Patient care can be improved in a variety of areas, particularly with regard to symptom management. Marie Flannery, RN, PhD, Debra Kelly, PhD, RN, OCN®, Amy Moore, MSN, RN, ACNS-BC, Karen Pekle, RN, ANPC, MS, AOCN®, and Chao Hsing Yeh, PhD, each presented studies they conducted that examined different aspects of symptom burden and management in oncology care during a session at the 41st Annual Congress in San Antonio, TX.
Pain and Distress During Bone Marrow Procedures
Moore began by discussing pain and distress in adults undergoing bone marrow aspiration and biopsy (BMAB). “I was surprised to see that the standard of care [for adults] was local anesthesia for bone marrow biopsy,” she said.
She said she was interested in procedural pain management in this population and sought to describe pain severity, pain quality and character, and distress levels during and one hour after BMAB procedures. “Patients can develop post-traumatic stress,” Moore said. “Is there a way for nurses to predict a patient’s response to pain?
A very limited number of previous studies have been published on this topic, and no clinical scientific guidelines recommend what patients should receive prior to the procedure, which leads to a wide variety in treatment patterns.
She conducted a multivariate correlational study of 152 inpatients at the Hospital of the University of Pennsylvania in Philadelphia. Patient-reported pain and distress were collected before the procedure, five minutes post-procedure, and an hour post-procedure.
Moore found that elevated levels of preprocedure distress was an independent predictor of poor procedure tolerance, yet it was not treated in 77% of patients who might have benefited from an anxiolytic. Patients were significantly distressed before the procedure and immediately post-procedure, although distress had mostly dissipated at one-hour post-procedure. Patients reported relatively intense but short-lived pain and distress, suggesting that fast-acting, short-lasting anxiolytic agents might produce a therapeutic benefit.
Symptom Priorities With Lung Cancer
Flannery next discussed her study of symptom priority in patients with advanced lung cancer. This patient population has the highest number of distress symptoms. The study’s goal was to have patients identify their priority symptom, which were assessed at baseline and nine weeks later. A total of 45 patients were first asked what the most important symptom was before then receiving and completing the M.D. Anderson Symptom Inventory-Lung Cancer (MDASI-L) checklist.
She found that the two most prevalent symptoms reported were pain and fatigue. Nearly one-third of the patient symptom responses were not even included on the MDASI-L, including rash, diarrhea, poor balance, blurred vision, swollen and puffy feet, and acid indigestion.
More than 70% of the patients reported a different symptom as the priority at week nine than they did at baseline. “What was important to the patient was not stable; [it] changed over time,” Flannery said.
Arthralgia From Breast Cancer Treatment
Yeh then discussed a management technique for breast cancer survivors who are experiencing arthralgia related to aromatase inhibitors (AIs). Up to 50% of breast cancer survivors report experiencing arthralgia. For post-menopausal women with hormone-receptor positive breast cancer, AI is the most effective treatment and is often continued for up to five years. If patients are experiencing arthralgia, adherence to long-term AI use can be very difficult, and nonadherence might lead to relapse.
Yeh noted that auricular point acupressure (APA)—a noninvasive, self-managed, and nonpharmaceutical traditional Chinese technique—can mitigate arthralgia, and it is something that nurses can easily learn and perform on patients.
She conducted a feasibility study that included a four-week APA intervention. Depending on what joint pain the patient was experiencing, acupressure performed on a specific point on the ear that is “connected” to the area can relieve pain. After four weeks of treatment, Yeh found that pain, stiffness, physical dysfunction, disability, and symptom severity decreased in this study population.
Lifestyle and Inflammation
Kelly discussed the associations among inflammation, perceived stress, and lifestyle behaviors of individuals with chronic graft-versus-host disease (cGVHD) following allogeneic stem cell transplant. The patients in her study were not routinely engaging in health-promoting lifestyle behaviors, and their perceived stress scores were higher than a healthy control group. Kelly noted that there was a relationship between lifestyle and inflammation.
She concluded that nurses play a vital role in helping this patient population engage in self-care strategies by providing information about modifiable factors with the potential to improve outcomes. Educating patients and caregivers about wellness, along with follow-up care plans and coordinated medical care, can help patients with cGVHD improve survivorship and overall quality of life.
Transdermal Patch for CINV
Pekle concluded the session by discussing the efficacy of a transdermal granisetron patch to control chemotherapy-induced nausea and vomiting (CINV) in patients with hematologic cancers. No guidelines are internationally agreed upon for CINV in hematologic malignancies, and this population often fails to thrive. CINV is a serious condition that can lead to malaise, weight loss, dehydration, electrolyte imbalances, feeding tube use, and hospitalization. Because hematologic cancers often require higher dosages and more frequently repeated cycles of treatment, CINV is more likely to occur in those with hematologic malignancies versus solid tumors.
She conducted a phase III, randomized, active-control, double-blind, parallel group, multicenter, subanalysis to assess safety and efficacy of the patch, with a primary endpoint of complete control (no vomiting, no use of rescue medication, and no more than mild nausea). The patch was used from the first to last administration of chemotherapy. The researchers found that the patch was as safe and effective as oral granisetron in preventing CINV for this population.
Flannery, M., Kelly, D., Moore, A., Pekle, K., & Yeh C.H. (2016). Analyzing symptom burden and management strategies. Session presented at the ONS 41st Annual Congress, San Antonio, TX, April 30, 2016.