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Journal of Pain and Symptom Management
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Brief Report
Pilot Study of a Brief Behavioral Intervention for Dyspnea in Patients With Advanced Lung Cancer Joseph A. Greer, PhD, James J. MacDonald, BA, Jeanne Vaughn, APRN-BC, Elene Viscosi, APRN-BC, Lara Traeger, PhD, Theresa McDonnell, DNP, APRN-BC, William F. Pirl, MD, MPH, and Jennifer S. Temel, MD Massachusetts General Hospital Cancer Center & Harvard Medical School, Boston, Massachusetts, USA
Abstract Context. Dyspnea is a common symptom in patients with advanced cancer that interferes with functional ability and quality of life (QOL). Although few evidence-based treatments for dyspnea exist, prior studies show support for nonpharmacological interventions that include elements of cognitive-behavioral therapy. Objectives. To examine the feasibility and utility of delivering a brief behavioral intervention for dyspnea in patients with lung cancer. Methods. For this single-group pilot study, eligible patients included those with advanced lung cancer (Stage III or IV nonsmall cell or extensive-stage small cell lung cancer) receiving outpatient cancer treatment who reported at least moderate breathlessness. The manualized intervention consisted of two sessions in which nurse practitioners taught participants breathing and relaxation techniques within the infusion clinic and encouraged home practice. Participants completed measures of breathlessness (Modified Medical Research Council Dyspnea Scale), QOL (Functional Assessment of Cancer Therapy-Lung Trial Outcome Index), and anxiety and depression symptoms (Hospital Anxiety and Depression Scale) at baseline and within six weeks after enrollment. Results. Of the 32 patients enrolled in the study (56.3% females; mean age 63.34 [SD] ¼ 7.96 years), 84.4% (N ¼ 27) completed all study procedures. Comparing the baseline to postassessments, we found significant improvements in Modified Medical Research Council Dyspnea Scale (P < 0.001), Functional Assessment of Cancer Therapy-Lung Trial Outcome Index (P ¼ 0.01), and Hospital Anxiety and Depression Scale-depression subscale (P < 0.001) scores. Conclusion. In this sample of patients with advanced lung cancer and dyspnea, we observed a high completion rate for the two-session behavioral intervention. Patients also reported improvements in dyspnea, QOL, and mood. Follow-up randomized controlled trials are needed to examine the efficacy of brief behavioral interventions for cancer-related dyspnea. J Pain Symptom Manage 2015;50:854e860. Ó 2015 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved. Key Words Non-small cell, small cell, lung cancer, dyspnea
Introduction Dyspnea is a common and debilitating symptom of advanced cancer, with approximately one-quarter to one-half of patients reporting clinically significant symptoms.1e3 Dyspnea reflects a subjective experience of distress or discomfort related to the sensation of
Dr. Greer and Mr. MacDonald are co-first authors who contributed equally to the article. Address correspondence to: Joseph A. Greer, PhD, Center for Psychiatric Oncology & Behavioral Sciences, Massachusetts General Hospital Cancer Center, Yawkey Building, Suite Ó 2015 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.
breathlessness,4 which may be episodic in nature (e.g., triggered on exertion) or continuous, occurring even at rest.5 Rates of dyspnea are much higher as patients approach the end of life.6 Several correlational studies have shown a strong association between the severity of dyspnea and worse
10B, Boston, MA 02114, USA. mgh.harvard.edu Accepted for publication: June 27, 2015.
E-mail:
jgreer2@
0885-3924/$ - see front matter http://dx.doi.org/10.1016/j.jpainsymman.2015.06.010
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quality of life (QOL).7e10 Among patients with advanced lung cancer in particular, many report clinically significant breathlessness that interferes with functioning and daily life activities.8 Although lung malignancy underlies and exacerbates symptoms of breathlessness, patient-reported dyspnea is also associated with psychological factors, such as anxiety and depression.11 We have found in our own investigation of patients with advanced lung cancer that those with dyspnea are more than twice as likely to report symptoms of panic disorder compared with those without breathlessness.12 Little evidence supports treatments for dyspnea in patients with cancer, beyond opioid administration.13,14 Systematic reviews show no benefit from supplemental oxygen or benzodiazepines for patients with cancer-related breathlessness.15,16 Nonpharmacological approaches for dyspnea have included supportive counseling, breathing control, muscle relaxation, coping strategies, energy conservation, and acupuncture.13,17 Few clinical trials of these methods exist, with mixed findings regarding efficacy across techniques. Nonetheless, interventions that include elements of cognitive-behavioral therapy, such as psychoeducation and breathing retraining, have shown promise and warrant further study.18 More recent trials have shown benefit from complex, multicomponent, intensive interventions for dyspnea,19,20 although such approaches may be challenging to scale for patients with advanced cancer undergoing treatment. For this single-group pilot study, we tested a brief point-of-care intervention for dyspnea. Nurse practitioners delivered the two-session behavioral intervention to patients with advanced lung cancer in the outpatient setting. The aims of the study were to evaluate the feasibility of the behavioral intervention and its potential effects on self-reported dyspnea in patients with advanced lung cancer. We also examined QOL and psychological distress as secondary outcomes given the strong associations of these factors with dyspnea.
Methods Participants Participant eligibility criteria included 1) age 18 years and older; 2) diagnosis of advanced lung cancer (i.e., Stage III or IV non-small cell lung cancer or extensive-stage small cell lung cancer); 3) Eastern Cooperative Oncology Group Performance Status (ECOG PS) ¼ 0 (asymptomatic) to 2 (symptomatic but in bed less than 50% of the time)21; 4) ongoing outpatient oncology treatment at the Massachusetts General Hospital (MGH) Cancer Center; 5) English
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language literacy; and 6) Modified Medical Research Council Dyspnea Scale (MMRCDS) score $2 (moderate symptoms). The Dana-Farber/Harvard Cancer Center Institutional Review Board approved all study procedures.
Measures Outcome Measures. The primary and secondary outcome measures included well-validated self-report instruments used extensively in patients with cancer. 1. Intervention feasibility (primary outcome): We examined the enrollment rate, study completion rate, as well as timing and location of the intervention administration. 2. Dyspnea (primary outcome): The MMRCDS is a validated self-report measure with a five-point grading system (from 0 to 4) to evaluate breathlessness, with higher scores indicating worse dyspnea.22,23 3. QOL (secondary outcome): The Functional Assessment of Cancer Therapy-Lung (FACT-L) consists of five subscales that assess physical, functional, emotional, and social well-being as well as lung cancer-specific symptoms during the previous week. For this study, we analyzed the Trial Outcome Index (TOI), which comprises the sum of the scores on the physical well-being, functional well-being, and lung cancer subscales of the FACT-L. Scores range from 0 to 84 on the FACT-L TOI, with higher scores indicating a better QOL.24 4. Anxiety and depression symptoms (secondary outcome): The Hospital Anxiety and Depression Scale (HADS) consists of two subscales (seven items each) measuring symptoms of anxiety and depression in the past week.25 Subscale scores range from 0 to 21 with a threshold of >7 indicating clinically significant anxiety or depression.26 Chart Review. We queried participants’ electronic health records to obtain information on cancer type, date of lung cancer diagnosis, ECOG PS, line of chemotherapy, opioid prescriptions, and demographic data.
Procedures Potential participants were identified through referrals from the MGH thoracic oncology clinicians. A trained research assistant (RA) approached referred patients either privately in the outpatient clinic or by telephone to assess for interest in study participation and to confirm eligibility. Eligible patients then participated in informed consent procedures before
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enrollment, after which the RA administered baseline self-report assessments in the outpatient setting. The RA then scheduled the first intervention session to take place on site with the study nurse practitioner during a regularly scheduled visit to the infusion suite. Within four weeks of the first session, the same nurse practitioner conducted the second session by either meeting with the patient again in the infusion suite or via telephone if the patient did not have a clinic visit scheduled. Within two weeks after completing the second session, the RA again administered the same self-report questionnaires as at baseline either in the clinic or by telephone.
Description of the Study Intervention We first created an intervention manual with stepby-step instructions for teaching the dyspnea management strategies, drawing from an evidenced-based cognitive-behavioral treatment for anxiety in patients with advanced cancer.27,28 To improve patient access to care, we integrated the intervention into the clinic setting by training two nurse practitioners working in the infusion suite in the administration of the behavioral techniques. The nurse practitioners reviewed the manual and participated in a two-hour didactic training session to reinforce their learning of the intervention components. These training sessions also included practicing and role playing the delivery of the intervention with the principal investigator, who is a clinical health psychologist with expertise in developing and testing cognitive-behavioral interventions for patients with cancer. Finally, the nurse practitioners received an intervention checklist to document administration of the intervention components with each participant. The behavioral intervention consisted of evidencebased approaches for dyspnea, including psychoeducation, behavioral techniques for managing acute breathlessness, and relaxation training for overall stress management.18 During the first intervention session, the study nurse practitioners provided participants with an overview of the cognitive-behavioral model, describing how breathlessness activates the physiological stress response. Specifically, the nurse practitioner explored with the patient the types of thoughts that breathlessness triggers (e.g., ‘‘I cannot get enough air; my cancer must be getting worse’’) and associated physiological (e.g., chest tightness, heart racing) and behavioral responses (e.g., avoiding strenuous or physically demanding tasks) that perpetuate stress, deconditioning, and worse dyspnea. Next, patients learned to cope with acute breathlessness with pursed-lips breathing,29 use of a battery-operated handheld fan (blowing air toward the face),30 and postural techniques to minimize the work of breathing.31,32 Finally, participants received training in
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relaxation exercises, including diaphragmatic breathing and guided breathing meditation, with instructions to practice these skills daily at times when they were not experiencing acute shortness of breath.33,34 Participants received MP3 players with a recording of a guided breathing exercise for home practice. Approximately two to three weeks later, the nurse practitioners conducted the second intervention session during which they reviewed and reinforced the behavioral skills, answered participants’ questions, and problem-solved obstacles to protocol adherence.
Statistical Analyses We performed our statistical analyses using SPSS, version 21.0 (IBM Corp., Armonk, NY). To analyze change in the self-report outcomes, we computed dependent-samples t-tests followed by repeatedmeasures analysis of variance models, adjusting for line of chemotherapy. We dichotomized the lines of chemotherapy variable as participants who received either one or two regimens (as these patients are more likely to have a disease response to chemotherapy) vs. three or greater. To examine differences in the proportion of patients meeting the threshold for clinically significant symptoms on the HADS at baseline and postassessment, we used the nonparametric McNemar’s test for paired samples. Finally, after the report of complete-case analyses mentioned later, we present missing data analyses to account for the participants who did not complete the study protocol for any reason.
Results As shown in Table 1, 32 patients enrolled in the study, most of whom were females (56.3%), married/cohabitating (59.4%), and white (93.8%), with a mean age of 63.3 years (SD ¼ 7.96). Most participants were diagnosed with advanced non-small cell lung cancer (90.1%) vs. small cell lung cancer and had a baseline ECOG PS of 1 (78.1%). Median time from cancer diagnosis to study enrollment was approximately 15 months.
Intervention Feasibility Fig. 1 shows the study enrollment and completion rates along with reasons for withdrawal. Between September 3, 2013 and September 5, 2014, the thoracic oncology clinicians at the MGH Cancer Center referred 57 patients to the study, and 32 (56.1%) patients enrolled. Of these 32 participants, four were unable to complete the entire intervention because of disease worsening or death, and one patient withdrew, transferring care to another hospital. The remaining 27 participants (84.4%) completed all
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Table 1 Participant Baseline Demographic and Clinical Characteristics (N ¼ 32) Patient Characteristic Age, mean (SD) Female, n (%) Education, n (%) High school graduate or GED Some college College graduate Doctorate Relationship status, n (%) Married or cohabitating Single Divorced or separated Widowed or loss of partner Race, n (%) Asian Black or African American White Ethnicity, n (%) Hispanic or Latino/a Not Hispanic or Latino/a Diagnosis, n (%) NSCLC (Stage III or IV) SCLC (extensive stage) Time since diagnosis (months), median (range) ECOG Performance Status, n (%) 0 1 2 Lines of chemotherapy, n (%) 1e2 regimens 3 or greater regimens Active opioid prescription, n (%) Dyspnea (MMRCDS), mean (SD) Quality of Life (FACT-L TOI), mean (SD) Psychological Distress (HADS), mean (SD) Anxiety symptoms Depression symptoms
n (%) or Mean (SD) 63.3 (7.96) 18 (56.3) 7 4 20 1
(21.9) (12.5) (62.5) (3.1)
19 8 3 2
(59.4) (25.0) (9.4) (6.3)
1 (3.1) 1 (3.1) 29 (90.6) 1 (3.1) 31 (96.9) 29 (90.6) 3 (9.4) 15.44 (1.18e91.60) 1 (3.1) 25 (78.1) 6 (18.8) 18 14 21 2.78 48.64
(56.3) (43.8) (65.6) (.79) (12.62)
6.63 (3.84) 8.11 (2.56)
GED ¼ General Education Development Test; NSCLC ¼ non-small cell lung cancer; SCLC ¼ small cell lung cancer; ECOG ¼ Eastern Cooperative Oncology Group; MMRCDS ¼ Modified Medical Research Council Dyspnea Scale; FACT-L TOI ¼ Functional Assessment of Cancer Therapy-Lung Trial Outcome Index; HADS ¼ Hospital Anxiety and Depression Scale.
Fig. 1. Diagram of study enrollment, retention, and completion rates.
reduction in dyspnea over time (mean difference ¼ 0.89; 95% CI 0.54, 1.24; t(26) ¼ 5.18, SE ¼ 0.17; P < 0.001; Cohen’s d ¼ 1.00). We also analyzed self-reported QOL from baseline to postassessments (Fig. 3), observing a significant improvement in FACT-L TOI scores (mean difference ¼ 4.87; 95% CI 8.61, 1.13; t(26) ¼ 2.67; SE ¼ 1.82; P ¼ 0.01; Cohen’s d ¼ 0.51). In addition to breathlessness and QOL, we examined change from baseline to postassessment in patients’ reported anxiety and depression symptoms using the HADS. We conducted these analyses using
study procedures. Nearly all the first intervention sessions took place within the infusion suite (n ¼ 31/ 32, 96.9%). Approximately half (n ¼ 14/27) of the second intervention sessions occurred within the infusion suite, with the remainder administered over the telephone. The mean period from baseline to postassessment was 29.1 days (SD ¼ 7.82). A review of the session documentation showed that the nurse practitioners adhered to the study protocol for all participants.
Change in Breathlessness, QOL, and Mood from Baseline to Postassessment The primary outcome of the study was change in patient-reported dyspnea on the MMRCDS from baseline to postassessment (Fig. 2). Complete-case analysis showed that participants reported significant
Fig. 2. Change in self-reported breathlessness on the Modified Medical Research Council Dyspnea Scale (MMRCDS). Note: Among study completers (N ¼ 27), participantreported breathlessness on the MMRCDS significantly improved from baseline (mean ¼ 2.70, SD ¼ 0.82) to postassessment (mean ¼ 1.81, SD ¼ 0.92), t(26) ¼ 5.18, P < 0.001.
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Fig. 3. Change in self-reported quality of life on the Functional Assessment of Cancer Therapy-Lung Trial Outcome Index (FACT-L TOI). Note: Among study completers, participant-reported quality of life on the FACT-L TOI significantly improved from baseline (mean ¼ 50.94, SD ¼ 12.25) to postassessment (mean ¼ 55.81, SD ¼ 13.42), t(26) ¼ 2.67, P ¼ 0.01.
both the continuous subscale scores and established clinical threshold values on each subscale (>7). The analyses of the continuous subscale scores showed that patients reported improvement in depression (mean difference ¼ 2.43; 95% CI 1.37, 3.50; t(26) ¼ 4.70; SE ¼ 0.52; P < 0.001; Cohen’s d ¼ 0.90) but not anxiety symptoms (mean difference ¼ 0.85; 95% CI 0.24, 1.94; t(26) ¼ 1.61; SE ¼ 0.53; P ¼ 0.12; Cohen’s d ¼ 0.31) over time. Additionally, when analyzing clinical cutoff values (Fig. 4), we observed a marginally significant difference in the proportion of patients who reported elevated depression at baseline compared with postassessment (baseline n ¼ 13/27, 48.1% vs. post n ¼ 7/ 27, 25.9%, McNemar’s test P ¼ 0.07). The proportion of patients reporting elevated anxiety symptoms at both time points was relatively similar (29.6% vs. 25.9%, McNemar’s test P ¼ 1.00). Finally, adjusting the primary and secondary analyses for line of chemotherapy, the results were essentially unchanged for the main effect of time on breathlessness (F(1,25) ¼ 24.09, P < 0.001), QOL (F(1,25) ¼ 6.96, P ¼ 0.01), and depression symptoms (F(1,25) ¼ 20.30, P < 0.001). We observed no significant interactions between time and line of chemotherapy for these outcomes (all P-values $0.45).
Missing Data Analyses Following the intent-to-treat principle, we assumed that the five participants who did not complete the study protocol were nonresponders to the intervention. We used a conservative method of imputing the worst postassessment sample scores for breathlessness
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Fig. 4. Proportion of patients reporting elevated anxiety and depression on the Hospital Anxiety and Depression Scale (HADS). Note: The graph shows the proportion of patients reporting elevated anxiety symptoms at both study time points (baseline n ¼ 8/27, 29.6% vs. post n ¼ 7/27, 25.9%, McNemar’s test P ¼ 1.00), as well as the proportion of patients who reported elevated depression symptoms at baseline (n ¼ 13/27, 48.1%) compared with postassessment (n ¼ 7/27, 25.9%), McNemar’s test P ¼ 0.07.
(MMRCDS ¼ 4), QOL (FACT-L TOI ¼ 24), and depression (HADS-depression subscale ¼ 14) for these individuals. Using this approach, the mean improvement in dyspnea (MMRCDS mean difference ¼ 0.63; 95% CI 0.25, 1.00; t(31) ¼ 3.40; SE ¼ 0.18; P ¼ 0.002; Cohen’s d ¼ 0.60) and depression (HADS-depression subscale mean difference ¼ 1.43; 95% CI 0.13, 2.72; t(31) ¼ 2.25; SE ¼ 0.64; P ¼ 0.03; Cohen’s d ¼ 0.40) remained significant over time, whereas QOL did not (FACT-L TOI mean difference ¼ 2.20; 95% CI 6.13, 1.72; t(31) ¼ 1.15; SE ¼ 1.92; P ¼ 0.26; Cohen’s d ¼ 0.20).
Discussion Among patients with advanced lung cancer, dyspnea remains a prevalent, often intractable, symptom that impairs QOL and tends to worsen as the disease progresses.35 In this pilot study, we found that the delivery of a brief behavioral intervention in the outpatient setting was feasible for individuals receiving treatment for advanced lung cancer. The intervention was associated with statistically and clinically significant reductions in breathlessness and depression as well as improvement in QOL from baseline to postassessment. Although the enrollment rate was average for a supportive care study (56.1%), participant attrition was quite low (15.6%) despite patients having advanced disease. The behavioral intervention for dyspnea was likely feasible because of several key factors. To help facilitate timely access and participation for patients, we designed the intervention to be brief, involving only two 30-minute sessions over a several week period. Additionally, participants were able to meet
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with the nurse practitioner for the first session during their regularly scheduled oncology appointments and then followed up with the same study clinician again in clinic or over the telephone. Finally, this approach required no additional visits to the Cancer Center, reducing the demands of time and travel on patients. The reported improvements in dyspnea, QOL, and depression may be a result of physiological and psychological factors. Participants learned breathing exercises as part of the intervention, which may have increased efficiency of breathing in the context of diminished lung capacity. Also, providing participants with proactive strategies to manage dyspnea may have led to a greater sense of control over breathlessness and functional well-being, thereby improving scores on measures of QOL and depression. Prior research shows that dyspnea is one of the most common uncontrolled symptoms for which patients with lung malignancies seek unplanned medical care.36 Perhaps, the study intervention helped empower patients to feel greater mastery in managing the distressing symptom on their own. Our behavioral intervention possesses several strengths in its manualized approach, short duration, and ease of administration within the flow of oncology care. Despite these advantages, several limitations of the study deserve consideration. First, as a singlegroup nonrandomized study, we are unable to conclude conclusively whether the intervention led to the improvements in patient-reported outcomes. Alternatively, some patients may have simultaneously responded to chemotherapy during the course of the study, perhaps accounting for the reduction in symptom burden. Nonetheless, when we adjusted the analyses for line of chemotherapy, the positive outcomes did not change. In addition, the method of recruitment was limited to a convenience sample based on clinician referral rather than population screening. Such an approach may have affected our enrollment rate and biased the sample to patients with more severe dyspnea. For future studies, investigators would also want to include long-term followup assessments to determine maintenance of gains over time. Finally, the sample was quite homogeneous with respect to cancer type, racial and ethnic backgrounds, and site of oncology care, perhaps limiting the generalizability of the results. Given the promising findings of this preliminary feasibility study, further investigation of the brief behavioral intervention is warranted within the context of a larger randomized controlled trial. We believe that this easy-to-administer time-efficient behavioral intervention has great potential to improve access to much needed symptom management and reduce suffering in those with poor prognosis cancers.
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Disclosures and Acknowledgments This study was funded by the Barbara McCue Endowed Fund at the MGH Cancer Center. The authors have no disclosures.
References 1. Bruera E, Schmitz B, Pither J, Neumann CM, Hanson J. The frequency and correlates of dyspnea in patients with advanced cancer. J Pain Symptom Manage 2000;19:357e362. 2. Dudgeon DJ, Kristjanson L, Sloan JA, Lertzman M, Clement K. Dyspnea in cancer patients: prevalence and associated factors. J Pain Symptom Manage 2001;21:95e102. 3. Walling AM, Weeks JC, Kahn KL, et al. Symptom prevalence in lung and colorectal cancer patients. J Pain Symptom Manage 2015;49:192e202. 4. American Thoracic Society. Dyspnea. Mechanisms, assessment, and management: a consensus statement. American Thoracic Society. Am J Respir Crit Care Med 1999;159: 321e340. 5. Simon ST, Higginson IJ, Benalia H, et al. Episodic and continuous breathlessness: a new categorization of breathlessness. J Pain Symptom Manage 2013;45:1019e1029. 6. Lutz S, Norrell R, Bertucio C, et al. Symptom frequency and severity in patients with metastatic or locally recurrent lung cancer: a prospective study using the Lung Cancer Symptom Scale in a community hospital. J Palliat Med 2001;4:157e165. 7. Tanaka K, Akechi T, Okuyama T, Nishiwaki Y, Uchitomi Y. Impact of dyspnea, pain, and fatigue on daily life activities in ambulatory patients with advanced lung cancer. J Pain Symptom Manage 2002;23:417e423. 8. Tanaka K, Akechi T, Okuyama T, Nishiwaki Y, Uchitomi Y. Prevalence and screening of dyspnea interfering with daily life activities in ambulatory patients with advanced lung cancer. J Pain Symptom Manage 2002;23:484e489. 9. Smith EL, Hann DM, Ahles TA, et al. Dyspnea, anxiety, body consciousness, and QOL in patients with lung cancer. J Pain Symptom Manage 2001;21:323e329. 10. Henoch I, Bergman B, Gustafsson M, GastonJohansson F, Danielson E. The impact of symptoms, coping capacity, and social support on quality of life experience over time in patients with lung cancer. J Pain Symptom Manage 2007;34:370e379. 11. Tanaka K, Akechi T, Okuyama T, Nishiwaki Y, Uchitomi Y. Factors correlated with dyspnea in advanced lung cancer patients: organic causes and what else? J Pain Symptom Manage 2002;23:490e500. 12. Shin JA, Kosiba JD, Traeger L, Greer JA, Temel JS, Pirl WF. Dyspnea and panic among patients with newly diagnosed non-small cell lung cancer. J Pain Symptom Manage 2014;48:465e470. 13. McCannon J, Temel J. Comprehensive management of respiratory symptoms in patients with advanced lung cancer. J Support Oncol 2012;10:1e9. 14. Dy SM, Lorenz KA, Naeim A, Sanati H, Walling A, Asch SM. Evidence-based recommendations for cancer
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fatigue, anorexia, depression, and dyspnea. J Clin Oncol 2008;26:3886e3895.
25. Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983;67:361e370.
15. Uronis HE, Currow DC, McCrory DC, Samsa GP, Abernethy AP. Oxygen for relief of dyspnoea in mildly- or non-hypoxaemic patients with cancer: a systematic review and meta-analysis. Br J Cancer 2008;98:294e299.
26. Snaith RP, Zigmond AS. The Hospital Anxiety and Depression Scale manual. London: GL Assessment Limited, 1994.
16. Simon ST, Higginson IJ, Booth S, Harding R, Bausewein C. Benzodiazepines for the relief of breathlessness in advanced malignant and non-malignant diseases in adults. Cochrane Database Syst Rev 2010;CD007354. 17. Bausewein C, Booth S, Gysels M, Higginson I. Non-pharmacological interventions for breathlessness in advanced stages of malignant and non-malignant diseases. Cochrane Database Syst Rev 2008;CD005623. 18. DiSalvo WM, Joyce MM, Tyson LB, Culkin AE, Mackay K. Putting evidence into practice: evidence-based interventions for cancer-related dyspnea. Clin J Oncol Nurs 2008;12: 341e352. 19. Farquhar MC, Prevost AT, McCrone P, et al. Is a specialist breathlessness service more effective and cost-effective for patients with advanced cancer and their carers than standard care? Findings of a mixed-method randomised controlled trial. BMC Med 2014;12:194. 20. Higginson IJ, Bausewein C, Reilly CC, et al. An integrated palliative and respiratory care service for patients with advanced disease and refractory breathlessness: a randomised controlled trial. Lancet Respir Med 2014;2:979e987. 21. Oken MM, Creech RH, Tormey DC, et al. Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol 1982;5:649e655. 22. Schilling RS, Hughes JP, Dingwall-Fordyce I. Disagreement between observers in an epidemiological study of respiratory disease. Br Med J 1955;1:65e68. 23. Mahler DA, Wells CK. Evaluation of clinical methods for rating dyspnea. Chest 1988;93:580e586. 24. Cella DF, Bonomi AE, Lloyd SR, et al. Reliability and validity of the Functional Assessment of Cancer Therapy-Lung (FACT-L) quality of life instrument. Lung Cancer 1995;12: 199e220.
27. Greer JA, Traeger L, Bemis H, et al. A pilot randomized controlled trial of brief cognitive-behavioral therapy for anxiety in patients with terminal cancer. Oncologist 2012;17: 1337e1345. 28. Greer JA, Park ER, Prigerson HG, et al. Tailoring cognitive-behavioral therapy to treat anxiety comorbid with advanced cancer. J Cogn Psychother 2010;24:294e313. 29. Nield MA, Soo Hoo GW, Roper JM, et al. Efficacy of pursed-lips breathing: a breathing pattern retraining strategy for dyspnea reduction. J Cardiopulm Rehabil Prev 2007;27:237e244. 30. Galbraith S, Fagan P, Perkins P, et al. Does the use of a handheld fan improve chronic dyspnea? A randomized, controlled, crossover trial. J Pain Symptom Manage 2010; 39:831e838. 31. O’Neill S, McCarthy DS. Postural relief of dyspnoea in severe chronic airflow limitation: relationship to respiratory muscle strength. Thorax 1983;38:595e600. 32. Sharp JT, Drutz WS, Moisan T, et al. Postural relief of dyspnea in severe chronic obstructive pulmonary disease. Am Rev Respir Dis 1980;122:201e211. 33. Yates P, Zhao I. Update on complex nonpharmacological interventions for breathlessness. Curr Opin Support Palliat Care 2012;6:144e152. 34. Thomas S, Bausewein C, Higginson I, et al. Breathlessness in cancer patientsdimplications, management and challenges. Eur J Oncol Nurs 2011;15:459e469. 35. Simoff MJ, Lally B, Slade MG, et al. Symptom management in patients with lung cancer: diagnosis and management of lung cancer, 3rd ed. American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013;143:e455See497S. 36. Patel MI, Williams DC, Wohlforth C, et al. Are patients with thoracic malignancies at risk for uncontrolled symptoms? J Oncol Pract 2015;11:e98ee102.
Journal of Pain and Symptom Management
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Brief Report
Pilot Study of a Brief Behavioral Intervention for Dyspnea in Patients With Advanced Lung Cancer Joseph A. Greer, PhD, James J. MacDonald, BA, Jeanne Vaughn, APRN-BC, Elene Viscosi, APRN-BC, Lara Traeger, PhD, Theresa McDonnell, DNP, APRN-BC, William F. Pirl, MD, MPH, and Jennifer S. Temel, MD Massachusetts General Hospital Cancer Center & Harvard Medical School, Boston, Massachusetts, USA
Abstract Context. Dyspnea is a common symptom in patients with advanced cancer that interferes with functional ability and quality of life (QOL). Although few evidence-based treatments for dyspnea exist, prior studies show support for nonpharmacological interventions that include elements of cognitive-behavioral therapy. Objectives. To examine the feasibility and utility of delivering a brief behavioral intervention for dyspnea in patients with lung cancer. Methods. For this single-group pilot study, eligible patients included those with advanced lung cancer (Stage III or IV nonsmall cell or extensive-stage small cell lung cancer) receiving outpatient cancer treatment who reported at least moderate breathlessness. The manualized intervention consisted of two sessions in which nurse practitioners taught participants breathing and relaxation techniques within the infusion clinic and encouraged home practice. Participants completed measures of breathlessness (Modified Medical Research Council Dyspnea Scale), QOL (Functional Assessment of Cancer Therapy-Lung Trial Outcome Index), and anxiety and depression symptoms (Hospital Anxiety and Depression Scale) at baseline and within six weeks after enrollment. Results. Of the 32 patients enrolled in the study (56.3% females; mean age 63.34 [SD] ¼ 7.96 years), 84.4% (N ¼ 27) completed all study procedures. Comparing the baseline to postassessments, we found significant improvements in Modified Medical Research Council Dyspnea Scale (P < 0.001), Functional Assessment of Cancer Therapy-Lung Trial Outcome Index (P ¼ 0.01), and Hospital Anxiety and Depression Scale-depression subscale (P < 0.001) scores. Conclusion. In this sample of patients with advanced lung cancer and dyspnea, we observed a high completion rate for the two-session behavioral intervention. Patients also reported improvements in dyspnea, QOL, and mood. Follow-up randomized controlled trials are needed to examine the efficacy of brief behavioral interventions for cancer-related dyspnea. J Pain Symptom Manage 2015;50:854e860. Ó 2015 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved. Key Words Non-small cell, small cell, lung cancer, dyspnea
Introduction Dyspnea is a common and debilitating symptom of advanced cancer, with approximately one-quarter to one-half of patients reporting clinically significant symptoms.1e3 Dyspnea reflects a subjective experience of distress or discomfort related to the sensation of
Dr. Greer and Mr. MacDonald are co-first authors who contributed equally to the article. Address correspondence to: Joseph A. Greer, PhD, Center for Psychiatric Oncology & Behavioral Sciences, Massachusetts General Hospital Cancer Center, Yawkey Building, Suite Ó 2015 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.
breathlessness,4 which may be episodic in nature (e.g., triggered on exertion) or continuous, occurring even at rest.5 Rates of dyspnea are much higher as patients approach the end of life.6 Several correlational studies have shown a strong association between the severity of dyspnea and worse
10B, Boston, MA 02114, USA. mgh.harvard.edu Accepted for publication: June 27, 2015.
E-mail:
jgreer2@
0885-3924/$ - see front matter http://dx.doi.org/10.1016/j.jpainsymman.2015.06.010
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quality of life (QOL).7e10 Among patients with advanced lung cancer in particular, many report clinically significant breathlessness that interferes with functioning and daily life activities.8 Although lung malignancy underlies and exacerbates symptoms of breathlessness, patient-reported dyspnea is also associated with psychological factors, such as anxiety and depression.11 We have found in our own investigation of patients with advanced lung cancer that those with dyspnea are more than twice as likely to report symptoms of panic disorder compared with those without breathlessness.12 Little evidence supports treatments for dyspnea in patients with cancer, beyond opioid administration.13,14 Systematic reviews show no benefit from supplemental oxygen or benzodiazepines for patients with cancer-related breathlessness.15,16 Nonpharmacological approaches for dyspnea have included supportive counseling, breathing control, muscle relaxation, coping strategies, energy conservation, and acupuncture.13,17 Few clinical trials of these methods exist, with mixed findings regarding efficacy across techniques. Nonetheless, interventions that include elements of cognitive-behavioral therapy, such as psychoeducation and breathing retraining, have shown promise and warrant further study.18 More recent trials have shown benefit from complex, multicomponent, intensive interventions for dyspnea,19,20 although such approaches may be challenging to scale for patients with advanced cancer undergoing treatment. For this single-group pilot study, we tested a brief point-of-care intervention for dyspnea. Nurse practitioners delivered the two-session behavioral intervention to patients with advanced lung cancer in the outpatient setting. The aims of the study were to evaluate the feasibility of the behavioral intervention and its potential effects on self-reported dyspnea in patients with advanced lung cancer. We also examined QOL and psychological distress as secondary outcomes given the strong associations of these factors with dyspnea.
Methods Participants Participant eligibility criteria included 1) age 18 years and older; 2) diagnosis of advanced lung cancer (i.e., Stage III or IV non-small cell lung cancer or extensive-stage small cell lung cancer); 3) Eastern Cooperative Oncology Group Performance Status (ECOG PS) ¼ 0 (asymptomatic) to 2 (symptomatic but in bed less than 50% of the time)21; 4) ongoing outpatient oncology treatment at the Massachusetts General Hospital (MGH) Cancer Center; 5) English
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language literacy; and 6) Modified Medical Research Council Dyspnea Scale (MMRCDS) score $2 (moderate symptoms). The Dana-Farber/Harvard Cancer Center Institutional Review Board approved all study procedures.
Measures Outcome Measures. The primary and secondary outcome measures included well-validated self-report instruments used extensively in patients with cancer. 1. Intervention feasibility (primary outcome): We examined the enrollment rate, study completion rate, as well as timing and location of the intervention administration. 2. Dyspnea (primary outcome): The MMRCDS is a validated self-report measure with a five-point grading system (from 0 to 4) to evaluate breathlessness, with higher scores indicating worse dyspnea.22,23 3. QOL (secondary outcome): The Functional Assessment of Cancer Therapy-Lung (FACT-L) consists of five subscales that assess physical, functional, emotional, and social well-being as well as lung cancer-specific symptoms during the previous week. For this study, we analyzed the Trial Outcome Index (TOI), which comprises the sum of the scores on the physical well-being, functional well-being, and lung cancer subscales of the FACT-L. Scores range from 0 to 84 on the FACT-L TOI, with higher scores indicating a better QOL.24 4. Anxiety and depression symptoms (secondary outcome): The Hospital Anxiety and Depression Scale (HADS) consists of two subscales (seven items each) measuring symptoms of anxiety and depression in the past week.25 Subscale scores range from 0 to 21 with a threshold of >7 indicating clinically significant anxiety or depression.26 Chart Review. We queried participants’ electronic health records to obtain information on cancer type, date of lung cancer diagnosis, ECOG PS, line of chemotherapy, opioid prescriptions, and demographic data.
Procedures Potential participants were identified through referrals from the MGH thoracic oncology clinicians. A trained research assistant (RA) approached referred patients either privately in the outpatient clinic or by telephone to assess for interest in study participation and to confirm eligibility. Eligible patients then participated in informed consent procedures before
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enrollment, after which the RA administered baseline self-report assessments in the outpatient setting. The RA then scheduled the first intervention session to take place on site with the study nurse practitioner during a regularly scheduled visit to the infusion suite. Within four weeks of the first session, the same nurse practitioner conducted the second session by either meeting with the patient again in the infusion suite or via telephone if the patient did not have a clinic visit scheduled. Within two weeks after completing the second session, the RA again administered the same self-report questionnaires as at baseline either in the clinic or by telephone.
Description of the Study Intervention We first created an intervention manual with stepby-step instructions for teaching the dyspnea management strategies, drawing from an evidenced-based cognitive-behavioral treatment for anxiety in patients with advanced cancer.27,28 To improve patient access to care, we integrated the intervention into the clinic setting by training two nurse practitioners working in the infusion suite in the administration of the behavioral techniques. The nurse practitioners reviewed the manual and participated in a two-hour didactic training session to reinforce their learning of the intervention components. These training sessions also included practicing and role playing the delivery of the intervention with the principal investigator, who is a clinical health psychologist with expertise in developing and testing cognitive-behavioral interventions for patients with cancer. Finally, the nurse practitioners received an intervention checklist to document administration of the intervention components with each participant. The behavioral intervention consisted of evidencebased approaches for dyspnea, including psychoeducation, behavioral techniques for managing acute breathlessness, and relaxation training for overall stress management.18 During the first intervention session, the study nurse practitioners provided participants with an overview of the cognitive-behavioral model, describing how breathlessness activates the physiological stress response. Specifically, the nurse practitioner explored with the patient the types of thoughts that breathlessness triggers (e.g., ‘‘I cannot get enough air; my cancer must be getting worse’’) and associated physiological (e.g., chest tightness, heart racing) and behavioral responses (e.g., avoiding strenuous or physically demanding tasks) that perpetuate stress, deconditioning, and worse dyspnea. Next, patients learned to cope with acute breathlessness with pursed-lips breathing,29 use of a battery-operated handheld fan (blowing air toward the face),30 and postural techniques to minimize the work of breathing.31,32 Finally, participants received training in
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relaxation exercises, including diaphragmatic breathing and guided breathing meditation, with instructions to practice these skills daily at times when they were not experiencing acute shortness of breath.33,34 Participants received MP3 players with a recording of a guided breathing exercise for home practice. Approximately two to three weeks later, the nurse practitioners conducted the second intervention session during which they reviewed and reinforced the behavioral skills, answered participants’ questions, and problem-solved obstacles to protocol adherence.
Statistical Analyses We performed our statistical analyses using SPSS, version 21.0 (IBM Corp., Armonk, NY). To analyze change in the self-report outcomes, we computed dependent-samples t-tests followed by repeatedmeasures analysis of variance models, adjusting for line of chemotherapy. We dichotomized the lines of chemotherapy variable as participants who received either one or two regimens (as these patients are more likely to have a disease response to chemotherapy) vs. three or greater. To examine differences in the proportion of patients meeting the threshold for clinically significant symptoms on the HADS at baseline and postassessment, we used the nonparametric McNemar’s test for paired samples. Finally, after the report of complete-case analyses mentioned later, we present missing data analyses to account for the participants who did not complete the study protocol for any reason.
Results As shown in Table 1, 32 patients enrolled in the study, most of whom were females (56.3%), married/cohabitating (59.4%), and white (93.8%), with a mean age of 63.3 years (SD ¼ 7.96). Most participants were diagnosed with advanced non-small cell lung cancer (90.1%) vs. small cell lung cancer and had a baseline ECOG PS of 1 (78.1%). Median time from cancer diagnosis to study enrollment was approximately 15 months.
Intervention Feasibility Fig. 1 shows the study enrollment and completion rates along with reasons for withdrawal. Between September 3, 2013 and September 5, 2014, the thoracic oncology clinicians at the MGH Cancer Center referred 57 patients to the study, and 32 (56.1%) patients enrolled. Of these 32 participants, four were unable to complete the entire intervention because of disease worsening or death, and one patient withdrew, transferring care to another hospital. The remaining 27 participants (84.4%) completed all
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Table 1 Participant Baseline Demographic and Clinical Characteristics (N ¼ 32) Patient Characteristic Age, mean (SD) Female, n (%) Education, n (%) High school graduate or GED Some college College graduate Doctorate Relationship status, n (%) Married or cohabitating Single Divorced or separated Widowed or loss of partner Race, n (%) Asian Black or African American White Ethnicity, n (%) Hispanic or Latino/a Not Hispanic or Latino/a Diagnosis, n (%) NSCLC (Stage III or IV) SCLC (extensive stage) Time since diagnosis (months), median (range) ECOG Performance Status, n (%) 0 1 2 Lines of chemotherapy, n (%) 1e2 regimens 3 or greater regimens Active opioid prescription, n (%) Dyspnea (MMRCDS), mean (SD) Quality of Life (FACT-L TOI), mean (SD) Psychological Distress (HADS), mean (SD) Anxiety symptoms Depression symptoms
n (%) or Mean (SD) 63.3 (7.96) 18 (56.3) 7 4 20 1
(21.9) (12.5) (62.5) (3.1)
19 8 3 2
(59.4) (25.0) (9.4) (6.3)
1 (3.1) 1 (3.1) 29 (90.6) 1 (3.1) 31 (96.9) 29 (90.6) 3 (9.4) 15.44 (1.18e91.60) 1 (3.1) 25 (78.1) 6 (18.8) 18 14 21 2.78 48.64
(56.3) (43.8) (65.6) (.79) (12.62)
6.63 (3.84) 8.11 (2.56)
GED ¼ General Education Development Test; NSCLC ¼ non-small cell lung cancer; SCLC ¼ small cell lung cancer; ECOG ¼ Eastern Cooperative Oncology Group; MMRCDS ¼ Modified Medical Research Council Dyspnea Scale; FACT-L TOI ¼ Functional Assessment of Cancer Therapy-Lung Trial Outcome Index; HADS ¼ Hospital Anxiety and Depression Scale.
Fig. 1. Diagram of study enrollment, retention, and completion rates.
reduction in dyspnea over time (mean difference ¼ 0.89; 95% CI 0.54, 1.24; t(26) ¼ 5.18, SE ¼ 0.17; P < 0.001; Cohen’s d ¼ 1.00). We also analyzed self-reported QOL from baseline to postassessments (Fig. 3), observing a significant improvement in FACT-L TOI scores (mean difference ¼ 4.87; 95% CI 8.61, 1.13; t(26) ¼ 2.67; SE ¼ 1.82; P ¼ 0.01; Cohen’s d ¼ 0.51). In addition to breathlessness and QOL, we examined change from baseline to postassessment in patients’ reported anxiety and depression symptoms using the HADS. We conducted these analyses using
study procedures. Nearly all the first intervention sessions took place within the infusion suite (n ¼ 31/ 32, 96.9%). Approximately half (n ¼ 14/27) of the second intervention sessions occurred within the infusion suite, with the remainder administered over the telephone. The mean period from baseline to postassessment was 29.1 days (SD ¼ 7.82). A review of the session documentation showed that the nurse practitioners adhered to the study protocol for all participants.
Change in Breathlessness, QOL, and Mood from Baseline to Postassessment The primary outcome of the study was change in patient-reported dyspnea on the MMRCDS from baseline to postassessment (Fig. 2). Complete-case analysis showed that participants reported significant
Fig. 2. Change in self-reported breathlessness on the Modified Medical Research Council Dyspnea Scale (MMRCDS). Note: Among study completers (N ¼ 27), participantreported breathlessness on the MMRCDS significantly improved from baseline (mean ¼ 2.70, SD ¼ 0.82) to postassessment (mean ¼ 1.81, SD ¼ 0.92), t(26) ¼ 5.18, P < 0.001.
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Fig. 3. Change in self-reported quality of life on the Functional Assessment of Cancer Therapy-Lung Trial Outcome Index (FACT-L TOI). Note: Among study completers, participant-reported quality of life on the FACT-L TOI significantly improved from baseline (mean ¼ 50.94, SD ¼ 12.25) to postassessment (mean ¼ 55.81, SD ¼ 13.42), t(26) ¼ 2.67, P ¼ 0.01.
both the continuous subscale scores and established clinical threshold values on each subscale (>7). The analyses of the continuous subscale scores showed that patients reported improvement in depression (mean difference ¼ 2.43; 95% CI 1.37, 3.50; t(26) ¼ 4.70; SE ¼ 0.52; P < 0.001; Cohen’s d ¼ 0.90) but not anxiety symptoms (mean difference ¼ 0.85; 95% CI 0.24, 1.94; t(26) ¼ 1.61; SE ¼ 0.53; P ¼ 0.12; Cohen’s d ¼ 0.31) over time. Additionally, when analyzing clinical cutoff values (Fig. 4), we observed a marginally significant difference in the proportion of patients who reported elevated depression at baseline compared with postassessment (baseline n ¼ 13/27, 48.1% vs. post n ¼ 7/ 27, 25.9%, McNemar’s test P ¼ 0.07). The proportion of patients reporting elevated anxiety symptoms at both time points was relatively similar (29.6% vs. 25.9%, McNemar’s test P ¼ 1.00). Finally, adjusting the primary and secondary analyses for line of chemotherapy, the results were essentially unchanged for the main effect of time on breathlessness (F(1,25) ¼ 24.09, P < 0.001), QOL (F(1,25) ¼ 6.96, P ¼ 0.01), and depression symptoms (F(1,25) ¼ 20.30, P < 0.001). We observed no significant interactions between time and line of chemotherapy for these outcomes (all P-values $0.45).
Missing Data Analyses Following the intent-to-treat principle, we assumed that the five participants who did not complete the study protocol were nonresponders to the intervention. We used a conservative method of imputing the worst postassessment sample scores for breathlessness
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Fig. 4. Proportion of patients reporting elevated anxiety and depression on the Hospital Anxiety and Depression Scale (HADS). Note: The graph shows the proportion of patients reporting elevated anxiety symptoms at both study time points (baseline n ¼ 8/27, 29.6% vs. post n ¼ 7/27, 25.9%, McNemar’s test P ¼ 1.00), as well as the proportion of patients who reported elevated depression symptoms at baseline (n ¼ 13/27, 48.1%) compared with postassessment (n ¼ 7/27, 25.9%), McNemar’s test P ¼ 0.07.
(MMRCDS ¼ 4), QOL (FACT-L TOI ¼ 24), and depression (HADS-depression subscale ¼ 14) for these individuals. Using this approach, the mean improvement in dyspnea (MMRCDS mean difference ¼ 0.63; 95% CI 0.25, 1.00; t(31) ¼ 3.40; SE ¼ 0.18; P ¼ 0.002; Cohen’s d ¼ 0.60) and depression (HADS-depression subscale mean difference ¼ 1.43; 95% CI 0.13, 2.72; t(31) ¼ 2.25; SE ¼ 0.64; P ¼ 0.03; Cohen’s d ¼ 0.40) remained significant over time, whereas QOL did not (FACT-L TOI mean difference ¼ 2.20; 95% CI 6.13, 1.72; t(31) ¼ 1.15; SE ¼ 1.92; P ¼ 0.26; Cohen’s d ¼ 0.20).
Discussion Among patients with advanced lung cancer, dyspnea remains a prevalent, often intractable, symptom that impairs QOL and tends to worsen as the disease progresses.35 In this pilot study, we found that the delivery of a brief behavioral intervention in the outpatient setting was feasible for individuals receiving treatment for advanced lung cancer. The intervention was associated with statistically and clinically significant reductions in breathlessness and depression as well as improvement in QOL from baseline to postassessment. Although the enrollment rate was average for a supportive care study (56.1%), participant attrition was quite low (15.6%) despite patients having advanced disease. The behavioral intervention for dyspnea was likely feasible because of several key factors. To help facilitate timely access and participation for patients, we designed the intervention to be brief, involving only two 30-minute sessions over a several week period. Additionally, participants were able to meet
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with the nurse practitioner for the first session during their regularly scheduled oncology appointments and then followed up with the same study clinician again in clinic or over the telephone. Finally, this approach required no additional visits to the Cancer Center, reducing the demands of time and travel on patients. The reported improvements in dyspnea, QOL, and depression may be a result of physiological and psychological factors. Participants learned breathing exercises as part of the intervention, which may have increased efficiency of breathing in the context of diminished lung capacity. Also, providing participants with proactive strategies to manage dyspnea may have led to a greater sense of control over breathlessness and functional well-being, thereby improving scores on measures of QOL and depression. Prior research shows that dyspnea is one of the most common uncontrolled symptoms for which patients with lung malignancies seek unplanned medical care.36 Perhaps, the study intervention helped empower patients to feel greater mastery in managing the distressing symptom on their own. Our behavioral intervention possesses several strengths in its manualized approach, short duration, and ease of administration within the flow of oncology care. Despite these advantages, several limitations of the study deserve consideration. First, as a singlegroup nonrandomized study, we are unable to conclude conclusively whether the intervention led to the improvements in patient-reported outcomes. Alternatively, some patients may have simultaneously responded to chemotherapy during the course of the study, perhaps accounting for the reduction in symptom burden. Nonetheless, when we adjusted the analyses for line of chemotherapy, the positive outcomes did not change. In addition, the method of recruitment was limited to a convenience sample based on clinician referral rather than population screening. Such an approach may have affected our enrollment rate and biased the sample to patients with more severe dyspnea. For future studies, investigators would also want to include long-term followup assessments to determine maintenance of gains over time. Finally, the sample was quite homogeneous with respect to cancer type, racial and ethnic backgrounds, and site of oncology care, perhaps limiting the generalizability of the results. Given the promising findings of this preliminary feasibility study, further investigation of the brief behavioral intervention is warranted within the context of a larger randomized controlled trial. We believe that this easy-to-administer time-efficient behavioral intervention has great potential to improve access to much needed symptom management and reduce suffering in those with poor prognosis cancers.
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Disclosures and Acknowledgments This study was funded by the Barbara McCue Endowed Fund at the MGH Cancer Center. The authors have no disclosures.
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