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Fannie Gaston-Johansson PhD, RN, FAAN Johns Hopkins University School of Nursing Sigma Theta Tau International 23 rd International Nursing Research Congress
The learner will be able: To describe the benefit of CCSP on quality of life among breast cancer survivors 2
Growing number of breast cancer survivors In 2011, 2.5 million breast cancer survivors living in the U.S. Longer survival highlights the need to improve health functioning, socioeconomic well-being, psychological/spiritual, family well-being, and quality of life during survivorship 3
Research examining coping interventions has mainly been conducted during treatment These studies have only examined coping interventions with one or two components Survivorship is complex requiring a comprehensive coping self-management treatment approach with several components 4
To determine differences between quality of life in a Comprehensive Coping Strategy Program (CCSP) treated and control group of breast cancer patients one year after treatment STT I 23rd International Nursing Research Congress 5
Study Population Intervention CCSP -Preparatory Education 1 Year Follow-up Quality of life Breast Cancer Patient Inner Coping Resources -Cognitive Restructuring -Coping Skills enhancement -Relaxation & Guided Imagery Health functioning Socioeconomic well being Psychological/ Spiritual well-being Family well-being 6
Four Components Content 1. Preparatory Education 2. Cognitive Restructuring 3. Coping Skills Enhancement Presentation of : a. Overview of common symptoms experienced by breast cancer patients during treatment b. Relationship between different symptoms and how symptoms can influence each other c. Aspects of adequate control of symptoms d. Treatment of pain and theoretical considerations Presentation and instruction in cognitive restructuring. Thinking can affect perceptions of a situation Instructor discourages use of negative coping self statements (e.g., catastrophizing) and strategies and encouraging the use of positive coping self statements and strategies (e.g., I feel relaxed ) 4. Relaxation with Guided Imagery Each component of relaxation is briefly presented, described, and demonstrated which includes brief progressive muscle relaxation procedure cue-controlled relaxation. Imagery is introduced into relaxation exercise and participants are encouraged to use their own imagery 7
Randomly assigned two-group experimental design National Cancer Institute (NCI), comprehensive cancer center Data collected at baseline and one year follow-up Sample (n = 73) 18 years Breast cancer, Stage II, III, IV Scheduled for high dose chemotherapy and stem cell transplantation 8
Institutional and IRB approval Randomized to CCSP or control group CCSP group receives CCSP training and reinforcement Control group receives usual care Data collected Performed analyses including descriptive statistics, Pearson correlations, hierarchical linear regression and analysis of covariance 9
CCSP administered 2 weeks before hospital admission (Session approximately 1.5 hours) Reinforced over 5 time points consisting of: -Responding to questions about CCSP and audiotape -Having participant listen to tape and observe performance of the relaxation exercise 10
Variables Instruments Quality of Life Quality of Life Index-Cancer Version Psychological Distress Anxiety Depression State-Trait Anxiety Inventory Beck Depression Inventory Coping Strategies Coping Strategies Questionnaire 11
R e s u l t s R e s u l t s 12
Age range 41 to 50 years Majority female, Caucasian, married Graduated college: 58% (n = 42) Employed: 71% (n = 52) Annual Income $50,000: 67% (n = 49) Stage II or Stage III:75% (n = 48) 13
Constructs *No significant differences between groups Anxiety CCSP Group (n = 38) Mean (SD) Control Group (n = 35) Mean (SD) State 39.9 (11.2) 39.7 (10.5) Trait 36.9 (8.7) 38.1 (9.2) Depression 9.9 (6.0) 11.9 (8.4) Coping Strategies Ignoring Pain 15.5 (8.1) 14.6 (7.7) Coping Self-Statements 21.9 (6.1) 23.0 (6.0) Reinterpretation 7.1 (6.8) 7.0 (6.9) Diverting Attention 18.1 (8.7) 15.3 (8.4) Praying 18.8 (8.7) 18.3 (7.5) Behavioral Adaptation 18.2 (5.3) 16.9 (6.0) Avoidance of Catastrophizing 30.5 (5.3) 30.2 (5.5) Overall Coping 130.1 (31.0) 125.3 (26.6) 14
To determine if there are differences between QOL in a CCSP-treated group and control group at baseline and 1-year follow-up 15
QOL Overall QOL Baseline 1 yr Follow-Up** Health functioning Baseline 1 yr Follow-Up* Socioeconomic Baseline* 1 yr Follow-Up* Psychological/Spiritual Baseline* 1 yr Follow-Up** Family Well-Being Baseline* 1 yr Follow-Up CCSP Group (n = 38) Mean (SD) 22.6 (4.3) 24.7 (3.6) 19.6 (6.1) 23.0 (5.7) 24.9 (3.5) 25.5 (3.6) 23.6 (4.6) 25.7 (3.9) 26.3 (4.8) 27.7 (3.2) Control Group (n = 35) Mean (SD) 20.6 (4.1) 21.9 (5.0) 18.2 (5.5) 20.2 (5.9) 22.7 (4.8) 23.4 (4.9) 21.3 (5.3) 21.3 (7.2) 23.7 (5.1) 26.2 (4.1) 16
To determine the relationship between QOL, anxiety, depression and coping strategies at baseline and QOL at 1-year follow-up 17
QOL Total Baseline Health Functioning QOL Total Follow-up 0.62** Health Functioning 0.56** 0.57** Socioeconomic 0.45** 0.29* 0.63** Psychological/ Spiritual Socioeconomic 0.51** 0.45* 0.42** 0.54** Psychological /Spiritual Family Family 0.38** 0.35** 0.27 0.28* 0.45** Anxiety - State - Trait -0.23 0.47** 0.12 0.41** -0.12-0.29* 0.27* -0.51** 0.01-0.23 Depression -0.42** -0.40** -0.28* -0.39** -0.22 Coping - Self- Statements - Reinterpretation - Avoidance of Catastrophizing 0.13-0.06 0.40** 0.12-0.08 0.35** 0.25* -0.07* 0.41-0.03-0.11 0.33** 0.05-0.04 0.16 18
To determine the effectiveness of the CCSP on QOL at 1 year follow-up 19
Model with incremental adjustment factors Overall QOL Beta Adj R 2 Health Functioning Beta Adj R 2 Socioeconomic Beta Adj R 2 Psychological/ Spiritual Beta Adj R 2 Family Beta Adj R 2 Unadjusted 0.31** 0.08 0.24* 0.04 0.25* 0.05 0.36** 0.12 0.20 0.03 Baseline QOL 0.15 0.38 0.15 0.33 0.08 0.39 0.22* 0.32 0.09 0.18 + disease stage, type of chemotherapy 0.18 0.39 0.19 0.35 0.05 0.35 0.26* 0.29 0.15 0.16 +demographics 0.59** 0.48 0.57** 0.47 0.60** 0.41 0.30* 0.32 0.48** 0.16 +trait anxiety 0.22 0.48 0.23* 0.46 0.02 0.40 0.33* 0.37 0.18 0.16 + coping selfstatements & avoidance of catastrophizing 0.26* 0.47 0.26* 0.47 0.05 0.43 0.37** 0.40 0.20 0.16 +Depression 0.26* 0.49 0.28* 0.51 0.03 0.41 0.39** 0.19 0.16 0.11 20
To determine the benefits of the CCSP intervention for patients who receive the CCSP 21
Majority reported CCSP was beneficial CSSP use: 55% reported using CCSP to cope with chemotherapy side effects Most frequent symptoms CCSP used for were psychological (51%) and sleep problems (60%) > 50% used CCSP before stressful events Handouts and tapes reported beneficial 77% reported tapes effective > 50% of time 66% reported handouts effective >50% of time Handouts and tapes used most frequently at bedtime 22
Women who received the CCSP had a better overall level of QOL at 1-year follow-up This suggests a long term effect of the CCSP which has clinical implications CCSP targets psychological symptoms and QOL but also empowers patients with education and a comprehensive set of coping skills 23
Sample from one site, a comprehensive cancer center Patients lost to one year follow up due to changes in contact information, death, or illness 24