Associations Between Demographic, Clinical, and Symptom Characteristics and Stress in Oncology Patients Receiving Chemotherapy.

BACKGROUND: Patients undergoing cancer treatment experience global stress and cancer-specific stress. Both types of stress are associated with a higher symptom burden. OBJECTIVE: In this cross-sectional study, we used a comprehensive set of demographic, clinical, and symptom characteristics to evaluate their relative contribution to the severity of global and cancer-specific stress. METHODS: Patients (N = 941) completed study questionnaires before their second or third cycle of chemotherapy. RESULTS: Consistent with our a priori hypothesis, we found both common and distinct characteristics associated with higher levels of global stress and cancer-specific stress. A significant proportion of our patients had scores on the Impact of Event Scale-Revised suggestive of subsyndromal (29.4%) or probable (13.9%) posttraumatic stress disorder. Four of the 5 stepwise linear regression analyses for the various stress scales explained between 41.6% and 54.5% of the total variance. Compared with various demographic and clinical characteristics, many of the common symptoms associated with cancer and its treatments uniquely explained a higher percentage of the variance in the various stress scales. Symptoms of depression made the largest unique contribution to the percentage of total explained variance across all 5 scales. CONCLUSION: Clinicians need to assess for global stress, cancer-specific stress, and depression in patients receiving chemotherapy. IMPLICATIONS FOR PRACTICE: Patients may benefit from integrative interventions (eg, mindfulness-based stress reduction, cognitive behavioral therapy, acupuncture) that simultaneously address stress and symptoms commonly associated with cancer and its treatments.

Polymorphisms in Cytokine Receptor and Regulator Genes are Associated with Levels of Exercise in Women Prior to Breast Cancer Surgery.

Background: Little is known about the genetic characteristics associated with exercise in women undergoing breast cancer surgery. Purpose: In a sample of women who were evaluated prior to breast cancer surgery (n = 310), we evaluated for differences in demographic and clinical characteristics between patients who did and did not exercise on a regular basis and evaluated for associations between polymorphisms in genes for pro- and anti-inflammatory cytokines, their receptors, and their transcriptional regulators. Methods: Patients completed an investigator-developed exercise questionnaire. Based on the recommended level of exercise (≥150 minutes/week), survivors were classified into no exercise (NoEx), less exercise (LessEx), or recommended exercise (RecEx) groups. Candidate gene analyses were done to identify relationships between polymorphisms and exercise group membership (i.e., NoEx vs. RecEx). Only 23.5% of the total sample met the recommendations for regular exercise. Results: Compared to the RecEx group (n = 78), patients in the NoEx group (n = 120) had less education; were less likely to report being White or Asia/Pacific Islander; more likely to report a lower household income; had a higher body mass index (BMI), had a poorer functional status; had a higher comorbidity burden; were more likely to self-report high blood pressure; and were more likely to have received neoadjuvant chemotherapy. Polymorphisms in IFNGR1 and NFKB1 were associated with membership in the NoEx group. Conclusions: While they warrant replication, our findings suggest that variations in cytokine-related genes may play a role in exercise behavior, and that clinicians need to assess for barriers to regular exercise and educate patients on its benefits.

Level of Exercise Influences the Severity of Fatigue, Energy Levels, and Sleep Disturbance in Oncology Outpatients Receiving Chemotherapy.

BACKGROUND: Fatigue and sleep disturbance are common co-occurring symptoms in patients receiving chemotherapy. While the results from meta-analyses support the use of exercise to decrease the severity of these symptoms, information is needed on patients' "real world experiences" with the use of exercise. OBJECTIVE: The aims of this study were to determine distribution of patients who did and did not exercise on a regular basis and evaluate for differences in demographic and clinical characteristics, as well as the severity of fatigue, decrements in energy, and sleep disturbance among the exercise groups. METHODS: Patients (n = 1033) completed self-report questionnaires prior to their second or third cycle of chemotherapy. Patients were categorized into 3 exercise (Ex) groups (ie, NoEx, <150 min/wk [LessEx]; ≥150 min/wk [RecEx]). Differences among the groups were evaluated using parametric and nonparametric tests. RESULTS: Only 19.1% of the patients were in the RecEx group. Patients in the NoEx group (37.2%) had fewer years of education, were more likely to be non-White and unemployed, had a higher body mass index, and a worse comorbidity profile. Patients in the NoEx group had higher levels of morning fatigue, lower levels of morning and evening energy, and higher levels of sleep disturbance. CONCLUSIONS: Findings from this real-world study suggest that lack of physical activity is associated with higher levels of fatigue and sleep disturbance. IMPLICATIONS FOR PRACTICE: Given that the most frequently used intervention in this study was walking, clinicians can recommend this inexpensive intervention to patients to manage fatigue and sleep disturbance.

Subgroups of patients undergoing chemotherapy with distinct cognitive fatigue and evening physical fatigue profiles.

PURPOSE: The purpose was to model cognitive fatigue and evening physical fatigue together to determine subgroups of patients with distinct cognitive fatigue AND evening physical fatigue profiles. Once these profiles were identified, differences among the subgroups in demographic and clinical characteristics, co-occurring symptoms, and quality of life outcomes were evaluated. METHODS: Oncology patients (n = 1332) completed self-report measures of cognitive fatigue and evening physical fatigue, six times over two cycles of chemotherapy. Latent profile analysis, which combined the two symptom scores, was done to identify subgroups of patients with distinct cognitive fatigue AND evening physical fatigue profiles. RESULTS: Three distinct profiles (i.e., Low [20.5%], Moderate [39.6%], and High [39.6%]) were identified. Compared to the Low class, patients in the High class were younger, female, and more likely to live alone and had a higher comorbidity burden and a lower functional status. In addition, these patients had a higher symptom burden and a poorer quality of life. CONCLUSION: Based on clinically meaningful cutoff scores, 80% of the patients in this study had moderate to high levels of both cognitive fatigue and evening physical fatigue. In addition, these patients experienced high levels of other common symptoms (e.g., anxiety, depression, sleep disturbance, and pain). These co-occurring symptoms and other modifiable characteristics associated with membership in the Moderate and High classes may be potential targets for individualized symptom management interventions.

Distinct diarrhea profiles during outpatient chemotherapy.

PURPOSE: Chemotherapy-induced diarrhea (CID) is a common symptom that occurs in 50 to 80% of patients. Given that the majority of the data on the occurrence and severity of CID is based on physician-rated toxicity criteria, this study's purposes were to identify subgroups of patients with distinct CID profiles and determine how these subgroups differ in terms of demographic and clinical characteristics; severity, frequency, and distress of CID; the co-occurrence of common GI symptoms; and QOL. METHODS: Patients (n = 1133) completed the Memorial Symptom Assessment Scale six times over two cycles of chemotherapy. Latent profile analysis was used to identify subgroups of patients with distinct diarrhea profiles. Differences among these subgroups were evaluated using parametric and nonparametric statistics. RESULTS: Four distinct diarrhea profiles were identified: none (58.3%), decreasing (22.0%), increasing (5.2%), and high (14.5%). Compared with the none class, patients in the high class had a lower functional status, a worse comorbidity profile, were more likely to have gastrointestinal cancer, and were more likely to receive chemotherapy on a 14-day cycle. No differences were found among the classes in the percentages of patients who received chemotherapy with a targeted therapy. CONCLUSION: Given that CID occurred in over 40% of the patients, clinicians should assess for this symptom and other common GI symptoms and initiate appropriate pharmacologic and dietary interventions.

A COVID-19 screening tool for oncology telephone triage.

PURPOSE: Symptoms associated with COVID-19 infection have made the assessment and triage of cancer patients extremely complicated. The purpose of this paper is to describe the development and implementation of a COVID-19 screening tool for oncology telephone triage. METHODS: An Ambulatory Oncology Clinical Nurse Educator and three faculty members worked on the development of an oncology specific triage tool based on the challenges that oncology nurses were having with the generic COVID triage tool. A thorough search of the published literature, as well as pertinent websites, verified that no screening tool for oncology patients was available. RESULTS: The screening tool met a number of essential criteria: (1) simple and easy to use, (2) included the most common signs and symptoms as knowledge of COVID-19 infection changed, (3) was congruent with the overall screening procedures of the medical center, (4) included questions about risk factors for and environmental exposures related to COVID-19, and (5) assessed patient's current cancer history and treatment status. Over a period of 3 weeks, the content and specific questions on the tool were modified based on information obtained from a variety of sources and feedback from the triage nurses. CONCLUSION: Within 1 month, the tool was developed and implemented in clinical practice. Oncology clinicians can modify this tool to triage patients as well as to screen patients in a variety of outpatient settings (e.g., chemotherapy infusion units, radiation therapy departments). The tool will require updates and modifications based on available resources and individual health care organizations' policies and procedures.

Association Between Physical Activity Levels and Chemotherapy-Induced Peripheral Neuropathy Severity in Cancer Survivors.

OBJECTIVES: To evaluate for differences in demographic and clinical characteristics, as well as subjective and objective measures of chemotherapy-induced peripheral neuropathy (CIPN), among different exercise groups. SAMPLE & SETTING: Cancer survivors (N = 290) were recruited from throughout the San Francisco Bay Area. METHODS & VARIABLES: Based on the recommended 150 minutes or more of exercise per week, survivors were classified into the no exercise (NoEx), less exercise (LessEx), or recommended exercise (RecEx) group. Survivors completed self-report questionnaires and underwent sensory and balance testing. RESULTS: Compared to the RecEx group, survivors in the NoEx group had less education, were less likely to be married/partnered, had a lower household income, had a higher level of comorbidity, and had poorer functional status. No differences were found among the groups in CIPN duration; pain intensity scores; or changes in light touch, cold, and pain sensations. IMPLICATIONS FOR NURSING: Clinicians can recommend walking as a therapeutic option for survivors with CIPN and refer them to physical therapy.

Identification of subgroups of chemotherapy patients with distinct sleep disturbance profiles and associated co-occurring symptoms.

STUDY OBJECTIVES: Purposes of this study were to identify subgroups of patients with distinct sleep disturbance profiles and to evaluate for differences in demographic, clinical, and various sleep characteristics, as well for differences in the severity of co-occurring symptoms among these subgroups. METHODS: Outpatients with breast, gynecological, gastrointestinal, or lung cancer (n = 1331) completed questionnaires six times over two chemotherapy cycles. Self-reported sleep disturbance was evaluated using the General Sleep Disturbance Scale (GSDS). Latent profile analysis was used to identify distinct subgroups. RESULTS: Three latent classes with distinct sleep disturbance profiles were identified (Low [25.5%], High [50.8%], Very High [24.0%]) across the six assessments. Approximately 75% of the patients had a mean total GSDS score that was above the clinically meaningful cutoff score of at least 43 across all six assessments. Compared to the Low class, patients in High and Very High classes were significantly younger, had a lower functional status, had higher levels of comorbidity, and were more likely to be female, more likely to have childcare responsibilities, less likely to be employed, and less likely to have gastrointestinal cancer. For all of the GSDS subscale and total scores, significant differences among the latent classes followed the expected pattern (Low < High < Very High). For trait and state anxiety, depressive symptoms, morning and evening fatigue, decrements in attentional function, and decrements in morning and evening energy, significant differences among the latent classes followed the expected pattern (Low < High < Very High). CONCLUSIONS: Clinicians need to perform in-depth assessments of sleep disturbance and co-occurring symptoms to identify high-risk patients and recommend appropriate interventions.

Crucial role for pathology residents in laboratory self-inspection, a single Institute's experience.

BACKGROUND: Training in patient safety, quality, and management is a key component of Graduate Medical Education (GME) training in all specialties. However, residency programs, especially Pathology programs, often find it challenging to create strong learning opportunities in these areas. OBJECTIVES: Focused quality assurance (QA) projects are one approach to teach and engage trainees in these key areas. Residents have been historically involved in different QA projects in our department but mainly in small secondary roles. Leading a large QA project that can enhance residents' management skills and improve clinical operations in our laboratory was the main objective of our project. DESCRIPTION: A new process for laboratory self-inspection led by residents was implemented that simulates the exact process of a formal outside College of American Pathologists (CAP) inspection. We aim to prove that resident-led QA activities not only have profound educational benefit but can also result in significant performance and operational improvement. RESULTS: For this paper, we focus on the Histology laboratory since the ramifications from the self-inspection process during a three year period were profound leading to change in management, workflow changes, and notable improvement in staff morale. CONCLUSION: The self-inspection process exposed the residents to operational issues and corrective actions that provided them the opportunity to take a more active role in laboratory management and helped prepare them for post-graduation challenges. It also helped the department identify and rectify many operational issues, confirmed by the enumeration of CAP deficiencies and significant improvement of staff morale.

Managing oral chemotherapy: the healthcare practitioner's role.

PURPOSE: [corrected] Management of the side effect profiles of the new oral cancer chemotherapeutic agents differs from those of traditional oral chemotherapy and hormonal therapy. The healthcare practitioner's role in counseling and managing these toxicities as well as methods for assessing and promoting adherence is reviewed. SUMMARY: Many side effects from traditional oral cancer chemotherapeutic agents are the result of their effects on healthy cells as well as cancer cells. The side effects from the novel targeted therapies differ from those of traditional chemotherapy. Managing side effects and patient self-administration in non-traditional settings without supervision may affect patient adherence, especially with the newer agents. Social and psychological factors also can affect adherence. Various methods are available to assess adherence, including obtaining prescription refill histories and performing pill counts. Counseling patients, asking patients to keep a diary of doses and side effects, and following up with patients at clinic visits or through telephone contact are all methods that promote adherence. Patient education should address the proper dose, frequency, timing with respect to food and other medications, what to do if a dose is missed, side effects to anticipate, and what to do if side effects occur. CONCLUSION: Healthcare practitioners play an important role in educating patients regarding potential side effects to oral chemotherapy and assessing and promoting adherence to the treatment regimen.

The continuum of care: a paradigm for the management of metastatic colorectal cancer.

New agents for the treatment of metastatic colorectal cancer have extended median overall survival to more than 20 months, an increase that has changed the view of advanced colorectal cancer from an acute to a chronic condition. This article proposes a shift in treatment strategy from the concept of successive "lines" of therapy, in which chemotherapy is continued until disease progression, to that of a continuum of care, in which the use of chemotherapy is tailored to the clinical setting and includes switching chemotherapy prior to disease progression, maintenance therapy, drug "holidays," and surgical resection of metastases in selected patients. In this approach, the distinction between lines of therapy is no longer absolute. This represents a paradigm shift in the management of metastatic colorectal cancer to that of a continuum of care approach that includes individualized planning, in which patients are given the opportunity to benefit from exposure to all active agents and modalities while minimizing unnecessary treatment and toxicity, with the ultimate goal of improving survival as well as quality of life.

Normal clotting.

OBJECTIVE: To review the normal coagulation process and the mechanisms that lead to abnormal clotting. DATA SOURCES: Primary and tertiary literature and the authors' clinical experience. CONCLUSION: The process of coagulation is complex and can be easily misunderstood. It is important to be familiar with normal coagulation before one can comprehend the coagulopathies associated with malignancies. IMPLICATIONS FOR NURSING PRACTICE: A thorough understanding of the coagulation process is a critical prerequisite to caring for patients with clotting disorders. Once the normal clotting process is understood, the abnormal becomes easier to recognize and the cancer-associated dysfunctions more readily identified.

Diagnosis, treatment, and nursing care of acute leukemia.

OBJECTIVE: To review the clinical presentation, current methods of diagnosis and classification, treatment modalities, and novel treatment approaches of acute myelogenous and lymphoblastic leukemia. DATA SOURCES: Professional journals, web sites, and books. CONCLUSION: The incidence of acute leukemia is increasing. As the population ages, it is anticipated that an even greater number will be diagnosed with this malignancy. The development of monoclonal antibodies, the recognition of the benefit of graft versus leukemia effect, and targeted therapies have improved overall survival rates. Still, age remains a significant prognostic variable. More research is needed to improve both the quality and the quantity of life for these patients. IMPLICATIONS FOR NURSING PRACTICE: Nurses must understand the rationale and implications of each phase of treatment to educate patients, administer treatments, manage side effects, and provide support throughout the continuum of care.

Overview of chemotherapy-induced diarrhea.

OBJECTIVES: To provide a general overview of chemotherapy-induced diarrhea (CID) that will highlight the pathophysiology, incidence, and impact of this problem, as well as describe the oncology nurse's role in the management of CID. DATA SOURCES: Primary and tertiary literature, the authors' clinical experience. CONCLUSION: CID is a frequent complication of many types of chemotherapy that can significantly affect patient quality of life, increase treatment costs, and limit the ability to deliver full doses of chemotherapy. Because patients may be reluctant to discuss diarrhea with their health care providers, vigilance on the part of the health care team is needed. IMPLICATIONS FOR NURSING PRACTICE: Through ongoing, regular patient contact, the oncology nurse is uniquely situated to monitor patients for the development of CID, assess its severity, and provide guidance to the health care team on the patient's status.