Screening for skin cancer.

CONTEXT: Malignant melanoma is often lethal, and its incidence in the United States has increased rapidly over the past 2 decades. Nonmelanoma skin cancer is seldom lethal, but, if advanced, can cause severe disfigurement and morbidity. Early detection and treatment of melanoma might reduce mortality, while early detection and treatment of nonmelanoma skin cancer might prevent major disfigurement and to a lesser extent prevent mortality. Current recommendations from professional societies regarding screening for skin cancer vary. OBJECTIVE: To examine published data on the effectiveness of routine screening for skin cancer by a primary care provider, as part of an assessment for the U.S. Preventive Services Task Force. DATA SOURCES: We searched the MEDLINE database for papers published between 1994 and June 1999, using search terms for screening, physical examination, morbidity, and skin neoplasms. For information on accuracy of screening tests, we used the search terms sensitivity and specificity. We identified the most important studies from before 1994 from the Guide to Clinical Preventive Services, second edition, and from high-quality reviews. We used reference lists and expert recommendations to locate additional articles. STUDY SELECTION: Two reviewers independently reviewed a subset of 500 abstracts. Once consistency was established, the remainder were reviewed by one reviewer. We included studies if they contained data on yield of screening, screening tests, risk factors, risk assessment, effectiveness of early detection, or cost effectiveness. DATA EXTRACTION: We abstracted the following descriptive information from full-text published studies of screening and recorded it in an electronic database: type of screening study, study design, setting, population, patient recruitment, screening test description, examiner, advertising targeted at high-risk groups or not targeted, reported risk factors of participants, and procedure for referrals. We also abstracted the yield of screening data including probabilities and numbers of referrals, types of suspected skin cancers, biopsies, confirmed skin cancers, and stages and thickness of skin cancers. For studies that reported test performance, we recorded the definition of a suspicious lesion, the "gold-standard" determination of disease, and the number of true positive, false positive, true negative, and false negative test results. When possible, positive predictive values, likelihood ratios, sensitivity, and specificity were recorded. DATA SYNTHESIS: No randomized or case-control studies have been done that demonstrate that routine screening for melanoma by primary care providers reduces morbidity or mortality. Basal cell carcinoma and squamous cell carcinoma are very common, but detection and treatment in the absence of formal screening are almost always curative. No controlled studies have shown that formal screening programs will improve this already high cure rate. While the efficacy of screening has not been established, the screening procedures themselves are noninvasive, and the follow-up test, skin biopsy, has low morbidity. Five studies from mass screening programs reported the accuracy of skin examination as a screening test. One of these, a prospective study, tracked patients with negative results to determine the number of patients with false-negative results. In this study, the sensitivity of screening for skin cancer was 94% and specificity was 98%. Several recent case-control studies confirm earlier evidence that risk of melanoma rises with the presence of atypical moles and/or many common moles. One well-done prospective study demonstrated that risk assessment by limited physical exam identified a relatively small (<10%) group of primary care patients for more thorough evaluation. CONCLUSIONS: The quality of the evidence addressing the accuracy of routine screening by primary care providers for early detection of melanoma or nonmelanoma skin cancer ranged from poor to fair. We found no studies that assessed the effectiveness of periodic skin examination by a clinician in reducing melanoma mortality. Both self-assessment of risk factors or clinician examination can classify a small proportion of patients as at highest risk for melanoma. Skin cancer screening, perhaps using a risk-assessment technique to identify high-risk patients who are seeing a physician for other reasons, merits additional study as a strategy to address the excess burden of disease in older adults.

Screening for bacterial vaginosis in pregnancy.

CONTEXT: Bacterial vaginosis (BV) is a strong independent risk factor for adverse pregnancy outcomes. BV is found in 9% to 23% of pregnant women. Symptoms include vaginal discharge, pruritus, or malodor, but often women with BV are asymptomatic. OBJECTIVES: To determine whether screening and treating pregnant women for BV reduces adverse pregnancy outcomes, as part of an assessment for the U.S. Preventive Services Task Force. DATA SOURCES: Randomized clinical trials of BV treatment in pregnancy that measured pregnancy outcomes were identified from multiple searches in MEDLINE from 1966 to 1999, the Cochrane Controlled Trials Register and Library, and national experts. STUDY SELECTION: All randomized controlled trials of BV treatment in pregnancy that specifically measured pregnancy outcomes. DATA EXTRACTION: The following information was abstracted: study design and blinding, diagnostic methods, antibiotic interventions, timing of antibiotic treatment in pregnancy, criteria for treatment, comorbidities, demographic details, risk factors for preterm delivery such as previous preterm delivery, compliance, rates of spontaneous and total preterm delivery less than 37 weeks and less than 34 weeks, preterm premature rupture of membranes, low birth weight less than 2500 grams, spontaneous abortion, postpartum endometritis, and neonatal sepsis. For each study, we measured the effect of treatment by calculating the difference in the rate of a given pregnancy outcome in the control group minus the treatment group (the absolute risk reduction [ARR]). A stepwise procedure based on the profile likelihood was applied to assess heterogeneity, to pool studies when appropriate, and to calculate the mean and 90% confidence intervals (CIs) for the effect of treatment. DATA SYNTHESIS: Seven randomized controlled trials met inclusion criteria for the meta-analysis. We found no benefit to BV treatment in average-risk women for any pregnancy outcome. Results of studies of high-risk populations, women with previous preterm delivery, were statistically heterogeneous. They clustered into two groups; one showed no benefit (ARR=-0.08, 90% CI=-0.19 to 0.04), whereas the three homogeneous studies showed potential benefit of BV treatment (pooled ARR=0.22; 90% CI=0.13 to 0.31) for preterm delivery before 37 weeks. Four high-risk studies reported results for preterm delivery less than 34 weeks. The pooled estimate showed no benefit (ARR=0.04; 90% CI=-0.02 to 0.09), but variation was noted among individual studies. Two trials of high-risk women found an increase in preterm delivery less than 34 weeks in women who did not have BV but received BV treatment. Comparisons of patient populations, treatment regimens, and study designs did not explain the heterogeneity among studies. CONCLUSIONS: We found no benefit to routine BV screening and treatment. A subgroup of high-risk women may benefit from BV screening and treatment; however, there may be a subgroup for whom BV treatment could increase the occurrence of preterm delivery.

Signs and symptoms associated with malignancy-induced hypercalcemia.

Hypercalcemia is a common life-threatening complication that often produces discomfort for the oncology patient. Prompt detection of this complication is imperative to prevent death and reverse uncomfortable symptoms. Laboratory analysis of a serum blood sample is presently the only means available to quantify hypercalcemia. A descriptive study was undertaken to determine what symptoms prompt oncology patients and their families to seek treatment of the hypercalcemia and to identify symptoms commonly associated with mild, moderate, and severe hypercalcemia. Seven hypercalcemic oncology patients were interviewed and observed on admission and during hospitalization for treatment of hypercalcemia. An identified significant other was also interviewed on admission and throughout the hospitalization to provide the researcher with information about subtle behavioral changes. A check-list of symptoms identified in the literature as being associated with hypercalcemia was completed. Symptoms that commonly led to admission included constipation, confusion, weakness, and anorexia. The most evident changes in a particular symptom within a given degree of hypercalcemia occurred in the mental status symptoms. The resulting data have implications for nurses in terms of patient assessment and of teaching patient and family about signs and symptoms of hypercalcemia that are observable at home.

The Bethesda system for classification of Pap smears: the clinical experience of one cancer screening center.

Since the initiation of the Bethesda System for the classification of cervical/vaginal cytology in 1988, anecdotal reports suggest that there may be an increased number of referrals for abnormalities. The purpose of this retrospective chart review (n = 533) was to describe (a) the adequacy of samples collected by an advanced practice nurse; (b) a comparison of the findings and referrals from Pap smears collected using the old numerical (I-V) system and the Bethesda system; and (c) findings from the follow-up of referrals of nonspecific Pap smears. A total of 108 smears were interpreted using the numerical system and 425 in the Bethesda System. Results included that 90% of the specimens were considered adequate for interpretation. Recommendations for repeat smears in women with nonspecific results were made to 128 women; 68 (53%) had a repeat Pap smear done. Of these women, 39 (57%) had a normal smear on repeat and 29 (43%) had a persistent nonspecific smear. When the numerical system was used, < 10% were referred for a repeat smear or further evaluation. In this study, there appears to be an increase in the number of referrals for further evaluation with the use of the Bethesda system. Nurses need to consider various ways to educate women regarding the changes due to the Bethesda system and the clinical implications of the new system.

Information needs regarding menopause. Results from a survey of women receiving cancer prevention and detection services.

Women often have questions related to menopause and hormone replacement therapy (HRT). A brochure entitled Understanding Menopause and Beyond was developed to address these issues. The purpose of this study was (a) to formally evaluate the relevance and utility of a brochure in understanding menopause and related health concerns and (b) to describe women's information needs at menopause. This descriptive study was conducted using a self-administered survey with a convenience sample of 200 pre-, peri-, and postmenopausal women attending a cancer screening center. On the basis of survey results, the topics most likely to be discussed with a health care provider were the risks and benefits of HRT and bone mineral density testing. The topics most frequently cited in the brochure that women previously did not know or understand were the questions to ask and the information to share with a health care provider and the risk factors for osteoporosis. The most important and informative sections of the brochure were those describing the risk factors for osteoporosis, the questions to ask and the information to share with a health care provider, and the risks and benefits of HRT. It was concluded that women have information needs regarding menopause not only related to the potential cancer risks, but also about related health issues such as osteoporosis, cardiovascular health, and emotional health. Furthermore, a targeted brochure can be effective in addressing these information needs. Oncology nurses who provide cancer screening and education services frequently receive questions about the safety and efficacy of HRT and other questions related to menopause. They therefore are uniquely qualified to address these concerns with their patients.

Exploring the psychosocial meaning of recurrent cancer: a descriptive study.

Many persons diagnosed with malignancy will experience one or more recurrences of malignancy. Little is known about the psychosocial meaning of recurrent cancer. Using Lazarus and Folkman's model of stress, appraisal and coping, the two purposes of this descriptive study were to (a) describe the meaning of a recurrence of cancer to the patient and (b) to explore if the patient perceives the diagnosis of recurrence as being different from the initial diagnosis of cancer. Purposeful sampling for persons with recent recurrent malignancy produced a sample (n = 20). Subjects completed an unstructured, indepth interview. The meaning of the recurrence was influenced by prior cancer-related experiences of the subjects and dominated by death and death-related concerns. Differences from the initial diagnosis included a deeper awareness of the significance of the "cancer diagnosis".

Factors associated with adequate pain control in hospitalized postsurgical patients diagnosed with cancer.

The inadequate management of pain continues to be a significant problem for persons with cancer. Experts suggest that contributing factors include discrepancies in pain assessment, inadequate administration of opiate therapy, and insufficient documentation of the patient's pain experience. This study, part of a multidepartmental investigation into the adequacy of pain management in hospitalized patients, describes the pain experience of surgical oncology patients. Its correlational ex post facto design (n = 34) was guided by Loeser's model of pain. Randomly selected surgical oncology patients were interviewed using a structured format. The patient's primary nurse and physician simultaneously completed brief assessments of their perceptions of the patient's pain intensity. Data were analyzed using descriptive and correlational statistics, and implications for nursing practice and future nursing research are discussed.

Managing the psychosocial consequences of cancer recurrence: implications for nurses.

Patients experiencing a recurrence of malignancy offer many unique challenges to nurses. One of these challenges is to assist patients in coping with the psychosocial impact of a recurrence of malignancy. A recurrence of malignancy is a distinctly different event from an initial diagnosis of cancer. As primary caregivers, nurses first must accurately assess not only the patient's perception of the recurrence but also its impact on the patient's family, social activities, and roles. Nurses must consider carefully their own feelings concerning recurrence of cancer and how these feelings influence the care they render to this group of patients. Appropriate nursing intervention includes not only the patient but also the family and significant others. Issues related to future nursing research with this population are discussed.

Case in point. Counseling about hormone replacement therapy.

Mrs. S's case demonstrates the dilemmas that many women face at menopause regarding HRT. No clear answer to her question exists. Oncology nurses need to help women understand that taking HRT is a decision that is best made after carefully weighing the risks and benefits of therapy. Mrs. S needs to realize that she has some risk factors for heart disease, osteoporosis, breast cancer, and uterine cancer. Depending on her motivation, Mrs. S can modify some of the risk factors (e.g., reducing her weight and cholesterol). Smoking cessation also would reduce her risk for heart disease and, to a lesser extent, osteoporosis. Although her risk for developing breast cancer is higher than for a woman without a family history of breast cancer, she only has one relative who was older when she developed breast cancer. This risk factor in itself probably would not be enough to advise her against taking HRT. Additional testing may offer some clarification. If her breasts are difficult to examine or her mammograms are difficult to interpret, Mrs. S may feel that the risk of missing breast cancer early is too high to justify taking HRT. An abnormal endometrial biopsy also may make Mrs. S decide against taking HRT. BMD testing might help to better assess her risk for osteoporosis. If some bone loss has occurred before menopause, she may want to give more consideration to taking HRT or medications such as alendronate sodium to reduce her risk for an osteoporotic fracture. Women need to understand that, often, no best answer is available to the question of whether or not to take HRT. With every decision comes some consequences. An understanding of risk factors and ways to maximize cardiovascular, breast, endometrial, and bone health are important factors to consider when making an informed decision. Clearly, this is an area where oncology nurses can provide tremendous patient education and support to women making decisions about HRT.

Osteoporosis: a concern for cancer survivors.

PURPOSE/OBJECTIVES: To describe the risk factors, prevention, diagnosis, management, and impact of osteoporosis on the lives of women who have survived breast and endometrial cancer. DATA SOURCES: Journal articles, selected textbooks, prescribing information, and conference proceedings. DATA SYNTHESIS: Women who have not been able to have estrogen-replacement therapy (including women who have survived breast and endometrial cancer) are at higher risk for developing osteoporosis. Osteoporosis is associated with significant medical costs and can have a detrimental effect on long-term quality of life (QOL) as well as increased mortality. Recently, significant advances have been made in the ability to detect and manage osteoporosis. CONCLUSIONS: Thorough assessment, appropriate evaluation, and treatment of osteoporosis can reduce the complications of this condition and ultimately improve the QOL for women surviving cancer. IMPLICATIONS FOR NURSING PRACTICE: Oncology nurses should include assessment of risk for osteoporosis into their practice. Education about the prevention of osteoporosis should be included with other wellness education. Women at higher risk for the development of osteoporosis should be referred for a diagnostic evaluation. Oncology nurses can provide women with osteoporosis with education about treatment as well as psychosocial support.

Cancer risk assessment: conceptual considerations for clinical practice.

PURPOSE/OBJECTIVES: To review current information on the types and components of risk assessment and associated considerations for clinical practice and education. DATA SOURCES: Published articles, book chapters, and clinical experience. DATA SYNTHESIS: Cancer risk assessment is a clinical process that is integral to cancer screening. Cancer risk assessment includes obtaining information about cancer risk factors and selecting the best means to communicate this information to individual patients. Ethical, psychosocial, and clinical factors are considerations. A comprehensive tool to provide consistency in documenting risk factors as part of a comprehensive cancer risk assessment is included. CONCLUSIONS: Nurses can conduct and interpret cancer risk assessments. Consideration of conceptual issues of risk assessment may enhance this process. IMPLICATIONS FOR NURSING PRACTICE: When implementing cancer risk assessments into cancer screening programs, nurses need to consider the purpose of conducting the risk assessment, how the information will be interpreted to the population being served, and the potential impact on an individual patient.

The role of the nurse in developing cancer screening programs.

PURPOSE/OBJECTIVE: To describe and provide an overview of the role that nurses can play in developing cancer screening programs. DATA SOURCES: Published articles, book chapters, and clinical experience. DATA SYNTHESIS: Many approaches and considerations are available for developing cancer screening programs. Planning considerations include needs assessment, patient-education strategies, funding, recruitment issues, follow-up strategies, staffing, policy development, and evaluation. An understanding of these considerations may lead to more effective cancer screening programs. CONCLUSIONS: Nurses can play an integral role in the development and management of cancer screening programs. Careful program planning may enhance this process. IMPLICATIONS FOR NURSING PRACTICE: Oncology nurses need to consider a wide range of issues when developing cancer screening programs, including the purpose of the program, how the program will be implemented, the population being served, and the potential impact on individuals being served.

Using brochures to educate the public about the early detection of prostate and colorectal cancer.

PURPOSE: To describe the development and the evaluation of two brochures intended to educate the public about prostate and colorectal cancer screening. DATA SOURCES: Clinical experience and published books, articles, and brochures. DATA SYNTHESIS: Personnel at the Cancer Screening Center of the Deaconess Health System in St. Louis, MO, developed two brochures intended to educate the public about prostate cancer and colorectal cancer screening. These brochures focus on early detection (based on American Cancer Society guidelines), signs and symptoms, and risk factors related to prostate and colorectal cancer. CONCLUSIONS: These brochures can be used effectively to educate a large number of people about prostate and colorectal cancer. IMPLICATIONS FOR NURSES: Oncology nurses may find these brochures to be an effective adjunct to existing resources used to educate the public about early detection of prostate and colorectal cancer.

The impact of mailing fecal occult blood test kits on return rate in a community cancer screening center.

PURPOSE/OBJECTIVES: To describe how mailing fecal occult blood test (FOBT) kits prior to office appointments rather than distributing the kits at office visits affects the return rate of completed tests and to describe the demographic characteristics of those who returned the tests and those who did not. DESIGN: Retrospective chart review. SETTING: An urban, community hospital cancer screening program. SAMPLE: 631 people; 382 returned the FOBTs; 128 did not return the tests; 121 refused all colorectal screening including fecal occult blood testing. METHODS: Charts were reviewed and abstracted using a form; data were entered and analyzed using descriptive statistics. MAIN RESEARCH VARIABLES: Completion and return of the FOBT and FOBT results. FINDINGS: The return rate when the FOBT was mailed prior to appointments was 85% compared to 32% for patients who received test kits in the office. Of those who completed the test, 80% also underwent digital rectal examinations and 26% underwent flexible sigmoidoscopies. Nine people demonstrated positive FOBT results, but no colorectal cancers were detected. CONCLUSIONS: In this retrospective chart review, mailing FOBT kits prior to office appointments appeared to be related to increased return rates. IMPLICATIONS FOR NURSING PRACTICE: Findings are preliminary in nature, but nurses must consider various methods of distributing FOBTs in order to increase return rates.

Educating women about early detection of gynecologic cancers using a brochure.

PURPOSE/OBJECTIVES: To develop and evaluate a brochure for educating women about screening for gynecologic cancers. DATA SOURCES: Journal articles and American Cancer Society (ACS) materials. DATA SYNTHESIS: This brochure focuses on early detection (based on ACS guidelines), signs and symptoms, and risk factors for cancers of the cervix, uterus, and ovaries as well as a detailed discussion of the Papanicolaou (Pap) test and the Bethesda System for grading test results. CONCLUSIONS: This brochure has been effective in educating a large number of women about early detection of gynecologic cancers. IMPLICATIONS FOR NURSING PRACTICE: Nurses can use this brochure as an effective adjunct to their public education programs that address early detection of gynecologic cancers.

Pathophysiology of hypokalemia in patients with cancer: implications for nurses.

Hypokalemia is a potentially life-threatening complication that occurs in many patients with cancer. Nurses need to be aware of the many common causes of this electrolyte disorder as well as appropriate assessment strategies that will enable potential problems to be detected and treated early. This article begins with a review of normal potassium balance and physiology, followed by a discussion of potential causes of hypokalemia in patients with cancer. These causes are grouped into four categories: inadequate dietary intake, extrarenal losses, redistribution abnormalities, and renal losses. Common causes of hypokalemia in patients with cancer are illustrated with case examples. Signs and symptoms associated with hypokalemia are discussed. Finally, implications for nursing assessment and intervention related to the administration of potassium are reviewed.

Teaching women about mammography through use of a brochure.

This paper describes the development and use of a brochure intended to educate women about the nature and benefits of mammography. This brochure, which is presented in its entirety, has several unique features. It addresses the myths associated with mammograms and includes a visual depiction of the difficult-to-understand concept of relative difference with respect to size of breast lesions.

Application of carcinogenesis theory to primary prevention.

PURPOSE/OBJECTIVES: To apply current cancer development theory to concepts of and interventions for cancer prevention. DATA SOURCES: Current medical and nursing literature. DATA SYNTHESIS: Carcinogenesis is a complex process that is only partially understood. The information that is available supports efforts to control the disease. However, the lack of detailed understanding limits attempts to alter the course of cancer. CONCLUSION: The understanding that cancer is the result of cumulative genetic errors can be used to direct oncology nursing interventions to prevent the disease. IMPLICATIONS FOR NURSING PRACTICE: Oncology nurses should be aware of the various factors that influence cancer development to prescribe primary prevention measures. Nurses also must be aware that efforts to understand carcinogenesis and exploit that knowledge are ongoing. Awareness of advances in the understanding of cancer development are keys to appropriate patient care.

Hereditary cancer syndrome: Part 1.--Clinical and educational issues.

PURPOSE/OBJECTIVES: To review current information on the biology and characteristics of hereditary cancer syndromes (HCS), and to identify families with HCS, various methods to communicate the diagnosis to families, and associated considerations for clinical practice and education. DATA SOURCES: Published articles and book chapters. DATA SYNTHESIS: HCS, which accounts for approximately 5%-10% of all malignancies, is characterized by diagnosis of the same malignancy in multiple family members, an earlier age of onset than expected, an increased frequency of bilateral cancers in paired organs, and the presence of premalignant syndromes. CONCLUSIONS: Identifying families with HCS and referring them to screening programs are necessary to reduce morbidity and mortality in these families. Many clinical, educational, and research issues are emerging. IMPLICATIONS FOR NURSING PRACTICE: Nurses need to be aware of HCS in order to identify families with HCS and refer them to screening programs. Information about HCS needs to be incorporated into basic, graduate, and continuing education nursing programs to increase awareness of HCS. Further nursing research is needed to better understand the best way to communicate the diagnosis to families, identify the psychosocial needs of individuals from these families, and facilitate cancer prevention and detection measures in these families.

Hereditary cancer syndrome: Part 2.--Psychosocial issues, concerns, and screening--results of a qualitative study.

PURPOSE/OBJECTIVES: To describe the feelings and concerns of family members with hereditary cancer syndrome (HCS) and their level of participation in prevention and early detection activities. DESIGN: Qualitative methods; content analysis of interviews. SETTING: Community, hospital-based cancer screening center with a special program of supportive services for families with HCS. SAMPLE: Purposeful theoretical sampling produced a sample (n = 13) of people with HCS. Most were Caucasian women representing a variety of types of HCS. METHODS: In-depth, unstructured, audiotaped interviews that lasted about 60 minutes. FINDINGS: Five themes emerged: (a) issues regarding communication with health professionals, (b) relationships with family members, (c) financial concerns, (d) psychosocial concerns, and (e) participation in screening activities. CONCLUSIONS: Individuals from families with HCS live with the knowledge that they have a high risk of developing malignancy. A true understanding of this risk may take time to comprehend. Many members of families with HCS require more education and support regarding cancer screening and prevention activities. IMPLICATIONS FOR NURSING PRACTICE: Nursing roles include being an educator on risk and early detection measures, a patient advocate, and a resource to all members of the family with HCS. Future nursing research can help identify specific psychosocial needs among different family members and specific psychosocial needs associated with different types of HCS.