Intensive Daily Symptom and Function Monitoring Is Feasible and Acceptable to Women Undergoing First-Line Chemotherapy for Gynecologic Cancer.

BACKGROUND: Women receiving chemotherapy for gynecologic cancer (GC) experience severe symptoms with associated functional changes. Understanding day-to-day symptom and function variation within and across chemotherapy treatment cycles could inform improved symptom management, but such studies are rare and may be infeasible in clinical care. OBJECTIVE: The aim of this study was to evaluate feasibility and acceptability of daily symptom monitoring combined with objective and self-reported functional assessments every 21 days during active chemotherapy for GC. METHODS: Thirty women enrolled in a prospective observational study during first-line chemotherapy completed a daily symptom and falls diary during their entire chemotherapy treatment period. Patient-reported outcomes and objective symptom and function testing were assessed before each chemotherapy appointment. Study outcomes included accrual and attrition rates, completion of study assessments, and qualitative perceptions of study participation. RESULTS: Participants were 92% White, 60% had high school or higher education, 68% were married/partnered, and 62% had stage III or IV cancer at diagnosis. The study had an 83% accrual rate, 6.6% early withdrawal rate, and 17% total attrition rate. Missing assessments for prechemotherapy patient-reported outcomes and objective assessments ranged from 27% to 35% and 35% to 47% respectively, with a general decrease across cycles. Daily diary completion rate was 83% overall. Participants rated study participation positively. CONCLUSIONS: Intensive daily symptom and function monitoring was feasible and acceptable to GC patients and may provide a sense of symptom controllability. IMPLICATIONS FOR PRACTICE: Daily symptom and function monitoring in research studies may provide patients with information to support symptom discussions with the clinical team. Future work should develop proactive symptom management interventions using personalized symptom trajectories.

Priorities to improve cancer caregiving: report of a caregiver stakeholder workshop.

PURPOSE: Caregivers of people with cancer represent a large, overburdened, and under-recognized part of the cancer care workforce. Research efforts to address the unmet needs of these caregivers are expanding with studies focused on caregivers' skill sets, physical and psychological health, and integration into healthcare delivery. As this field of research continues to expand, integrating caregivers' input is vital to studies to ensure that research aligns with their experiences. METHODS: This is a focus group study of 15 cancer caregivers conducted during a cancer caregiving workshop at the University of Pittsburgh in February 2020. During the workshop, caregivers reviewed, critiqued, and proposed priorities to support caregivers of adults with cancer. We used a multistage consensus building approach to identify priority areas of research and clinical practice to address caregivers' experiences and needs. We used descriptive content analysis to summarize caregivers' priorities. RESULTS: Caregiver-identified priorities included (1) training and information about cancer and treatment, (2) caregiver integration into the patient's healthcare delivery, (3) assistance with navigating the healthcare system, (4) focus on caregiver health and well-being, and (5) policy reform to address caregiver needs. We identified ways in which these priorities can inform cancer caregiving research and practice. CONCLUSION: These recommendations should be considered by researchers, clinicians, cancer center leadership, and policymakers interested in creating caregiver-focused research protocols, interventions, and support systems.

Integrating Family Caregiver Support Into a Gynecologic Oncology Practice: An ASCO Quality Training Program Project.

PURPOSE: A needs assessment of family caregivers (CGs) in our gynecologic oncology clinic found that 50% of CGs report nine or more distressing unmet needs, but only 19% of patients had a documented CG. We conducted an ASCO Quality Training Program project with the following aims: (1) to identify and document primary CGs for 85% of patients within two clinic visits of a gynecologic cancer diagnosis, and (2) assess the needs of and provide interventions to 75% of identified family CGs. METHODS: Plan-Do-Study-Act (PDSA) methodology and tools endorsed by the ASCO Quality Training Program were used. An interprofessional team reviewed baseline data (ie, any mention of a family CG in the electronic health record visit note; CG distress survey), defined the problem and project aims, created process maps, and identified root causes of poor CG identification and documentation. Eight successive PDSA cycles were implemented between October 2018 and March 2019 to address identified root causes. RESULTS: For aim 1, CG identification increased from 19% at baseline to 57% postimplementation, whereas for aim 2, assessment improved from 28% at baseline to 60% postimplementation. Results fell somewhat short of initial goals, but they represent an important initial improvement in care. The core team has begun additional PDSA cycles to improve CG identification rates and extend the momentum of the project. CONCLUSION: This project demonstrated that a CG assessment protocol can be implemented in a large, academic, gynecologic oncology clinic. Additional efforts to integrate CG identification, assessment, and intervention more fully within the clinic and electronic health record are under way.

Psychobehavioral risk factors for financial hardship and poor functional outcomes in survivors of multiple primary cancers.

OBJECTIVE: Survivors of multiple primary cancers (MPC) are at increased risk for poor health outcomes compared with survivors of single cancers. Using an adapted psychobehavioral stress-response model, the study purpose was to identify pathways and individual risk factors associated with poor health outcomes in adults with MPC. METHODS: Adult MPC survivors (N = 211) with first cancers (stages I-III) diagnosed within 1 to 10 years were recruited via tumor registry. Employing a cross-sectional design, established questionnaires were used to operationalize patient characteristics and theoretical constructs including perceived stress, psychological and behavioral responses, financial hardship, social role function, and physical health. Disease and treatment data were obtained via registry and medical records. Structural equation modeling (SEM) was performed to fit, test, and modify the hypothesized psychobehavioral model. RESULTS: Following measurement model refinement, an SEM linking self-management behaviors, distress, financial hardship, and functional health demonstrated a good fit: χ2 (200, N = 206) = 332.06, P < .01; Tucker-Lewis index (TLI) = .95, comparative fit index (CFI) = .96, standardized root mean residual (SRMR) = .06, root-mean-square error of approximation (RMSEA) = .06. Less use of self-management behaviors predicted higher distress which, in turn, predicted higher financial hardship; higher distress and financial hardship predicted poorer functional health. Several sociodemographic and personal factors predicted self-management behaviors and distress. CONCLUSIONS: The hypothesized stress-response model was partially supported. Data supported pathways among self-management behaviors, distress, financial hardship, and functional health. Self-management and distress may represent modifiable intervention targets for MPC survivors. High body mass index (BMI), less education, greater neuroticism, and lower social support were associated with less use of self-management behaviors and higher distress and should be further evaluated as potential markers of vulnerability.

Nurse Author: Who Me? Yes, You!

BACKGROUND AND PURPOSE: Potential nurse authors may find writing a challenge, including managing the publication process from getting started through submission to revision of the work and its acceptance. This special article presents strategies to help inexperienced writers develop and hone skills for journal publication. POTENTIAL PUBLICATION STRATEGIES: Tips discussed here that may lead to manuscript acceptance include selecting a topic of interest, using motivational self-talk approaches and structuring time to write, choosing coauthors, targeting a journal for submission, writing strong sentences in active voice, developing a structured abstract, using correct citation and reference formats, understanding reviews and resubmitting the manuscript, and keeping momentum to produce continued writing results. Practical writing hints are also suggested for inexperienced writers. RELEVANCE AND CONCLUSION: These strategies can help guide nurse writers in planning, navigating the system, and finding success as a published author.

Chemotherapy in older adult gynecologic oncology patients: Can a phenotypic frailty score predict tolerance?

OBJECTIVE: Evaluate the ability of an office-administered phenotypic frailty assessment to predict chemotherapy tolerance in older adult gynecologic oncology patients, and describe practice patterns for chemotherapy administration in this population. METHODS: Prospective, single-institution cohort study of gynecologic oncology patients 65 or older initiating chemotherapy. Phenotypic frailty testing at an office visit encompassed components of two validated frailty assessments: Fried Score (physical testing and patient response) and FRAIL Scale (patient response only). Patients were followed through three cycles of neoadjuvant chemotherapy or six cycles of adjuvant chemotherapy. Standard statistics examined the relationship of frailty to chemotherapy regimen, ability to complete chemotherapy, and complications. RESULTS: Eighty patients were included, 65% with ovarian and 34% with endometrial cancer. On average 57% of patients were fit, 32% intermediately frail, and 11% frail. 68% received adjuvant chemotherapy versus 32% neoadjuvant. The majority (81%) received IV chemotherapy on a 21-day cycle and 81% initially received a regimen consistent with standard-of-care chemotherapy (SOCC). Age was not associated with receiving SOCC, or tolerance or completion of chemotherapy. Frailty was associated with non-initiation of SOCC in all patients and inability to complete SOCC in adjuvant patients. Complications and regimen alterations were common but were not associated with frailty. CONCLUSIONS: There is a need to develop tools to help physicians predict chemotherapy tolerance among older adult gynecologic oncology patients in order to prevent both under- and over-treatment while minimizing morbidity. However, in this study phenotypic frailty assessment had limited predictive utility. Among adjuvant chemotherapy patients, frailty was associated with inability to complete SOCC and thus may be helpful in selecting patients appropriate for less aggressive chemotherapy regimens.

Sexual Health as Part of Gynecologic Cancer Care: What Do Patients Want?

OBJECTIVE: Sexual health is important to quality of life; however, the sexual health of gynecologic cancer patients is infrequently and inadequately addressed. We sought to understand patient experiences and preferences for sexual health care to help inform strategies for improvement. METHODS/MATERIALS: An anonymous, cross-sectional survey of outpatient gynecologic cancer patients at a large academic medical center was performed as part of a larger study examining patient and caregiver needs. The survey explored patient-provider discussions about sexuality across 3 domains (experiences, preferences, barriers) and 4 phases of cancer care (diagnosis, treatment, treatment completion, follow-up). Age, relationship status, sexual activity, and cancer type were recorded. RESULTS: Mean age was 63 years. Most patients had ovarian cancer (38%) or endometrial cancer (32%). Thirty-seven percent received treatment within the last month, 55% were in a relationship, and 35% were sexuality active. Thirty-four percent reported sexuality as somewhat or very important, whereas 27% felt that it was somewhat or very important to discuss. Importance of sexuality was associated with age, relationship status, and sexual activity but not cancer type. Fifty-seven percent reported never discussing sexuality. Age was associated with sexuality discussions, whereas relationship status, sexual activity, and cancer type were not. The most common barrier to discussion was patient discomfort. Follow-up was identified as the best time for discussion. Sexuality was most often discussed with a physician or advanced practice provider and usually brought up by the provider. CONCLUSIONS: Demographic predictors of importance of sexuality to the patient are age, relationship status, and sexual activity. Providers primarily use age as a proxy for importance of sexuality; however, relationship status and sexual activity may represent additional ways to screen for patients interested in discussing sexual health. Patient discomfort with discussing sexuality is the primary barrier to sexual health discussions, and awareness of this is key to developing effective approaches to providing sexual health care.

Nausea as a sentinel symptom for cytotoxic chemotherapy effects on the gut-brain axis among women receiving treatment for recurrent ovarian cancer: an exploratory analysis.

PURPOSE: Nausea is a common and potentially serious effect of cytotoxic chemotherapy for recurrent ovarian cancer and may function as a sentinel symptom reflecting adverse effects on the gut-brain axis (GBA) more generally, but research is scant. As a first exploratory test of this GBA hypothesis, we compared women reporting nausea to women not reporting nausea with regard to the severity of other commonly reported symptoms in this patient population. METHODS: A secondary analysis of data systematically collected from women in active chemotherapy treatment for recurrent ovarian cancer (n = 158) was conducted. The Symptom Representation Questionnaire (SRQ) provided severity ratings for 22 common symptoms related to cancer and chemotherapy. Independent sample t tests and regression analyses were used to compare women with and without nausea with regard to their experience of other symptoms. RESULTS: Nausea was reported by 89 (56.2 %) women. Symptoms that were significantly associated with nausea in bivariate and regression analyses included abdominal bloating, bowel disturbances, dizziness, depression, drowsiness, fatigue, headache, lack of appetite, memory problems, mood swings, shortness of breath, pain, sleep disturbance, urinary problems, vomiting, and weight loss. Symptoms that were not associated with nausea included hair loss, numbness and tingling, sexuality concerns, and weight gain. CONCLUSIONS: Nausea experienced during chemotherapy for recurrent ovarian cancer may be an indicator of broader effects on the gut-brain axis. A better understanding of the mechanisms underlying these effects could lead to the development of novel supportive therapies to increase the tolerability and effectiveness of cancer treatment.

Wearable Technology to Garner the Perspective of Dementia Family Caregivers.

Family caregivers of individuals with dementia typically have limited opportunity during brief clinical encounters to describe the dementia-related behaviors and interactions they find difficult to handle. Lack of objective data depicting the nature, intensity, and impact of these manifestations of the underlying disease further constrains the extent to which strategies recommended by nurses or other health care providers can be tailored to the situation. The current article describes a prototype wearable camera system used to gather image and voice data from the caregiver's perspective in a pilot feasibility intervention study conducted with 18 caregiving dyads. Several scenarios are presented that include salient events (i.e., behaviors or interactions deemed difficult by the caregiver or identified as concerning by the research team during screening) captured in the resulting video. The current authors anticipate future wearable camera systems and software will automate screening for salient events, providing new tools for assessment and intervention by nurses.

Usability of a Wearable Camera System for Dementia Family Caregivers.

Health care providers typically rely on family caregivers (CG) of persons with dementia (PWD) to describe difficult behaviors manifested by their underlying disease. Although invaluable, such reports may be selective or biased during brief medical encounters. Our team explored the usability of a wearable camera system with 9 caregiving dyads (CGs: 3 males, 6 females, 67.00 ± 14.95 years; PWDs: 2 males, 7 females, 80.00 ± 3.81 years, MMSE 17.33 ± 8.86) who recorded 79 salient events over a combined total of 140 hours of data capture, from 3 to 7 days of wear per CG. Prior to using the system, CGs assessed its benefits to be worth the invasion of privacy; post-wear privacy concerns did not differ significantly. CGs rated the system easy to learn to use, although cumbersome and obtrusive. Few negative reactions by PWDs were reported or evident in resulting video. Our findings suggest that CGs can and will wear a camera system to reveal their daily caregiving challenges to health care providers.

Overcoming practical challenges to conducting clinical research in the inpatient stroke rehabilitation setting.

BACKGROUND: There is a shortage of published empirical studies conducted in acute inpatient stroke rehabilitation, though such studies are greatly needed in order to shed light on the most efficacious inpatient stroke rehabilitation interventions. The inherent challenges of inpatient research may dissuade researchers from undertaking this important work. OBJECTIVE: This paper describes our institution's experience devising practical solutions to research barriers in this setting. METHOD: Through concentrated efforts to overcome research barriers, such as by cultivating collaborative relationships and capitalizing on unanticipated benefits, we successfully facilitated conduct of five simultaneous inpatient stroke studies. RESULTS: Tangible benefits realized include increased effectiveness of research participant identification and enrollment, novel collaborative projects, innovative clinical care initiatives, and enhanced emotional and practical support for patients and their families. We provide recommendations based on lessons learned during our experience, and discuss benefits of this collaboration for our research participants, clinical staff, and the research team.

The Stroke Assessment of Fall Risk (SAFR): predictive validity in inpatient stroke rehabilitation.

OBJECTIVE: To evaluate relative accuracy of a newly developed Stroke Assessment of Fall Risk (SAFR) for classifying fallers and non-fallers, compared with a health system fall risk screening tool, the Fall Harm Risk Screen. DESIGN AND SETTING: Prospective quality improvement study conducted at an inpatient stroke rehabilitation unit at a large urban university hospital. PARTICIPANTS: Patients admitted for inpatient stroke rehabilitation (N = 419) with imaging or clinical evidence of ischemic or hemorrhagic stroke, between 1 August 2009 and 31 July 2010. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Sensitivity, specificity, and area under the curve for Receiver Operating Characteristic Curves of both scales' classifications, based on fall risk score completed upon admission to inpatient stroke rehabilitation. RESULTS: A total of 68 (16%) participants fell at least once. The SAFR was significantly more accurate than the Fall Harm Risk Screen (p < 0.001), with area under the curve of 0.73, positive predictive value of 0.29, and negative predictive value of 0.94. For the Fall Harm Risk Screen, area under the curve was 0.56, positive predictive value was 0.19, and negative predictive value was 0.86. Sensitivity and specificity of the SAFR (0.78 and 0.63, respectively) was higher than the Fall Harm Risk Screen (0.57 and 0.48, respectively). CONCLUSIONS: An evidence-derived, population-specific fall risk assessment may more accurately predict fallers than a general fall risk screen for stroke rehabilitation patients. While the SAFR improves upon the accuracy of a general assessment tool, additional refinement may be warranted.

Reliability and validity of the Executive Interview (EXIT) and Quick EXIT among community dwelling older adults.

OBJECTIVES: To investigate the psychometric properties of the Executive Interview (EXIT) and Quick EXIT in community dwelling older adults. DESIGN: Secondary analysis of data obtained as part of a longitudinal study of cognitive function in late-life depression. SETTING: A university hospital. PARTICIPANTS: Community-dwelling adults (N = 422), aged 59 years and older, with current or recent history of non-psychotic unipolar major depression, and never-depressed comparison subjects. MEASUREMENTS: The EXIT and other measures of executive control functions (ECF), non-executive cognitive domains, and global cognitive function. We calculated Quick EXIT scores from the EXIT. RESULTS: The EXIT demonstrated high inter-rater reliability (Intraclass correlation coefficient = 0.978, F(7, 21) = 174.85, p <0.001), and both the EXIT and Quick EXIT demonstrated moderate internal consistency (α = 0.66 and α = 0.68, respectively). Both tests also demonstrated acceptable convergent validity against several standard tests of ECF (rs -0.399 to 0.322, except for the Trail Making Test B, where rs was 0.057 to 0.063) as well as against measures of multifactorial cognitive function (rs -0.432 to 0.491). Both tests, however, demonstrated inconsistent discriminant validity against a variety of standard non-ECF tests (rs -0.013 to 0.376). CONCLUSIONS: Both the EXIT and the Quick EXIT have adequate reliability and appear to require ECF in this population. However, both the EXIT and the Quick EXIT also reflect non-ECF domains. The EXIT and Quick EXIT should be considered to be measures of global cognitive function rather than pure ECF measures. Given similar reliability and validity, the Quick EXIT is recommended clinically as it is briefer and less burdensome than the full EXIT.

An integrative review of factors associated with falls during post-stroke rehabilitation.

PURPOSE: Our aims were to evaluate evidence of risk factors for falls among patients in stroke rehabilitation and to offer recommendations for clinical practice and future research. METHOD: We conducted an integrative review of the literature published from 1990 to 2009 that describes empirical investigations of risk factors for post-stroke falls during inpatient rehabilitation. We searched Medline, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycInfo, and Embase databases, using the search terms "accidental falls,""fall risk,""risk factors,""risk assessment,""stroke," and "cerebrovascular disorders." We extracted information regarding study design, sample, potential risk factors, analytic methods, findings, and limitations from the 14 articles that met our inclusion criteria, and we rated the level of evidence for each study. FINDINGS: Available empirical evidence points to impaired balance, visuospatial hemineglect, and impaired performance of activities of daily living as risk factors for falls during inpatient rehabilitation for stroke. Associations between falls and cognitive function, incontinence, visual field deficits, and stroke type were less clear, while relationships between falls and age, gender, stroke location, and impaired vision and hearing were not supported. CONCLUSIONS: The relatively sparse literature pertaining to risk factors for falls among stroke rehabilitation inpatients indicates that deficits affecting balance, perception, and self-care significantly increase the likelihood of falls. Particularly intriguing is the less well established role of post-stroke cognition in falls in this population. A conceptual model is needed to guide scientific inquiry and clinical practice in this area. CLINICAL RELEVANCE: When clinicians in the inpatient stroke rehabilitation setting evaluate which patients are at greatest risk to fall, stroke-specific risk factors such as impaired balance, visuospatial hemineglect, and self-care deficits may be better predictors than more general risk factors such as age, incontinence, and sensory impairments. Patients with these stroke-specific deficits may benefit from the use of aggressive fall prevention interventions.

Symptom identification in the chronically critically ill.

Ascertaining the symptom experience of chronically critically ill (CCI) patients is difficult because of communication impairment and fluctuations in patient cognition and physiologic conditions. The use of checklist self-report ratings is hampered by the inability of most CCI patients to respond verbally to symptom queries. In addition to the communication problems caused by mechanical ventilation, the apparently diverse idioms of symptom expression add to the potential for miscommunication regarding symptom experience. Although patient communication impairment is a major barrier to symptom identification, symptom assessment and treatment are fundamental components of nursing care for CCI. This article reviews and describes the unique constellation of symptoms experienced by many critically ill patients. We report our observations of symptom communication among CCI patients and nurses and discuss inconsistency in the language of symptom expression among nurses and patients. Clinically applicable strategies to improve nurse-patient symptom communication and suggestions for refinement of symptom assessment in chronic critical illness are provided.