- Email: [email protected]
Research Round-up
Research Round-up This section provides a summary of research of interest to cancer nurses. It is divided into studies concerning cancer treatment advances, cancer service developments and the experiences of patients and carers.
CANCER TREATMENT ISSUES Miller AB, To T, Baines CJ et al. (2002) The Canadian National Breast Screening Study-1: breast cancer mortality after 11 to 16 years of follow-up. A randomised screening trial of mammography in women age 40 to 49 years. Annals of Internal Medicine 137: 305--312.
The breast cancer screening debate continues. The above article is summarised in Evidencebased Medicine (Volume 8, March/April 2003), with an attached commentary. The research is considered to be of high quality with over 16 years of data. Over 50,000 women in a Canadian study that involved an annual clinical breast examination (CBE) and instruction on breast self-examination (BSE) were allocated to additional annual screening consisting of mammography, CBE, and instruction and evaluation on BSE (n=25, 214) or to usual care (n=25, 216). The main outcome measure was breast cancer mortality. After 5 years, the groups did not differ for breast cancer mortality rates, and continued to show no difference over the next 9 years. One hundred and five deaths occurred in the mammography group and 108 in the usual care group. The conclusion is that adding annual mammography and BSE did not reduce breast cancer mortality any more than a single breast examination and usual health care. The commentary also suggests that any benefits from intensive screening interventions would be better targeted at women with a positive family history of breast cancer. The commentator also suggests that mammography will not prevent most breast cancer deaths, and that resources should be directed towards studying the efficacy of more sensitive detection systems or developing predictive risk models with greater discriminatory power. Lis C, Grutsch J, Vashi et al. (2003) Is serum albumin an independent predictor of survival in patients with breast cancer? Journal of Parenteral and Enteral Nutrition 27: 10--15. European Journal of Oncology Nursing 7(3), 210 ^212 & 2003 Elsevier Ltd. All rights reserved. doi:10.1016/S1462-3889(03)00056 -5
The importance of nutritional assessment and intervention is supported by the above study. Evidence already exists about the relationship between serum albumin levels and mortality. The above authors gathered baseline serum albumin levels of 180 consecutively treated patients with breast cancer from 1993 to 1999. Low serum albumin was defined as less than 3.5 g/dl. The mean age of the patients was 51 years, with a range of 28--88 years. In the total sample 28 patients died, and nine developed cancer recurrence. The overall 5-year survival rate was 69%. Using Cox regression model to analyse the relationship between mortality and serum albumin level it was demonstrated that normal levels of albumin (greater than 3.5 g/dl) reduced the risk of death by 72%. Tumour stage was the only other factor that impacted more significantly on survival. It is suggested that serum albumin is a powerful prognostic variable that should be used, where appropriate, alongside other methods of nutritional assessment. The authors also conclude that intensive nutritional support for at-risk cancer patients can have a positive effect on outcome.
CANCER SERVICE DEVELOPMENTS Mytton E & Adams A (2003) Do clinical nurse specialists in palliative care de-skill or empower general ward nurses? International Journal of Palliative Nursing 9: 64--72.
This small-scale study examined role expectations between general nurses and specialist palliative-care nurses. Semi-structured interviews were carried out with eight general nurses and two palliative-care nurses about their interactions with each other. Using a vignette of a typical patient-based scenario involving both physical and psychosocial needs, each group of nurses were asked to comment on their own, as well as the other group’s, anticipated input. A number of expectations were elicited including looking to the specialists for advice on symptom control, facilitating communication with palliative patients and planning long-term-care options. They were also seen as an educational resource for general nurses (although this aspect of the role was often not formally addressed).
Research round up 211
They were also seen as having the skills, and the time to spend on meeting supportive-care needs. This small study touches on a number of complex issues, such as the assumption that general nurses already possess palliative-care skills that are at risk of being lost due to the input of specialists. As previous work has also shown, general settings are not the most conducive to palliative care—a very practical reason why some nurses (and other professionals) may be more likely to ‘hand over’ palliative care to specialists. The authors agree there is now a need to conduct further research to verify and expand on these findings. Joffe S, Manocchia M, Weeks J & Cleary P (2003) What do patients value in their hospital care? An empirical perspective on autonomy centred bioethics. Journal of Medical Ethics 29: 103--108.
Current thinking places increasing value in the concepts of autonomy and shared decision making. This American study explored the relative importance of feeling involved in decisions alongside people’s confidence and trust in health-care providers and being treated with respect and dignity. The research involved a cross-sectional survey with 51 hospitals in the Massachusetts area. Twelve thousand six hundred and eighty patients who were recently discharged from hospital responded to the survey. The main outcome measure was whether they would definitely recommend the hospital to their family and friends. Following logistic regression analysis, being treated with respect and dignity, and having confidence in health providers, were more strongly associated with the likelihood of recommending the hospital than feeling involved in decision making. Courtesy and availability of staff, continuity of care and physical comfort were also significantly associated with a willingness to recommend the hospital. The authors argue that involving patients in decision making may not always be the most important concern for them. Instead, more fundamental aspects of care remain the essential benchmarks against which people may judge the quality of the health care they experience.
THE EXPERIENCES OF PATIENTS AND CARERS Hudson P (2003) The experience of research participation for family caregivers of palliative care cancer patients. International Journal of Palliative Nursing 9: 120--123.
Palliative-care researchers (and Human Ethics Committees) are often charged with ensuring that patients and families are not asked to take part in ethically questionable research at an
already traumatic time. This study set out to explore this dilemma by asking 103 family caregivers, who had originally participated in a trial of two models of palliative-care provision, to evaluate their involvement. Family members were sent a questionnaire asking about the benefits and negative aspects of being involved in research whilst supporting someone who was dying of cancer. Almost two-thirds reported benefits and 90% stated that no negative outcomes had resulted. As others have shown, participation in research may indeed benefit families as a result of interacting with researchers and sharing their experiences with them. However, the relatively low response rate reported in this study (44%) limits the extent to which the findings can be accepted. Only by examining this issue further will some gatekeepers be persuaded that, rather than causing harm, there may be benefits in inviting patients and families to add to our knowledge of their needs. Parry C (2003) Embracing uncertainty: an exploration of the experiences of childhood cancer survivors. Qualitative Health Research 13: 227--246.
The theoretical concept of uncertainty forms the basis for a study that explores the meanings attached to it by a group of childhood cancer survivors. In-depth qualitative interviews were carried out with 23 men and women who were diagnosed with cancer before the age of 18. The sample included the common range of childhood cancers (leukaemias, sarcomas, Wilm’s Tumour, CNS or brain tumours). All those taking part, however, were Caucasian which the author accepts is a limitation of the study. The accounts of the survivors suggest that although uncertainty is sometimes distressing, it can become a catalyst for change and result in a greater appreciation of life. Having faced cancer, the participants spoke of having developed greater awareness of the purpose of life, gaining confidence and resilience and being more optimistic about life’s problems. The paper presents rich and thought-provoking data. Participants tell of how they initially looked for signs of their cancer recurring and then gradually learning to let go of this anxiety. Stress or illness heightened their awareness of cancer once again, whereas milestones in life such as leaving home, marriage and bereavements reinforced their general awareness of uncertainty. Rather than always being experienced as distressing however, Parry describes the participant’s reflections as ‘‘bittersweet experiences that also reminded them of the tenuous nature of human existence and deepened their gratitude to be alive’’. (p. 234). In her conclusion, she challenges practitioners to question the place of spiritual needs within psychosocial care and suggests that uncertainty should not necessarily be viewed as a negative emotion. European Journal of Oncology Nursing 7(3), 210 ^212
212 European Journal of Oncology Nursing
Instead, by viewing it alongside related concepts such as coping and adaptation, it may be possible to appreciate the personal learning that can also result from the enduring uncertainty that follows cancer. Langeveld NE, Grootenhuis M & Voute P et al. (2003) No excess fatigue reported in young adult survivors of childhood cancer. European Journal of Cancer 39: 204--214.
An alternative approach was adopted in this research to examine the contested issue of fatigue in a group of 416 childhood cancer survivors and 1026 young adults with no history of cancer. Both groups were asked to complete the Multidimensional Fatigue Inventory (MF1-20) and The Center for Epidemiologic Studies Depression Scale (CES-D). Only small differences were found between the mean scores for fatigue in both populations, with women experiencing more fatigue than men. Using logistic regression analysis, the researchers
European Journal of Oncology Nursing 7(3), 210 ^212
suggest that being female and unemployed were the only demographic characteristics strongly associated with fatigue. Severe late effects and specific cancer diagnoses were more closely associated with higher levels of fatigue. Depression was also significantly associated with all dimensions of fatigue. Despite the fact that previous clinical experience had suggested to the researchers that fatigue was a problem in childhood cancer survivors, the study did not support this to the extent that might have been expected. They suggest that further work is needed to unpick the complex somatic and psychological aspects of fatigue that may not be fully elucidated by research approaches such as this. Dr Daniel Kelly Research Fellow in Cancer Nursing, City University, London, UK E-mail address: [email protected]
CANCER TREATMENT ISSUES Miller AB, To T, Baines CJ et al. (2002) The Canadian National Breast Screening Study-1: breast cancer mortality after 11 to 16 years of follow-up. A randomised screening trial of mammography in women age 40 to 49 years. Annals of Internal Medicine 137: 305--312.
The breast cancer screening debate continues. The above article is summarised in Evidencebased Medicine (Volume 8, March/April 2003), with an attached commentary. The research is considered to be of high quality with over 16 years of data. Over 50,000 women in a Canadian study that involved an annual clinical breast examination (CBE) and instruction on breast self-examination (BSE) were allocated to additional annual screening consisting of mammography, CBE, and instruction and evaluation on BSE (n=25, 214) or to usual care (n=25, 216). The main outcome measure was breast cancer mortality. After 5 years, the groups did not differ for breast cancer mortality rates, and continued to show no difference over the next 9 years. One hundred and five deaths occurred in the mammography group and 108 in the usual care group. The conclusion is that adding annual mammography and BSE did not reduce breast cancer mortality any more than a single breast examination and usual health care. The commentary also suggests that any benefits from intensive screening interventions would be better targeted at women with a positive family history of breast cancer. The commentator also suggests that mammography will not prevent most breast cancer deaths, and that resources should be directed towards studying the efficacy of more sensitive detection systems or developing predictive risk models with greater discriminatory power. Lis C, Grutsch J, Vashi et al. (2003) Is serum albumin an independent predictor of survival in patients with breast cancer? Journal of Parenteral and Enteral Nutrition 27: 10--15. European Journal of Oncology Nursing 7(3), 210 ^212 & 2003 Elsevier Ltd. All rights reserved. doi:10.1016/S1462-3889(03)00056 -5
The importance of nutritional assessment and intervention is supported by the above study. Evidence already exists about the relationship between serum albumin levels and mortality. The above authors gathered baseline serum albumin levels of 180 consecutively treated patients with breast cancer from 1993 to 1999. Low serum albumin was defined as less than 3.5 g/dl. The mean age of the patients was 51 years, with a range of 28--88 years. In the total sample 28 patients died, and nine developed cancer recurrence. The overall 5-year survival rate was 69%. Using Cox regression model to analyse the relationship between mortality and serum albumin level it was demonstrated that normal levels of albumin (greater than 3.5 g/dl) reduced the risk of death by 72%. Tumour stage was the only other factor that impacted more significantly on survival. It is suggested that serum albumin is a powerful prognostic variable that should be used, where appropriate, alongside other methods of nutritional assessment. The authors also conclude that intensive nutritional support for at-risk cancer patients can have a positive effect on outcome.
CANCER SERVICE DEVELOPMENTS Mytton E & Adams A (2003) Do clinical nurse specialists in palliative care de-skill or empower general ward nurses? International Journal of Palliative Nursing 9: 64--72.
This small-scale study examined role expectations between general nurses and specialist palliative-care nurses. Semi-structured interviews were carried out with eight general nurses and two palliative-care nurses about their interactions with each other. Using a vignette of a typical patient-based scenario involving both physical and psychosocial needs, each group of nurses were asked to comment on their own, as well as the other group’s, anticipated input. A number of expectations were elicited including looking to the specialists for advice on symptom control, facilitating communication with palliative patients and planning long-term-care options. They were also seen as an educational resource for general nurses (although this aspect of the role was often not formally addressed).
Research round up 211
They were also seen as having the skills, and the time to spend on meeting supportive-care needs. This small study touches on a number of complex issues, such as the assumption that general nurses already possess palliative-care skills that are at risk of being lost due to the input of specialists. As previous work has also shown, general settings are not the most conducive to palliative care—a very practical reason why some nurses (and other professionals) may be more likely to ‘hand over’ palliative care to specialists. The authors agree there is now a need to conduct further research to verify and expand on these findings. Joffe S, Manocchia M, Weeks J & Cleary P (2003) What do patients value in their hospital care? An empirical perspective on autonomy centred bioethics. Journal of Medical Ethics 29: 103--108.
Current thinking places increasing value in the concepts of autonomy and shared decision making. This American study explored the relative importance of feeling involved in decisions alongside people’s confidence and trust in health-care providers and being treated with respect and dignity. The research involved a cross-sectional survey with 51 hospitals in the Massachusetts area. Twelve thousand six hundred and eighty patients who were recently discharged from hospital responded to the survey. The main outcome measure was whether they would definitely recommend the hospital to their family and friends. Following logistic regression analysis, being treated with respect and dignity, and having confidence in health providers, were more strongly associated with the likelihood of recommending the hospital than feeling involved in decision making. Courtesy and availability of staff, continuity of care and physical comfort were also significantly associated with a willingness to recommend the hospital. The authors argue that involving patients in decision making may not always be the most important concern for them. Instead, more fundamental aspects of care remain the essential benchmarks against which people may judge the quality of the health care they experience.
THE EXPERIENCES OF PATIENTS AND CARERS Hudson P (2003) The experience of research participation for family caregivers of palliative care cancer patients. International Journal of Palliative Nursing 9: 120--123.
Palliative-care researchers (and Human Ethics Committees) are often charged with ensuring that patients and families are not asked to take part in ethically questionable research at an
already traumatic time. This study set out to explore this dilemma by asking 103 family caregivers, who had originally participated in a trial of two models of palliative-care provision, to evaluate their involvement. Family members were sent a questionnaire asking about the benefits and negative aspects of being involved in research whilst supporting someone who was dying of cancer. Almost two-thirds reported benefits and 90% stated that no negative outcomes had resulted. As others have shown, participation in research may indeed benefit families as a result of interacting with researchers and sharing their experiences with them. However, the relatively low response rate reported in this study (44%) limits the extent to which the findings can be accepted. Only by examining this issue further will some gatekeepers be persuaded that, rather than causing harm, there may be benefits in inviting patients and families to add to our knowledge of their needs. Parry C (2003) Embracing uncertainty: an exploration of the experiences of childhood cancer survivors. Qualitative Health Research 13: 227--246.
The theoretical concept of uncertainty forms the basis for a study that explores the meanings attached to it by a group of childhood cancer survivors. In-depth qualitative interviews were carried out with 23 men and women who were diagnosed with cancer before the age of 18. The sample included the common range of childhood cancers (leukaemias, sarcomas, Wilm’s Tumour, CNS or brain tumours). All those taking part, however, were Caucasian which the author accepts is a limitation of the study. The accounts of the survivors suggest that although uncertainty is sometimes distressing, it can become a catalyst for change and result in a greater appreciation of life. Having faced cancer, the participants spoke of having developed greater awareness of the purpose of life, gaining confidence and resilience and being more optimistic about life’s problems. The paper presents rich and thought-provoking data. Participants tell of how they initially looked for signs of their cancer recurring and then gradually learning to let go of this anxiety. Stress or illness heightened their awareness of cancer once again, whereas milestones in life such as leaving home, marriage and bereavements reinforced their general awareness of uncertainty. Rather than always being experienced as distressing however, Parry describes the participant’s reflections as ‘‘bittersweet experiences that also reminded them of the tenuous nature of human existence and deepened their gratitude to be alive’’. (p. 234). In her conclusion, she challenges practitioners to question the place of spiritual needs within psychosocial care and suggests that uncertainty should not necessarily be viewed as a negative emotion. European Journal of Oncology Nursing 7(3), 210 ^212
212 European Journal of Oncology Nursing
Instead, by viewing it alongside related concepts such as coping and adaptation, it may be possible to appreciate the personal learning that can also result from the enduring uncertainty that follows cancer. Langeveld NE, Grootenhuis M & Voute P et al. (2003) No excess fatigue reported in young adult survivors of childhood cancer. European Journal of Cancer 39: 204--214.
An alternative approach was adopted in this research to examine the contested issue of fatigue in a group of 416 childhood cancer survivors and 1026 young adults with no history of cancer. Both groups were asked to complete the Multidimensional Fatigue Inventory (MF1-20) and The Center for Epidemiologic Studies Depression Scale (CES-D). Only small differences were found between the mean scores for fatigue in both populations, with women experiencing more fatigue than men. Using logistic regression analysis, the researchers
European Journal of Oncology Nursing 7(3), 210 ^212
suggest that being female and unemployed were the only demographic characteristics strongly associated with fatigue. Severe late effects and specific cancer diagnoses were more closely associated with higher levels of fatigue. Depression was also significantly associated with all dimensions of fatigue. Despite the fact that previous clinical experience had suggested to the researchers that fatigue was a problem in childhood cancer survivors, the study did not support this to the extent that might have been expected. They suggest that further work is needed to unpick the complex somatic and psychological aspects of fatigue that may not be fully elucidated by research approaches such as this. Dr Daniel Kelly Research Fellow in Cancer Nursing, City University, London, UK E-mail address: [email protected]