Most breast cancer patients experience functional limitations while undergoing cancer treatment[1
]. These limitations interfere with roles which they value in their daily lives, known as “participation restrictions” (i.e., instrumental activities of daily living, social, work and leisure activities)[5
]. Participation restrictions during treatment not only affect quality of life but may also lead to enduring restrictions long after cancer treatment has ended[6
]. For example, most breast cancer survivors experience a reduction in physical activity levels by as much as two hours per week from pre-diagnosis to one year post-diagnosis, particularly for vigorous activities[6
]. When participation restrictions are added to negative mood states such as anxiety and depression, a downward spiral of worsening mood and participation restrictions can result[8
]. Programs of aerobic exercise and physical therapy may help underlying impairments such as fatigue and lymphedema, which contribute to participation restrictions, [9
], but adherence to exercise and home-based physical therapy programs is typically poor[9
Overcoming participation restrictions and adhering to self-directed rehabilitation programs therefore may not be possible without addressing environmental and practical barriers. Addressing such barriers falls within the realms of problem solving therapies [19
]and occupational therapy interventions[20
], however such interventions have not been tested for this purpose in breast cancer survivors undergoing chemotherapy. Furthermore, for populations who have difficulty accessing the services of a cancer center, such as rural patients, interventions which are feasible to implement are required. Developing such interventions is a key area of research necessary for reducing cancer health disparities.
To address these issues we designed a telephone-delivered problem solving and occupational therapy intervention (PST-OT) to assist rural breast cancer patients undergoing adjuvant therapy to reduce participation restrictions in valued areas (e.g., self care, work, social, and leisure activities), and promote adherence to activities that support this task (i.e., aerobic exercise, upper extremity physical therapy and stress management). Theoretically, the PST-OT intervention is derived from a self-regulation perspective of disability and adaptation [21
]. Disability represents a discrepancy between the person's intrinsic capabilities and demands of the environment[22
]. Adaptation involves reducing this discrepancy[23
PST-OT was partially adapted from our earlier research to prevent depression in medical populations. In these prevention studies the problem solving treatment focused on reducing participation restrictions caused by the medical problem (e.g., macular degeneration and stroke)[24
]. Problem solving interventions address two main aspects of problem solving: problem orientation and problem-solving style[19
]. A positive problem orientation frames situations as challenges rather than as threats and accepts negative emotions that accompany those challenges rather than avoiding them. A problem solving style focuses on rational problem solving strategies using a set of adaptive skills, such as generating alternative solutions (i.e., brainstorming) and considering their consequences rather than acting impulsively or avoiding problems.
A key modification for the new PST-OT intervention was the integration of the Person, Environment, Occupation Model (PEO) of occupational therapy into the brainstorming stage of problem solving[26
]. In the PEO model the term “occupation” refers to “valued activities,” which are the meaningful and purposeful activities that occupy one's time, contribute to one's identity and community, and reflect one's culture. The PEO model suggests three potentially complementary courses of action in response to impaired function. When faced with a participation restriction the individual can: (1) change something about their personal skills and capabilities such as through exercise, physical therapy and stress management, (2) change the environment in which the activity is performed, or (3) change the nature of the activity itself. Thus, the OT component of PST-OT was to educate regarding environmental and activity adaptation. Because the intervention was conducted entirely by phone no “hands on” OT modalities were administered as part of the intervention.
Prior to testing the efficacy of a novel intervention it is necessary to demonstrate the feasibility of delivering the intervention and test the study methods with the population of interest. This step is perhaps particularly important when the patient population is ill, as is the case for women undergoing chemotherapy for breast cancer. The primary aim of the Living Well with Breast Cancer pilot study was to evaluate 1) the feasibility of recruiting and retaining the study sample and 2) the acceptability of the PST-OT intervention. A secondary aim was an exploratory evaluation of possible intervention effects on measures of function, quality of life and emotional state.