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1.  Predictors of Stage of Adoption for Colorectal Cancer Screening Among African American Primary Care Patients 
Cancer nursing  2014;37(4):241-251.
Background
Compared with other racial groups, African Americans have the highest colorectal cancer (CRC) incidence and mortality rates coupled with lower screening rates.
Objective
Our study examined the predictors of stage of adoption for fecal occult blood testing (FOBT) and colonoscopy among African American primary care patients who were non-adherent to published screening guidelines.
Methods
Baseline data (N = 815) in a randomized clinical trial were analyzed. Participants were categorized into precontemplation, contemplation, and preparation stages for FOBT and colonoscopy. Predictor variables were demographics, clinical variables, CRC health beliefs and knowledge, and social support. Hierarchical modeling was to identify significant predictors of stage of adoption.
Results
Older, male, Veterans Affairs participants and those with higher perceived self-efficacy, family/friend encouragement, and a provider recommendation had higher odds of being at a more advanced stage of adoption for FOBT. Patients with a history of cancer and higher perceived barriers had higher odds of being at an earlier stage of adoption for FOBT. Predictors of more advanced stage of adoption for colonoscopy included higher perceived benefits, higher perceived self-efficacy, family/friend encouragement, and a provider recommendation for colonoscopy. Higher income (> 30K vs. < 15K) was predictive of earlier stage of adoption for colonoscopy.
Conclusions
Enhancing self-efficacy, encouragement from family and friends, and provider recommendations are important components of interventions to promote CRC screening.
Implications for Practice
Nurses can utilize knowledge of the characteristics associated with stage of adoption to educate and motivate their African American primary care patients to complete CRC screening tests.
doi:10.1097/NCC.0b013e3182a40d8d
PMCID: PMC3991768  PMID: 24145250
Colorectal cancer; screening; stage of adoption; health beliefs
2.  Effects of a Randomized Controlled Trial to Increase Repeat Mammography Screening in Iranian Women 
Cancer nursing  2015;38(4):288-296.
Background
Although mammography use has increased in developed countries, regular screening in developing countries including Iran remains low. Multiple frameworks, including the Health Belief Model (HBM) and the Theory of Planned Behavior (TPB), have been used to understand screening practices among Iranians. The HBM includes intrapersonal constructs such as perceptions of breast cancer and mammography. The TPB includes interpersonal and environmental constructs, such as perceived control and subjective norms.
Objectives
The current study had 2 objectives: (1) to examine changes in the HBM and TPB constructs and repeat mammography screening in women receiving either intervention and women in the control group and (2) to compare changes in the HBM and TPB constructs and repeat mammography screening across the 2 interventions.
Methods
One hundred eight-four women from 3 randomly selected health centers in Sanandaj, Iran, participated. Eligibility criteria were being 50 years or older, having received a mammogram in the past 2 to 3 years, and no intention to obtain a mammogram within the next year.
Results
The TPB and HBM participants exhibited greater changes in the HBM and TPB constructs and were more likely to have a mammogram relative to control participants. The TPB and HBM participants exhibited comparable changes in constructs and repeat mammography.
Conclusion
Findings suggest both interventions equally improved mammography screening. Additional studies are furthermore warranted to address nonadherent Iranian women’s needs in line with these conceptual models.
Implications for Practice
Use of the HBM and TPB constructs in clinical practice may be helpful to promote continued screening among this population.
doi:10.1097/NCC.0000000000000185
PMCID: PMC4326613  PMID: 25122130
Health belief model; Iran; Mammogram repeat; Theory of planned behavior
3.  Falls in the Community Dwelling Elderly with a History of Cancer 
Cancer nursing  2010;33(2):149-155.
doi:10.1097/NCC.0b013e3181bbbe8a
PMCID: PMC4471335  PMID: 20142742
4.  The Resilience in Illness Model (RIM) Part 1: Exploratory Evaluation in Adolescents and Young Adults with Cancer 
Cancer nursing  2014;37(3):E1-E12.
Background
Resilience is a positive health outcome identified by the Committee on Future Direction for Behavioral and Social Sciences as a research priority for the National Institutes of Health. The Resilience in Illness Model (RIM) was developed from a series of qualitative and quantitative studies, to increase understanding of how positive health protective factors (i.e. social integration, family environment, courageous coping and derived meaning) may influence resilience outcomes. The RIM also includes two risk factors, illness-related distress and defensive coping.
Objective
The purpose of this two-part paper is to report on evaluation of the RIM for adolescents/young adults with cancer (AYA). Here, in Part 1, our purpose is to describe the exploratory RIM evaluation and in Part 2 we describe the confirmatory RIM evaluation.
Methods
An exploratory evaluation of RIM was done using exploratory latent variable structural equation modeling with a combined sample from two studies of pre-adolescents, and AYA with cancer ages 10 -26 years (n=202).
Results
Results, including goodness-of-fit indices, support the RIM as a theory with a high level of explained variance for outcomes of resilience (67%) and self-transcendence (63%). Variance explained for proximal outcomes ranged from 18% to 76%.
Conclusions
Findings indicate that, following confirmatory testing, the RIM may be a useful guide to developing targeted interventions that are grounded in the experiences of the AYA.
Implications for Practice
Increased understanding of the AYA cancer experience to improve holistic care.
doi:10.1097/NCC.0b013e31828941bb
PMCID: PMC3758400  PMID: 23519038
5.  Distress in patients with acute leukemia: A concept analysis 
Cancer nursing  2014;37(3):218-226.
Background
Patients with acute leukemia require immediate and aggressive in-patient treatment that results in many weeks to months of hospitalization. Thus, it is not surprising that distress has been found in as many as 45.5% of patients. While distress is a regularly reported outcome measure in clinical research, currently there is a lack of a clear consistent and universal definition of this concept.
Objective
The purpose of this article is to examine the current state of the science surrounding the concept of distress and propose a model of distress for patients with acute leukemia.
Interventions/Methods
The Walker and Avant framework was used to guide the analysis of the concept of distress in patients with AL. The findings from this analysis were then used to generate a model guided by the current science.
Results
Distress in AL is generally accepted as multi-dimensional, quantifiable, subjective and temporal. Antecedents to distress include: demographics; intrinsic factors; social support; disease progression; treatment; and communication. Consequences to distress include: decreased quality of life; patient outcomes; as well as the severity of physical and psychological symptoms.
Conclusions
Distress is an outcome measure that is frequently assessed and reported within the literature. The operationalization of distress varies by investigator, limiting its generalizabiliy.
Implications for Practice
The proposed conceptual model may be used to guide further research on distress in patients with AL at high risk for negative outcomes. Improved understanding of patient distress may guide interventions aimed at managing the psychosocial needs for patients receiving treatment for AL.
doi:10.1097/NCC.0b013e31829193ad
PMCID: PMC3779488  PMID: 23632470
distress; acute leukemia; concept analysis; quality of life; symptoms
6.  Caregiver-Reported Neuropsychiatric Symptoms in Patients Undergoing Treatment for Head and Neck Cancer: A Pilot Study 
Cancer nursing  2014;37(3):227-235.
Background
Patients with cancer experience multiple neuropsychiatric symptoms. While individual symptoms have been studied in patients with head and neck cancer, the broader context of neuropsychiatric symptoms needs to be explored.
Objective
The aims of this pilot study were: 1) to determine the caregiver-reported prevalence and severity of neuropsychiatric symptoms in patients with head and neck cancer, 2) to determine the associated level of caregiver distress, and 3) to describe the effects of neuropsychiatric symptoms on patients and their caregivers.
Methods
Twenty-three family caregivers of patients with head and neck cancer completed the Neuropsychiatric Inventory Questionnaire and participated in a semi-structured interview.
Results
All caregivers reported that patients experienced at least one neuropsychiatric symptom (Mean 7.5; Range 1–12). The most frequently reported symptoms were trouble with appetite and eating (95.7%), altered nighttime behaviors (82.6%), depression/dysphoria (78.3%), decreased alertness (69.6%), inattention (60.9%), apathy/indifference (56.5%), anxiety (56.5%), irritability/lability (52.5%), agitation/aggression (52.2%), and slowed behavior (43.5%). The mean severity rating for nine symptoms was moderate to severe. Most symptoms caused mild to moderate levels of caregiver distress. Qualitative data indicated that neuropsychiatric symptoms negatively affected patients, their caregivers, and other family members. Patients required more caregiver support resulting in increased caregiver burden and distress.
Conclusions
Neuropsychiatric symptoms are common and troubling in patients with head and neck cancer during treatment. Further investigation of their effects on patients and family caregivers is needed.
Implications for Practice
Clinicians should monitor for and treat neuropsychiatric symptoms throughout treatment, and provide caregiver and patient education and support.
doi:10.1097/NCC.0b013e31829194a3
PMCID: PMC4304699  PMID: 23619332
neuropsychiatric symptoms; head and neck cancer; caregiving
7.  Heterogeneous Demographic and Cultural Profiles of Non-adherent Chinese-American Patients to Colorectal Cancer Screening: A Latent Class Analysis 
Cancer nursing  2014;37(2):106-113.
Background
Colorectal cancer (CRC) is one of the leading causes of cancer death for Chinese Americans, but their CRC screening rates remain low.
Objective
We examined subgroups of Chinese-American patients non-adherent to CRC screening guidelines to better inform clinical practices to effectively promote screening.
Methods
Using latent class analysis (LCA) of data from 327 participants recruited from 18 primary care clinics, we classified non-adherent patients based on sociodemographics, screening barriers, attitudinal and clinical factors for CRC screening.
Results
The best-fitting LCA model described three distinctive classes: Western Healthcare Class (WHC, 35%), Eastern Healthcare Class (EHC, 18%) and Mixed Healthcare Class (MHC, 46%). WHC patients were highly-educated with average 20 years of U.S. residency, high level of English proficiency, the least Eastern cultural views of care and the greatest exposure to physician recommendations, but reported having no time for screenings. EHC patients were highly-educated seniors and recent immigrants with the least CRC knowledge and the more Eastern cultural views. MHC patients had low level of education, resided in the U.S. for 20 years, and had relatively long relationships with physicians, but their knowledge and cultural views were similar to those of EHC patients.
Conclusions
Non-adherent Chinese-American patients are heterogeneous. It is essential to have future intervention programs tailored to address specific screening beliefs and barriers for subtypes of non-adherent patients.
Implications for Practice
Training primary care physicians to recognize patients’ different demographic characteristics and healthcare beliefs may facilitate physician’s communication with patients to overcome their barriers and improve screening behaviors.
doi:10.1097/NCC.0b013e3182888b5b
PMCID: PMC3692589  PMID: 23519040
colorectal cancer screening; Chinese Americans; cultural view of healthcare; latent class analysis
8.  Patient and Clinician Communication Of Self-Reported Insomnia During Ambulatory Cancer Care Clinic Visits 
Cancer nursing  2014;37(2):E51-E59.
Background
Insomnia, the most commonly reported sleep wake disturbance in people with cancer, has an adverse affect on quality of life including emotional well being, distress associated with other symptoms, daily functioning, relationships and ability to work.
Objective
The aim of this study was to describe the content of discussions between clinicians and 120 patients with self-reported insomnia and to examine the associations of socio-demographic, clinical and environmental factors with insomnia.
Interventions/Methods
A secondary analysis was conducted with self reported symptom data, socio- demographic, clinical and environmental factors. Recordings of clinician and patient discussions during clinic visits were examined by conducting a content analysis.
Results
Severe insomnia was more likely to be reported by women, minority and lower income individuals. Seven major topics were identified in the discussions. The clinicians did not always discuss insomnia; discussion rates differed by diagnosis and clinical service.
Conclusions
Reporting of insomnia by the patient and clinician communication about insomnia may have differed by demographic and clinical characteristics. Clinicians attended to insomnia about half the time with management strategies likely to be effective. Explanations may be that insomnia had a low clinician priority for the clinic visit or lack of clear evidence to support insomnia interventions.
Implications for Practice
A better understanding is needed about why insomnia is not addressed even when reported by patients; it is well known that structured assessments and early interventions can improve quality of life. Research is warranted to better understand potential disparities in cancer care.
doi:10.1097/NCC.0b013e318283a7bc
PMCID: PMC3696527  PMID: 23448958
9.  Comparison of Groups with Different Patterns of Symptom Cluster Intensity across the Breast Cancer Treatment Trajectory 
Cancer nursing  2014;37(2):88-96.
Background
Comparing subgroups with different patterns of change in symptom intensity would assist in sorting out individuals at risk for more severe symptoms and worse functional outcomes.
Objective
To identify and compare subgroups of breast cancer patients with different patterns of change in a psycho-neurological symptom cluster intensity (PSCI) across the treatment trajectory.
Methods
This secondary analysis used the data from 160 breast cancer patients undergoing chemotherapy or radiation treatment. PSCI was a composite score of five symptoms (depressed mood, cognitive disturbance, fatigue, insomnia, and pain) in a psycho-neurological cluster at each of three time points (i.e., at baseline and at two follow-ups after chemo or radiation treatment).
Results
Five distinct subgroups representing different patterns of PSCI during breast cancer treatment were identified: the gradually increasing pattern subgroup (Group 1); the constantly low pattern subgroup (Group 2); the start low with dramatic increase & decrease pattern subgroup (Group 3); the constantly high pattern subgroup (Group 4); and the start high with dramatic decrease & leveling pattern subgroup (Group 5). Patients without previous cancer treatment experience, with higher level of education, treated with chemotherapy, and/or with more limitations at the baseline were more likely to follow the pattern Group 4. Patients in Group 4 had the most serious functional limitations measured at the second follow-up time point.
Conclusion
The results suggest the need to evaluate interventions for specific subgroups and to examine the causal mechanisms underlying a psycho-neurological symptom cluster.
Implication
Clinicians should consider these diverse symptom experiences for assessment/management.
doi:10.1097/NCC.0b013e31828293e0
PMCID: PMC3711971  PMID: 23448957
symptom clusters; symptom management; symptom assessment; patterns of changes; psycho-neurological symptoms
10.  The Effect of a Community-Based Exercise Intervention on Symptoms and Quality of Life 
Cancer nursing  2014;37(2):E43-E50.
Background
Moderate intensity physical activity in women with breast cancer has been reported to improve physical and psychological outcomes. Yet, initiation and adherence to a routine physical activity program for cancer survivors after therapy may be challenging.
Objective
The purpose of this study was to determine the feasibility and effect of a community-based exercise intervention on physical and psychological symptoms and quality of life (QOL) in breast cancer survivors.
Methods
A one group pre-post test design was used to evaluate a thrice weekly, 4 to 6 month supervised exercise intervention on symptoms and QOL. Data were collected at baseline and end of the intervention, using the Breast Cancer Prevention Trial Checklist, the Symptom Distress Scale, Centers for Epidemiology Scale for Depression and the Medical Outcomes Short Form.
Results
There were 26 participants with an average age of 51.3 years (SD=6.2) and most were married, well educated and employed. The intervention was delivered at 3 community fitness centers and adherence ranged from 75%-98%. Vasomotor, musculoskeletal, and cognitive symptoms were common but only muscle stiffness, fatigue and depression significantly changed over time (p=0.04, p =0.05 p=0.01 respectively). QOL improved significantly in the areas of physical, emotional and social function, pain, vitality and mental health.
Conclusions
Providing an exercise intervention in the community where women live and work is feasible and improves physical, psychological and functional well-being.
Implications for Practice
Exercise is a key component of cancer rehabilitation and needs to be integrated into our standard care.
doi:10.1097/NCC.0b013e318288d40e
PMCID: PMC3855633  PMID: 23519041
11.  Antineoplastic Drug Exposure in an Ambulatory Setting: a Pilot Study 
Cancer nursing  2015;38(2):111-117.
Background
Exposure to antineoplastic drugs confers health risks to workers, yet little is known about the exposure after a drug spill. Nor has the relationship between exposure and organizational factors such as staffing and work environment been studied.
Objective
To evaluate drug spills prospectively using biological measures and correlate drug spills with organizational factors.
Methods
Prospective questionnaires with 8-hour timed urine samples were collected from nursing and pharmacy personnel who reported a drug spill in one academic health center's infusion center. Urine was collected similarly from workers who did not report a spill. Liquid chromatography tandem mass spectrometry techniques identified detectable drug levels. After the prospective sampling period, workers were surveyed on workloads, practice environment, and safety behaviors.
Results
From 81 eligible individuals, 40 participated in the prospective study and 19 completed retrospective questionnaires. Four spills were reported by 9 personnel as multiple employees were exposed to drug spills. Four participants who reported a spill showed detectable levels of antineoplastic drugs. Four participants who did not report a spill had detectable levels of docetaxel. Compared with respondents who did not report a spill, collegial relations with physicians were significantly poorer for workers who reported spills.
Conclusions
The study protocol successfully captured drug spill reports and biological samples. Workers have detectable levels of antineoplastic drugs through both drug spills and environmental contamination.
doi:10.1097/NCC.0000000000000143
PMCID: PMC4232489  PMID: 24831047
12.  [No title available] 
PMCID: PMC4295204  PMID: 19444078
13.  Feasibility and Acceptability of the PROMIS Measures in Children and Adolescents in Active Cancer Treatment and Survivorship 
Cancer nursing  2014;37(1):10.1097/NCC.0b013e3182a0e23d.
Background
Patient-reported outcomes (PROs) related to symptoms, function, and quality of life during and following cancer treatment can guide care for pediatric cancer patients. To advance the science of PROs, the National Institutes of Health funded the Patient Reported Outcomes Measurement Information System (PROMIS).
Objective
To assess feasibility and acceptability of the PROMIS pediatric measures, as defined by enrollment and attrition rates as well as missingness by measure, item, participant, and assessment time point.
Methods
8-to-18 year olds participated in two studies: PROMIS I, a cross-sectional study of children in active cancer treatment or survivorship, and PROMIS II, a longitudinal study with 3 assessment time points for children receiving curative treatment.
Results
PROMIS I (n=200) and PROMIS II (n=94) had enrollment rates of 92.5% and 89.7%, respectively. For PROMIS I, measure missingness was acceptable (8% missed any measures) and was not related to other study variables. For PROMIS II, measure missingness was minimal (0.8%), and item-level missingness was relatively low. In general, items that were skipped asked about experiences that participants had not encountered in the past 7 days.
Conclusions
In both studies, the PROMIS instruments demonstrated good feasibility and acceptability among pediatric cancer patients. Overall, we had high enrollment, low attrition, and acceptable rates of measure and item missingness.
Implications for Practice
Our results demonstrate that PROMIS measures are acceptable to 8-to-18 year-olds in different points of cancer care and feasible for use in pediatric cancer inpatient and outpatient settings.
doi:10.1097/NCC.0b013e3182a0e23d
PMCID: PMC3859798  PMID: 24036439
14.  A Labor of Love 
Cancer nursing  2013;36(6):474-483.
Background
Evidence suggests that emotional distress and objective demands of cancer caregiving are comparable to those of dementia caregiving, yet little research has focused on the physical health of cancer caregivers. Whether the stress leads directly to changes in health or whether the stress leads to changes in health behaviors, which in turn affect health, has not been systematically examined.
Objective
The objective of this study was to review the research literature regarding changes in health behaviors associated with caring for an individual with cancer.
Methods
Literature was reviewed from multiple databases including CINAHL (Cumulative Index to Nursing and Allied Health Literature), CINAHL Plus, PsycNET, PubMed, SCOPUS, EMBASE, and Web of Science. Key words included “health behavior,” “health promotion,” ”caregivers/caregiving,” “cancer/oncology,” “diet/nutrition,” “exercise/physical activity,” “stress management,” “smoking” and “alcohol.” Studies were included if they involved informal adult caregivers and at least 1 behavior associated with a healthy lifestyle. Of the 866 studies identified, 8 met the criteria.
Results
Studies revealed conflicting information, with some suggesting deleterious changes in behaviors, whereas others found the changes protective.
Conclusions
The lack of uniformity of terminology and conflicting findings make it difficult to conclude the impact of the caregiving experience on the health behaviors of cancer caregivers. Something is placing caregivers at risk for illness and early death, but the mechanisms behind the risk and the role of unhealthy behaviors are not clear.
Implications for Practice
At a minimum, cancer caregivers should be screened for behavior changes and disease risk. Developing standardized measures for future research including controlled, longitudinal studies is needed.
doi:10.1097/NCC.0b013e3182747b75
PMCID: PMC4196265  PMID: 23132126
Burden; Cancer; Caregivers; Health behaviors; Screening; Stress
15.  Measuring Vincristine-Induced Peripheral Neuropathy in Children with Acute Lymphoblastic Leukemia 
Cancer nursing  2013;36(5):E49-E60.
Background
Vincristine-induced peripheral neuropathy (VIPN) is difficult to quantify in children.
Objective
The study objective was to examine the reliability, validity, and clinical feasibility of several VIPN measures for use in children with acute lymphoblastic leukemia.
Interventions/Methods
Children (N = 65) aged 1–18 years receiving vincristine at four academic centers participated in the study. Baseline and pre-vincristine VIPN assessments were obtained using the Total Neuropathy Score-Pediatric Vincristine (TNS-PV), the National Cancer Institute Common Terminology Criteria for Adverse Events, the Balis grading scale, and the FACES pain scale. TNS-PV scores (n = 806) were obtained over 15 weeks. Blood was obtained at several time-points to quantify pharmacokinetic parameters.
Results
Cronbach’s alpha for a reduced TNS-PV scale was 0.84. TNS-PV scores correlated with cumulative vincristine dosage (r = 0.53, p = 0.01), pharmacokinetic parameters (r = 0.41, p = 0.05), and grading scale scores (r = 0.46 – 0.52; p = 0.01). FACES scores correlated with the TNS-PV neuropathic pain item (r = 0.48; p = 0.01), and were attainable in all ages. A 2-item V-Rex score (vibration and reflex items) was the most responsive to change (es 0.65, p < 0.001). TNS-PV scores were attainable in 95% of children ≥ 6 years.
Conclusions
The TNS-PV is reliable and valid for measuring VIPN. It is sensitive to change over time (15 weeks) and feasible for use in children ≥ 6 years of age.
Implications for Practice
The TNS-PV may be a useful tool for assessing vincristine toxicity in children with acute lymphoblastic leukemia.
doi:10.1097/NCC.0b013e318299ad23
PMCID: PMC3951303  PMID: 23842524
16.  Symptom Distress in Older Adults Following Cancer Surgery 
Cancer nursing  2013;36(4):10.1097/NCC.0b013e31826dd517.
Background
Symptom distress remains a significant health problem among older adults with cancer following surgery. Understanding factors influencing older adults’ symptom distress may lead to early identification and interventions, decreasing morbidity and improving outcomes.
Objective
We conducted this study to identify factors associated with symptom distress following surgery among 326 community-residing patients ages 65 and older diagnosed with thoracic, digestive, gynecologic, and genitourinary cancers.
Methods
Secondary analysis using combined subsets of data from five nurse-directed intervention clinical trials targeting patients post-surgery at academic cancer centers in northwest and northeastern United States. Symptom distress was assessed by the Symptom Distress Scale at baseline, 3, and 6 months.
Results
A multivariable analysis, using Generalized Estimating Equations, showed symptom distress was significantly less at 3 and 6 months (3 months: p<0.001, 6 months: p=0.002) than at baseline while controlling for demographic, biologic, psychological, treatment, and function covariates. Thoracic cancer, comorbidities, worse mental health, and decreased function were, on average, associated with increased symptom distress (all p<0.05). Participants ages 75 and older reported increased symptom distress over time compared with those ages 65 to 69 (p<0.05).
Conclusions
Age, type of cancer, comorbidities, mental health, and function may influence older adults’ symptom distress following cancer surgery.
Implications for Practice
Older adults generally experience decreasing symptom distress after thoracic, abdominal, or pelvic cancer surgery. Symptom management over time for those with thoracic cancer, comorbidities, worse mental health, decreased function, and ages 75 and older may prevent morbidity and improve outcomes of older adults following surgery.
doi:10.1097/NCC.0b013e31826dd517
PMCID: PMC3818245  PMID: 23047803
Cancer; Surgery; Older; Symptom Distress
17.  Personal Financial Effects of Multiple Myeloma and its Treatment 
Cancer nursing  2013;36(4):301-308.
Background
Improvements in some treatment programs for multiple myeloma (MM) are increasing survival. As patients live longer with MM as a chronic disease, the personal financial effects of MM treatment become a serious concern.
Objective
The objective of this study was to identify the personal financial effects of MM and its treatment in five areas: employment, disability, health/medical and life insurance, retirement, and out-of-pocket expenses.
Methods
We mailed a questionnaire about financial issues to 1015 patients who had received intensive treatment for MM at the study site. Data analysis included descriptive statistics and comparisons using independent t-tests.
Results
Our sample (n=762; mean age 61, SD 9.26), experienced issues with employment (66% employed at diagnosis and treatment; 33% employed at questionnaire time), disability (35% applied), health/medical and life insurance (29% lost coverage and 8% changed coverage), retirement (13% retired during treatment), and out-of-pocket expenses (36% of income in first treatment year and 28% of income during most recent 12 months).
Conclusions
Issues of employment, disability, health insurance, retirement, and out-of-pocket costs for treatment are major challenges for patients.
Implications for Practice
In the midst of assessing physical needs during clinical trials for chemotherapy and stem cell transplants, health care providers must keep sight of patients' personal financial needs so that we can intervene promptly with referrals to social work, rehabilitation therapy, and other health care professions to help patients decrease the personal financial effects of MM and its treatment.
doi:10.1097/NCC.0b013e3182693522
PMCID: PMC3973128  PMID: 23047800
18.  ResearchTracking: Monitoring Gender and Ethnic Minority Recruitment and Retention in Cancer Symptom Studies 
Cancer nursing  2013;36(3):E1-E6.
Background
Recruiting and retaining participants for clinical trials, particularly women and ethnic minorities, is challenging. Studies are lacking, however, in which investigators examine gender and ethnic differences in research processes. Such information is important for findings to adequately represent the available population.
Objective
The study aim was to examine study recruitment processes (referral, eligibility, consent/enrollment) and study retention (completion) for gender and ethnic differences.
Methods
A descriptive comparative analysis of data from two randomized clinical trials focused on cancer outpatients with pain and/or fatigue. A computerized ResearchTracking software allowed documentation of recruitment and retention effort outcomes..
Results
Among the 1,464 referred patients, 612 (42%) were eligible for study participation. Lack of ongoing care at the study settings and English skills were the main reasons for ineligibility. There were no gender differences in consent/enrollment or completion rates. Ethnic minority patients were represented proportionally to the available population (13%) and were equally willing to consent/enroll and complete both studies as their white counterparts, if they were eligible.
Conclusions
Specific strategies to target language eligibility barriers are necessary to increase minority participation.
Implications for Practice
Future studies could include audio-aided tools in their native language to help recruit patients with limited English skills, if the study tools can be validly translated into other languages and are equivalent to English versions. Efforts to educate and garner support of providers could improve enrollment of patients in cancer studies, especially in studies of audio or video-recorded patient-provider interaction.
doi:10.1097/NCC.0b013e31826909a8
PMCID: PMC3639328  PMID: 23051871
19.  Faith Among Low-Income, African American/Black Men Treated for Prostate Cancer 
Cancer nursing  2010;33(6):470-478.
Background
Understanding how low-income, uninsured African American/black men use faith to cope with prostate cancer provides a foundation for the design of culturally appropriate interventions to assist underserved men cope with the disease and its treatment. Previous studies have shown spirituality to be a factor related to health and quality of life, but the process by which faith, as a promoter of action, supports coping merits exploration.
Objective
Our purpose was to describe the use of faith by low-income, uninsured African American/black men in coping with prostate cancer and its treatment and adverse effects.
Methods
We analyzed data from a qualitative study that used in-depth individual interviews involving 18 African American men ranging in ages from 53 to 81 years. Our analysis used grounded theory techniques.
Results
Faith was used by African American men to overcome fear and shock engendered by their initial perceptions of cancer. Faith was placed in God, health care providers, self, and family. Men came to see their prostate cancer experience a new beginning that was achieved through purposeful acceptance or resignation.
Conclusions
Faith was a motivator of and source for action. Faith empowered men to be active participants in their treatment and incorporate treatment outcomes into their lives meaningfully.
Implication
By understanding faith as a source of empowerment for active participation in care, oncology nurses can use men's faith to facilitate reframing of cancer perceptions and to acknowledge the role of men's higher being as part of the team. Studies are needed to determine if this model is relevant across various beliefs and cultures.
doi:10.1097/NCC.0b013e3181e1f7ff
PMCID: PMC3923421  PMID: 20555257
African American/black; Faith; Prostate cancer
20.  Attitudes Toward Participation in Breast Cancer Randomized Clinical Trials in the African American Community 
Cancer nursing  2007;30(4):261-269.
Participation of African Americans in research trials is low. Understanding the perspectives of African American patients toward participation in clinical trials is essential to understanding the disparities in participation rates compared with whites. A qualitative study was conducted to discover attitudes of the African American community regarding willingness to participate in breast cancer screening and randomized clinical trials. Six focus groups consisting of 8 to 11 African American women (N = 58), aged 30 to 65, were recruited from local churches. Focus group sessions involved a 2-hour audiotaped discussion facilitated by 2 moderators. A breast cancer randomized clinical trial involving an experimental breast cancer treatment was discussed to identify the issues related to willingness to participate in such research studies. Six themes surrounding willingness to participate in randomized clinical trials were identified: (1) Significance of the research topic to the individual and/or community; (2) level of trust in the system; (3) understanding of the elements of the trial; (4) preference for “natural treatments” or “religious intervention” over medical care; (5) cost-benefit analysis of incentives and barriers; and (6) openness to risk versus a preference for proven treatments. The majority (80%) expressed willingness or open-mindedness to the idea of participating in the hypothetical trial. Lessons learned from this study support the selection of a culturally diverse research staff and can guide the development of research protocols, recruitment efforts, and clinical procedures that are culturally sensitive and relevant.
doi:10.1097/01.NCC.0000281732.02738.31
PMCID: PMC3908682  PMID: 17666974
African American; Breast cancer; Clinical trials; Focus group study
21.  A Pilot Exploration of Symptom Trajectories in Adolescents with Cancer during Chemotherapy 
Cancer nursing  2013;36(1):60-71.
Background
Chemotherapy is frequently administered in repetitive cycles. Adolescents with cancer suffer from multiple symptoms related to chemotherapy but knowledge of symptom trajectories across a cycle is limited. Examining trajectories over a cycle may reveal key periods to manage symptoms.
Objectives
The aims of this pilot were to describe the trajectory of symptoms (pain, sleep, fatigue, appetite, nausea, fatigue) and biological and behavioral variables (anxiety, stress, hematologic function) across one cycle; and examine relationships between variables.
Interventions/Methods
Nine adolescents with cancer within six months of diagnosis participated. Data were collected by surveys, chart review, and biologic measures on days 1 and 2 of the cycle, one week later (nadir), and day 1 of the following cycle. To evaluate the trajectory, a simple random effects repeated measures analysis was computed.
Results
The significant trajectories were fatigue (P = 0.003), difficulty sleeping (P = 0.032), and nausea (P = 0.04). Most of the adolescents reported some anticipatory anxiety about receiving chemotherapy. Significant correlations between symptoms and biobehavioral variables included anticipatory anxiety and nausea (P = 0.86, P = 0.003), trait anxiety and fatigue (r = −0.82, P < 0.001), and stress and pain (r = 0.78, P = 0.039).
Conclusions
Multiple symptoms were experienced across the cycle. Three symptoms displayed significant trajectories indicating that patterns of symptoms may be anticipated.
Implications for Practice
Pilot findings suggest monitoring symptoms, stress and anxiety across a cycle is important, not only during chemotherapy administration, but also prior to being admitted for chemotherapy.
doi:10.1097/NCC.0b013e318250da1a
PMCID: PMC3416951  PMID: 22561919
22.  Enhancing Self-Efficacy for Optimized Patient Outcomes through the Theory of Symptom Self-Management 
Cancer nursing  2013;36(1):E16-E26.
Background
In today’s world, greater patient empowerment is imperative since 90 million Americans live with one or more chronic conditions such as cancer. Evidence reveals that healthy behaviors such as effective symptom self-management can prevent or reduce much of the suffering from cancer. Oncology nurses play a pivotal role in developing a symptom self-management plan that is critical to optimizing a patient’s symptom self-management behaviors.
Objective
This article uses exemplars to describe how oncology nurses can apply a tested middle-range theory, the Theory of Symptom Self-Management, to clinical practice by incorporating interventions to increase a patient’s perceived self-efficacy to optimize patient outcomes.
Methods
The Theory of Symptom Self-Management provides a means to understand the dynamic aspects of symptom self-management and provides a tested framework for the development of efficacy enhancing interventions for use by oncology nurses in clinical practice.
Results
Exemplars based on the Theory of Symptom Self-Management that depict how oncology nursing can use perceived self-efficacy enhancing symptom self-management interventions to improve the functional status and quality of life of their patients.
Conclusion
Guided by a theoretical approach, oncology nurses can have a significant positive impact on the lives of their patients by reducing the symptom burden associated with cancer and its treatment.
Implications for Practice
Oncology nurses can partner with their patients to design tailored approaches to symptom self-management. These tailored approaches provide the ability to implement patient specific behaviors that recognize, prevent, relieve, or decrease the timing, intensity, distress, concurrence, and unpleasant quality of symptoms.
doi:10.1097/NCC.0b013e31824a730a
PMCID: PMC3526102  PMID: 22495550
23.  Patterns and Correlates of Missed Nursing Care in Inpatient Oncology Units 
Cancer nursing  2013;36(6):E51-E57.
doi:10.1097/NCC.0b013e318275f552
PMCID: PMC3577984  PMID: 23151503
24.  Living My Family's Story 
Cancer nursing  2012;35(6):493-504.
Background
Based on known or suggested genetic risk factors, a growing number of women now live with knowledge of a potential cancer diagnosis that may never occur. Given this, it is important to understand the meaning of living with high risk for hereditary breast cancer.
Objective
The objective of the study was to explore how women at high risk for hereditary breast cancer (1) form self-identity, (2) apply self-care strategies toward risk, and (3) describe the meaning of care through a high-risk breast program.
Methods
Interpretive hermeneutic phenomenology guided the qualitative research method. Women at high risk for hereditary breast cancer were recruited from a high-risk breast program. Open-ended interview questions focused on experiences living as women managing high risk for breast cancer. Consistent with hermeneutic methodology, the principal investigator led a team to analyze the interview transcripts.
Results
Twenty women participated in in-depth interviews. Analysis revealed that women describe their own identity based on their family story and grieve over actual and potential familial loss. This experience influences self-care strategies, including seeking care from hereditary breast cancer risk experts for early detection and prevention, as well as maintaining a connection for early treatment “when” diagnosis occurs.
Conclusions
Healthy women living with high risk for hereditary breast cancer are living within the context of their family cancer story, which influences how they define themselves and engage in self-care.
Implications for Practice
Findings present important practical, research, and policy information regarding health promotion, psychosocial assessment, and support for women living with this risk.
doi:10.1097/NCC.0b013e31824530fa
PMCID: PMC3635541  PMID: 22544165
Genetics; Hereditary breast; cancer risk; Nursing; Phenomenology
25.  Partners’ Long-term Appraisal of Their Caregiving Experience, Marital Satisfaction, Sexual Satisfaction, and Quality of Life 2 Years After Prostate Cancer Treatment 
Cancer nursing  2013;36(2):10.1097/NCC.0b013e3182567c03.
Background
Partners of men treated for prostate cancer report more emotional distress associated with a diagnosis of prostate cancer than the men report; the duration of distress for partners is seldom examined.
Objectives
The purpose of this study was to determine the long-term effects of prostate cancer treatment on partners’ appraisal of their caregiving experience, marital satisfaction, sexual satisfaction, and quality of life (QOL) and factors related to these variables.
Methods
This exploratory study evaluated QOL among spouses of prostate cancer survivors at 24 months after treatment. Partners completed a battery of self-report questionnaires in a computer-assisted telephone interview.
Results
The sample consisted of 121 partners with average age of 60 years. There was a significant relationship between partners’ perceptions of bother about the man’s treatment outcomes and negative appraisal of their caregiving experience and poorer QOL. Younger partners who had a more negative appraisal of caregiving also had significantly worse QOL.
Conclusions
Men’s treatment outcomes continued to bother the partner and resulted in more negative appraisal and lower QOL 2 years after initial prostate cancer treatment. Younger partners may be at greater risk of poorer QOL outcomes especially if they have a more negative view of their caregiving experience.
Implications for Practice
Findings support prior research indicating that prostate cancer affects not only the person diagnosed with the disease but also his partner. Partners may benefit from tailored interventions designed to decrease negative appraisal and improve symptom management and QOL during the survivorship period.
doi:10.1097/NCC.0b013e3182567c03
PMCID: PMC3814170  PMID: 22728952
Age; Caregivers; Family; Prostate cancer; Quality of life; Spouses

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