Implementation of a Multidisciplinary Model of Care for Women With Metastatic Breast Cancer: Challenges and Lessons Learned.

INTRODUCTION: The present study examined the feasibility and effects of integrating a multidisciplinary team (MDT) model of care for women with metastatic breast cancer (MBC) into a large Australian cancer center. The challenges encountered and lessons learned are described. PATIENTS AND METHODS: In the present prospective, longitudinal, mixed-methods implementation study, the MDT model included face-to-face consultations with a breast care nurse and social worker, followed by a MDT case discussion and face-to-face delivery of a personalized management plan. Data were collected to describe the cohort of women living with MBC who had attended a specialist breast cancer service and their supportive care needs. RESULTS: A total of 62 women with median age of 60 years (interquartile range [IQR], 37-82 years) participated. The median interval from the first breast cancer diagnosis was 5.7 years (IQR, 2.0-11.6 years), and the median interval from the diagnosis of MBC was 2.0 years (IQR, 0.9-3.6 years). The MDT care model required new resources and cross-sector participation. However, the participants indicated a preference for personalized needs assessment and care planning at the diagnosis of MBC. CONCLUSIONS: The results highlight the challenges of implementing and evaluating an MDT care model for women with MBC. The model coordinated MDT collaboration to strengthen the delivery of complex care plans. Investment in cross-sector partnerships to optimize care coordination for women with MBC was needed.

Identifying cut-off scores for job demands and job control in nursing professionals: a cross-sectional survey in Germany.

OBJECTIVES: Nurses are generally found to be vulnerable to burnout, but nurses working in cancer care are even more so, since this profession is characterised by continuous confrontation with suffering and death. This study was designed to identify cut-off scores for job strain, that is, low job control and high job demands, for a sample of nurses working in breast cancer care. The main goal was to find cut-off scores, which predict the risk of nurses of developing a mental disorder from high job strain. DESIGN: The design was a cross-sectional survey study. SETTING: The study is based on an employee survey in breast cancer centres in Germany. PARTICIPANTS: 688 nurses received a questionnaire; 329 nurses from 33 hospitals participated in the survey (return rate: 50.2%). PRIMARY AND SECONDARY OUTCOME MEASURES: Dependent variable: psychological well-being, measured by the WHO-5 Well-being Index; independent variables: job control and job demands, measured by the Job Content Questionnaire (JCQ). RESULTS: Multivariable analysis indicates that low job control and high job demands are prognostic factors for low well-being. In a receiver operating curve (ROC) analysis, the cut-off scores, which demonstrated a maximum Youden index, were 34.5 for job control and 31.4 for job demands. The combination of both scales from a logistic regression analysis resulted in an area under the curve of 0.778. Sensitivity and specificity are 70.3% and 74.2%, respectively. The total of correct classification was 63.3%. CONCLUSION: The determined cut-off scores indicate that there is a risk of becoming psychologically ill from a high workload when an individual reaches a score of ≤34.5 for job control and ≥31.4 for job demands. The described method of establishing risk-based cut-off scores is promising for nursing practice and for the field of occupational health. Transferability and generalisability of the cut-off scores should be further analysed.

Guilt among husband caregivers of Chinese women with breast cancer: The roles of male gender-role norm, caregiving burden and coping processes.

Caregiver guilt (i.e., feeling of inadequacy in providing care to patients) is commonly experienced and studied among husbands of breast cancer survivors in Western countries. However, little is known about the psychosocial correlates of caregiver guilt in their Chinese counterparts. A total of 176 husbands of Chinese breast cancer survivors completed a cross-sectional survey in Weifang, Shandong province, China. As expected, hierarchical regression results showed that higher caregiving burden was associated with higher levels of caregiver guilt. However, for those who had stronger endorsement of the "Masculinity strength" gender-role norm, higher seeking social support from spouse was associated with higher guilt; for those with higher levels of marital satisfaction, higher protective buffering (i.e., hiding of concerns and negative emotions to protect others) was associated with lower caregiver guilt. Western assumptions on the harm of protective buffering and the benefits of support seeking as well as related supportive evidence among Western populations do not directly apply to the Chinese culture, which should be brought awareness to research and practice. Practitioners should consider the cultural background of the caregivers and should not simply encourage support seeking and discourage protective buffering.

MENOS4 trial: a multicentre randomised controlled trial (RCT) of a breast care nurse delivered cognitive behavioural therapy (CBT) intervention to reduce the impact of hot flushes in women with breast cancer: Study Protocol.

BACKGROUND: Women who have been treated for breast cancer may identify vasomotor symptoms, such as hot flushes and night sweats (HFNS), as a serious problem. HFNS are unpleasant to experience and can have a significant impact on daily life, potentially leading to reduced adherence to life saving adjuvant hormonal therapy. It is known that Cognitive Behavioural Therapy (CBT) is effective for the alleviation of hot flushes in both well women and women who have had breast cancer. Most women with breast cancer will see a breast care nurse and there is evidence that nurses can be trained to deliver psychological treatments to a satisfactory level, whilst also maintaining treatment fidelity. The research team will assess whether breast care nurses can effectively deliver a CBT intervention to alleviate hot flushes in women with breast cancer. METHODS: This study is a multi-centre phase III individually randomised controlled trial of group CBT versus usual care to reduce the impact of hot flushes in women with breast cancer. 120-160 women with primary breast cancer experiencing seven or more problematic HFNS a week will be randomised to receive either treatment as usual (TAU) or participation in the group CBT intervention plus TAU (CBT Group). A process evaluation using May's Normalisation Process Theory will be conducted, as well as practical and organisational issues relating to the implementation of the intervention. Fidelity of implementation of the intervention will be conducted by expert assessment. The cost effectiveness of the intervention will also be assessed. DISCUSSION: There is a need for studies that enable effective interventions to be implemented in practice. There is good evidence that CBT is helpful for women with breast cancer who experience HFNS, yet it is not widely available. It is not yet known whether the intervention can be effectively delivered by breast care nurses or implemented in practice. This study will provide information on both whether the intervention can effectively help women with hot flushes and whether and how it can be translated into routine clinical practice. TRIAL REGISTRATION: ISRCTN 12824632 . Registered 25-01-2017.

Complementary and Alternative Medicine Use and Symptom Burden in Women Undergoing Chemotherapy for Breast Cancer in Malaysia.

BACKGROUND: Complementary and alternative medicine (CAM) is commonly used for cancer- and chemotherapy-related symptoms. Nurses are likely to encounter many CAM users in their practice. OBJECTIVE: The aims of this study were to assess CAM use and examine the symptom burden of CAM and non-CAM users among patients with breast cancer who are undergoing chemotherapy. METHODS: A CAM use questionnaire and the Side-Effect Burden Scale were administered to 546 patients. Complementary and alternative medicine use was categorized as mind-body practices (MBPs), natural products (NPs), or traditional medicine (TM). RESULTS: We identified 386 CAM users (70.7%) in this study. The CAM users reported a higher marginal mean total symptom burden score (40.39 ± 2.6) than non-CAM users (36.93 ± 3.21), although this difference was not statistically significant (P = .09). Triple-modality (MBP-NP-TM) CAM users had a significantly higher marginal mean total symptom burden score (47.44 ± 4.12) than single-modality (MBP) users (34.09 ± 4.43). The risk of having a high total symptom burden score was 12.9-fold higher among the MBP-NP-TM users than among the MBP users. CONCLUSIONS: Complementary and alternative medicine use is common among Malaysian patients who are undergoing chemotherapy for breast cancer. However, CAM and non-CAM users reported similar symptom burdens, although single-modality use of MBP is likely associated with a lower symptom burden. IMPLICATIONS FOR PRACTICE: Nurses should keep abreast of current developments and trends in CAM use. Understanding CAM use and the related symptom burden will allow nurses to initiate open discussion and guide their patients in seeking additional information or referrals for a particular therapy.

Transgender Patient Screening: Breast Cancer Risk Assessment and Screening Recommendations
.

BACKGROUND: When a discrepancy exists between an individual's biologic sex and the deeply felt sense of being male or female, a transgender orientation may result. 
. OBJECTIVES: The purpose of this article is to summarize breast cancer risk assessment and screening recommendations for transgender individuals. 
. METHODS: A review of the literature was done to determine if evidence-based screening guidelines exist for transgender individuals and how they can be applied to clinical practice. 
. FINDINGS: Most of the available research is descriptive of this patient population and identifies barriers in accessing healthcare services rather than how to provide care. The medical community must address transgender individuals' specific healthcare needs in a comprehensive and affirmative manner.

Assessing patient outcomes and cost-effectiveness of nurse-led follow-up for women with breast cancer - have relevant and sensitive evaluation measures been used?

AIMS AND OBJECTIVES: To explore how interventions using nurse-led follow-up in breast cancer care have been evaluated with a focus on patient outcomes and cost-effectiveness. BACKGROUND: As part of the advancement of breast care, nurse-led follow-up is increasingly used as an alternative to routine hospital follow-up in outpatient clinics. There is evidence suggesting that patients appear to be satisfied with the nurse-led follow-up, but there is a lack of evidence of whether this perception equates to patients' satisfaction with the model of physician-led follow-up. DESIGN: Systematic review. METHOD: Three databases were searched, and 29 RCT were initially screened. Finally, 13 articles were critically appraised. Searches included articles between 2005-2013. The quality of appraisal assessment was inspired by the GRADE system. RESULTS: The results show that there are many different instruments used when evaluating nurse-led follow-up, which makes it difficult to compare the studies. Several of the studies used QoL as an outcome measure; this is a broad concept that includes several aspects ranging from social role and psychosocial issues to symptoms and therefore difficult to use as an outcome measure. Only two of the studies made any cost-effective analyses, and the results are hard to interpret. CONCLUSIONS: Nurse-led follow-up can potentially result in better continuity of care and the availability of more time to provide psychosocial support and address patients' information needs. However, more well-conducted research is needed before equivalence to physician-led follow-up can be assessed in terms of survival, recurrence, patient well-being and cost-effectiveness. RELEVANCE TO CLINICAL PRACTICE: Results from well-conducted evaluation studies of nurse-led services based on theory are needed so that relevant interventions can be implemented in clinical practice. There is a need to in future studies include cost-effectiveness analyses to compare nurse-led services with other types of follow-up.

Experiencing an Intimate Partner's Breast Cancer: Attachment, Caregiving, and Burden in Men.

OBJECTIVE: This study examined interrelationships among adult attachment orientations, caregiving, and caregiver burden in men of female partners with breast cancer, and tested whether caregiving patterns mediated associations between men's attachment orientations and their self-reported caregiver burden. METHOD: The participants were 124 male partners of women with breast cancer. These participants completed assessments related to attachment, caregiving, and caregiver burden. Path models examined the associations between constructs and tested mediational effects. RESULTS: Findings demonstrated significant associations between men's adult attachment orientations and their experience of caregiver burden. In addition, the maintenance of proximity in caregiving completely mediated the respective associations of attachment security and attachment avoidance to caregiver health problems, on one hand, and to the caregiver's self-esteem (e.g., another indicator for caregiver burden), on the other. Moreover, we found a direct effect of attachment avoidance on health problems. CONCLUSIONS: This study highlighted the importance of addressing adult attachment dispositions and caregiving to understanding the relational processes implicated in caregiver burden. The results support the conclusion that men's adult attachment orientations and caregiving patterns toward their female partners with breast cancer are relevant contributors to men's perceptions of caregiver burden.

Exploring patient support by breast care nurses and geographical residence as moderators of the unmet needs and self-efficacy of Australian women with breast cancer: Results from a cross-sectional, nationwide survey.

PURPOSE: This study investigated whether use of services of a breast care nurse (BCN) at any time during treatment for breast cancer led to reduced unmet needs and increased self-efficacy among women with breast cancer. A secondary aim was to analyse comparisons between urban and rural and remote dwellers. METHOD: Participants were Australian women who completed treatment for breast cancer at least 6 months before the survey date, recruited through two national databases of women diagnosed with breast cancer. The cross-sectional online survey consisted of two well validated measures, the SCNS-SF34 and the CASE-Cancer Scale. Statistical data were analysed using SPSS, with chi-square used to measure statistical significance. RESULTS: A total of 902 participants responded to the survey. Unmet needs in the psychological domain were most prominent. Respondents who used the services of a BCN were significantly less likely to report unmet needs regarding tiredness, anxiety; future outlook; feelings about death and dying; patient care and support from medical staff; and provision of health systems and information. Scores of self-efficacy showed women using the services of a BCN had significantly higher self-efficacy when seeking and obtaining information (ρ ≤ 0.001) and understanding and participating in care (ρ = 0.032). Urban dwellers were more likely to have choice of health care service, but overall neither unmet needs nor perceived self-efficacy varied statistically significantly by remoteness. CONCLUSIONS: Women with breast cancer experience a range of unmet needs; however those using BCN services demonstrated positive outcomes in terms of decreased unmet needs and increased self-efficacy.

Reliability Estimates for the Arabic Versions of the Cancer Behavior Inventory-Brief and the Functional Assessment of Cancer Therapy-Breast.

PURPOSE: The study aims were to (a) test reliability of the Arabic versions of the Cancer Behavior Inventory-Brief Arabic (CBI-BA) among patients diagnosed with any type of cancer and the Functional Assessment of Cancer Therapy-Breast (FACT-BA) in women with breast cancer and (b) assess participant understanding of CBI-BA items. METHODS: A cross-sectional design was used to assess preliminary evidence for internal consistency reliability of the CBI-BA and the FACT-BA in a community-dwelling sample of Arabicspeaking persons diagnosed with cancer. Participants were randomly selected for cognitive interview. RESULTS: Cronbach's alphas were ≥.76 for the CBI-BA, .91 for the FACT-BA, and .43-.89 for the FACT-BA subscales. Cognitive interviews revealed several CBI-BA items required revision. CONCLUSION: The total CBI-BA and the FACT-BA scales have adequate internal consistency reliability estimates.

Breast Cancer Survivors and Sexuality: A Review of the Literature Concerning Sexual Functioning, Assessment Tools, and Evidence-Based Interventions.

BACKGROUND: Most breast cancer survivors (BCSs) experience sexual dysfunction from treatment-induced hormonal changes, making sexual assessment an important component of survivorship care. However, because many oncology healthcare providers do not perform such assessment, a number of BCSs endure unidentified sexual dysfunction. Barriers to assessment faced by providers must be identified, and further research should examine the perspectives of BCSs and their partners regarding preferences for sexual assessment and interventions. OBJECTIVES: The purpose of this literature review was to explore tools used to assess sexual functioning and evidence-based interventions used to treat sexual dysfunction in BCSs. METHODS: Articles published from 2003-2013 that reported on the effects of breast cancer and its treatment on sexual functioning in BCSs and located through online database searches (PubMed, the Cochrane Library, MEDLINE, CINAHL) were reviewed. FINDINGS: Sexual dysfunction is a common problem among BCSs. Using various assessment tools, providers should regularly assess sexual functioning in BCSs during and after treatment to improve quality of life for BCSs and their partners.

Políticas de saúde pública para o controle do câncer de mama no Brasil / Public health policies for breast cancer control in Brazil / Políticas de salud pública para el control del cáncer de mama en Brasil

Objetivou-se descrever as ações de saúde pública para o controle do câncer de mama no Brasil. Revisão narrativa, sem restrição temporal, foi realizada em sites governamentais e analisada com base nas políticas de saúde vigentes no País. São resultados foram identificadas 48 publicações, constatando-se que o tratamento dessa neoplasia passou a ser considerado no cenário da saúde pública a partir de 1984 e que só em 1996 iniciou-se um programa específico para esse agravo. As ações, recursos, público-alvo e indicadores de rastreio foram definidos em 2004, mas o monitoramento destas práticas por sistema informatizado ocorreu após dois anos de sua implantação. Em conclusão, evidenciou-se, pela documentação analisada, que houve um aumento considerável de intervenções públicas para o controle do câncer de mama a partir de 1998 e, que o direcionamento para as ações de rastreio e detecção precoce se deu a partir de 2004.

This study described public healthcare measures for breast cancer control in Brazil. A narrative review of official government websites was performed, with no time restriction, and analyzed against current health policies in place in Brazil. As a result, 48 publications were detected, revealing that cancer treatment has been considered in public health circles since 1984, but not until 1996 was a specific program started for this disease. In 2004, the measures, resources, target public and screening and early detection indicators were defined, but computerized monitoring of these practices started two years after implementation. In conclusion, the documentation reviewed showed that public health interventions for breast cancer control have increased considerably since 1998, and that more policies have been directed to screening and early detection since 2004.

El objetivo fue describir las acciones de salud pública para el control del cáncer de mama en Brasil. Revisión narrativa, sin restricción de tempo, que fue realizada en sitios gubernamentales y analizada con base en las políticas públicas de salud en vigor en el país. Los resultados son: se identificaron 48 publicaciones en las que se constató que el tratamiento de esa neoplasia pasó a ser considerado en el escenario de la salud pública a partir de 1984 y que, sólo en 1996, se inició un programa específico para esa enfermedad. Las acciones, recursos, público meta e indicadores de tamizaje fueron definidos en 2004, pero el monitore o por medio de sistema informático se concretizó dos años después de su implantación. En conclusión, se evidenció, a partir de la documentación analizada, que hubo un considerable aumento de intervenciones públicas para el control del cáncer de mama a partir de 1998 y que las acciones de tamizaje masivo y detección temprana ocurrió a partir de 2004.

Prevalence and correlates of strength exercise among breast, prostate, and colorectal cancer survivors.

PURPOSE/OBJECTIVES: To identify and compare the prevalence and correlates of strength exercise among breast, prostate, and colorectal cancer survivors.
 DESIGN: Cross-sectional, descriptive survey.
 SETTING: Nova Scotia, Canada.
 SAMPLE: 741 breast, prostate, and colorectal cancer survivors.
. METHODS: A stratified sample of 2,063 breast, prostate, and colorectal cancer survivors diagnosed from 2003-2011 were identified and mailed a questionnaire. Descriptive, chi-square, and logistic regression analyses were used to determine any correlations among the main research variables. 
 MAIN RESEARCH VARIABLES: Strength exercise behavior; medical, demographic, and motivational correlates using the Theory of Planned Behavior.
 FINDINGS: Of 741 respondents, 23% were meeting the strength exercise guidelines of two or more days per week. Cancer survivors were more likely to meet guidelines if they were younger, more educated, had a higher income, better perceived general health, fewer than two comorbidities, and a healthy body weight. In addition, those meeting guidelines had significantly more favorable affective attitude, instrumental attitude, injunctive norm, perceived behavioral control, planning, and intention. The correlates of strength exercise did not differ by cancer site.
 CONCLUSIONS: The prevalence of strength exercise is low among breast, prostate, and colorectal cancer survivors in Nova Scotia and the correlates are consistent across those survivor groups. 
. IMPLICATIONS FOR NURSING: Nurses should take an active role in promoting strength exercise among cancer survivors using the Theory of Planned Behavior, particularly among those survivors at higher risk of not performing strength exercise. 


Factors influencing breast cancer screening and risk assessment among young African American women: An integrative review of the literature.

PURPOSE: This integrative review was conducted to examine factors that influence mammography screening and use of cancer genetic services among younger African American women at increased risk for developing breast cancer. DATA SOURCES: Research articles were identified using PubMed, CINAHL, PsychINFO, and Cochrane library to find studies published from 2003 to 2013. CONCLUSIONS: Findings from this review indicate that while younger African American women receive mammograms more often than the general population, they are not being referred for genetic testing when appropriate. This is a major concern because African American women tend to experience more aggressive forms of breast cancer at an earlier age than the general population; it is imperative that they undergo genetic testing for optimal management of their breast cancer risk. IMPLICATIONS FOR PRACTICE: Nurse practitioners have a significant role in breast cancer screening and genetic testing of at-risk women, particularly in identifying and referring young women for testing. Further communication efforts are needed to improve young women's knowledge of breast cancer risk and the benefits of genetic testing. Reducing barriers to breast healthcare services requires nursing efforts that focus on populations at greatest risk for poor health outcomes.

Geographical comparisons of information and support needs of Australian women following the primary treatment of breast cancer: a 10-year replication study.

BACKGROUND: In 2002, Raupach and Hiller examined the use of and satisfaction with information and support following treatment of breast cancer from a sample of participants in South Australia. In 2013 this study was replicated to include participants Australia wide and analyse comparisons based on geographical location. Statistical comparisons with the original study were also conducted. DESIGN: A 10 year replication study using a cross-sectional needs analysis survey. SETTING AND PARTICIPANTS: Women aged 18+ years diagnosed with breast cancer between 6 and 30 months ago were sourced from two national databases of women diagnosed with breast cancer. RESULTS: A total of 325 participants completed the survey. The Internet was the most commonly used source of information with 70% (n = 229 of 325) of women using the internet for information, a statistically significantly higher percentage compared with the 2002 study. The study found the top four information issues rated as moderately/extremely important by women in 2013 were identical in 2002. A comparison of sources of support used showed that women in outer regional, remote and very remote areas were statistically more likely to use the breast care nurse (BCN) for support (P = 0.044). CONCLUSIONS: The study provides useful, up-to-date data about information and support services used by Australian women with breast cancer. Comparisons with the earlier study show some of the needs of women have changed over time, but others have remained the same. Geographic comparisons overall, demonstrate many consistent findings regardless of location, however, the important work of the breast care nurse is an area in need of further research.

The development of a nursing assessment and symptom management clinic.

The Anne Arundel Medical Center (AAMC) DeCesaris Cancer Institute (DCI) began its participation in the ONS Foundation-supported Breast Cancer Care Quality Measures Set pilot study in 2010. The design and measures of the project were intriguing, paving a path for DCI to define quality measures and outcomes that were of value to the AAMC's oncology population and system. As the pilot program was getting underway, measurement instruments were selected for fatigue, distress, and sleep-wake disturbances. These were used as quality measures for care of patients receiving chemotherapy, to be reported to the Oncology Quality Council, AAMC DCI's Executive Quality Council, and the AAMC Board of Directors. Scores for these quality measures, as well as patient satisfaction scores for the Outpatient Infusion Center, have increased markedly since the 2010 pilot test. The increases in scores inspired nursing leadership, in conjunction with AAMC DCI's Medical Oncology Executive Committee, to develop an innovative nursing model, the advanced oncology nurse practitioner-led symptom management clinic, to systematically and efficiently treat the needs of patients with cancer.

Incorporating breast cancer care data into clinical assessment.

Participation in the ONS Foundation-supported Breast Cancer Care Quality Measures Set pilot study was an opportunity for staff at a National Cancer Institute-designated comprehensive cancer center to improve their process for introducing a change in practice. The institution's treatment area revised a documentation tool, and the medical practice area embarked on an education project based on evidence-based practice from the Oncology Nursing Society's Putting Evidence Into Practice initiative. After implementation, an increase in the number of patients being assessed for the quality measures of fatigue and sleep-wake disturbances was noted. In addition, the number of patients being educated on neutropenia using evidence-based information increased.

Improving psychosocial assessment in a community-based cancer center.

Numerous articles have demonstrated that patients undergoing treatment for cancer experience distress. Research has also shown that patients whose distress is effectively identified and treated may tolerate their chemotherapy better and have improved quality of life. Oncology nurses at the Lowell General Hospital Cancer Center, through their participation in the Breast Cancer Care Measures portion of the ONS Foundation-supported Breast Cancer Quality Measures Set pilot and the Oncology Quality Collaborative, identified that the distress assessment used at their institution was ineffective. The assessment tool did not identify the reason for the patient's distress and therefore was ineffective at triggering appropriate interventions needed for resolution of the patient's distress. The following article highlights the process by which the Lowell General Hospital Cancer Center implemented a new distress assessment tool and uses a patient case study to illustrate its effectiveness.

Influence of nurse navigation on wait times for breast cancer care in a Canadian regional cancer center.

BACKGROUND: The wait times for breast cancer care in our region do not meet acceptable benchmarks. We implemented the Interior Breast Rapid Access Investigation and Diagnosis (IB-RAPID) nurse navigation program to address this issue. METHODS: The IB-RAPID prospective database was reviewed for patients entering the program between April 1, 2011 and April 30, 2012 (2011/2012 cohort), and was compared with patients from the same area in 2010. The main end point was the time between the 1st diagnostic imaging test and the surgery. Multiple linear regression was performed to investigate factors influencing the wait times. RESULTS: The wait times decreased with the introduction of IB-RAPID (59 vs 48 days; median). Stage of disease, total number of biopsies, and magnetic resonance imaging (MRI) use influenced wait times. MRI significantly delayed surgical intervention in both groups with those not having an MRI having a shorter wait time to surgery (68.5 vs 57.6 days; mean) in 2011/2012. CONCLUSION: The implementation of nurse navigation for patients with breast cancer appears to be effective at reducing the wait times for surgical treatment.