Impact + resistance training improves bone health and body composition in prematurely menopausal breast cancer survivors: a randomized controlled trial.

UNLABELLED: Our randomized controlled trial in prematurely menopausal breast cancer survivors showed that impact + resistance training prevented increases in percentage of body fat compared with controls and also improved BMD at the hip and prevented BMD loss at the spine among exercise-trained women who were menopausal for >1 year. INTRODUCTION: Cancer treatment-related menopause worsens bone health and body composition in breast cancer survivors (BCS). We investigated whether impact + resistance training could improve bone mineral density (BMD), reduce bone turnover, build muscle, and decrease fat mass in BCS with premature menopause. METHODS: We conducted a randomized controlled trial in 71 BCS (mean age, 46.5 years) within 5 years of treatment-related menopause. Women were randomly assigned to one of two groups: (1) impact + resistance training (prevent osteoporosis with impact + resistance (POWIR)) or (2) exercise placebo (FLEX) 3×/week for 1 year. Outcomes were hip and spine BMD (in grams per square centimeter) and body composition (percent body fat (%BF) and lean and fat mass (in kilograms)) by DXA and bone turnover markers (serum osteocalcin (in nanograms per milliliter) and urinary deoxypryrodinoline (in nanomoles per milliliter). RESULTS: There were no significant group × time interactions for bone outcomes when using an intent-to-treat approach on the full sample. In analyses restricted to BCS who were menopausal for ≥1 year, POWIR increased BMD at the hip and slowed BMD loss at the spine compared with FLEX (femoral neck-POWIR, 0.004 ± 0.093 g/cm(2) vs. FLEX, -0.010 ± 0.089 g/cm(2); p < 0.01; spine-POWIR, -0.003 ± 0.114 g/cm(2) vs. FLEX, -0.020 ± 0.110 g/cm(2); p = 0.03). POWIR prevented increases in %BF (POWIR, 0.01 % vs. FLEX, 1.3 %; p < 0.04). Women with attendance to POWIR at ≥64 % had better improvements in %BF than women attending less often (p < 0.03). CONCLUSION: Impact + resistance training may effectively combat bone loss and worsening body composition from premature menopause in BCS.

Exercise reduces daily fatigue in women with breast cancer receiving chemotherapy.

PURPOSE: Cancer treatment-related fatigue is the most prevalent and distressing symptom of cancer therapy. Interventions to minimize fatigue are needed. The purpose of this study was to examine the relationship between exercise and fatigue over the first three cycles of chemotherapy in women receiving either cyclophosphamide, methotrexate, and fluorouracil (CMF) or doxorubicin and cyclophosphamide (AC) for breast cancer. METHODS: Seventy-two newly diagnosed women with breast cancer were instructed in a home-based moderate-intensity exercise intervention. Measures of functional ability, energy expenditure, and fatigue were obtained at baseline and posttest. Subjects maintained daily records of four types of fatigue, and exercise duration, intensity, and type. RESULTS: Exercise significantly reduced all four levels of fatigue (P < 0.01). As the duration of exercise increased, the intensity of fatigue declined (P < 0.01). There was a significant carry-over effect of exercise on fatigue, but the effect lasted only 1 d. The level of fatigue at study entry was not associated with number of days of exercise or amount of exercise a woman engaged in. CONCLUSIONS: The impact of exercise on fatigue was significant and suggests the effectiveness of a low- to moderate-intensity regular exercise program in maintaining functional ability and reducing fatigue in women with breast cancer receiving chemotherapy.

Long-term persistence of symptoms.

OBJECTIVES: To provide a brief review of cognitive changes, fatigue, lymphedema, and peripheral neuropathy as persistent symptoms, and provide assessment and management information. DATA SOURCES: Published articles and research studies. CONCLUSIONS: As the number of people surviving cancer for extended periods of time continues to increase, the phenomenon of symptoms that persist following the completion of treatment is being recognized. IMPLICATIONS FOR NURSING PRACTICE: Research is needed to provide adequate knowledge about symptoms that persist following cancer treatment.

Psychometric testing of fatigue instruments for use with cancer patients.

BACKGROUND: Cancer treatment-related fatigue (CRF) is a common side effect of cancer treatment. A problem identified in most reviews of CRF is lack of sound approaches to measurement that are congruent with the conceptualization of CRF as a self-perceived state. The diversity of instruments available to measure fatigue and the lack of comprehensive testing of several promising instruments with cancer patients undergoing treatment provided the rationale for this study. The purpose of this article is to report the results of psychometric testing of several fatigue instruments in patients undergoing cancer treatment. OBJECTIVES: The aims of this study were to determine the reliability, validity, and responsiveness of each instrument and to determine the ability of each instrument to capture CRF. METHODS: Existing fatigue instruments with published psychometric information that indicated suitability for further testing were selected and included the Profile of Mood States Short Form fatigue subscale (F_POMS-sf), Multidimensional Assessment of Fatigue (MAF), Lee Fatigue Scale (LFS), and the Multidimensional Fatigue Inventory (MFI). Data were collected at a university-based clinical cancer center and a freestanding comprehensive cancer center. Subjects completed all study instruments, which were presented in random order, at a time when CRF was expected to be high and again when it was expected to be low. A subset of subjects completed the instruments within 48 hours of one of the data collection points when CRF was expected to be relatively unchanged to provide stability data. RESULTS: Reliability estimates using Cronbach's alpha indicated that all instruments examined had good internal consistency. Test-retest correlations showed good stability for total scores on all the instruments, but some subscales of the LFS and MFI had marginal stability. Factor analysis of all instruments indicated that only the LFS and the F_POMS-sf fully supported their construct validity. All of the instruments showed responsiveness to changes in CRF related to treatment. CONCLUSIONS: The results of the study provide researchers and clinicians with detailed comparisons of the performance of established fatigue measures in cancer patients undergoing treatment to use when selecting measures of CRF.

Fatigue patterns observed in patients receiving chemotherapy and radiotherapy.

The purpose of this study was to describe the patterns of cancer-related fatigue (CRF) and vigor in patients receiving chemotherapy or radiation therapy. Five studies that measured fatigue and vigor with the Profile of Mood States were used to describe the pattern of CRF and vigor during and after both types of treatment. Repeated-measures ANOVA was used to determine differences over time in each study. Results demonstrate different patterns of CRF for patients receiving chemotherapy and radiation therapy. Chemotherapy-related CRF peaks in the days after chemotherapy, whereas radiation therapy-related CRF gradually accumulates over the course of treatment. The CRF associated with both forms of treatment gradually declines over time. The prevalence, intensity, and persistence of CRF during treatment and for months after treatment is complete make this symptom one that cannot be ignored.

Does emotional expression make a difference in reactions to breast cancer?

PURPOSE/OBJECTIVES: To examine the feasibility of using an emotional expression intervention with patients with cancer and test the hypothesis that emotional expression improves psychosocial adjustment. DESIGN: Sequentially randomized pretest/post-test design with repeated measures. SETTING: Two radiation therapy (RT) facilities. SAMPLE: Women completing RT for stage I or II breast cancer, who spoke and read English, were independent in self-care, and provided written consent. Subjects (N = 44) were middle-aged (mean = 53.6 years), Caucasian, married, and well educated. METHODS: Following a baseline interview, subjects were sequentially randomized to an attentional control group, a single dose, or a three-dose emotional expression writing group. Interventions were administered at the time of completion of RT. Follow-up telephone interviews were completed at 1, 4-6, 16, and 28 weeks post-RT. MAIN RESEARCH VARIABLES: Positive and negative affect, intrusiveness of thoughts, use of avoidant coping, side effect severity, trait negative affectivity, content of written essay, and themes derived from content analysis. FINDINGS: A high level of acceptance and completion of emotional expression existed, but no effect of the intervention on psychosocial adjustment was evident. Process measures in the three-dose group changed as expected. No relationship existed between content changes and outcome measures. CONCLUSIONS: Emotional expression is feasible for patients with cancer, but the efficacy of the intervention in improving mood and decreasing cognitive intrusion and avoidance was not supported. Emotional expression processes were consistent with those seen in other samples and may influence outcomes that were not addressed in this study. IMPLICATIONS FOR NURSING PRACTICE: More extensive testing is needed, including additional outcome variables. Essays reveal concerns around communication, recurrence, and health behavior changes that should be considered in practice.

Self-care and breast cancer recovery.

PURPOSE: This study identified self-care behaviors used by women during and after radiation therapy for early-stage breast cancer. DESCRIPTION OF STUDY: Interviews with 23 women 7 months post-radiation therapy for breast cancer were analyzed for descriptions of self-care. The interviews were part of the final data collection in a longitudinal study investigating experiences post-treatment. RESULTS: Self-care behaviors reported most frequently were establishing a good support network, living life to the fullest despite illness, regulating feelings, managing stress, and taking responsibility for one's own health. Results suggest that breast cancer patients have many needs that continue to require attention post-radiation therapy, making self-care an important consideration throughout recovery. CLINICAL IMPLICATIONS: Quality of self-care may make a significant difference to women after treatment for breast cancer. Healthcare providers can promote self-care by encouraging patients to conserve energy, to engage in relationships, and to maintain a positive outlook and by suggesting activities that help patients cope, adapt, and manage symptoms during and after treatment.

Planning and conducting a multi-institutional project on fatigue.

PURPOSE/OBJECTIVES: To describe the process used in proposal development and study implementation for a complex multisite project on cancer treatment-related fatigue (CRF), identify strategies used to manage the project, and provide recommendations for teams planning multisite research. DATA SOURCES: Information derived from project team meeting records, correspondence, proposals, and personal recollection. DATA SYNTHESIS: The project was built on preexisting relationships among the three site investigators who then built a team including faculty, research coordinators, staff nurses, and students. Study sites had a range of organizational models, and the proposal was designed to capitalize on the organizational and resource strengths of each setting. Three team members drawn from outside oncology nursing provided expertise in measurement and experience with fatigue in other populations. Planning meetings were critical to the success of the project. Conference calls, fax technology, and electronic mail were used for communication. Flexibility was important in managing crises and shifting responsibility for specific components of the work. The team documented and evaluated the process used for multisite research, completed a major instrumentation study, and developed a cognitive-behavioral intervention for CRF. CONCLUSIONS: Accomplishments during the one-year planning grant exceeded initial expectations. The process of conducting multisite research is complex, especially when the starting point is a planning grant with specific research protocols to be developed and implemented over one year. Explicit planning for decision-making processes to be used throughout the project, acknowledging the differences among the study settings and planning the protocols to capitalize upon those differences, and recruiting a strong research team that included a member with planning grant and team-building expertise were essential elements for success. IMPLICATIONS FOR NURSING PRACTICE: Specific recommendations for others planning multisite research are related to team-building, team membership, communication, behavioral norms, role flexibility, resources, feedback, problem management, and shared recognition.

Concerns, affect, and cognitive disruption following completion of radiation treatment for localized breast or prostate cancer.

PURPOSE/OBJECTIVES: To describe concerns, cognitive disruption, and affect following the completion of radiation treatment (RT) for localized breast or prostate cancer. DESIGN: Cross-sectional, descriptive. SETTING: Two RT centers associated with a university hospital. SAMPLE: Patients who completed RT for prostate (n = 9) or breast cancer (n = 11). The mean age of the sample is 64 years. Ninety percent are Caucasian, 80% are married, 50% are of Latter-day Saint faith, and 50% are retired. All had early stage disease, with a mean of 20 months post-RT. METHODS: One-time interview using qualitative methods and the Life Orientation Test, Revised Impact of Events Scale, state scale of the Positive and Negative Affect Schedule, satisfaction items of the Sarason Social Support Questionnaire, and Side Effect Severity Checklist. MAIN RESEARCH VARIABLES: Frequency of intrusive thoughts or avoidant behavior, positive and negative affect, dispositional optimism, satisfaction with social support, severity of side effects, and themes extracted from semistructured interviews. FINDINGS: Most subjects had unexpected intrusive thoughts about cancer; more than one-third avoided reminders of cancer. The level of positive affect was high, as was optimism. The level of negative affect was low. Subjects' satisfaction level with social support was high. Fatigue was the most frequently reported continuing side effect. Relative optimism, acceptance, vigilance, and trust of healthcare providers were major themes. Avoidance, comparison, maintaining normalcy, and information seeking were common coping strategies. CONCLUSIONS: Subjects perceived themselves to be doing well. Fatigue was the most common long-term side effect. Subjects continued to seek information. Symptom vigilance and interpretation were important, as were having a positive outlook and maintaining normalcy. IMPLICATIONS FOR NURSING PRACTICE: Nurses must acknowledge the potential for concerns about symptoms and continuing side effects and what they mean for the patient. Clinicians need to provide accurate information about common post-treatment experiences. Clinicians also must remember that subjects have vivid recollections of both positive and negative interactions with healthcare providers.

Use of research-based practices by oncology staff nurses.

PURPOSE/OBJECTIVES: To determine the extent to which oncology staff nurses adopted eight specific research-based practices and the impact of demographic and resource factors on adoption of these practices. DESIGN: Cross-sectional mail survey. SETTING: National. SAMPLE: 1,100. METHODS: Network sampling techniques: 2,000 Oncology Nursing Society (ONS) staff nurses were randomly and proportionally selected from seven practice setting categories; each ONS nurse was asked to recruit a non-ONS staff nurse colleague. Both groups completed the Oncology Nursing Practice Questionnaire, which measures adoption of eight research-based practices. MAIN RESEARCH VARIABLES: Extent of adoption, including awareness, persuasion, and implementation of eight specific practices; nurse demographics; and work-related resources. FINDINGS: Awareness was high, with 53%-96% of nurses reporting awareness of the eight practices. Overall, 28% were aware of all practices while 10% were aware of half or fewer. Less-aware nurses differed from other nurses in demographics and resources. Computed "extent of adoption" scores showed that almost 90% of aware nurses used seven of the practices at least sometimes. CONCLUSIONS: Oncology staff nurses with awareness of a practice were implementing the practice in their organization. IMPLICATIONS FOR NURSING PRACTICE: The findings establish a need for developing educational programs to enhance awareness of specific practices and to creatively reach nurses who are unlikely to seek programs outside their employing agencies.

Using computerized clinical nursing data bases for nursing research.

Computerized clinical nursing data bases (CCNDBs) have significant potential as sources of data for research on the processes and outcomes of nursing care. The emergence of nurse-managed practice sites, in which patient care is driven predominantly by nurses' decisions, has prompted renewed interest in using data from these practices to answer questions that are important to nurses. The purpose of this article is to articulate strategies for using CCNDBs for nursing research. Recognition of the differences between clinical and research data bases is essential. The steps involved in obtaining and using computerized clinical data can be grouped into three phases: (1) locating and accessing CCNDBs, (2) assessing the content and quality of the data, and (3) extracting and analyzing the data. Processes involved in phase 1 include determining the research question, identifying eligible CCNDBs, negotiating access to the CCNDB, and ensuring the privacy and confidentiality of subjects. In phase 2 the processes include determining the content of the candidate CCNDBs, assessing the quality of the data in candidate CCNDBs, and determining the technical usability of data in candidate CCNDBs. Phase 3 involves mapping CCNDB data elements to research variables; determining data and record selection criteria; writing and implementing a query to select the desired records; designing a data base and record structure for research variables; performing analytic procedures on the research data; and reporting results of the research. Phases and procedures are discussed in detail in the article.

Fatigue and weakness in cancer patients: the symptoms experience.

OBJECTIVES: To distinguish between fatigue and weakness and review symptom management for both and to suggest directions for research and practice. DATA SOURCES: Articles and book chapters pertaining to fatigue and weakness. CONCLUSIONS: Fatigue and weakness are important but long-neglected symptoms, and comparatively little effort has been invested in developing techniques to mitigate these symptoms. Research is needed to differentiate between these concepts, to determine the relation between fatigue and weakness, to delineate their causes, and to develop interventions aimed at the prevention and treatment of these symptoms. IMPLICATIONS FOR NURSING PRACTICE: Early assessment of risk factors, mobility and sensory problems, and usual level of activity will help identify those patients who may benefit from nursing interventions or referrals for occupational or physical therapy. It is important to repeatedly evaluate these symptoms in relation to treatment, situational changes, interventions used to manage other symptoms, and tumor progression. Developing clinical guidelines and intervention strategies will contribute greatly to the functional independence and the quality of life of patients.

Patients' use of prevention behaviors in managing side effects related to chemotherapy.

PURPOSE/OBJECTIVES: To describe the use of prevention and early detection behaviors related to the side effects of chemotherapy. DESIGN: Cross-sectional, descriptive, and secondary analysis. SETTING: A large university hospital and university-affiliated community hospital. SAMPLE: 46 adult patients with cancer starting a cycle of IV chemotherapy who were predominantly white, married, and female. METHODS: Self-report utilizing a 17-item, self-administered prevention and early detection questionnaire called the Prevention Behaviors Questionnaire (PBQ); questionnaires were completed two days and five days after treatment. MAIN RESEARCH VARIABLE: Prevention and early detection behaviors. FINDINGS: Patients reported using an average of 8.8 prevention behaviors two days after chemotherapy and 9.2 behaviors five days after chemotherapy. "Tried to think more positively" was the most frequently used behavior. Internal consistency and test-retest correlation coefficients on the questionnaire were calculated to be 0.81 and 0.78, respectively. CONCLUSIONS: The PBQ had adequate internal consistency and test-retest reliability. Patients reported using many prevention and detection behaviors, although very little is known about the efficacy of these behaviors in reducing or preventing the side effects of chemotherapy. IMPLICATIONS FOR CLINICAL PRACTICE: This exploratory study does not have direct implications for practice but identifies an area for future research that may affect what nurses teach patients and how they assist patients to cope with treatment.

A comparison of patient-reported side effects among three chemotherapy regimens for breast cancer.

Patient's perceptions of side effects and the influence of treatment on daily activities are important considerations in choosing a chemotherapy regimen. However, there are no studies comparing patients' experiences with three commonly used chemotherapy regimens for breast cancer. The authors compared the patient-reported side effects and disruption in usual activities for cyclophosphamide and fluorouracil combined with methotrexate (CMF), doxorubicin (CAF), or mitoxantrone (CNF) in 86 women receiving treatment for breast cancer. The incidence and severity of side effects and disruption in usual activities were recorded by patients in a self-care diary (SCD) 2 and 5 days after the first and second drug cycles. Patients reported a mean of 3.2 to 4.9 side effects at each point in time. Fatigue, nausea, anorexia, taste changes, and headache were the most frequently reported side effects and did not differ in incidence among the three drug regimens. When repeated measures analysis of covariance was conducted using mean substitution for missing data and controlling for stage of disease, women receiving CAF reported more severe nausea than women receiving CMF or CNF (P < 0.05). Fatigue was significant for time; however, a distinct clinical pattern of fatigue was not apparent. Patients reported moderate levels of disruption in activities of daily living, with those receiving CAF having greater disruption. There was no difference among treatment groups in reports of overall disruption in activities. These data on patient reported experiences with side effects of chemotherapy can be used to prepare patients for specific side effects of treatment and facilitate symptom management.

1991 Oncology Nursing Society Research Priorities Survey.

Documenting current research priorities is an ongoing process that is important to furthering the research agenda of oncology nursing. The purpose of this study was to update and partially replicate previous Oncology Nursing Society (ONS) research priorities surveys. Questionnaires were sent to a convenience sample of 429 ONS members involved in research or in ONS leadership. The response rate was 70% (N = 310). Respondents identified a combination of clinical problems, research issues, and cancer care economic factors among their top 10 research priorities. Quality of life and symptom management consistently were ranked as the highest priority items across all three methods used to rank-order the items. Respondents also provided suggestions for future ONS/Oncology Nursing Foundation small grants and for expansion of current ONS research activities. These findings provide direction for the focus of oncology nursing research by suggesting topics for research, by identifying areas that require additional research funding, by recommending new research activities for ONS, and by promoting research as the basis for oncology nursing practice.

Use and perceived efficacy of self-care activities in patients receiving chemotherapy.

Information about chemotherapy side effects and the efficacy of self-care activities used to deal with these side effects is needed to direct nursing interventions for patients receiving chemotherapy. Using the self-care diary (SCD) developed for this study, a sample of 49 adult patients with cancer recorded their side effects, rated the severity of each side effect, and reported on the use and efficacy of self-care activities two days after treatment. Data were collected again five days after treatment to examine the test-retest reliability of the side effect severity component of the SCD. The most common side effect, experienced by 81% of the subjects, was fatigue. Other side effects reported by more than one-third of the subjects were sleeping difficulty, nausea, decreased appetite, and changes in taste or smell. The most frequently reported side effects received mean severity scores indicative of moderate severity. The most commonly used self-care activities were rated as providing some relief to moderate relief of individual side effects. None of the reported self-care activities received mean efficacy ratings that indicated complete side effect relief.

Involving clinicians in nursing research.

Collaborative relationships between researchers and clinicians are important in developing the research base for nursing practice. Clinicians contribute to the research process by identifying practice problems, reformulating practice problems into research questions, critiquing the conceptualization and design of the study, evaluating the clinical feasibility of the research protocol, assisting in implementing the research protocol, raising clinical questions relevant to data analyses, and interpreting the results of the study from a clinical perspective. Collaboration between clinicians and researchers on clinical nursing research has the potential to improve patient care by increasing the number of studies completed, enhancing the clinical relevance of oncology nursing research, and strengthening the conceptualization and design of the studies.