Nurse-Delivered Brief Behavioral Treatment for Insomnia in Lung Cancer Survivors: A Pilot RCT.

Objective/Background: Insomnia occurs in 50 to 80% of lung cancer survivors. Cognitive behavioral therapy is the standard treatment for insomnia (CBTI); however, treatment length and lack of psychologists trained in CBTI limits access. Brief Behavioral Treatment for Insomnia (BBTI), a nurse-delivered modified CBTI, is proposed. This feasibility pilot study sought to compare the BBTI intervention to attention control Healthy Eating Program (HEP) for insomnia in lung cancer survivors. Participants: The participants comprised adults, 21 years of age or older with insomnia and stage I/II non-small cell lung cancer, more than 6 weeks from surgery and living in Western NY. Methods: Participants (n = 40) were randomly assigned to an experimental (BBTI) or attention control condition (Healthy Eating Program). Thirty participants completed the study. Results: Participants were 66 years of age (± 7.6; range 53-82), 40% (n = 16) male, 87.5% (n = 35) Caucasian, 50% (n = 20) married, BMI 27.7 (± 5.8), and 12% (n = 5) never smokers. Baseline sleep diary sleep efficiency, ISI and other baseline covariates were balanced between the groups. Sleep efficiency improved ≥85% in BBTI group (p = .02), but not in HEP control group (p = 1.00). Mean ISI for BBTI and attention control were 6.40 ± 4.98 and 14.10 ± 4.48 (p = .001) respectively. In addition, BBTI group mean total FACT-L score improved by 6.66 points from baseline while HEP group score worsened (p = .049). Conclusions: BBTI is a practical, evidence-based, clinically relevant intervention that improved sleep and quality of life in lung cancer survivors with insomnia. Additional research to evaluate efficacy, duration, and implementation strategies are essential.

Trajectory of insomnia symptoms in older adults with lung cancer: using mixed methods.

CONTEXT: A knowledge gap exists in our understanding of the illness and insomnia symptom treatment trajectory in adults with inoperable non-small cell lung cancer (NSCLC). OBJECTIVES: Compare valid and reliable sleep-wake measures for insomnia to interpretations of narrative descriptions of sleep to improve our comprehension of sleep-wake disturbances in adults with NSCLC. METHODS: This study employed mixed methods (quantitative and qualitative) in a longitudinal design to study adults (n = 26) from ambulatory thoracic clinics. Valid and reliable surveys (Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale), 7-day sleep diary, and actigraphy were obtained with interview narrative interpretations of sleep experiences in the context of lung cancer. Data collection occurred at four-time points: baseline (before chemotherapy), pre-second chemotherapy, pre-third chemotherapy, and 6 months from baseline. Sleep measures were compared to interpretations from interview narratives to understand context of survey measures. RESULTS: Objective quantitative results were congruent with interview narrative interpretations that reflected participants' sleep-wake experiences. Objective sleep-wake measures for insomnia over-time described increasing sleep latency and decreasing sleep duration. The interview narratives provided context and insight into participants' subjective insomnia experiences. While participants' insomnia symptoms were present, they were resigned to endure insomnia, and the subjective measures reflected a more positive perception of sleep outcomes. CONCLUSION: A mixed methods approach provides a deeper understanding of sleep-wake disturbances and the differing quantitative objective and subjective results of sleep measures in the context of the participants' experience of the trajectory of insomnia symptoms before, during, and after lung cancer treatment.

Military veteran cancer survivors' preferences for a program to address lifestyle change and psychosocial wellness following treatment.

This study aimed to understand military veteran cancer survivors' preferences regarding the delivery of post-treatment wellness services. Thirty-three military veteran cancer survivors were interviewed about their perceptions of three models of health service delivery (home-, primary care-, and oncology-based services). Conventional qualitative content analysis revealed strengths and weaknesses of each service delivery model's content and structure (e.g., program location, inclusion of emotional support, access to clinical experts). All service delivery programs had strengths, with clinic-based programs offering the greatest breadth of services deemed important for wellness by cancer survivors.

Experiences of Patients With Advanced Lung Cancer: Being Resigned to Sleep-Wake Disturbances While Maintaining Hope for Optimal Treatment Outcomes.

BACKGROUND: Sleep-wake disturbances are prevalent in patients with lung cancer yet are infrequently studied over time. This article reports on the qualitative results of a mixed-methods study of newly diagnosed patients' narratives over 6 months. OBJECTIVE: The objective of this study was to gain an understanding of the treatment and illness trajectory related to sleep-wake disturbances as well as the beliefs and practices of patients while seeking optimal treatment outcomes. METHODS: Longitudinal interview narratives of 26 patients' experiences with advanced lung cancer diagnosis (at baseline, pre-second and third treatment, and 6 months) were obtained from participants recruited from Veterans Administration Hospital Center and a Comprehensive Cancer Center in Northeast United States. Analysis of illness narratives used interpretive phenomenology based on Heideggarian hermeneutic traditions. RESULTS: At diagnosis, participants described poor sleep such as trouble falling asleep and frequent awakenings. Over time, as the treatment worsened their sleep symptoms, these participants still maintained hope for more time with treatment. This focus enabled them to tolerate the sleep-wake disturbances and treatment adverse effects. As the treatment effectiveness declined, their focus changed to spiritual meanings for the future and to keep living life with a purpose. CONCLUSIONS: By explicating lung cancer patients' experiences with sleep-wake disturbances, nurses will gain insight into potential interventions to improve sleep and support effective outcomes as well as open a dialogue about hope. IMPLICATIONS FOR PRACTICE: Findings offer insight for oncology nurses to provide opportunities for dialogue about treatment options and techniques to improve sleep, which will facilitate patients living their lives.

Sleeping with the enemy: sleep and quality of life in patients with lung cancer.

BACKGROUND: Patients with lung cancer have the poorest sleep quality compared with other patients with cancer and noncancer control subjects. However, few studies have examined sleep longitudinally. OBJECTIVE: The objective of this study was to characterize and correlate sleep quality, daytime sleepiness, sleep-wake actigraphy, and quality of life (QOL) before, during, and after chemotherapy for non-small cell lung cancer (NSCLC). METHODS: Using a prospective repeated-measures 1-group design, patients scheduled to receive chemotherapy for NSCLC were recruited. Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, Functional Assessment of Cancer Treatment-Lung (FACT-L), and Motionlogger Actigraph were used for data collection. RESULTS: Poor nocturnal sleep and QOL were evident among 29 patients with NSCLC before treatment. The FACT-L subscale scores worsened and then improved significantly from baseline through 2 rounds of chemotherapy. Objective sleep duration and sleep efficiency were positively associated with FACT-L scores, whereas objective sleep latency and wake after sleep onset were negatively associated with FACT-L scores. Sleepy patients had significantly worse FACT-L scores than did nonsleepy patients. The FACT-L subscale items that demonstrated significant worsening and then improvement over time were shortness of breath, weight loss, coughing, and chest tightness. Lung cancer patients experience early and middle insomnia before and during treatment. CONCLUSION: Poor sleep quality is common in patients receiving treatment for NSCLC and is related to poorer QOL and respiratory symptoms. IMPLICATION FOR PRACTICE: Patients with NSCLC require routine screening for sleep disturbances. A positive screen for sleep disturbance warrants a thorough sleep assessment using practice guidelines and, if necessary, referral to a sleep specialist for diagnosis and treatment.

Perceptions of barriers and facilitators to health behavior change among veteran cancer survivors.

OBJECTIVE: This study aimed to identify barriers and facilitators to health behavior change related to body size in a sample of veteran cancer survivors. METHODS: A qualitative study was conducted with a sample of 35 male and female cancer survivors receiving care at a Veterans Administration comprehensive cancer center. Participants completed individual interviews regarding barriers and facilitators to lifestyle change and responded to a brief questionnaire regarding current health behaviors. RESULTS: Participants reported suboptimal adherence to recommended health behavior goals and the majority were overweight or obese (80%). Qualitative analysis revealed numerous barriers and facilitators to health behavior change across six broad categories: environmental factors, health services delivery factors, health-related factors, factors related to attitudes toward change, factors related to enacting change, and motivational factors. Veteran cancer survivors were impacted by common barriers to change affecting the general population, cancer-specific factors related to personal diagnosis and treatment history, and health service delivery factors related to the Veterans Administration health care system. CONCLUSIONS: There are many barriers and facilitators that exist in diverse domains for veteran cancer survivors, each of which offers unique challenges and opportunities for improving engagement in behavior change following cancer diagnosis and treatment.

Multi-institutional, randomized, double-blind, placebo-controlled trial to assess the efficacy of a mucoadhesive hydrogel (MuGard) in mitigating oral mucositis symptoms in patients being treated with chemoradiation therapy for cancers of the head and neck.

BACKGROUND: The objective of this trial was to determine how a mucoadhesive hydrogel (MuGard), a marketed medical device, would fare when tested with the strictness of a conventional multi-institutional, double-blind, randomized, placebo-controlled study format. METHODS: A total of 120 subjects planned to receive chemoradiation therapy (CRT) for treatment of head and neck cancers were randomized to receive either MuGard or sham control rinse (SC) during CRT. Subjects completed the validated Oral Mucositis Daily Questionnaire. Weight, opiate use, and World Health Organization (WHO) oral mucositis (OM) scores were recorded. Subjects who dosed at least once daily during the first 2.5 weeks of CRT were included in the efficacy analysis. RESULTS: Of 120 subjects enrolled, 78 (SC, N=41; MuGard, N=37) were eligible for efficacy analysis. Both cohorts were similar in demographics, baseline characteristics, primary tumor type, and planned CRT regimen. MuGard effectively mitigated OM symptoms as reflected by area under the curve of daily patient-reported oral soreness (P=.034) and WHO scores on the last day of radiation therapy (P=.038). MuGard was also associated with nonsignificant trends related to therapeutic benefit including opioid use duration, and OM scores (WHO criteria) at CRT week 4. Rinse compliance was identical between cohorts. No significant adverse events were reported, and the adverse event incidence was similar between cohorts. CONCLUSIONS: Testing MuGard, a rinse marketed as a device, in a standard clinical trial format demonstrated its superiority to SC in mitigating OM symptoms, delaying OM progression, and its safety and tolerability.

Sleep, mood, and quality of life in patients receiving treatment for lung cancer.

PURPOSE/OBJECTIVES: To distinguish relationships among subjective and objective characteristics of sleep, mood, and quality of life (QOL) in patients receiving treatment for lung cancer. DESIGN: Descriptive, correlational study. SETTING: Two ambulatory oncology clinics. SAMPLE: 35 patients with lung cancer. METHODS: The following instruments were used to measure the variables of interest: Pittsburgh Sleep Quality Index (PSQI), Hospital Anxiety and Depression Scale, Functional Assessment of Cancer Treatment-Lung (FACT-L), a sleep diary, and a motionlogger actigraph. MAIN RESEARCH VARIABLES: Sleep, mood, and QOL. FINDINGS: Significant differences were found between sleep diary and actigraph measures of sleep efficiency (p = 0.002), sleep latency (p = 0.014), sleep duration (p < 0.001), and wake after sleep onset (p < 0.001). Poor sleepers (PSQI score greater than 5) were significantly different from good sleepers (PSQI score of 5 or lower) on sleep diary measures of sleep efficiency and sleep latency and the FACT-L lung cancer symptom subscale, but not on mood or actigraphy sleep measures. CONCLUSIONS: Although patients with lung cancer may report an overall acceptable sleep quality when assessed by a single question, those same patients may still have markedly increased sleep latencies or reduced total sleep time. The findings indicate the complexity of sleep disturbances in patients with lung cancer. Lung cancer symptoms had a stronger association with sleep than mood. Research using prospective methods will help to elucidate their clinical significance. IMPLICATIONS FOR NURSING: Patients receiving treatment for lung cancer are at an increased risk for sleep disturbances and would benefit from routine sleep assessment and management. In addition, assessment and management of common symptoms may improve sleep and, ultimately, QOL. KNOWLEDGE TRANSLATION: A high frequency of sleep disturbances in patients receiving treatment for lung cancer was evident, and poor sleepers had lower QOL. Sleep disturbances may be more related to lung cancer symptoms than anxiety or depression. Improving lung cancer symptoms such as dyspnea may improve sleep.

Lasting impact: understanding the psychosocial implications of cancer among military veterans.

This qualitative study aimed to identify Veterans' perceptions of how cancer affects their life following treatment, particularly in relation to treatment side effects and identity as a cancer survivor. A diverse sample of 35 Veteran cancer survivors participated in semistructured, individual interviews. Thematic analysis revealed the enduring impact of diagnosis and chronic uncertainty regarding recurrence, psychological side effects that were periodic and typically self-managed, and physical side effects as common, but considered an acceptable trade-off for increased chances of survival. Perceptions of the term cancer survivor varied considerably among participants. Implications for survivorship wellness and care planning are discussed.

The experience of a diagnosis of advanced lung cancer: sleep is not a priority when living my life.

PURPOSE/OBJECTIVES: To describe common practices and shared meanings of sleep-wake disturbances in individuals with newly diagnosed non-small cell lung cancer (NSCLC) before treatment and evaluate their preexisting sleep disturbances. RESEARCH APPROACH: Open-ended interviews of patients newly diagnosed with lung cancer. SETTING: A Veterans Administration hospital and a comprehensive cancer center in the northeastern United States. PARTICIPANTS: 26 patients newly diagnosed with NSCLC who chose chemotherapy treatment. METHODOLOGIC APPROACH: Interpretive phenomenology based on Heideggarian hermeneutics. MAIN RESEARCH VARIABLES: Meaning of diagnosis on life experiences and sleep practices. FINDINGS: Participants described four related themes: (a) the diagnosis as devastating yet not surprising, (b) treatment as hope for more time, (c) keeping life normal, and (d) sleep patterns as long lived. CONCLUSIONS: Although participants did not complain about sleep difficulties, they described a history of sleep disturbances and poor sleep hygiene. Participants focused their trust on the treatment, giving them more time to follow their priorities and ignoring the effects of sleep deprivation on their quality of life. INTERPRETATION: Healthcare professionals may design interventions to encourage keeping life as normal as possible, focusing on improving sleep, which may ultimately prolong patients' lives.

Growth curve analysis of BMI in relation to primary care utilization in prostate cancer survivors.

SUMMARY: Cancer survivors are advised to maintain a healthy BMI to optimize quality of life. In the VA healthcare system, multidisciplinary primary care clinics are responsible for screening and management of overweight or obesity, but it is unclear if cancer survivors are accessing or benefiting from these services. This study aimed to determine if primary care utilization was associated with changes in BMI of prostate cancer survivors, a group with very high rates of long-term survival. Data on demographics, comorbidities, cancer treatment, body size, and number of primary care encounters (medical, behavioral health, nutrition, and weight management program) were collected from electronic medical records and the local tumor registry for 406 early stage prostate cancer survivors who were overweight or obese at diagnosis. Growth curve modeling assessed BMI trajectories in relation to primary care utilization. Results indicated that survivors averaged 18 primary care encounters over the observation period but rarely accessed behavioral health, nutrition, or weight management program services. The average BMI trajectory was non-linear, showing an increase in BMI until 3.2 years after diagnosis followed by deceleration. Primary care utilization was inversely associated with BMI growth, (ß = -0.05, p < 0.01). This association was not impacted by demographic, cancer treatment, or comorbidities. Although primary medical care encounters were associated with modest reductions in BMI, overweight or obese prostate cancer survivors appear to be underutilizing the full range of primary care services that could address the motivational, informational, dietary, and physical activity barriers associated with weight loss.:

Longitudinal assessment of BMI in relation to ADT use among early stage prostate cancer survivors.

INTRODUCTION: The use of androgen deprivation therapy (ADT) for prostate cancer is on the rise, but its adverse side effects may include increased fat mass and decreased lean muscle mass. The net effect of ADT on BMI is unknown. METHODS: Primary, incident cases of early stage prostate cancer (n = 473) were identified from the Buffalo VA Medical Center tumor registry and matched to body size, demographic, comorbidity, and treatment exposure data from veteran medical records. Multilevel modeling was used to assess the association between ADT and changes in BMI. RESULTS: On average, survivors were overweight at diagnosis and showed small, non-significant changes in BMI over time. However, among those survivors with a history of ADT, a significant decrease of 0.05 BMI units per year was associated with each additional dose of ADT (p < 0.001). When the association between BMI rate of change and ADT was allowed to vary with respect to age, additional doses of ADT predicted stronger decreases in BMI for younger survivors as compared to older survivors (p < 0.05). Neither a history of surgery nor radiation influenced the association between ADT use and BMI. CONCLUSIONS: Declines in BMI in relation to ADT exposure may be reflective of unfavorable changes in body composition, especially decreased muscle mass, that is most pronounced in younger survivors. IMPLICATIONS FOR CANCER SURVIVORS: Survivors on ADT may benefit from close monitoring of physical functioning and referral for exercise interventions to preserve muscle mass and improve health related quality of life.

A phase II study of first-line biweekly capecitabine and bevacizumab in elderly patients with metastatic colorectal cancer.

PURPOSE: This phase II study was conducted to determine the efficacy and safety of capecitabine and bevacizumab in untreated elderly metastatic colorectal cancer patients. METHODS: Patients received 1500 mg/m(2)/dose of capecitabine twice daily x 7 days and bevacizumab at 5mg/kg on day 1, in 2 week-cycles. RESULTS: The study was closed early, due to poor accrual, after a total of 16 patients enrolled. Four patients had an objective response and 11 patients had stable disease. The median time to progression and overall survival were 9.5 and 21.2 months, respectively. The most common grade >or= 3 toxicities included diarrhea (13%) and hand and foot syndrome (25%). Three patients had an arterial thrombotic event and one patient developed a bowel perforation. CONCLUSIONS: In this underpowered phase II study in elderly patients with metastatic colorectal cancer, capecitabine plus bevacizumab was associated with considerable clinical activity but at an increased risk of hand and foot syndrome and arterial thrombotic events.

Cisplatin and fluorouracil alone or with docetaxel in head and neck cancer.

BACKGROUND: A randomized phase 3 trial of the treatment of squamous-cell carcinoma of the head and neck compared induction chemotherapy with docetaxel plus cisplatin and fluorouracil (TPF) with cisplatin and fluorouracil (PF), followed by chemoradiotherapy. METHODS: We randomly assigned 501 patients (all of whom had stage III or IV disease with no distant metastases and tumors considered to be unresectable or were candidates for organ preservation) to receive either TPF or PF induction chemotherapy, followed by chemoradiotherapy with weekly carboplatin therapy and radiotherapy for 5 days per week. The primary end point was overall survival. RESULTS: With a minimum of 2 years of follow-up (> or =3 years for 69% of patients), significantly more patients survived in the TPF group than in the PF group (hazard ratio for death, 0.70; P=0.006). Estimates of overall survival at 3 years were 62% in the TPF group and 48% in the PF group; the median overall survival was 71 months and 30 months, respectively (P=0.006). There was better locoregional control in the TPF group than in the PF group (P=0.04), but the incidence of distant metastases in the two groups did not differ significantly (P=0.14). Rates of neutropenia and febrile neutropenia were higher in the TPF group; chemotherapy was more frequently delayed because of hematologic adverse events in the PF group. CONCLUSIONS: Patients with squamous-cell carcinoma of the head and neck who received docetaxel plus cisplatin and fluorouracil induction chemotherapy plus chemoradiotherapy had a significantly longer survival than did patients who received cisplatin and fluorouracil induction chemotherapy plus chemoradiotherapy. (ClinicalTrials.gov number, NCT00273546 [ClinicalTrials.gov].).