Study Protocol for the Breathe Easier Trial: A Pilot RCT of a Dyad-Based, Multiple-Behavior Intervention for Improving Physical and Emotional Health in Survivors Facing Lung Cancer.

BACKGROUND: Research targeting survivors of lung cancer has yet to adequately address the management of physical deconditioning and unresolved symptoms (dyspnea, fatigue). The objective of the Breathe Easier trial is to test the feasibility and preliminary effects of a theory-based, multiple-behavior intervention (physical activity, smoking reduction for current smokers, stress management) targeting survivors of localized non-small-cell lung cancer (NSCLC, stages I-III) and their supportive partners. METHODS: This pilot RCT will enroll 30 dyads (60 participants). Each dyad will consist of one survivor and one partner (defined as a family member or friend) Dyads will be randomized to the Intervention Group (IG) or the Attention Control Group (AC). IG members will receive the 12-week, home-based intervention based on the individual and family self-management theory, which targets improvements in self-efficacy, social support, and self-regulation. Improvement in lifestyle behaviors is a proximal outcome. Improvements in physical and emotional health are distal outcomes. Breathe Easier (IG) includes educational content written in plain language as well as breathing exercises and meditations; SMART goal setting; daily text messaging; and weekly telephone calls with trained staff. The AC program includes relevant National Institutes of Health publications plus weekly telephone chats. Members who currently smoke will also receive an evidence-based smoking cessation resource. DISCUSSION: Breathe Easier focuses on changes in multiple behaviors in dyads coping with a diagnosis of NSCLC (stages I-III) with the overall purpose of improving physical and emotional health. Findings will provide additional evidence of the feasibility and preliminary effects of this intervention. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05956782; This trial was registered retrospectively.

Development and testing of "Is Lung Cancer Screening for You?" A computer-based decision aid.

PURPOSE: To reduce lung cancer mortality, individuals at high-risk should receive a low-dose computed tomography screening annually. To increase the likelihood of screening, interventions that promote shared decision-making are needed. The goal of this study was to investigate the feasibility, acceptability, usability, and preliminary effectiveness of a computer-based decision aid. METHODS: Thirty-three participants were recruited through primary-care clinics in a small southeastern-US city. Participants used a computer-based decision aid ("Is Lung Cancer Screening for You?") during a clinic appointment. Paper surveys collected self-reported feasibility, acceptability, and usability data. A research coordinator was present to observe each patient's and health-care provider's interactions, and to assess the fidelity of shared decision-making. RESULTS: The decision aid was feasible, acceptable for use in a clinic setting, and easy for participants to use. Patients had low decisional conflict following use of the decision aid and had high screening intention and actual screening rates. Shared decision-making discussions using the decision aid were nearly 6 min on average. CONCLUSION: Computer-based decision aids are feasible for promoting shared lung cancer-screening decisions. A more robust study is warranted to measure the added value of a computer-based version of this aid versus a paper-based aid.

Mindfulness-Based Interventions for Survivors of Lung Cancer and Their Partners: A Systematic Review.

BACKGROUND: Survivors of lung cancer and their partners often have complex unresolved physical, psychosocial, and behavioral needs that can negatively affect the survivors' and partners' well-being. This systematic review aimed to (1) examine the content and delivery of mindfulness-based interventions (MBIs) and (2) summarize and synthesize the current evidence for effectiveness of MBIs targeting survivors of lung cancer and/or one selected partner (dyads). METHOD: Six databases were searched for interventional studies published in English between 1980 and June 2020 using three terms (lung neoplasms, mindfulness, caregivers). For outcome measures, the interventions focused on behavioral change (meditation, yoga, stretching, breathing), symptom management (dyspnea, fatigue, sleep disruption, anxiety, depression, stress reduction), and knowledge. Two reviewers independently assessed article eligibility. One reviewer performed and another independently verified data extraction. The Cochrane risk-of-bias tool for randomized trials was used to critically appraise RCTs. RESULTS: Searching yielded 307 records, of which 64 were assessed for eligibility. Six studies investigated the impact of an MBI on survivors and partners. Four studies were single-arm feasibility studies; two were RCTs. Two feasibility studies and one RCT recruited romantic couples whereas the others recruited asymmetrical dyads. The single-arm studies reported strong feasibility and acceptability. RCTs reported significant outcomes for reduced cancer-related distress and depression, and improved QOL, self-compassion, mindfulness skills, and rumination. CONCLUSION: Dyadic intervention research is a growing field. Few interventions target individuals with lung cancer and their partners. No interventions target partners alone. Future research should evaluate rigorous methodologies that enhance the understanding of independent and interdependent health-related effects within dyads and across relationships and settings.

The association between lung cancer stigma and race: A descriptive correlational study.

BACKGROUND: Stigma is a formidable burden for survivors of lung cancer that can reduce the quality of life (QOL), resulting in physical, social and psychological challenges. This study investigates associations between stigma and depression, QOL and demographic and health-related characteristics, including race. DESIGN: An adapted conceptual model derived from the Cataldo Lung Cancer Stigma Scale guided this descriptive correlation study assessing stigma in African American and Caucasian survivors of lung cancer. Self-reported, written surveys measuring depression, QOL, lung cancer stigma and demographics were administered. Statistical analysis was conducted to assess associations between stigma and depression, stigma and QOL and stigma and race, while adjusting for demographic characteristics. RESULTS: Participants (N = 56) included 30 Caucasian and 26 African American survivors of lung cancer recruited from a cancer registry of an American College of Surgeons-accredited programme, a survivors' support club and an ambulatory oncology practice in the southeastern United States. Statistical analysis yielded (1) a significant moderate positive association between depression and lung cancer stigma; (2) a significant moderate negative association between QOL and lung cancer stigma; and (3) significant relationships between race and lung cancer stigma, specifically higher degree of stigma among African Americans compared to Caucasians. CONCLUSION: Stigma affects many aspects of survivors' lives. Healthcare professionals need to consider how health-related stigma may further complicate the physical burdens, psychological distresses and social challenges that accompany the disease, especially among African American survivors. Additional enquiry and interventions are needed to assist with mitigating the negative effects of stigma on survivors and their family members and friends. PATIENT OR PUBLIC CONTRIBUTION: Fifty-six survivors of lung cancer participated in this descriptivecorrelation study. They completed written surveys measuring depression, QOL, and lung cancer stigma, plus an investigator-developed demographic information form.

Systematic Review of Functional Outcomes in Cancer Rehabilitation.

OBJECTIVE: To systematically review the evidence regarding rehabilitation interventions targeting optimal physical or cognitive function in adults with a history of cancer and describe the breadth of evidence as well as strengths and limitations across a range of functional domains. DATA SOURCES: PubMed, Cumulative Index to Nursing and Allied Health Plus, Scopus, Web of Science, and Embase. The time scope was January 2008 to April 2019. STUDY SELECTION: Prospective, controlled trials including single- and multiarm cohorts investigating rehabilitative interventions for cancer survivors at any point in the continuum of care were included, if studies included a primary functional outcome measure. Secondary data analyses and pilot/feasibility studies were excluded. Full-text review identified 362 studies for inclusion. DATA EXTRACTION: Extraction was performed by coauthor teams and quality and bias assessed using the American Academy of Neurology (AAN) Classification of Evidence Scheme (class I-IV). DATA SYNTHESIS: Studies for which the functional primary endpoint achieved significance were categorized into 9 functional areas foundational to cancer rehabilitation: (1) quality of life (109 studies), (2) activities of daily living (61 studies), (3) fatigue (59 studies), (4) functional mobility (55 studies), (5) exercise behavior (37 studies), (6) cognition (20 studies), (7) communication (10 studies), (8) sexual function (6 studies), and (9) return to work (5 studies). Most studies were categorized as class III in quality/bias. Averaging results found within each of the functional domains, 71% of studies reported statistically significant results after cancer rehabilitation intervention(s) for at least 1 functional outcome. CONCLUSIONS: These findings provide evidence supporting the efficacy of rehabilitative interventions for individuals with a cancer history. The findings should be balanced with the understanding that many studies had moderate risk of bias and/or limitations in study quality by AAN criteria. These results may provide a foundation for future work to establish clinical practice guidelines for rehabilitative interventions across cancer disease types.

A Prospective Pilot Study Evaluating Feasibility and Preliminary Effects of Breathe Easier: A Mindfulness-based Intervention for Survivors of Lung Cancer and Their Family Members (Dyads).

Objective: Symptom burden remains a distressing problem for survivors with non-small-cell lung cancer (stages I-IIIa). This pilot study evaluated feasibility and preliminary effects of a tailored mindfulness-based intervention, Breathe Easier, which encompasses meditation, 2 levels of mindful hatha yoga, breathing exercises, and participant interaction. METHODS: Participants were recruited from 2 cancer programs in the US Southeast. A family member was required for participation. Sixty-two participants enrolled (20% recruitment) and 49 completed the intervention (79% retention). Participants chose level 1 yoga (basic) or level 2 (more advanced). Of the completers, survivors were 39% male and 65% Black. A community-based participatory research framework helped identify the specific needs and interests of potential participants and foreseeable barriers to implementation. A 2-month prospective, 1-group, pre-post design evaluated feasibility. Intervention dosage was measured using written protocols. Attendance and completion of daily home assignments measured adherence. Acceptability was assessed using a 10-item questionnaire, completed at three time points. Preliminary outcome data collected pre- and post-intervention tested the hypothesis that participants who received the 8-week intervention Breathe Easier would, post-intervention, demonstrate (a) less dyspnea, (b) less fatigue, (c) less stress, (d) improved sleep, (e) improved anxiety and depression, and (f) improved functional exercise capacity. Exit interviews were conducted, transcribed verbatim, and analyzed for content using descriptive statistics. RESULTS: Quantitative and qualitative measures indicated strong feasibility. Over time, level 1 participants had statistically less dyspnea, fatigue and improved exercise capacity, as well as improved sleep, and stress scores. Level 2 participants experienced slightly increased dyspnea and fatigue but improved sleep, stress, and exercise capacity. All participants experienced anxiety and depression within normal limits pre- and post-intervention. Five major themes emerged out of exit interviews: Learning to Breathe Easier; Interacting with Others as a Personal Benefit; Stretching, Releasing Tension, and Feeling Energized; Enhancing Closeness with Committed Partners; Refocusing on Living; and Sustaining New Skills as a Decision. CONCLUSIONS: The study offers insight into the feasibility of an 8-week in-person mindfulness-based intervention with a unique subset of understudied survivors of lung cancer and family members. Outcome data interpretation is limited by the 1-group design and sample size.

A Focus Group Evaluation of Breathe Easier: A Mindfulness-Based mHealth App for Survivors of Lung Cancer and Their Family Members.

PURPOSE: To explore attitudes and acceptance (i.e., intent for future adoption) of survivors of lung cancer and their family members toward a dyad-focused mHealth mindfulness-based intervention (MBI). APPROACH: Focus groups. SETTING: Community hospital setting in South Carolina. PARTICIPANTS: Survivors n = 11 (M = 64.6 years; 73% female; 64% African American) of non-small cell lung cancer (stage I-IIIa) and their family members, n = 8 (M = 58.6 years; 38% female; 75% African American). INTERVENTION: A fully functional prototype mHealth app to deliver a tailored MBI for survivors of lung cancer and their family members. METHOD: Semi-structured focus groups were conducted and assessed using thematic data analysis to identify the benefits, concerns, needs, and expectations of the app. RESULTS: Convenience and health were the top benefits of using the app, while cost and difficulty of use were the top concerns. Survivors mentioned benefits more than their family members did. Participants felt positively about adding a community network to the app. Finally, participants expected to hear about Breathe Easier from their care provider. CONCLUSION: Participants perceived a benefit to having credible health information delivered through an mHealth app. Guidance and credible health information regarding lung cancer survivorship should be accessible and convenient for everyone impacted by the disease. Thus, future research should explore platforms for a virtual support system and understanding dissemination of mHealth apps through health care providers.

What makes a good health 'app'? Identifying the strengths and limitations of existing mobile application evaluation tools.

Research using mHealth apps has the potential to positively impact health care management and outcomes. However, choosing an appropriate mHealth app may be challenging for the health researcher. The author team used existing evaluation tools, checklists, and guidelines to assess selected mHealth apps to identify strengths, challenges, and potential gaps within existing evaluation tools. They identified specific evaluation tool components, questions, and items most effective in examining app content, usability, and features, including literacy demand and cultural appropriateness; technical information; practical aspects of app functionality; and evolving capabilities of mobile medical apps. Challenges included the subjective nature of the results, time required to complete the evaluation, lack of emphasis on evidence-based content, and inadequate tool flexibility. Health researchers considering the integration of mobile apps into research will benefit from evaluation tools that assess both evidence-based content and the ability of the mobile app to securely integrate with other digital technologies involved in patient care. Next steps will include the involvement of health care providers and professionals, including nurses a wide range of expertise, to develop an mHealth evaluation tool that focuses on identifying quality, evidence-based mobile apps into patient outcomes research.

Health behavior changes in African American family members facing lung cancer: Tensions and compromises.

PURPOSE: Behavioral interventions targeting cancer survivors often fail to address the clustering of unhealthy behaviors among family members and friends, and the impact of close relationships on behavior change. The study's aim was to identify factors associated with receptivity and preferences for lifestyle behavior change among family members of African-American survivors of lung cancer. METHODS: Principles of social cognitive theory guided the design. A descriptive, qualitative study recruited 26 African-American family members of lung cancer survivors from two teaching hospitals in the southeastern United States. A 20-item Information Form collected demographic, health status, and health behavior information. Family members participated in one of three semi-structured focus group discussions. RESULTS: Four major themes emerged: family members and survivors both resisted the caregiver role; dramatic changes evoked by the diagnosis of lung cancer were facilitators and barriers to lifestyle choices; leaning on faith was the primary source of support; and these families live with a constant threat of multiple cancers. Findings emphasize the importance of meaningful conversations among health-care providers, survivors, and family members during the time of diagnosis, treatment, and recovery, so that family members are better prepared to cope with anticipated changes. CONCLUSIONS: This study highlights the stressors that affect family members and sheds light on their unique needs. The stressors limit their ability to change health behaviors. Family members need basic education, skills training, and support related to the lung cancer diagnosis and other cancers. Current methods to provide these services are limited in their accessibility, availability, and effectiveness.

Lung cancer screening: Practice guidelines and insurance coverage are not enough.

BACKGROUND AND PURPOSE: Low-dose computed tomography (LDCT) is expected to increase early detection of lung cancer and improve survival. The growth in the number of advanced nurse practitioners (NPs) in primary care settings increases the likelihood that an NP will serve as a patient's provider. This study's purpose was to examine knowledge, attitudes, and practices regarding LDCT among NPs who work in primary care settings. METHODS: An explanatory, sequential, mixed-method design used a 32-item questionnaire, followed by a semi-structured telephone interview. The development of the survey and interview questions were guided by a conceptual framework representing a temporal sequence for behavior change and potential barriers to guideline adherence. CONCLUSIONS: Nurse practitioners believe that shared decision making with their high-risk patients about LDCT is within their scope of their practice. Working in time-constrained primary care settings, NPs have limited abilities to improve the uptake of LDCT. Substantial patient barriers exist that deter follow through on providers' recommendation. Disseminating guidelines and authorizing health insurance reimbursement is insufficient. IMPLICATIONS FOR PRACTICE: Research is needed that investigates the screening process so that barriers can be closely studied. Culture change is needed where early detection has greater value for insurers, providers, and patients.

A national survey of primary care physicians: Perceptions and practices of low-dose CT lung cancer screening.

Soon after the National Lung Screening Trial, organizations began to endorse low-dose computed tomography (LCDT) screening for lung cancer in high-risk patients. Concerns about the risks versus benefits of screening, as well as the logistics of identifying and referring eligible patients, remained among physicians. This study aimed to examine primary care physicians' knowledge, attitudes, referral practices, and associated barriers regarding LDCT screening. We administered a national survey of primary care physicians in the United States between September 2016 and April 2017. Physicians received up to 3 mailings, 1 follow-up email, and received varying incentives to complete the survey. Overall, 293 physicians participated, for a response rate of 13%. We used weighted descriptive statistics to characterize participants and their responses. Over half of the respondents correctly reported that the US Preventive Services Task Force recommends LDCT screening for high-risk patients. Screening recommendations for patients not meeting high-risk criteria varied. Although 75% agreed that the benefits of LDCT screening outweigh the risks, fewer agreed that there is substantial evidence that screening reduces mortality (50%). The most commonly reported barriers to ordering screening included prior authorization requirements (57%), lack of insurance coverage (53%), and coverage denials (31%). The most frequently cited barrier to conducting LDCT screening shared decision making was patients' competing health priorities (42%). Given the impact of physician recommendations on cancer screening utilization, further understanding of physicians' LDCT screening attitudes and shared decision-making practices is needed. Clinical practice and policy changes are also needed to engage more patients in screening discussions.

Developing and testing a brief clinic-based lung cancer screening decision aid for primary care settings.

BACKGROUND: Cancer screening-related decisions require patients to evaluate complex medical information in short time frames, often with primary care providers (PCPs) they do not know. PCPs play an essential role in facilitating comprehensive shared decision making (SDM). OBJECTIVE: To develop and test a decision aid (DA) and SDM strategy for PCPs and high-risk patients. DESIGN: The DA was tested with 20 dyads. Each dyad consisted of one PCP and one patient eligible for screening. A prospective, one-group, mixed-method study design measured fidelity, patient values, screening intention, acceptability and satisfaction. RESULTS: Four PCPs and 20 patients were recruited from an urban academic medical centre. Most patients were female (n = 14, 70%), most had completed high school (n = 15, 75%), and their average age was 65 years old. Half were African American. Patients and PCPs rated the DA as helpful, easy to read and use and acceptable in terms of time frame (observed t = 11.6 minutes, SD 2.7). Most patients (n = 16, 80%) indicated their intent to be screened. PCPs recommended screening for most patients (n = 17, 85%). CONCLUSIONS: Evidence supports the value of lung cancer screening with LDCT for select high-risk patients. Guidelines endorse engaging patients and their PCPs in SDM discussions. Our findings suggest that using a brief, interactive, plain-language, culturally sensitive, theory-based DA and SDM strategy is feasible, acceptable and may be essential to effectively translate and sustain the adoption of LDCT screening recommendations into the clinic setting.

Knowledge of, attitudes toward, and use of low-dose computed tomography for lung cancer screening among family physicians.

BACKGROUND: The results of the National Lung Screening Trial showed a 20% reduction in lung cancer mortality and a 6.7% reduction in all-cause mortality when high-risk patients were screened with low-dose computed tomography (LDCT) versus chest x-ray (CXR). The US Preventive Services Task Force has issued a grade B recommendation for LDCT screening, and the Centers for Medicare and Medicaid Services and private insurers now cover the screening cost under certain conditions. The purpose of this study was to assess the knowledge of, attitudes toward, and use of LDCT screening for lung cancer among family physicians. METHODS: A 32-item questionnaire was distributed to members of the South Carolina Academy of Family Physicians in 2015. Descriptive statistics were calculated. RESULTS: There were 101 respondents, and most had incorrect knowledge about which organizations recommended screening. Many physicians continued to recommend CXR for lung cancer screening. Most felt that LDCT screening increased the odds of detecting disease at earlier stages (98%) and that the benefits outweighed the harms (75%). Concerns included unnecessary procedures (88%), stress/anxiety (52%), and radiation exposure (50%). Most physicians discussed the risks/benefits of screening with their patients in some capacity (76%); however, more than 50% reported making 1 or no screening recommendations in the past year. CONCLUSIONS: Most family physicians report discussing LDCT with patients at high risk for lung cancer; however, referrals remain low. There are gaps in physician knowledge about screening guidelines and reimbursement, and this indicates a need for further educational outreach. The development of decision aids may facilitate shared decision-making discussions about screening, and targeted interventions may improve knowledge gaps. Cancer 2016;122:2324-2331. © 2016 American Cancer Society.

Planning and Implementation of Low-Dose Computed Tomography Lung Cancer Screening Programs in the United States.

BACKGROUND: One of the largest, most expensive randomized, controlled trials, the National Lung Screening Trial, found that annual low-dose computed tomography (LDCT) scans led to a 20% reduction in lung cancer deaths. OBJECTIVES: This study describes the characteristics and program implementation barriers experienced by LDCT screening programs in the United States. METHODS: Using a mixed-methods approach, Lung Cancer Alliance Screening Centers of Excellence were surveyed and interviewed in 2013. Representatives from 65 centers completed an electronic questionnaire, followed by in-depth interviews with 13 physicians and nurse navigators regarding their institution's screening programs. FINDINGS: Participants cited low patient demand and few physician referrals as barriers, but few centers reported needing additional staff or equipment. Those interviewed discussed the importance of a multidisciplinary team and overcoming barriers related to insurance reimbursement, costs, and physician knowledge to improve program implementation.

Recruiting family dyads facing thoracic cancer surgery: Challenges and lessons learned from a smoking cessation intervention.

PURPOSE: Persistent smoking after a cancer diagnosis has adverse effects. Most smoking cessation interventions focus on individual behaviors; however, family members who smoke are major barriers to success. This article describes challenges and lessons learned related to recruitment and retention to a longitudinal, dyadic-centered smoking cessation intervention study for individuals confronting a new diagnosis of thoracic cancer and their family members who smoke. METHODS: A prospective, one-group repeated measures, mixed-method feasibility study measured recruitment, retention, adherence, and acceptability over a 6-month period in a thoracic surgery clinic at a university cancer center. A multidisciplinary, multi-component decision aid-"Tobacco Free Family"-was used to intervene with the dyads. Study recruitment occurred preoperatively with a thoracic surgery team member assessing smoking status. RESULTS: During the 6-month recruitment period, 50 patients who smoked were screened, and 18 eligible families were approached to participate. Sixteen participants (8 dyads) enrolled. Patients were all male, and participating family members were all female-either spouses or long-term girlfriends. Others types of family members declined participation. CONCLUSION: Recruitment was lower than anticipated (44%), retention was high (100%), and maximizing convenience was the most important retention strategy. Oncology nurses can assess the smoking status of patients and family members, facilitate understanding about the benefits of cessation, refer those willing to stop to expert resources, and help motivate those unwilling to quit. Research is needed to continue developing strategies to help patients with thoracic cancer and their families facing surgery as an impetus for stopping smoking. Novel intervention delivery and communication need further exploration.

A decision aid to improve smoking abstinence for families facing cancer.

PURPOSE/OBJECTIVES: To test the feasibility of a multidisciplinary, multicomponent, theory-based decision aid. DESIGN: Prospective, one-group repeated measures. SETTING: Thoracic surgery clinic in a university hospital cancer center in central Virginia. SAMPLE: 8 dyads, consisting of 16 total participants. METHODS: A multidisciplinary, multicomponent smoking cessation intervention incorporated a theory-based decision aid. Enrollment occurred preoperatively; four face-to-face visits and an exit interview were conducted during six months. MAIN RESEARCH VARIABLES: Feasibility was evaluated based on four criteria: recruitment, retention, adherence, and acceptability. FINDINGS: The recruitment rate was 44%, and the retention rate was 100%. Adherence to the intervention and the acceptability of the decision aid were greater for patients than family members. Patients had greater abstinence than family members before surgery and at six months. Exit interview themes included (a) preoperative timing was acceptable and (b) involving household members who smoke was important. CONCLUSIONS: Recruiting male patients and their female partners is feasible. Participants liked convenience, autonomy, and a family approach. Family members wanted more control over cessation timing and a more intensive approach to weight and mental health management. Successful dyads worked together to maintain abstinence. IMPLICATIONS FOR NURSING: Oncology nurses can assess patients' and family members' smoking status, facilitate understanding about specific benefits of smoking cessation and the obstacle posed by household smokers, and make referrals to expert resources. Encouraging smoke-free environments is an important step toward reducing secondhand smoke exposure and promoting cessation.

Emerging issues on the impact of smoking on health-related quality of life in patients with lung cancer and their families.

Compelling evidence exists that continued smoking after a diagnosis of lung cancer adversely affects treatment effectiveness, survival, risk of recurrence, second malignancy, and health-related quality of life (HRQOL). The importance of HRQOL to patients with cancer and their families has been well documented. Because of increasing evidence of the benefits of smoking cessation, more research has focused on the impact of smoking on HRQOL. Smoking is a behavior that clusters in families; patients who smoke are likely to have family members who smoke, and together they experience impaired HRQOL. This article describes the evidence regarding HRQOL measurement in individuals diagnosed with lung cancer and their family members who smoke and explores the implications for nursing practice. Oncology nurses are in a critical position to advocate for the integration of HRQOL assessment into clinical settings, monitor patient and family member smoking status and environmental tobacco smoke exposure, and support development of smoking cessation interventions to enhance HRQOL.

Driving forces that transformed the care of individuals with cancer from 1900-1940.

PURPOSE/OBJECTIVES: To identify driving forces that established the groundwork for a more dedicated approach to health care for individuals with cancer in the early 20th century. DATA SOURCES: Letters, books, and journal articles published in the early 20th century, as well as materials and communications from several archival sources. DATA SYNTHESIS: The increasing incidence of cancer cases and the building of cancer hospitals were among the dramatic forces in the late 19th century that contributed to the transformation of the clinical care of individuals with advanced cancer. Historical research provided evidence for the early development of the specialization of oncology nursing. CONCLUSIONS: In the late 19th and early 20th centuries, the stigma attached to cancer contributed to delays in diagnosis. The great majority of patients were diagnosed with advanced diseases that were incurable. Providing care to patients with cancer was a problem in hospitals and homes. Radical surgeries and the therapeutic use of radium placed unique demands on patients, their family caregivers, and nurses. Nurses adopted new roles and provided detailed bedside care routines; educated patients, families, and the public; published journal articles and textbooks; and advocated for change. IMPLICATIONS FOR NURSING: Early leaders provided the vision, established the foundation, and cultivated the passion for the emergence of specialized nurses to provide individualized care to patients with cancer. Oncology nurses and nurse leaders are needed to sustain the continual transformation of the specialty so that the individualized needs of patients with cancer are met.