public health issue. Many patients report long-term impairments following even "mild" injuries, but reliable criteria for diagnosis and prognosis are lacking. Every clinical trial for TBI treatment to date has failed to demonstrate reliable and safe improvement in outcomes, and the existing body of literature is insufficient to support the creation of a new classification system. Concussion, or mild TBI, is a highly heterogeneous phenomenon, and numerous factors interact dynamically to influence an individual's recovery trajectory. Many of the obstacles faced in research and clinical practice related to TBI and concussion, including observed heterogeneity, arguably stem from the complexity of the condition itself. To improve understanding of this complexity, we review the current state of research through the lens provided by the interdisciplinary field of systems science, which has been increasingly applied to biomedical issues. The review was conducted iteratively, through multiple phases of literature review, expert interviews, and systems diagramming and represents the first phase in an effort to develop systems models of concussion. The primary focus of this work was to examine concepts and ways of thinking about concussion that currently impede research design and block advancements in care of TBI. Results are presented in the form of a multi-scale conceptual framework intended to synthesize knowledge across disciplines, improve research design, and provide a broader, multi-scale model for understanding concussion pathophysiology, classification, and treatment.

The Potential Role of Symptom Questionnaires in Palliative and Supportive Cancer Care Delivery

PURPOSE OF REVIEW

The American Society of Clinical Oncology (ASCO) palliative care recommendations have been updated into a full guideline. Symptom questionnaires-completed and reviewed with patients during care delivery-are poised to play a large role in this guideline because they provide a more comprehensive understanding of symptoms. This article provides an overview of the guideline and describes how symptom questionnaires can be used to satisfy the guideline.

RECENT FINDINGS

Standardized symptom questionnaires can be used for three purposes in care delivery: symptom management, referral to specialty palliative and supportive care, and to assess high-quality care. Challenges include necessary changes to clinic workflow to collect patient responses and respond to electronic alerts for worsening symptoms. Symptom questionnaires administered as part of routine care delivery are highly informative and worth the time to enhance symptom management in routine care, to increase referrals, and to standardize performance metrics.

The Relationship of Patient-Provider Communication on Quality of Life among African-American and White Cancer Survivors

Prior research has demonstrated poorer patient-provider communication ratings among African American compared to White patients. The quality of patient-provider communication has been shown to impact treatment outcomes among cancer patients. A secondary data analysis design was used to determine the relationship of six patient-provider communication variables on the physical health quality of life (PHQOL) and mental health quality of life (MHQOL) of African American and White cancer patients (N = 479). We also examined whether the relationship between communication patterns and QOL differed based on race/ethnicity. Mean physical and mental health QOL scores for the sample were 69.8 and 77.6, respectively. After controlling for significant sociodemographic, clinical, and hospital variables, results showed that patients who experienced fewer interpersonal communication barriers who were more satisfied with the information given by providers had higher PHQOL and MHQOL scores. Additionally, patients who felt more comfort in asking questions or had fewer unmet information needs had higher MHQOL. A stratified analysis showed that the relationship of overall satisfaction with information on MHQOL was stronger among African American patients than White patients. Future research should focus on the development of interventions to improve patient-provider communication as a means for enhancing QOL outcomes among cancer survivors.