Manfred Stommel

Symptom clusters in elderly patients with lung cancer.

PURPOSE/OBJECTIVES To identify the number, type, and combination (cluster) of symptoms experienced by patients with lung cancer. DESIGN A secondary analysis of data collected as part of a larger study. SETTING 24 sites that included community hospitals, medical clinics, oncology clinics, and radiation-oncology clinics. SAMPLE 220 patients newly diagnosed with lung cancer, ranging in age from 65-89 years (mean = 72 years, SD = 5.02), 38% with early-stage and 62% with late-stage lung cancer. METHODS Subject self-report. FINDINGS Factor analysis found that the symptoms of fatigue, nausea, weakness, appetite loss, weight loss, altered taste, and vomiting form a cluster. Initial staging of cancer, the number of comorbid conditions, and being treated with chemotherapy emerged as significant predictors of the symptoms reported. Few differences were noted between men and women. Correlation was found among the numbers of symptoms reported, symptom severity, and limitations attributed to symptoms. CONCLUSIONS Patients with lung cancer report multiple distressing symptoms related to symptom severity and limitations. IMPLICATIONS FOR NURSING Assessment of multiple symptoms is recommended in patients with lung cancer.

Depression and functional status as predictors of death among cancer patients

The current study examined the extent to which depression and functional limitations contribute to the mortality of newly diagnosed cancer patients. The analysis focused on differences in survival times among cancer patients with new experiences of depressive symptoms and functional limitations and patients with a history of such limitations.

A cluster of symptoms over time in patients with lung cancer

BackgroundPatients with lung cancer present late in the disease and have multiple symptoms. Previous research has shown the symptom cluster of fatigue, weakness, weight loss, appetite loss, nausea, vomiting, and altered taste to be present at time of lung cancer diagnosis. ObjectivesThe study determined whether the symptom cluster identified at the time of diagnosis remained 3 and 6 months later, and whether there was a difference in the mean number of symptoms and the mean level of symptom severity over time. The relation of the severity rating for individual symptoms at the time of diagnosis and at 3 and 6 months after diagnosis was examined. Predictors for the number of symptoms and whether the symptom cluster was predictive of death were determined. MethodsSecondary analysis of an existing data set for 112 patients with newly diagnosed lung cancer assessed at diagnosis and at 3 and 6 months was performed and determined whether they were alive or dead 19 months after diagnosis. ResultsThe cluster of seven symptoms had internal consistency that remained at 3 and 6 months. The mean symptom severity and the number of symptoms at diagnosis were correlated with later ratings, but decreased in severity over time. A similar decrease in severity rating was seen for the individual symptoms in the cluster. The stage of cancer at diagnosis was the most predictive of the number of cluster symptoms reported. Death 6 to 19 months after diagnosis was predicted by age, stage of cancer at diagnosis, and symptom severity at 6 months. ConclusionsThe symptom cluster remains over the course of lung cancer and is an independent predictor of the patient’s death. Symptom severity, the number of symptoms reported, and the severity of the individual symptoms decreased over time. The stage of cancer at diagnosis is the best predictor of symptoms later in the disease.

Gender bias in the measurement properties of the center for epidemiologic studies depression scale (CES-D)

Confirmatory factor-analytic models are used to examine gender biases of individual items of the Center for Epidemiologic Studies Depression (CES-D) Scale. In samples containing 708 cancer patients and 504 caregivers of the chronically ill elderly, two CES-D items are identified as producing biased responses in comparisons of male and female respondents. Three additional CES-D items are excluded on the basis of other psychometric problems, yielding a subset of 15 CES-D items that capture almost all the information of the original 20-item CES-D scale but are free of any gender bias. Gender differences in mean levels of depressive symptomatology are significantly reduced, but not eliminated, when the 15-item scale is used.

The Impact of Age, Treatment, and Symptoms on the Physical and Mental Health of Cancer Patients A Longitudinal Perspective

Background. To describe continuing care and rehabilitation needs of cancer patients, a longitudinal design (6 months) was performed among patients 50 years of age and older with solid tumors. The study examined how age, type of treatment, site of cancer, and symptom experience affect physical functioning and their mental health; age, site of cancer and the interval of time out of treatment influence changes in their symptom experience; and age, site of cancer, the interval of time out of treatment, and changes in symptom experience influence changes in physical and mental health.

Gender, Symptom Experience, and Use of Complementary and Alternative Medicine Practices Among Cancer Survivors in the U.S. Cancer Population

PURPOSE/OBJECTIVES To identify relationships among gender, physical and psychological symptoms (pain, insomnia, fatigue, and depression), and use of specific complementary and alternative medicine (CAM) practices among survivors in the U.S. cancer population. DESIGN Secondary analysis of the 2002 National Health Interview Survey (NHIS). The CAM Healthcare Model, an extension of the Behavioral Model for Health Services Use, guided the study. SETTING United States. SAMPLE 2,262 adults (aged 18 years and older) diagnosed with cancer representing more than 14.3 million cancer survivors in the United States . METHODS NHIS interview data on use of CAM practices (diet, yoga, tai chi, qigong, meditation, guided imagery, relaxation, and deep breathing) were examined in relationship to gender and symptoms. Analysis was conducted using Stata 9.2 software for population estimation. Binary logistic regression, the primary statistical model employed in the analysis, focused on between-subject differences in practice use. MAIN RESEARCH VARIABLES Dichotomous outcome variables included use of at least one CAM practice and use of specific individual CAM practices. Independent variables included gender, age, education, race, provider contact, cancer diagnosis, pain, insomnia, fatigue, depression, and health status. FINDINGS CAM practice use was more prevalent among female, middle-aged, Caucasian, and well-educated subjects. Pain, depression, and insomnia were strong predictors of practice use, with differences noted by gender and practice type. CONCLUSIONS CAM practices are widely used in the U.S. cancer population, especially among women. Symptom experience influences likelihood of use, with increased odds when men report symptoms. IMPLICATIONS FOR NURSING Study findings inform oncology nurses on the benefits of integrating self-care CAM practices in relationship to gender into the symptom management care plan for cancer survivors. Findings reported in this study will help guide future CAM practice intervention studies.

Adherence to the 2008 adult physical activity guidelines and mortality risk.

BACKGROUND Mortality differentials by level and intensity of physical activity have been widely documented. A comprehensive review of scientific evidence of the health benefits of physical activity led the USDHHS to issue new Federal Guidelines for physical activity in 2008. Reductions in mortality risk associated with adherence to these Guidelines among the general U.S. adult population have not yet been studied. PURPOSE This study compared the relative mortality risks of U.S. adults who met the 2008 Guidelines with adults who did not meet the recommendations. METHODS Cox proportional hazards models were used to examine the relative mortality risks of U.S. adults aged ≥18 years, using data from the 1997-2004 National Health Interview Survey and linked mortality records for deaths occurring in 1997-2006 (analyzed in 2010). Risks for adults with and without chronic health conditions were examined separately. RESULTS Meeting the recommendations for aerobic activity was associated with substantial survival benefits, especially among the population having chronic conditions, with estimated hazard ratios ranging from 0.65 to 0.75 (p<0.05). While strengthening activities by themselves did not appear to reduce mortality risks, they may provide added survival benefits to those already engaged in aerobic activities. The relative benefits of physical activity were greatest among adults who had at least one chronic condition. CONCLUSIONS Adherence to the 2008 Physical Activity Guidelines was associated with reduced all-cause mortality risks among U.S. adults, after controlling for sociodemographic characteristics, BMI, smoking, and alcohol use.

Physical functioning and depression among older persons with cancer

PURPOSE The purpose of this study was to help identify factors to assess which elderly patients are likely to experience problems with physical and psychological functioning in association with cancer or its treatment. DESCRIPTION OF STUDY A study was undertaken with a sample of 420 patients with cancer who were between the ages of 65 and 98 years and had received an incident diagnosis of breast, colon, lung, or prostate cancer. An analysis of covariance technique was used to determine how cancer site, treatment type, stage of disease, gender, age, comorbidity, symptom severity, and pre-diagnosis levels of physical functioning were related to physical functioning deficit, and how all of these in turn influenced patient depressive symptomatology. RESULTS Pre-diagnosis physical functioning, symptom severity, and days since surgery were significant predictors of physical functioning deficit. Patients who had been treated only with surgery experienced greater physical functioning deficits than did patients who had received both surgery and adjuvant therapy. This apparent anomaly was partly explained by the time interval from surgery to interview. Higher levels of symptom severity, lower levels of prior physical functioning, and greater physical functioning deficits all predicted higher levels of depressive symptomatology. CLINICAL IMPLICATIONS In the care of elderly patients with cancer, it is important for healthcare providers to consider the pre-diagnosis levels of physical functioning of patients with cancer to understand and anticipate the physical and psychological consequences of cancer and its treatment. Equally important is the proper management of patient symptoms in maximizing both the physical and psychological quality of life.

Predictors of use of complementary and alternative therapies among patients with cancer.

PURPOSE/OBJECTIVES To determine predictors of use of complementary and alternative medicine (CAM) therapies among patients with cancer. DESIGN Secondary analysis of two federally funded panel studies. SETTING Urban and rural communities in the midwestern United States. SAMPLE Patients with lung, breast, colon, or prostate cancer (N = 968) were interviewed at two points in time. 97% received conventional cancer treatment, and 30% used CAM. The sample was divided evenly between men and women, who ranged in age from 28-98; the majority was older than 60. METHODS Data from a patient self-administered questionnaire were used to determine CAM users. Responses indicated use of herbs and vitamins, spiritual healing, relaxation, massage, acupuncture, energy healing, hypnosis, therapeutic spas, lifestyle diets, audio or videotapes, medication wraps, and osteopathic, homeopathic, and chiropractic treatment. MAIN RESEARCH VARIABLES Dependent variable for analysis was use or nonuse of any of the identified CAM therapies at time of interviews. Independent variables fell into the following categories: (a) predisposing (e.g., gender, age, race, education, marital status), (b) enabling (e.g., income, health insurance status, caregiver presence, geographic location), and (c) need (e.g., cancer stage, site, symptoms, treatment, perceived health need). FINDINGS Significant predictors of CAM use were gender, marital status, cancer stage, cancer treatment, and number of severe symptoms experienced. CONCLUSIONS Patients with cancer are using CAM while undergoing conventional cancer treatment. IMPLICATIONS FOR NURSING Nurses need to assess for CAM use, advocate for protocols and guidelines for routine assessment, increase knowledge of CAM, and examine coordination of services between conventional medicine and CAM to maximize positive patient outcomes.

Comparison of changes in physical functioning of elderly patients with new diagnoses of cancer

BACKGROUND Controversy surrounds the impact of site of cancer and treatments on functioning of elderly cancer patients. OBJECTIVES This research determines (1) whether age, gender, comorbid conditions, site and stage of cancer, and treatments are related to losses in physical functioning at 4 observations during the year after diagnosis; (2) whether symptoms are a mediating variable between treatment and function; and (3) which indicators account for true change in functioning in the year after diagnosis. METHODS An inception cohort of 907 patients aged > or =65 years and newly diagnosed with breast, colon, lung, or prostate cancer were accrued from 24 community oncology programs. Stage and treatment data were obtained from medical records. Physical functioning was measured with the SF-36 subscale. Interviews were conducted at 6 to 8, 12 to 16, 26 to 30, and 52 weeks after diagnosis. RESULTS Men scored 10 points higher on physical function than women at all observation points. Patients with > or =3 comorbid conditions scored lower in functioning. Interactions between site of cancer and treatment modalities were observed. Pain, fatigue, and numbers of symptoms were independent predictors of loss of function. Surgery, female gender, and number of symptoms predicted reliable change in function. CONCLUSIONS Elderly patients with cancer report levels of function similar to other chronic conditions. Scores on physical function varied by site of cancer; the pattern of change was similar among sites. Age, comorbidity, treatment modalities, and symptom reports each had an independent effect on loss of functioning. Untreated breast cancer patients had lower functioning, suggesting a possible treatment bias.