Ann M. Berger

Impact of adjuvant breast cancer chemotherapy on fatigue, other symptoms, and quality of life.

PURPOSE/OBJECTIVES To identify differences in fatigue, other physical symptoms, and psychological symptoms and their relationship to quality of life (QOL) during chemotherapy and as long as one year after. DESIGN Longitudinal, descriptive design embedded in a pilot intervention study. SETTING Midwestern urban oncology clinics and patient homes. SAMPLE 25 Caucasian women, aged 40-65 years (-X = 54.3), with stage I or II breast cancer receiving doxorubicin-based chemotherapy. METHODS The Piper Fatigue Scale, Hospital Anxiety and Depression Scale, Symptom Experience Scale, and Medical Outcomes Study Short-Form General Health Survey were completed before and after each treatment; 30, 60, and 90 days after the last treatment; and one year after the first treatment. MAIN RESEARCH VARIABLES Fatigue, physical and psychological symptoms, and QOL. FINDINGS Fatigue levels were moderately intense during treatments and decreased significantly over time. Sleep disturbances and pain were the most frequent, intense, and distressing other physical symptoms. Anxiety was highest at baseline, and depression was highest during the fourth chemotherapy treatment. Fatigue was correlated with other physical and psychological symptoms at some times during treatments and consistently following treatments. Higher fatigue was associated with lower QOL in several domains. CONCLUSIONS Fatigue is associated with other physical and psychological symptoms that fluctuate during and after treatment. Higher fatigue compromises QOL. IMPLICATIONS FOR NURSING Interventions targeting primary or cluster symptoms can reduce the impact of adjuvant chemotherapy on fatigue, other symptoms, and QOL.

Sleep wake disturbances in people with cancer and their caregivers: state of the science.

PURPOSE/OBJECTIVES To review the state of the science on sleep/wake disturbances in people with cancer and their caregivers. DATA SOURCES Published articles, books and book chapters, conference proceedings, and MEDLINE, the Cumulative Index to Nursing and Allied Health Literature, PsycINFO, and the Cochrane Library computerized databases. DATA SYNTHESIS Scientists have initiated studies on the prevalence of sleep/wake disturbances and the etiology of sleep disturbances specific to cancer. Measurement has been limited by lack of clear definitions of sleep/wake variables, use of a variety of instruments, and inconsistent reporting of sleep parameters. Findings related to use of nonpharmacologic interventions were limited to 20 studies, and the quality of the evidence remains poor. Few pharmacologic approaches have been studied, and evidence for use of herbal and complementary supplements is almost nonexistent. CONCLUSIONS Current knowledge indicates that sleep/wake disturbances are prevalent in cancer populations. Few instruments have been validated in this population. Nonpharmacologic interventions show positive outcomes, but design issues and small samples limit generalizability. Little is known regarding use of pharmacologic and herbal and complementary supplements and potential adverse outcomes or interactions with cancer therapies. IMPLICATIONS FOR NURSING All patients and caregivers need initial and ongoing screening for sleep/wake disturbances. When disturbed sleep/wakefulness is evident, further assessment and treatment are warranted. Nursing educational programs should include content regarding healthy and disrupted sleep/wake patterns. Research on sleep/wake disturbances in people with cancer should have high priority.

Cancer-related fatigue: Implications for breast cancer survivors

Cancer‐related fatigue (CRF) has been documented as 1 of the most distressing symptoms reported by breast cancer survivors. CRF affects functioning and impacts quality of life. Possible causal factors include physical conditions, affective and cognitive states, proinflammatory cytokines, and metabolic factors. Several common problems are associated with CRF in women with breast cancer, including treatment side effects, obesity, arm/upper quadrant symptoms, sleep disturbances, psychological effects, and comorbid conditions. In this article, the authors review the state of the knowledge regarding these issues and nonpharmacologic and pharmacologic interventions for CRF. Physical activity and psychosocial interventions are recommended for practice. Numerous limitations of past studies need to be considered in the design of future studies. CRF is prevalent in preoperative, postoperative, and ongoing surveillance phases. Throughout the continuum of care for women with breast cancer, clinicians must screen, further assess as indicated, and treat CRF, because it is associated with emotional distress and limits function and willingness to exercise. Cancer 2012;118(8 suppl):.

Impact of Shift Work on the Health and Safety of Nurses and Patients

Shift work generally is defined as work hours that are scheduled outside of daylight. Shift work disrupts the synchronous relationship between the bodys internal clock and the environment. The disruption often results in problems such as sleep disturbances, increased accidents and injuries, and social isolation. Physiologic effects include changes in rhythms of core temperature, various hormonal levels, immune functioning, and activity-rest cycles. Adaptation to shift work is promoted by reentrainment of the internally regulated functions and adjustment of activity-rest and social patterns. Nurses working various shifts can improve shift-work tolerance when they understand and adopt counter measures to reduce the feelings of jet lag. By learning how to adjust internal rhythms to the same phase as working time, nurses can improve daytime sleep and family functioning and reduce sleepiness and work-related errors. Modifying external factors such as the direction of the rotation pattern, the number of consecutive night shifts worked, and food and beverage intake patterns can help to reduce the negative health effects of shift work. Nurses can adopt counter measures such as power napping, eliminating overtime on 12-hour shifts, and completing challenging tasks before 4 am to reduce patient care errors.

Update on the state of the science: sleep-wake disturbances in adult patients with cancer.

PURPOSE/OBJECTIVES To update the state of the science on sleep-wake disturbances in adult patients with cancer, focusing on insomnia in the areas of prevalence, mechanisms and models, measurement, interventions, and implications for practice, health policy, education, and research. DATA SOURCES Published articles, books, book chapters, MEDLINE, CINAHL, and PsycINFO computerized databases. DATA SYNTHESIS Since the 2004 conference on Sleep-Wake Disturbances in People With Cancer and Their Caregivers, an increased focus has existed on the prevalence and distress experienced by patients with cancer with sleep-wake disturbances, particularly insomnia. Evidence suggests that altered physiology directly related to the cancer process may play a prominent role in disrupting sleep, circadian rhythms, and hypothalamic-pituitary-adrenal axis-regulated processes. Reliable and valid objective and subjective measurements for screening and assessing sleep-wake disturbances are ready for use in clinical and research settings, and an increasing amount of intervention studies have reported sleep-wake outcomes in adult patients with cancer. CONCLUSIONS Cognitive behavioral therapy interventions are likely to be effective, but effectiveness has not been established for complementary, education or information, or exercise interventions. IMPLICATIONS FOR NURSING Multidisciplinary research teams should test the effectiveness of interventions to reduce sleep-wake disturbances in adult patients with cancer. Settings should create the infrastructure to initiate and sustain evidence-based oncology nursing practice, clinicians should educate the public about sleep, and public policies should promote adoption of healthy sleep patterns and early diagnosis and treatment of sleep disorders.

Behavioral therapy intervention trial to improve sleep quality and cancer-related fatigue

Background: To determine whether sleep quality and fatigue associated with breast cancer adjuvant chemotherapy treatments can be improved with behavioral therapy (BT) [Individualized Sleep Promotion Plan (ISPP©)] including modified stimulus control, modified sleep restriction, relaxation therapy, and sleep hygiene.

Methodological Challenges When Using Actigraphy in Research

Actigraphy has become a valuable clinical and research tool to objectively evaluate sleep, daytime activity, and circadian activity rhythms in healthy individuals as well as persons with primary and comorbid insomnia. However, procedures used for sampling, data processing, and analysis are not consistently reported in the literature. The wide variability in how actigraphy is reported makes it difficult to compare findings across studies. The procedures and reporting methods from 21 studies that used actigraphs to assess sleep and wake in adult patients with cancer are reviewed to highlight the differences in reporting strategies. Patients with cancer were chosen to illustrate the methodological challenges related to procedures and reporting in one population. The aim of this article was to advance standards of information presented in publications to enable comparisons across research studies that use actigraphy. Specific methodological challenges when using actigraphy in research include instrumentation, selection of pertinent variables, sampling, and data processing and analysis. Procedural decisions are outlined and discussed, and suggestions are made for standardized actigraphy information to include in research reports. More consistent procedures and reporting will advance the science of sleep, daytime activity, and circadian activity rhythms and their association with other health-related variables.

One-Year Outcomes of a Behavioral Therapy Intervention Trial on Sleep Quality and Cancer-Related Fatigue

PURPOSE To determine 1-year outcomes of a four-component behavioral therapy (BT) sleep intervention (Individualized Sleep Promotion Plan [ISPP]) versus a healthy eating control (HEC) on cancer-related fatigue in women receiving breast cancer adjuvant chemotherapy treatment (CTX). PATIENTS AND METHODS A total of 219 participants from 12 oncology clinics were randomly assigned in a clinical trial. Before CTX, research nurses coached intervention participants to develop a BT plan including stimulus control, modified sleep restriction, relaxation therapy, and sleep hygiene. BT plans were revised before each CTX and 30, 60, and 90 days after the last CTX and reinforced 7 to 9 days later. HEC participants received nutritional information and equal attention. Pittsburgh Sleep Quality Index (PSQI), Daily Diary, Wrist Actigraph, and Piper Fatigue Scale measures and Repeated Linear Mixed Model analysis following the Intent to Treat paradigm were used. RESULTS Sleep quality differed over 1 years time (F [4,162] = 7.7, P < .001; by group, F [1,173] = 4.8, P = .029; and over time by group, F [4,162] = 3.3, P = .013). Pairwise comparisons revealed significant differences between groups at 90 days (P = .002) but not at 1 year (P = .052). Seven days of diary and actigraphy data did not corroborate with monthly reflections (PSQI). The night awakenings (Actigraph) pattern was significantly different by group over time (P = .046), with no differences between groups at 90 days or at 1 year. Fatigue was lower at 1 year than before CTX; no group effects were found. CONCLUSION The BT group, on average, experienced significant improvement on global sleep quality compared with the HEC group, but not on objective sleep or fatigue outcomes.

Feasibility of a Sleep Intervention During Adjuvant Breast Cancer Chemotherapy

PURPOSE/OBJECTIVES To evaluate the feasibility of an intervention designed to promote sleep and modify fatigue during four cycles of adjuvant breast cancer chemotherapy. DESIGN Prospective, repeated measures, quasi-experimental feasibility study. SETTING Midwestern urban oncology clinics. SAMPLE 25 women between the ages of 40-65 (mean = 54.3) with stage I-II breast cancer receiving doxorubicin-based chemotherapy. METHODS Each woman developed, reinforced, and revised an individualized sleep promotion plan (ISPP) with four components: sleep hygiene, relaxation therapy, stimulus control, and sleep restriction techniques. A daily diary, the Pittsburgh Sleep Quality Index, a wrist actigraph, and the Piper Fatigue Scale were used to collect data two days before and seven days after each treatment. MAIN RESEARCH VARIABLES Adherence, sleep and wake outcomes, and fatigue. FINDINGS Adherence rates with the components of the ISPP varied during treatments one through four: sleep hygiene (68%-78%), relaxation therapy (57%-67%), stimulus control (46%-67%), and sleep restriction (76%-80%). Mean sleep and wake outcomes at baseline, peak, and rebound times were that (a) sleep latency remained brief (less than 30 minutes per night), (b) time awake after sleep onset exceeded the desired less than 30 minutes per night, (c) sleep efficiency scores remained stable at 85%-90%, (d) total rest time remained stable at 8-10 hours per night, (e) subjective ratings of feelings on arising were stable, and (f) nighttime awakenings were 8-10 per night. Fatigue outcomes were that fatigue was stable two days after each treatment and mean daily fatigue intensity was lower at treatment three than at treatment one but rebounded at treatment four. CONCLUSIONS The intervention was feasible, adherence rates improved over time, and most sleep and wake patterns were consistent with normal values. Revisions will focus on decreasing nighttime awakenings. IMPLICATIONS FOR NURSING Adopting behaviors to promote sleep may assist in maintaining sleep and managing fatigue during chemotherapy.

Adherence, Sleep, and Fatigue Outcomes After Adjuvant Breast Cancer Chemotherapy: Results of a Feasibility Intervention Study

PURPOSE/OBJECTIVES To evaluate outcomes of an intervention designed to promote sleep and modify fatigue after adjuvant breast cancer chemotherapy. DESIGN Prospective, repeated measures, quasi-experimental, feasibility study. SETTING Midwestern urban oncology clinics. SAMPLE 21 female participants, ages 43-66 years (meanX = 55.3) with stage I or II breast cancer status post four cycles of doxorubicin chemotherapy. Eight had four additional cycles of paclitaxel, 10 also had radiation, and 18 took tamoxifen. METHODS each woman continued to revise her Individualized Sleep Promotion Plan (ISPP), developed during her first cycle of chemotherapy, that included sleep hygiene, relaxation therapy, stimulus control, and sleep restriction components. The daily diary, Pittsburgh Sleep Quality Index, wrist actigraph, and Piper Fatigue Scale were used for seven days 30, 60, and 90 days after the last chemotherapy treatment and one year after the first chemotherapy treatment. MAIN RESEARCH VARIABLES Adherence and sleep and wake, fatigue, and ISPP components. FINDINGS Adherence to the ISPP components remained high at all times (77%-88%) except for stimulus control (36%-56%). Sleep outcome means and the actigraph revealed that (a) sleep latency remained less than 30 minutes per night, (b) the time awake after sleep onset exceeded the desired less than 30 minutes per night, (c) sleep efficiency scores ranged from 82%-92%, (d) total rest time ranged from seven to eight hours per night, (e) feelings on arising ranged from 3.7-3.8 (on a 0-5 scale), (f) nighttime awakenings ranged from 10-11 per night, and (g) daytime naps ranged from 10-15 minutes in length. Fatigue remained low, from 2.9-3.5 on a 0-10 scale. CONCLUSIONS Adherence rates remained high for most components. Sleep and wake patterns were within normal limits except for the number and duration of night awakenings. Fatigue remained low. IMPLICATIONS FOR NURSING Future testing using an experimental design will focus on increasing ISPP adherence and decreasing nighttime awakenings. Adopting behavioral techniques to promote sleep may result in improved sleep and lower fatigue after chemotherapy.