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A. Molassiotis
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MS26 - Exploring the Diverse Impact that the Thoracic Oncology Nurse Can Make... (ID 43)
- Event: WCLC 2013
- Type: Mini Symposia
- Track: Nurses
- Presentations: 1
- Moderators:M. Duffy, D. Borthwick
- Coordinates: 10/30/2013, 14:00 - 15:30, Bayside 105, Level 1
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MS26.1 - Symptom Clusters (ID 584)
14:05 - 14:25 | Author(s): A. Molassiotis
- Abstract
- Presentation
Abstract
Symptom clusters is a relatively new field of study, recognizing that patients are often experience multiple concurrent symptoms and some of them may be interlinked. Understanding these clusters may improve the management of unrelieved symptoms in patients with lung cancer. A symptom cluster is defined as two or more symptoms that are related to each other and that occur together (Kim et al, 2005; Molassiotis et al, 2010). A small amount of research has highlighted over the past decade the different symptom clusters that are reported by patients with lung cancer. Brown et al (2011) have shown a five-symptom cluster that includes fatigue, breathlessness, cough, pain and anorexia, present in 64% of women with lung cancer. Henoch et al (2009) identified three clusters, including a pain cluster (pain, nausea, bowel issues, appetite loss, fatigue); a mood cluster (mood, outlook, concentration, insomnia), and a respiratory cluster (breathing, cough). The latter respiratory cluster has also been shown with our own work and it was stable at various assessments over the first 12 months from diagnosis (Molassiotis et al, 2010). Depression, fatigue and pain is another one (Fox & Lyon, 2006) as is pain, fatigue and insomnia (Hoffman et al, 2007). On the clinical level, it is suggested that physicians and oncology nurses should think in terms of these naturally clustering symptoms when recommending plans for symptom management, in order to be more effective in the overall management of a larger spectrum of symptoms. However, all these studies have some methodological shortcoming, as many of the identified clusters reflect the measurement symptom tool used each time, some have small sample sizes and are often secondary analyses. Patients who experience symptom clusters are more distressed and have more severe symptom-reporting than those who experience single symptoms, and they form a particular group of patients in need of more careful intervention. More recently we have carried out a qualitative study with 19 patients and their caregivers assessed at diagnosis, and 3, 6 and 12 months post-diagnosis. We have identified, for a first time using such methodology and the patients experience, a consistent and stable symptom cluster of fatigue, breathlessness and cough, which we called it ‘respiratory distress’ symptom cluster (Molassiotis et al, 2011). Two other messages came out clearly from this study: a) that the patients’ symptom experiences and coping efforts need to be understood within the context of a panorama of symptoms which frequently co-occur and which may interact in complex ways. This suggests that it may therefore be potentially problematic within the lung cancer population to determine a patient's experience of a single symptom in isolation given the complex array of symptoms that patients may experience. b) cough, which is under-represented in research within this population, may play an important role in shaping the patients' symptom experience, and may be linked with breathlessness more strongly than we currently think. Also both breathlessness and cough lead to anxiety and emotional distress. How do we improve the symptom cluster experience? We need to develop symptom interventions that are moving from a reductionist model of focusing on a single symptom to understanding the clinical usefulness and relationships of symptoms through symptom clusters and developing interventions that affect all symptoms in the cluster. This area is still in its infancy and there are only a couple of ongoing trials with such more ‘complex’ interventions. How do these broader interventions look like? Complementary therapies may be good ‘candidates’ for such an approach; indeed, we have carried out a trial using acupuncture to manage cancer-related fatigue in breast cancer patients, and we have seen that many patients reported also reductions in hot flushes and joint pains too. Mindfulness therapy may be a good option for the common mood-related symptom cluster. Educational interventions could also be appropriate approaches. However, how one structures and develops a new intervention to attend to clusters of symptoms needs significant thinking and energy. Our team is currently testing a new such intervention focusing on the respiratory distress symptom cluster. However, to ‘shape’ the intervention we followed several steps: Through patient and caregiver interviews (Ellis et al, 2012) important implications for patient participation and adherence to the intervention were identified, including the perceived relevance of potential techniques; appreciable benefits in the short-term; convenience; patient preferences; timing of the intervention; venue; caregiver involvement; the provider of the intervention, and contact with other patients. Through health care professionals’ focus group interviews (Wagland et al, 2012) it was clear that to have a successful intervention we had to consider also staffing time and space, and there was a recognition that the preference of most patients to make as few hospital visits as possible also complicated the teaching of such interventions. Moreover, it was recognized that there may only be a small window of opportunity in which to effectively teach lung cancer patients a novel non-pharmacological intervention as the period between diagnosis and the onset of severe symptoms is often short. Finally, we assessed patient preferences for the intervention components through a discrete choices experiment (Molassiotis et al, 2012). After this work, we developed the intervention that includes primarily diaphragmatic breathing exercises, cough suppression exercises, and acupressure (main intervention) together with anxiety management, vocal hygiene, and energy conservation techniques, delivered through two educational sessions as a self-management strategy that involves both patients and caregivers. Currently we are testing this intervention in a pilot trial aiming to explore the impact of this novel non-pharmacological supportive intervention on symptom distress, coping and service utilisation in patients with lung cancer and their caregivers, and to test the feasibility of carrying out a trial using this intervention, including practical and logistical issues of providing the intervention in practice. The trial has currently recruited 60/100 patients and is envisaged to complete recruitment by the end of 2013. Preliminary findings from the trial will be presented.Only Members that have purchased this event or have registered via an access code will be able to view this content. To view this presentation, please login, select "Add to Cart" and proceed to checkout. If you would like to become a member of IASLC, please click here.
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O11 - Symptom Management (ID 137)
- Event: WCLC 2013
- Type: Oral Abstract Session
- Track: Supportive Care
- Presentations: 1
- Moderators:B. Ivimey, I.N. Olver
- Coordinates: 10/28/2013, 16:15 - 17:45, Bayside Gallery A, Level 1
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O11.06 - The effects of inspiratory muscle training in the management of breathlessness in patients with lung cancer: a pilot feasibility randomized trial (ID 3179)
17:00 - 17:10 | Author(s): A. Molassiotis
- Abstract
- Presentation
Background
Breathlessness in patients with lung cancer is common symptom affecting 50-70% of patients, rising to 90% for those with advanced lung cancer. Managing breathlessness is complex, treatment options are limited and treatments are sometimes unsuccessful. Inspiratory muscle training (IMT) is a non-pharmacological method that has shown positive results in Chronic Obstructive Pulmonary Disease and mixed results in other respiratory illnesses. As this treatment method has never been tested in patients with lung cancer, the aim of the current study was to assess how feasible this treatment is in the lung cancer population and explore changes in outcome variables, before launching a larger randomized trial.Methods
Pilot feasibility randomized trial in patients with lung cancer having stable disease. The experimental group received training using a pressure threshold device (commercially available from Phillips Respironics). Patients were instructed to do 5 sessions weekly for 12 weeks for a total of 30mins per day, divided over 2 sessions. Patients in the control group received standard care and received the treatment at the end of their trial participation. Outcome measures were completed at baseline and monthly for 3 months, and included: physiological parameters (FEV1,FVC); perceived severity of breathlessness in six 10-point VAS assessing average breathlessness over past 24 hours, worst breathlessness over past 24hrs, breathlessness now, distress from breathlessness, ability to cope with breathlessness and satisfaction with breathlessness management; modified Borg scale; quality of life using the short form-Chronic Respiratory Disease Questionnaire (with subscales on dyspnea, fatigue; emotional function and mastery of breathlessness); Hospital Anxiety & Depression Scale, and safety.Results
46 patients (M=37, F=9) at a mean age of 69.5 years old and a mean of 16 months post-diagnosis who were not currently receiving chemotherapy/radiotherapy were recruited from 3 centres in the UK and Cyprus. Seventy-percent had NSCLC and advanced disease. There were no changes in FEV1 and FVC levels between groups. There were time by intervention interaction effects in average breathlessness and worst breathlessness in past 24hrs (p<0.01) with the intervention arm showing stable breathlessness and the control group deteriorating, but no between-group differences. Statistical and clinically important differences were seen with regards to ability to cope with breathlessness (p=0.02), satisfaction with breathlessness management (p=0.024), fatigue (p=0.007), emotional function (p=0.006), breathlessness mastery (p=0.031), anxiety (p=0.027) and depression (p=0.048). The m-Borg difference between the 2 groups at 3 months was 0.80, which is borderline clinically significant but not statistically significant. Changes were more evident in the 3-month assessment. IMT was safe with only a small number of patients complaining of muscle fatigue and dizziness.Conclusion
This trial shows the IMT is feasible and safe in patients with lung cancer with significant benefits particularly in their ability to cope with breathlessness and emotional distress. The details of this trial allow us to refine the treatment protocol and findings guarantee a fully-powered larger trial (N should be around 196 with m-Borg as primary outcome).Only Members that have purchased this event or have registered via an access code will be able to view this content. To view this presentation, please login, select "Add to Cart" and proceed to checkout. If you would like to become a member of IASLC, please click here.
