A systematic review of rehabilitation and exercise recommendations in oncology guidelines.

Guidelines promote high quality cancer care. Rehabilitation recommendations in oncology guidelines have not been characterized and may provide insight to improve integration of rehabilitation into oncology care. This report was developed as a part of the World Health Organization (WHO) Rehabilitation 2030 initiative to identify rehabilitation-specific recommendations in guidelines for oncology care. A systematic review of guidelines was conducted. Only guidelines published in English, for adults with cancer, providing recommendations for rehabilitation referral and assessment or interventions between 2009 and 2019 were included. 13840 articles were identified. After duplicates and applied filters, 4897 articles were screened. 69 guidelines were identified with rehabilitation-specific recommendations. Thirty-seven of the 69 guidelines endorsed referral to rehabilitation services but provided no specific recommendations regarding assessment or interventions. Thirty-two of the 69 guidelines met the full inclusion criteria and were assessed using the AGREE II tool. Twenty-one of these guidelines achieved an AGREE II quality score of ≥ 45 and were fully extracted. Guidelines exclusive to pharmacologic interventions and complementary and alternative interventions were excluded. Findings identify guidelines that recommend rehabilitation services across many cancer types and for various consequences of cancer treatment signifying that rehabilitation is a recognized component of oncology care. However, these findings are at odds with clinical reports of low rehabilitation utilization rates suggesting that guideline recommendations may be overlooked. Considering that functional morbidity negatively affects a majority of cancer survivors, improving guideline concordant rehabilitative care could have substantial impact on function and quality of life among cancer survivors.

Follow the trail: Using insights from the growth of palliative care to propose a roadmap for cancer rehabilitation.

Despite research explicating the benefits of cancer rehabilitation interventions to optimize physical, social, emotional, and vocational functioning, many reports document low rates of referral to and uptake of rehabilitation in oncology. Cancer rehabilitation clinicians, researchers, and policy makers could learn from the multidisciplinary specialty of palliative care, which has benefited from a growth strategy and has garnered national recognition as an important and necessary aspect of oncology care. The purpose of this article is to explore the actions that have increased the uptake and integration of palliative care to yield insights and multimodal strategies for the development and growth of cancer rehabilitation. After examining the history of palliative care and its growth, the authors highlight 5 key strategies that may benefit the field of cancer rehabilitation: 1) stimulating the science in specific gap areas; 2) creating clinical practice guidelines; 3) building clinical capacity; 4) ascertaining and responding to public opinion; and 5) advocating for public policy change. Coordinated and simultaneous advances on these 5 strategies may catalyze the growth, utilization, and effectiveness of patient screening, timely referrals, and delivery of appropriate cancer rehabilitation care that reduces disability and improves quality of life for cancer survivors who need these services.

"If I have a limited amount of time left, this is not how I want to spend it": A qualitative descriptive study of factors influencing daily life participation following a cancer diagnosis.

OBJECTIVE: Following a cancer diagnosis, restricted participation in daily life is common. Restricted participation can be temporary or long lasting. The aim of this study was to characterize how daily life participation is impacted following a cancer diagnosis. METHODS: Eligible individuals included adults (>18 years) with any stage/grade brain, breast, colorectal, or lung cancer in any phase of treatment or post-treatment. Participants completed a semi-structured interview about how their life participation was impacted following their cancer diagnosis. Data were analyzed through team-based thematic analysis. RESULTS: Forty adults, 10 per disease category, participated. Four themes were identified that supported or hindered daily life participation: (1) self-expectations, (2) expectations of others, (3) awareness of mortality, and (4) symptoms and side effects of cancer. Participants discussed how their cancer experience resulted in a reprioritization of what they valued doing in their life. However, many survivors struggled to adapt and described a tension between their need to adapt to their current life circumstances and their contrasting desire to stay connected with their pre-cancer selves through daily life participation. The mental health challenges associated with decreased participation were also outlined by participants. CONCLUSIONS: Cancer survivors' daily life participation is influenced by expectations from themselves and others, awareness of mortality, and disease symptoms/side effects. Future interventions can target these domains to supports survivors' life participation.

Trajectories of participation in daily life among individuals newly diagnosed with cancer: A 5-month longitudinal study.

PURPOSE: To determine how participation in daily life is impacted during the first six months following a new cancer diagnosis and to identify risk factors for participation restrictions. Patient-reported outcomes (PROs) were used to suggest referrals to rehabilitation services. METHODS: Participants (n = 123) were adults (> 18 years) with the newly diagnosed primary brain, breast, colorectal, or lung cancer. PROs were collected at baseline (within 30 days of diagnosis/treatment initiation), two and five months post baseline. Daily life participation was assessed through the community participation indicators (CPI) (score range: 0-1) and patient-reported outcome measurement information system (PROMIS) ability to participate, (score range: 20-80; mean: 50, SD: 10). PROMIS-43 profile was also completed. Linear mixed-effect models with random intercept evaluated change in participation over time. RESULTS: The baseline total sample mean CPI score was 0.56; patients reported mildly impaired participation based on PROMIS scores (baseline: 46.19, 2-month follow-up: 44.81, 5 months: 44.84). However, no statistically significant changes in participation were observed over the study period. Risk factors for lower participation included receiving chemotherapy, lower physical function, higher anxiety and fatigue, and reduction in employment, p < 0.05. PROs indicated that roughly half of the participants may benefit from physical or occupational therapy or mental health support, but only 20-36% were referred by their medical team. CONCLUSION: People newly diagnosed with cancer experience impaired participation, but they are infrequently referred to supportive services such as rehabilitation. The use of PROs to assess participation, physical function, and mental health can promote access to supportive care services by identifying patients who may benefit from rehabilitation beyond those identified through routine clinical care.

Activity Engagement after Cancer in Community-Based Survivors.

This paper discusses the activity engagement in a sample of cancer survivors (n = 25) seeking community-based support. A modified version of the Activity Card Sort (ACSm) was used to measure activity engagement after cancer. On average, participants reported a 27% reduction in activity engagement since their cancer diagnosis. Findings provide direction for continued study of the needs of survivors in community-based cancer care and generate ideas on occupational therapy's unique role in community-based survivorship.

Assessments used to measure participation in life activities in individuals with cancer: a scoping review.

PURPOSE: Individuals with cancer are at high risk for restricted participation in meaningful life activities such as work, school, and social activities. Evaluating participation in life activities is identified as a critical component of rehabilitation referral and triage systems. This scoping review investigates what assessments are used to measure participation in life activities in individuals with cancer. METHODS: Six databases were systematically searched using keywords and controlled vocabulary through February 2020. Eligible studies used the term participation in the context of life situations and had an assessment with at least 5 participation-specific questions. RESULTS: A total of 4604 unique articles were identified and screened for eligibility. Thirty-two studies were included; 20 unique assessments of participation were identified. Assessments were developed with the primary purpose of measuring participation (n = 8); global or physical function (n = 9); community integration (n = 1); social activity (n = 1); or occupational gaps (n = 1). Most assessments (12/20) were not developed with the purpose of measuring participation and only 4 assessments measured key components of participation other than frequency. CONCLUSION: Measuring participation in life activities is a developing area in oncology research. Most studies do not accurately or comprehensively measure this construct. The heterogeneity in assessments used indicates no clear consensus on a gold-standard participation measure for use among cancer survivors. Comprehensively measuring participation will help identify individuals in need of rehabilitation services and is an essential first step to inform the development of targeted interventions to enhance participation.

Usability and acceptability of a mobile application prototype for a combined behavioural activation and physical rehabilitation intervention in acute respiratory failure survivors.

BACKGROUND: Acute respiratory failure survivors experience depression symptoms and new impairments in physical function. Behavioural activation, an evidence-based nonpharmacological treatment for depression, combined with physical rehabilitation, is a promising intervention. Notably, mHealth applications (Apps) are potentially effective methods of delivering home-based interventions. OBJECTIVES: The objective of this study was to evaluate the usability and acceptability of a prototype App to deliver a combined, home-based behavioural activation and rehabilitation intervention to acute respiratory failure survivors. METHODS: A prospective user-preference study was conducted with acute respiratory failure survivors and self-designated care partners. Survivors were adults with at least mild depression symptoms before hospital discharge who received mechanical ventilation in the intensive care unit for ≥24 h. Survivors and care partners reviewed the App during a single in-person home visit and completed the System Usability Scale (range: 0-100; score >73 considered "good") and a semistructured interview. RESULTS: Ten patient/care partner dyads completed study. The median [interquartile range] patient age was 50 [40-64] years, and 50% were female. The median System Usability Scale scores among patients and care partners were 76 [68-83] and 88 [75-94], respectively. Qualitative feedback supported usability and acceptability of the App, with three themes reported: (1) stigma associated with depression, (2) App as a motivator for recovery, and (3) App providing multidisciplinary support for survivor and care partner. CONCLUSIONS: A mobile App prototype designed to deliver a combined behavioural activation and rehabilitation intervention was usable and acceptable to survivors of acute respiratory failure and their care partners. Given the reported stigma associated with depression, the self-directed App may be particularly valuable for motivation and multidisciplinary support.

Qualitative insights into how men with low-risk prostate cancer choosing active surveillance negotiate stress and uncertainty.

BACKGROUND: Active surveillance is a management strategy for men diagnosed with early-stage, low-risk prostate cancer in which their cancer is monitored and treatment is delayed. This study investigated the primary coping mechanisms for men following the active surveillance treatment plan, with a specific focus on how these men interact with their social network as they negotiate the stress and uncertainty of their diagnosis and treatment approach. METHODS: Thematic analysis of semi-structured interviews at two academic institutions located in the northeastern US. Participants include 15 men diagnosed with low-risk prostate cancer following active surveillance. RESULTS: The decision to follow active surveillance reflects the desire to avoid potentially life-altering side effects associated with active treatment options. Men on active surveillance cope with their prostate cancer diagnosis by both maintaining a sense of control over their daily lives, as well as relying on the support provided them by their social networks and the medical community. Social networks support men on active surveillance by encouraging lifestyle changes and serving as a resource to discuss and ease cancer-related stress. CONCLUSIONS: Support systems for men with low-risk prostate cancer do not always interface directly with the medical community. Spousal and social support play important roles in helping men understand and accept their prostate cancer diagnosis and chosen care plan. It may be beneficial to highlight the role of social support in interventions targeting the psychosocial health of men on active surveillance.

Coaching Family Caregivers to Become Better Problem Solvers When Caring for Persons with Advanced Cancer.

Family caregivers of persons with advanced cancer often take on responsibilities that present daunting and complex problems. Serious problems that go unresolved may be burdensome and result in negative outcomes for caregivers' psychological and physical health and affect the quality of care delivered to the care recipients with cancer, especially at the end of life. Formal problem-solving training approaches have been developed over the past several decades to assist individuals with managing problems faced in daily life. Several of these problem-solving principles and techniques were incorporated into ENABLE (Educate, Nurture, Advise, Before Life End), an "early" palliative care telehealth intervention for individuals diagnosed with advanced cancer and their family caregivers. A hypothetical case resembling the situations of actual caregiver participants in ENABLE that exemplifies the complex problems that caregivers face is presented, followed by presentation of an overview of ENABLE's problem-solving key principles, techniques, and steps in problem-solving support. Though more research is needed to formally test the use of problem-solving support in social work practice, social workers can easily incorporate these techniques into everyday practice.

Development and initial evaluation of a telephone-delivered, behavioral activation, and problem-solving treatment program to address functional goals of breast cancer survivors.

The purpose of this research was to develop and pilot test an intervention to optimize functional recovery for breast cancer survivors. Over two studies, 31 women enrolled in a goal-setting program via telephone. All eligible women enrolled (37% of those screened) and 66% completed all study activities. Completers were highly satisfied with the intervention, using it to address, on average, four different challenging activities. The longitudinal analysis showed a main effect of time for overall quality of life (F(5, 43.1) = 5.1, p = 0.001) and improvements in active coping (F (3, 31.7) = 4.9, p = 0.007), planning (F (3, 36.0) = 4.1, p = 0.01), reframing (F (3, 29.3) = 8.5, p < 0.001), and decreases in self-blame (F (3,31.6) = 4.3, p = 0.01). The intervention is feasible and warrants further study to determine its efficacy in fostering recovery and maximizing activity engagement after cancer treatment.

A Content Analysis of Functional Recovery Strategies of Breast Cancer Survivors.

Seventeen breast cancer survivors completed a 6-week, telephone-delivered, behavioral activation/problem-solving intervention designed to reduce participation restrictions. A content analysis of the session data was conducted to identify the goals and patterns of goal attainment and to understand what women were trying to achieve in their recovery. The 17 women set 141 goals. Sixty-six (47%) of the goals reflected a desire to add a new activity to their routine and 75 (53%) of the goals reflected a desire to perform a routine activity more efficiently. The women primarily set goals to address challenges in exercising (24%), work (13%), nutrition (12%), instrumental activities of daily living (IADLs; 10%), stress management (9%), and social activities (9%). The women set an average of 8 goals and met 71% of their goals. The intervention shows promise in helping women set and achieve a number of functional goals as part of breast cancer recovery.

Behavioral Activation: Values-Aligned Activity Engagement as a Transdiagnostic Intervention for Common Geriatric Conditions.

Scalable, transdiagnostic interventions are needed to meet the needs of a growing population of older adults experiencing multimorbidity and functional decline. Behavioral activation (BA) is a pragmatic, empirically supported treatment for depression that focuses on increasing engagement in values-aligned activities. We propose BA is an ideal transdiagnostic intervention approach for older adults because it (a) specifically targets activity restriction, a shared characteristic of common conditions of aging; and (b) has strong potential for scalability through delivery by a broad range of clinician and nonclinician interventionists and via telehealth. We describe the history of BA and review recent literature demonstrating impacts beyond depression including on cognition, social isolation, and disability. We also describe the feasibility of delivering BA across interventionists, settings, and modalities. Our approach advances scholarship by proposing BA as a scalable, transdiagnostic behavioral intervention to address functional decline in older adults with common geriatric conditions.

Preferences for Participation Measurement Among Individuals Diagnosed With Cancer: A Qualitative Content Analysis.

Individuals with cancer experience occupational participation restrictions, but there is no consensus on how to measure this construct. The objective of this study is to describe the perspectives and preferences of individuals with cancer regarding participation measurement. Forty individuals with brain, breast, colorectal, and lung cancer provided feedback on three participation measures in semi-structured interviews. Through an iterative, team-based content analysis approach, interview text was coded using the study codebook and organized into themes. Core themes included (a) participation measures highlighted occupational priorities, (b) measuring participation can identify supportive care needs, (c) measures must balance thoroughness with speed of completion, (d) measurement timeframe varies by treatment phase, and (e) evaluating community engagement is not a priority for some individuals with cancer. Integrating participation measures into cancer care can support referrals to occupational therapy and supportive services. It is essential to consider time since cancer diagnosis and client priorities when selecting participation measures.

Measuring Occupational Participation among People Diagnosed with Cancer: Interview FindingsOccupational participation focuses on an individual doing what they find important or meaningful in their daily life. Regular assessment of the occupational participation needs of people diagnosed with cancer is important, given their widespread daily life challenges. However, there is no information on preferred approaches for assessing occupational participation. We interviewed 40 people diagnosed with cancer to understand what they liked and disliked about participation surveys and the process of completing them. Key findings included that evaluating participation (a) helped participants reflect on their occupational priorities, (b) can help the medical team have a more holistic view of an individual's needs and connect people with cancer with supportive services, and (c) should be done using brief yet thorough surveys. People diagnosed with cancer recommended less focus on community engagement and more focus on mental health in surveys. Individual priorities and phase of treatment should inform occupational participation survey selection.

Finding the Optimal Exercise Dose While Living With Cancer-Related Fatigue: A Qualitative Study.

PURPOSE: To gain insight into how survivors of breast cancer (SBCs) with cancer-related fatigue (CRF) self-monitor and manage exercise dose in the context of daily life, and how they identify an optimal exercise dose. PARTICIPANTS & SETTING: 11 SBCs with CRF who reported weekly exercise were recruited from a breast cancer center at a large urban hospital in the northeastern region of the United States. METHODOLOGIC APPROACH: One-on-one semistructured interviews were conducted using a descriptive phenomenologic method. Inductive data analysis was performed within and across cases. FINDINGS: The following themes emerged: examining the impact of exercise, finding an optimal dose, and remaining flexible to sustain exercise. Participants used trial and error to explore exercise dose, examining the effects of varying doses on daily life. These effects had behavioral implications and resulted in a nonlinear process and the perception that an optimal exercise dose is dynamic within the context of daily life. IMPLICATIONS FOR NURSING: Strategies to support SBCs with CRF to efficiently achieve optimal exercise doses with fewer setbacks may improve individuals' ability to self-manage and mitigate CRF. This study's findings provide practical approaches for nurses to encourage the initiation and adoption of exercise behaviors after treatment for breast cancer.

Reporting Rigor of Cancer Rehabilitation Interventions: Application of the CReDECI-2 Guidelines.

ABSTRACT: Clear reporting of cancer rehabilitation interventions is critical for interpreting and translating research into clinical practice. This study sought to examine the completeness of intervention reporting of cancer rehabilitation interventions addressing disability and to identify which elements are most frequently missing. This was a secondary analysis of randomized controlled trials included in two systematic reviews examining effectiveness of cancer rehabilitation interventions that address cancer-related disability, including functional outcomes. Eligible trials were reviewed for intervention reporting rigor using the Criteria for Reporting the Development and Evaluation of Complex Interventions in Healthcare 2 checklist. Intervention descriptions for cancer rehabilitation interventions were generally incomplete. Approximately 85% ( n = 157) of trials described ≤50% of Criteria for Reporting the Development and Evaluation of Complex Interventions in Healthcare 2 checklist items. Commonly underreported items included description of the intervention's underlying theoretical basis, fidelity, description of process evaluation or external conditions influencing intervention delivery, and costs or required resources for intervention delivery. The findings reveal that cancer rehabilitation intervention descriptions lacked necessary detail in this body of literature. Poor descriptions limit the translation of research to clinical practice. To ensure higher-quality study design and reporting, future intervention research should incorporate an intervention reporting checklist to ensure more complete descriptions for research and practice.

Enhancing Efficiency and Reach Using Facebook to Recruit Breast Cancer Survivors for a Telephone-Based Supportive Care Randomized Trial During the COVID-19 Pandemic.

PURPOSE: Evidence supporting social media-based recruitment of cancer survivors is limited. This paper describes how we used Facebook during the COVID-19 pandemic to augment our recruitment of breast cancer survivors for our two-site telephone-based randomized clinical trial (RCT) at Dartmouth-Hitchcock Medical Center and the University of Alabama at Birmingham. METHODS: Originally a two-site RCT of a telephone-delivered breast cancer survivorship intervention, we extended our clinic-based recruitment to Facebook. Participant characteristics, geographic reach, and baseline outcomes were compared across recruitment sources (ie, two clinics and Facebook) using descriptive statistics and effect sizes. RESULTS: Enrollment rates (20%-29%) were comparable across recruitment sources. The 21-month Facebook marketing campaign accounted for 59% (n = 179/303) of our total sample and had the greatest geographic reach, recruiting women from 24 states. The Facebook campaign reached a total of 51,787 unique individuals and cost $88.44 in US dollars (USD) per enrolled participant. Clinic samples had a greater proportion of women who were widowed (8% v 1%; P = .03) and Facebook had a higher proportion of women with a household income over $40,000 USD (83% v 71%; P = .02). There were no statistically significant differences between Facebook and the two clinics on baseline survey scores. CONCLUSION: Augmenting traditional recruitment with Facebook increased our RCT's geographic and sociodemographic reach and supported meeting recruitment goals in a timely way. In the wake of the COVID-19 pandemic, cancer survivorship researchers should consider using social media as a recruitment strategy while weighing the advantages and potential biases introduced through such strategies.

Problem-solving strategies of women undergoing chemotherapy for breast cancer.

BACKGROUND: Many women undergoing chemotherapy for breast cancer experience side effects that make it difficult to perform daily occupations. PURPOSE: To summarize the types of challenges, goals, and adaptive strategies identified by women with stage 1-3 breast cancer participating in a pilot study of Problem-solving Treatment-Occupational Therapy (PST-OT). METHODS: Content analysis of 80 PST-OT sessions. FINDINGS: Women addressed 11 types of challenging activities, with exercise and instrumental activities of daily living (IADL) being the most common. Most women set a goal to adapt a current activity, but also set goals to find a new activity, plan the steps of a current activity, or gather information about a possible activity change in the future. The adaptive strategies generated by the women were grouped into five types. Most often they found ways to add a new step to an activity, but they also brainstormed about when, how, where, and with whom they could do activities. IMPLICATIONS: The women were usually trying to adapt familiar activities but also were looking for ways to include new, healthy occupations into their routines.

Perspectives of Participation in Daily Life From Cancer Survivors: A Qualitative Analysis.

Objective: To characterize how survivors of cancer define participation. Design: Cross-sectional qualitative study. Setting: Participants were enrolled from a large academic medical center in the Midwestern United States. Interviews were conducted over Zoom or phone. Participants: Survivors of cancer (N=40) with brain, breast, colorectal, or lung cancer (n=10 per group). Participants were purposively sampled to maximize variation in the study sample. Participant ages ranged from 26-83 years, with a mean age of 55 years. Seventy percent of participants were receiving active cancer treatment at the time of the interview. Interventions: Not applicable. Main Outcome Measures: Participant perspectives gathered from 1-on-1 semistructured interviews. Qualitative description and thematic analysis were used to analyze interview transcripts and develop themes from the data. Results: Survivors described participation as doing valued activities and highlighted 4 common aspects: (1) control; (2) social connection; (3) engaging in various contexts; and (4) cultivation of joy and purpose. Fully participating in life involved being able to do what they want to do without restrictions or limitations. Survivors' perspectives of control outlined how competence, choice, adaptations, and locus of control influence broader feelings of control and participation. Interviews highlighted that participation remains central to daily life among survivors of cancer. Conclusions: Rehabilitation researchers and clinicians need to establish a standard and comprehensive definition of participation. Rehabilitation providers need to consistently evaluate how participation is affected among survivors of cancer and use measures that include core aspects of participation identified in this study and previous research. Comprehensively defining participation will improve the design and selection of measurement tools and support comprehensive assessment of survivor experiences.

Impact of non-pharmacological interventions on activity limitations and participation restrictions in older breast cancer survivors: A scoping review.

Cancer-related disability is a complex problem for older breast cancer survivors. One aspect of cancer-related disability is a survivor's inability to complete meaningful daily activities and engage in life roles, referred to as activity limitations and participation restrictions respectively. There is a limited understanding of how interventions influence activity limitations and participation restrictions in this population. A scoping review was undertaken to identify and characterize nonpharmacological interventions developed to address activity limitations and participation restrictions. A systematic search of electronic databases (Ovid Medline, Embase, EBSCO CINAHL, and Ovid PsycINFO) was conducted in April 2020 and updated October 2020. Eleven studies met inclusion criteria. Most frequently observed delivery features were in-person and one-on-one format. Six interventions incorporated telehealth delivery components. Interventions were often complex and varied in content. Exercise and behavioral strategies were among the most frequently used active ingredients. Activity limitations and participation restrictions were often secondary outcomes, and measures of these outcomes were varied in content and assessment method. Study samples were not representative of the current population of older adult breast cancer survivors. Future intervention research should clarify intervention delivery, content, and dose, prioritize comprehensive measurement of activity limitations and participation restrictions, as well as recruit and involve representative study samples to enhance generalizability of findings.

Feasibility study of a randomized controlled trial of a telephone-delivered problem-solving-occupational therapy intervention to reduce participation restrictions in rural breast cancer survivors undergoing chemotherapy.

OBJECTIVE: Breast cancer patients receiving adjuvant chemotherapy often experience functional effects of treatment that limit participation in life activities. The purpose of this study was to examine the feasibility of conducting a randomized controlled trial (RCT) of a novel intervention for these restrictions, determine acceptability of the intervention, and preliminarily assess its effects. METHODS: A pilot RCT of a telephone-delivered Problem-solving and Occupational Therapy intervention (PST-OT) to improve participation restrictions in rural breast cancer patients undergoing chemotherapy. Thirty-one participants with Stages 1-3 breast cancer were randomized to 6 weekly sessions of PST-OT (n = 15) and usual care (n = 16). The primary study outcome was the feasibility of conducting the trial. Secondary outcomes were functional, quality of life and emotional status as assessed at baseline, 6 and 12 weeks. RESULTS: Of 46 patients referred 31 were enrolled (67% recruitment rate), of which 6 participants withdrew (81% retention rate). Twenty-four participants completed all study-related assessments (77%). Ninety-two percent of PST-OT participants were highly satisfied with the intervention, and 92% reported PST-OT to be helpful/very helpful for overcoming participation restrictions. Ninety-seven percent of planned PST-OT treatment sessions were completed. Completion rates for PST-OT homework tasks were high. Measures of functioning, quality of life, and emotional state favored the PST-OT condition. CONCLUSION: This pilot study suggests that an RCT of the PST-OT intervention is feasible to conduct with rural breast cancer patients undergoing adjuvant chemotherapy and that PST-OT may have positive effects on function, quality of life, and emotional state.