Patients' and Clinicians' Perceptions of the Clinical Utility of Predictive Risk Models for Chemotherapy-Related Symptom Management: Qualitative Exploration Using Focus Groups and Interviews.

BACKGROUND: Interest in the application of predictive risk models (PRMs) in health care to identify people most likely to experience disease and treatment-related complications is increasing. In cancer care, these techniques are focused primarily on the prediction of survival or life-threatening toxicities (eg, febrile neutropenia). Fewer studies focus on the use of PRMs for symptoms or supportive care needs. The application of PRMs to chemotherapy-related symptoms (CRS) would enable earlier identification and initiation of prompt, personalized, and tailored interventions. While some PRMs exist for CRS, few were translated into clinical practice, and human factors associated with their use were not reported. OBJECTIVE: We aim to explore patients' and clinicians' perspectives of the utility and real-world application of PRMs to improve the management of CRS. METHODS: Focus groups (N=10) and interviews (N=5) were conducted with patients (N=28) and clinicians (N=26) across 5 European countries. Interactions were audio-recorded, transcribed verbatim, and analyzed thematically. RESULTS: Both clinicians and patients recognized the value of having individualized risk predictions for CRS and appreciated how this type of information would facilitate the provision of tailored preventative treatments or supportive care interactions. However, cautious and skeptical attitudes toward the use of PRMs in clinical care were noted by both groups, particularly in relationship to the uncertainty regarding how the information would be generated. Visualization and presentation of PRM information in a usable and useful format for both patients and clinicians was identified as a challenge to their successful implementation in clinical care. CONCLUSIONS: Findings from this study provide information on clinicians' and patients' perspectives on the clinical use of PRMs for the management of CRS. These international perspectives are important because they provide insight into the risks and benefits of using PRMs to evaluate CRS. In addition, they highlight the need to find ways to more effectively present and use this information in clinical practice. Further research that explores the best ways to incorporate this type of information while maintaining the human side of care is warranted. TRIAL REGISTRATION: ClinicalTrials.gov NCT02356081; https://clinicaltrials.gov/study/NCT02356081.

Assessment of the Effectiveness, Socio-Economic Impact and Implementation of a Digital Solution for Patients with Advanced Chronic Diseases: The ADLIFE Study Protocol.

Due to population ageing and medical advances, people with advanced chronic diseases (ACD) live longer. Such patients are even more likely to face either temporary or permanent reduced functional reserve, which typically further increases their healthcare resource use and the burden of care on their caregiver(s). Accordingly, these patients and their caregiver(s) may benefit from integrated supportive care provided via digitally supported interventions. This approach may either maintain or improve their quality of life, increase their independence, and optimize the healthcare resource use from early stages. ADLIFE is an EU-funded project, aiming to improve the quality of life of older people with ACD by providing integrated personalized care via a digitally enabled toolbox. Indeed, the ADLIFE toolbox is a digital solution which provides patients, caregivers, and health professionals with digitally enabled, integrated, and personalized care, supporting clinical decisions, and encouraging independence and self-management. Here we present the protocol of the ADLIFE study, which is designed to provide robust scientific evidence on the assessment of the effectiveness, socio-economic, implementation, and technology acceptance aspects of the ADLIFE intervention compared to the current standard of care (SoC) when applied in real-life settings of seven different pilot sites across six countries. A quasi-experimental trial following a multicenter, non-randomized, non-concurrent, unblinded, and controlled design will be implemented. Patients in the intervention group will receive the ADLIFE intervention, while patients in the control group will receive SoC. The assessment of the ADLIFE intervention will be conducted using a mixed-methods approach.

Real time remote symptom monitoring during chemotherapy for cancer: European multicentre randomised controlled trial (eSMART).

OBJECTIVE: To evaluate effects of remote monitoring of adjuvant chemotherapy related side effects via the Advanced Symptom Management System (ASyMS) on symptom burden, quality of life, supportive care needs, anxiety, self-efficacy, and work limitations. DESIGN: Multicentre, repeated measures, parallel group, evaluator masked, stratified randomised controlled trial. SETTING: Twelve cancer centres in Austria, Greece, Norway, Republic of Ireland, and UK. PARTICIPANTS: 829 patients with non-metastatic breast cancer, colorectal cancer, Hodgkin's disease, or non-Hodgkin's lymphoma receiving first line adjuvant chemotherapy or chemotherapy for the first time in five years. INTERVENTION: Patients were randomised to ASyMS (intervention; n=415) or standard care (control; n=414) over six cycles of chemotherapy. MAIN OUTCOME MEASURES: The primary outcome was symptom burden (Memorial Symptom Assessment Scale; MSAS). Secondary outcomes were health related quality of life (Functional Assessment of Cancer Therapy-General; FACT-G), Supportive Care Needs Survey Short-Form (SCNS-SF34), State-Trait Anxiety Inventory-Revised (STAI-R), Communication and Attitudinal Self-Efficacy scale for cancer (CASE-Cancer), and work limitations questionnaire (WLQ). RESULTS: For the intervention group, symptom burden remained at pre-chemotherapy treatment levels, whereas controls reported an increase from cycle 1 onwards (least squares absolute mean difference -0.15, 95% confidence interval -0.19 to -0.12; P<0.001; Cohen's D effect size=0.5). Analysis of MSAS sub-domains indicated significant reductions in favour of ASyMS for global distress index (-0.21, -0.27 to -0.16; P<0.001), psychological symptoms (-0.16, -0.23 to -0.10; P<0.001), and physical symptoms (-0.21, -0.26 to -0.17; P<0.001). FACT-G scores were higher in the intervention group across all cycles (mean difference 4.06, 95% confidence interval 2.65 to 5.46; P<0.001), whereas mean scores for STAI-R trait (-1.15, -1.90 to -0.41; P=0.003) and STAI-R state anxiety (-1.13, -2.06 to -0.20; P=0.02) were lower. CASE-Cancer scores were higher in the intervention group (mean difference 0.81, 0.19 to 1.43; P=0.01), and most SCNS-SF34 domains were lower, including sexuality needs (-1.56, -3.11 to -0.01; P<0.05), patient care and support needs (-1.74, -3.31 to -0.16; P=0.03), and physical and daily living needs (-2.8, -5.0 to -0.6; P=0.01). Other SCNS-SF34 domains and WLQ were not significantly different. Safety of ASyMS was satisfactory. Neutropenic events were higher in the intervention group. CONCLUSIONS: Significant reduction in symptom burden supports the use of ASyMS for remote symptom monitoring in cancer care. A "medium" Cohen's effect size of 0.5 showed a sizable, positive clinical effect of ASyMS on patients' symptom experiences. Remote monitoring systems will be vital for future services, particularly with blended models of care delivery arising from the covid-19 pandemic. TRIAL REGISTRATION: Clinicaltrials.gov NCT02356081.

Development of a Remote Monitoring Application to Improve Care and Support Patients in the First 30 Days Following Colorectal Cancer Surgery.

OBJECTIVE: To design and develop a digital monitoring application to support and improve the care of patients in the first 30 post-operative days following colorectal cancer surgery. DATA SOURCES: Patient interviews, health professional focus groups, patient co-creation activities, and health professional prioritization discussions. CONCLUSION: The structured and iterative co-design activities adopted in this study with key stakeholders, including patients and health professionals, lead to the development of a prototype application (app) to support patients at home during the first 30 days following surgery for colorectal cancer. A similar approach could be implemented to develop comparable apps for patients with other cancer diagnoses requiring different surgical procedures. Further research should focus on the continued development and testing of this app in relation to patient care and outcomes as well as the app's affect on nursing and other health services. IMPLICATIONS FOR NURSING PRACTICE: Clinical implementation of remote monitoring following discharge home after surgery for colorectal cancer gives patients the opportunity to report issues of concern to relevant health professionals. This could facilitate the early identification of concerning signs and symptoms, ensuring appropriate and timely interventions to minimize readmission rates. Patients' experiences during the recovery period could also be improved through the provision of reliable and relevant online information. More specifically, health professionals could easily identify those patients requiring additional support to manage their recovery, for example, those with more severe symptoms or problems, facilitating the direction of appropriate health services to those most in need of their expertise.

Adaptation and Implementation of a Mobile Phone-Based Remote Symptom Monitoring System for People With Cancer in Europe.

BACKGROUND: There has been an international shift in health care, which has seen an increasing focus and development of technological and personalized at-home interventions that aim to improve health outcomes and patient-clinician communication. However, there is a notable lack of empirical evidence describing the preparatory steps of adapting and implementing technology of this kind across multiple countries and clinical settings. OBJECTIVE: This study aimed to describe the steps undertaken in the preparation of a multinational, multicenter randomized controlled trial (RCT) to test a mobile phone-based remote symptom monitoring system, that is, Advanced Symptom Management System (ASyMS), designed to enhance management of chemotherapy toxicities among people with cancer receiving adjuvant chemotherapy versus standard cancer center care. METHODS: There were 13 cancer centers across 5 European countries (Austria, Greece, Ireland, Norway, and the United Kingdom). Multiple steps were undertaken, including a scoping review of empirical literature and clinical guidelines, translation and linguistic validation of study materials, development of standardized international care procedures, and the integration and evaluation of the technology within each cancer center. RESULTS: The ASyMS was successfully implemented and deployed in clinical practices across 5 European countries. The rigorous and simultaneous steps undertaken by the research team highlighted the strengths of the system in clinical practice, as well as the clinical and technical changes required to meet the diverse needs of its intended users within each country, before the commencement of the RCT. CONCLUSIONS: Adapting and implementing this multinational, multicenter system required close attention to diverse considerations and unique challenges primarily related to communication and clinical and technical issues. Success was dependent on collaborative and transparent communication among academics, the technology industry, translation partners, patients, and clinicians as well as a simultaneous and rigorous methodological approach within the 5 relevant countries.

WISECARE+: Results of a European study of a nursing intervention for the management of chemotherapy-related symptoms.

While the use of chemotherapy has significantly improved survival rates, the symptoms associated with chemotherapy remain a major burden for patients. Preventing or appropriately managing side effects significantly improves patients' functional status and quality of life, ultimately leading to greater patient acceptance of chemotherapy. However, symptom assessment and management are fraught with difficulties such as poor patient recall, retrospective assessment conducted by clinicians and lack of appropriate, clinically relevant and patient friendly symptom assessment and management tools. Furthermore the differences between clinician and patient perceptions of stresses and distress during chemotherapy are well recognised. This study aimed to evaluate the impact of a nursing intervention incorporating structured symptom assessment and management, facilitated by information technology, on chemotherapy-related symptoms, nausea, vomiting, fatigue and mucositis. This pan-European study, involved 8 clinical sites from Belgium, Denmark, England, Ireland and Scotland. Adults (n=249) receiving first line chemotherapy for breast, lung, ovarian or colorectal cancer, osteosarcoma, acute myeloid leukaemia (AML), acute lymphoblastic leukaemia (ALL) or lymphoma were recruited to the study. Patients completed daily symptom assessment questionnaires for 14 days following consecutive cycles of chemotherapy. Symptom outcomes were compared before and after the introduction of the intervention with positive impact on patients' experiences of nausea, vomiting and oral problems. Fatigue was not significantly improved.

Patterns of fatigue during a course of chemotherapy: results from a multi-centre study.

Fatigue is a highly prevalent condition among patients with cancer affecting between 70% and 100% and patients describe their fatigue experiences as the most distressing of symptoms. However, the management of fatigue is complicated by our current lack of understanding of its pathophysiology. This study aimed to gain an insight into the longitudinal fatigue experiences of patients receiving chemotherapy. A convenience sample of patients receiving chemotherapy (n=249) were recruited and recorded their fatigue experiences using a paper questionnaire for 14 consecutive days following each cycle of chemotherapy. Fatigue was reported in 57% of all completed questionnaires. Patients report fatigue as a relatively constant presence following chemotherapy. Moreover, fatigue experiences increase over consecutive cycles of chemotherapy. This study supports the existing evidence illustrating fatigue as a significant problem for patients with cancer and provides new data demonstrating patterns of fatigue over the duration of a course of chemotherapy. Understanding this experience of fatigue should prompt health professionals providing care for this patient population to seek and test a range of management strategies to help patients maintain their quality of life during cancer treatment.

Evaluation of the feasibility and acceptability of an oral care diary by patients during chemotherapy.

BACKGROUND: A significant proportion of patients undergoing chemotherapy for many cancer types may experience oral problems, such as mucositis and any deterioration in the health of the oral cavity can have a significant effect on a person's well-being. Trends towards shorter hospital stays and the increase in out-patient chemotherapy mean that patients are required to adopt increasingly participatory roles in their self-care and are subsequently coping with mouth problems while they are at home without the direct support of oncology health professionals. OBJECTIVES: This study aimed to evaluate the acceptability and feasibility of an oral care diary by patients receiving chemotherapy. DESIGN: An oral care diary was developed to incorporate oral assessment using the Oral Assessment Guide (Eilier, J., Berger, A., Peterson, M., 1988. Development, testing and application of the oral assessment guide. Oncology Nurse Forum 15, 325-330) and guidance about oral self-care. This exploratory study utilised purpose designed pre- and post-study questionnaires and semi-structured interviews to evaluate patients' perceptions and experiences of the oral care diary. SETTING: The study took place in 2-day chemotherapy units in Scotland: 1 in a cancer centre and 1 in a district general hospital. PARTICIPANTS: A consecutive sample of patients (n=45) receiving out-patient chemotherapy for a range of cancer diagnoses participated in the study over 2 cycles of chemotherapy. METHODS: Following recruitment, patients were instructed in the use of the oral care diary to assess their mouth daily while at home on a daily basis. Patients were asked to complete 2 structured purpose designed questionnaires-the first prior to starting diary completion and the second following their participation in the study. Nine patients participated in semi-structured interviews to explore their actual experiences of using the oral care diary in more depth. RESULTS: The participants found the oral care diary acceptable and feasible. Awareness of oral symptoms and related mouth self-care post-chemotherapy improved. CONCLUSIONS: The oral care diary is an acceptable and feasible method of enhancing oral self-care during a course of chemotherapy. Further study is required to evaluate its impact on clinical outcomes.

Technology into practice: young people's, parents' and nurses' perceptions of WISECARE+.

UNLABELLED: Technology is a central aspect of young people's lives, with the internet and mobile phone technology providing the preferred means of communication. This pilot explored perceptions and experiences of young people, parents and healthcare professionals on the role of technology in monitoring and managing chemotherapy-related toxicity. AIM: To introduce the WISECARE+ process for recording and communicating symptoms following chemotherapy to a teenage patient population and evaluate its usefulness with patients, parents and nursing staff. METHOD: A convenience sample of 11 young people (aged 13 to 20 years) with a haematological or solid tumour undergoing primary treatment, were recruited from two UK regional paediatric oncology centres. The young people completed a daily symptom questionnaire for 14 consecutive days following a course of chemotherapy. They evaluated the presence or absence of symptoms of nausea, vomiting, fatigue and oral problems, their severity and how much the symptom bothered them. Perception questionnaires were completed by the 11 young people, four parents and eight nurses at the end of the 14 days. RESULTS: Young people and parents found the symptom questionnaire simple to understand, easy to complete and they liked the paper format. The nurses' confidence with IT varied but all felt that it could be useful in their clinical practice. CONCLUSION: These young people appeared to gain from their participation in the project, especially in relation to completing the questionnaire as they were able to see a change in symptoms over time that was encouraging, particularly in situations where the young person had been quite ill. This work is continuing with formats such as a handheld computer or mobile phone being considered to collect symptom information. Additional factors such as reading levels and dyslexia are also being considered.

Patient-Reported Self-Efficacy, Anxiety, and Health-Related Quality of Life During Chemotherapy: Results From a Longitudinal Study.

PURPOSE/OBJECTIVES: To explore changes over time in self-efficacy and the predictive ability of changes in state anxiety and health-related quality of life during chemotherapy.
. DESIGN: Secondary analysis of a longitudinal dataset derived from a larger, multicenter study.
. SETTING: Outpatient oncology clinics across eight general hospitals in England, Scotland, and Northern Ireland.
. SAMPLE: 137 patients scheduled to receive adjuvant chemotherapy for breast or colorectal cancer.
. METHODS: At the beginning of each of six chemotherapy cycles, participants completed the Strategies Used by People to Promote Health questionnaire, the State-Trait Anxiety Inventory, and the Functional Assessment of Cancer Therapy-Breast or -Colorectal questionnaire. Multilevel model analysis was used to analyze longitudinal data, adjusted for demographic and clinical variables.
. MAIN RESEARCH VARIABLES: Self-efficacy, anxiety, and health-related quality of life.
. FINDINGS: No significant time effects were found for patients' overall perceived self-efficacy or self-efficacy parameters. A trend toward greater self-efficacy was evident as chemotherapy progressed. Self-efficacy was significantly associated with decreased state anxiety throughout chemotherapy. Increases in overall self-efficacy and perceived ability to maintain a positive attitude were significantly associated with over-time increases in physical, emotional, and functional well-being, as well as with fewer cancer-related concerns.
. CONCLUSIONS: Findings highlight the importance of clinical assessments throughout treatment that focus on patients' perceived self-efficacy as a positive regulator of mood and well-being. 
. IMPLICATIONS FOR NURSING: The current study suggests self-efficacy enhancement should be a key component of psycho-behavioral programs designed to support patients with cancer throughout chemotherapy.

The eSMART study protocol: a randomised controlled trial to evaluate electronic symptom management using the advanced symptom management system (ASyMS) remote technology for patients with cancer.

INTRODUCTION: While some evidence exists that real-time remote symptom monitoring devices can decrease morbidity and prevent unplanned admissions in oncology patients, overall, these studies have significant methodological weaknesses. The electronic Symptom Management using the Advanced Symptom Management System (ASyMS) Remote Technology (eSMART) study is designed to specifically address these weaknesses with an appropriately powered, repeated-measures, parallel-group stratified randomised controlled trial of oncology patients. METHODS AND ANALYSIS: A total of 1108 patients scheduled to commence first-line chemotherapy (CTX) for breast, colorectal or haematological cancer will be recruited from multiple sites across five European countries.Patients will be randomised (1:1) to the ASyMS intervention (intervention group) or to standard care currently available at each site (control group). Patients in the control and intervention groups will complete a demographic and clinical questionnaire, as well as a set of valid and reliable electronic patient-reported outcome measures at enrolment, after each of their CTX cycles (up to a maximum of six cycles) and at 3, 6, 9 and 12 months after completion of their sixth cycle of CTX. Outcomes that will be assessed include symptom burden (primary outcome), quality of life, supportive care needs, anxiety, self-care self-efficacy, work limitations and cost effectiveness and, from a health professional perspective, changes in clinical practice (secondary outcomes). ETHICS AND DISSEMINATION: Ethical approval will be obtained prior to the implementation of all major study amendments. Applications will be submitted to all of the ethics committees that granted initial approval.eSMART received approval from the relevant ethics committees at all of the clinical sites across the five participating countries. In collaboration with the European Cancer Patient Coalition (ECPC), the trial results will be disseminated through publications in scientific journals, presentations at international conferences, and postings on the eSMART website and other relevant clinician and consumer websites; establishment of an eSMART website (www.esmartproject.eu) with publicly accessible general information; creation of an eSMART Twitter Handle, and production of a toolkit for implementing/utilising the ASyMS technology in a variety of clinical practices and other transferable health care contexts. TRIAL REGISTRATION NUMBER: NCT02356081.

Trajectories and predictors of state and trait anxiety in patients receiving chemotherapy for breast and colorectal cancer: Results from a longitudinal study.

PURPOSE: To examine the trajectories and predictors of state and trait anxiety in patients undergoing chemotherapy for breast or colorectal cancer. METHODS: Secondary analysis of data collected as part of a large multi-site longitudinal study. Patients with breast or colorectal cancer completed validated scales assessing their state and trait anxiety levels (State-Trait Anxiety Inventory) and symptom burden (Rotterdam Symptom Checklist) at the beginning of each chemotherapy cycle. Longitudinal mixed model analyses were performed to test changes of trait and state anxiety over time and the predictive value of symptom burden and patients' demographic (age, gender) and clinical characteristics (cancer type, stage, comorbidities, ECOG performance status). RESULTS: Data from 137 patients with breast (60%) or colorectal cancer (40%) were analysed. Linear time effects were found for both state (χ2 = 46.3 [df = 3]; p < 0.001) and trait anxiety (χ2 = 17.708 [df = 3]; p = 0.001), with anxiety levels being higher at baseline and gradually decreasing over the course of chemotherapy. Symptom burden (ß = 0.21; SD = 0.06; p = 0.001) predicted state anxiety throughout treatment, but this effect disappeared when accounting for trait anxiety scores before the start of chemotherapy (ß = 0.85; SD = 0.05; p < 0.001). Patients' baseline trait anxiety was the only significant predictor of anxiety throughout treatment. CONCLUSIONS: Changes in the generally stable characteristic of trait anxiety indicate the profoundly life-altering nature of chemotherapy. The time point before the start of chemotherapy was identified as the most anxiety-provoking, calling for interventions to be delivered as early as possible in the treatment trajectory. Patients with high trait anxiety and symptom burden may benefit from additional support.

Developing, delivering, and evaluating cancer nursing services: searching for a United Kingdom evidence base for practice.

The drive toward evidence-based healthcare aims to promote effectiveness and thereby improve quality. The challenge for cancer nursing is to continually evaluate what it does, retaining effective interventions and working to develop new ones and refine those interventions that require improvement, thereby enhancing both practice and patient outcomes. The aim of the project was to assimilate an evidence base to support the development, delivery, and evaluation of cancer nursing services in the United Kingdom. It was believed that determining the extent of the current United Kingdom evidence base through a review of the literature and current and recent research endeavors would allow for comparison with current priorities and facilitate informed strategic planning regarding the process of research commissioning. A rigorous, explicit, and thorough literature review was undertaken of all United Kingdom literature pertaining to cancer nursing and related issues published between 1980 and 2000. Fourteen individual databases were searched using specific keywords, thesaurus terms, and additional search terms. Data were extracted from each individual publication and stored in a purpose-designed database. Current and recent United Kingdom cancer nursing research projects were identified through a mailed survey questionnaire sent to people and organizations involved in cancer-related research. Research projects were categorized according to Royal College of Nursing research priority themes: Care and Caring Practices, Healthcare Environment, Organization and Management of Care, and Healthcare Workforce. Four-hundred forty-six pieces of literature were considered appropriate for inclusion in the review. Two-hundred sixty-four pieces of evidence were included in the Care and Caring Practices theme, which also had the greatest number of current and recent research projects (48%, n = 50). The Healthcare Environment theme included 80 pieces of evidence but only 3% (n = 3) of the current and recent research projects. Thirty-two percent (n = 33) of the current/recent research projects fell into the third theme of Organization and Management of Care, which contained a total of 104 pieces of evidence. The final theme, Healthcare Workforce, included 17% (n = 18) of the current and recent research projects, and the literature review incorporated 49 pieces of evidence in this theme. A number of recommendations have been drawn, which focus on methodological challenges, research considerations, and gaps in the evidence base. The drive toward evidence-based practice is essential for cancer nurses to establish who they are, what they do, and what effect they have on patient outcomes. Currently, although the United Kingdom evidence base for practice is vast, it frequently lacks depth. Although evaluating national evidence for practice is valuable, a more global approach to evidence synthesis is required. Through such endeavors, cancer nurses should realize their potential, support the strategic development of cancer nursing research, and so generate an evidence base that supports their unique contribution to patient outcomes.

Institutional management of cancer-related fatigue: a comparison of clinical specialties.

Fatigue is the most common symptom associated with cancer and its treatment and is now widely recognized as a significant problem for patients with cancer (Ream & Richardson 1999). As a result of the restructuring of cancer services, much of the care given to patients is delivered by a multitude of nurses across a spectrum of clinical settings. While some research, albeit minimal, has evaluated nurses' knowledge and attitudes of cancer-related fatigue in various clinical settings, factors associated with institutional management of fatigue and the support and encouragement given to nurses by institutions regarding cancer-related fatigue appears to be unexplored. Nurses were recruited from community, general medical, general surgical and oncology clinical settings. A postal questionnaire to evaluate institutional cancer-related fatigue management was administered. Data were analysed descriptively. Institutional management of fatigue is poor across the clinical specialties involved in this survey. Topics addressed were interdisciplinary working, documentation and standards, accountability, information giving, staff education and quality assurance initiatives. Little difference was detected across the clinical specialties for the majority of these issues. Although individual health professionals have a personal responsibility to ensure the care they provide addresses patients' needs appropriately, institutional support and direction is essential. It seems that health-care institutions have not recognized the importance of this issue. This unacceptable situation must be resolved to ensure all health professionals are supported by their institutions to make every effort to improve the management of this symptom for patients with cancer.

Older people with cancer: perceptions and feelings about information, decision-making and treatment--a pilot study.

Several studies have identified inadequacies in the care and treatment received by older patients with cancer, as opposed to their younger counterparts. These include over or under diagnosis, ineffective symptom management and lower survival rates in older people with cancer. Despite these inadequacies, there is lack of evidence of older peoples' perspectives regarding their cancer diagnosis and treatment. This on going 2-site hospital based study focuses on older people's perceptions of information and decision-making in relation to treatment for cancer by using a semi-structured interview schedule. Results of the pilot study with 6 patients are presented and discussed in the light of research and clinical implications.

Guidelines for clinical practice: development, dissemination and implementation.

Clinical guidelines are one of the most promising and effective advances for defining and improving the quality of care. However, their development, dissemination and implementation in practice are rarely straightforward. Within nursing practice, guidelines have the potential to ensure the clinical application of research findings, thus ensuring that the profession rejects ineffective practices while employing those shown to work. Nevertheless, the benefits and limitations of clinical guidelines should be carefully considered by practitioners, managers and consumers of health care alike.

Organising UK cancer nursing services: a review.

This article describes an NTResearch survey which outlines how UK cancer nursing services have evolved over the past seven years in response to changes in government policy.