Self-management for adult patients with cancer: an integrative review.

Copyright B 2015 Wolters Kluwer Health, Inc. All rights reserved.

Marilyn J. Hammer, PhD, DC, RN Elizabeth A. Ercolano, DNSc, RN, AOCNS Fay Wright, MS, RN, APRN-BC Victoria Vaughan Dickson, PhD, CRNP, RN, FAHA Deborah Chyun, PhD, RN, FAHA, FAAN Gail D’Eramo Melkus, EdD, C-NP, FAAN

Self-management for Adult Patients With Cancer An Integrative Review

K E Y

W O R D S

Background: Individuals with cancer are surviving long term, categorizing cancer as

Cancer

a chronic condition, and with it, numerous healthcare challenges. Symptoms, in

Self-care

particular, can be burdensome and occur from prediagnosis through many years after

Self-management

treatment. Symptom severity is inversely associated with functional status and quality

Symptom-management

of life. Objective: Management of these millions of survivors of cancer in a stressed healthcare system necessitates effective self-care strategies. The purpose of this integrative review is to evaluate intervention studies led by nurse principal investigators for self-care management in patients with cancer. Methods: PubMed, CINAHL (Cumulative Index to Nursing and Allied health Literature), and the Cochrane Database were searched from January 2000 through August 2012. Search terms included ‘‘symptom management and cancer,’’ ‘‘self-management and cancer,’’ and ‘‘self-care and cancer.’’ All articles for consideration included intervention studies with a nurse as the primary principal investigator. Results: Forty-six articles were included yielding 3 intervention areas of educational and/or counseling sessions, exercise, and complementary and alternative therapies. Outcomes were predominately symptom focused and often included functional status and quality of life. Few studies had objective measures. Overarching themes were mitigation, but not prevention or elimination of symptoms, and improved quality of life related to functional status. No one intervention was superior to another for any given outcome. Conclusions: Current interventions that direct patients in self-care management

Author Affiliations: College of Nursing, New York University (Drs Hammer, Dickson, Chyun, and Melkus and Ms Wright); and Yale School of Nursing, New Haven, Connecticut (Dr Ercolano). The authors have no funding or conflicts of interest to disclose.

Correspondence: Marilyn J. Hammer, PhD, DC, RN, College of Nursing, New York University, 726 Broadway, 10th Floor, New York, NY 10003 ([email protected]). Accepted for publication November 4, 2013. DOI: 10.1097/NCC.0000000000000122

E10 n Cancer NursingTM, Vol. 38, No. 2, 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

Hammer et al

of symptoms and associated challenges with cancer/survivorship are helpful, but incomplete. No one intervention can be recommended over another. Implications for Practice: Guiding patients with cancer in self-care management is important for overall functional status and quality of life. Further investigation and tailored interventions are warranted.

T

he diagnosis of cancer has historically been associated with the beginning of the end of life.1,2 For some, this still holds true. For many more, new exacting procedures and targeted therapies have led to long-term survival that can be quantified not just in years, but in decades. Although cancer is now classified as a chronic condition,3,4 new challenges in cancer survival have emerged, such as long-term care and symptom management.5,6 Increasing survival coincides with declining mortality rates7; however, the number of individuals being diagnosed with cancer continues to rise and is estimated to reach 27 million by 2050.8 The current annual worldwide incidence of all cancers is 12.7 million with a prevalence of 28.8 million people.9 In addition, the lifetime risk of a newborn today developing cancer over the course of a lifetime is 41.24%.10 However discouraging, the high risk is not entirely out of our control, as approximately 30% of cancers are linked to lifestyle behaviors (high body mass index, low fruit and vegetable consumption, physical inactivity, tobacco use, and alcohol consumption).9 This composite epidemiological evidence highlights the tremendous need for health management of so many individuals globally. Management of these millions of survivors of cancer in a stressed healthcare system necessitates effective self-care strategies.5,11 Being an active participant from diagnosis through longterm survival also gives patients a level of autonomy that can enhance overall quality of life. Among the many challenges, symptoms can be particularly burdensome and as devastating as the diagnosis of cancer itself.12 Furthermore, increased symptom presence and severity are inversely associated with functional status and quality of life.12,13 Importantly, the symptoms can start before or during cancer treatments and can persist for years,14,15 underscoring the tremendous need for self-management. Formally guiding patients in self-management through the development of self-care models began more than 30 years ago with the empiric process involving decision-based behavior choices in response to a situation.14 In cancer, many models of care are focused on posttreatment follow-up and are predominately led and managed by healthcare providers.5 The Chronic Care Model is one that takes into account cancer as a chronic condition with an emphasis on how self-management may shift depending on the phase the patient is in (diagnosis, treatment, posttreatment, end of life).4 Within this context, numerous studies have focused on strategies to manage symptoms, predominately focusing on them individually, even though it has been established that symptoms often occur in defined clusters.12,16Y19 Bakitas and colleagues17 have evaluated existing models of care addressing the need for optimizing symptom management in patients with cancer, highlighting the need for more refined models and theories to better guide practice. To help facilitate this process, this

Integrative Review: Cancer Self-management

integrative review evaluates intervention studies conducted by nurses as the principal investigators for self-care management in patients with cancer.

n

Methods

This integrative review followed the Preferred Reporting Items of Systematic Reviews and Meta-analysis (PRISMA) statement guidelines to identify, select, and critically appraise the relevant literature.20 Per the PRISMA guidelines, establishing the literature search parameters (research question) began with the PICOS (Population, Intervention, Comparator, Outcomes, Study Design) approach20 and included adults/older adults with cancer who received an intervention to help with self-management from disease and treatment-related effects, with comparison to same patient populations receiving usual care, and through an experimental design study. PubMed, the CINAHL (Cumulative Index to Nursing and Allied health Literature), and the Cochrane Database were searched from January 2000 through August 2012. Search terms included ‘‘symptom management and cancer,’’ ‘‘self-management and cancer,’’ and ‘‘self-care and cancer.’’ All articles for consideration included intervention studies with a nurse as the primary principal investigator. The Cochrane Database was used to find intervention studies that had been cited within other reviews that fit our criteria for inclusion. Exclusion criteria included studies that addressed the following areas without also containing a self-care intervention: medications (eg, use of narcotics for pain control), surgical procedures, treatment decision making, perception, needs assessment, evaluations of patient-provider communication, evaluations of screenings, evaluation of barriers to symptom management, and validation of assessment questionnaires. Non-English articles were also excluded. Three researchers separately conducted the literature search (one for each database) and then conducted a secondary search in one of the other databases so that each database was searched by 2 different reviewers. A master database was created with the initial article selection based on the set criteria. Two reviewers then went through each article until agreement was met by both for which final articles to include. The process began with an initial identification of 28 987 articles. All articles identified in CINAHL and Cochrane were also found in PubMed, leaving 4733 after duplicates were eliminated. Another 4639 were eliminated based on abstract review and 48 full-text articles were eliminated based on exclusion criteria (Figure). The final 46 articles included in this review had interventions for the management of pain, depression, fatigue, sleep disturbances, and other symptoms Cancer NursingTM, Vol. 38, No. 2, 2015

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

n

E11

Figure n Preferred Reporting Items of Systematic Reviews and Meta-analysis (PRISMA) flow chart. and challenges (eg, nausea and vomiting, coping, physical functioning, quality of life).

n

Results

Overview Three major intervention categories were found among the studies in this review, including educational and/or counseling sessions (in person and/or via telephone) (n = 26) (Table 1A), exercise (n = 17) (Table 1B), and complementary and alternative medicine (CAM) therapies (n = 5) (Table 1C). Three studies fit into 2 different intervention categories and were evaluated for each category in which they fit for the purposes of this review. Williams and Schreier21,22 combined instructional, exercise, and relaxation techniques for symptom management, whereas Faithfull et al23 focused on exercise, problem solving, and coping mechanisms. The other 43 studies each fit into 1 of the 3 intervention categories. All studies required some form of instruction, guidance, monitoring, and/or counseling to help patients better self-manage their home care. The composite subject number by intervention category was as follows: educational/counseling, n = 3253; exercise, n = 1148; and CAM, n = 642. The numbers of subjects by cancer site per intervention category are shown in Table 2. The majority of studies were conducted on women with breast cancer exclusively21,22,24Y42 or included breast cancer among other cancer diagnoses.15,17Y19,43Y54 Studies that did not contain patients

with breast cancer included the diagnoses of lung cancer,4,55,56 prostate cancer,23,57 ovarian cancer,58 melanoma,59 and multiple myeloma.60 One study did not specify cancer site.61 The number of outcomes measured across studies ranged from 1 to 13 with a mean of 3.8 outcomes per study. More than 80% of the studies had 2 or more outcome measures. The large majority of outcomes were subjective, measured by patient selfreport. A few studies contained objective measures including ˙ O2),44 bone mineral density,32 maximum oxygen consumption (V 33,35 biomarkers caloric or energy expenditure,39,40 and urine 23 volume. Most outcomes were symptom focused. The symptom cluster of pain, depression, fatigue, and sleep disturbance has been established,12,16 yet interventions focused on this cluster are minimal. Among the studies in this review, fatigue was the most frequently targeted symptom, appearing as an outcome measure in 61% of the studies. Overall, more studies reported improvements in fatigue with interventions.4,15,19,21,22,24Y26,31,37Y39,41,42,46Y49,51,54,59,60 Pain, depression, and sleep disturbances were independently measured in 23.9%, 26%, and 21.7% of the studies, respectively. The only study that targeted all symptoms of this cluster was the Pro-self Fatigue Control home exercise program.30 The other group of symptoms evaluated as a cluster included breathlessness, fatigue, and anxiety.4 Although most studies investigated multiple outcomes, they were measured as separate (yet coexisting) outcomes, a reflection of the various measurement tools. Some positive findings were noted with the studies that ˙ O2 as included biological measures. Griffith et al44 measured V a marker of physical functioning with an exercise intervention


Hammer et al


Cancer NursingTM, Vol. 38, No. 2, 2015


n

E13

54

PRMQE feasibility

Berger et al,26 2003

RCT

Bakitas, et al, 2009

RCT pilot

RMED pilot

Badger et al,24 2005

Barsevick, et al,43 2002

RMED

RCT

Study Design

Badger et al,25 2001

Armes et al, 2007

Author(s)

ISPP: sleep hygiene counseling, relaxation therapy, sleep restriction, and stimulus control

Energy conservation (ECAM) for reduction of cancer treatment-related fatigue

In person self-help courses, telephone calls for uncertainty management, independent self-help (IS) course or combo IS/phone Self-Help Intervention Project (SHIP): Uncertainty and enabling skills for self-care, self-help, psychological adjustment, and overall QOL delivered via classes, telephone, independent-study, or combinations Palliative Care, Project ENABLE II: nurse-led structured educational and problem-solving sessions

3 Individual, face-to-face, 60-min behaviorally oriented, CRF-specific sessions at 3Y4 weekly intervals (coinciding with administration of chemotherapy)

Intervention Details

Women in their mid-50s diagnosed with stages IYIII breast cancer, receiving adjuvant treatment for breast cancer

Women with breast cancer treated by surgery and adjuvant therapies

Nonmetastatic, histologically proven cancer diagnosis

Patient Population

52 wk

6 wk

Women aged 43Y66 y with stage I or II breast cancer post 4 cycles of doxorubicin

Adults (18+) initiating Q3 cycles of CTX or 6 wk of RT for breast, lung, prostate, or colorectal cancer

3 mo to 3 y Life-limiting cancer, within 8Y12 wk of new diagnosis of GI (unresectable stage (to death or III or IV), lung (stage IIIB or IV completion nonYsmall cell or extensive small cell), of study) GU (stage IV), or breast (stage IV and visceral crisis, lung or liver metastasis, ER-negative, H-EGFR 2Ypositive cancer

6 wk

6 wk

12 wk

Intervention Duration

Table 1A & Table of Articles: Educational/Counseling Interventions

21

300

322

48

169

55

n

Findings

(continues)

QOL, symptom Improvements in QOL and depressed mood for intensity, intervention group and depressed compared with usual care. mood No differences in symptom intensity or reduced days of hospitalizations, emergency department visits, or time in the intensive care unit Fatigue Varying patterns of fatigue found between intervention and control groups Fatigue and sleep Positive for adherence to disturbance protocol and low fatigue

Fatigue, physical Improvement in physical functioning, trend toward functioning, decreased cancer-related and fatigue, and no improvement distress in fatigue-related distress in intervention group compared with usual care Depression, Improvement with fatigue, fatigue in women who adverse effects reported higher levels of depression Depression, Positive for decreased fatigue, stress depression, fatigue, and stress and increased positive affect

Outcomes Measured

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Hammer et al

18

Quasi-experimental Nurse-led cognitive-behavioral intervention, ‘‘Helping Her single group Heal’’ for partners of women pretest/posttest with breast cancer

RCT

Cochrane et al,28 2011

Dulko and Mooney,55 2010

Faithfull et al,23 Quasi-experimental Nurse-led group and individual 2011 pretest/posttest program of pelvic floor muscle design exercises, bladder retraining, problem-solving, and coping mechanisms

Nurse practitioner-led audit and feedback intervention for pain control

RCT

Cimprich et al,27 2005

Nurse-led psychoeducation on symptom management and coaching in the use of progressive muscle relaxation 1 wk prior to RT + 3 repeated sessions Oncology NP and health education-led ‘‘Taking CHARGE’’ self-management tool to aid transition from treatment to survivorship

Nurse-led, cognitive-behavioral intervention (6 times)


RCT

Secondary analysis from 2 RCTs

Study Design

Chan et al,4 2011

Byma et al, 2009

Author(s)

Women within 6 mo of a first diagnosis of stages 0YIII breast cancer

Woman Q25 y old who completed primary treatment for early stage I or II breast cancer

Adults/older adults ages 25Y90 y undergoing chemotherapy for solid tumors Patients able to communicate in Chinese with stage 3 or 4 lung cancer Q16 y old scheduled to receive palliative RT average 4.3 Gy/fraction

Patient Population

24 wk

Men with locally confined prostate cancer up to stage T3bNO with moderate-to-severe urinary symptoms 93 mo following treatment with neoadjuvant hormone therapy and radiation doses 65Y74 Gy

Admission Patients with cancer undergoing initial courses through of chemotherapy at 2 discharge chemotherapy centers and 2 community cancer centers

10 wk

7 wk

~14 wk

8 wk


Table 1A & Table of Articles: Educational/Counseling Interventions, Continued

15

113

9

49

140

330

n

Prostate and bladder symptoms, QOL, and self-efficacy

Pain assessment

Problem solving, psychological well-being, symptom and adverse effect management Anxiety, depression, adjustment, marital quality

Symptom cluster involving anxiety, breathlessness, and fatigue

Pain, fatigue

Outcomes Measured

(continues)

Intervention group reported program was useful for problem solving, psychological well-being, managing symptoms and adverse effects, functional wellness, and personal/ social relationships Improvements noted pre-to-post test for anxiety, depression, adjustment, and marital quality in patients whose partners received the intervention Intervention group had less pain interference with general activity and sleep and better satisfaction with pain relief compared with control group. No difference in pain intensity found Improvement in prostate symptoms/ bladder voiding volume and frequency issues, and emotional distress

Significant for pain resolution; not significant for time to resolution, fatigue resolution, or time to fatigue resolution Significant for breathlessness, fatigue, anxiety, and functional ability

Findings




n

E15

RCT

Miaskowski et al,52 2007

RCT

McCorkle et al,58 2009

RCT

RCT

Lengacher et al,34 2009

Miaskowski et al,53 2004

RCT

Given et al,19 2002

Author(s)

Study Design

Advanced practice oncology nurse-led intervention for postoperative self-management and further treatment decision-making skills PRO-SELF nurse-led in-home psychoeducational intervention and telephone follow-up intervention to aid with pain control PRO-SELF nurse-led in-home psychoeducational intervention and telephone follow-up intervention to aid with pain control

Mindfulness-based stress reduction program

Problem-solving approaches to symptom management and improving physical functioning and emotional health


6 wk

6 wk

24 wk

6 wk

20 wk


Oncology outpatients with metastatic cancer to the bone

Women Q21 y old who underwent abdominal surgery for suspected primary diagnosis of ovarian cancer Oncology outpatients with metastatic cancer to the bone

Patients with cancers of the breast, colon, lung, gynecological tissue, or patients with lymphoma undergoing an initial course of chemotherapy at 2 chemotherapy centers and 2 community cancer centers Women Q21 y old with stage 0, I, II, or III breast cancer who completed surgery and received adjuvant radiation and/or chemotherapy within the prior 18 mo

Patient Population


167

174

123

125

113

n

Pain, mood status

Pain intensity, amount of analgesics prescribed and opioids taken

QOL, depression, uncertainty, symptom distress

Psychological and physical symptoms; QOL

Pain, fatigue, other symptoms, physical and social functioning

Outcomes Measured

(continues)

Better pain reduction in intervention group and more appropriately prescribed analgesics compared with control group Statistical and clinical significance for outcomes in intervention group with use of responder analysisa

Lower fear of recurrence/ recurrence concerns, anxiety, and depression; higher physical functioning and energy; lower physical health-related role limitations in intervention group. No differences between groups for social support, perceived stress, optimism, and spirituality Positive for intervention targeting both physical and psychological QOL aspects

Intervention was significant for reduction of no. of symptoms and improved physical and social functioning; decreased reporting of pain and fatigue at 20 wk

Findings



Hammer et al

57


RCT

RCT pilot

RCT

Ream et al,48 2002

Ream et al,49 2006

Nurse-led intervention: fatigue education, fatigue diary, and in-person coaching

Nurse-led intervention for self-management of fatigue via energy conservation/ optimizing activity and functioning

Symptom assessment and education to self-manage symptoms

Randomized Nurse-led psychoeducational repeated measures cognitive reframing, problem solving intervention

Study Design

Molassiotis et al,46 2009

Mishel et al, 2002

Author(s)

103

8

164

Course of Individuals Q18 y old capecitabine with colorectal or breast cancer with Q6 mo half-life prognosis who were receiving capecitabine 16 wk Individuals Q18 y old scheduled to begin chemotherapy for gastrointestinal, respiratory, or breast cancer or lymphoma 12 wk Individuals 18Y70 y old, chemotherapy-naive, diagnosed with non-Hodgkin lymphoma or gastrointestinal, nonYsmall cell lung, colorectal, breast, or unknown primary cancer

n 239

Patient Population Men (Caucasian and African American) with localized prostate cancer

6 wk



Fatigue, anxiety, depression, coping

Fatigue, anxiety, depression, coping

Anxiety, depression, fatigue, and toxicity

Illness uncertainty, self-control, cancer knowledge, symptom distress

Outcomes Measured

(continues)

Less fatigue, distress, anxiety, and depression and better coping and well-being in intervention group compared with control group

Improved coping and decreased fatigue in 3rd cycle of chemotherapy

Caucasian men significant decrease in urinary symptoms, uncertainty and problem solving from baseline to 4 mo after intervention completed compared with control group. African Americans reported significant decreases from 4 to 7 mo after intervention completed Significant for oral mucositis; diarrhea, constipation; nausea, pain, and fatigue (first 4 cycles) and insomnia (all cycles); not significant for depression

Findings




n

E17

RCT

RCT

Wilkie et al,56 2010

Williams, and Schreier,21 2004

Study Design

Audiotape instructional material with telephone support on nutritional management of adverse effects, exercise, and relaxation techniques for symptom self-management

Audiotape instructional material with telephone support on nutritional management of adverse effects, exercise, and relaxation techniques for symptom self-management

Self-monitoring and reporting of a coaching intervention via videotape with in-home, and telephone support

Nurse-led intensive home-based education program for pain control

Nurse-led intervention to help patients understand nature of symptoms and improve beliefs in ability to control symptoms; problem-solving skills


12 wk

12 wk

4 wk

8 wk

20 wk


120

Individuals Q18 y old diagnosed with cancer and informed of diagnosis

Women Q18 newly diagnosed with breast cancer who were chemotherapy naive and then received cyclosphosphamide, methotrexate, and fluorouracil or doxorubicin and cytoxan Women Q18 y old newly diagnosed with breast cancer, receiving chemotherapy

71

71

151

124

Individual Q21 y old with newly diagnosed stage III or IV or recurrent cancer (solid tumor or non-Hodgkin lymphoma) undergoing chemotherapy

Patients with small cell or non-small cell lung cancer

n

Patient Population

Anxiety, fatigue, sleep disturbances; self-care behaviors

Anxiety, nail self-care diary, adverse effect severity, self-care behaviors

Pain, anxiety, depression, coping

Pain, anxiety, and depression

Symptom severity for pain, fatigue, nausea, vomiting, insomnia, dyspnea, weakness, anorexia, fever, dry mouth, mouth sores, constipation, depression

Outcomes Measured

Fatigue, insomnia, weakness and pain were most reported symptoms. Intervention group and those with lower baseline severity had lower symptom severity at 10 and 20 wk. Significant differences between groups occurred mostly in patients G60 y old. Depression at baseline predicted symptom severity at 20 wk Intervention group had decreased pain level at week 4. Continued decreased pain in those with high baseline pain. Better pain knowledge in intervention group, but did not correlate with decreased pain Intervention group more likely to provide unsolicited symptom information to providers. No significant differences in coping Most frequent adverse effects were fatigue, nausea, vomiting, and taste alterations. Improvements found in intervention group; none in control group. Anxiety decreased for both groups, more for intervention group Improvements in intervention group on self-care behaviors, anxiety, and fatigue. No improvement in sleep disturbances.b

Findings

Abbreviations: CRF, cancer-related fatigue; CTX, chemotherapy treatment; ECAM, Energy Conservation and Activity Management; ENABLE, Educate, Nurture, Advise Before Life Ends; ER-negative, estrogen receptor negative; GI, gastrointestinal; GU, genitourinary; H-EGFR 2 positive, human epidermal growth factor receptor 2 positive; ISPP, individualized sleep promotion plan; n, number of subjects who completed the study; PRMQE, prospective repeated-measures quasi-experimental; QOL, quality of life; RCT, randomized controlled trial; RMED, repeated-measures experimental design; RT, radiation treatment. a Different outcomes analyzed from Miaskowski et al, 2004.53 b Different outcomes analyzed from Williams and Schreier’s 2004 study.21

RCT

RCT

van der Peet et al,61 2009

Williams and Schreier,22 2005

RCT

Sherwood et al,51 2005

Author(s)




Hammer et al

RTC

Longitudinal RCT

RCT

Griffith et al,44 2009

Headley et al,31 2004

Irwin et al,32 2009

Faithfull et al,23 2011


Home-based waking and resistance 24 wk band exercise program during treatment


n

Outcomes Measured Findings

Intervention group maintained 24 Aerobic capacity, lean body mass; control group strength, lean body lost lean body mass. Intervention weight, fatigue, mood, group had improved nighttime and sleep quality sleep with decreased daytime sleepiness and daytime fatigue. Daytime sleepiness decreased with increases in minutes of daytime sleep for both groups Women with breast cancer 119 Pain, depression, No statistical significance, but a treated with chemotherapy + fatigue, sleep trend found in changing levels radiation disturbances of fatigue and pain over time

Patients Q40 y old with multiple myeloma being treated with high dose chemotherapy and autologous HCT

Patient Population

Improvement in prostate Men with locally confined prostate 15 Prostate and symptoms/bladder voiding bladder cancer up to stage T3bNO with volume and frequency issues, symptoms, QOL, and moderate-to-severe urinary and emotional distress self-efficacy symptoms 93 mo following treatment with neoadjuvant hormone therapy and radiation doses 65Y74 Gy ˙ O2, physical Patients undergoing treatment 126 V Intervention group with prostate Individualized exercise program Prior to treatment for stages I, II, or II prostate through treatment cancer had improved (mostly walking; also included functioning, role or breast cancer with completion cardiorespiratory jogging, running, swimming, limitations, and pain chemotherapy, chemotherapy + fitness, and physical functioning. and biking) based on ACSM radiation, or brachytherapy Less pain compared with control guidelines group for all intervention group patients 32 Fatigue and QOL Slower decline in total and physical 4 wk Women Q18 y old diagnosed Seated exercise program using well-being and less increase in with stage IV breast cancer home videotape 3 times/wk for fatigue starting with the third and scheduled to initiate 4 cycles of chemotherapy cycle of chemotherapy outpatient chemotherapy Intervention group had decreased 24 wk Physically inactive postmenopausal 137 Anthropometry, DXA Progressive exercise program % body fat and increased lean scans for body fat, women diagnosed 1Y10 y prior (walking or other by choice), body mass with maintenance of lean mass, and bone with stage 0-IIIA breast cancer 15 min intense aerobic activity bone mineral density compared density who completed chemotherapy 3 times/wk at health club + with control group with and/or radiation treatment 2 times/wk at home, increased increased % body fat, decreased Q6 mo prior to 30-min sessions lean body mass and bone density (continues)

Unspecified Pro-self home-based walking or stationary bicycle program for the management of cancer-related fatigue Quasi-experimental Nurse-led group and individual 24 wk program of pelvic floor muscle pretest/posttest exercises, bladder retraining, design problem-solving, and coping mechanisms

RCT

Study Design

Dodd et al,30 RCT 2010

Coleman et al,60 2003

Author(s)

Table 1B & Table of Articles: Exercise Interventions




n

E19

33

RCT

RCT pilot

Study Design

Home-based aerobic exercise program

Pretest/ posttest

Pretest/post test

Single group Moderate-intensity exercise program intervention with fatigue and exercise diary

Schwartz,39 2000

Schwartz,40 2000b

Schwartz et al,41 2001

Home based progressive aerobic exercise program

Walking program with targeted heart rate at 50%Y70% max heart rate

Multimodel exercise program (walking and cycling) including high- and low-intensity training, body awareness, relaxation, and massage Individualized regulated walking program determined by exercise physiologist

Progressive weight-loaded walking 3 times/wk on treadmill starting at 10 min with progression to 45 min/session


Mock et al,37 RCT 2005

Mock et al,38 RCT 2001

Midtgaard et al,36 2011

Knobf et al, 2008

Author(s)

8 wk

8 wk

8 wk

6Y24 wk

6Y24 wk

6 wk

16Y24 wk


Table 1B & Table of Articles: Exercise Interventions, Continued Outcomes Measured

Women who had surgery for stage IYIV breast cancer, chemotherapy naive, no previous radiotherapy

Women, Q18 y with new diagnosis of infiltrating ductal breast cancer, chemotherapy-naive

Findings

(continues)

Improvement in level and duration of fatigue in women who adhered to exercise program Weight maintenance and 71 Weight change, BMI, improved functional ability anorexia, nausea, fatigue, in women who adhered to caloric expenditure during exercise program exercise, and functional ability 61 Fatigue, functional ability, The greater duration of exercise, energy expenditure the less fatigue reported; benefit sustained one day

Less fatigue in intervention group

Less fatigue and emotional distress and higher functional ability in women who exercised Q90 min/wk on 3 or more days

High adherence to exercise. No 26 Type I N-terminal statistically significant changes propeptides, in biomarkers, lean muscle osteocalcin, weight, mass, percent fat mass, or DXA scan, heart rate, weight. and exercise adherence Increase in fat mass for patients who took adjuvant endocrine therapy 209 Anxiety and depression Decrease found in depression, but not anxiety

n

48 Fatigue; QOL Women recently treated for stage I, II, or IIIa breast cancer by definitive surgery and were scheduled to receive outpatient adjuvant chemotherapy or radiation therapy Sedentary women 18Y70 y old 108 Fatigue; QOL with stage 0YIII breast cancer receiving outpatient adjuvant chemotherapy or radiation therapy 27 Fatigue; functional ability Women, Q18 y with new diagnosis of stage IYIV breast cancer, chemotherapy-naive

Adults with solid tumors or hematologic malignancies

Premenopausal/perimenopausal women with stage 1 or II breast cancer diagnosed 1Y3 y prior who completed chemotherapy and or radiation therapy with or without adjuvant endocrine therapy

Patient Population



Hammer et al

Audiotape instructional material with telephone support on nutritional management of adverse effects, exercise (walking and other), and relaxation techniques for symptom self-management Audiotape instructional material with telephone support on nutritional management of adverse effects, exercise (walking and other), and relaxation techniques for symptom self-management

Williams, and RCT Schreier,21 2004

12 wk

12 wk

6 wk

16 wk

Intervention Duration 12

Individuals Q18 y old beginning IFN-! treatment Q5 million IU/m2 for treatment of stage II or III melanoma

Women Q18 newly diagnosed 71 with breast cancer who were chemotherapy naive and then received cyclosphosphamide, methotrexate, and fluorouracil or doxorubicin and cyclophosphamide (Cytoxan) 71 Women Q18 y old newly diagnosed with breast cancer, receiving chemotherapy

62 Taiwanese women 18Y72 y old, newly diagnosed with stage I or II breast cancer, scheduled for chemotherapy following recovery from surgery

n

Patient Population

Findings

Fatigue, functional ability, All adhered to exercise; fatigue cognitive function was lower with exercise + med; improved functional ability for all, greater in exercise + med group, some cognitive slowing in exercise-only group Intervention group had better Fatigue, sleep QOL, exercise self-efficacy and disturbances, physical behavior, and exercise capacity functioning; QOL compared with control group. Sleep disturbances and fatigue were lower in intervention group. Fatigue difference noted at nadir and end of program only Most frequent adverse effects were Anxiety, nail fatigue, nausea, vomiting, and self-care diary, adverse taste alterations. Improvements effect severity, self-care found in intervention group; behaviors none in control group. Anxiety decreased for both groups, more for intervention group Improvements in intervention group Anxiety, fatigue, sleep on self-care behaviors, anxiety,and disturbances; self-care fatigue. No improvement in sleep behaviors disturbances.a

Outcomes Measured

Abbreviations: ACS, American Cancer Society; ACSM, American College of Sports Medicine; BMI, body mass index; BSET, Bandura’s Self-efficacy Theory; DXA, dual-energy x-ray absorptiometry; HCT, hematopoietic cell ˙ O2, peak oxygen uptake. transplantation; IFN-!, interferon !; n, number of subjects who completed the study; QOL, quality of life; RCT, randomized controlled trial; V a Different outcomes analyzed from Williams and Schreier, 2004 study.21

Williams and RCT Schreier,22 2005

BSET-based walking program for Taiwanese women with modified exercise guidelines per ACS and ACSM

Wang et al,42 RCT 2011

Single group Home based progressive aerobic intervention exercise program + daily (morning) 20 mg oral sustained-release methylphenidate

Schwartz et al,59 2002


Study Design

Author(s)

Table 1B & Table of Articles: Exercise Interventions, Continued




n

E21

15

Outcomes Measured

Adults/older adults 20Y76 y old with 48 Fatigue and physical activity cancer; completed chemo a month prior; not scheduled for future chemotherapy; expected to live 93 mo 123 Fatigue, distress, anxiety, 2 Cycles of Individuals 918 y old with first presence chemotherapy diagnosis of breast, colon, or lung cancer with 92 matched cycles of chemotherapy

2 wk

n

Adults with cancer receiving radiation, 200 Sleep quality, fatigue, mood status, and toxicity chemotherapy, oral antitumor agents, or endocrine therapy, report difficulty sleeping of 94 (0- to 10-point scale), life expectancy Q6 mo, ECOG performance score 0 or 1 160 Nausea intensity, vomiting, Women with breast cancer and retching beginning 2nd or 3rd cycle of cyclophosphamide + 5-FU, doxorubicin with paclitaxel or docetaxel, or 5-FU, epirubicin, and cyclophosphamide who had moderate or greater nausea on previous chemotherapy cycle Adult patients with cancer without 77 Frequency and duration of neurological involvement nausea and vomiting; QOL, distress, decision-making control, and psychological state Women 918 y old with stage IYIIIA 34 Pain, anxiety, depression, fatigue, sleep disturbances, breast cancer scheduled to receive and biomarkers (IL-6, at least 4 cycles of an TNF-!, IL-1$) and CRP) anthracycline-containing chemotherapy regimen

Patient Population

No improvements in symptoms; better chemotherapy infusion experience with intervention

Decreased nausea and vomiting frequency and duration and distress in intervention group. Attrition rate of 50% noted Correlations found between depression, anxiety, fatigue, and sleep disturbances; depression and TNF-!; depression and CRP. Symptoms increased over time. Depression and sleep disturbances increased less in intervention group Less fatigue and greater physical activity for acupuncture and acupressure groups compared with sham group

Improvement in fatigue, reported less drowsiness and trouble with sleep, but not statistically significant improvement sleep; no differences in toxicity or mood between groups Delayed an less nausea intensity and amount of vomiting in intervention group

Findings

Abbreviations: 5-FU, 5-flurourocil; CINV, chemotherapy-induced nausea and vomiting; CRP, C-reactive protein; ECOG, Eastern Cooperative Oncology Group; IL-6, interleukin 6; IL-1$, interleukin 1$; n, number of subjects who completed the study; QOL, quality of life; RCT, randomized controlled trial; PRN, as needed; TNF-!, tumor necrosis factor !.

Virtual reality distraction intervention

RCT; Acupuncture and acupressure feasibility

Schneider and Cross-over Hood,50 2007

Molassiotis et al,47 2007

RCT Pilot

Lyon et al,35 2010

Cranial stimulation for symptom 6Y8 wk management

Administration of flavonoid-rich 1 wk concord grape juice for CINV

RCT

8 wk


Ingersoll et al,45 2010

Valerian vs placebo


1.5 wk Nurse-led instructions on acupressure at Pericardium 6 acupressure wrist point, bilaterally in the morning and unilaterally PRN

RCT

Study Design

Dibble et al,29 RCT 2007

Barton et al, 2011

Author(s)

Table 1C & Table of Articles: Complementary and Alternative Medicine Interventions

Table 2 & Composite Subject Numbers by Cancer Site and Intervention Cancer Site Breast Lung Prostate Colon/colorectal/rectal Gastrointestinal Gynecological Genitourinary Lymphoma Multiple myeloma Melanoma Other/unspecified Total

Education/Counseling, n (%)

Exercise, n (%)

1157 (35.6) 734 (22.6) 297 (9.1) 252 (7.7) 186 (5.7) 162 (5.0) 43 (1.3) 7 (0.2) 0 (0.0) 0 (0.0) 415 (12.8) 3253

1012 (88.2) 0 (0.0) 85 (7.4) 7 (0.6) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 24 (2.1) 12 (1.0) 8 (0.7) 1148

and found favorable results in patients with prostate cancer. Also using an exercise intervention, Irwin et al32 evaluated bone mineral density and body fat percent in physically inactive postmenopausal survivors of breast cancer. Maintenance of bone mineral density and lower body fat was found in the intervention group.32 Heart rate, propeptides, osteocalcin, bone mineral density, weight, and fat mass were also measured by Knobf et al33 in a pilot exercise study without finding statistically significant differences between intervention and control groups. Biomarkers were also measured in a study evaluating cranial stimulation with depression and the proinflammatory cytokine, tumor necrosis factor ! (TNF-!), being correlated.35 Finally, Schwartz39 investigated weight change, body mass index, and caloric expenditure, and Schwartz et al41 measured energy expenditure in exercise studies with greater functional ability reported in the exercise groups.

Educational and/or Counseling Sessions There were various types of educational and/or counseling sessions that guided patients toward self-assessment and management of cancer/treatment-related challenges. The major commonality of these programs included cognitive-behavioralYtype therapies of focusing on perception, behavior, and belief in the ability to control a situation62 and/or similar types of repeated contact psychoeducational, problem-solving sessions. Most of the studies had both in-person and telephone contact with the patients as part of the intervention.4,17Y19,21Y23,25,27,30,43,46,49,51Y53,56 Few were in-person sessions only,26,28,34,48,54,55 and just 3 exclusively delivered the intervention via telephone.24,43,57 Differences between mode of delivery and outcome were not found in this review. The contents of the interventions varied, although they were similarly themed. The main method was a multifaceted approach that included awareness/assessment of symptoms experienced, a variety of self-directed interventions, evaluation of effectiveness, and revisions, as needed. Interventions included activity prioritization/ activity scheduling/energy conservation,43,48,49,54 coping/reframing/ problem solving/decision making,4,17Y19,23Y25,27,28,51,55,57,58 initiating contact with/providing unsolicited information to a healthcare provider,46,52,53,56,61 relaxation techniques,4,21,22,26

Complementary and Alternative Medicine, n (%) 457 50 6 35 8 2 0 26 0 0 58 642

(71.2) (7.8) (0.9) (5.5) (1.3) (0.3) (0.0) (4.0) (0.0) (0.0) (9.0)

sleep hygiene,26 and mindfullness.34 An example of a commonly themed approach was an intervention focused on helping patients manage fatigue through the steps of (1) fatigue recognition; (2) applying meaning to the fatigue; (3) maintaining a diary about fatigue and it’s relation to sleep disturbances; (4) applying coping mechanisms such as distraction, activity scheduling, and graded task management; and (5) goal setting.54 Statistical significance was not found; however, a trend toward improvement in fatigue was noted. Similarly, Barsevick et al43 used the Common Sense Model in a repeated telephone-session intervention to guide patients in the self-management of fatigue through coping skills, discussion of strategies for energy conservation, creating activity prioritization lists, and daily journaling to monitor the fatigue and perceived interference with activities. Evaluation and revisions were then made accordingly. This strategy was found to be feasible and helpful in moderating the expected increase in fatigue over time; however, no statistical significance was found.43 The education/cognitive counseling interventions to help patients with symptom recognition and coping strategies utilized established cognitive-behavioral therapy techniques, requiring specialized training for those delivering the sessions. Cognitive-behavioral techniques focus on teaching the patient how to recognize or assess what is being felt, followed by reframing the negative perceptions about it and adapting coping strategies.63 Variations on this were found throughout the studies. For example, Byma et al18 added the element of mastery to the cognitive-behavioral intervention to increase patient perception about symptom control, enhancing situational appraisal and behavioral response. All studies utilizing some form of cognitive/educational approach showed positive effects,4,17Y19,23Y25,27,28,51,55,57,58 with fewer showing statistical significance.4,18,19,51,57 Statistical significance was found, however, in the ENABLE (Educate, Nurture, Advise, Before Life Ends) II intervention, a multiapproach psychoeducational intervention that boasted improvements in mood (P = .02) and quality of life (P = .02).17 Advanced practice nurses led patients in self-management strategies utilizing educational and problemsolving approaches through the end of life.17 A number of interventions targeted control of specific symptoms4,17,18,25,30,34,46,51Y54,58,61 and/or broader scopes of


Hammer et al

physical functioning, social functioning, quality of life, and/or coping.17,19,34,52,54,56,58 The majority of the interventions using educational/counselingYtype protocols focused on fatigue management.4,18,19,21,22,24Y26,43,46,48,49,51,54,64 Lower levels of fatigue were noted in concordance with improvements in other symptoms including depression and stress/distress,24,49 anxiety,4,21,22,49 pain,19,46,51 nausea,21,22,46 constipation and diarrhea,46 insomnia,46,51 breathlessness,4 functional status,4,19 and well-being.49 Two studies did not find statistically significant improvements between intervention and control groups.18,30 A few studies had unique targets. For example, the ‘‘Helping Her Heal’’ protocol focused on partners of women with breast cancer and included a nurse-led cognitive-behavioral intervention, with noted positive outcomes for the patient and partner in anxiety, depression, adjustment, and marital quality.28 A study by Dulko and Mooney55 targeted pain through an audit and feedback approach. Results showed decreased pain and general activity interference, improved sleep, and better satisfaction with pain relief compared with the control group; however, differences between groups in pain intensity were not found.55 A mindfulness-based stress reduction program also had a different focus showing positive effects for decreased fear about recurrence, anxiety, and depression, and higher levels of physical functioning and energy, coupled with lower levels of healthrelated role limitations.34 Another specifically focused on counseling sessions to help with sleep and relaxation.26 Overall findings from these in-person sessions were positive with an overarching quality of life and/or symptom-driven quality-of-life theme. More definitive findings between specific interventions and focused outcomes were not found among these studies.

Exercise Exercise for symptom management, physical functioning, and overall quality of life for patients undergoing treatments for cancer has been tested in numerous studies. The studies in this review used walking programs,21,22,30,32,33,36Y38,42,44,60 with few exceptions. Schwartz and colleagues39Y41,59 incorporated the 12-minute walk test to measure endurance before and after aerobic activity; however, the aerobic activity itself was not described. Faithfull et al23 conducted a study for bladder involvement in men being treated for prostate cancer. Patients were instructed on pelvic floor exercises to improve bladder function/ reduce voiding and frequency issues.23 One other study incorporated a seated exercise program for women undergoing chemotherapy for breast cancer and found a slower decline in adverse effects by the third chemotherapy session.31 All of these studies directed patients to self-initiate and maintain a program of exercise, providing a long-term helpful self-management tool. Paralleling the large majority of educational/counseling interventions, these exercise studies most frequently focused on controlling cancer-related fatigue. Although counterintuitive, cancer-related fatigue is not relieved by rest65 but in fact can show improvement with exercise, as evidenced by the 69% of exercise studies in this review that targeted fatigue management, with 100% of them boasting improvements in fatigue.21,22,31,37Y42,59,60


In addition to fatigue management, a few studies found exercise helped with the maintenance of lean body mass32,60 or weight maintenance.39 Another study found no statistically significant difference in weight, fat mass, or muscle mass between those who exercised and those who did not exercise.33 This was a progressive weight-loaded walking program with an increase over time from 10 to 45 minutes per walking session,33 compared with the aerobic and strength-training program60 and moderateintensity exercise program39 in the studies that showed body composition benefits. Other studies concentrated on functional ability and quality of life, showing benefits with aerobic exercise.38Y41,44 Schwartz et al59 also investigated differences in outcomes with exercise between patients being treated with or without interferon alpha (IFN-!) for melanoma. Those who adhered to the aerobic exercise program and took IFN-! had improved functional ability compared with those who exercised and did not take IFN-!.59 Some cognitive slowing was also detected in the exercise-only group.59 Exercise programs were further used for the control of anxiety and depression,21,22,36 nausea vomiting, other symptoms, and self-care behaviors.21,22 Williams and Schreier21,22 found benefit for those who exercised (coupled with relaxation techniques and nutritional management) against nausea, vomiting, taste alterations, anxiety, fatigue, and self-care behaviors, but without benefit against sleep disturbances. More recently, Midtgaard et al36 reported a decrease in depression, but not anxiety for adult with solid tumor cancers or hematologic malignancies who participated in a multimodel exercise program with body awareness, relaxation, and massage techniques. Although the exercise programs in these studies had some difference, particularly being coupled with other interventions, making it difficult to assess the benefits of exercise alone, aerobic exercise stands out for benefits of symptom management and physical functioning. These positive outcomes were also linked with overall well-being and quality of life. Of particular note is the management of cancer-related fatigue through exercise, although fatigue is unable to be prevented or eradicated through exercise.

Complementary and Alternative Medicine Therapies Advances in Western medicine have improved survival and quality of life for patients with cancer tremendously, yet not completely. To enhance benefit and/or for those not experiencing benefit from Western approaches, CAM methods have become increasingly used. The National Institutes of Health recognized this benefit and created an office of alternative medicine in 1991 that evolved into the full the National Center for Complementary and Alternative Medicine in 1998.66 Complementary and alternative medicine therapies can include a variety of herbal remedies (plant-based medicinal properties) and/or Eastern healing techniques. Self-management behaviors utilizing these therapies include patients being selfdirected in seeking out providers who could administer the treatments and/or self-application, such as manipulating acupressure Cancer NursingTM, Vol. 38, No. 2, 2015


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points on oneself. In this review, 2 studies evaluated the healing modality of acupressure29,47 or acupuncture.47 Dibble et al29 found delayed and decreased nausea intensity and amount of vomiting in the acupressure group. Molassiotis et al47 showed that patients with cancer who had received chemotherapy treatment had less fatigue and greater physical activity levels with acupressure or acupuncture. Cranial stimulation, different from acupressure/acupuncture, was used to control symptoms and also assessed for the inflammatory markers of C-reactive protein and TNF-!.35 Correlations were found between depression, anxiety, fatigue, and sleep disturbances as well as between depression and levels of C-reactive protein and TNF-!.35 Symptoms increased over time for all patients with the only benefit noted with less of an increase in depression and sleep disturbances in the intervention group.35 Another noninvasive intervention was the use of virtual reality distraction for the management of fatigue, distress, anxiety, and presence.50 No improvements were found with symptoms; however, patients reported a better chemotherapy infusion experience with the virtual reality.50 Although we excluded studies that used pharmaceuticals for symptom control, we did evaluate the herbaceutical properties in grape juice45 and valerian15 for symptom control as a patient self-management strategy. Barton et al15 found improvements in fatigue and patient reports of less drowsiness and difficulty with sleeping while taking valerian compared with those taking a placebo, but found no statistically significant improvements with sleep, toxicity, or mood between groups. The flavonoidrich properties in Concord grape juice were found to decrease nausea and vomiting frequency and duration and related distress in the intervention group compared with controls.45 Because these were 2 isolated studies investigating different plant-based medicinal properties for different outcomes, they can only be evaluated in this review as separate modalities with positive effects for the outcomes they measured. Overall, the CAM modalities differed in their approaches and targeted outcomes. From these few studies, however, there is an underlying theme of benefit from CAM therapies, and further evaluation is warranted.

n

Discussion

Three major categories of interventions (educational and/or counseling sessions, exercise, and CAM therapies) were found within our search for studies that guided patients with cancer in self-management of their healthcare needs. Multiple outcomes were targeted with a predominant theme of symptom management and overall quality of life. Among the many symptoms, fatigue was the most frequently targeted outcome with all modalities. This is likely a reflection of prior studies that found fatigue as the most disturbing cancer-related symptom,67Y69 which can persist for years after treatment.70 Overall, findings were variable and showed positive trends, but not statistical significance. Some of these vast differences in findings may be attributable to the timing of when patients were given the interventions, how long they were followed up, and

variations in focus. For example, Cimprich et al27 created the ‘‘Taking CHARGE’’ self-management program for the posttreatment transition to survivorship phase for women with breast cancer. This program showed great success in psychological well-being, problem solving, symptom management, functional wellness, and relationships.27 Alternately, Bakitas and colleagues17 targeted self-management for end of life, with favorable outcomes noted in depression and quality of life. Several protocols also had uniquely targeted focuses, making comparisons with other studies difficult. For example, a study focused educational sessions for the management of prostate and bladder symptoms with related emotional distress for men with prostate cancer.23 As noted above, few studies evaluated biological measures. Currently, we can only speculate that fatigue and other symptoms that cluster with (pain, depression, and sleep disturbances)12,16,30,52,53,64 or breathlessness and anxiety,4 as well as the many other burdensome symptoms such as nausea, vomiting, gastrointestinal disturbances, taste alterations,21,29,45 and cachexia,71,72 may all share a similar underlying pathophysiological processes of inflammation. The studies in this review that utilized exercise may have tapped into this mechanism but minimally evaluated it. The success of exercise for the control of symptoms,21Y23,31,36Y38,40Y42,44,59,60 functional ability,31,38Y42,59 well-being and/or quality of life,23,31,37,38,42 and body composition and/or control of biological markers32,33,35,39,44,59 is clinical evidence for the support of these inflammatory pathways. Further biophysiological studies are warranted. It is also important to note that aside from, or in some cases in addition to, exercise, all intervention categories in this review have shown some levels of success. A few exercise studies also included an educational/counseling component.21Y23 Favorable outcomes were also found with most of these educational/ counseling. Heightened awareness and early interception with the onset of symptoms, as seen with the ENABLE (Educate, Nurture, Advise Before Life Ends) II intervention,17 may be the optimal approach. Patient activation, self-management, and empowerment showed improved physical and psychosocial outcomes compared with patients receiving usual care.17 It is more difficult to comment on the few CAM studies. Acupuncture and/or acupressure showed promising results for symptom management29,47 as did cranial stimulation35 and virtual reality distraction,50 but with little understanding of the mechanisms. Introducing these modalities to patients can help them selfdirect to seek CAM practitioners as their symptoms arise, which in the long run may reduce the amount of visits to their primary healthcare providers while also fostering autonomy. Limitations of these studies and this review as a whole, however, are numerous. Most of these studies were confined to a few weeks or a few months; therefore, the long-term sustainability was not assessed. Some were also small pilot studies and, although clinically significant, were not statistically significant and able to be generalized to larger populations. Subject size ranged from n = 848 to n = 322.17 Analytical approaches and measurement tools also varied. Few conducted repeatedmeasures/multivariate analysis, and most used 2 2 and/or the Student t test. Evaluation tools ranged widely. For example,


Hammer et al

Badger et al25 developed their own tool to evaluate depression through a 16-item adverse-effects checklist, whereas Midtgaard et al36 used the established Hospital Anxiety and Depression Scale. The vast differences between study instruments and analyses inhibited the ability to draw evidence-based conclusions about any interventions. Among the 46 studies, 61% reported using a theoretical framework to guide the research study. The most frequently used model was Dodd’s Symptom Management Model.18,30,46,47,52,53 The majority of studies also focused on women with breast cancer (Table 2), necessitating the need for studies in other populations of patients with cancer, as various malignancies and treatments can have widely varying challenges. Although all studies were run by nurse principal investigators, details about the individuals and their specialized training in working directly with the patients were lacking, for the most part. Other studies had limited information. For example, the study utilizing acupuncture was delivered by licensed acupuncturists, but details about their training were not disclosed.47 Acupressure in the study by Dibble et al29 was delivered by nurse research assistants who received a 2-hour training, but details about the training were also not disclosed. Finally, the studies were so diverse from one another that it was difficult to come to definitive conclusions about any specific modality for specific issues and only generalizations could be made.

6.

7.

8. 9. 10.

11.

12.

13.

14. n

Conclusions

15.

Overall, the studies in this review were found to be informative in providing a foundation for future directions in self-care management of patients with cancer. The main overarching themes included both educational/counseling sessions and exercise for mitigation, but not prevention or elimination of symptoms, and improved quality of life related to functional status. Current interventions that direct patients in self-care management of symptoms and associated challenges with cancer/survivorship are helpful, but incomplete. No one intervention can be recommended over another. With long-term patient survival putting cancer into the chronic condition category, further investigation for self-care management and the creation of solid guidelines are warranted.

16.

17.

18. 19.

20.

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