Sharon Kozachik

Effect of a Cognitive Behavioral Intervention on Reducing Symptom Severity During Chemotherapy

PURPOSE To describe a randomized trial of a cognitive behavioral intervention on reducing symptom severity among patients diagnosed with solid tumors and undergoing a first course of chemotherapy and to determine whether the intervention had an additive or interactive effect on symptom severity in the presence of supportive care medications. PATIENTS AND METHODS Patients (N = 237) were accrued from comprehensive and community cancer centers, interviewed, and randomly assigned to either the experimental intervention (n = 118) or conventional care (n = 119). A symptom severity index, based on summed severity scores across 15 symptoms, was the primary outcome. Each patients site of cancer, stage at diagnosis, chemotherapy protocols, and use of supportive medications were learned from medical records. RESULTS Groups were equivalent at baseline, and attrition by characteristics by group was not different. The proportion of patients not receiving chemotherapy at 10 and 20 weeks did not differ by group. At the 10- and 20-week observations, there was a significant interaction between the experimental group and baseline symptom severity. Patients in the experimental group who entered the trial with higher symptom severity reported significantly lower severity at 10 and 20 weeks. Controlling for chemotherapy treatment status at follow-up and supportive care medications did not alter the effect of the experimental intervention. CONCLUSION Compared with conventional care alone, the experimental intervention was effective among patients who entered the trial with higher levels of symptom severity. Age, sex, site or stage of cancer, and supportive medications did not modify the effect of this cognitive behavioral intervention on symptom severity.

Intervention to improve psychological functioning for newly diagnosed patients with cancer.

PURPOSE/OBJECTIVES To test the effects of a computer-based nursing intervention designed to provide patients and family caregivers with concrete, objective information on symptom management; provide education about disease and treatment; coordinate medical resources; and provide emotional support and counseling. DESIGN Two-site, randomized clinical trial. SETTINGS A large, urban, midwestern, tertiary-cancer center and a community-based cancer center in a medium-sized midwestern city. SAMPLE 109 patients newly diagnosed with breast, colon, or lung cancer who were receiving chemotherapy; 54 received standard care, and 55 participated in the intervention group. METHODS Outcome data were collected via structured telephone interviews at three time points: baseline, midway through the intervention, and one month postintervention. The intervention consisting of nine visits, five in person and four by telephone, was conducted over 18 weeks by advanced practice oncology nurses. MAIN RESEARCH VARIABLES Psychosocial functioning, anxiety, and depression. FINDINGS Patients who received the intervention had significantly less depression between baseline and the midway point, as well as less anxiety and greater improvement in the role-emotional and mental health subscales of the Medical Outcomes Study 36 Short Form. CONCLUSIONS Cancer-care nursing interventions can decrease psychosocial morbidity and improve quality of life for newly diagnosed patients with cancer undergoing treatment. Additional research is needed to understand who benefited most from the intervention. IMPLICATIONS FOR NURSING This nurse-directed intervention resulted in improved mental health for patients; however, physical subscales were not changed. Further work is needed to determine why depression and mental health were affected yet physical health and symptoms did not differ between groups. Results support the important role of nurses in addressing mental health issues in patients and families experiencing cancer.

A cognitive behavioral intervention for symptom management in patients with advanced cancer.

PURPOSE/OBJECTIVES To evaluate the effectiveness of a cognitive behavioral intervention in decreasing symptom severity in patients with advanced cancer undergoing chemotherapy. DESIGN Prospective, randomized clinical trial based on cognitive behavioral theory. SETTING Six urban cancer centers in the midwestern United States. SAMPLE 124 patients 21 years of age or older were recruited and randomized to receive conventional care or conventional care and an intervention. Participants were newly diagnosed with stage III, stage IV, or recurrent cancer (solid tumor or non-Hodgkin lymphoma), undergoing chemotherapy, cognitively intact, and able to read and speak English. METHODS Data were gathered via telephone interviews at baseline and 10 and 20 weeks after randomization. Nurses with experience in oncology delivered a five-contact, eight-week intervention aimed at teaching patients problem-solving techniques to affect symptom severity. MAIN RESEARCH VARIABLES Gender, site of cancer, age, symptom severity and depressive symptoms at baseline, group (i.e., experimental versus control), and total symptom severity. FINDINGS Patients in the experimental group and those with lower symptom severity at baseline had significantly lower symptom severity at 10 and 20 weeks; the experimental difference at 20 weeks occurred primarily in those 60 years of age and younger. Depressive symptoms at baseline predicted symptom severity at 20 weeks; however, age, gender, and site of cancer did not affect symptom severity at either time point. CONCLUSIONS A cognitive behavioral intervention to teach problem-solving skills can be effective for patient symptom self-management during and following an intervention. IMPLICATIONS FOR NURSING Problem-solving strategies should be included in educational programs for patients with advanced cancer, particularly those 60 years of age and younger.

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.

Sleep onset insomnia symptoms during hospitalization for major burn injury predict chronic pain.

&NA; Both cross‐sectional studies of chronic pain and sleep deprivation experiments suggest a bi‐directional relationship between sleep and pain. Few longitudinal studies, however, have assessed whether acute insomnia following traumatic injury predicts the development of persistent pain. We sought to evaluate (1) whether in‐hospital insomnia independently predicts long‐term pain after burn injury and (2) whether in‐hospital pain predicts future insomnia symptoms. We analyzed data on 333 subjects hospitalized for major burn injury (72.7% male; mean age = 41.1 ± 14.5 years) who were participating in the multi‐site, Burn Model System project. Subjects completed measures of health, function (SF‐36), and psychological distress (Brief Symptom Inventory) while in hospital, at 6, 12, and 24 months after discharge. Participants were categorized as either having or not having sleep onset insomnia at discharge. Linear mixed effects analyses revealed that persons reporting insomnia at discharge (40.5%) had significantly decreased improvement in pain and increased pain severity during long‐term follow‐up (p < 0.001). More severe pain during the week preceding hospital discharge, time from injury, lack of college education and older age also contributed independent effects on chronic pain (p < 0.05). In a reciprocal model (N = 299), more severe pain during the week preceding discharge predicted increased rates of long‐term sleep onset insomnia. In‐hospital insomnia and pre‐burn mental health symptoms were also highly significant predictors of insomnia. This study provides support for a long‐term, prospective and reciprocal interaction between insomnia and pain. Future work should ascertain whether treatment of insomnia and pain during acute injury can prevent or minimize chronic pain.

A New Program in Pain Medicine for Medical Students: Integrating Core Curriculum Knowledge with Emotional and Reflective Development

OBJECTIVE Improvements in clinical pain care have not matched advances in scientific knowledge, and innovations in medical education are needed. Several streams of evidence indicate that pain education needs to address both the affective and cognitive dimensions of pain. Our aim was to design and deliver a new course in pain establishing foundation-level knowledge while comprehensively addressing the emotional development needs in this area. SETTING One hundred eighteen first-year medical students at Johns Hopkins School of Medicine. OUTCOME MEASURES Performance was measured by multiple-choice tests of pain knowledge, attendance, reflective pain portfolios, and satisfaction measures. RESULTS Domains of competence in pain knowledge included central and peripheral pain signalling, pharmacological management of pain with standard analgesic medications, neuromodulating agents, and opioids; cancer pain, musculoskeletal pain, nociceptive, inflammatory, neuropathic, geriatric, and pediatric pain. Socio-emotional development (portfolio) work focused on increasing awareness of pain affect in self and others, and on enhancing the commitment to excellence in pain care. Reflections included observations on a brief pain experience (cold pressor test), the multidimensionality of pain, the role of empathy and compassion in medical care, the positive characteristics of pain-care role models, the complex feelings engendered by pain and addiction including frustration and disappointment, and aspirations and commitments in clinical medicine. The students completing feedback expressed high levels of interest in pain medicine as a result of the course. DISCUSSION We conclude that a 4-day pain course incorporating sessions with pain specialists, pain medicine knowledge, and design-built elements to strengthen emotional skills is an effective educational approach. SUMMARY Innovations in medical education about pain are needed. Our aim was to design and deliver a new course for medical students addressing both the affective and cognitive dimensions of pain. Combining small-group sessions with pain specialists, active-learning approaches to pain knowledge, and design-built elements to strengthen emotional skills was highly effective.

Predictors of patterns of pain, fatigue, and insomnia during the first year after a cancer diagnosis in the elderly

Pain (P), fatigue (F), and insomnia (I) are among the most prevalent, distressing, and undermanaged symptoms experienced by cancer patients. Research has demonstrated that PFI co-occur; what remain unclear are the patterns and stability of PFI and the patient, disease, and treatment characteristics that predict PFI patterns over time. This secondary analysis used a data set composed of 867 elders (46% women) who were newly diagnosed with breast, colorectal, lung, or prostate cancer and followed at 4 points during the year after diagnosis. The universitys institutional review board approved this study. Descriptive statistics and multistate transition models using multinomial logistic regression were used. The typical participant was 72.6 years old, who reported 7.9 symptoms and 2.7 comorbidities. Previous PFI pattern was consistently associated with significantly increased risks of subsequent PFI pattern. At observations 1 to 3, lung cancer, treatment, higher comorbidity with breast cancer, and late-stage colorectal cancer were significantly associated with increased risks of PFI patterns. Advancing age was not significantly associated with increased risks of PFI patterns. Pain, fatigue, and insomnia co-occurrence declined over time but was associated with significantly increased risks of death or loss to follow-up and increased reports of other symptoms. Pain, fatigue, and insomnia co-occurrence is associated with adverse outcomes and should be proactively targeted for intervention.

Subjective sleep quality in women experiencing intimate partner violence: Contributions of situational, psychological, and physiological factors†

This study, guided by an adaptation of the theory of unpleasant symptoms, examined the complex relationships of childhood maltreatment, intimate partner violence (IPV), posttraumatic stress disorder (PTSD), depression, and physical health symptoms with global sleep quality and disruptive nighttime behaviors. Data were analyzed using covariance structure analysis. A convenience sample of 157 women currently experiencing IPV was recruited from crisis shelters and community agencies. Findings provide empirical support that women concurrently experiencing PTSD, depression, and stress-related physical health symptoms demonstrated poor global sleep quality and frequent disruptive nighttime behaviors. Posttraumatic stress disorder and stress health symptoms functioned as mediators of childhood maltreatment and IPV effects on both global sleep quality and disruptive nighttime behaviors, but depression did not.

2008 ONS research priorities survey.

PURPOSE/OBJECTIVES To determine the priorities of oncology nursing research, including the effect of evidence-based practice resources as identified by the Oncology Nursing Society (ONS) membership in June 2008. DESIGN Descriptive, cross-sectional. SETTING A Web-based survey of ONS members. SAMPLE Stratified into three groups: a representative random sample of the general membership (n = 4,460, 421 responded), an over-sampled random sample of advanced practice nurses (n = 980, 149 responded), and all ONS members who were doctorally prepared (n = 589, 143 responded); 713 responded overall. METHODS The 2004 survey was revised and the new 2008 survey was beta tested. The invitation to complete the survey was sent via e-mail with a link to the survey Web site. A follow-up reminder was sent one week after the initial invitation. MAIN RESEARCH VARIABLES 70 oncology nursing research topic questions, divided into five categories, and two additional categories regarding ONS Putting Evidence Into Practice resources. FINDINGS Quality of life and pain were the two highest rated topics, consistent with 2000 and 2004 research priority survey findings. Eleven topics were new to the top 20 ranked priority topics in 2008. Differences in rankings were apparent between member groups. CONCLUSIONS The respondents represented the broad spectrum of ONS membership. Changes in topic rankings indicate that oncology nursing research priorities have shifted since the 2004 survey. The lag in research result dissemination to clinical practice may account for differences in topic rating between groups. IMPLICATIONS FOR NURSING The survey results will be used to develop the 2009-2013 ONS Research Agenda. The results also will assist the ONS Foundation and other funding agencies in setting priorities.

Patterns of Use of Complementary Therapies Among Cancer Patients and Their Family Caregivers

Complementary therapies (CTs) are gaining popularity in the general population, including cancer patients, yet little is known about characteristics differentiating the use of one versus more CTs, about the patterns and persistence of CT use over time, or about the characteristics of cancer patients and their family caregivers who elect to participate in a study involving the use of CTs. The focus of this quasi-experimental study was to offer an 8-week, 5-contact, nurse-delivered intervention involving guided imagery, reflexology, and reminiscence therapy to cancer patients undergoing chemotherapy and their family caregivers. Participants were allowed to elect to use none or any combination of CTs. Twenty-seven percent of eligible patients signed consent forms and agreed to participate. The typical participant was Caucasian, married, and had at least a high school education. Higher levels of education predicted use of more than 1 CT among cancer patients; there were no significant predictors for caregivers. Female patients were more likely to complete the CT protocol than their male counterparts, but there were no associations between CT protocol completion and caregiver demographics. Patients and family caregivers who elected to use more than 1 CT did not consistently implement their CTs. Participants who elected to use only 1 CT were more consistently performing their CT over time, suggesting that this lower level of CT use may be easier to integrate into their lives during cancer treatment.