Religiousness, Spirituality, and Salivary Cortisol in Breast Cancer Survivorship: A Pilot Study.

BACKGROUND: Psychoneuroimmunological theory suggests a physiological relationship exists between stress, psychosocial-behavioral factors, and neuroendocrine-immune outcomes; however, evidence has been limited. OBJECTIVE: The primary aim of this pilot study was to determine feasibility and acceptability of a salivary cortisol self-collection protocol with a mail-back option for breast cancer survivors. A secondary aim was to examine relationships between religiousness/spirituality (R/S), perceptions of health, and diurnal salivary cortisol (DSC) as a proxy measure for neuroendocrine activity. METHODS: This was an observational, cross-sectional study. Participants completed measures of R/S, perceptions of health, demographics, and DSC. RESULTS: The sample was composed of female breast cancer survivors (n = 41). Self-collection of DSC using a mail-back option was feasible; validity of mailed salivary cortisol biospecimens was established. Positive spiritual beliefs were the only R/S variable associated with the peak cortisol awakening response (rs = 0.34, P = .03). Poorer physical health was inversely associated with positive spiritual experiences and private religious practices. Poorer mental health was inversely associated with spiritual coping and negative spiritual experiences. CONCLUSIONS: Feasibility, validity, and acceptability of self-collected SDC biospecimens with an optional mail-back protocol (at moderate temperatures) were demonstrated. Positive spiritual beliefs were associated with neuroendocrine-mediated peak cortisol awakening response activity; however, additional research is recommended. IMPLICATIONS FOR PRACTICE: Objective measures of DSC sampling that include enough collection time points to assess DSC parameters would increase the rigor of future DSC measurement. Breast cancer survivors may benefit from nursing care that includes spiritual assessment and therapeutic conversations that support positive spiritual beliefs.

Perspectives of the Breast Cancer Survivorship Continuum: Diagnosis through 30 Months Post-Treatment.

This study explored breast cancer survivors' perspectives regarding their experiences of the survivorship continuum from diagnosis through 30 months post-treatment. The sample included women (N = 379) with newly-diagnosed breast cancer undergoing treatment at a Midwestern university-affiliated cancer center. Semi-structured interviews were conducted using the Lymphedema and Breast Cancer Questionnaire at time of diagnosis, post-operatively, quarterly during the first year, and then semi-annually thereafter through 30 months post-treatment. A mixed-methodology was used to analyze participants' comments. Themes central to long-term survivorship experiences included social support, positive worldviews, breast cancer and lymphedema health literacy, religious/spiritual beliefs, self-empowerment, and recovery expectations. These themes were consistent with a psychoneuroimmunological model of health in which psychosocial variables mediate stress and influence health outcomes. Qualitative data showed that social support and positive worldviews were the two themes with the most significant impact on long-term breast cancer survivorship experiences. Survivors expressed a need to advance their health care literacy in order to share ownership of breast cancer and lymphedema treatment decisions. Since breast cancer is an immune-mediated disease, long-term survivorship planning should address psychosocial factors that influence the long-term psychological distress associated with immune dysfunction.

Exploring the usefulness of botanicals as an adjunctive treatment for lymphedema: a systematic search and review.

OBJECTIVES: To provide a critical analysis of the current published research regarding the use, risks, and benefits of botanicals in the treatment of lymphedema and to provide health professionals with current knowledge of safe, appropriate use of botanicals for treatment of lymphedema. TYPE: This systematic search and review addresses the use of botanicals in the treatment of lymphedema in order to develop a best evidence synthesis of the research. LITERATURE SURVEY: Articles were identified from 11 major medical indices published from 2004-2012 using search terms for lymphedema and management. Eighty-five articles met the inclusion criteria of evidence-based lymphedema therapies for the category "complementary and alternative methods for lymphedema therapy." METHODOLOGY: Two clinical lymphedema experts reviewed the studies according to level of evidence guidelines established by the Oncology Nursing Society, Putting Evidence into Practice, and subdivided the methods into subcategories that included Botanical, Pharmaceutical, Physical Agent Modalities, and Modalities of Contemporary Value. The pharmaceutical articles were excluded (5) because they fell outside the inclusion criteria. Twenty-two articles were used in a separate review of physical agent modalities and modalities of contemporary value for lymphedema. Botanicals generated substantial research (11) and warranted its own independent review. SYNTHESIS: The levels of evidence are weak, because research conclusions were limited by size, dose, and study design. A limited number of randomized controlled trials have been performed, and reliability is not always evident, particularly in the context of large systematic reviews where evidence was bundled. CONCLUSIONS: Evidence supporting the use of botanicals for the treatment of lymphedema is insufficient. Some evidence suggests benefits for the treatment of chronic venous insufficiency. Development of specific and sensitive measurement methods may change how botanicals are studied and establish a body of evidence for their use.

Thai nurses' perspectives on the use of complementary and alternative medicine among Thai breast cancer survivors in northern Thailand.

Breast cancer survivors are more likely to seek complementary and alternative medicine (CAM) for their health and well-being than other cancer patients. The purpose of the study was to describe how Thai nurses perceive the use of CAM in Thai breast cancer survivors. An ethno-nursing research method was used. Fifteen Thai nurses who had experience in taking care of Thai breast cancer survivors who used CAM from a tertiary care referral and resource centre in the lower northern part of Thailand were interviewed. Two major themes emerged from this study: Meaning of care practices in CAM was seen as: (i) an additional beneficial choice for health; and (ii) emotional and psychological healing. Nurses should be concerned about CAM use in Thai breast cancer survivors. Open communication about CAM helps ensure that safe and holistic care is provided. Further research to enhance integration of CAM into health care is needed.

Complementary, alternative, and other noncomplete decongestive therapy treatment methods in the management of lymphedema: a systematic search and review.

OBJECTIVES: (1) To provide a critical analysis of the contemporary published research that pertains to complementary, alternative, and other noncomplete decongestive therapies for treatment of lymphedema (LE), and (2) to provide practical applications of that evidence to improve care of patients with or at risk for LE. TYPE: This study meets the defining criteria as a systematic search and review because it includes varied study types. All studies that met the inclusion criteria were evaluated for weight of evidence and value. LITERATURE SURVEY: The systematic search and review includes articles published in the contemporary literature (2004-2012). Publications published from 2004-2011 were retrieved from 11 major medical indices by using search terms for LE and management approaches. Literature archives were examined through 2012. Data extraction included study design, objectives pertaining to LE, number and characteristics of participants, interventions, and outcomes. Study strengths and weaknesses were summarized. Study evidence was categorized according to the Oncology Nursing Society Putting Evidence into Practice level-of-evidence guidelines after achieving consensus among the authors. No authors participated in development of nor benefitted from the review of these modality methods or devices. METHODOLOGY: Extracted data from 85 studies were reviewed in 4 subcategories: botanical, pharmaceutical, physical agent modality, and modalities of contemporary value. After review, 47 articles were excluded, which left 16 articles on botanicals and pharmaceuticals and 22 articles for physical agent modality and/or modalities of contemporary value. Pharmaceuticals were later excluded. The authors concluded that botanicals had generated sufficient studies to support a second, more specific systematic review; thus, botanicals are reported elsewhere. SYNTHESIS: It was found that limited high-level evidence was available for all categories. Well-constructed randomized controlled trials related specifically to LE were limited. Objective outcome measures over time were absent from several studies. The rationale for the use and benefits of the specific modality, as related to LE, was often anecdotal. Subject numbers were fewer than 50 for most studies. CONCLUSIONS: No interventions were ranked as "recommended for practice" based on the Putting Evidence into Practice guidelines. Two treatment modalities in 3 studies were ranked as "likely to be effective" in reducing LE or in managing secondary LE complications. Consideration should be given that many of the PAMs demonstrate long-standing support within the literature, with broad parameters for therapeutic application and benefit for secondary conditions associated with LE. However, further investigation as to their individual contributory value and the factors that contribute to their efficacy, specific to LE, has not been done. It also is significant to mention that the majority of these studies focused on breast cancer-related LE. Studies that explored treatment interventions for LE-related vascular disorders (eg, chronic venous insufficiency, congenital dysphasia, trauma) were sparse. Limitations of the literature support the recommendations for future research to further examine the level of evidence in these modalities for LE management.

Complementary and alternative medicine and lymphedema.

OBJECTIVES: To review the evidence for the effectiveness of complementary and alternative medicine (CAM) on cancer-related lymphedema. DATA SOURCES: CINAHL, PsycINFO, and PubMed (1990-2012). CONCLUSION: To date, there is insufficient evidence to draw conclusions about the benefits of CAM use for cancer patients with lymphedema. Although some CAM types may offer positive effects for the management of lymphedema, negative adverse effects have also been observed. IMPLICATIONS FOR NURSING PRACTICE: Oncology nurses and therapists should be aware of and ready to educate cancer patients about the potential effects of CAM. A conversation about the potential risks and benefits of CAM use should be provided.

Management of lymphedema for cancer patients with complex needs.

OBJECTIVES: The purpose of this paper was to discuss the management of lymphedema in patients with advanced disease. DATA SOURCES: Peer-reviewed literature. CONCLUSION: Management of lymphedema in patients with advanced cancer is complex because of multi-factorial issues. Basic components of skin care, compression, massage, and exercise can be applied for these patients. Key concepts are: 1) optimizing quality of life, 2) respecting patients' choices, and 3) providing psychological support to the patients and their families. IMPLICATIONS FOR NURSING PRACTICE: Management plans for patients with lymphedema in advanced disease should be flexible. Holistic and collaborative approaches are essential to achieve the goal of caring for these patients.

Performance care practices in complementary and alternative medicine by Thai breast cancer survivors: an ethnonursing study.

The purpose of this study was to explore how Thai breast cancer survivors perform care practices in complementary and alternative medicine to promote their health and well-being. Research was conducted using an ethnonursing method. Data were collected through semi-structured interviews with 17 Thai breast cancer survivors in Thailand. The transcribed interviews were analyzed using the ethnonursing analysis method. The findings showed Thai breast cancer survivors started their care practices in complementary and alternative medicine immediately following a diagnosis of breast cancer. They sought out and gathered alternative medicine information from several sources, such as the people around them, media resources, books, magazines, or newspapers. After gathering information, Thai breast cancer survivors would try out various types of complementary medicines rather than use only one type because of information from other people and their own evaluation. The findings of this study indicate the need for a conversation about complementary medicine use between healthcare providers and Thai breast cancer survivors as an on-going process throughout the cancer trajectory to ensure that safe and holistic care is provided.

A systematic review of the evidence for complete decongestive therapy in the treatment of lymphedema from 2004 to 2011.

OBJECTIVE: To critically analyze the contemporary published research that pertains to the individual components of complete decongestive therapy (CDT), as well as CDT as a bundled intervention in the treatment of lymphedema. DATA SOURCES: Publications were retrieved from 11 major medical indices for articles published from 2004-2010 by using search terms for lymphedema and management approaches. Literature archives of the authors and reference lists were examined through 2011. STUDY SELECTION: A research librarian assisted with initial literature searches by using search terms used in the Best Practice for the Management of Lymphoedema, plus expanded terms, for literature related to lymphedema. Authors sorted relevant literature for inclusion and exclusion; included articles were sorted into topical areas for data extraction and assessment of level of evidence by using a published grading system and consensus process. The authors reviewed 99 articles, of which 26 met inclusion criteria for individual studies and 1 case study did not meet strict inclusion criteria. In addition, 14 review articles and 2 consensus articles were reviewed. DATA EXTRACTION: Information on study design and/or objectives, participants, outcomes, intervention, results, and study strengths and weaknesses was extracted from each article. Study evidence was categorized according to the Oncology Nursing Society Putting Evidence into Practice level of evidence guidelines after achieving consensus among authors. DATA SYNTHESIS: Levels of evidence were only moderately strong, because there were few randomized controlled trials with control groups, well-controlled interventions, and precise measurements of volume, mobility and/or function, and quality of life. Treatment interventions were often bundled, which makes it difficult to determine the contribution of each individual component of treatment to the outcomes achieved. CONCLUSIONS: CDT is seen to be effective in reducing lymphedema. This review focuses on original research about CDT as a bundled intervention and 2 individual components, manual lymph drainage and compression bandages. Additional studies are needed to determine the value and efficacy of the other individual components of CDT.

Mindfulness-based stress reduction among breast cancer survivors: a literature review and discussion.

PURPOSE/OBJECTIVES: To evaluate and discuss existing studies of mindfulness-based stress reduction (MBSR) among breast cancer survivors. DATA SOURCES: Articles published from 1987-2009 were retrieved using MEDLINE®, CINAHL®, Ovid, and Scopus. Key words, including mindfulness-based stress reduction and mindfulness meditation, were combined with breast cancer. DATA SYNTHESIS: The search resulted in 26 articles that were narrowed down to 16 by selecting only quantitative studies of MBSR conducted with breast cancer (n = 7) or heterogeneous types of cancer in which the predominant cancer was breast cancer (n = 9). Most studies were one-group pre- and post-test design and examined the effect of MBSR on psychological outcomes. Overall, the studies had large effect sizes on perceived stress and state anxiety and medium effect sizes on symptoms of stress and mood disturbance. Four studies measured biologic outcomes and had small effect sizes, except cytokine production, which showed a large effect size at 6- and 12-month follow-ups. CONCLUSIONS: Future studies using randomized, control trials and longitudinal, repeated-measures designs are needed. Studies conducted with heterogeneous types of cancer and gender should be analyzed and the results reported separately. IMPLICATIONS FOR NURSING: The comprehensive summary and critical discussion of existing studies of MBSR usage among breast cancer survivors provide essential information that can be used by nurses and others working in the healthcare setting.

Nonpharmacologic supportive strategies to promote quality of life in patients experiencing cancer-related fatigue: a systematic review.

Cancer-related fatigue (CRF) is a distressing symptom that affects the quality of life (QOL) of patients with breast cancer and their families. The effectiveness of pharmacologic therapies alone has not been sufficient in the management of CRF; therefore, a combination of pharmacologic and nonpharmacologic approaches is justified. The purpose of this article is to critically review the literature related to nonpharmacologic supportive strategies in enhancing QOL among patients with breast cancer experiencing CRF. The results show that exercises (e.g., home-based exercise, supervised exercise), education and counseling, sleep therapy, and complementary therapy are feasible as effective nonpharmacologic supportive interventions to improve QOL in patients with breast cancer suffering from CRF. Therefore, nurses may consider these nonpharmacologic supportive strategies as adjunctive interventions to pharmacologic interventions in enhancing QOL for patients with breast cancer experiencing CRF. However, because previous studies had some methodologic limitations, such as small sample size, lack of objective measures, or predominantly Caucasian sample, future research to further explore nonpharmacologic interventions in this area is warranted.

Effects of mindfulness-based stress reduction (MBSR) on health among breast cancer survivors.

The purpose of this study was to examine the effects of a MBSR program on physiological and psychological outcomes among early-stage breast cancer survivors. A quasi-experimental, pre-and posttest control group design was selected. The intervention group received the MBSR intervention. The control group received no MBSR intervention. ANOVA and ANCOVA were used to analyze data. The intervention group demonstrated statistically significant improvement in physiological and psychological outcomes including reduced blood pressure, heart rate, and respiratory rate and increased mindfulness state at the level of p = .05 to p = .001. The effects of MBSR on reducing stress in this sample were statistically significant on the physiological outcome (morning cortisol) at the measurement after the intervention completion, but this effect was not sustained at 1-month follow-up. MBSR showed a trend toward improving psychological outcomes by reducing mood disturbance in this sample.

Complementary and alternative medicine use among women with breast cancer: a systematic review.

Patients with breast cancer use complementary and alternative medicine (CAM) despite the fact that no studies have shown altered disease progression attributable to CAM use. The purpose of this systematic review is to summarize research as it relates to CAM use among women with breast cancer. Among the many findings of the review, biologically based practices were noted as the types of CAM most used by women with breast cancer, followed by mind-body medicine, whole medical systems, and energy medicine. Sources of information about CAM use for women with breast cancer vary widely, including family, friends, mass media, healthcare providers, CAM providers, and self-help groups. Sociodemographic factors that appear to be related to CAM use were younger age, higher education, higher income, married status, involvement in a support group, and health insurance. The reasons for CAM use reported by women with breast cancer were to help healing, to promote emotional health, and to cure cancer. Oncology nurses should learn more about CAM use among women with breast cancer. Open communication about CAM use helps ensure that safe and holistic care is provided. Additional research in this particular area is needed.

Breast cancer survivors' perspectives of care practices in Western and alternative medicine.

PURPOSE/OBJECTIVES: To explore perspectives of breast cancer survivors about their care with Western medicine and alternative medicine. RESEARCH APPROACH: Qualitative, ethnonursing. SETTING: Cancer center in the midwestern region of the United States. PARTICIPANTS: 9 breast cancer survivors who had experienced health care involving Western medicine and alternative medicine. METHODOLOGIC APPROACH: Semistructured interviews were conducted to elicit each participant's perspective about care practices. Data were analyzed with an ethnonursing qualitative data analysis method. MAIN RESEARCH VARIABLES: Care practices in Western medicine and care practices in alternative medicine. FINDINGS: Western medicine was seen as traditional or mainstream treatment, whereas alternative medicine was seen as anything not involving hospitals and doctors or as complementary. Perceived outcomes from alternative therapies were coping with disease and treatment, holistic care, and emotional support, whereas perceived outcomes from Western medicine were negative things that they had to go through and as an instrument of God. Kinship, social, economical, educational, and belief factors influenced care practices. CONCLUSIONS: Care practices from alternative medicine or Western medicine vary for breast cancer survivors. Many factors influence their selection decisions about care practices. INTERPRETATION: Nurses should be concerned about what care practices mean to breast cancer survivors. Further research should be considered to evaluate the potential contribution of each factor to breast cancer survivors' decision making about care practices.