Mei You

An Intervention to Improve Adherence and Management of Symptoms for Patients Prescribed Oral Chemotherapy Agents: An Exploratory Study

Background: Use of oral chemotherapy agents to treat cancer has increased. Patients are responsible for adhering to complex regimens while managing symptoms from adverse effects of the chemotherapy. Objective: This study examined an intervention to manage symptoms and adherence to oral agents. Methods: A 3-group pilot study determined how an Automated Voice Response (AVR) system alone (n = 40), or the AVR with strategies to manage symptoms and adherence (n = 40), or the AVR with strategies to manage adherence (n = 39) reduced symptom severity and improved adherence. Participants received a Symptom Management Toolkit, completed a baseline interview, and were randomized to receive 8 weekly AVR calls. An exit interview occurred at 10 weeks. Results: Mean age was 59.6 years, with 70% female and 76% white, and 42% were nonadherent, with missed doses increasing with regimen complexity. Symptom severity declined over time in all groups. No difference was found in adherence rates, and higher adherence was related with lower symptom severity across groups. Conclusions: Adherence, a significant clinical problem, can affect efficacy of the cancer treatment. The AVR intervention alone was just as effective as the AVR plus the nurse intervention at promoting adherence and managing symptoms from adverse effects. Implications for Practice: Nurses need to focus on patient education by ensuring patient understanding of oral agent regimen and the need to adhere to the oral agent for efficacious cancer treatment. Nurses can promote the use of medication reminders and self-management of symptoms from adverse effects, to support adherence to the oral agent.

A pilot study of an automated voice response system and nursing intervention to monitor adherence to oral chemotherapy agents.

This study was designed to develop and test a system to monitor adherence with nonhormonal oral chemotherapeutic agents using an automated voice response (AVR) system plus nursing intervention. Participants were patients diagnosed with solid tumor cancers, primarily breast, colon, and lung cancers, who received the Symptom Management Toolkit and participated in an interview for symptom severity, satisfaction, and beliefs about oral agents. Patients received weekly AVR calls, which assessed adherence to oral agents and severity of 15 symptoms. Patients who reported adherence of below 100% of the prescribed oral agents or symptoms of 4 or greater (0-10 scale) for 3 consecutive weeks were called by a nurse for assistance with symptom management and adherence to oral chemotherapy medications. After the 8 weekly AVR calls, patients participated in a follow-up interview and medical record review. Participants were 30 oncology patients who were ambulatory and treated at 2 cancer centers in Midwest United States. The results indicate 23.3% nonadherence rate to oral chemotherapy medications due to symptoms and forgetting to take the medication. An association between symptom management and adherence was found. Symptom severity and beliefs about medications were not significantly different between adherent and nonadherent patients. This pilot study demonstrated the ability to accrue patients for a longitudinal trial and informed intervention design while providing guidance for future interventions and research studies.

Health-related quality-of-life outcomes: a reflexology trial with patients with advanced-stage breast cancer.

PURPOSE/OBJECTIVES To evaluate the safety and efficacy of reflexology, a complementary therapy that applies pressure to specific areas of the feet. DESIGN Longitudinal, randomized clinical trial. SETTING Thirteen community-based medical oncology clinics across the midwestern United States. SAMPLE A convenience sample of 385 predominantly Caucasian women with advanced-stage breast cancer receiving chemotherapy and/or hormonal therapy. METHODS Following the baseline interview, women were randomized into three primary groups: reflexology (n = 95), lay foot manipulation (LFM) (n = 95), or conventional care (n = 96). Two preliminary reflexology (n = 51) and LFM (n = 48) test groups were used to establish the protocols. Participants were interviewed again postintervention at study weeks 5 and 11. MAIN RESEARCH VARIABLES Breast cancer-specific health-related quality of life (HRQOL), physical functioning, and symptoms. FINDINGS No adverse events were reported. A longitudinal comparison revealed significant improvements in physical functioning for the reflexology group compared to the control group (p = 0.04). Severity of dyspnea was reduced in the reflexology group compared to the control group (p < 0.01) and the LFM group (p = 0.02). No differences were found on breast cancer-specific HRQOL, depressive symptomatology, state anxiety, pain, and nausea. CONCLUSIONS Reflexology may be added to existing evidence-based supportive care to improve HRQOL for patients with advanced-stage breast cancer during chemotherapy and/or hormonal therapy. IMPLICATIONS FOR NURSING Reflexology can be recommended for safety and usefulness in relieving dyspnea and enhancing functional status among women with advanced-stage breast cancer.

Managing Symptoms Among Patients With Breast Cancer During Chemotherapy: Results of a Two-Arm Behavioral Trial

PURPOSE In this study, we compare symptom response and times to response among patients with breast cancer who were assigned to either a cognitive behavioral Nurse-Administered Symptom Management intervention or an Automated Telephone Symptom Management (ATSM) intervention. PATIENTS AND METHODS Patients with breast cancer were identified from a larger trial. Baseline equivalence existed between arms, and there was no differential attrition by arm. Anchor-based definition of response using mild, moderate, and severe categories of symptom severity were used. Responses and times to response for 15 symptoms were investigated in relation to trial arm, comorbid conditions, treatment protocols, and metastatic versus localized disease. RESULTS The ATSM arm was more effective among patents with metastatic disease. Compared with patients receiving combination chemotherapy protocols, those treated with single agents had greater response and shorter time to response. CONCLUSION An educational information intervention delivered via an automated voice response system that assesses symptoms and refers patients to a Symptom Management Guide is more effective than a complex cognitive behavioral approach in terms of producing greater symptom responses in shorter time intervals among patients with metastatic disease.

Do Older Adults With Cancer Fall More Often? A Comparative Analysis of Falls in Those With and Without Cancer

PURPOSE/OBJECTIVES To examine whether a history of cancer increased the likelihood of a fall in community-dwelling older adults, and if cancer type, stage, or time since diagnosis increased falls. DESIGN A longitudinal, retrospective, cohort study. SETTING A home- and community-based waiver program in Michigan. SAMPLE 862 older adults aged 65 years or older with cancer compared to 8,617 older adults without cancer using data from the Minimum Data Set-Home Care and Michigan cancer registry. METHODS Reports of falls were examined for 90-180 days. Generalized estimating equations were used to compare differences between the groups. MAIN RESEARCH VARIABLES Cancer, falls, patient characteristics, comorbidities, medications, pain, weight loss, vision, memory recall, and activities, as well as cancer type, stage, and time since diagnosis. FINDINGS A fall occurred at a rate of 33% in older adults with cancer compared to 29% without cancer (p < 0.00). Those with a history of cancer were more likely to fall than those without cancer (adjusted odds ratio 1.16; 95% confidence interval [1.02, 1.33]; p = 0.03). No differences in fall rates were determined by cancer type or stage, and the odds of a fall did not increase when adding time since cancer diagnosis. CONCLUSIONS The fall rate was higher in older adults with cancer than in older adults without cancer. IMPLICATIONS FOR NURSING Nurses need to assess fall risk and initiate fall prevention measures for older adults at the time of cancer diagnosis. KNOWLEDGE TRANSLATION When caring for older adults with cancer, nurses should be aware of an increased risk for falls. Healthcare staff also should be aware of an increased risk for falls in that population during cancer treatment. Evidence-based fall prevention measures should be included in care plans for older adult cancer survivors.

Response analysis for multiple symptoms revealed differences between arms of a symptom management trial.

OBJECTIVE To describe the methodology of evaluating the response of cancer patients to interventions directed at lowering severity of multiple symptoms, and to compare two arms of a symptom management trial to determine factors associated with response and time to response. STUDY DESIGN AND SETTING Randomized trial comparing a nurse-assisted symptom management (NASM) cognitive-behavioral intervention with an automated telephone symptom management (ATSM). Patients in both arms received six intervention contacts over 8 weeks. Analyses of the intervention contact data for 190 patients in NASM arm and 164 patients in the ATSM arm were conducted. Severities of 15 cancer-related symptoms were assessed at each intervention contact, and an anchor-based definition of response was adopted. Analyses were carried out using generalized estimating equations and Cox marginal proportional hazard models. RESULTS When compared with patients in the NASM, patients in the ATSM had better response to manage anxiety, depression, poor appetite, cough, and fatigue. NASM was more successful in managing cancer pain. Response and time to response were associated with several patient and disease characteristics. CONCLUSION The approach described here presents an analytic and clinical improvement over methods that examine each symptom separately or use summed scores of severity.

Issues Related to Overadherence to Oral Chemotherapy or Targeted Agents

Use of oral chemotherapy or targeted agents is shifting how cancer treatment is administered, moving it from supervised office visits to self-administration at home. This study examines issues related to overadherence to oral agents that were noted during a trial conducted by the authors comparing an automated voice system to strategies to reduce symptom severity and improve adherence. Overadherence to oral agents may be a significant clinical problem, occurring more often in patients with complex dosing regimens, and may lead to increased symptom severity from side effects of treatment. Avoiding overadherence may be important for the reduction or prevention of symptoms and potentially life-threatening toxicity. Nurses need to discuss with their patients the importance of the timing of the administration of their oral oncolytic regimen, as well as to provide prompts to assist in self-administration as prescribed so that overadherence can be avoided.

Deconstruction of Nurse-Delivered Patient Self-Management Interventions for Symptom Management: Factors Related to Delivery Enactment and Response

This research examines the processes by which patient self-management interventions are related to symptom responses among cancer patients. A total of 333 patients from two randomized clinical trials were combined. Each patient received a six-contact 8-week patient self-management intervention delivered by a nurse to address symptoms. Nurses’ decisions to deliver the strategies, patient enactment of strategies, and their success were investigated using patient- and symptom-level characteristics. Generalized estimating equation modeling accounted for clustering of symptoms and strategies delivered for each symptom within patient. Patient self-management intervention strategies were classified into four classes. Strategies were delivered by nurses for symptoms with higher interference and longer duration. Patient and symptom factors were related to enactment strategies. Symptom responses were related to number of strategies tried by patients. Delivery and enactment of strategies were related to both patient and symptom characteristics.

Differential symptom reporting by mode of administration of the assessment: automated voice response system versus a live telephone interview.

Background:Automated voice response (AVR) systems have been used to collect patient-reported outcome data. Mode of administration of the assessment may affect patient reporting. Objective:To evaluate if there is a differential reporting of symptoms by the mode of assessment: AVR versus a live telephone interview among cancer patients with solid tumors undergoing chemotherapy. Research Design:Randomized clinical trial comparing a nurse-assisted symptom management with an automated telephone symptom management. After completing intake telephone interview administered by a person, patients were randomized to either nurse arm or AVR arm to receive a 6-contact 8-week symptom management intervention. Patients in the nurse arm were called by specially trained nurses, and patients in the AVR arm were contacted via automated system to assess their symptoms and deliver symptom management strategies. Subjects:Two hundred patients in nurse arm, and 186 patients in the AVR arm completed the first intervention contact. Measures:Severities of 14 cancer-related symptoms were rated by patients at intake interview and at first intervention contact before the receipt of any interventions. Results:When compared with patients contacted by a nurse, patients contacted by the AVR reported higher severity of nausea and vomiting, diarrhea, poor appetite, constipation, diarrhea, pain, and alopecia controlling for prior intake symptom assessment that was free of mode effect. Symptom reporting varied by age, with the oldest group of patients reporting higher severity to the nurse. Conclusion:Mode effect needs to be considered in designing trials for symptom management and in symptom monitoring in clinical practice.

Quality of life among advanced breast cancer patients with and without distant metastasis

This study presents the results of a secondary analysis of data collected during a trial of reflexology that aimed to improve health-related quality of life (HRQOL) among women with advanced breast cancer in treatment. A comparison of HRQOL (functioning, symptoms, spirituality) of those with (n = 298) and without (n = 87) distant metastasis is presented. Following the intake interview, 385 women were randomised to reflexology, lay foot manipulation or conventional care control, and were interviewed again at weeks 5 and 11. Those with distant metastasis were older, had fewer comorbid conditions, and a smaller proportion were employed. Longitudinal analysis of HRQOL at intake, 5 and 11 weeks revealed that those with distant metastasis had lower functioning and more pain; however, no differences were found on fatigue, nausea, shortness of breath, sleep quality, anxiety, depressive symptoms or spirituality. Despite advanced disease, 56% of all women in this study were below the clinical screening cut-off for depressive symptoms. These findings may indicate that patients with advanced breast cancer have adapted emotionally and spiritually; however, the management of physical symptoms remains a priority.