Nurse Intervention Approach Feasible in Addressing Cancer Symptom Clusters

Nurse Intervention Approach Feasible in Addressing Cancer Symptom Clusters

A nurse-coordinated approach to symptom cluster management was feasible, and highlighted the need for self-management strategies to target more than 1 symptom experienced by patients with cancer, according to pilot study results presented at the 49th Oncology Nursing Society Congress.

While it is known that patients can experience various symptoms as a result of their disease and its treatment, practice guidelines often are only written for single symptoms, with 1 or more approach for providers to address each individual symptom.

“This results in a high self-management burden for patients and families, as they're encouraged to understand, select, administer, and then monitor the effects of multiple self-management strategies,” Kristine Kwekkeboom, Ph.D , RN, FAAN, Lillian S. Moehlman Bascom Professor of Nursing at the University of Wisconsin – Madison School of Nursing, said during the presentation, adding that few interventions address multiple, co-occurring symptoms that could ease this burden for patients.

“Patients rarely experience a single symptom in isolation. Rather, they suffer an average of 8 or more symptoms concurrently, often in symptom clusters, which negatively impacts functional status, quality of life, and decisions to interrupt or forego cancer treatment,” she said.

As a result, Kwekkeboom and colleagues designed a nurse-coordinated approach to symptom cluster management. First, they reviewed 27 guidelines for self-management strategies with effects across 2 or more systems, creating a matrix in response to patients’ descriptions of co-occurring symptoms. “For example, guidelines for anxiety and guidelines for constipation, it's recommended to do physical activity as a treatment strategy for their respective symptoms. And we created a matrix to organize the self-management strategies by the symptoms for which they're recommended,” Kwekkeboom explained.

Next, they selected items for a web-based survey of system cluster experiences and selected strategies that could be effective for more than 1 symptom.

In her presentation, Kwekkeboom expanded on the feasibility of their nurse-coordinated approach to symptom cluster management, including recruitment, retention, and the successful coordination of a symptom cluster management plan.

In the randomized pilot trial, patients received weekly assessments and usual care in cycle 1, followed by either the same routine or weekly assessment plus nurse-led self-management in cycle 2. In the patient sampling, individuals were 18 years of age or older; had breast, lung, gastrointestinal (GI), or gynecologic cancer; had experienced 2 or more symptoms during their last chemotherapy cycle; had planned to receive at least 2 additional chemotherapy cycles; and had access to the internet via computer or tablet

In the trial, patients completed weekly web-based symptom cluster assessments that included the presence, severity, and distress of symptoms; symptom cluster occurrence; and selection of a priority symptom cluster to also determine the relationship among their clustered symptoms, the duration, and any causal attributions.

In the intervention arm of cycle 2, the following steps were taken by nurse interventionists:

• Evaluate symptoms, relationships, duration, and causal attributions to identify an etiology or casual symptom.
• Using the matrix, identify all strategies targeting the etiology or causal symptom, or identify strategies with demonstrated beneficial effects across 2 or more symptoms in a cluster if there is no etiology or causal symptom.
• Eliminate conflicting recommendations.
• Prioritize evidence-based strategies.
• Consider patient preferences, prior effectiveness, and ease of adoption.

“That first meeting took place in person at a clinic appointment, and subsequent meetings could take place either by phone or video conference at the patient's preference,” Kwekkeboom added. “Instructions for self-management strategies were provided on a study website. We also had paper copies available if that was the patient's preference.”

In total, 41 patients were eligible for the study. Among this group, mean age was 60 years, and the majority of patients were female (66%). Patients were diagnosed with GI (34%), lung (24%), breast (22%), or gynecologic (20%) cancers. With a retention rate of 83% (n = 34), the intervention group comprised 16 patients who completed the nurse-coordinate approach, while 18 patients received usual care.

The intervention group altogether compiled 58 weekly symptom cluster reports, ranging from 2 to 12 symptoms per cluster. Further, 54 of those reports (93%) led to successful coordination of a self-management plan. Kwekkeboom noted that, on average, they were able to manage 3 symptom clusters with 1 self-management strategy.

She also acknowledged 3 challenges: difficulty determining multi-symptom etiology, lack of clarity in prioritizing strategies with differing levels of evidence by symptom, and symptoms with few or no guideline-based self-management recommendations.

“We determined that the study procedures are feasible,” Kwekkeboom said. “And our next step would be a full-scale trial to evaluate the efficacy of this approach to symptom cluster management, looking at symptom cluster control, as well as perceived self-management burden for patients and families, and also to evaluate the impact on disadvantaged groups.”

Further, she added, it is important for nurses to ask patients to describe their symptom clusters. “It was just amazing to me how those participants describe the different experiences of the same 3 co-occurring symptoms. So, ask patients to tell you and consider self-management strategies that have effects across more than 1 symptom.”

Reference:

Kwekkeboom K, Eo Y, Hawn R, Miller M, Stevens J. Feasibility of a Nurse-Coordinated Intervention to Reduce Self-Management Burden in Patients with Cancer Experiencing Multiple Co-Occurring Symptoms: A Pilot Randomized Trial. Presented at: 49th Annual Oncology Nursing Society Congress; April 24-28, 2024; Washington D.C.