Walking groups for women with breast cancer: Mobilising therapeutic assemblages of walk, talk and place.

Walking is widely accepted as a safe and effective method of promoting rehabilitation and a return to physical activity after a cancer diagnosis. Little research has considered the therapeutic qualities of landscape in relation to understanding women's recovery from breast cancer, and no study has considered the supportive and therapeutic benefits that walking groups might contribute to their wellbeing. Through a study of a volunteer-led walking group intervention for women living with and beyond breast cancer (Best Foot Forward) we address this gap. A mixed-methods design was used including questionnaires with walkers (n = 35) and walk leaders (n = 13); telephone interviews with walkers (n = 4) and walk leaders (n = 9); and walking interviews conducted outdoors and on the move with walkers (n = 15) and walk leaders (n = 4). Questionnaires were analysed descriptively. Interviews were audio-recorded, transcribed verbatim, and analysed thematically. Our study found that the combination of walking and talking enabled conversations to roam freely between topics and individuals, encouraging everyday and cancer-related conversation that created a form of 'shoulder-to-shoulder support' that might not occur in sedentary supportive care settings. Walking interviews pointed to three facets of the outdoor landscape - as un/natural, dis/placed and im/mobile - that walkers felt imbued it with therapeutic qualities. 'Shoulder-to-shoulder support' was therefore found to be contingent on the therapeutic assemblage of place, walk and talk. Thus, beyond the physical benefits that walking brings, it is the complex assemblage of walking and talking in combination with the fluid navigation between multiple spaces that mobilises a therapeutic assemblage that promotes wellbeing in people living with and beyond breast cancer.

Training in self-needling and performing it as part of a clinical trial: the practitioner and patient experience.

OBJECTIVE: To explore the experience of training and performing self-needling from both the practitioners' and patients' perspective. METHODS: A qualitative study was conducted using focus groups and interviews, nested within our multi-site randomised controlled trial, Acupuncture for Cancer-Related Fatigue in Patients with Breast Cancer. Patients allocated to self-needling across two UK study sites and all therapists who were involved in the trial were invited to participate. The interviews/focus groups were then transcribed verbatim and analysed thematically by the process of content analysis. RESULTS: Of the 67 eligible patients, 8 (12%) contributed to the focus groups and 15 practitioners (100%), contributed to the study by either attending a focus group or being interviewed. Themes identified for patients included: the allocation to self-needling, teaching techniques and practical considerations and whether they would self-needle again. Themes identified for practitioners included: views on self-needling, teaching self-needling and future implications of self-needling. CONCLUSIONS: Self-needling was found to be acceptable to, and manageable by, patients, and enthusiastically adopted by most practitioners. Methods of teaching self-needling need to be developed and evaluated with guidelines recommended for best practice.

"No decision about me without me" in the context of cancer multidisciplinary team meetings: a qualitative interview study.

BACKGROUND: Cancer care is commonly managed by multidisciplinary teams (MDTs) who meet to discuss and agree treatment for individual patients. Patients do not attend MDT meetings but recommendations for treatments made in the meetings directly influence the decision-making process between patients and their responsible clinician. No research to-date has considered patient perspectives (or understanding) regarding MDTs or MDT meetings, though research has shown that failure to consider patient-based information can lead to recommendations that are inappropriate or unacceptable, and can consequently delay treatment. METHODS: Semi-structured interviews were conducted with current cancer patients from one cancer centre who had either upper gastrointestinal or gynaecological cancer (n = 9) and with MDT members (n = 12) from the teams managing their care. Interview transcripts were analysed thematically using Framework approach. Key themes were identified and commonalities and discrepancies within and between individual transcripts and within and between patient and team member samples were identified and examined using the constant comparative method. RESULTS: Patients had limited opportunities to input to or influence the decision-making process in MDT meetings. Key explanatory factors included that patients were given limited and inconsistent information about MDTs and MDT meetings, and that MDT members had variable definitions of patient-centredness in the context of MDTs and MDT meetings. Patients that had knowledge of medicine (through current/previous employment themselves or that of a close family member) appeared to have greater understanding and access to the MDT. Reassurance emerged as a 'benefit' of informing patients about MDTs and MDT meetings. CONCLUSIONS: There is a need to ensure MDT processes are both efficient and patient-centred. The operationalization of "No decision about me without me" in the context of MDT models of care - where patients are not present when recommendations for treatment are discussed - requires further consideration. Methods for ensuring that patients are actively integrated into the MDT processes are required to ensure patients have an informed choice regarding engagement, and to ensure recommendations are based on the best available patient-based and clinical evidence.

Meta-Analysis of Randomized Controlled Trials of Acupuncture for Cancer-Related Fatigue.

BACKGROUND: Fatigue is a distressing and pervasive problem for people with cancer. In recent years, acupuncture has gained increasing attention among researchers as an alternative management strategy for cancer-related fatigue (CRF). This review aimed to evaluate the effectiveness of acupuncture for CRF. METHODS: Five databases (Medline, CINAHL, Scopus, the Cochrane Library, and CAJ Full-text Database) were searched up to May 2013. Randomized controlled trials (RCTs) of acupuncture for the treatment of CRF were considered for inclusion. RESULTS: Seven RCTs were included for meta-analysis, involving a total of 689 subjects. Three studies compared acupuncture with sham acupuncture for CRF with follow-up at 10 weeks; the standardized mean difference (SMD) for general CRF change values was -0.82 (95% confidence interval [CI] = -1.90 to 0.26). When acupuncture plus education intervention was compared with usual care, there was a statistically significant difference for the change score of general CRF (SMD = -2.12; 95% CI = -3.21 to -1.03). The SMD for general CRF change scores between acupuncture with no treatment or wait-list control was -1.46 (95% CI = -3.56 to 0.63). Finally, the SMD for general CRF change scores between acupuncture with acupressure or self-acupuncture was -1.12 (95% CI = -3.03 to 0.78). Three trials reported data for general quality of life and functioning status, reporting enough data for statistical pooling but showing no statistically significant difference (Zscore = 1.15,P= .25, SMD = 0.99, 95% CI = -0.70 to 2.68 andZscore = 1.13,P= .26, SMD = 1.38, 95% CI = -1.02 to 3.79, respectively). TheI(2)statistics of all statistically pooled data were higher than 50%, indicating heterogeneity between the trials. CONCLUSIONS: There were 4 sets of comparison for the effectiveness of acupuncture for CRF; statistical pooling of the reduction in CRF from baseline to follow-up showed in favor of acupuncture. However, 3 sets of comparison for the pooled estimates of effect sizes had no statistical significance. Although one set of comparison (acupuncture plus education interventions vs usual care) had statistically significant differences, it is unclear whether this pooled positive outcome is attributable to the effects of acupuncture or to the education intervention. In addition, the duration of follow-up in these included trials was up to 10 weeks, and some RCTs had methodological flaws. Further rigorously designed RCTs adhering to acceptable standards of trial methodology are required to determine the effectiveness of acupuncture and its long-term effects on CRF.

Development and testing of the patient-reported chemotherapy indicators of symptoms and experience: patient-reported outcome and process indicators sensitive to the quality of nursing care in ambulatory chemotherapy settings.

BACKGROUND: Outcome indicators are increasingly advocated to demonstrate the impact of high-quality care; however, generic measures do not encompass outcomes relevant to specialist areas. OBJECTIVE: The aim of this study was to develop an outcome measure (Patient-Reported Chemotherapy Indicators of Symptoms and Experience [PR-CISE]) for use in ambulatory chemotherapy settings and assess its feasibility, acceptability, and preliminary efficacy in clinical practice. METHODS: Three areas were covered by PR-CISE--symptom management, safe medication administration, and experience of supportive care. Outcome selection was guided by review of evidence and reference groups of users, clinicians, and experts. Over 12 weeks, PR-CISE was distributed to patients receiving ambulatory chemotherapy at 10 cancer centers. Data were analyzed descriptively and with case mix adjustment using regression-based models. RESULTS: There were 2466 responses. There was variability across centers in terms of symptom experience and support provided. Across the whole sample, 25% reported moderate or severe nausea; however, rates varied between centers (25%-75%). Similar results emerged for other symptoms. When asked about support for symptom management, 80% reported that chemotherapy nurses asked about and were aware of symptom severity and provided useful information/advice. Once again, there was substantial variability between centers. Unexplained variation remained after case mix adjustment, suggesting that differences may be "real" rather than caused by population differences. Stakeholders planned to make changes to care delivery based on data on their performance. CONCLUSIONS: We successfully developed and tested indicators assessing the quality of care provided in ambulatory chemotherapy services. IMPLICATIONS: Results show that monitoring outcomes demonstrate potential differences in care quality and provide a stimulus to improve the experience and health of patients.

A systematic review of complementary and alternative medicine interventions for the management of cancer-related fatigue.

Fatigue, experienced by patients during and following cancer treatment, is a significant clinical problem. It is a prevalent and distressing symptom yet pharmacological interventions are used little and confer limited benefit for patients. However, many cancer patients use some form of complementary and alternative medicine (CAM), and some evidence suggests it may relieve fatigue. A systematic review was conducted to appraise the effectiveness of CAM interventions in ameliorating cancer-related fatigue. Systematic searches of biomedical, nursing, and specialist CAM databases were conducted, including Medline, Embase, and AMED. Included papers described interventions classified as CAM by the National Centre of Complementary and Alternative Medicine and evaluated through randomized controlled trial (RCT) or quasi-experimental design. Twenty studies were eligible for the review, of which 15 were RCTs. Forms of CAM interventions examined included acupuncture, massage, yoga, and relaxation training. The review identified some limited evidence suggesting hypnosis and ginseng may prevent rises in cancer-related fatigue in people undergoing treatment for cancer and acupuncture and that biofield healing may reduce cancer-related fatigue following cancer treatments. Evidence to date suggests that multivitamins are ineffective at reducing cancer-related fatigue. However, trials incorporated within the review varied greatly in quality; most were methodologically weak and at high risk of bias. Consequently, there is currently insufficient evidence to conclude with certainty the effectiveness or otherwise of CAM in reducing cancer-related fatigue. The design and methods employed in future trials of CAM should be more rigorous; increasing the strength of evidence should be a priority.

The psychosocial experience of patients with end-stage renal disease and its impact on quality of life: findings from a needs assessment to shape a service.

Background. A needs assessment was conducted on renal patients registered to a leading hospital trust in London in order to explore their psychological, social, and spiritual needs. The aim of the needs assessment was to create an evidence base for the development of a comprehensive health psychology service to run concurrently with a renal counselling support service within the department. Methodology. This study utilised a series of semistructured face-to-face interviews and focus groups with renal patients and their carers, to explore how ESRD impacted quality of life. Results. A thematic analysis was undertaken. Seven emergent themes were identified that influenced the quality of life of people with EDRD: physiological impact, impact of treatment, impact on daily life, psychological impact, impact on relationships, social impact and coping responses. Conclusion. The needs assessment clearly identified that ESRD carries with it emotional, physical, psychological, social, and existential burdens. The data from this needs assessment study has created an evidence base upon which future health psychology services can be built within this leading UK hospital.

Acupuncture for cancer-related fatigue in patients with breast cancer: a pragmatic randomized controlled trial.

PURPOSE: We aimed to assess the effectiveness of acupuncture for cancer-related fatigue (CRF) in patients with breast cancer. PATIENTS AND METHODS: We conducted a pragmatic, randomized controlled trial comparing acupuncture with enhanced usual care. Three hundred two outpatients with breast cancer participated. We randomly assigned 75 patients to usual care and 227 patients to acupuncture plus usual care (random assignment of 1:3 respectively) with minimization controlling for baseline general fatigue and maintenance treatment. Treatment was delivered by acupuncturists once a week for 6 weeks through needling three pairs of acupoints. The usual care group received a booklet with information about fatigue and its management. Primary outcome was general fatigue at 6 weeks, measured with the Multidimensional Fatigue Inventory (MFI). Other measurements included the Hospital Anxiety and Depression Scale, Functional Assessment of Cancer Therapy-General quality-of-life scale, and expectation of acupuncture effect. Analyses were by intention to treat. RESULTS: Two hundred forty-six of 302 patients randomly assigned provided complete data at 6 weeks. The difference in the mean General Fatigue score, between those who received the intervention and those who did not, was -3.11 (95% CI, -3.97 to -2.25; P < .001). The intervention also improved all other fatigue aspects measured by MFI, including Physical Fatigue and Mental Fatigue (acupuncture effect, -2.36 and -1.94, respectively; both at P < .001), anxiety and depression (acupuncture effect, -1.83 and -2.13, respectively; both at P < .001), and quality of life (Physical Well-Being effect, 3.30; Functional Well-Being effect, 3.57; both at P < .001; Emotional Well-Being effect, 1.93; P = .001; and Social Functioning Well-Being effect, 1.05; P < .05). CONCLUSION: Acupuncture is an effective intervention for managing the symptom of CRF and improving patients' quality of life.