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1.  Creating Computable Algorithms for Symptom Management in an Outpatient Thoracic Oncology Setting 
Journal of pain and symptom management  2013;46(6):911-924.e1.
Adequate symptom management is essential to ensure quality cancer care, but symptom management is not always evidence based. Adapting and automating national guidelines for use at the point of care may enhance use by clinicians.
This article reports on a process of adapting research evidence for use in a clinical decision support system that provided individualized symptom management recommendations to clinicians at the point of care.
Using a modified ADAPTE process, panels of local experts adapted national guidelines and integrated research evidence to create computable algorithms with explicit recommendations for management of the most common symptoms (pain, fatigue, dyspnea, depression, and anxiety) associated with lung cancer.
Small multidisciplinary groups and a consensus panel, using a nominal group technique, modified and subsequently approved computable algorithms for fatigue, dyspnea, moderate pain, severe pain, depression, and anxiety. The approved algorithms represented the consensus of multidisciplinary clinicians on pharmacological and behavioral interventions tailored to the patient’s age, comorbidities, laboratory values, current medications, and patient-reported symptom severity. Algorithms also were reconciled with one another to enable simultaneous management of several symptoms.
A modified ADAPTE process and nominal group technique enabled the development and approval of locally adapted computable algorithms for individualized symptom management in patients with lung cancer. The process was more complex and required more time and resources than initially anticipated, but it resulted in computable algorithms that represented the consensus of many experts.
PMCID: PMC4096777  PMID: 23680580
Lung cancer and symptom management algorithms; decision making; decision support systems; guideline implementation; consensus methods
2.  Smoking cessation is challenging even for patients recovering from lung cancer surgery with curative intent 
Although it is recommended that smokers undergoing surgery for lung cancer quit smoking to reduce post-operative complications, few studies have examined patterns of smoking in the peri-operative period. The goals of this study were to determine: 1) patterns of smoking during post-operative recovery, 2) types of cessation strategies used to quit smoking, and 3) factors related to smoking after lung cancer surgery.
Data were collected from 94 patients through chart review, tobacco, health-status, and symptom questionnaires at 1, 2, and 4-months after surgery. Smoking status was assessed through self-report and urinary cotinine measurement.
Eighty-four patients (89%) were ever-smokers and 35 (37%) reported smoking at diagnosis. Thirty-nine (46%) ever-smokers remained abstinent, 13 (16%) continued smoking at all time-points, and 32 (38%) relapsed. Ten (46%) of those who relapsed were former-smokers and had not smoked for at least 1-year. Sixteen (46%) of those who were smoking at diagnosis received cessation assistance with pharmacotherapy being the most common strategy. Factors associated with smoking during recovery were younger age and quitting smoking ≤ six-months before the diagnosis of lung cancer. Factors that were marginally significant were lower educational level, male gender, lower number of comorbidities, and the presence of pain
Only half of those who were smoking received assistance to quit prior to surgery. Some patients were unable to quit and relapse rates post-surgery were high even among those who quit more than 1-year prior. Innovative programs incorporating symptom management and relapse prevention may enhance smoking abstinence during post-operative care.
PMCID: PMC3805262  PMID: 19321223
lung cancer; thoracic surgery; smoking cessation; symptom management
3.  Factors associated with smoking abstinence among smokers and recent-quitters with lung and head and neck cancer 
Smoking cessation among cancer patients is critical for improving outcomes. Understanding factors associated with smoking abstinence after the diagnosis of cancer can provide direction to develop and test interventions to enhance cessation rates. The purpose of this study was to identify determinants of smoking outcomes among cancer patients.
Standardized questionnaires were used to collect data from 163 smokers or recent-quitters (quit ≤ 6 mo) at study entry of which 132 and 121 had data collected at 3 and 6-months. Biochemical verification was conducted with urinary cotinine and carbon monoxide. Descriptive statistics, Cronbach alpha coefficients, Pearson correlations, Fisher’s exact test, and multivariable logistic regression were used for analyses.
Seven-day-point-prevalence-abstinence (PPA) rates were 90/132 (68%) at 3-months; 46/71 (65%) among lung and 44/61 (72%) among head and neck cancer patients, whereas 7-day-PPA rates were 74/121 (61%) at 6-months; 31/58 (53%) among lung and 43/63 (68%) among head and neck cancer patients. Continuous abstinence rates were 63/89 (71%) at 3-months; 32/45 (71%) among lung and 31/44 (70%) among head and neck cancer patients, whereas continuous abstinence rates were 46/89 (52%) at 6-months; 18/45 (40%) among lung and 28/44 (64%) among head and neck cancer patients. Lower cancer-related, psychological and nicotine withdrawal symptoms were associated with increased 7-D-PPA abstinence rates at 3 and 6 months in univariate models. In multivariable models, however, decreased craving was significantly related with 7-day-PPA at 3-months and decreased craving and increased self-efficacy were associated with 7-D-PPA at 6-months. Decreased craving was the only factor associated with continuous abstinence at 6-months.
Smoking outcomes among lung and head and neck cancer patients appear to have remained the same over the last two decades despite the availability of an increased number of pharmacotherapy options to treat tobacco dependence. Decreased craving and increased self-efficacy were the most consistent factors associated with improved smoking outcomes but symptom control may also play a role in optimal management. Use of combined, and/or higher doses of pharmacotherapy along with behavioral interventions that increase self-efficacy and manage symptoms may promote enhanced cessation rates.
PMCID: PMC3322288  PMID: 22093155
smoking cessation; tobacco dependence; lung cancer; head and neck cancer; smoking cessation interventions; symptom management; craving
4.  Patient report of receipt and interest in smoking cessation interventions after a diagnosis of cancer 
Cancer  2011;117(13):2961-2969.
Smoking cessation is essential after the diagnosis of cancer to enhance clinical outcomes. Although effective smoking cessation treatments are available, less than one-half of smokers with cancer report receiving treatment. Reasons for the low dissemination in treatment are unclear.
Data were collected from questionnaires and medical record reviews from 160 smokers or recent-quitters with lung or head and neck cancer. Descriptive statistics, Cronbach alpha coefficient and logistic regression were used in the analyses. The median age of participants was 57 years, 63% (n=101) were male, 93% (n=149) were white, and 57% (n=91) had lung cancer.
Eight-six percent (n=44) of smokers and 75% (n=82) of recent-quitters reported that health care providers gave advice to quit smoking. Sixty-five percent (n=33) of smokers and 47% (n=51) of recent-quitters reported that they were offered assistance from their health care providers to quit smoking. Fifty-one percent (n=26) of smokers and 20% (n=22) of recent-quitters expressed an interest in a smoking cessation program. An individualized smoking cessation program was the preferred type of program. Among smokers, younger, early stage patients and those with partners who were smokers were more interested in programs.
While the majority of patients received advice and were offered assistance to quit smoking, one-half of smokers were interested in cessation programs. Innovative approaches to increase interest in cessation programs need to be developed and tested in this population
PMCID: PMC3314027  PMID: 21692055
cancer; smoking cessation programs; evidence-based tobacco treatment; smoking-related malignancies; patient preference
5.  Smoking Cessation and Lung Cancer: Oncology Nurses Can Make a Difference 
Seminars in oncology nursing  2008;24(1):16-26.
Provide an overview of the impact of smoking after a diagnosis of lung cancer, discuss the relationship between smoking cessation and improved outcomes during the lung cancer trajectory, present information about tobacco dependence evidence-based treatments, reimbursement for these treatments, and tobacco-related resources available for patients and health care professionals, and emphasize the important role of nurses.
Published articles, reports, websites, and research studies.
Tobacco use is associated with 30% of cancer deaths. Prevention of tobacco use and cessation are primary ways to prevent lung cancer. However, even after a diagnosis of lung cancer, smoking cessation is important in improving survival and quality of life. Although effective tobacco dependence treatments are available to help smokers quit smoking, persistent efforts over repeated contacts may be necessary to achieve long-term cessation.
Oncology nursing action is essential in the identification of and intervention with patients who struggle with tobacco dependence after diagnosis.
PMCID: PMC2249620  PMID: 18222148
smoking cessation interventions; tobacco dependence treatment and lung cancer

Results 1-5 (5)