Showing papers in "Cancer Practice in 1998"

A Multidimensional Measure of Fatigue for Use with Cancer Patients

Abstract: purpose: The purpose of this study was to develop and validate a multidimensional measure of fatigue for use with cancer patients. description of study: Items for the Multidimensional Fatigue Symptom Inventory (MFSI) were generated through literature review, discussion with healthcare providers,and a survey of currently available measures of fatigue. The 83-item MFSI was designed to assess global, somatic, affective, cognitive, and behavioral symptoms of fatigue. The instrument was administered on three occasions to 275 women who had received or were undergoing treatment for breast cancer and 70 women with no history of cancer. Reliability, validity, and factorialstructure of the MFSI were analyzed. results: The factor analysis produced five empirically derived scales that correspond generally to the five rationally derived scales. Reliability of the rationally and empirically derived scales was excellent (alpha coefficients .87 to .96). Estimates of test-retest reliability were also favorable. Other results support the validity of both the rationally and empirically derived scales. The MFSI appears to be sensitive to fatigue, accurately discriminating cancer patients from control subjects and between patients with varying levels of performance status. clinical implications: The MFSI may be useful in identifying patterns of fatigue within individual patients and across treatment modalities. Such specificity may allow the clinician to develop, implement, and evaluate interventions that are targeted for differing patterns of fatigue. Because the measure is keyed to a 1-week time frame, it may be useful during the course of cancer treatment. The MFSI appears to be a valid and reliable tool to assess the full spectrum of symptoms that characterize the construct of fatigue.

The informational needs of patients with cancer and their families

Abstract: PURPOSE: Seven years ago, the National Cancer Institute compiled a review of the literature published from 1979 to 1990 on information, education, and communication needs of patients with cancer and their families. Because of its potential value to health professionals and to the community, an updated report of relevant literature is presented in this article. The report provides analysis to assist health professionals in tailoring the quantity, variety, and timing of information they present to the patient with cancer and his or her family. OVERVIEW: This review incorporates a sample of 66 articles published from 1990 to 1997. Of these 44 articles address the information, education, and communication needs of patients with cancer and their families. The discussion focuses on how health professionals can maximize patient comprehension and retention of information, encourage patient participation in health decision making, and foster dialogue with patients and families. CLINICAL IMPLICATIONS: Steps should be taken within healthcare organizations to ensure that ongoing informational needs assessment and education are a routine part of comprehensive cancer patient care. This analysis points to the importance of tailoring information to meet patients' educational background, cultural orientation, and general level of comprehension. Healthcare providers must not only consider the degree to which a patient with cancer desires information, but also how active a role he or she wishes to take in making treatment decisions. In addition, health professionals should be aware that the informational needs of patients and family members change throughout the course of care and therefore should be reassessed periodically.

Cross‐Cultural Issues in the Disclosure of Cancer

Abstract: purpose: To increase awareness of cultural differences in the disclosure of a cancer diagnosis or prognosis, the author reviews several surveys of patients and physicians from around the world. overview: The Western medical community is increasingly emphasizing full truthful dislosure of cancer diagnoses or prognoses and respect for autonomy as necessary prerequisites to ethical practice. However, surveys of European, Japanese, Native American, and various ethnic American (including Korean, Chinese, Mexican, Hispanic, African, and European American) cancer patients and physicians reveal that many cultures consider complete and accurate disclosure of cancer undesirable. Cultural differences in the rates of disclosure of a cancer diagnosis or prognosis; the physician's use of euphemisms to give a true or false diagnosis; as well as considerations of how to disclose a cancer diagnosis are described. clinical implications: Developing an awareness about cross-cultural practices regarding cancer disclosure issues allows the clinician to become more sensitive to the expectations of culturally and individually diverse cancer patients. To this end, all healthcare professionals should be informed about how the patient would like to be informed of a diagnosis and how involved he or she would like family members to be. In addition, an awareness of the use of nonverbal communication in some cultures and the psychosocial impact of certain terms, such as “cancer,” is essential. Often, phrases such as “ malignant tumor” or “growth” are less inflammatory and are more readily accepted. In ascertaining a knowledge of various cultural preferences and developing a sensitivity to these preferences, clinicians are better able to provide effective care to individuals from a variety of cultural and individual backgrounds.

Quality of life in cancer patients: use of a revised Hospice Index

Abstract: Purpose Improving or maintaining the quality of life for persons with cancer is a major goal of end-of-life care; however, to measure quality-of-life outcomes, a valid and reliable measure is needed. The purpose of this project was to report the psychometric properties of the revised Hospice Quality of Life Index (HQLI), including validity and reliability for hospice patients with cancer. Description Data were collected from home care hospice patients with cancer (n = 255) and a group of apparently healthy adults in the community (n = 32). The revised HQLI is a 28-item self-report instrument that includes three subscales: Psychophysiological Well-being, Functional Well-being, and Social/Spiritual Well-being. Results Evidence for validity was provided in three ways. First, factor analysis confirmed the three subscales (Psychophysiological, Functional, and Social/Spiritual Well-being). Second, a weak significant correlation was found between the Easterm Cooperative Oncology Group Performance Status Rating scores and HQLI scores (r = .26; P = .00). Third, the HQLI was able to discriminate between hospice patients with cancer and apparently healthy adults (lambda = .34; P = .00). In addition, the mean scores of these two groups were significantly different (t = 6.64; P = .00). However, only a minimal difference in scores was found on the Social/Spiritual Well-being subscale between the cancer and healthy groups. Reliability for the revised HQLI was high for both the total scale (alpha = .88) and the subscales (alpha =.82-.85). Clinical implications Emphasis has been placed recently on understanding quality of life from the patient's perspective. The development of a valid and reliable tool can guide care givers in providing meaningful quality-of-life care. The HQLI provides patients the opportunity to express beliefs about quality-of-life issues and to maintain direction over a critical aspect of their care. Of note from this study, the significant difference between groups in functional well-being and minimal difference in social/spiritual well-being suggest that patients are able to appraise their functional abilities realistically and still maintain their social network and spiritual beliefs. Indeed, it may be that patients give family relationships and spiritual beliefs greater focus during a terminal illness.

Influence of Culture on Cancer Pain Management in Hispanic Patients

Abstract: PURPOSE: The purpose of this pilot study was to describe the influence of culture on cancer pain management in Hispanic (Mexican and Central American) patients DESCRIPTION OF STUDY: This qualitative study is guided by the conceptual framework of the Pain and Quality of Life model and the Biocultural Model of Pain It was developed as a companion study to a National Cancer Institute (NCI)-funded project to disseminate a pain education program for adult patients with cancer and their family care givers in community home-care agencies After completing the NCI study, Hispanic subjects were invited to participate in the qualitative companion study A total of 17 subjects, the majority of whom were women, were interviewed The Hispanic Pain Experience Questionnaire (HPEQ) was used to elicit answers to open-ended questions regarding the perception and management of cancer pain RESULTS: Themes that emerged from the questionnaire were Influence of Culture, Expressions of Pain, Managing Pain/Medications, and Use of Nondrug Interventions Responses suggest that culture, family beliefs, and religion contribute significantly to management and expression of pain by the patient and care giver In addition, this group showed that pain may be approached with stoicism; therefore, lack of verbal or behavioral expression of pain does not indicate a lack of pain itself These patients also demonstrated a reliance on folk beliefs and nondrug interventions The most common reason cited for noncompliance with pharmacologic treatment was an inability to understand instructions CLINICAL IMPLICATIONS: When providing care to Hispanic patients, it is imperative to be nonjudgmental, sensitive, and respectful To improve compliance, the multidisciplinary cancer team should 1) incorporate the patients' folk healthcare practices and beliefs into the plan of care when possible; 2) involve family members and friends in the patient's care, identifying one key family contact; and 3) ensure that instructions for medications are available in Spanish and understood by the patient and care giver When patients' overall beliefs and values are respected, compliance with pharmacological and other interventions may increase accordingly

Side effects of cyclophosphamide, methotrexate, and 5-fluorouracil (CMF) chemotherapy for breast cancer.

Abstract: PURPOSE: The purpose of this study was to describe the range of side effects experienced by a sample of patients receiving six cycles of cyclophosphamide, methotrexate, 5-fluorouracil (CMF) chemotherapy in the treatment of breast cancer. The study aimed to document the incidence and severity of side effects after each cycle of treatment and to determine which side effects patients perceived as most "troublesome." DESCRIPTION OF STUDY: A sample of 52 women receiving chemotherapy on an outpatient basis completed a reliable and valid self- report questionnaire after each treatment cycle. The questionnaire listed 61 potential problems and prompted respondents to note any unlisted problems that they had experienced. Respondents assessed the severity of each problem on a five-point adjectival scale. The participants provided a total of 260 questionnaires assessable for data analysis. RESULTS: A total of 94 different side effects were reported. The most commonly reported problem was alopecia (mean incidence = 91%), followed by fatigue (89%), and weight gain (68%). Postchemotherapy nausea ranked 12th in terms of incidence. However, in response to an open question, patients judged fatigue and nausea to be the "most troublesome" problems, followed by difficulty sleeping and sore eyes. CLINICAL IMPLICATIONS: A most important implication of these findings is that the incidence of a side effect is not a reliable guide to the significance of the problem in terms of patient well-being; alopecia may be the most common problem identified, but it does not appear to be the problem that is most troublesome to patients. To further understand and alleviate the side effects of chemotherapy, the following measures are necessary. Patient education should be based on detailed, regimen- specific information. Routine, systematic assessment of the individual patient's side effects is desirable. Because many side effects appear to be controlled only moderately, healthcare providers must work toward more sophisticated, holistic symptom management strategies.

Rituximab: a new therapeutic monoclonal antibody for non-Hodgkin's lymphoma

Abstract: Rituximab is an effective single agent available for short-course outpatient treatment in low-grade NHL, particularly with follicular histology (IWF B-D), that offers a relatively nontoxic alternative to chemotherapy regimens currently available. Early indications are that retreatment is effective with similar levels of predictable adverse events to the initial course of therapy. Further development is awaited of regimens that combine rituximab with chemotherapeutic agents to enhance treatment efficacy without overlapping side effects in low-grade NHL as well as use in other CD20+ malignancies.

Spirituality and Quality of Life in Gynecologic Oncology Patients

Abstract: PURPOSE: The inclusion of spiritual well-being in healthcare assessments can provide insight into patients' needs and coping resources. This study explored the relationship between spiritual well-being and quality of life (QOL) in gynecologic oncology patients in an attempt to clarify the significance of spiritual well-being in the assessment process. DESCRIPTION OF STUDY: Eighteen women with gynecologic cancer completed a self-administered questionnaire that obtained sociodemographic, medical, spiritual, and functional information. The Spiritual Well-being Scale was used to assess spiritual well-being, and the Functional Living Index: Cancer (FLIC) measured QOL. Data were analyzed using descriptive statistics, comparison of means, and analysis of variance. RESULTS: Patients with gynecologic cancers other than ovarian reported a better QOL and a higher degree of spiritual, existential, and religious well-being. Older patients consistently reported higher degrees of spiritual well-being and QOL than did younger patients. Married patients consistently reported higher degrees of spiritual well-being than patients who were not married (never married or separated). Catholic patients scored higher in degrees of religious and spiritual well-being as well as in FLIC scores than other patients. CLINICAL IMPLICATIONS: Health professionals do not generally assess spiritual well-being in their evaluations of patients' needs. The findings from this study support the inclusion of spirituality as part of routine patient assessment and intervention. Clinical intervention that would increase a patient's level of spiritual awareness and his or her level of comfort associated with a personal perspective on death could help decrease the patient's level of psychosocial distress. Despite the medical establishment's bias to the contrary, religion and spirituality are positively associated with both physical and mental health and may be particularly significant to terminally ill patients. The curricula of medical, nursing, and other health schools should be redesigned appropriately.

Self‐Help Intervention Project. Women receiving breast cancer treatment.

Abstract: PURPOSE: The purpose of this study was to determine the efficacy of self-care/self-help promotion and uncertainty management interventions offered by the Self-Help Intervention Project (SHIP) for women receiving chemotherapy, radiation therapy, or hormone therapy for breast cancer. DESCRIPTION OF STUDY: One hundred ninety-three women were randomly assigned either to one of three intervention groups (self- help course, uncertainty management, or self-help course plus uncertainty management) or to a control group. Data were analyzed by a repeated measures multivariate analysis of variance procedure using a two-level blocking factor (high and low resourcefulness) and four outcome variables (self-care, self-help, psychological adjustment, and confidence in cancer knowledge). Data were collected at baseline (T1), which was after initiation of adjuvant therapy, allowing for the emergence of treatment-related side effects; 6 to 8 weeks after T1 (T2); and 3 months after T2 (T3). RESULTS: At baseline, women having high resourcefulness compared with women having low resourcefulness evidenced greater self-care, self-help, psychological adjustment, and confidence in cancer knowledge. Participation in SHIP interventions resulted in higher levels of self-care, self-help, psychological adjustment, and confidence in cancer knowledge by time effect in a significant number of women regardless of their baseline resourcefulness. Women participating in SHIP interventions who had low baseline resourcefulness demonstrated the greatest change over time in the outcome variables. Post hoc results indicated that the effect primarily was the result of changes in psychological adjustment, confidence in cancer knowledge, and self-care. CLINICAL IMPLICATIONS: The findings of this study address both the treatment effect for supportive care interventions and the needs that have emerged from review of the last 20 years of supportive care research. Some SHIP interventions evidenced more strength than others; data indicated that large percentages of women with low resourcefulness who received no SHIP interventions experienced a decrement in self-care, self-help, confidence in cancer knowledge, and psychological adjustment over the time that they received adjuvant therapy. Women's level of confidence in their knowledge about cancer being sufficient for self-management and self-help activities was not linked to baseline resourcefulness level. Thus, inherent resourcefulness was not a factor in need for supportive services that could maintain or increase confidence in cancer knowledge usefulness for self-management and self-help. Healthcare providers should note that although the women with low resourcefulness benefited the most from the interventions, women who evidenced high resourcefulness at baseline reported the same level of need for confidence in cancer knowledge and for self-help.

Social support and cancer screening in African American, Hispanic, and Native American women.

Abstract: PURPOSE: Minority women have higher rates of mortality from breast and cervical cancers and lower rates of utilization of screening tests than white women. Innovative ways to increase screening in these populations are needed urgently. This report examines the effectiveness of screening interventions based on social support for breast and cervical cancers in African American, Hispanic, and Native American women. OVERVIEW: Despite the availability of mammography, clinical breast examination, and Papanicolaou smears, many women do not follow recommendations to obtain these tests. Further, many of the traditional approaches to health education have not been effective in minority populations. Additional strategies to promote screening for breast and cervical cancers are needed, particularly for women who, by virtue of language and/or culture, are outside the mainstream. Nontraditional approaches, or social support interventions, may be particularly effective in promoting cancer screening and reducing cancer mortality in high-risk minority women. CLINICAL IMPLICATIONS: Programs that use social support offer the potential to draw on the strengths of a population--the ties between individuals, the importance of the family, and traditional cultural values--to improve screening for breast and cervical cancers in minority groups. In developing a social support intervention, healthcare providers should consider the similarities and differences among populations; collaborate with representatives of the target community; incorporate social support within hospitals and clinics; and include social support as an essential component of the clinical encounter.

Uncertainty in prostate cancer. Ethnic and family patterns.

Abstract: Purpose Prostate cancer occurs 37% more often in African-American men than in white men. Patients and their family care providers (FCPs) may have different experiences of cancer and its treatment. This report addresses two questions: 1) What is the relationship of uncertainty to family coping, psychological adjustment to illness, and spiritual factors? and 2) Are these patterns of relationship similar for patients and their family care givers and for whites and African-Americans? Description of study A sample of white and African-American men and their family care givers (N = 403) was drawn from an ongoing study, testing the efficacy of an uncertainty management intervention with men with stage B prostate cancer. Data were collected at study entry, either 1 week after post-surgical catheter removal or at the beginning of primary radiation treatment. Measures of uncertainty, adult role behavior, problem solving, social support, importance of God in one's life, family coping, psychological adjustment to illness, and perceptions of health and illness met standard criteria for internal consistency. Analyses of baseline data using Pearson's product moment correlations were conducted to examine the relationships of person, disease, and contextual factors to uncertainty. Results For family coping, uncertainty was significantly and positively related to two domains in white family care providers only. In African-American and white family care providers, the more uncertainty experienced, the less positive they felt about treatment. Uncertainty for all care givers was related inversely to positive feelings about the patient recovering from the illness. For all patients and for white family members, uncertainty was related inversely to the quality of the domestic environment. For everyone, uncertainty was related inversely to psychological distress. Higher levels of uncertainty were related to a poorer social environment for African-American patients and for white family members. For white patients and their family members, higher levels of uncertainty were related to lower scores on adult role behavior (shopping, running errands). For white family members, higher levels of uncertainty were related to less active problem solving and less perceived social support. Finally, higher levels of uncertainty were related to the importance of God for white patients and family care providers. Clinical implications The clearest finding of the present study is that there are ethnic differences in the relationship of uncertainty to a number of quality-of-life and coping variables. This has immediate implications for the assessment of psychosocial responses to cancer and cancer treatment. Much of what is in curricula is based on clinical and research experience primarily with white individuals. The experience of uncertainty related to cancer and its treatment is influenced by the cultural perspectives of patients and their families. To assist patients and families with the inevitable uncertainties of the cancer experience, healthcare providers need to reconsider their ethnocentric assumptions and develop more skill in assessing patient and family beliefs, values, cultural perspectives, and the influence of these on patient and family uncertainties.

Cost Considerations as Potential Barriers to Cancer Treatment

Abstract: purpose: An analytical cross-sectional survey was conducted to determine the prevalence of barriers to cancer treatment in Texas as perceived by diagnosed cancer patients. Results reported here address the role of insurance coverage, indirect costs (transportation, lodging, and work days lost), and direct costs of care as barriers to treatment for white, black, and Hispanic cancer patients. Specific objectives of the analyses undertaken here are to examine 1) racial/ethnic differences in insurance coverage; 2) barriers relating to insurance coverage experienced by cancer patients; and 3) role of treatment-related costs as barriers to cancer treatment. description of study: A mail questionnaire was developed to assess the perceived barriers to cancer treatment in Texas for adult cancer patients, 17 years and older, who had been diagnosed with breast, colon, cervical, prostate, or lymphoma during the period of 1989 to 1993. The sampling frame for this study was obtained from a network of cancer treatment facilities throughout the state of Texas within the University of Texas M.D. Anderson Cancer Center Texas Community Oncology Network. A total of 593 cancer patients returned their surveys, yielding a 65.2% response rate. Weighting adjustments were then made to correct for differential sampling and response rates by racial groupings and type of cancer. All of the analyses used adjusted weights. results: The findings document the financial considerations (insurance, direct and indirect costs) as they relate to barriers to cancer treatment. Specific insurance premium-related barriers with regard to maintaining and affording coverage were more prevalent for blacks. Hispanics were less likely to have insurance coverage; however, more blacks reported being denied insurance coverage when they changed jobs compared with whites and Hispanics. Minorities, particularly Hispanics, were more likely to have experienced cost-related barriers associated with medications, diagnostic tests, and hospitalizations. In addition, Hispanics experienced significant out-of-pocket costs in paying for cancer treatment. clinical implications: This research shows the need for staff at cancer treatment facilities to be aware that there are nonclinical, financial factors that are important considerations in the treatment of cancer patients. Assessment of cancer patients during the diagnostic and treatment stages, possibly through case management, will provide information on potential barriers to treatment for individual patients. Hospital programs that reimburse out-of-pocket costs, transportation costs to obtain services, and lodging accommodations may be available. Additional services may be offered through cancer advocacy groups, such as the American Cancer Society and the National Coalition for Cancer Survivors, to assist patients with managing costs and overcoming barriers to care.

Alternative care. Patient choices for adjunct therapies within a cancer center.

Abstract: purpose Prompted by an increased interest in and awareness of alternative medicine, the Sutter Cancer Center in Sacramento, California, sponsored a telephone survey of its cancer patients. The primary purpose of this 1994 survey was: 1) to determine patient perceptions and attitudes regarding alternative care providers, and 2) to determine whether the Sutter Cancer Center should provide support for these types of therapies to its patients. description of study The Center conducted a 95-item telephone survey of its patients with cancer, using an independent professional research firm. A random sample of 503 adult patients completed the 15-minute telephone survey between January 27 and March 8, 1994. The sample included more women than men (62%, 38%, respectively), and patients ranged in age from 18 to 88 years. All respondents had been treated for cancer at the Center within the past 2 years. Survey questions included areas such as cancer diagnosis, awareness of alternative therapies, attitude toward alternative therapies, and perception of oncologists' attitude toward alternative therapies. The analysis of the survey results contained two phases: descriptive analysis and comparative analysis. The descriptive aspect is included in this report. results Of the 503 respondents, 82 (16%) had considered utilizing alternative therapy for cancer after a diagnosis was made. Most respondents were moderately familiar with alternative therapy, such as nutrition therapy (59%), herbal therapy (63%), and acupuncture (62%). Only 6% of respondents actually saw a provider of alternative therapies; providers were most frequently nutritionists, counselors, herbalists, and massage therapists. The user patient profile clearly indicates that usage is highest in patients with a diagnosis of at least 1 year. Seventy-five percent reported that they would prefer to receive a referral from their doctors, while 20% would prefer to use a telephone referral line. Two thirds of patients felt that alternative care providers should be encouraged by the medical profession, and 85% indicated that alternative care should be offered at the cancer center as part of oncology treatment. clinical implications The results of this survey clearly reflect the patients' desires to integrate mainstream medicine with some forms of alternative/complementary medicine. Consequently, the Sutter Cancer Center has established a multidisciplinary group of healthcare professionals, including oncologists, nurses, social workers, and alternative practitioners, to evaluate the clinical, psychosocial, and financial impact of integrating wellness/complementary medicine into the existing treatment model at this facility. Providing alternative therapy within a cancer center ensures the availability of both the most advanced conventional treatment and care as well as accurate information and guidance with regard to alternative therapies. This service allows the patient and the cancer care team to focus not only on the patient's physical symptoms, but also on his or her overall quality of life. key terms Alternative care; Cancer; Complementary medicine; Healing; Quality of life

Knowledge and Practices Among Korean Americans

Abstract: purpose: The purpose of this study was to examine knowledge and practices of colorectal cancer screening among Korean Americans. description of study: The sample consisted of 104 Korean American men and 159 women, 40 to 69 years of age, living in the Chicago area. The National Health Interview Survey (NHIS) Cancer Control Supplement Questionnaire, prepared by the National Center for Health Statistics, was used to collect data regarding colorectal cancer screening knowledge and practices. The NHIS questionnaire was translated into Korean with minor modification. results: The percentages of male respondents ever having had a digital rectal exam (DRE) and fecal occult blood test (FOBT) were 13.5% and 10.6%, respectively. Only 11.3% of women reported DRE and 8. 8% FOBT. Multiple logistic regression analysis results indicate that gender, education, knowledge of the seven cancer warning signals, and length of residence in the United States were significantly related to having heard of DRE. For those having had DRE, knowledge of the seven cancer warning signals, and length of residence in the United States were the only significant variables. Gender and education were significantly related to having heard of FOBT. None of the variables were found to be significantly related to having had FOBT. The findings indicate that a majority of respondents were unaware of these cancer screening examinations and forego these tests due to an underestimation of their importance. clinical implications: The findings of this study underscore the importance of cancer education and further research addressing the cancer screening needs of Korean Americans. Currently, Korean Americans do not see healthcare providers or health brochures as valuable sources of health information. Therefore, healthcare professionals need to target this population by 1) co-ordinating their efforts with church and other community leaders and 2) developing health brochures that are in the Korean language and sensitive to the Korean culture.

Perceptions of Quality of Life in Hispanic Patients with Cancer

Abstract: Purpose The purpose of this study was to describe perceptions of quality of life (QOL) of Hispanic patients with cancer pain. Description of study This qualitative pilot study is guided by the conceptual framework of pain and QOL. From interviews with 17 Hispanic patients with cancer pain, data on perceptions of QOL were analyzed and are reported here. Results The study demonstrated the influence of culture on perceptions of QOL and the impact of pain on QOL. Several themes were identified for each domain of QOL, including physical, psychological, social, and spiritual well-being. The role of the family and faith in God were important components of QOL for all patients. Clinical implications It is important for clinicians to devote greater attention to cultural assessment and to include cultural beliefs in cancer care to improve QOL for Hispanic patients. The role of the family and religious beliefs should be included in the planning and evaluation of each patient's care.

Recruitment of African Americans into prostate cancer screening.

Abstract: PURPOSE: Both incidence and mortality rates for prostate cancer are significantly higher in African American men than in white men. This report identifies community sites for the optimal recruitment of African American men into prostate cancer screening. DESCRIPTION OF STUDY: A descriptive study was conducted, providing an educational program to 1369 African American men, 1264 of whom completed a survey on demographic data, prostate cancer knowledge, and prostate cancer screening history. The programs were offered at six different types of community sites, including various work sites, churches, housing projects, National Association for Advancement of Colored Persons (NAACP) sites, barber shops, and a state fairground. Free prostate cancer screening was offered to all participants. RESULTS: The advertised mass screening site (state fairground), the most common method used nationally to recruit African American men for cancer screening, was the least effective site, with only 16 men completing the survey. Of the 1264 men completing the survey at all community sites, 597 men (47%) did so at work sites and 438 (35%) did so at churches. Per site, the largest percentage of men who had never been screened was at work sites (n = 276, 46%) and NAACP sites (n = 22, 33.8%). The highest percentage of men who obtained free screening were at the state fairground (14 of 16), churches (256 of 438), and work sites (336 of 597). The most prostate cancers were detected at the housing projects, where 3 of 38 (7.9%) men who were screened received diagnoses of prostate cancer. CLINICAL IMPLICATIONS: To reduce prostate mortality rates in African American men, healthcare providers need to make a concerted effort to increase prostate cancer education and screening in this population. To be effective, recruitment of African American men must move from a provider/health site orientation to a consumer/community orientation. These findings indicate that recruitment strategies are more successful if efforts are based in the community or where a large number of African American men live and/or work. Because a history of screening has been shown to be a predictor for current participation, programs need to target men who have not had previous screening ever or within the last year. In addition, the large percentage of men recruited at work sites who had not been screened previously indicates an opportunity for collaboration with healthcare professionals in employee health programs. Efforts to increase participation in prostate cancer screening will be enhanced significantly by eliciting the active involvement of community leaders.

The Role of the Physician as an Information Source on Mammography

Abstract: purpose: The value of mammography for asymptomatic women younger than 50 years of age has been under debate, and it had been suggested that each woman should decide for herself whether to start having mammograms in her 40s. This decision-making process requires women to have knowledge of screening guidelines. This study reported key determining informational factors that led women age 40 and older to obtain a mammogram. description of study: To examine the relationship between sources of information and utilization of mammography, the authors conducted a communitywide telephone survey, in English and Spanish, of a stratified random sample of 999 white, black, and Hispanic women in Dade County, Florida. The survey was designed to measure knowledge, attitudes, practices, and beliefs about breast cancer, its prevention, and its early detection. Data for 784 women 40 years and older are analyzed and reported here. results: The most commonly cited source of information was the media (90.2%). In a logistic regression, having had a checkup in the past year was the strongest predictor of having had a recent mammogram as opposed to a distant one (OR 4.17; 95% CI 2.92–5.95). Women who named their physician as an important source of information about health and prevention were also more likely to have had a recent examination (OR 1.85; 95% CI 1.27–2.69). clinical implications: This analysis of the relationship between the source of information and utilization of mammography suggests that physicians, as sources of information, serve to motivate women to obtain a mammogram. This is true even after taking into account the patient's age and utilization of the healthcare system for preventive care in general. For this reason, it is imperative that clinicians be aware of national guidelines for breast cancer screening; of the risks and benefits of screening measures; and of the implications of a positive and negative test result. In addition, clinicians must realize the importance of follow-up to remind the patient to obtain a mammogram or other screening test and should develop strategies to provide this service.

HOPE. Home Care Outreach for Palliative Care Education.

Abstract: Purpose The goal of this project was to develop and test an educational program to extend the principles of palliative care into home-care agencies. The specific aims were: 1) to assess current practices within select home-care agencies regarding care of the dying; 2) to design the educational program, the HOPE (Home Care Outreach for Palliative Care Education) curriculum, to include relevant content for realistic implementation in home-care agencies; 3) to implement the HOPE project in two home-care agencies; and 4) to assess outcomes of the project and plan for future dissemination to home-care agencies and organizations. Description of program A pilot project developed and tested five training modules including overview of end-of-life care, pain management, symptom management, communicating with patients and families, and the death event. A needs assessment survey completed by 134 home-care agencies provided input for the training course development. The five-part curriculum was developed by an interdisciplinary team of investigators and consultants and implemented in two agencies with 52 staff members participating. Two agencies then were selected to participate in pilot testing the curriculum. Precourse and postcourse surveys provided evaluation of the program content. Results Results from the home-care agency survey demonstrated the need for improving end-of-life care. Only 32% of nonhospice agencies reporting the availability of specially trained nurses for care of the terminally ill, and only 16% of the agencies reported providing such training. Pilot testing of the HOPE curriculum suggested that it was well received by staff members. Assessment of both self-effectiveness and agency effectiveness revealed greater comfort with content such as communication and other symptom management followed by the areas of pain management, managing the death at home, and cultural issues in end-of-life care. The overall rating of end-of-life care increased from a mean rating of 5.97 to 7.42 for self-assessment and from 6.59 to 7.94 for agency assessment (on a scale of 0 to 10, with 0 = not at all effective to 10 = very effective). This project identified areas of education needed to improve care at the end of life. The HOPE curriculum will be refined and extended to reach other home-care agencies to benefit their staffs and the patients they serve. Clinical implications Home care agencies provide extensive care to patients and families facing many physical and psychosocial demands at the end of life. Palliative care education is important to support home-care professionals across all disciplines in optimum end-of-life care. This education should focus on aspects of physical care, such as treatment of pain, dyspnea, confusion, and fatigue, and also to address decisions about physical care, such as hydration/nutrition at the end of life. Psychosocial dimensions of care at home can be improved by attention to issues such as communication with dying patients and families, cultural considerations, and the special care required at the time of the actual death at home.

An examination of nursing attitudes and pain management practices.

Abstract: Purpose The purpose of this evaluation is to examine the relationship among nurses' pain management attitudes and pain management practices and to begin to explore the theoretical underpinnings that may influence this relationship. Description of study A convenience sample of 29 female registered nurses working in hospice or home health settings participated in an educational program 1 day per week for 6 weeks. All participants were asked to complete the Cancer Pain Knowledge Inventory and Survey of Expectations and Pain Assessment Questionnaire 5 weeks before, immediately before, immediately after, 6 months after, and 12 months after the program. Seventeen participants completed all questionnaires at the 6-month follow-up; 16 participants completed all questionnaires at the 1-year follow-up. Personal beliefs about pain were evaluated in relation to the dimensions and treatment of pain. Intentions and expectations to perform specific activities were evaluated in relation to in-depth assessments, equianalgesic conversions, demonstration of new ideas, and communication. Results Nurses' attitudes, beliefs, intentions, and expectations about pain and pain management influenced nurses' patient care and educational activities. Nurses who believed that patients should be pain free and nurses who focused on both the dimensions and treatment of pain implemented more pain management activities. In general, nurses who had high intentions and expectations performed more pain management activities. Clinical implications Although nurses reported change in attitude, and high expectancy for change, feelings of increased credibility, and increased motivation as advocates for new approaches to practice, nurses sometimes found it difficult to implement new practices because of constraints in time and collaborative efforts. To implement new knowledge and achieve individualized goals for change, nurses must be allowed adequate time to analyze the relationships between their beliefs about pain and the ways that they solve patients' pain problems. In addition, more support for multidisciplinary collaboration is needed.

A Provider Survey

Abstract: PURPOSE: Lack of physician recommendation is a major predictor of underutilization of breast and cervical cancer screening. The authors conducted a comprehensive two-part study of Florida primary care providers to determine which providers were not screening their older patients and why. This article reports on the study's quantitative survey component. DESCRIPTION OF STUDY: After an initial mailing of surveys to 2052 randomly sampled, licensed medical and osteopathic physicians, nurse practitioners, and certified nurse midwives, a follow-up mailing and phone calls resulted in 496 usable surveys. Outcome variables were whether or not primary care providers performed screening tests for their asymptomatic, women patients older than 50 years of age. Predictor variables included: age, race, gender, training, specialty, practice size, and location of the providers, and the percentage of older patients that they served. RESULTS: The best predictors of primary care providers not screening their asymptomatic women patients who were older than 50 years of age were providers also being older than 50, specializing in geriatrics or adult health, and working in a small or rural practice. An analysis of providers' responses to structured survey items related to their own and their patients' attitudes about screening indicated that providers often miss the opportunity to screen due to a combination of patient, provider, practice, and access barriers. CLINICAL IMPLICATIONS: The authors recommend that public health and primary care practitioners collaborate in developing strategies that address areas of potential change for overcoming these four barriers, while also considering the essential public health services of assessment, policy development, and assurance. These strategies should be designed to facilitate the breast and cervical cancer screening process for both providers and patients, so that providers feel more comfortable performing and recommending these important tests, particularly for underserved groups of older women.

Lung cancer in African Americans. A call for action.

Abstract: PURPOSE: The authors present information about current trends in the incidence, risk factors, types, presentation, and treatment for lung cancer common to all Americans and highlight factors that are unique to African Americans. Barriers to effective care and strategies for implementing culturally competent programs for lung cancer are outlined. OVERVIEW: Disparity in the incidence and mortality rates of cancer between African Americans and white Americans has been increasing at an alarming rate since 1950. For African-American men and women, lung cancer accounted for the largest increase in the incidence of cancer between 1988 and 1992: African-American men experienced an increase of 170%, and African-American women had a dramatic increase of 464%. Lung cancer is by far the most common cause of cancer death in this population, accounting for 32% of the mortality rate in men and 20% in women. Unfortunately, lung cancer in African Americans has received little attention, and culturally competent programs are needed urgently to promote lung cancer prevention, early detection, and treatment in this population. CLINICAL IMPLICATIONS: Healthcare providers' lack of knowledge about cultural influences on care is a barrier to providing adequate healthcare to individuals of different ethnic groups. Knowledge about cultural differences, respect for individual opinions about health and illness, and ability to negotiate differences are essential qualities for health professionals who serve culturally diverse populations. Because of the morbidity and mortality rates associated with lung cancer in the African-American population, prevention, early detection, and treatment programs are needed urgently. However, for these programs to succeed, the multidisciplinary cancer care team (nurses, physicians, social workers, psychologists, health educators, clergy) must provide information and care in culturally appropriate ways. Partnerships with family, extended kin networks, and religious and community leaders are essential. Finally, to minimize morbidity and maximize quality of life during the illness trajectory, comprehensive education and supportive care services are needed for those who have been diagnosed with lung cancer.

Leptomeningeal involvement in chronic lymphocytic leukemia.

Abstract: purpose: This review and case report address the rare complication of leptomeningeal involvement in patients with chronic lymphocytic leukemia. overview: Chronic lymphocytic leukemia is the most common form of leukemia, with more than 200,000 cases reported in the past 20 years. An uncommon complication of the disorder is central nervous system invasion. To date, only 21 cases have been reported, and their presenting symptoms have been heterogeneous and often nonspecific, including headache, cranial nerve abnormalities, confusion, ataxia, nausea, vomiting, and fever. The diagnosis is confirmed by the presence of a clonal population of lymphocytes in the cerebrospinal fluid. Treatment is either intrathecal or intraventricular chemotherapy with adjuvant radiation therapy or radiation alone. Prognosis is improved by prompt and aggressive therapy. In this case report, a 61-year-old man developed severe ataxia, vertigo, and occipital headaches 4 weeks after diagnosis with otherwise asymptomatic chronic lymphocytic leukemia. After treatment with both radiation to the head and neck and intrathecal methotrexate the patient achieved complete symptom resolution. Thus far, no additional systemic cytotoxic chemotherapy has been necessary. clinical implications: Because central nervous system invasion is uncommon in chronic lymphocytic leukemia, it may go undiagnosed and under-reported. Providers of patients with this disease need to be aware of possible central nervous system invasion when patients present with cranial nerve signs or symptoms and/or nonspecific neurologic manifestations. Early identification and prompt central nervous system-directed chemotherapy can affect morbidity and quality of life positively.

Options in the treatment of chemotherapy-induced emesis.

Abstract: PURPOSE: The incidence and duration of chemotherapy-induced emesis,pathophysiology of the emetic response, and antiemetic treatment of options are reviewed. OVERVIEW: Nausea and vomiting are among the most common and debilitating side effects of cancer chemotherapy. If not controlled, these side effects may interfere with the delivery of potentially life-saving treatment. Acute, delayed, and anticipatory nausea and vomiting may be prevented by appropriate antiemetic therapy. Drug selection is based on the emetogenicity of the patient's cancer treatment and potency of the antiemetic agent. Efficacy and safety of the antiemetic regimen are often improved by combining agents with different mechanisms of action. CLINICAL IMPLICATIONS: By preventing and controlling chemotherapy-induced emesis, clinicians may improve cancer patients' functional status and quality of life significantly. Improved tolerability may lead to greater patient acceptance of chemotherapy and prevent premature withdrawal from or cessation of treatment. Controlling chemotherapy-induced emesis also helps to decrease the direct and indirect costs of managing cancer.

The impact of radiation therapy on quality of life in patients with cancer.

Abstract: purpose: This study was conducted to evaluate the physical and mental status change during and after a course of radiation treatment in patients with cancer. description of study: Twenty-four patients with various malignant diseases were enrolled, including 9 men and 15 women, whose median age was 64.5, to receive radiation therapy. All patients also received psychosocial support from nurses, social workers, and/or organized support groups. The Rand 36-item survey 1.0 (SF-36) was completed at the beginning, the second week, the completion of treatment, and 1 and 3 months after treatment for the evaluation of physical component scores and mental component scores. Karnofsky performance scale and toxicity scores were determined by the treating nurses and physicians. results: The physical component scores of evaluated patients before treatment were approximately 20% lower than those of the general U.S. population, whereas mental component scores were similar to those of the general U.S. population. After treatment started, Karnofsky performance scale decreased concurrently with an increased rate of toxicity. Both physical and mental component scores were relatively stable throughout the course of evaluation. Mental component scores were the only predictor of toxicity during the treatment. Karnofsky performance scale dropped to their lowest point at the completion of treatment and then improved at 1-month follow-up. clinical implications: The patients who had higher mental component scores before treatment appeared to have higher, and improving, physical component scores throughout the course of evaluation. Along with complementary social support, the implementation of psychosocial support early and throughout the course of treatment may result in physical benefits and improving overall quality of life. Care should also be taken to make psychosocial support available to patients after the completion of treatment.

Missed cancer screening opportunities among older women: a review.

Abstract: PURPOSE: The authors present an analysis of the literature and findings from a qualitative research study as a framework for discussion of potential strategies to increase utilization of breast and cervical cancer screening among older women. The qualitative findings are one component of a comprehensive two-part study investigating why providers miss the opportunity to screen older women for cancer. OVERVIEW: Qualitative analysis of in-depth interviews with experts in cancer control (academicians, clinicians, and cancer center administrators) and a survey of primary care providers revealed four emergent themes of patient, provider, office, and access barriers that contribute to underutilization of screening. Patient and provider barriers represent human factors or reasons why both groups may be reluctant to participate in screening. Office and access barriers exemplify systems factors that impede the screening process for both groups. Primary care providers may miss the opportunity to perform or recommend screening for underserved groups of older women because of their perceptions of these human and systems factors. CLINICAL IMPLICATIONS: In light of the critical importance of primary care providers' recommendations, health professionals and community leaders should collaborate in developing multifaceted programs to help providers feel more comfortable about promoting screening to their patients. Such comprehensive, coordinated initiatives, which adapt successfully proven strategies to community needs and resources, may be essential to increase utilization of screening among underserved groups of older American women.

Self-care and breast cancer recovery.

Abstract: PURPOSE: This study identified self-care behaviors used by women during and after radiation therapy for early-stage breast cancer. DESCRIPTION OF STUDY: Interviews with 23 women 7 months post-radiation therapy for breast cancer were analyzed for descriptions of self-care. The interviews were part of the final data collection in a longitudinal study investigating experiences post-treatment. RESULTS: Self-care behaviors reported most frequently were establishing a good support network, living life to the fullest despite illness, regulating feelings, managing stress, and taking responsibility for one's own health. Results suggest that breast cancer patients have many needs that continue to require attention post-radiation therapy, making self-care an important consideration throughout recovery. CLINICAL IMPLICATIONS: Quality of self-care may make a significant difference to women after treatment for breast cancer. Healthcare providers can promote self-care by encouraging patients to conserve energy, to engage in relationships, and to maintain a positive outlook and by suggesting activities that help patients cope, adapt, and manage symptoms during and after treatment.

Cancer Screening of Older Women A Primary Care Issue

Abstract: purpose: The purpose of this retrospective chart review was to examine whether family practice physicians and residents were screening older women for breast, gynecologic, and colorectal cancers as recommended by the American Cancer Society, the Guide to Clinical Preventive Services, and Healthy People 2000. methods: A retrospective chart review of women 60 years and older who were seen at least twice between July 1, 1992, and June 30, 1993, in a midwestern family practice residency program was completed. From the original sample of 660 potential subjects, a systematic random selection of every third chart was identified for review, resulting in a sample of 201. Analysis of the data was performed by descriptive statistics and chi-square tests. A series of multiple regression models using age, number of visits, type and gender of provider, and personal or family history of cancer as predictor variables was performed. results: Breast cancer screening was offered to approximately 70% of the sample, with only about one third of the older women receiving mammography or clinical breast examination. Recommendations for gynecologic cancer screening were given to 63% of the sample, with less than one third receiving Papanicolaou smears. Recommendations for digital rectal examination, fecal occult blood test, and flexible sigmoidoscopy were 58%, 59%, and 30%, respectively. The percentages of patients who actually received these tests were considerably lower. clinical implications: Barriers for appropriate cancer screening for older women exist for both the provider and the patient; however, many of these obstacles can be overcome. Improving the resident's exposure to the current recommendations, increasing geriatric content in the training program, and initiating a reminder system may reduce some of the provider barriers. The use of midlevel providers may increase the preventive services offered to older women as well as educate and empower these women to become responsible for their own healthcare. Together, physicians and midlevel providers can become patient advocates through political activism, encouraging legislation that guarantees payment for cancer screening tests. Finally, primary care providers can become actively engaged in research that explores the healthcare concerns of older women.