Common and distinct risk factors that influence more severe and distressing shortness of breath profiles in oncology outpatients.

BACKGROUND: Shortness of breath occurs in 10%-70% of oncology patients. Very little is known about interindividual variability in its severity and distress and associated risk factors. Using latent profile analyses (LPAs), purpose was to identify subgroups of patients with distinct severity and distress profiles for shortness of breath as single symptom dimensions. In addition, a joint LPA was done using patients' severity AND distress ratings. For each of the three LPAs, differences among the shortness of breath classes in demographic, clinical, symptom, stress, and resilience characteristics were evaluated. METHODS: Patients completed ratings of severity and distress from shortness of breath a total of six times over two cycles of chemotherapy. All of the other measures were completed at enrollment (i.e., prior to the second or third cycle of chemotherapy). Separate LPAs were done using ratings of severity and distress, as well as a joint analysis using severity AND distress ratings. Differences among the latent classes were evaluated using parametric and nonparametric tests. RESULTS: For severity, two classes were identified (Slight to Moderate [91.6%] and Moderate to Severe [8.4%]). For distress, two classes were identified (A Little Bit to Somewhat [83.9%] and Somewhat to Quite a Bit [16.1%]). For the joint LPA, two classes were identified (Lower Severity and Distress [79.9%] and Higher Severity and Distress [20.1%]). While distinct risk factors were associated with each of the LPAs, across the three LPAs, the common risk factors associated with membership in the worse class included: a past or current history of smoking, poorer functional status, and higher comorbidity burden. In addition, these patients had a higher symptom burden and higher levels of cancer-specific stress. CONCLUSIONS: Clinicians can use the information provided in this study to identify high-risk patients and develop individualized interventions.

Various types of stress and greater use of disengagement coping are associated with worse sleep disturbance in oncology patients undergoing chemotherapy.

Various types of stress and the choice of coping strategies may be risk factors for higher levels of sleep disturbance in oncology patients. Purposes were to evaluate for differences in global, cancer-specific, and cumulative life stress, as well as resilience and the use of coping strategies among three subgroups of patients with distinct sleep disturbance profiles (i.e., Low, High, Very High). Oncology outpatients (n = 1331) completed measures of global (Perceived Stress Scale), cancer-specific (Impact of Event Scale-Revised), and cumulative life (Life Stressor Checklist-Revised) stress, resilience (Connor-Davidson Resilience Scale) and coping (Brief Cope) prior to their second or third cycle of chemotherapy. Sleep disturbance was assessed six times over two chemotherapy cycles. Differences were evaluated using parametric and non-parametric tests. All stress measures showed a dose response effect (i.e., as the sleep disturbance profile worsened, levels of all types of stress increased). Compared to Low class, the other two classes reported higher levels of global perceived stress and higher occurrence rates and effect from previous stressful life events. Impact of Event Scale-Revised scores for the Very High class indicated post-traumatic symptomatology. Patients in High and Very High classes had resilience scores below the normative score for the United States population and used a higher number of disengagement coping strategies. Our findings suggest that very high levels of sleep disturbance are associated with higher levels of various types of stress, lower levels of resilience, and higher use of disengagement coping strategies. Clinicians need to perform routine assessments and implement symptom management interventions to reduce stress and encourage the use of engagement coping strategies.

The Faculty Nurse Attending Model at the Mount Sinai Hospital.

The ongoing nursing shortage and the ravages of the COVID-19 pandemic have further challenged nursing staff with devastating shortages. This article describes the Faculty Nurse Attending Model, an innovative approach incorporating nursing faculty into staffing and the ongoing interdisciplinary rounds at the Mount Sinai Hospital in New York City. The Mount Sinai Phillips School of Nursing faculty actively participates in the pilot unit to support nursing practice and ensure that the curricula address contemporary practice.

Oncology Outpatients With Worse Anxiety and Sleep Disturbance Profiles Are at Increased Risk for a Higher Symptom Burden and Poorer Quality of Life.

BACKGROUND: Anxiety and sleep disturbance are frequent symptoms during chemotherapy. OBJECTIVES: Purposes were to identify subgroups of oncology outpatients with distinct joint anxiety and sleep disturbance profiles, as well as evaluate for differences in demographic and clinical characteristics, sleep disturbance characteristics, severity of common symptoms, and quality-of-life outcomes among these subgroups. METHODS: Oncology outpatients (n = 1331) completed self-report measures of anxiety and sleep disturbance 6 times over 2 chemotherapy cycles. Latent profile analysis was done to identify subgroups of patients with distinct joint anxiety and sleep disturbance profiles. RESULTS: Three profiles were identified (ie, no anxiety and low sleep disturbance (59.7%), moderate anxiety and high sleep disturbance (32.5%), high anxiety and very high sleep disturbance (7.8%)). Compared with the no anxiety and low sleep disturbance class, the other 2 classes were younger; less likely to be married; had a lower annual household income; and had childcare responsibilities. Patients in the 2 worse profiles had problems with both sleep initiation and maintenance. These patients reported higher levels of depressive symptoms, trait and state anxiety, and evening fatigue, as well as lower levels of morning and evening energy, cognitive function, and poorer quality of life. CONCLUSIONS: More than 40% of patients had moderate or high levels of anxiety and high or very high levels of sleep disturbance. Modifiable risk factors associated with these profiles may be used to develop targeted interventions for 1 or both symptoms. IMPLICATIONS FOR PRACTICE: Clinicians need to assess for the co-occurrence of anxiety and sleep disturbance.

Distinct Worst Pain Profiles in Oncology Outpatients Undergoing Chemotherapy.

BACKGROUND: While pain is a significant problem for oncology patients, little is known about interindividual variability in pain characteristics. OBJECTIVE: The aims of this study were to identify subgroups of patients with distinct worst pain severity profiles and evaluate for differences among these subgroups in demographic, clinical, and pain characteristics and stress and symptom scores. METHODS: Patients (n = 934) completed questionnaires 6 times over 2 chemotherapy cycles. Worst pain intensity was assessed using a 0- to 10-point numeric rating scale. Brief Pain Inventory was used to assess various pain characteristics. Latent profile analysis was used to identify subgroups of patients with distinct pain profiles. RESULTS: Three worst pain profiles were identified (low [17.5%], moderate [39.9%], severe [42.6%]). Compared with the other 2 classes, severe class was more likely to be single and unemployed and had a lower annual household income, a higher body mass index, a higher level of comorbidity, and a poorer functional status. Severe class was more likely to have both cancer and noncancer pain, a higher number of pain locations, higher frequency and duration of pain, worse pain quality scores, and higher pain interference scores. Compared with the other 2 classes, severe class reported lower satisfaction with pain management and higher global, disease-specific, and cumulative life stress, as well as higher anxiety, depression, fatigue, sleep disturbance, and cognitive dysfunction scores. CONCLUSIONS: Unrelieved pain is a significant problem for more than 80% of outpatients. IMPLICATIONS FOR PRACTICE: Clinicians need to perform comprehensive pain assessments; prescribe pharmacologic and nonpharmacologic interventions; and initiate referrals for pain management and psychological services.

Symptom clusters in oncology outpatients: stability and consistency across a cycle of chemotherapy.

OBJECTIVES: Improved understanding of the stability and consistency of symptom clusters across time, symptom dimensions and cancer diagnoses will lead to refinements in symptom assessments and management, and provide direction for mechanistic studies. Study purposes were to describe the occurrence, severity and distress of 38 symptoms; evaluate the stability and consistency of symptom clusters across a cycle of chemotherapy, three symptom dimensions and four distinct cancer types; and identify common and distinct symptom clusters. METHODS: Oncology outpatients (n=1329) completed the Memorial Symptom Assessment Scale prior to their next cycle of chemotherapy (T1), 1 week after chemotherapy (T2) and 2 weeks after chemotherapy (T3). Symptom clusters were identified using exploratory factor analysis using unweighted least squares. GEOMIN rotated factor loadings with absolute values ≥0.40 were considered meaningful. Clusters were stable if they were identified across each time point and/or dimension. Clusters were consistent if the same two or three symptoms with the highest factor loadings were identified across each time point and/or dimension. RESULTS: Patients reported 13.9 (±7.2) symptoms at T1, 14.0 (±7.0) at T2 and 12.2 (±6.8) at T3. Psychological, weight gain, gastrointestinal and respiratory clusters were stable across time and dimensions. Only the psychological, weight gain and respiratory clusters were consistent across time and dimensions. CONCLUSION: Given the stability of the psychological, weight gain and gastrointestinal clusters across cancer diagnoses, symptoms within these clusters need to be routinely assessed. However, respiratory and hormonal clusters are unique to specific cancer types and the symptoms within these clusters are variable.

Improved 30-Day Heart Failure Readmissions Following Implementation of an Advanced Cardiovascular Education (ACE) Academy.

BACKGROUND: Heart failure readmissions are common, though some are preventable through evidence-based management. LOCAL PROBLEM: Despite outperforming national benchmarks for 30-day readmissions, compliance with an evidence-based institutional heart failure management pathway was inconsistent. The purpose of this project was to reduce 30-day heart failure readmission rates through an educational intervention and an electronic health record (EHR) redesign. METHODS: The cardiac services nursing leadership team conducted an education and documentation needs assessment to identify knowledge gaps and practical barriers to effective utilization of evidence-based interventions for heart failure management. INTERVENTIONS: This intervention included an Advanced Cardiovascular Education (ACE) Academy and an EHR workflow redesign for clinical and supportive nursing staff. RESULTS: The 30-day heart failure readmission rates reduced immediately following the intervention, and rates continued to decrease over a 3-year follow-up. CONCLUSIONS: Even among hospitals outperforming national benchmarks, 30-day heart failure readmissions can be reduced and sustained with enhanced education and EHR redesign.

Identification of Distinct Symptom Profiles in Cancer Patients Using a Pre-Specified Symptom Cluster.

CONTEXT: Pain, fatigue, sleep disturbance, and depression often co-occur in oncology patients and negatively impact quality of life (QOL). OBJECTIVES: Study purposes were to identify subgroups of patients with distinct symptom profiles based on their experiences with a pre-specified symptom cluster (i.e., pain, fatigue, depression, sleep disturbance) and to identify demographic, clinical, and symptom characteristics and QOL outcomes associated with each distinct profile. METHODS: Patients with breast, lung, gastrointestinal, and gynecologic cancers (n = 1340) were recruited from outpatient clinics during their first or second cycle of chemotherapy. They completed valid and reliable measures of pain, fatigue, sleep disturbance. depression, and QOL prior to their next dose of chemotherapy. Latent class profile analysis was used to identify the patient subgroups. Differences among the profiles were evaluated using parametric and non-parametric tests. RESULTS: Three distinct profiles were identified (i.e., Low (44.0%), Moderate (45.1%), High (10.8%). Compared to Low class, Moderate and High classes were younger and more likely to be female. Compared to the other two classes, High class was less likely to be married/partnered and employed, more likely to have a lower income and childcare responsibilities, had lower functional status, a higher body mass index, and exercised less. For both QOL scales, differences in subscale and total scores followed the same pattern (Low>Moderate>High). CONCLUSIONS: Over 55% of patients undergoing chemotherapy had a moderate to high symptom burden associated with these four common co-occurring symptoms. Multimodal interventions are needed to decrease symptom burden and improve QOL outcomes in these patients.

Stability of Symptom Clusters in Patients With Gynecologic Cancer Receiving Chemotherapy.

BACKGROUND: Patients with gynecologic cancer undergoing chemotherapy experience multiple co-occurring symptoms. Understanding how symptom clusters change over time is essential to the development of interventions that target multiple co-occurring symptoms. OBJECTIVE: The aim of this study was to assess the relative stability of symptom clusters across a chemotherapy cycle in patients with gynecologic cancer. METHODS: This is a longitudinal, descriptive study. Eligible patients (n = 232) were English-speaking adults (≥18 years old) with gynecologic cancer. Data were collected in the week before patients' second or third cycle of chemotherapy (T1) and at 1 (T2) and 2 (T3) weeks after chemotherapy. Three dimensions of the symptom experience (occurrence, severity, and distress) were assessed using a modified version of the Memorial Symptom Assessment Scale. Symptom clusters for each dimension and time point were identified through exploratory factor analysis. RESULTS: A 5-factor solution was selected for each exploratory factor analysis. Hormonal, respiratory, and weight change clusters were identified across all dimensions and time points. A psychological symptom cluster was identified at T1 for occurrence and severity and at T2 and T3 for all 3 dimensions. A gastrointestinal symptom cluster was identified at T1 for occurrence and at T2 and T3 for all 3 dimensions. The hormonal, respiratory, psychological, and weight change symptom clusters exhibited common symptoms across dimensions and time points. CONCLUSIONS: Hormonal, respiratory, weight change, and psychological symptom clusters are relatively stable across a cycle of chemotherapy in patients with gynecologic cancer. IMPLICATIONS FOR PRACTICE: Clinicians need to assess patients for multiple co-occurring symptoms and initiate multimodal interventions.

Anxiety profiles are associated with stress, resilience and symptom severity in outpatients receiving chemotherapy.

PURPOSE: The purposes of this study, in a sample of oncology patients (n = 1326) receiving chemotherapy, were to identify subgroups of patients with distinct anxiety profiles and evaluate for differences in demographic and clinical characteristics, stress and resilience measures, and severity of co-occurring symptoms (i.e., depression, sleep disturbance, attentional function, fatigue, pain). METHODS: Patients completed self-report questionnaires a total of six times over two cycles of chemotherapy. Severity of state anxiety was evaluated using the Spielberger State Anxiety Inventory and resilience was assessed using the Connor-Davidson Resilience Scale. Symptoms were assessed using the Center for Epidemiologic Studies Depression Scale, General Sleep Disturbance Scale, Lee Fatigue Scale, Attentional Function Index and Brief Pain Inventory. RESULTS: Based on the findings from the latent profile analysis that utilized the six assessments of state anxiety, 47.7% of the patients were classified as "Low," 28.3% as "Moderate," 19.5% as "High," and 4.5.% as "Very High." Anxiety levels remained relatively stable across the six timepoints. Compared to the Low class, membership in the Moderate, High, and Very High classes was associated with a number of characteristics (e.g., younger age, female gender, lower functional status, more comorbidities). Those patients with higher levels of anxiety reported higher levels of stress, lower levels of resilience, and increased severity of co-occurring symptoms. CONCLUSION: Our findings suggest that a substantial number of oncology patients may warrant referral to psychological services. Clinicians need to perform systematic assessments of anxiety, stress, and common symptoms and initiate appropriate interventions to enhance resilience and coping.

Higher Levels of Stress Are Associated With a Significant Symptom Burden in Oncology Outpatients Receiving Chemotherapy.

CONTEXT: A cancer diagnosis and associated treatments, as well as the uncertainty of the disease course, are stressful experiences for most patients. However, little information is available on the relationship between stress and symptom burden. OBJECTIVES: The study purpose was to evaluate for differences in the severity of fatigue, lack of energy, sleep disturbance, and cognitive function, among three groups of patients with distinct stress profiles. METHODS: Patients receiving chemotherapy (n = 957) completed measures of general, cancer-specific, and cumulative life stress and symptom inventories. Latent profile analysis was used to identify subgroups of patients with distinct stress profiles. RESULTS: Three distinct subgroups of patients were identified (i.e., stressed [39.3%], normative [54.3%], resilient [5.7%]). For cognitive function, significant differences were found among the latent classes (stressed < normative < resilient). For both sleep disturbance and morning and evening fatigue, compared to the normative and resilient classes, the stressed class reported higher severity scores. Compared to the normative and resilient classes, the stressed class reported low levels of morning energy. Compared to the normative class, the stressed class reported lower levels of evening energy. CONCLUSIONS: Consistent with our a priori hypothesis, patients in the stressed class had the highest symptom severity scores for all four symptoms and all these scores were above the clinically meaningful cutoffs for the various instruments.

Prescribed Walking for Glycemic Control and Symptom Management in Patients Without Diabetes Undergoing Chemotherapy.

BACKGROUND: Hyperglycemia may potentiate symptom experiences. Exercise is a nonpharmacological intervention that can potentially improve glycemic control and mitigate symptom experiences in patients undergoing chemotherapy for cancer. OBJECTIVES: The primary objective was to assess the feasibility of patients engaging in a walking exercise study for 6 months. We also evaluated the effects of a prescribed walking program on glycemic control and for changes over time in the severity of pain, fatigue, depression, and sleep disturbance in patients undergoing chemotherapy for breast, lung, gynecologic, or gastrointestinal cancer. METHODS: A randomized pilot intervention study was conducted to evaluate differences within and between a prescribed walking program intervention group and a control group. All patients were followed for 6 months, had glycosylated hemoglobin A1c measured at enrollment and 6 months, and completed symptom questionnaires at enrollment, 3 months, and 6 months. Data were analyzed using descriptive statistics and analysis of covariance. RESULTS: Most of the patients who enrolled completed the 6-month study. The few who withdrew expressed feeling overwhelmed. The sample was predominately non-Hispanic White female patients with breast cancer with a normal-to-slightly-overweight body mass index. The intervention group had a slight decrease in glycosylated hemoglobin A1c at 6 months. In addition, at 6 months, compared to the control group, the intervention group had significantly less sleep disturbance and depression. No other within- or between-group differences were found. DISCUSSION: It is feasible for patients undergoing chemotherapy to participate in a prescribed walking program. Exercise, such as walking, may decrease hyperglycemia and symptom severity. Additional research with larger samples is warranted.

Alterations in Patterns of Gene Expression and Perturbed Pathways in the Gut-Brain Axis Are Associated With Chemotherapy-Induced Nausea.

CONTEXT: Despite current advances in antiemetic treatments, approximately 50% of oncology patients experience chemotherapy-induced nausea (CIN). OBJECTIVES: The purpose of this study was to evaluate for differentially expressed genes and perturbed pathways associated with the gut-brain axis (GBA) across two independent samples of oncology patients who did and did not experience CIN. METHODS: Oncology patients (n = 735) completed study questionnaires in the week before their second or third cycle of chemotherapy. CIN occurrence was assessed using the Memorial Symptom Assessment Scale. Gene expression analyses were performed in two independent samples using ribonucleic acid sequencing (Sample 1, n = 357) and microarray (Sample 2, n = 352) methodologies. Fisher's combined probability method was used to determine genes that were differentially expressed and pathways that were perturbed between the two nausea groups across both samples. RESULTS: CIN was reported by 63.6% of the patients in Sample 1 and 48.9% of the patients in Sample 2. Across the two samples, 703 genes were differentially expressed, and 37 pathways were found to be perturbed between the two CIN groups. We identified nine perturbed pathways that are involved in mechanisms associated with alterations in the GBA (i.e., mucosal inflammation, disruption of gut microbiome). CONCLUSION: Persistent CIN remains a significant clinical problem. Our study is the first to identify novel GBA-related pathways associated with the occurrence of CIN. Our findings warrant confirmation and suggest directions for future clinical studies to decrease CIN occurrence.

Symptom Clusters in Patients With Gastrointestinal Cancers Using Different Dimensions of the Symptom Experience.

CONTEXT: Patients with gastrointestinal (GI) cancers undergoing chemotherapy (CTX) experience multiple cooccurring symptoms. OBJECTIVES: The aim of this study was to describe the occurrence, severity, and distress of 38 symptoms and to identify symptom clusters based on three symptom dimensions (i.e., occurrence, severity, and distress) in patients with GI cancers receiving CTX (n = 399). We compared whether the numbers and types of symptom clusters differed based on the dimension of the symptom experience used to create the clusters. METHODS: A modified version of the Memorial Symptom Assessment Scale was used to assess the occurrence, severity, and distress of 38 symptoms before the initiation of the patient's next dose of CTX. Exploratory factor analysis was used to determine the symptom clusters. RESULTS: These patients experienced 13.0 (±7.1) symptoms before their second or third dose of CTX. For all three symptom dimensions, four symptom clusters were identified, namely psychological distress, CTX-related, GI, and weight change. The number and types of symptom clusters were relatively similar using all three symptom dimensions. However, some variability was found in the specific symptoms within each of the clusters. CONCLUSION: Our findings suggest that patients with GI cancers experience multiple cooccurring symptoms. Consistent with previous studies of patients with a variety of cancer diagnoses, psychological and GI clusters are common. Clinicians need to assess for and tailor interventions for these symptom clusters.

Risk Factors Associated With Chemotherapy-Induced Nausea in the Week Before the Next Cycle and Impact of Nausea on Quality of Life Outcomes.

CONTEXT: Despite current advances in antiemetic treatments, between 19% and 58% of oncology patients experience chemotherapy-induced nausea (CIN). OBJECTIVES: Aims of this post hoc exploratory analysis were to determine occurrence, severity, and distress of CIN and evaluate for differences in demographic and clinical characteristics, symptom severity, stress; and quality of life (QOL) outcomes between oncology patients who did and did not report CIN in the week before chemotherapy (CTX). Demographic, clinical, symptom, and stress characteristics associated with CIN occurrence were determined. METHODS: Patients (n = 1296) completed questionnaires that provided information on demographic and clinical characteristics, symptom severity, stress, and QOL. Univariate analyses evaluated for differences in demographic and clinical characteristics, symptom severity, stress, and QOL scores between the two patient groups. Multiple logistic regression analysis was used to evaluate for factors associated with nausea group membership. RESULTS: Of the 1296 patients, 47.5% reported CIN. In the CIN group, 15% rated CIN as severe and 23% reported high distress. Factors associated with CIN included less education; having childcare responsibilities; poorer functional status; higher levels of depression, sleep disturbance, evening fatigue, and intrusive thoughts; as well as receipt of CTX on a 14-day CTX cycle and receipt of an antiemetic regimen that contained serotonin receptor antagonist and steroid. Patients in the CIN group experienced clinically meaningful decrements in QOL. CONCLUSION: This study identified new factors (e.g., poorer functional status, stress) associated with CIN occurrence. CIN negatively impacted patients' QOL. Pre-emptive and ongoing interventions may alleviate CIN occurrence in high-risk patients.

Differences in symptom occurrence, severity, and distress ratings between patients with gastrointestinal cancers who received chemotherapy alone or chemotherapy with targeted therapy.

BACKGROUND: Approximately 28% of patients with gastrointestinal (GI) cancers will receive targeted therapy (TT) because of the associated increases in survival. Only four studies have examined the symptom experience of these patients. To date, no studies have evaluated for differences in symptom occurrence, severity, and distress between patients who received chemotherapy (CTX) alone (n=304) or CTX with TT (n=93). METHODS: Patients completed self-report questionnaires, approximately one week after they received CTX. A modified version of the Memorial Symptom Assessment Scale (MSAS) was used to obtain data on symptom occurrence, severity, and distress. Binary logistic regression analyses were used to test for differences in symptom occurrence rates between the two treatment groups. Ordinal logistic regression analyses were used to test for differences in severity and distress ratings between the two treatment groups. RESULTS: Patients who received CTX with TT were significantly younger (P=0.009); were diagnosed with cancer longer (P=0.004); had a higher number of prior treatments (P=0.024); had metastatic disease, specifically to the liver (P<0.001); had a diagnosis of anal, colon, rectum, or colorectal cancer (CRC) (P<0.001); and were positive for detection of B-Raf proto-oncogene, serine/threonine kinase (BRAF) and Kirsten rat sarcoma viral oncogene homolog (KRAS) mutations (both P<0.001). In addition, CTX treatment regimens were significantly different between the two groups (P<0.001). After controlling for significant covariates, patients who received TT reported lower occurrence rates for lack of energy, cough, feeling drowsy, and difficulty sleeping (all, P<0.05). Patients who received TT reported lower severity scores for dry mouth (P=0.034) and change in the way food tastes (P=0.035). However, they reported higher severity scores for "I don't look like myself" (P=0.026). No differences in symptom distress scores were found between the two treatment groups. CONCLUSIONS: This study is the first to evaluate for differences in the symptom experience of GI cancer patients who received CTX alone or CTX with TT using a multidimensional symptom assessment scale. While between group differences in patients' symptom experiences were identified, both treatment groups warrant ongoing assessments to optimally manage their symptoms.

Predictors of the multidimensional symptom experience of lung cancer patients receiving chemotherapy.

PURPOSE: Few studies have examined interindividual variability in the symptom experience of lung cancer patients. We aimed to identify the most prevalent, severe, and distressing symptoms, and risk factors associated with increased symptom burden. METHODS: Lung cancer patients (n = 145) reported occurrence, severity, and distress for 38 symptoms on the Memorial Symptom Assessment Scale 1 week after chemotherapy. Using multidimensional subscales, risk factors for higher global distress, physical, and psychological symptoms were evaluated using simultaneous linear regression. RESULTS: Mean age was 64.0 years and 56.6% were female. Mean Karnofsky Performance Status score was 79.1 (SD 14.6) and mean Self-Administered Comorbidity Questionnaire score was 7.3 (SD 3.9). The most distressing and prevalent symptom was fatigue. Problems with sexual interest/activity had the highest mean severity rating. Patients with lower functional status (p = 0.001) and higher comorbidity (p = 0.02) reported higher global distress. Similarly, lower functional status (p = 0.003) and higher comorbidity (p = 0.04) were associated with a higher physical symptom burden along with lower body mass index (p = 0.02). Higher psychology symptom burden was associated with lower functional status (p = 0.01), younger age (p = 0.02), non-metastatic disease (p = 0.03), higher number of prior treatments (p = 0.04), and income (p = 0.03). CONCLUSIONS: Fatigue was the most distressing and prevalent symptom among lung cancer patients receiving chemotherapy. Lower functional status was associated with a higher burden of global distress, physical, and psychological symptoms. Younger age and non-metastatic disease were additional risk factors for increased psychological symptoms. Together, these risk factors can help clinicians identify lung cancer patients at increased need for aggressive symptom management.

Delivery of Quality Oncology Care in a Large, Urban Practice: A Primer.

A comprehensive quality improvement program is critically important for participation in value-based reimbursement models. Seven essential characteristics must be addressed in the development of a cancer-focused quality program. These include leadership, environment, engagement, ethos, metrics, accountability, and sustainability (Q=LE3MAS). This article describes how to address each essential characteristic and provides examples from the experience at Mount Sinai Hospital, a large, urban, academic hospital/health system in New York City.

Comparison of subgroups of breast cancer patients on pain and co-occurring symptoms following chemotherapy.

PURPOSE: The purposes of this study, in a sample of women with breast cancer receiving chemotherapy (CTX), were to identify subgroups of women with distinct experiences with the symptom cluster of pain, fatigue, sleep disturbance, and depressive symptoms and evaluate differences in demographic and clinical characteristics, differences in psychological symptoms, and differences in pain characteristics among these subgroups. METHODS: Patients completed symptom questionnaires in the week following CTX administration. Latent class profile analysis (LCPA) was used to determine the patient subgroups. RESULTS: Three subgroups were identified: 140 patients (35.8 %) in the "low," 189 patients (48.3 %) in the "moderate," and 62 patients (15.9 %) in the "all high" latent class. Patients in the all high class had a lower functional status, a higher comorbidity profile, a higher symptom burden, and a poorer quality of life. CONCLUSIONS: Study findings provide evidence of the utility of LCPA to explain inter-individual variability in the symptom experience of patients undergoing CTX. The ability to characterize subgroups of patients with distinct symptom experiences allows for the identification of high-risk patients and may guide the design of targeted interventions that are tailored to an individual's symptom profile.

Glycosylated Hemoglobin A1c and Lack of Association With Symptom Severity in Patients Undergoing Chemotherapy for Solid Tumors.

PURPOSE/OBJECTIVES: To assess the effects of high blood sugar at the levels of diabetic or prediabetic states during cancer treatment because patients undergoing chemotherapy (CTX) experience multiple symptoms that vary among individuals and may be affected by glucose levels. DESIGN: Descriptive, cross-sectional. SETTING: Two comprehensive cancer centers, one Veterans Affairs hospital, and four community-based oncology programs. SAMPLE: 244 outpatients with breast, gastrointestinal, gynecologic, and lung cancers. METHODS: Patients completed demographic and symptom questionnaires. Glycosylated hemoglobin A1c (HbA1c) was evaluated to determine diabetic state. Descriptive statistics and one-way analyses of variance were used in the analyses. MAIN RESEARCH VARIABLES: HbA1c, symptom severity scores, patient and clinical characteristics (e.g., age, gender, comorbidities, sociodemographic information, body mass index [BMI], lifestyle factors). FINDINGS: HbA1c results showed 9% of the sample in the diabetic and 26% in the prediabetic state. Patients in the diabetic state reported a higher number of comorbid conditions and were more likely to be African American. Patients in the prediabetic state were older aged. Patients in the diabetic and prediabetic states had a higher BMI compared to nondiabetic patients. No differences in symptom severity or quality-of-life (QOL) scores were found among the three diabetic states. CONCLUSIONS: This study is the first to evaluate for associations between diabetic states and symptom severity and QOL scores in patients receiving CTX. This study confirmed that older age, as well as having higher BMI and having multiple comorbidities, were associated with increased mean glycemic levels. IMPLICATIONS FOR NURSING: Clinicians should assess and identify patients with diabetes or prediabetes undergoing treatment for cancer. Patients who are older aged, those with a high BMI, and those with multiple comorbid conditions may be at increased risk for higher glycemic states.