The relationship of depression and stressors to immunological assays: a meta-analytic review.

This is a broad meta-analysis of the relations of both depression and stressors to immunological assays. The number of study samples (greater than 180) and measures (greater than 40) is much more extensive than any so far. Analyses are done by both fixed and random effects. By a fixed-effects analysis, both major depression and naturally occurring acute stressors are associated with (1) an overall leukocytosis, (2) mild reductions in absolute NK-cell counts and relative T-cell proportions, (3) marginal increases in CD4/CD8 ratios, and (4) moderate decreases in T- and NK-cell function. However, the degree of heterogeneity of the studies' results raises questions about their robustness. Therefore, we also did the first random effects analysis to estimate what is likely to appear in future studies. For depression, the analysis showed the immunological correlates included (1) an overall leukocytosis, manifesting as a relative neutrophilia and lymphoenia; (2) increased CD4/CD8 ratios; (3) increased circulating haptoglobin, PGE(2), and IL-6 levels; (4) reduced NK-cell cytotoxicity; and (5) reduced lymphocyte proliferative response to mitogen. For stressors, the random effects analysis showed that future studies are likely to find the following effects: (1) an overall leukocytosis, manifesting as an absolute lymphocytosis; (2) alterations in cytotoxic lymphocyte levels, CD4/CD8 ratios, and natural killer cell cytotoxicity with the direction of change depending on the chronicity of the stressor; (3) a relative reduction of T-cell levels; (3) increased EBV antibody titers; (4) reduced lymphocyte proliferative response and proportion of IL-2r bearing cells following mitogenic stimulation; and (5) increased leukocyte adhesiveness. The random-effects analysis revealed that for both major depression and naturally occurring stressors the following effects are shared: leukocytosis, increased CD4/CD8 ratios, reduced proliferative response to mitogen, and reduced NK cell cytotoxicity. The implications for these findings for disease susceptibility and the pathophysiology of these conditions is discussed.

Mastery of postprostatectomy incontinence and impotence: his work, her work, our work.

PURPOSE/OBJECTIVES: To describe couples' experiences of postprostatectomy incontinence and impotence. DESIGN: Descriptive, qualitative. SETTING: Northeastern U.S. metropolitan area. SAMPLE: Subsample of 20 (10 control and 10 intervention) couples from a large quantitative clinical trial of a Standardized Nursing Intervention Protocol (SNIP) postprostatectomy. METHODS: Interviews were conducted using a semistructured guide. Data were analyzed using grounded theory techniques. MAIN RESEARCH VARIABLE: Couples' experiences of coping with postprostatectomy incontinence and impotence. FINDINGS: Managing postprostatectomy incontinence and impotence required work. Men's work focused on regaining mastery and encompassed understanding incontinence as healing, mastering incontinence, networking, confronting impotence and putting it into perspective, and prioritizing. Wives were supportive by managing anxiety, encouraging mastery, putting impotence into perspective, and reassuring their spouses. Established routines brought couples through the experience together while strengthening intimacy. SNIP couples found the nurses to be sources of information, support, and affirmation. CONCLUSIONS: Couples worked to deal with postprostatectomy incontinence and impotence within the context of surviving cancer and maintaining a loving relationship. This gave unique meaning to their symptoms and led the couples to value the fact that the men were alive and work toward regaining mastery. Mastery emerged as a key concept from the findings. IMPLICATIONS FOR NURSING PRACTICE: Nurses can gain from an enhanced understanding of postprostatectomy incontinence and impotence as meaningful within the greater context of patients having had cancer. Nurses can hasten couples' abilities to regain a sense of mastery by providing information, supporting couples' work, providing positive affirmation, and being available.

Development and validation of a telephone questionnaire to characterize lymphedema in women treated for breast cancer.

BACKGROUND AND PURPOSE: Accurate and economical characterization of lymphedema is needed for population-based studies of incidence and risk. The purpose of this study was to develop and validate a telephone questionnaire for characterizing lymphedema. SUBJECTS: Forty-three women who were treated previously for breast cancer and who were recruited from physical therapy practices and a cancer support organization were studied. METHODS: Questionnaire assessment of the presence and degree of lymphedema was compared with physical therapists' diagnoses, based primarily on circumferential measurements. Twenty-five of the 43 subjects were measured independently by 2 physical therapists to assess interobserver agreement. RESULTS: Interobserver agreement on clinical assessments of the presence and degree of lymphedema was high (20/25, weighted kappa=.80); all of the disagreements were between judgments of whether there was no lymphedema or mild lymphedema. For the diagnosis of at least moderate lymphedema (differential in the circumferences of the upper extremities greater than 2 cm), sensitivity of the questionnaire varied from 0.86 to 0.92 and specificity was 0.90. However, sensitivity (varying from 0.93 to 0.96) was higher than specificity (varying from 0.69 to 0.75) for the diagnosis of any lymphedema. DISCUSSION AND CONCLUSION: A few straightforward questions exhibited excellent agreement with physical therapists' assessments for identifying at least moderate lymphedema.

Determinants of place of death for terminal cancer patients.

Approximately two-third of cancer patients, when asked about the preferred place of death, wish to die in their own homes. However, the majority of deaths from cancers in most western countries occur in a hospital. When a person dies from other than sudden or traumatic causes, the death appears to be a function of a complex interplay of personal and cultural values and physical and medical factors, as well as various health care systems forces. This article reviews the determinants of place of death for terminal cancer patients from published studies in hopes of shedding light on the difficulties of dying patients to realize their preferences for place of death. These insights may contribute to modification of hospice care systems so health professionals will be more responsive to the needs of their dying patients to retain control and die with dignity and help health professionals achieve the proposed outcome of hospice care.

Enhancing caregiver outcomes in palliative care.

BACKGROUND: Families are increasingly replacing skilled health care workers in the delivery of unfamiliar complex care to their relatives with cancer, despite other obligations and responsibilities that characterize their lives. METHODS: The authors review the needs of cancer caregivers and describe intervention strategies not only presented in the literature, but also implemented in their own program of research to address those needs during the palliative phase of cancer. RESULTS: Research suggests that developing interventions that teach caregivers to become proficient in the physical and psychological aspects of patient care will benefit both patients and caregivers. CONCLUSIONS: Despite the fact that a cancer diagnosis can cause major changes in family roles and functioning,as well as increased responsibility for complex care being absorbed by family caregivers, data supporting the effectiveness of caregiver interventions have been limited.

Nurses' use of palliative care practices in the acute care setting.

This study examines the reported use of palliative care practices by nurses caring for terminally ill patients in the acute care setting. Randomly selected nurses (n = 180) from six randomly selected hospitals in Connecticut completed a self-administered questionnaire. Factors associated with use of palliative care practices were examined by using bivariate and multivariate analyses. Most nurses surveyed (88.5%) reported using palliative care practices when caring for their terminally ill patients. Factors associated with greater use included greater knowledge about hospice, having practiced nursing for less than 10 years, and having had hospice training in the past 5 years. A substantial proportion of nurses reported that they never discuss hospice (51.7 per cent of nurses) and prognosis (26.6 per cent of nurses) with their terminally ill patients. Educational preparation (bachelor's degree versus less education) was not associated with greater use of palliative care practices. Palliative care practices are commonly used by nurses in the acute care setting. However, many report having limited training and substantial gaps in knowledge about hospice among this group of nurses, suggesting greater attention to palliative care and hospice may be warranted in nursing educational programs.

Fatigue and quality of life outcomes of exercise during cancer treatment.

PURPOSE: Despite the recognition of fatigue as a common and distressing symptom during cancer treatment, there are few evidence-based interventions available to manage such fatigue. The purpose of this multi-institutional pilot study was to explore the effects of a home-based moderate walking exercise intervention on fatigue, physical functioning, emotional distress, and quality of life (QOL) during breast cancer treatment. DESCRIPTION OF STUDY: Fifty-two women were recruited from five university hospital outpatient departments for this pilot study with an experimental design. Subjects were randomly assigned to the walking program or to usual care during adjuvant chemotherapy or radiation therapy for breast cancer. Symptoms, physical functioning, and QOL were measured at baseline, midtreatment, and at the end of treatment. RESULTS: Women who exercised at least 90 minutes per week on 3 or more days reported significantly less fatigue and emotional distress as well as higher functional ability and QOL than women who were less active during treatment. CLINICAL IMPLICATIONS: A home-based walking exercise program is a potentially effective, low-cost, and safe intervention to manage fatigue and to improve QOL during adjuvant chemotherapy or radiation therapy for breast cancer. This health-promoting self-care activity needs further testing in large randomized clinical trials.

A specialized home care intervention improves survival among older post-surgical cancer patients.

CONTEXT: Changes in the healthcare system have resulted in shortened hospital stays, moving the focus of care from the hospital to the home. Patients are discharged post-operatively with ongoing needs, and whether they receive nursing care post-hospitalization can influence their recovery and survival. Little information is available about the factors that influence outcomes, including the survival of older cancer patients after cancer surgery. OBJECTIVE: To compare the length of survival of older post-surgical cancer patients who received a specialized home care intervention provided by advanced practice nurses (APNs) with that of patients who received usual follow-up care in an ambulatory setting. We also assessed potential predictors of survival in terms of depressive symptoms, symptom distress, functional status, comorbidities, length of hospital stay, age of patient, and stage of disease. DESIGN: A randomized controlled intervention study. SETTING: Discharged older cancer patients after surgery at a Comprehensive Cancer Center in southeastern Pennsylvania. PATIENTS: Three hundred seventy-five patients aged 60 to 92, newly diagnosed with solid cancers, were treated surgically between February 1993 and December 1995. One hundred ninety patients were randomized to the intervention groups and 185 to the usual care group. INTERVENTION: The intervention was a standardized protocol that consisted of standard assessment and management post-surgical guidelines, doses of instructional content, and schedules of contacts. The intervention lasted 4 weeks and consisted of three home visits and five telephone contacts provided by APNs. Both the patients and their family caregivers received comprehensive clinical assessments, monitoring, and teaching, including skills training. MAIN OUTCOME MEASURE: Time from enrollment of patients into the study until death or last date known alive at the end of November 1996. RESULTS: During the 44-month follow-up period, 93 (24.8%) of 375 patients died. Forty-one (22%) of those who died were patients in the specialized home care intervention group, compared with 52 (28%) in the usual care group. Stage of disease at diagnosis differed between the two groups at baseline (38% late stage patients in the intervention group compared with 26% in the control group, P = .01), so stratified analysis was performed. Overall, the specialized home care intervention group was found to have increased survival (P = .002 using stratified log-rank test). Among early stage patients only, there was no difference in survival between the intervention and control groups. Among late stage patients, there was improved survival in the intervention group. For example, 2-year survival among late stage intervention group cases was 67% compared with 40% among control cases. When Cox's proportional hazard model was used to adjust for significant baseline covariates, the relative hazard of death in the usual care group was 2.04 (CI: 1.33 to 3.12; P = .001) after adjusting for stage of disease and surgical hospitalization length of stay. CONCLUSIONS: This is the first empirical study of post-surgical cancer patients to link a specialized home care intervention by advanced practice nurses with improved survival. Additional research is needed to test home care interventions aimed at maintaining quality of life outcomes and their effects on survival of post-surgical cancer patients.

Cancer care: impact of interventions on caregiver outcomes.

The purpose of this review is to examine the research literature on interventions aimed at caregivers who, in the current health care environment, are assuming increasing responsibility for the complex care of significant others experiencing cancer. The general aim of the review is to synthesize the literature on interventions targeted to cancer caregivers and to summarize outcomes associated with the various intervention strategies described. Three broad categories of interventions were described in the literature: (1) educational, (2) counseling/psychotherapeutic, and (3) hospice and palliative home care. The review included studies that met the following criteria: data-based studies that described an intervention aimed at assisting caregivers to care for patients with cancer, studies published between 1975 and January 1999, and studies published in English. A total of 29 published papers was included. Although the original intent was to limit the review to studies that associated interventions with outcomes, a lack of well-delineated outcome variables was revealed as a major gap in the literature. Thus, some studies that did not include outcome variables were reviewed and the following conclusions made: (1) there is a dearth of data-based literature describing interventions aimed at caregivers; interventions that are described often lack well-defined effects due to a lack of or poor operationalization of outcomes; (2) of the small number of studies in this area, many used small samples and lacked randomization; and (3) studies often revealed selection bias to well-adjusted caregivers who were accepting of support, able to obtain respite care in order to participate, and often willing to avail themselves of a group-style intervention.

Participant characteristics before and 4 months after attendance at a family caregiver cancer education program.

Recent trends in health care have placed an increased burden on cancer caregivers. In response, nurses and social workers have been taught to implement a 6-hour psychoeducation program for cancer caregivers that addresses symptom management, psychosocial support, and resource identification. Longitudinal data from a convenience sample of 187 cancer caregivers who attended the program are reported. Data were collected before attendance and 4 months later. Findings confirm the chronic and consuming nature of cancer caregiving. Data indicate that perception of burden did not worsen even when caregiving tasks increased in intensity. Caregiver perceptions of their own health actually improved over time. In addition, the number of caregivers who said they were well informed and confident about caregiving after program attendance increased over time. Further study that randomizes caregivers to intervention/control groups is needed to substantiate the role of similar programs in enhancing caregiver skills and minimizing caregiver burden over time.

Information needs of elderly postsurgical cancer patients during the transition from hospital to home.

PURPOSE: To describe information needs of elderly postsurgical cancer patients. Few reports have described learning needs of postsurgical cancer patients during the initial weeks after hospitalization. Responding to information needs during the transition to home is important for helping patients and families to appropriately manage illness. DESIGN: Descriptive, using records kept for patients assigned to the experimental group in a larger study completed in 1996. The sample was 148 American patients surgically treated for a new diagnosis of prostate, breast, gastrointestinal, lung, or head and neck cancer. Information needs were identified from topics addressed by advanced practice nurses during 4-week episodes of home care. METHODS: Content analysis of 3,280 statements of teaching interventions. FINDINGS: Teaching themes were instructing on postoperative self-care, advising on symptom management, clarifying the illness experience, discussing psychological responses, and preparing patients and families to coordinate follow-up care. Topics included describing the expected course of illness, informing about community resources, identifying events that require physician notification, and advising on pain management. Topic emphasis varied by site of cancer. CONCLUSIONS: Information needs of elderly postsurgical cancer patients during transition from hospital to home are extensive. Teaching interventions ranged from giving concrete instructions about care of a surgical wound to interpreting complex information about options for cancer treatment. Elderly postsurgical cancer patients need informational support during the transition from hospital to home.

Cancer prevention education in developing countries: toward a model for nurse educators.

The National Cancer Institute, United States of America, funded a series of continuing education courses in cancer prevention between 1986 and 1994 for nurses from developing countries. The purpose of this program was to stimulate interest and facilitate an increase in the participants' knowledge of primary and secondary cancer prevention. The long-term objectives were to increase the number of nurses, internationally, prepared to engage in the prevention and the early detection of cancer in their countries, to expand the international cancer nursing network, and to have these nurses ultimately play a role in reducing the incidence of cancer in developing countries. More than 50 nations were represented. Participants were chosen for their demonstrated ability to influence nursing education and practice in their country. They completed a demographic data sheet, an attitude inventory, a program evaluation and pre- and postconference activities surveys. Before and after attending the conference, participants were asked to identify anticipated problems and obstacles to their goal achievement. These problems included a lack of screening facilities and a lack of primary prevention services. Although numerous differences existed in their education, experience, and personal attributes, the participants voiced common problems with cancer prevention programs. Results from the postconference survey showed a substantial increase in cancer-related activities conducted by the participants. Activities included an increase in cancer content in nursing education programs, an increase in public and professional presentations on cancer prevention, and improvement in the delivery of cancer care.

Describing the work of nursing: the case of postsurgical nursing interventions for men with prostate cancer.

Nursing interventions were provided to older men following prostate surgery during a controlled clinical trial examining nursing care and its effects on quality of life outcomes. The Nursing Intervention Lexicon and Taxonomy (NILT), consisting of 7 categories of nursing interventions, was used to classify intervention statements extracted from 32 home care records. Two major categories of interventions were patient teaching (45%) and psychologically based interventions (20%). In a comparison of the types of interventions provided upon discharge from the hospital with those provided at the end of 1 month of home care, it appeared that patients had not yet shifted from the crisis to the chronic phase of their illness course based on Rolland's framework.

Effects of home care on caregivers' psychosocial status.

PURPOSE: To examine changes in the psychosocial status of caregivers of post-surgical patients with cancer, and how their status was affected by (a) whether caregivers had physical problems of their own, and (b) whether the patient received a home care intervention. Many studies in this area to date have not included sufficient measurement points to identify fluctuations in psychosocial status over time. In addition, many have used caregiver health as an outcome rather than a predictor. DESIGN: Longitudinal, randomized trial using a sample of 161 caregivers of cancer patients being treated at one large university hospital in the northeastern United States, 1993-1996. Half the patients were randomly assigned to receive a standardized home-care nursing intervention. The population of interest was caregivers of patients who were (a) diagnosed with a solid-tumor cancer within the past 2 months, (b) age 60 or older, (c) hospitalized for surgical treatment of the cancer and expected to live at least 6 months, and (d) had a complex problem at hospital discharge. All caregivers were living with the patient at time of discharge. METHODS: Data were collected in structured interviews administered at the time of the patients' discharge and approximately 3 and 6 months later. Psychosocial status was measured using the Caregiver Reaction Assessment and the CES-Depression scale. A repeated-measures analysis of variance was performed for each psychosocial measure, using as factors Time (i.e., interview 1, 2, or 3), Group (treatment and control), and Caregiver Physical Problem. FINDINGS: Overall, psychosocial status improved from baseline to 3 months, and was about the same at 6 months. Among caregivers with physical problems, the psychosocial status of those in the treatment group declined compared to those in the control groups in the 3 months after discharge; an opposite pattern was observed in the following 3 months. CONCLUSIONS: People who are caregivers for cancer patients and have physical problems of their own are at risk for psychologic morbidity, which may have a delayed onset. This delay may reflect the replacement of an initial optimism with discouragement as the reality of long-term illness sets in. Home care may create a situation in which caregivers are required to confront the realities of long-term caregiving quickly, cutting short their initial optimism, but also preparing them for what is to come.

Testing a theory for health-related quality of life in cancer patients: a structural equation approach.

The purpose of this study was to test a Roy Adaptation Model-based theory of health-related quality of life in patients with newly diagnosed cancer. Using a structural equation model, health-related quality of life (HRQOL) was regarded as a latent variable measured by 4 empirical indicators representing the 4 biopsychosocial response modes of the Roy Adaptation Model (RAM). The response modes are physiologic, self-concept, interdependence, and role function. These were empirically represented by physical symptoms, affective status, social support, and functional support, respectively. In this secondary analysis, 3 RAM propositions were tested in a sample of 375 newly diagnosed postsurgical cancer patients 60 years and over. These were: (a) that the 4 response modes are interrelated; (b) that environmental stimuli of gender, race, age, income, marital status, cancer treatment, and severity of illness influence the biopsychosocial response modes; and (c) that the biopsychosocial responses soon after diagnosis predict biopsychosocial responses 3 months later. The analyses did not support the proposition that all 4 response modes were interrelated. The results, however, revealed that severity of illness and adjuvant cancer treatment had the strongest association with the biopsychosocial responses and should be considered the focal environmental stimuli. The remaining environmental stimuli can be considered contextual. Also, the proposition that initial biopsychosocial responses predicted later responses was supported.

Social factors, treatment, and survival in early-stage non-small cell lung cancer.

OBJECTIVES: This study assessed the importance of socioeconomic status, race, and likelihood of receiving surgery in explaining mortality among patients with stage-I non-small cell lung cancer. METHODS: Analyses focused on Black and White individuals 75 years of age and younger (n = 5189) diagnosed between 1980 and 1982 with stage-I non-small cell lung cancer in Detroit, San Francisco, and Seattle. The main outcome measure was months of survival after diagnosis. RESULTS: Patients in the highest income decile were 45% more likely to receive surgical treatment and 102% more likely to attain 5-year survival than those in the lowest decile. Whites were 20% more likely to undergo surgery than Blacks and 31% more likely to survive 5 years. Multivariate procedures controlling for age and sex confirmed these observations. CONCLUSIONS: Socioeconomic status and race appear to independently influence likelihood of survival. Failure to receive surgery explains much excess mortality.

Providing accurate information to women about tamoxifen therapy for breast cancer: current indications, effects, and controversies.

PURPOSE/OBJECTIVES: To address the uses of and current controversies surrounding tamoxifen therapy for the treatment and possible prevention of breast cancer so nurses may provide patients with accurate information. Factors that may hinder assimilation of information and strategies to enhance patient understanding are discussed. DATA SOURCES: Published, data-based articles and texts. DATA SYNTHESIS: The role of tamoxifen in controlling breast cancer includes adjuvant treatment for early stage breast cancer and palliative treatment of advanced disease. Investigational uses of tamoxifen include breast cancer prevention in women at high risk for the disease. Although tamoxifen has its proven benefits, confusion regarding who should take it still exists. CONCLUSIONS: Medical information as it relates to life-threatening disease often is transmitted to the public in an alarmist manner. While women still have legitimate concerns about tamoxifen use (e.g., increased risk of endometrial cancer and thromboembolic events), the benefits of this treatment for breast cancer (e.g., increased disease-free and overall survival, reduction in contralateral breast cancer) appear to far outweigh the risks. IMPLICATIONS FOR NURSING PRACTICE: Nurses should be cognizant of issues related to tamoxifen therapy so they can assist women in making informed decisions. Unbiased communication of the facts with attention to each woman's situation can facilitate individual consideration of options in an informed manner.