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PURPOSE/OBJECTIVES To explore the process of coping with breast cancer among African American women and their spouses. DESIGN Exploratory, qualitative study using grounded theory methods. SETTING Large metropolitan area in the mid-Atlantic United States. SAMPLE 12 African American couples (N = 24). METHODS African American women and their spouses were asked to complete a background data sheet and participate in a face-to-face semistructured interview. Qualitative data were audiotaped and transcribed verbatim. Themes were identified using the constant comparative method. Quantitative data were analyzed with descriptive statistics. MAIN RESEARCH VARIABLES The process of coping with breast cancer among African American couples. FINDINGS The basic social concern was living through and beyond a breast cancer diagnosis. The core variable was merging strengths to cope with and survive a breast cancer diagnosis. Six main categories emerged to describe how African American couples actively worked together to cope with a breast cancer diagnosis: walking together, praying together, seeking together, trusting together, adjusting together, and being together. CONCLUSIONS African American couples described the importance of combining their strengths and working together as a couple to cope with a breast cancer diagnosis. IMPLICATIONS FOR NURSING Nurses must understand the importance of developing culturally sensitive and culturally relevant interventions to assist African American couples with effectively coping with a breast cancer diagnosis. When providing care to African American couples, nurses should incorporate the six categories of walking, praying, seeking, trusting, adjusting, and being together to help couples cope with the various phases of the breast cancer experience.

Purpose/objectives To review and summarize the current state of the evidence for exercise as an intervention for cancer-related fatigue and to facilitate application to clinical practice. Data sources Articles, abstracts, and practice guidelines published through October 2003. Data synthesis The strength of the evidence of effectiveness of exercise in managing cancer-related fatigue is growing. Conclusions All patients with cancer should be encouraged to maintain an optimum level of physical activity during and following cancer treatment. Patients with breast cancer and other selected patients should receive recommendations for moderate exercise programs. Referrals to physical therapy and/or rehabilitation may benefit certain patients, including those with comorbidities or deconditioning. Published multidisciplinary evidence-based guidelines for exercise programs involving patients with cancer are needed. Implications for nursing Nurses may participate in implementing exercise interventions with patients with cancer in various roles depending on skill and knowledge--from encouraging physical activity to referring patients to physical therapy and/or rehabilitation programs to prescribing and monitoring exercise in certain patient populations.

C ancer-related fatigue (CRF) has been operationally defined by the National Comprehensive Cancer Network (NCCN) as a “persistent, subjective sense of tiredness related to cancer or cancer treatment that interferes with usual functioning.”1(p309) In people with no known pathology or limitations, fatigue is a universal human experience that is regarded as a basic protective mechanism against the depletion of metabolic energy reserves. With adequate rest, nourishment, and sleep, fatigue in these individuals is self-limiting. However, in contrast to exercise-induced fatigue experienced by these individuals, the fatigue experienced by patients with cancer is of greater magnitude and persistence, tends to remain after rest periods, is more disruptive to activities of daily living, and has a more negative affective impact.2 Until recently, medical advice for patients undergoing treatment for cancer was to obtain additional rest and avoid activities that are physically challenging. Currently, the use of exercise as an adjunct therapy for cancer treatment-related symptoms has gained favor in oncology rehabilitation as a promising intervention.3 The purpose of this update is to examine evidence from recent (since 1997) randomized clinical trials (RCTs) regarding the effectiveness of exercise as an intervention for CRF. The sources of data included all those RCTs found from MEDLINE and CINAHL literature searches for the selected time period using the key words “exercise,” “fatigue,” and “cancer.” The effects of exercise on fatigue in patients with cancer, both those in intervention programs and survivors (5-year), are summarized in the Table. We present findings from 8 recent RCTs, 6 of which involved patients with breast cancer, and provide suggestions for exercise program protocols and for future research endeavors. The majority of articles in the literature involve patients with breast cancer, and physical therapists should take note of this point when making clinical judgments based on the …

Despite the high prevalence of cancer-related fatigue and its documented negative effects on patients' quality of life, limited evidence is available to support interventions to prevent or treat cancer-related fatigue. Both pharmacologic and nonpharmacologic interventions have been tested, with aerobic exercise programs and anemia correction by erythropoietin demonstrating greatest effectiveness. This article reviews the available evidence and describes gaps in knowledge. Recommendations for future research on interventions for cancer-related fatigue are presented.

purpose: The aims of this pilot study were the following: 1) to examine patterns of adherence to a brisk walking program in women receiving adjuvant chemotherapy or radiation therapy for newly diagnosed breast cancer using a prospective, randomized, controlled experimental design; 2) to examine the influence of disease symptoms and treatment side effects on exercise levels; and 3) to suggest methods that may improve future clinical trials of moderate-intensity exercise in similar populations. description of study: Fifty-two patients with newly diagnosed breast cancer were randomly assigned to one of two treatment arms: usual care or usual care plus exercise. Those assigned to the exercise group received a standardized, self-administered, home-based brisk walking intervention in addition to usual care. Each day subjects completed self-report diary forms that elicited information about activity levels, and the occurrence of symptoms and side effects during cancer treatment. results: Analyses of self-reported daily activity levels revealed a diffusion of treatment effect. Fifty percent of the usual-care group reported maintaining or increasing their physical activity to a moderate-intensity level, while 33% of the exercise group did not exercise at the prescribed levels. Analyses of self-reported disease symptoms and treatment side effects did not reveal clinically meaningful differences between the two groups. clinical implications: The results of this study suggest that women who exercised regularly before receiving a breast cancer diagnosis attempted to maintain their exercise programs. Women who lead sedentary lifestyles may benefit from a structured exercise program that includes information and support related to exercise adherence strategies.

Purpose: Despite the recognition of fatigue as a common and distressing symptom during cancer treatment, there are few evidence-based interventions available to manage such fatigue. The purpose of this multi-institutional pilot study was to explore the effects of a home-based moderate walking exercise intervention on fatigue, physical functioning, emotional distress, and quality of life (QOL) during breast cancer treatment. Description of study: Fifty-two women were recruited from five university hospital outpatient departments for this pilot study with an experimental design. Subjects were randomly assigned to the walking program or to usual care during adjuvant chemotherapy or radiation therapy for breast cancer. Symptoms, physical functioning, and QOL were measured at baseline, midtreatment, and at the end of treatment. Results: Women who exercised at least 90 minutes per week on 3 or more days reported significantly less fatigue and emotional distress as well as higher functional ability and QOL than women who were less active during treatment. Clinical implications: A home-based walking exercise program is a potentially effective, low-cost, and safe intervention to manage fatigue and to improve QOL during adjuvant chemotherapy or radiation therapy for breast cancer. This health-promoting self-care activity needs further testing in large randomized clinical trials.

Fatigue has been described as the most common, most debilitating side effect of cancer treatment and is frequently reported as a long-term complication of treatment as well. Despite the prevalence of fatigue and its profoundly negative effect on patients' quality of life, little is known about the specific mechanisms that underlie fatigue in cancer patients or how to prevent it and treat it effectively. The National Comprehensive Cancer Network (NCCN) Fatigue Practice Guidelines Panel has reviewed the available evidence and the consensus of practitioners regarding the management of fatigue and has developed clinical practice guidelines. These guidelines are presented in this article, with a discussion of levels of evidence for interventions recommended by the guidelines. Gaps exist in our knowledge of fatigue and further research is needed to support the NCCN Practice Guidelines for fatigue; however, there is a developing body of knowledge and consensus of clinicians regarding the management of fatigue in cancer patients. Additional research directed toward the knowledge gaps would strengthen the Practice Guidelines.

Summary These investigators have made a significant contribution to the development of knowledge related to fatigue in children and adolescents with cancer. This program of research has made a strong beginning with fundamental qualitative research exploring the concept of fatigue, the development of an early model to explain the concept and give direction to future research, and the development of age-appropriate quantitative instruments to describe fatigue. The next phase of the research is moving appropriately to include correlational and experimental designs to extend the science. The research has high scientific merit and great significance, both for the discipline and for the children struggling to cope with this disease and the fatigue that so often accompanies it. The investigators are to be highly commended.

Purpose: This longitudinal, descriptive outcomes study was conducted to compare the emotional responses and needs of the caregivers of patients who undergo bone marrow transplantation (BMT) for hematologic malignancies, as observed in an inpatient/outpatient (IPOP) setting with those in an inpatient setting. Description of study: A convenience sample of 43 caregivers for patients undergoing either autologous or allogeneic BMT was selected from both the inpatient unit (n = 26) and the IPOP ambulatory setting (n = 17). Emotional responses were measured by the Profile of Mood States. The importance and satisfaction of informational, patient-care, and psychological needs were assessed with the Caregiver Needs Survey, a modified version of the Home Cancer Caregiver Needs Survey. Data were collected at six points across the BMT trajectory, from before the procedure to 12 months after. Descriptive statistics were used to report sample characteristics, emotional responses, and needs. Nonparametric statistics were used to compare the IPOP and inpatient caregiver groups, and to identify relationships between emotional responses and needs within groups. Results: IPOP caregivers were found to have significantly less mood disturbance at points before discharge. Both groups showed a decrease in mood disturbance 6 and 12 months after BMT. IPOP caregivers had higher levels of satisfaction of their informational and psychological needs at day 21. Significant correlations between total mood disturbance and satisfaction of informational, psychological, and patient-care needs were found for inpatient caregivers across treatment time points. Clinical implications: These findings support the IPOP model of care as being less emotionally distressing for and better meeting the needs of family caregivers. Specific implications for practice include the importance of caregiver education in the area of patient-care information and of assessment and intervention to meet caregiver psychological needs. Continued evaluation of the impact of changes in care delivery on family caregivers is essential for the provision of comprehensive cancer care.

1. Women with breast cancer are at high risk for fatigue as a side effect of treatment with surgery, radiation, and chemotherapy. The risk is compounded by the multiple roles of women who return to work during treatment. 2. The fatigue experience includes a physical component of decreased functional status, an affective component of emotional distress, and a cognitive component of difficulty concentrating. These characteristics of fatigue may present significant challenges for employees. 3. The Family Medical Leave Act provides 12 weeks of unpaid leave to receive medical treatment and/or recover from treatment for breast cancer. 4. The nurse in the workplace can assess and monitor the effects of fatigue and teach employees to manage fatigue through energy conservation, effective use of energy, and health promotion activities to restore energy levels.

Learning Objectives Describe the benefits and limited risks of a low-cost, home-based exercise program. Impart to patients information on an easily implemented, sustainable, at-home exercise intervention. Purpose. Exercise use among patients with cancer has been shown to have many benefits and few notable risks. The purpose of this study was to evaluate the impact of a home-based walking intervention during cancer treatment on sleep quality, emotional distress, and fatigue. Methods. A total of 138 patients with prostate (55.6%), breast (32.5%), and other solid tumors (11.9%) were randomized to a home-based walking intervention or usual care. Exercise dose was assessed using a five-item subscale of the Cooper Aerobics Center Longitudinal Study Physical Activity Questionnaire. Primary outcomes of sleep quality, distress, and fatigue were compared between the two study arms. Results. The exercise group (n = 68) reported more vigor (p = .03) than control group participants (n = 58). In dose response models, greater participation in aerobic exercise was associated with 11% less fatigue (p < .001), 7.5% more vigor (p = .001), and 3% less emotional distress (p = .03), after controlling for intervention group assignment, age, and baseline exercise and fatigue levels. Conclusion. Patients who exercised during cancer treatment experienced less emotional distress than those who were less active. Increasing exercise was also associated with less fatigue and more vigor. Home-based walking is a simple, sustainable strategy that may be helpful in improving a number of symptoms encountered by patients undergoing active treatment for cancer.

Background Cancer treatment is associated with decline in measured and self-reported physical function and increased pain. In the current study, the authors evaluated the impact of a walking intervention on these outcomes during chemotherapy/radiation. Methods Patients with breast, prostate, and other cancers (N=126) were randomized to a home-based walking intervention (exercise) or usual care (control). Exercise dose during the intervention was assessed using a 5-item Physical Activity Questionnaire. Outcome measures were cardiorespiratory fitness, expressed as peak oxygen uptake (VO2) measured during treadmill testing (n=85) or estimated by 12-minute walk (n=27), and self-reported physical function, role limitations, and pain derived from Medical Outcomes Study Short Form 36. Linear regression was used to evaluate pre-to-post intervention change outcomes between groups. Results The mean (standard deviation) age of the patients was 60.2 (10.6) years. Diagnoses included prostate (55.6%) and breast (32.5%) cancer. Treatment included external beam radiotherapy (52.3%) and chemotherapy (34.9%). Exercise patients reported worsening Medical Outcomes Study physical function role limitations by the end of cancer treatment (P=.037). Younger age was associated with improved Medical Outcomes Study physical function (P=.048). In all patients, increased exercise dose was associated with decreased Medical Outcomes Study pain (P=.046), regardless of diagnosis. The percent change of VO2 between prostate and nonprostate cancer patients when adjusted for baseline VO2 and Physical Activity Questionnaire values was 17.45% (P=.008), with better VO2 maintenance in the prostate group. Conclusions Exercise during cancer treatment improves cardiorespiratory fitness and self-reported physical function in prostate cancer patients and in younger patients, regardless of diagnosis, and may attenuate loss of those capacities in patients undergoing chemotherapy. Exercise also reduces the pain experience.

The purpose of this cross-sectional, correlational study was to describe stomatitis-related pain in women with breast cancer undergoing autologous hematopoietic stem cell transplant. The hypotheses that significant, positive relationships would exist between oral pain and stomatitis, state anxiety, depression, and alteration in swallowing were tested. Stomatitis, sensory dimension of oral pain, and state anxiety were hypothesized to most accurately predict oral pain overall intensity. Thirty-two women were recruited at 2 East Coast comprehensive cancer centers. Data were collected on bone marrow transplantation day +7 +/- 24 hours using Painometer, Oral Mucositis Index-20, Oral Assessment Guide, State-Trait Anxiety Inventory, and Beck Depression Inventory. Data analysis included descriptive statistics, correlations, and stepwise multiple regression. All participants had stomatitis; 47% had oral pain, with a subset reporting continuous moderate to severe oral pain despite pain management algorithms. Significant, positive associations were seen between oral pain, stomatitis, and alteration in swallowing and between oral pain with swallowing and alteration in swallowing. Oral pain was not significantly correlated with state anxiety and depression. Oral sensory and affective pain intensity most accurately predicted oral pain overall intensity. Future research needs to explore factors that affect perception and response to stomatitis-related oropharyngeal pain and individual patient response to opioid treatment.

There is a dearth of knowledge about the quality of life of African American women during the breast cancer treatment phase. This pilot study explored spiritual wellbeing, religious coping, and the quality of life of African American women during the breast cancer treatment phase. The sample included a total of 11 African American women from the mid-Atlantic and southeastern United States. The Roy Adaptation Model (RoyAndrews, 1999) served as a guide for this study. This pilot study used a descriptive cross-sectional design. Data were analyzed utilizing descriptive statistics and the Spearman rho correlational analysis. African American women used more positive religious coping than negative religious coping. Significant relationships were found between spiritual well-being and the QOL domains of physical, emotional, and functional well-being. These findings suggest that nurses should incorporate spiritual and religious support in the care of African American women during the breast cancer treatment phase.

Title. Using a conceptual model in nursing research – mitigating fatigue in cancer patients Aim. This paper is a discussion of the use of the Levine Conservation Model to guide the investigation of an exercise intervention to mitigate cancer-related fatigue. Background. Researchers use conceptual models or theoretical frameworks to provide an organizing structure for their studies, to guide the development and testing of hypotheses, and to place research finding within the context of science. Selection of an appropriate and useful framework is an essential step in the development of a research project. Method. A descriptive approach is used to present the components of the conceptual model and details of the articulation of the study intervention and outcomes with the model. Findings. The Levine Conservation Model provided a useful framework for this investigation, conducted in 2002–2006, of the effects of exercise on fatigue and physical functioning in cancer patients. The four conservation principles of the model guided the development of the exercise intervention, the identification of salient outcomes for patients, and the selection of appropriate instruments to measure study variables. The model is also proving useful in the analysis and interpretation of data in relation to the conservation principles. Conclusion. Use of an appropriate conceptual model facilitates the design and testing of theory-based interventions and the development of science to support nursing practice.

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

Objectives. We estimated the prevalence of and risk factors for intimate partner violence in China. Methods. Our cross-sectional, comparative prevalence study used a face-to-face survey of randomly selected women attending an urban outpatient gynecological clinic at a major teaching hospital in Fuzhou, China. Multiple logistic regression models were used to assess risk factors for intimate partner violence. Results. Of the 600 women interviewed, the prevalence of lifetime intimate partner violence and violence taking place within the year before the interview was 43% and 26%, respectively. For lifetime intimate partner violence, partners who had extramarital affairs and who refused to give respondents money were the strongest independent predictors. For intimate partner violence taking place within the year before the interview, frequent quarreling was the strongest predictor. Conclusions. Intimate partner violence is prevalent in China, with strong associations with male patriarchal values and conflict resolutions. Efforts to reduce intimate partner violence should be given high priority in health care settings where women can be reached.

In this article, we examine emerging themes in the research and theoretical literature on care at the end of life to develop a conceptual framework to guide further research in this area. The integrity of the human person is the organizing concept, and the spiritual domain is at the core of the psychological, physical, and functional domains. This framework extends beyond previous frameworks for care at the end of life by including the relationship of the health professional and the health care organization to the integrity of the person. Also, outcomes in this framework extend beyond quality of life and comfort to include patient decision-making methods and achievement of life goals. Attention is given to the cultural dimension of personhood in our multicultural society, and the definition of end of life is expanded to include both the acute phase of terminal illness and the frailty of health associated with advanced age.

Fatigue is the most prevalent and debilitating symptom experienced by breast cancer patients receiving adjuvant chemotherapy or radiation therapy and few evidence-based treatments are available to manage this distressing side-effect. The purpose of this multi-institutional randomized controlled trial was to determine the effects of exercise on fatigue levels during treatment for breast cancer. Sedentary women (N=119) with Stage 0-III breast cancer receiving outpatient adjuvant chemotherapy or radiation therapy were randomized to a home-based moderate-intensity walking exercise program or to usual care for the duration of their cancer treatment. Of participants randomized to exercise, 72% adhered to the exercise prescription; 61% of the usual care group adhered. The intention-to-treat analysis revealed no group differences in part because of a dilution of treatment effect as 39% of the usual care group exercised and 28% of the exercise group did not. When exercise participation was considered using the data analysis method of instrumental variables with principal stratification, a clinically important and statistically significant (p=0.03) effect of exercise on pretest-to-posttest change in fatigue levels was demonstrated. Adherence to a home-based moderate-intensity walking exercise program may effectively mitigate the high levels of fatigue prevalent during cancer treatment.

Objectives To describe the management of fatigue and anemia in patients with cancer. Data sources Published literature and clinical experience. Conclusion Anemia is a common cause of cancer-related fatigue. Epoetin alfa increases hemoglobin, decreases transfusion requirements, and improves energy and quality of life in patients with cancer-related anemia. Nonpharmacologic treatment options include exercise, nutrition optimization, and psychosocial interventions. Effective management of fatigue improves overall cancer treatment, quality of life, and functional status. Implications for nursing practice Fatigue and anemia are commonly undertreated complications of cancer and its treatment. Oncology nurses play a key role in identifying and managing these conditions.

Summary Fatigue is one of the most prevalent and distressing symptoms of cancer, and is a common side-effect of many of the treatments available for the management of malignant disease. We critically assess the evidence for cancer-related fatigue and its treatment in adults. Little is known about the cause and mechanisms of fatigue, and research into methods of alleviating the condition has focused on treatment for anaemia and behavioural Interventions, such as exercise, both of which are effective in reducing fatigue. Although research into the condition has increased considerably in the past decade, important gaps in knowledge remain.

This evaluation of a program of research on fatigue in children with cancer is a critique of the model developed as an outcome of the research. Emphasis is placed on the research methods as well as on the contribution to knowledge development related to pediatric cancer-related fatigue.

Body image, as a component of self-concept, was compared in four groups of women (N = 257) who received the most common types of treatment for breast cancer: mastectomy, mastectomy with delayed reconstruction, mastectomy with immediate reconstruction, and conservative surgery. Data were collected by mailed questionnaires using self-report instruments. Comparison of groups using analysis of covariance with age as a covariate indicated that mean body image in the conservative surgery group was significantly more positive than in either the mastectomy group or in the mastectomy with immediate reconstruction group. No differences in self-concept were evident among the four groups.

Fatigue is a common symptom in patients with cancer and is nearly universal in those undergoing cytotoxic chemotherapy, radiation therapy, bone marrow transplantation, or treatment with biologic response modifiers. The problem, which affects 70% to 100% of cancer patients, has been exacerbated by the increased use of fatigue-inducing multimodal treatments and dose-dense, dose-intense protocols. In patients with metastatic disease, the prevalence of cancer-related fatigue exceeds 75%, and cancer survivors report that fatigue is a disruptive symptom months or even years after treatment ends. Patients perceive fatigue to be the most distressing symptom associated with cancer and its treatment, more distressing even than pain or nausea and vomiting, which, for most patients, can generally be managed with medications. For the most recent version of the guidelines, please visit NCCN.org

Cancer- and treatment-related anemia has received increasing attention, particularly because relationships between anemia and quality of life (QOL) or treatment outcomes are under investigation. This guideline recognizes the multiple etiologies of cancer- and treatment-related anemia, but specifically addresses the treatment of anemia caused by the myelosuppressive effects of chemotherapy and the anemia associated with chronic disease. It provides guidelines for the use of erythropoietic agents in patients with cancer who are receiving chemotherapy. For the most recent version of the guidelines, please visit NCCN.org

PURPOSE: To determine whether a shift in care from an inpatient-based to an outpatient-based bone marrow transplantation (BMT) program decreased charges to payers without increasing clinical complications or out-of-pocket costs to patients. PATIENTS AND METHODS: This nonrandomized prospective cohort study compared clinical and economic outcomes for 132 consecutive BMT patients with hematologic malignancies who received either inpatient- or outpatient-based BMT care. RESULTS: Seventeen of 132 BMT patients underwent outpatient-based BMT. Compared with the inpatient-based group, the outpatient-based group had a markedly lower mean number of inpatient hospital days (22 v 47; P < .001) and decreased mean inpatient facility charges ($61,059 less per patient; P < .0001) but had higher mean outpatient facility charges ($49,732 higher; P < .0001). Total professional fees were similar for the groups. The mean total charge to payers was only 7% less ($12,652; P = .21) for outpatient-based BMT than for inpatient-based BMT, but total charge was 34% less for outpatient compared with inpatient BMT ($54,240; P = 0.056) in a subset of patients who had a standard rather than high risk of treatment failure. There was no significant difference between groups in out-of-pocket costs for transportation, lodging, meals, home nursing, household assistance, child care, medication expenses, or unreimbursed medical bills. There also was no significant difference between groups in reported income lost, involuntary unemployment, or months of disability. The two groups had similar rates of major complications, including death, significant acute graft-versus-host disease, and veno-occlusive disease of the liver. CONCLUSION: Increased use of outpatient-based BMT should produce substantial cost savings for payers without adverse effects on patients for those patients who do not have a high risk of treatment failure.