Skin reactions during radiotherapy for breast cancer: the use and impact of topical agents and dressings

Radiation skin reactions occur in the majority of cases of patients undergoing radiotherapy for breast cancer with varying degrees of severity. Guidelines for skin care and for the use of topical agents and dressings have developed over the years of practice but there is little empirical evidence on which to base a decision for best practice. This paper describes the incidence of radiation skin reactions in a sample of 126 women treated for breast cancer post-lumpectomy. The results show that by the end of whole breast irradiation between 4-8% of patients will have no reaction and less than 10% will have moist desquamation as measured by the RTOG acute scoring system. The majority of patients did not require application of a topical agent during the treatment period. Statistical analysis of relationships between the severity of radiation skin reaction and the use of topical agents found no support for additional healing or preventative benefit. However, these topical agents were found to promote comfort. The use of Fixomull as a protector and potential preventive measure for moist desquamation is described.

'They're part of the team': participant evaluation of the ACTIVE intervention

This study used participant feedback to qualitatively evaluate an intervention (Assessing Caregivers for Team Intervention through Videophone Encounters [ACTIVE]) that used videophone technology to include patients and/or their family caregivers in hospice interdisciplinary team meetings. Data were generated during individual interviews with hospice staff members and family caregivers who participated in ACTIVE intervention. Modified grounded theory procedures served as the primary analysis strategy. Results indicated that ACTIVE intervention enhanced team functioning in terms of context, structure, processes and outcomes. Participants discussed challenges and offered corresponding recommendations to make the intervention more efficient and effective. Data supported the ACTIVE intervention as a way for hospice providers to more fully realise their goal of maximum patient and family participation in care planning.

The use of videophones for patient and family participation in hospice interdisciplinary team meetings: a promising approach

Inclusion of patients and caregivers in decisions related to the delivery of care is inherent in the hospice philosophy. Telemedicine technologies offer a potential solution to the challenges presented by the geographic distance between team meetings and the home environment. While inclusion requires additional coordination by the hospice team, it also offers an important opportunity to improve communication between the team and the patient and family. A modified conceptual model based on two previous frameworks is outlined to support patient and family involvement in hospice team meetings. Further research is suggested to determine the structural feasibility of patient and family involvement via videophone as well as the structural and procedural changes resulting from this inclusion. Finally, clinical outcomes and family evaluation of the inclusion experience need to be thoroughly researched before final conclusions may be reached.

Performance Status Assessment in Home Hospice Patients Using a Modified Form of the Karnofsky Performance Status Scale

The Karnofsky Performance Status (KPS) scale is considered to be the gold standard for quantifying the physical functioning of patients with cancer. However, problems have been identified with the scoring system when the scale is used in the home hospice setting. The goal of this study was to compare assessments of performance status using two instruments, the KPS and a modified version, the Thorne-KPS (TKPS). The TKPS avoids reference to location of care and has new descriptors for assessing the frequency of professional visits and the proportion of time spent in bed. Comparisons were made on a sample of 78 home-hospice patients in Perth, Western Australia. The median score for both scales was 60. The scales agreed in 56% of ratings overall but after correcting for chance, agreement was reduced to 47%. However, 91% of the 34 discrepancies occurred within one or two levels of the 11-point scale. TKPS scores were consistently lower than KPS scores and were spread over a wider range of the scale. The strongest agreement occurred at the higher levels of performance and the weakest agreement was within the middle levels of the scales. Further studies are required to determine which of the two scales more accurately reflects performance status and survival time. However, the results to date suggest that the TKPS may be a more objective and sensitive measure of functional performance in home hospice patients.

Decision making in Greek and English registered nurses in coronary care units

Clinical decision-making is an integral component of the role of the professional nurse. The aim of the study was to identify the quality of decision making of Greek and English coronary care nurses during the acute and recovery phases post-myocardial infarction (MI), and determine factors that best predict clinical decision-making in these two discrete groups of nurses. By identifying best practice from standard textbooks and expert practitioners, Clinical Decision-Making cards were developed and employed to explore nurse decision-making. A questionnaire (influencing factor questionnaire-IFQ) was also administered to determine which factors predicted quality nurse decision-making in the acute and recovery phase of post-MI patient care. The results showed that nurses in England made better quality clinical decisions in the recovery phase of MI than the Greek counterparts (p<0.001). Variables were identified which best-predicted decision-making. Interestingly, the main finding of this study was that English nurses had greater autonomy in the recovery phase and therefore made more clinical decisions concerning the patient psychosocial recovery than Greek nurses. Nurses perceived clinical experience as the strongest factor influencing decision-making.

Development and testing of a cancer appetite and symptom questionnaire

BACKGROUND

Poor appetite and weight loss are common in patients with cancer, contributing to an increase in morbidity and mortality. Early identification of those at greatest risk is problematic. The Council on Nutrition Appetite Questionnaire (CNAQ) is short and easy to use, although it is not specific to cancer populations. The present study aimed to build on the CNAQ to develop a cancer appetite and symptom questionnaire (CASQ) for predicting weight loss in patients with cancer.

METHODS

The content validity of the CNAQ was assessed by an expert panel (n = 41) using the content validity index (CVI). The resulting CASQ was tested for reliability among patients receiving radiotherapy (n = 34). Predictive validity of the CASQ was determined in patients with lung or upper gastrointestinal cancer (n = 185), comparing CASQ scores (possible range 0-48) recorded at baseline with percentage weight change after 12 weeks.

RESULTS

 In all but one CNAQ item, the CVI was above the minimum level of agreement (>0.70). Comments from expert panel members led to minor modifications and the introduction of new items resulting in the 12-item CASQ. The intraclass correlation coefficient of the CASQ was 0.80 [95% confidence interval (CI) = 0.68-0.92] and the difference between total scores at two time points was -0.20 (95% CI = -1.21 to 0.80). The optimum cut-off point of the instrument to predict >10% weight loss was 29/30 (area under curve = 0.75; sensitivity 71%, specificity 66%, positive predictive value 19%, negative predictive value 95%) [Correction added on 30 April 2012, after first online publication: in the preceding sentence, <10% was corrected to >10%].

CONCLUSIONS

The CASQ can predict weight loss among patients with lung and upper gastrointestinal cancer. Acknowledgment of the low positive predictive value is needed if the instrument is to be used within clinical practice.

Relocation stress syndrome: the case of palliative care patients

Transfer of patients from palliative care services to nursing homes is necessary at present when a patient is relatively stable, but does not have adequate support systems at home. With the ageing of the population and the increasing incidence of cancer, the need for inpatient palliative care beds is growing with corresponding pressure for patients to be transferred to nursing homes. Transfer to a nursing home in the general population has been described extensively in the gerontology literature where a critical early phase of relocation has been identified by a high incidence of morbidity and mortality. The vulnerability of terminally ill patients means that they are at increased risk of suffering from stress associated with a transfer. The prognosis of a patient may be shorter than the time required for adjustment to the patient's new home. The issues surrounding transfer of palliative care patients to nursing homes and possible strategies designed to reduce distress associated with transfers are explored.

A comparison of education in Greek and English nurses

BACKGROUND

Curriculum is an important component of nurse education and is thought to vary from country to country.

AIM

To determine the level of cardiac knowledge in Greek and English final-year student nurses.

METHOD

Subjects were final-year diploma and degree student nurses (n = 161) from Greece and England. Pictographs (testing knowledge in a pictorial form) were used as a method of data collection. Three anatomical cardiac diagrams were used. Students were asked to label 20 anatomical parts.

RESULTS

Final-year English student nurses have better knowledge in the discrete area of cardiac anatomy and physiology (P < 0.05) than their Greek counterparts. Problems associated with translation and interpretation were avoided using pictographs and were shown to be useful measures for determining knowledge in nurses from different countries.

CONCLUSION

The findings of the study are important because they show differences in anatomical knowledge levels between Greek and English students. More research is needed to explore further different levels of knowledge and education within the European Union and the consequences for nurse decision-making and patient outcomes.

Just go with the flow: a qualitative study of fatigue in biotherapy

The purpose of this qualitative study was to describe and explore the experience of fatigue in patients who had received biotherapy or biochemotherapy. A one-time face-to-face interview was conducted with 10 patients who had consented to be in a larger quantitative study of fatigue. Seven were men and all but two were currently receiving treatment. The study took place at a midwestern cancer centre in the USA. A content analysis of the transcribed interviews was undertaken. The two investigators coded the transcripts independently and then compared and discussed the codes and themes until consensus was reached. Four themes emerged: (i) life-disrupting severity of the fatigue, (ii) altered sleep patterns, (iii) informational needs met, and (iv) advice for other patients. The strongest theme was the advice to 'be strong and go with the flow' was meaningful for these patients and the only wisdom they could pass on to future patients. Boredom associated with cognitive fatigue and the inability to accomplish work and other tasks was also revealed. Conclusions drawn from this study relate to the degree of suffering patients experienced in undergoing biotherapy as they reported fatigue and other problems and also the strong desire to complete treatment despite the difficulties that they experienced.

Optimising the management of primary breast cancer in older women - a report of a multi-disciplinary study day

PURPOSE

The objectives of the study day were to (i) develop an in-depth understanding around the biology and treatment options; (ii) explore the specific physical and psychosocial needs and consideration including patients perspective; and (iii) gain insight into the development of a dedicated, holistic and multi-disciplinary clinic service and the importance of supporting research, for older women with primary breast cancer.

DESIGN

The format included presentations (with lectures from external and local faculty, and short research papers from Nottingham) with a number of interactive discussions, and sharing of patients' experience.

RESULTS

Four sessions were held covering (i) pathological features, (ii) role of radiotherapy and adjuvant chemotherapy, (iii) role of surgery, geriatric assessment and quality of life issues, and (iv) challenges in running research trials.

CONCLUSIONS

A dedicated and joint team approach is required to improve clinical service and support research, in order to optimise the management of primary breast cancer in older women.

Predictors of family satisfaction with an Australian palliative home care service: a test of discrepancy theory

Five interesting findings emerged from this study: Although study results demonstrate support for Porter's Discrepancy Theory, the most compelling outcome is the finding that family care perceptions may be the best predictor of family care satisfaction. Family members' age may be a predictor of family care satisfaction. Family functioning may be a useful clinical indicator to identify families who are less satisfied with care and in greater need of support. The length of time that clients receive the care service may alter family care satisfaction. Differences in findings reported in this study compared with Canadian results point to the need for cross-cultural research in this area. This research is the first Australian study to test discrepancy theory as a framework for understanding family care satisfaction in a home hospice context. Results from this study may assist health care providers to more sensitively address the care perceptions of families in this care setting and extend theory development research that is needed to guide palliative care practice with families.

Predicting the severity of radiation skin reactions in women with breast cancer

PURPOSE/OBJECTIVES

To develop a method of predicting the severity of acute radiation skin reactions.

DESIGN

Prospective, descriptive correlational with repeated measures.

SETTING

Outpatient radiation oncology department in a metropolitan public teaching hospital in Western Australia.

SAMPLE

126 adult women aged 30-78 receiving postlumpectomy radiation therapy for breast cancer.

METHODS

Data about potential predictive factors were collected during the first week of radiation. Weekly observations of the skin reaction using the Radiation Therapy Oncology Group scoring system were recorded throughout treatment with an inter-rater reliability of 0.85.

RESULTS

Chi square analysis and t-tests revealed many factors related to severe skin reactions on a univariate level. Logistic regression analysis calculated the relative risk and probability of developing a severe skin reaction. Predictive factors included weight, breast size, lymphocele aspiration, smoking, age, skin cancer, tumor stage, and radiation dose.

CONCLUSIONS

In addition to radiation dose, some factors that impair wound healing also contribute to the cause of patient-to-patient variation, thus making it possible to predict who is likely to develop a severe skin reaction.

IMPLICATIONS FOR NURSING PRACTICE

The findings will assist in individualizing the assessment, education, and management of women undergoing radiation therapy for breast cancer. Further research could lead to the development of a method of risk assessment for skin reactions for use in radiation therapy nursing.

An exercise intervention for advanced cancer patients experiencing fatigue: a pilot study

Fatigue is reported by advanced cancer patients to be their most prevalent and distressing symptom. Despite this, few interventions have been developed and tested to manage this debilitating symptom. This paper describes a pilot study undertaken to test the effects of a 28-day exercise intervention on levels of fatigue in advanced cancer patients. All participants were able to increase their activity levels with no increase in reported fatigue. Furthermore, a trend was noted in all patients toward increased quality of life scores and decreased anxiety scores. All participants described a sense of satisfaction in attaining increased activity levels. These preliminary pilot results suggest that patients who initially report the highest levels of fatigue may achieve the largest decrease in fatigue scores. These findings provide support for the suitability of this intervention for the palliative care population and justify the importance of further hypothesis testing.

Management of radiation skin reactions: literature review and clinical application

As many as 95% of patients treated with radiation therapy for cancer will experience a skin reaction. Some reactions are immediate, while others may be later (e.g., months after treatment). Therefore, nurses must be familiar with management of this side effect. This paper reviews current knowledge related to skin reactions from ionizing radiation and recommends guidelines for nursing practice.