2003 Congress Abstracts

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OPENING THE WINDOW ON HOT FLASHES. Nancy Gantz, MSN, RN, CS, AOCN^®, Dana-Farber Cancer Institute, Boston, MA.

Background/Rationale: Data suggests that 65% of breast cancer survivors experience hot flashes, reported as severe by the majority of women. Breast cancer treatment often results in acceleration of menopause, causing women to experience hot flashes. Daily activity, sleep, sexuality, and mood are impacted by the hot flash experience. Current approaches to management of hot flashes, utilizing pharmacologic and nonpharmacologic interventions, should be based on available data from clinical trials. Much research has been weak in supporting various interventions and the data is mixed. To date, there is no definitive effective treatment. Oncology advanced practice nurses face a dilemma in choosing appropriate treatment and are in need of guidelines to better inform their practice.
Intervention: An algorithm was developed to better manage the distressing symptom of hot flashes. A flow chart details a menu incorporating past medical history, risk factors, and review of systems. Interventions with supportive data based on recent clinical trials are highlighted at several points. Examples are SSRI antidepressants, Soy, and Black Cohash. Decision consequences lead to clinical end points. The algorithm was mailed with an explanatory letter to 10 APNs in breast oncology in the New England area.
Evaluation: Results of the algorithm utilization in a variety of clinical practice settings are pending. For purposes of feedback, a five-item response summary was included with the explanatory letter mailed to 10 APNs. Responses will reflect usefulness, ease of interpretation, and suggestions for improvement.
Discussion: APNs can benefit from an algorithm on hot flash management for breast cancer patients. Current mixed data on effective interventions for this population warrant a tool that is useful to the clinician and beneficial for the patient.

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PEGFILGRASTIM WAS OBSERVED TO BE AS SAFE AND EFFECTIVE AS FILGRASTIM IN ELDERLY PATIENTS WITH BREAST CANCER. Cindi Bedell, RN, MSN, OCN^®, U.S. Oncology, Dallas, TX.

Elderly cancer patients have been identified as a population at greater risk for neutropenic complications (Balducci, 2001). The elderly may have unique challenges with daily Filgrastim therapy, including daily transportation to the doctor’s office, potentially placing a significant burden on the patient and caregiver, especially if the caregiver must take off work. The oncology nurse is in a position to assess and identify elderly patients at risk for neutropenia. We have previously reported the comparability of pegfilgrastim, a pegylated long-acting analog of filgrastim dosed once-per-chemotherapy cycle, and filgrastim in 2 trials of breast cancer patients receiving doxorubicin and docetaxel, a regimen where approximately 40% of patients experience febrile neutropenia (FN) without growth factor support (Misset, 1999).
We retrospectively analyzed pooled data from these pivotal trials assessing the comparability of a single subcutaneous injection of pegfilgrastim, either at a fixed 6 mg dose, irrespective of patient weight, or 100 mcg/kg, and daily filgrastim (5 mcg/kg) among younger (< 65 years) and older (>65 years) patients the all-cycle incidence of FN, IV anti-infective use (IV), and hospitalization (HSP). Adverse events and concomitant medications (CM) were safety end points.
The age-adjusted relative risk (RR) of FN was significantly lower for pegfilgrastim (RR = 0.57; 95% CI: 0.36, 0.90) compared with Filgrastim. The proportions of pegfilgrastim and filgrastim patients with FN was 10% and 18%, respectively, in the younger age group, and 15% and 22%, respectively, in the older age group. The observed incidence of IV and HSP were lower among pegfilgrastim patients, regardless of age. Pegfilgrastim was well tolerated in both older and younger patients with side effects including cytokine-related bone pain, similar to filgrastim. No treatment group differences were found in the 9 CM classes analyzed.
Pegfilgrastim was observed to have a significantly reduced risk of FN with comparable safety to filgrastim among elderly patients.
Administering pegfilgrastim at a fixed 6 mg dose once-per-cycle simplifies treatment, while raising nursing challenges to equip the elderly patients to care for themselves at home, including self-monitoring for signs of infection or other complications of chemotherapy.

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PROMOTING BREAST HEALTH AMONG YOUNG WOMEN IN COLLEGE THROUGH BREASTIVAL EVENTS. Lillie Shockney, RN, BS, MAS, Johns Hopkins Breast Center, Baltimore, MD.

Numerous attempts have been made to conduct education and outreach programs on college campuses regarding the topic of breast cancer, and most have fallen short of their goal. This is a challenging consumer audience to effectively reach, who either already fears the disease so much they do not attend educational programs or believe that they are immune or untouchable by the disease at this point in time in their lives.
In 2001, the director of education and outreach of the Johns Hopkins Breast Center created a program, with the support of a small sorority of 13 female students of JHU, that would address many goals including: create an interactive event that students would willingly attend with enthusiasm and demonstrate an interest in learning about how to improve and maintain good breast health; educate students about at least 8 facts regarding breast health/breast cancer; train students how to perform breast self exams; educate students about proactive steps they can do to reduce their risk; create an event that can be replicated at other college campuses.
Seven breast cancer organizations participated and were given flash card questions about breast health and breast cancer for students to answer at each booth (true/false and multiple choice). Upon correctly answering questions at every booth, the student was then rewarded with food from Hard Rock Café, given a free dessert, cosmetics, hair care products, and a chance to win a “booby prize” (door prize).
Out of a campus of 1,100 students, 600 students attended with 347 students visiting every booth and answering flash card questions correctly. 252 female students signed the banner, “I got the message. I understand the importance of my breast health.” 61% surveyed said they learned something new about breast cancer. 100% surveyed said they would attend a Breastival event again.
The Johns Hopkins Breast Center has created a Breastival Resource and Planning Kit to help other breast centers and colleges easily replicate this event. As of June 1, 2002, fourteen other breast centers/colleges have obtained the kit and are holding breastivals now. This innovative method of educating students has proven very effective!

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”NO, IT’S NOT MASTITIS”: DIAGNOSIS OF AND INNOVATIVE COMBINATION TREATMENT FOR INFLAMMATORY BREAST CANCER. Arlene Berman, RN, MS, OCN^®, Sandra Swain, MD, Jennifer Low, MD, and Pia Nierman, RN, BSN, National Institutes of Health, National Cancer Institute, Bethesda, MD.

Inflammatory breast cancer (IBC) is an aggressive form of locally advanced breast cancer (LABC), which affects approximately 5% of women with breast cancer. Signs and symptoms may include redness of the breast, increase in breast size, breast induration, edema, and heaviness. Color changes are not always bright red but may vary from reddish purple or reddish brown to faint pink. Prompt diagnosis of IBC is often delayed because these women present with mastitis-like symptoms and are treated with a course of antibiotics for a presumed infection. Diagnosis may be made more difficult because a definite mass cannot be found in many patients. Pathologically, IBC is associated with dermal lymphatic invasion by breast cancer cells, but this is not required for diagnosis. Education of nurses is necessary to increase awareness of the signs and symptoms of IBC.
Increased micro vessel density and vascular endothelial growth factor (VEGF) expression are associated with IBC. We are using Bevacizumab, an anti-angiogeneic agent directed against VEGF-A, in combination with standard chemotherapy for patients with IBC. Patients receive bevacizumab alone for cycle 1, and then receive bevacizumab, doxorubicin, and docetaxel every three weeks for cycles 2 through 7. Local control is achieved with mastectomy and radiation therapy. After completion of radiation therapy, patients receive bevacizumab alone for 8 additional cycles. Serial tumor biopsies and dynamic contrast-enhanced MRI are used to evaluate tumor responses to bevacizumab and to chemotherapy. Seven patients have been enrolled to date, and the combination therapy and the planned studies have been well tolerated. Clinical trials with molecular and functional endpoints to assess drug effectiveness are feasible and may provide valuable insight into both angiogenesis and IBC.

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EXPANDING THE COMFORT OF MASTECTOMY PATIENTS WITH THE PAPILLA GOWN. Ho-Soon M. Cho, PhD, RN, Jae-Eun Paek, PhD, Tara Fedric, MS, RN, Maisie S. Kashka, PhD, RN, and Albert Y. Choi, MA, Texas Woman’s University College of Nursing, Dallas, TX.

Currently, 175,000 women undergo invasive surgery for breast cancer in United States every year, and many require the placement of Jackson-Pratt drains which are secured with large safety pins on the hospital gown. The hospital gowns are tied in the back, increasing the discomfort for breast surgery patients. The patients also experience fear that the JP drainage tubes will be pulled out or will tug on the surgical wound site. The papilla gown addresses these issues and attempts to remedy them.
The purpose of this study is to compare the patient’s physiological and psychological comfort level in three types of clothing: standard hospital gown, patient’s own clothing, and the modified standard gown, namely the papilla gown. The papilla gown was invented and designed by these investigators. Patients using the papilla gown will report higher scores of ambulation than those using their own clothing or the hospital gown. The study will use the quasi-experimental design in physician offices setting with mastectomy patients. The data will be completed on the second and on the seventh postoperative day using the comfort questionnaire and patient data form developed by the investigators. The evaluation method will be used to measure the content validity based on Lynn’s criteria. In order to test the reliability of the instrument, the Cronbach’s alpha test will be used. Specially trained physician’s office nurses will explain the purpose of the research and the confidentiality of the study, as well as distribute the papilla gowns and questionnaires on their visiting day prior to their surgery. Thirty mastectomy patients from physician’s offices will be recruited using a non-probability randomized sampling technique. Data will be analyzed using the statistical package for social science. To determine if differences in age exists between the two groups, a two independent samples t-test will be conducted. A univariate ANOVA will be conducted to determine if significant differences exist in comfort based on group, age, marital status, pain management, and type of surgery. In cases where significant factors consist of more than two levels, Tukey’s t-test will be the post-hoc test to determine which levels of the factors differ in comfort.

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FATIGUE, DEPRESSION, AND BIOMARKERS IN WOMEN WITH BREAST CANCER: A PILOT STUDY. Barbara Piper, DNSc, RN, AOCN^®, FAAN, University of Nebraska Medical Center, Omaha, NE; Judith Payne, PhD, RN, Wayne State University, Detroit, MI; Ian Rabinowitz, MD, University of New Mexico, Albuquerque, NM; and M. Bridget Zimmerman, PhD, University of Iowa, Iowa City, IA.

Because fatigue and depression frequently correlate with one another, a common biologic pathway has been proposed for these states. This is the first study to examine how specific biologic markers, serotonin and bilirubin, are related to these states. This is a significant area for research as findings can contribute to an improved understanding of underlying mechanisms, risk factors, and treatments. Components of the integrated fatigue model guided this correlational, repeated measures study at a large southwestern university cancer center. Data were collected using the standardized Piper Fatigue Scale (PFS), the Center for Epidemiologic Depression Survey (CES-D), a demographic form, and medical record data. Newly diagnosed breast cancer patients (N = 11), stages I or II, and age and menopausally-matched healthy controls (N = 11) completed instruments during chemotherapy (CT) cycles 1 and 4, on day 1 before CT, and two weeks later at nadirs (T1–T4). All women were admitted days 1–3, cycles 1 and 4. Bilirubins and CBCs were drawn day 1; serotonins days 2 and 3. Descriptive and inferential statistics were used in data analysis. Subjects were Caucasian (54.5%) and Hispanic (36.5%), high school educated, with a mean age of 47.5 years. Patients had significantly higher mean fatigue (PFS)(p < .0001) and depression scores (CES-D) (p = .006), and bilirubin and serotonin were significantly reduced (p < .05). Serotonin (p = .03) and bilirubin (p = .007) significantly correlated with fatigue, and serotonin significantly correlated with depression (p = .004). These differences in patients and their associated biomarkers warrant further study and underscores the need to screen for these states in practice.

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CONTEMPORARY MEASUREMENT OF SYMPTOM DISTRESS IN WOMEN WITH BREAST CANCER. Marcia Boehmke, DNS, ANP, RN, University at Buffalo, State University of New York, Buffalo, NY.

Cancer evokes considerable stress from diagnosis through treatment, with each patient’s trek unique. This unique response is known as “symptom distress” and refers to the perception of discomfort as experienced by the individual. Identification and management of patients at risk for high levels of symptom distress are essential because higher levels of distress have been equated with diminished self-care, altered social relationships, and decreased adherence to treatment protocols, curtailing survival.
A limitation of research to date has been the lack of consensus related to the measurement of the symptom distress construct. To date, observable signs and symptoms have received greater attention than the women’s response to and coping with the occurrence of these symptoms. Ehlke (1988) points out that women with breast cancer do not experience difficulty breathing and coughing (measured by most symptom distress tools) and omit variables like child-care, marriage, and body image, commonly experienced. One aim of this study was to examine instrument sensitivity in the measurement of symptom distress levels experienced by women with early stage breast cancer undergoing adjunct chemotherapy.
The theoretical framework chosen for this study was the Lazarus and Folkman Model of Stress and Coping. This descriptive, correlational, longitudinal study used convenience sampling to recruit 120 women with stage I and II breast cancer from six socio-economically diverse oncology settings in Buffalo, New York.
The analysis determined that the McCorkle and Rhodes symptom distress scales were highly correlated for all data collection points (r = .90; r = .84; r = .77, respectively), but not correlated with a visual analogue scale measuring anxiety levels (-.042). Anecdotal comments from women suggest that the instruments might not be sensitive measures.
The results of this study implicated fatigue, insomnia, body image, and diminished concentration as symptoms causing women the most symptom distress; however, comments made by the women suggest accessing women’s perspectives on their total symptom experiences have not been taken into account. A qualitative study is needed to access symptoms most bothersome to these women (taking into account the advent of new therapies/antiemetics, which were absent when current symptom distress measurements were developed) as well as self-care strategies employed.

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WEIGHT AND BODY COMPOSITION CHANGES IN PREMENOPAUSAL WOMEN RECEIVING ADJUVANT CHEMOTHERAPY FOR BREAST CANCER. Carolyn Ingram, RN, DNSc, CON(C), McMaster University School of Nursing, Hamilton, Ontario, Canada.

Research indicates a decrease in chemotherapy-associated weight gain related to modern breast cancer chemotherapy. However, studies have begun to suggest that there are important body composition changes at this time. This study examined weight change during adjuvant chemotherapy, changes in body composition, and relationships between body composition and weight change. Brown’s Conceptual Framework for Cancer-Related Weight Change guided the research. This prospective, correlational study examined a convenience sample of 91 pre-menopausal women with stage I and II breast cancer receiving adjuvant chemotherapy (AC, CEF, or CMF) at two clinics in Ontario. Eight AC subjects also received tamoxifen. Most had lumpectomies and stage II disease. Their mean age was 44 years (SD 5.9). Most were white, married, working, and had some post-secondary education. Data were collected before treatment began, at the start of cycles 2, 4, and 6 (if applicable), and at the end of treatment. The body composition measure was bioelectrical impedance analysis. Weights and heights were obtained using standardized techniques. Reliability and validity for all measures were well established. Data analysis included descriptive statistics, correlations, and regression analysis. Subjects’ BMI indicated slight overweight at baseline (M = 26 kg/m2, SD 6.6). Of these, 45% were significantly overweight (M = 30.7 kg/m2, SD 7.1). Overall, the sample gained 1.4 kg (SD 3.4) during therapy. An increase or decrease of > 2.5 kg defined “weight change.” Using this definition, 55% of women maintained stable weights, while 34% gained (M = 5 kg, SD 1.4), and 11% lost weight (M = 4.2 kg, SD 1.4). Although adult weight gain is primarily associated with increased fat mass, weight gainers in this study also gained lean body mass (54% lean increase for AC, 35% for CMF, and 19% for CEF subjects). These findings lay the groundwork for targeting interventions to treatment, weight, and body composition profiles.

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INFORMATION NEEDS OF WOMEN WITH BREAST CANCER IN RECOVERY. Frances Cartwright-Alcarese, RN, PhD(c), AOCN^®, Mount Sinai Medical Center, New York, NY.

An estimated 203,500 women in the United States in 2002 will be diagnosed with breast cancer. The five-year survival rate for localized breast cancer is 97%, and the survival rate for all stages combined continues to improve. After primary therapy is completed, these women face the challenges of ongoing survival related to their symptom experience (number of symptoms [NOS], severity of symptoms [SOS], and symptom distress [SD]) associated with stage of disease (SOD) and ongoing therapy (OT). The need to examine information needs (IN) of women who are in breast cancer recovery is strongly indicated in the adjustment and quality-of-life literature. This study integrates components of Derdiarian’s (1987a, 1987b) cancer information needs model and Coping Theory (Lazarus, 1993; Lazarus & Folkman, 1984). This framework suggests that dimensions of IN are related to symptom experience associated with SOD and OT among survivors of breast cancer. IN are measured as a score on the Toronto Information Needs Questionnaire – Breast Cancer (TINQ – BC) (Galloway et al., 1998). Symptom experience is measured as the incidence, severity, and distress subscale on the Breast Cancer Treatment Response Inventory (BCTRI) (Hoskins, 1990). A descriptive, correlational design will examine the relationship between IN related to symptom experience associated with SOD and OT among survivors in the recovery phase of breast cancer. A sample of 134 women diagnosed with breast cancer, who have completed primary therapy, and are in ongoing recovery is being accrued. Descriptive statistics including means, standard deviation (SD), ranges, and skewness for all data will be calculated and reported. Pearson correlation matrix of IN, NOS, SOS, and SOD will be generated and examined for relevant zero-order correlations. To assess the main effects of SOD and OT, as well as their possible interaction on the other variables, four two-way analyses of variance will be performed, treating IN, NOS, SOS, and SOD each as the dependent variable. This data will identify needs specific to the growing number of breast cancer survivors in recovery. This information can be used by the oncology nurse to guide development of interventions that will address these women’s perceptions of information need.

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VIRTUAL REALITY INTERVENTION FOR OLDER WOMEN WITH BREAST CANCER. Susan Schneider, PhD, RN, AOCN^®, Duke University, Durham, NC.

This pilot study explored the feasibility of using virtual reality (VR) as a distraction intervention with 20 women, aged 50 and older, who received outpatient chemotherapy for breast cancer at a comprehensive cancer center.
Seventy five percent of new cases and 84% of breast cancer deaths occur in women aged 50 and older. Chemotherapy is prescribed to diminish tumor mass and increase disease-free survival. Chances for survival are enhanced if women receive all of the recommended chemotherapy treatments. However, because of chemotherapy-related distress symptoms, patients often have difficulty adhering to the regimen. It is imperative that potentially effective interventions be tested on the elderly since these adults have often been excluded from intervention trials, leading to a gap in the evidence base for care of older adults.
With VR, the individual wears a headset that projects images with the corresponding sounds. A computer mouse manipulates the image. For this study, a head-mounted display was used to display encompassing images and block competing stimuli in the chemotherapy treatment room. Lazarus and Folkman’s Stress and Coping Model was used to guide the study. A crossover design was used to determine whether VR was an effective distraction intervention for reducing chemotherapy-related symptom distress in older women. The Symptom Distress Scale, the Revised Piper Fatigue Scale, and the State Anxiety Inventory were used to measure symptom distress.
For two matched chemotherapy treatments, one pre-test and two post-test measures were employed. Participants were randomly assigned to receive the VR distraction intervention during one chemotherapy treatment and to receive no distraction intervention (control condition) during an alternate treatment.
Data collection will be completed September 2002. Final results will be presented. Paired t-tests will be used to test for differences in levels of symptom distress immediately and 48 hours following chemotherapy treatments. An open-ended questionnaire was used to elicit responses regarding the ease of equipment use, length of time used, and effectiveness of VR as a distracter.
Preliminary findings suggest that it is feasible to use VR with older adults. Subjective comments suggest that the VR distracter is effective at relieving symptom distress. (Funding: NINR (1-P20-NR07795-01.)

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FACTORS RELATED TO DELAYED HEALTH-SEEKING BEHAVIOR IN PATIENTS WITH BREAST CANCER. Young-Ja Lee, RN, MS, Doctoral Candidate, Seoul Junior Health College, Seoul, Korea; and Won-Hee Lee, RN, PhD, Yonsei University College of Nursing, Seoul, Korea.

Purpose/Objectives: Because early diagnosis and treatment of breast cancer is very important, this study was done to explore the factors related to delayed health seeking behavior with regard to mammography test for breast screening based on health belief model.
Design: Descriptive, correlational study.
Sample: 400 women over age 30, obtained through purposive sampling. Subjects who found lump in her breast recruited at the breast cancer outpatient department and X-ray department for checking mammography and had agreed to participate in this study in five cancer centers of university teaching hospital in Seoul, Korea.
Instrument: Instrument was developed by the Korean Version of Champion’s Health Belief Model Scale: Perceptions of breast cancer susceptibility, seriousness, perceived benefits of and barriers to mammography, health motivation, and perceived confidence over using the context of breast cancer and mammography. Research team developed the scale to measure the demographic data and health- related behaviors including breast cancer risk factors.
Data Analysis: Descriptive, correlational analysis and logistic regression were used.
Findings: Now data is in the process of analysis.
Implications for Nursing Practice: These results will contribute to expand the understanding of Korean women health-seeking behaviors, specifically, delayed health-seeking behaviors in obtaining mammograms. We can suggest the clinical approaches for counseling women about the risk of delaying the hospital check-up and new media approaches for early cancer detection. These study results will be utilized to develop interventions for Korean women.

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EVIDENCE-BASED PRACTICE: PSYCHOSOCIAL CARE FOR WOMEN NEWLY DIAGNOSED WITH BREAST CANCER. Sheila Evans, RN, MS, AOCN^®, Sibley Memorial Hospital, Washington, DC.

Feelings of distress and anxiety are common symptoms among women newly diagnosed with breast cancer. Research reports that the most effective psychosocial interventions for these patients include health education, information about effective coping skills, and emotional support.
In January 2000, we implemented our first formal psychosocial program for women newly diagnosed with breast cancer. Entitled Coping Skills, it was modeled after the Fawzy and Fawzy structured psychoeducational intervention published in 1994. The Fawzy and Fawzy intervention used a supportive group format that met for six weekly sessions lasting 90 to 120 minutes. We adapted the original model for our urban, east coast community hospital population. As a result, Coping Skills is offered every other month and consists of four, 90-minute sessions facilitated by a social worker. Participants receive a copy of the patient manual developed by Fawzy and Fawzy. Session content follows the intervention model including health education, coping skills training, stress management, and psychological support.
Initially, participant satisfaction surveys alone were used for program evaluation. The evaluation process has evolved during the past year to include F. Fawzy’s Dealing with Illness-R tool. Informal verbal feedback is consistently positive.
In conclusion, Fawzys’ research identified effective ways to meet the psychosocial needs of individuals newly diagnosed with cancer. The continuing success of the coping skills program is the result of implementing evidence-based practice into clinical care. (Funding from the Susan G. Komen Breast Cancer Foundation assisted with implementing the program.)

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A PILOT STUDY TO EXPLORE THE RESOURCES AND THE SELF-CARE ACTIVITIES OF WOMEN WITH SIDE EFFECTS FROM CONVENTIONAL BREAST CANCER THERAPY. Barbara Owens, RN, MSN, University of Texas Health Science Center at San Antonio, San Antonio, TX.

Purpose and Background: The purpose of this pilot study was to examine complementary and alternative therapies (CAT) used for the side effects experienced after conventional therapy(s) for breast cancer. Braden’s Self-Help Model was the framework for this study (Nursing Research, 39: 42–47, 1990). The five categories of self-care activities designated by the National Center for Complementary and Alternative Medicine (NCCAM) were explored to improve the conceptual identification of CAT. The rates of CAT used by women after diagnosis of breast cancer in the literature range from 39% to 84%, which reflect different variables used for exploration of CAT. Controlled clinical trials have generated little data on the relationship between CAT and quality of life outcome.
Method: A convenience sample of 33 Black, Hispanic, and non-Hispanic white women during the time they experienced side effects of breast cancer treatment were asked about the prevalence and types of CAT used. A descriptive statistical analysis was used to examine which CATs were used as resources that moderated uncertainty and improved quality of life.
Results: The percent of each NCCAM category used by this sample was: 1) Alternative medical systems = 12%, 2) Mind/body therapies = 91%, 3) Biologically-based therapies = 73%, 4) Manual therapies = 21%, and 5) Energy therapies = 3%. All but one in this sample had used at least two complementary treatments or remedies. The most frequently used therapies were humor (91%), music (88%), and prayer (88%). Energy therapy and hypnosis were each used by only one person, followed by chiropractic and acupuncture treatments used by only 12% in this sample. Ninety percent of the women reported perceived improvement in quality of life with use of CAT.
Conclusions: Based on the results of this study, information to guide development of CAT among women during treatment of breast cancer in this cancer treatment and research center in South Texas will be offered. This study also provided information that will be useful in constructing an instrument to measure CAT and in clarifying the conceptual entities to separate CAT into different variables during the experience of breast cancer.

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USING A SYMTOM DISTRESS TOOL IN AN OUTPATIENT BREAST CENTER. Michelle Willman, RN, BSN, OCN^®, Waukesha Memorial Hospital Center for Breast Care, Waukesha, WI; Joan Bink, RN, BSN, Oconomowoc Memorial Hospital Center for Breast Care, Oconomowoc, WI; and Joy Swain, RN, BSN, OCN^®, and Catherine Rapp, MS, RN, AOCN^®, Waukesha Memorial Hospital, Waukesha, WI.

Learning of an abnormal mammogram and having a breast biopsy are stressful events. In the literature, anxiety is often correlated to lengthy wait times and more invasive biopsy procedures. In spite of wait times less than two weeks, many women were significantly anxious when they presented for needle biopsy in our centers for breast care. The goal of this project was to find a tool that would allow for assessment of women’s levels and sources of distress. The Psychosocial Distress Thermometer and Problem List (PDT) was adapted from the NCCN Psychosocial Distress Practice Guidelines. The PDT was given to a convenience sample of 51 women to complete on the day of, but prior to their breast biopsies. In our sample, 55% of the women experienced significant distress (score of 5 or greater). Not surprisingly, the most prevalent cause of distress was emotional problems (89%). However, additional sources of distress included physical problems (61%), practical problems (46%), family problems (25%), and spiritual concerns (14%). Oncology nurses intervened with any woman indicating a distress level of 5 or greater, and made interdisciplinary referrals as needed. For most women with a benign result, the distress was relieved by knowledge of their biopsy results. Of the 45% of women who indicated a distress level less than 5, emotional problems (57%) were again the most prevalent source, followed by physical problems (52%), practical problems (26%), family problems (13%), and spiritual concerns (4%). An incidental finding was that women who requested an anti-anxiety medication prior to the procedure did not necessarily have correspondingly high distress scores on the PDT. The results demonstrated that the PDT is a usable and appropriate tool for our outpatient setting. Women appreciated and were surprised by attention to their “other” needs. Continued use of the PDT will provide consistent assessment and communication across our breast cancer treatment continuum. In addition, it will facilitate identification and early intervention for women with both benign and malignant results.

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SISTERS FOR BREAST HEALTH: IMPROVING THE HEALTH OF THE COMMUNITY. Karen McGough, ARNP, MS, AOCN^®, Sandra Jones, MS, ARNP, and Maria Scruggs-Weston, BS, St. Anthony’s Health Care, St. Petersburg, FL.

Sisters for Breast Health (SFBH) is an innovative community health program whose purpose is to promote early detection of breast cancer by providing breast health education and facilitating mammogram utilization for African-American women over 40 who reside in South Pinellas County, Florida. Needs assessment have determined that African-American women in South Pinellas County are medically underserved, specifically in the area of breast health. Data from the American Cancer Society and the tumor registry of St. Anthony’s Health Care is consistent: African-American women have a slightly lower incidence of breast cancer than white women, but higher mortality. Furthermore, the American Cancer Society recommends increased participation in routine screening mammography and detection to decrease mortality and improve survival.
SFBH utilizes the concept of “Sistah Parties” with women in the African-American community coming forward to serve as hostesses in their own homes. The “Sistah Parties” offer women a chance to get together for an enjoyable evening where the focus is breast health. The program revolves around the concept that, with knowledge and support, women are strengthened and empowered to take control of their health. Barriers to participation in annual screening mammograms are fear, putting needs of others before self needs, lack of trust in the system, little knowledge about prevention, and a fatalistic attitude that breast cancer cannot be successfully treated. SFBH specifically addresses these barriers through “Sistah Parties.”
Health behavior change is a process that is dynamic; therefore, evaluation of long-term cultural change is in process. It is evident that that “Sistahs” are progressing along the continuum. Current evaluation methods consist of measuring the number of women who participated and received education and the number of participants who followed though with having a mammogram. Through pre-tests, post-tests, and surveys, the “Sistahs” have shown statistical improvements in knowledge about breast health, likelihood of having yearly mammogram, comfort level in having a mammogram, and comfort level in speaking with women in your family about breast health. Cancer early-detection programs in the African-American community can be improved by designing programs that incorporate methods to promote health behavior change within the culture.

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RATIONALE FOR THE DEVELOPMENT OF THE FACT-N: A NEUTROPENIA-SPECIFIC QUALITY-OF-LIFE TOOL. Nancy Anderson, BSN, OCN^®, Northwestern Medical Faculty Foundation, Inc., Chicago, IL; and David Cella, PhD, Elizabeth Calhoun, PhD, Karen Novak, RN, MSN, OCN^®, ACNP, Northwestern Medical Faculty Foundation, Inc., Chicago, IL; Chih-Hung Chang, PhD, and Emily Welshman, MSW, Feinberg School of Medicine, Institute for Health Services Research and Policy Studies, Chicago, IL.

Quality-of-life (QOL) is an increasingly important measure for assessing cancer treatments. QOL is affected by changes in physical, functional, emotional, and social well-being. Clearly, chemotherapy is expected to produce changes in QOL, and validated tools that capture QOL changes have been used in clinical trials. One such tool, the FACT-G (Functional Assessment of Cancer Therapy – General), uses a 5-point scale (“0” means “not at all” while “4” means “very much”) to assess how patients view their current condition, with questions regarding specific symptoms, concerns, and emotions. The FACT-N is a neutropenia-specific QOL tool currently being developed and validated as a companion tool to the 27-item FACT-G. Validation is an important step in the development of a QOL tool because it indicates that the survey questions capture meaningful and relevant issues specific to the topic (in this case, neutropenia), and that the tool can reasonably be expected to produce accurate responses when used in different studies. The FACT-N questions were developed after reviewing medical literature and conducting interviews with 10 clinicians, 25 patients with cyclic neutropenia, 25 with congenital neutropenia, and 25 patients with chemotherapy-induced neutropenia (CIN). Fifty-one questions were initially generated. Twelve experts rated the items for clarity, relevance, and redundancy, and identified 19 items that came to comprise the FACT-N. In order to test reliability and validity, the FACT-N was administered to 60 chemotherapy patients. All patients completed the FACT-N at baseline, and those experiencing neutropenia received the survey again. All patients completed the FACT-N with the last chemotherapy cycle. The results suggest that the FACT-N has internal consistency, meaning that the items measure the underlying concept. Additionally, two subscales, a 7-item fatigue subscale and a 4-item worry subscale, exist within the FACT-N. Preliminary data on the relationship of FACT-N responses to neutrophil count changes during chemotherapy will be presented. In summary, the FACT-N represents the first neutropenia-specific QOL tool. It will ultimately be incorporated into oncology clinical trials, providing oncology nurses with a better understanding of the overall impact of chemotherapy on patient’s lives and the effectiveness of interventions designed to minimize this impact.

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PATIENT-REPORTED DEPRESSION AND ANXIETY IN PATIENTS WITH CANCER IMPROVES FOLLOWING REDUCTION IN ANEMIA-RELATED FATIGUE WITH DARBEPOETIN ALFA THERAPY. Mary Amorajabi, RN, and Simon Tchekmedyian, MD, Pacific Shores Medical Group, Long Beach, CA; and Joel Kallich, PhD, Amgen Inc., Thousand Oaks, CA.

Introduction: Fatigue is associated with the anemia that is frequently observed in patients with cancer, and can have a greater impact on patients than pain, potentially decreasing emotional well-being and reducing health-related quality of life (HRQOL) (Vogelzang 1997; Ludwig 1998).
Treatment of anemia with erythropoietic agents has been shown to reduce fatigue and improve HRQOL (Demetri 1998). This analysis investigated the psychologic outcomes associated with treating anemia.
Methods: Anemic (hemoglobin < = 11 g/dL) patients with cancer undergoing chemotherapy, who were enrolled in two international clinical trials, received 12 weeks of treatment with darbepoetin alfa, epoetin alfa, or placebo (n = 607). Darbepoetin alfa has a longer serum half-life and greater biologic activity than epoetin alfa, allowing less-frequent administration. The psychologic status of patients was assessed using the Brief Symptom Inventory (BSI), Depression and Anxiety scales, and the Functional Assessment of Cancer Therapy (FACT)-General scale (including fatigue as well as functional, physical, emotional, and social/family well-being scales).
Results: Patients with a > or = 2 g/dL increase in hemoglobin (n = 200) reported a mean change in FACT-Fatigue scale score of 3.8 (95% CI: 2.2, 5.5), compared with only 1.0 (95% CI: -0.1, 2.0) for patients with a < 2 g/dL increase in hemoglobin (n = 402). Patients reporting clinically important reductions in fatigue (> = 3-point increase in FACT-Fatigue scale score) exhibited a reduction in depression and anxiety as reflected in the change from baseline of -5.1 (95% CI: -6.8, -3.5) (n = 271) and -6.1 (95% CI: -7.7, -4.5) (n = 270) in the BSI Depression and Anxiety scale scores, respectively. Patients without clinically important reductions in fatigue (< 3-point increase in FACT-Fatigue scale score) exhibited an increase in depression and anxiety as reflected in the change from baseline of 3.1 (95% CI: 1.5, 4.7) (n = 333) and 1.6 (95% CI: 0.1, 3.1) (n = 335) in the BSI Depression and Anxiety scale scores, respectively. Change in FACT-Fatigue score was significantly correlated with change in BSI Depression score (r = -0.3495; p < 0.001) and BSI Anxiety score (r = -0.3529; p < 0.001). Clinically important reductions in fatigue were also associated with improvements in emotional well-being and overall health scores.
Conclusions: These findings indicate that the treatment of anemia in patients with cancer reduces fatigue, which subsequently reduces depression and anxiety, and improves emotional well-being and overall health. It is therefore important to recognize and appropriately manage anemia-related fatigue in patients with cancer.

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EFFECTS OF THE NEUTROPENIC DIET IN THE OUTPATIENT SETTING. Debra DeMille, MS, RD, Pennsylvania Hospital, Joan Karnell Cancer Center, Philadelphia, PA; Cathy Fortenbaugh, RN, AOCN^®, CNS, Capital Health System, Trenton, NJ; Mary Pat Lynch, CRNP, MSN, AOCN^®, Pennsylvania Hospital, Philadelphia, PA; Priscilla Deming, RN, MSN, Hospital of the University of Pennsylvania, Philadelphia, PA; and Milagros Cappa, RN, BSN, CCRP, and Ann Christian, RN, OCN^®, Pennsylvania Oncology Hematology Associates, Philadelphia, PA.

Chemotherapy patients are being instructed in the neutropenic diet based on past research involving a total protective environment. There have been no studies evaluating the effects of the neutropenic diet alone in the outpatient setting. This descriptive pilot study asks 3 questions: Are outpatients receiving chemotherapy able to comply with a neutropenic diet? Is there a difference in the number of febrile admissions between compliant versus non-compliant patients? Is there a difference in the number of positive blood cultures between compliant versus non-compliant patients? Patients between 18 and 70 years old receiving outpatient chemotherapy are recruited from the Pennsylvania Hospital Joan Karnell Cancer Center and Pennsylvania Oncology and Hematology Associates. Enrollment is 12 weeks starting day 1 of cycle 1. Patients are instructed in the neutropenic diet before starting chemotherapy. Compliance assessment telephone calls are made at weeks 6 and 12. Hospital admission charts are reviewed at study completion. This study’s neutropenic diet is based on a 120-institution survey by Smith and Besser. The evaluation tool measures dietary compliance through target questions about food safety and diet restrictions utilizing the Likert scale. Admission, blood culture events, and patient perception of compliance are questioned. The content validity was established through review of the tool by a multi-disciplinary team. Descriptive statistics will be used to address the first question. Occurrence of compliance within the sample will be analyzed as both raw and frequency data. Sample demographic data will be analyzed descriptively using mean, median, mode, and standard deviation calculations. Inferential statistics will be used to address the second and third questions. T-test analysis with a p value of 0.05 will be used to determine statistically significant differences in mean number of febrile admissions and positive blood cultures between subjects who are compliant versus non-compliant. Statistically significant differences will be reported as trends for guiding future design of a broader, randomized clinical trial. Healthcare professionals may change dietary education based on compliance and outcome information from this study. 16 patients have been enrolled to date. The study will be completed by November 1, 2002.

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TARGETED COLONY-STIMULATING FACTOR USE IN PATIENTS AT RISK FOR NEUTROPENIC COMPLICATIONS FROM BREAST CANCER ADJUVANT CHEMOTHERAPY: CLINICAL IMPACT OF A PREDICTIVE RISK MODEL. Anne Zobec, RN, MS, NP, AOCN^®, The Oncology Clinic, P.C., Colorado Springs, CO; Judy DeGroot, RN, MSN, OCN^®, Amgen, Colorado Springs, CO; and Kelly Mack, RN, MSN, NP, AOCN^®, Rocky Mountain Cancer Center, Denver, CO.

Full-dose chemotherapy improves survival in early stage breast cancer (ESBC). Delivery of at least 85% of the planned dose on time (PDOT) may be necessary for an optimal outcome, yet a significant portion of ESBC patients treated in community practice do not receive this level of dose intensity. Neutropenia is often responsible for the dose delays and reductions that result in frequent failure to reach PDOT. While prophylactic colony-stimulating factor (CSF) is an alternative to dose modifications, its universal use in all patients is not considered cost-effective. Identifying patients at risk for neutropenic complications (NC) would allow targeted use of CSF, providing cost-effective protection to the patients who need it most. Silber et al. (1998) determined that the first cycle absolute neutrophil count nadir (FCANC) may be useful to stratify ESBC patients according to their risk of subsequent NC, including episodes of severe neutropenia (ANC < 500 cells/mm3) and febrile neutropenia (FN), and chemotherapy dose delays and reductions. We report on the prospective application of this risk model to determine its clinical impact in a population of ESBC patients receiving standard adjuvant chemotherapy. Patients were assigned to CSF based on their FCANC: Those with FCANC £500 cells/mm3 (high-risk patients; n = 360) received filgrastim 5 mcg/kg/day in all subsequent cycles, while those with FCANC > 500 cells/mm3 (low-risk; n = 264) received filgrastim only if they developed FN or had a neutropenia-related dose modification. Study patients were compared to 1,022 historical control ESBC patients treated with similar regimens. While most study patients (95%) received at least 85% PDOT, with no difference between the high-risk and low-risk groups, only 78.7% of the historical controls received at least 85% PDOT. Hospitalization and FN were more common in the high-risk patients compared to the low-risk patients, but were lower overall in the study patients than in the historical controls (2.9% versus 7.3%, and 7.5% versus 10.3%, respectively). These results suggest that risk model-guided prophylactic CSF use improves outcomes compared to current standard practice. Nurses can proactively evaluate an individual patient’s risk using factors such as FCANC and recommend appropriate supportive therapy to help their patients achieve optimal treatment outcomes.

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PEGFILGRASTIM (NEULASTA™) SUPPORTS DOSE-DENSE CHOP-R GIVEN EVERY 14 DAYS TO PATIENTS WITH NON-HODGKIN’S LYMPHOMA. Jerry Hinton, RN, OCN^®, CCRC, Erin O’Rourke, RN, OCN^®, Susan Dyer, BSN, OCN^®, Timothy Moore, MD, Nancy Merriman, RN, OCN^®, and Kevin Miller, BSN, OCN^®, Mid-Ohio Oncology/Hematology, Columbus, OH.

CHOP has long been the treatment of choice for aggressive NHL. Attempts to improve upon CHOP with more complex or higher dose regimens have resulted in greater toxicity, but not greater efficacy. Maintaining CHOP dose intensity has been associated with improved survival, and it is possible that increasing the dose-intensity by decreasing the time between cycles may further improve outcomes. Recently, investigators have shown that CHOP given every 14 days with Filgrastim support is superior to standard 21-day CHOP (Blood 2001; 98:725a). In addition, adding the monoclonal antibody rituximab to standard CHOP (CHOP-R) has also been shown to improve survival (NEJM 2002; 346:235). Given these advances, the next logical step is to evaluate dose-dense CHOP-R. This phase II trial was designed to assess the feasibility of giving CHOP-R every 14 days with pegfilgrastim, rather than daily Filgrastim. Pegfilgrastim, a pegylated version of Filgrastim, is administered as a single 6 mg fixed dose just once per chemotherapy cycle. Patients with previously untreated intermediate or aggressive NHL and relapsed low-grade NHL were eligible for this study. Rituximab was given on day 1, CHOP on day 3, and pegfilgrastim on day 4, for up to 8 cycles. To date, 15 patients have entered the trial (mean age of 61, range 37–77; 8 females, 7 males); 10 have completed therapy and 5 remain in treatment. A total of 84 cycles have been administered. Eight cycles have been delayed for toxicity (grade 2 diarrhea, n = 1; grade 3 stomatitis/pharyngitis, n = 4; grade 4 thrombocytopenia and neutropenia, n = 3) and 4 patients have had an episode of febrile neutropenia. Fully 90% of planned cycles were given on time, with no dose reductions, and all patients have attained a CR or near-CR status with no evidence of progressive disease. Complete data for the protocol-planned 30 enrolled patients will be presented at the meeting. These preliminary results suggest that CHOP-R can be given safely every 14 days with pegfilgrastim support. Oncology nurses may see dose-dense CHOP and CHOP-R increasingly used in practice. Data regarding the effects of pegfilgrastim with these regimens are important, as nurses will be integral in administering this therapy.

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NEUTROPENIC PRECAUTIONS: A JOURNEY TO THE DEVELOPMENT OF EVIDENCE-BASED STANDARDS. Bonnie Wivell (Setters), RN, BSN, OCN^®, University of Colorado Hospital, Aurora, CO; Cyndi Cramer, BA, RN, OCN^®, Tampa General Hospital, Tampa, FL; Patricia Will, RN, OCN^®, North Colorado Medical Center, Greeley, CO; and Elizabeth “Dianna” Johnson, RN, OCN^®, St. Mary’s Hospital, Tucson, AZ.

Neutropenia is a common side effect of cancer treatment. It is the primary dose limiting toxicity of most chemotherapy regimens often resulting in neutropenic complications such as dose delays/reductions and febrile neutropenia, which can have an overall mortality rate as high as 10%. Concern over the potential negative clinical outcomes due to neutropenic complications, the inconsistencies in nursing management of the neutropenic patient, and the lack of nursing research to guide the development of evidenced-based neutropenia standards of practice lead to the formation of the ONS Neutropenia Focus Group in 2000. The ultimate goal of this focus group is to establish a set of national evidenced-based neutropenic precaution guidelines and patient/caregiver teaching strategies. The process has at least three phases, two of which have now been completed. Phase I was a collection of information by focus group members with regard to neutropenic precautions currently utilized at various healthcare institutions. This collection of information lead to Phase II, the development of a neutropenic precautions survey. The goal of this survey was to identify the following: 1) Neutropenic precautions utilized in inpatient/outpatient settings, if any, 2) Patient care standards currently employed in various healthcare institutions, and 3) Patient/caregiver teaching strategies. The survey was sent to 1,500 randomly selected oncology nurses nationwide utilizing the ONS membership database. Returned surveys will be analyzed with the intent of sharing these results at the 2003 ONS Congress in a poster abstract format. Data available for presentation will include the most consistently utilized neutropenic precautions, associated patient care standards, and patient/caregiver educational strategies utilized in both the inpatient and outpatient settings. Analysis of the Phase II results will determine development of Phase III, including identification of nursing research opportunities to further clarify and develop evidenced-based neutropenia standards of practice.

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OPTIMIZED USE OF PHARMACOLOGIC AND COMPLEMENTARY THERAPIES TO DECREASE CHEMOTHERAPY-INDUCED NAUSEA AND VOMITING. Maryann Rosenthal, RN, MSN, OCN^®, Jennifer Hood, RN, OCN^®, Mary Booher, RN, BSN, OCN^®, Debra Ann Peter, RN, MSN, and Nicole Reimer, RN, BSN, OCN^®, Lehigh Valley Hospital, Allentown, PA.

Staff nurses on a 26 bed, inpatient hematology-oncology unit in a tertiary care community teaching hospital questioned whether their patients were achieving adequate control of chemotherapy induced nausea and vomiting. Their initial belief, based on clinical observations of patients, was that symptom management could be improved with optimized use of pharmacologic interventions. Despite having evidenced-based chemotherapy administration clinical practice guidelines that include pre-, concomitant-, and post-chemotherapy antiemetics, some patients receiving chemotherapy suffered nausea and vomiting. The first step in the performance improvement (PI) process was to confirm the nurses’ beliefs with the patients’ perceptions. Following completion of their chemotherapy regimen, patients were asked by a professional nurse to state “yes” or “no” to the question, “Did you feel satisfied with the way your nausea was controlled during your hospital stay?” The study confirmed that opportunities for improvement existed related to nausea control. Working in collaboration with our nurse researcher and unit-based pharmacist, retrospective medical record data was collected for each patient who had been surveyed. We investigated whether the patients had antiemetics ordered and administered according to the clinical practice guidelines. We found that the majority of patients who were not satisfied with the way their nausea was controlled did not have antiemetics ordered and/or administered in accordance with the clinical practice guidelines. For example, antiemetics were not consistently ordered according to the clinical practice guidelines and antiemetics ordered “prn” were not always administered in a timely manner. In conjunction with the aforementioned investigation, we completed an evidence table utilizing related literature from the past three years. The evidence revealed that antiemetic orders included within our clinical practice guidelines are consistent with the most recent research; however, we did we include a full range of complementary antiemetic therapies within our chemotherapy nausea and vomiting prevention standard. This presentation will describe these first steps in our PI initiative, as well as relate the action plans implemented to address the aforementioned opportunities for improvement. Participants will receive copies of our evidence table and evidenced-based chemotherapy administration clinical practice guidelines and associated nursing standards of care, including complementary therapies.

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EDUCATION FOR ONCOLOGY NURSING: APPLYING COMPLEMENTARY AND ALTERNATIVE MEDINCE IN THE PRACTICE SETTING. Teresa Rojas-Cooley, RN, BSN, Marcia Grant, RN, DNSc, FAAN, and Grace Dean, RN, PhD, City of Hope National Medical Center and Beckman Research Institute, Duarte, CA.

Background and Rationale: Complementary and alternative medicine (CAM) use in the oncology population has recently increased from 30% to 85%. A 2001 study reported that 65% of oncology patients do not disclose CAM use to the tealthcare team. CAM therapies may have harmful effects for patients when used with radiation or chemotherapy, and many nurses are not prepared to assess CAM use or adverse reactions. CAM information, however, is readily available. Analysis of published CAM information revealed 52 articles in 20 journals over 6 years. In addition, 43 published studies included 18 articles in ONF or Cancer Nursing.
Methods/Practices: Two educational sessions were used to identify what practicing nurses want to know about CAM. A roundtable session at ONS Congress 2002 attracted 7 oncology nurses (range of experience of 2–25 years). High interest areas were aromatherapy, Reiki, herbs, and CAM research. Lively discussions included what therapies were safe, whether CAM is within the scope of nursing practice, and what research supports CAM. A written evaluation revealed the need to know more about aromatherapy and meditation. The second session, interdisciplinary grand rounds held at a cancer center, included nine nurses (range of experience of 7–25 years), and five other disciplines. Minimal discussion occurred despite several attempts at open-ended questions regarding scope of practice, legality, and evidence-based practice issues. The evaluation revealed a need for information on all types of CAM.
Interpretation: Assessing and evaluating CAM use in cancer patients should be a high priority for oncology nurses. However, even nurses who sought out a CAM educational session are uncomfortable with their CAM knowledge and its application to practice. The lack of discussion in grand rounds may indicate staff nurses’ discomfort with CAM. Nonetheless, it is essential for nurses to become competent in assessing CAM use in cancer patients.
Discussion: Staff nurses need to support the growing number (85%) of cancer patients already using CAM. The priority for education is to help integrate evidenced-based CAM into standard oncology nursing care. This presentation includes available CAM resources.

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AROMATHERAPY: GUIDELINES FOR SAFE INCORPORTATION INTO NURSING PRACTICE. Cherie Perez, RN, BS, CCRA, RMT, University of Texas M.D. Anderson Cancer Center, Houston, TX.

Complimentary therapies are used by a number of cancer patients to either manage symptoms or supplement treatment. A survey at University of Texas M.D. Anderson Cancer Center in 1999 showed that 70% of patients had tried complimentary therapies. These therapies are readily available, often reasonably priced, and can be self managed. Recent surveys have indicated that aromatherapy is growing in popularity in acute and long term care settings. However, there is little reported research with aromatherapy in these settings. In fact, a review of the literature indicates a lack of knowledge in terms of dosing, methods of administration, and therapeutic outcomes. Although many people who use aromatherapy are not formally certified, it is important that they have a level of knowledge regarding essential oils, their potential side effects, and dosing. There are licensed caregivers, such as massage therapists or estheticians who regularly utilize aromatherapy within their practice. These practitioners have received an introduction to the use of essential oils and are not excluded from using them, although they may not have received formal certification. There is an increasing interest in aromatherapy by nursing caregivers, especially related to symptom management for cancer therapy. However, most nurses have not received specific education in the use of essential oils, selection of oils, contraindication, or interactions. Despite this lack of knowledge, aromatherapy is increasingly included as a part of holistic nursing care and has been recognized as such by one state board of nursing. It is important to realize that recognition or interest does not negate the need for some type of formal training for preparation and use. This presentation will provide an overview of aromatherapy, qualifications necessary for practice, and information related to the safety and toxicity of the commonly used essential oils. It will also include information regarding the best approaches for safe administration. Finally, it will include an overview of the research that has been completed in acute and long-term care settings. Although these studies are relatively few in number and most include small samples, there is some support showing the value of aromatherapy in patient care.

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SUPPORTING THE SPIRITUAL CONNECTION: CREATION AND DEVELOPMENT OF A SPIRITUALITY QUEST GROUP FOR CANCER SURVIVORS. Marsha Komandt, RN, BSN, OCN^®, Inova Fairfax Hospital, Falls Church, VA.

The spiritual quest of an individual is a very personal one, in particular those struggling with a serious illness such as cancer, as they frequently turn to spiritual values to help them cope with or understand their illness. Research and patients’ and family writings, stories, and support groups have validated this basic tenet. Therefore, a spirituality quest group was implemented within our community hospital’s cancer program. From an initial one-evening spiritual class offered to cancer survivors ten years ago to the successful development of a monthly spiritual group, five years occurred. Groundwork consisted of collaboration with the chaplaincy services department of our hospital and the initial co-facilitators’ participation in a parish nursing program. We were also influenced by the Joint Commission on Accreditation of Healthcare Organizations, which recommends that hospitals provide pastoral care and spiritual services for patients since, for many, it is an “integral part of health care and daily life.” When the actual spirituality group met for its first session, much discussion naturally centered on “what is spirituality?” and what name the group would be called. After many creative names, the fundamental “Spirituality Quest” was chosen, as it reflected the connection between the questioning and the experiencing of one’s beliefs. The group’s quest for spirituality has been more closely linked to their hopefulness and their connection with each other, even though guest speakers have addressed various kinds of spirituality, for example, Salesian, Tibetan, Native American, as well as ways of touching the soul through our senses with music, art, sound, and nature. This presentation will review the literature on the role of spirituality in health and cancer care, the multi-disciplined approach of establishing a spirituality group within a cancer center, the variety of themes covered in the group, the meaning of spirituality shared, and the impact on participants’ quality of life. It is hoped that our experience will encourage oncology nurses to tap into the resources that may already exist within their own healthcare facilities or to create a program that will address the holistic approach, including spirituality, to oncology patient centered care.

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LAUNCHING A COMPLEMENTARY THERAPY PROGRAM IN ONCOLOGY: A NURSING INITIATIVE IN HOLISTIC CARE. Judith Kostka, RN, MS, MBA, and Barbara Coughlin, RN, LMT, Cape Cod Hospital, Hyannis, MA; and Jeanne Jackson, RN, Falmouth Hospital, Falmouth, MA.

A complementary therapy program in oncology was launched by two hospitals in the Cape Cod HealthCare (CCHC) system in 2001. Two pilot studies using complementary therapies with chemotherapy outpatients were conducted to evaluate patient benefit. The program has grown to include three locations, including radiation therapy. Two nurses, trained in complementary therapies, provide these services.
CCHC executive management decided to explore options for integrating complementary therapy in oncology in 2000. A consultant provided background information, and the oncology nurse manager assumed project oversight. The cancer leadership team approved a three-month pilot offering five to fifteen minutes of gentle massage to interested patients in the infusion room two days a week. The goal was to offer a voluntary, non-invasive and holistic opportunity for patients to experience increased comfort and relaxation in the midst of their treatment experience. The purpose of the study was to assess patient and staff satisfaction. The findings from the pilot (n = 50) demonstrated an extremely high level of patient satisfaction with 100% of respondents saying that massage therapy services should continue to be offered. Trends included reports of decreased pain, nausea, and anxiety, and increased physical comfort and overall well-being. In addition, staff reported benefit to their patients, improvement of patient symptoms, no disruption in their job responsibilities, and a consensus that massage therapy services should continue to be made available to patients.
At the conclusion of the pilot, the cancer leadership team approved expanded services to medical oncology and the inclusion of radiation therapy. The hours of service were doubled to 20/week. A three-month pilot study was then conducted at the other CCHC outpatient chemotherapy clinic (n = 47), and included additional modalities (reflexology, aromatherapy, and therapeutic touch). Findings demonstrated an equally high level of satisfaction with 100% of patients requesting that services be continued. Services average an additional 10 hours/week at this facility. The hospitals assume the full cost of the program, and hospitals’ complementary therapy committee credentials the holistic nurses. Plans to expand the program are under consideration and include offering services to oncology inpatients as well as hospice and palliative care patients.

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CREATING AN ENVIRONMENT FOR CARING THROUGH STORYTELLING. Catherine Rapp, MS, RN, AOCN^®, and Mary Pat Johnston, RN, MS, AOCN^®, Waukesha Memorial Hospital, Waukesha, WI.

The stresses inherent in oncology nursing are well documented. Add to them, concerns about the nursing shortage, economic downturns, and fast-paced home lives, and you have a situation ripe for oncology nurse burn out and attrition. In our multi-site regional cancer center, our goal was to create an environment that maximizes support and growth, with the belief that such an environment will foster a workplace where care and caring happens for patients, families, and colleagues. To accomplish this goal, two interactive small group sessions were designed, focusing on mentoring. Each set of 2 sessions was limited to eight participants. Sessions were scheduled throughout the summer. Mentoring was defined as “A developmental, empowering, and nurturing relationship that extends over time. It involves mutual sharing, learning, and growth that occurs in an atmosphere of respect and affirmation” (Haley-Andrews). This definition is different than the paired “precepting” that is so often described in the literature. First, ground rules were established, emphasizing the need for confidentiality and safety in disclosure. Participants identified and discussed key characteristics of a mentor, and were led, using guided-imagery, through a journey with the mentors in their lives. Then, storytelling was introduced as a means for making visible our work as oncology nurses, connecting with patients and families during some of the most vulnerable times of their lives. The facilitator told a professional story of mentoring to model the process and to create a desire for group members to explore their own stories. Once the stage was set, each one wrote a story of a significant personal or professional mentoring event in their life. During the second session, each person told her story, reflecting on its personal meaning. Group members were asked to respond to each story, describing its meaning and impact for them. On conclusion, they wrote brief evaluative thoughts about the experience. Though just a beginning, the impact of the shared experiences in the stories is clear. The 36 oncology nurses attending have a renewed commitment to each other and to the work that they do every day.

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CANCER FITNESS: OUTCOME MEASURES AND FEATURES OF A THREE-TIERED PROGRAM. Susan Lasker-Hertz, RN, MSN, AOCN^®, HealthONE, Denver, CO; Connie Carson, BS, MS, PhD, Healthcare Consultant, Littleton, CO; and Pat Stanfill-Edens, RN, MS, MBA, HCA, Inc., Nashville, TN.

Until recently, the concept of a physically fit cancer survivor was seen as an oxymoron. Today, cancer survivors want to incorporate fitness into their treatment regimen to combat fatigue, aid in the healing process, and counteract the negative effects of cancer treatments.
Jones and Courneya (Cancer Practice, March/April 2002, Vol. 10, No. 2) reported that 82.2% of cancer survivors did not want to have to initiate the topic of exercise to their healthcare providers. Practical information must be available to oncology nurses so that they can offer exercise as a viable treatment adjunct to their patients.
In 2002, HealthONE Clinic Services developed a fitness program sponsored by HCA Cancer Care, part of HCA, Inc. Approximately 250 individuals have graduated from this program. In addition to the outcome measures and results, this poster session will offer specific and clinically appropriate information that nurses can use to educate patients on exercise strategies at all stages of their cancer journey.
The topics specifically addressed include relevant research on the importance of cancer fitness, precautionary risks and contraindications, clinical performance measures for documentation of changes in functional status, fatigue, and overall well-being, sample exercise plans and logs, reimbursement concerns, marketing materials, physician referral strategies, community resources, patient’s responses to the program, and specifics of the three tiers as listed below.
The rehabilitation tier provides lymphedema services, patient specific programs for bone marrow transplant and brain tumor patients, energy conservation techniques to reduce fatigue, and strategies to enhance activities of daily living.
The second tier is for more physically fit patients. Individualized exercise treatment plans and fitness goals are established. Cancer exercise specialists supervise all workouts.
The most independent tier allows individuals to design their own exercise programs. Assistance is provided in establishing fitness goals and documenting outcomes using a cancer exercise guide developed for this program.
Through fitness opportunities, cancer survivors are empowered to enjoy healthier lifestyles, to create opportunities for psychological support, and to make changes to reverse the affects of cancer related symptoms.

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COMPLEMENTARY AND ALTERNATIVE MEDICINE IN THE 21ST CENTURY IN THE UNITED STATES. Colleen Lee, RN, MS, AOCN^®, National Institutes of Health, National Cancer Institute, Bethesda, MD.

Complementary and alternative medicine (CAM) has advanced to the forefront of western medicine in the 21st century in the U.S. Either as treatment for medical conditions or symptomatic relief, CAM is sought by itself or in addition to conventional medicine. While percentages of cancer patients who use CAM remain variable, APNs are compelled to become well informed regarding CAM practices. The acronym C-A-M is suggested as an approach that oncology nurses can reliably use when advocating CAM and cancer care. “C” represents clarifying fact from fiction. “A” represents acknowledging our perceptions. “M” represents mixing and Un-mixing medicines. Clarifying fact from fiction. Mainstream oncologists and CAM practitioners struggle with a comprehensive definition of CAM. Complementary medicine in cancer care includes interventions that augment surgery, chemotherapy, and/or radiation or for symptom management. Alternative medicine in cancer care includes interventions independent of standard treatment. The known facts about CAM may be accurate in certain circumstances. The fiction may be that results are universal for all individuals. Inconsistencies with quality control, scientific design, and confounding variables undermine “facts.” APNs need to become experts in recognizing reputable CAM research data and promoting sound research design. Acknowledging our perceptions. Popularity of CAM in cancer care is complex. When cancer patients are terminally ill, who would question a patient’s desire to extend life with an alternative approach? But what if that same patient used an alternative approach upfront? Oncology nursing undergraduate and graduate curriculums train nurses to approach the cancer diagnosis with uniform principles and practices of western medicine. Personal and corporate biases need to be acknowledged. A profitable way to accomplish this is through dialogue. Alternately, APNs need to recognize that ridicule is often a mask for ignorance. Non-judgmental responses are optimal. Mixing and un-mixing medicines. The hippocratic oath of “Do no harm” is vital when CAM is paired with conventional cancer therapy. APNs have a responsibility to the practice of oncology and patients. Supportive avenues are: 1) encourage partnering in planning care, 2) promote access to CAM databases, journals, and reputable internet sites, 3) generate surveys to discover reasons for nondisclosure, 4) support licensure of colleagues practicing CAM, 5) develop clinical trials and publish results in peer-reviewed journals, 6) generate scholarly papers examining CAM practice, perceptions, and opportunities to build bridges in CAM and cancer care.

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ROCKY MOUNTAIN TEAM SURVIVOR: A MODEL FOR A FITNESS AND ACTIVITY SUPPORT PROGRAM DESIGNED TO ENHANCE AND IMPROVE OVERALL QUALITY OF LIFE FOR WOMEN CANCER SURVIVORS. Mary Malkiel, RN, BSN, MS, LAc, OCN^®, Rocky Mountain Cancer Center–Midtown, Denver, CO.

Cancer and its ensuing treatment often compromise the well-being and quality of life (QOL) for those with a current or past diagnosis of cancer. Recent studies and anecdotal evidence have shown that exercise, as part of an integrated cancer care program, can improve mood (Segar, M.L., Katch, V.L., & Roth, R.S., (1998). Oncology Nursing Forum, 25(1), 107–113), enhance immunity (Shephard, R.J., & Shek, P.N. (1995). Can J Appl Physiol, 20(1), 1–25), reduce symptoms (Courneya, K.S., & Friedenreich, C.M. (1999). Ann Behav Med, 21(2), 171–179), increase longevity and decrease risk of cancer (Rockhill, B., et al. (1999). Arch Intern Med, 159(19), 2290–2296).
Rocky Mountain Team Survivor (RMTS) is a non-profit organization providing fitness and activity programs for free or at minimal cost, to all women cancer survivors (WCSs) within the Denver metro area. Founded by an oncology nurse who is also a cancer survivor, a priority of RMTS is to provide fun, informal activities in a safe and supportive environment. These activities are open to women in any stage of treatment or recovery, with any type of cancer, regardless of age or ability. The ultimate goal is to empower WCSs to take an active role in their ongoing physical and emotional healing, while improving their quality of life. Core programs include weekly walks, a weekly indoor training program, and monthly swim clinics. Seasonal activities include snowshoeing, cross-country skiing, hiking, and biking. RMTS also participates as a group in local events such as the Danskin Women’s Triathlon, and Race for the Cure. This year, 110 WCSs participated in the Danskin Triathlon as part of RMTS.
The goal of this poster session is to educate 2003 Congress participants about relevant research on cancer and exercise, specific information about RMTS, how to develop a similar model exercise support program, women’s responses to the programs, and community support and resources.
Nurses are in a unique position to educate and counsel their patients on the benefits of exercise both during and after cancer treatment. By informing oncology nurses about this topic and the possibilities for similar programs within their community, they have the opportunity to affect significant change in their patient’s QOL.

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DEVELOPING AND IMPLEMENTING A FAMILY-CENTERED CARE PROGRAM IN AN ACUTE CARE ONCOLOGY UNIT. Kyla Dropkin, RN, BSN, MS-N, and Victoria Norton, BSN, OCN^®, Park Nicollet Health Services, St. Louis Park, MN.

Families and friends bring important support to their loved one’s healthcare experience. Encouraging a caring individual’s presence helps reassure, comfort, and heal a patient. For our 41-bed inpatient oncology unit at Park Nicollet Health Services, we wanted to formally offer families the opportunity to be directly involved in their loved one’s care.
Our voluntary program took the informal family involvement we already incorporated into patient care, gave permission to the caregiver to participate in care, and added formalized education and recognition. The patient would select a loved one who would assist with their physical, emotional, and spiritual support and their education. Staff would validate and support the level of care the caregiver wished to provide. Participants in this program varied from wanting to wear identification that they were a VIP (as we called them) to their loved one, to assisting with feeding, bathing, and ambulation.
Essential components of developing this program included nursing administration support, learning from other institutions using similar models, forming a unit committee including staff, developing processes specific to our unit, and educating all staff—nurses, nursing assistants, physicians, and other professionals in contact with our patients.
The success of this program comes from our commitment to establish a healthcare environment involving family collaboration and participation, and encouraging open communication between patients, families, and healthcare professionals. We recognize and support family strengths and individuality, while respecting different methods of coping and healing. The result is an atmosphere that respects the patient’s dignity and independence, and welcomes and honors racial, ethnic, cultural, and socioeconomic diversity. Patient and family feedback has been positive and they have been more active members of the healthcare team.
Currently, we continue to adjust the program to fit our culture and patient and family needs. We plan to expand the family-centered care program to other inpatient units at this hospital, who have been eager for us to bring it to them.

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MEETING PATIENT NEEDS: INTEGRATING A HEALING ARTS PROGRAM TO CANCER CARE AND INTRODUCING THEM IN A UNIQUE AND MEANINGFUL WAY. Patrick McLaughlin, MD, and Kelly Sakalian, RN, MSN, CS, AOCN^®, Providence Hospital, Southfield, MI.

Surgery, chemotherapy, and radiation have long been standard treatments for cancer. In addition to these therapies that focus on disease, there exists a healing tradition, which emphasizes not only the disease, but also the individual. These two approaches should not be seen as mutually exclusive, but as complementary to each other. With the understanding that many patients are already seeking complementary therapies before, during, and after cancer treatment, a healing arts program was developed. The primary goal of the program is to augment state-of-the-art clinical care with a healing arts program that supports cancer patients along their journey. The programs address the person as a whole, including body, mind, and spirit. Included are programs on spirituality, patient education, art, massage, Reiki, music therapy, meditation, humor, exercise, journaling, and nutrition.
To introduce the variety of healing arts programs available to cancer patients and their support people, Boost Camp, a daylong orientation program, was made available. Served up like a “Whitman’s sampler,” Boost Camp is informational, interactive, engaging, and highly entertaining. Boost Camp is held once a month and gives participants a chance to meet the practitioners, try out each of the programs, ask questions, and learn about the healing arts programs. Throughout the day, participants receive healing tools to add to their toolkits from each of the different healing arts practitioners. By the end of the day, each participant goes home with a wide array of small treasures.
Since the inception of the program in December 2000, 310 patients and their support people have attended. The response to the program by the participants has been overwhelmingly favorable. The evaluations showed that the participants would recommend the program to a friend, and Boost Camp definitely, or mostly, provided an orientation to the healing arts programs. Data regarding programs patients are attending or those that they have an interest in will be presented.
We believe that our healing arts program offers the cancer patient a unique approach to healing the body, mind, and spirit. The presentation of the programs in a one-day program has proven to be very effective.

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EFFECTS OF EXERCISE ON DAILY FATIGUE IN WOMEN WITH BREAST CANCER UNDERGOING CHEMOTHERAPY. Hsin-Tien Hsu, RN, MSN, Noreen C. Facione, RN, PhD, FNP, Maria Cho, RN, MS, Marylin J. Dodd, RN, PhD, FAAN, Steven M. Paul, PhD, and Christine A. Miaskowski, RN, PhD, FAAN, University of California, San Francisco, San Francisco, CA.

Significance & Problem: Breast cancer was the leading cancer for American women in 2000. Cancer-related fatigue (CRF) has been recognized as a distressing side effect of cancer treatment. Studies have shown that adriamycin and cyclophosphamide (AC), a frequent chemotherapy regimen for breast cancer, is associated with higher fatigue levels 48 to 72 hours post administration. Exercise is one of the few interventions suggested to alleviate CRF. The present investigators observed a dramatic day-to-day fluctuation in fatigue. Although two studies have reported daily fatigue levels, our analyses of fatigue scores further extend our knowledge in the area.
Purpose: To compare daily patterns of fatigue in breast cancer women who did and did not exercise while receiving 4 cycles of AC chemotherapy.
Theoretical Framework: Piper’s Integrated Fatigue Model.
Methods: Longitudinal, randomized repeated measures design. 46 women (exercise = 16; control = 30), ages 33–69 (mean = 48.9) with stage I or II breast cancer receiving four 21-day cycles of AC. Exercisers followed a formal, individualized exercise prescription during chemotherapy. Fatigue intensity was measured daily from cycle 2 to cycle 4 of AC (range 53–29 days).
Data Analysis: Descriptive analyses, repeated measures analysis of variance.
Findings: Exercisers experienced shorter duration of peak fatigue and greater amplitude of fatigue scores than non-exercisers. The average levels of peak fatigue for both groups were 5 to 7 (moderate fatigue) on a 0 to 10 scale. 60% of exercisers reported peak fatigue levels within days 14 to 17 after chemotherapy during cycle 2 and within days 16 to 19 during cycle 3. Peak fatigue of some non-exercisers was reported for the first 3 days or days 13 to 17 during cycles 2 and 3. The most common peak fatigue pattern during cycle 4 in both groups was a sharply increased fatigue level within 24 hours after chemotherapy. Highest fatigue often occurred during the latter half of cycle 3 or beginning of cycle 4. Exercisers reported slightly higher average fatigue level than non-exercisers over four cycles of chemotherapy.
Implication for Nursing Practice: Results show shorter duration, but greater amplitude of fatigue, therefore clinical implications are premature. (Funded by NIH, National Cancer Institute, RO1 CA83316.)

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QUALITY OF LIFE AND FATIGUE IN LUNG CANCER PATIENTS: DOES A SEATED EXERCISE PROGRAM MAKE A DIFFERENCE? Lauri John, PhD, RN, CNS, University of Texas at Austin School of Nursing, Austin, TX.

Problem/Purpose: Fatigue has frequently been implicated as a distressing effect of lung cancer and its treatment that negatively affects quality of life (QOL). Studies have shown that walking programs reduce fatigue and improve general well-being in women with breast cancer; however, there are no studies of the effects of modified exercise programs on QOL in lung cancer patients, whose participation in a walking program might be limited due to climate, safety, and/or scheduling concerns. The purpose of this pilot study is to determine the feasibility of a major research study to determine the effects of a seated exercise program on QOL and fatigue in lung cancer patients and to explore strategies used by lung cancer patients to maintain or promote QOL.
Framework: Roy’s Adaptation Model.
Design: Randomized clinical trial with repeated measures.
Setting: Participants will be recruited from oncology clinics in central Texas. The study will take place in participants’ homes.
Sample: Twenty lung cancer patients who are beginning outpatient chemotherapy with or without radiation therapy and are medically able to participate in a low to moderate intensity seated exercise program.
Methods: All participants will receive standard instructions about fatigue management, maintain a daily activity diary, and complete the Functional Assessment of Cancer Therapy-Lung (FACT-L), which measures QOL in lung cancer patients, and the Fatigue Subscale of the FACT, which measures fatigue every two weeks for three months. Participants randomized to the intervention group will be given a videotape of a low to moderate intensity seated exercise program and individualized instructions about how to modify exercise intensity. They will be encouraged to perform the exercises at least three times per week. Qualitative data regarding all participants’ perceptions of QOL and fatigue, as well as strategies used by lung cancer patients to maintain or promote QOL will be assessed at the end of the three-month study period.
Implications: Inclusion of a tailored exercise program in chemotherapy teaching for patients with lung cancer may improve quality of life, reduce fatigue, and improve treatment tolerance.

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SYMPTOM CLUSTERS PREDICT FATIGUE SEVERITY IN ONCOLOGY OUTPATIENTS. Claudia West, RN, MS, Steven Paul, PhD, Christine Miaskowkski, RN, PhD, Marylin Dodd, RN, PhD, and Kathryn Lee, RN, PhD, University of California, San Francisco, San Francisco, CA.

Recent work suggests that the presence of one or more symptoms (specifically pain, fatigue, or sleep disturbance) can influence outcomes in oncology outpatients. The purpose of this study was to determine whether the number of symptoms an oncology outpatient reported affects fatigue severity. Oncology outpatients (n = 117) who were receiving active treatment for their disease were recruited from four sites. The majority of the patients were female (75.2%) and Caucasian (86.2%) with a mean age of 59.6 years. The patients completed a demographic questionnaire, a numeric rating scale for worst pain, the Lee Fatigue Scale (LFS), the General Sleep Disturbance Scale (GSDS), and the Center for Epidemiological Studies - Depression Scale (CES-D). Patients were classified into one of four symptom groupings (i.e., 0, 1, 2, or 3 symptoms) based on pre-established cutoffs for pain, fatigue, and sleep disturbance. A linear stepwise multiple regression analysis was used to determine which of the following ten variables were significant, independent predictors of fatigue: age, gender, years of education, living arrangements, hematocrit, Karnofsky Performance Status score, CES-D score, quality of sleep score, excessive daytime sleepiness score, and total number of symptoms. The optimal regression equation included only four of these ten variables and explained 56.7% of the total variance in fatigue (F {4, 92} = 30.06, p = 0.000). The significant, unique contributions of these four variables were: 7.84% for number of symptoms (p = 0.000), 7.45% for excessive daytime sleepiness (p = 0.000), 5.06% for depression (p = 0.001), and 2.79% for quality of sleep (p = 0.017). These findings suggest that increased levels of fatigue occur in patients who are experiencing multiple symptoms, are depressed, have poorer sleep quality, and report excessive daytime sleepiness.

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INFLUENCE OF INTENSIVE CANCER PAIN MANAGEMENT IN THE DEVELOPMENT OF FATIGUE, HALLUCINATION, AND SEDATION. Shirley Hwang, RN, MS, Janet Cogswell, RN, MSN, AOCN^®, Erma Morales, RN, MSN, Victor Chang, MD, Yvette Alejandro, RN, BSN, and Pamela Osenenko, RN, VA New Jersey Health Care System, East Orange, NJ.

The purpose of this study was to identify independent predictors of clinically significant fatigue (usual fatigue = > 3/10) and analgesic related CNS toxicity (hallucinations and sedation) 1 week after intensive opioid management. The study is based on a multidimensional biopsychosocial framework. One hundred and thirty eight (138) patients with worst cancer pain severity = > 4/10 completed the Brief Pain Inventory, Brief Fatigue Inventory, and Memorial Symptom Assessment Scale-Short Form at baseline and week 1. Patients reporting hallucinations, confusion, sedation, and myoclonus were assessed at both time points. The median age was 67 years (43–86). At day 1, median KPS was 60 (40–80), hemoglobin 11.8 mg/dL (6.8–16), usual fatigue severity 5 (0–10), and worst pain severity 9 (4–10) with morphine equivalent daily dose (MEDD) 20 mg (0–3, 120). At week 1, there was a significant improvement in KPS (median 70 {20–90}, p < 0.0001), and in worst pain severity (6 {0–10}, p < 0.0001). The MEDD was 90 mg (0–3, 120), and the percentage of patients on opioids increased from 65% to 96%. CNS toxicity included greater sedation in 49 patients (28%), difficulty concentrating in 25 patients (19%), confusion in 28 patients (18%), myoclonus in 25 patients (17%), and hallucinations 18 patients (13.6%). However, only hallucinations (7% versus 18%, p = 0.007) and sedation (34% versus 54%, p = 0.001) showed a significantly higher incidence at week 1. Patients with hallucinations (RR = 0.44, p = 0.004) and sedation (RR = 0.67, p = 0.02) were at increased risk for poor pain outcome at week 1. By multidimensional multivariate logistic analysis, the presence of feeling confused, hemoglobin level, preexisting hallucinations, and difficulty sleeping (p < 0.0001 & = 0.02, 0.03, 0.02, respectively) predicted hallucinations independently. Feeling drowsy, preexisting sedation, older age, and KPS (p = 0.001, 0.007, 0.005, 0.03, respectively) predicted sedation independently. Clinically significant fatigue was present in 71% of patients; feeling drowsy, feeling nervous, sedation, and difficulty concentrating (p < 0.0001 & = 0.03, 0.05, 0.05, respectively) predicted clinically significant fatigue independently. Most patients required further fatigue management. MEDD did not predict hallucinations, sedation, or fatigue in univariate analyses. In conclusion, patients with preexisting CNS symptoms, difficulty sleeping, older age, lower hemoglobin, and poor KPS are at increased risk for developing hallucinations and sedation after intensive cancer pain management.

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WHO BENEFITS FROM ENERGY CONSERVATION FOR CANCER-RELATED FATIGUE? Andrea Barsevick, DNSc, RN, AOCN^®, Fox Chase Cancer Center, Philadelphia, PA; William Dudley, PhD, University of Utah, Salt Lake City, UT; Lillian Nail, PhD, RN, FAAN, Oregon Health and Science University, Portland, OR; and Susan Beck, PhD, APRN, University of Utah, Salt Lake City, UT.

The purpose of this secondary analysis of data from a randomized clinical trial (RCT) was to identify characteristics that predict benefit from an energy conservation/activity management (ECAM) intervention for cancer-related fatigue. The Common Sense Model provided the conceptual basis for the RCT. Valid and reliable measures were used to evaluate fatigue at baseline and two follow-up points of expected high fatigue. The RCT demonstrated that teaching energy conservation (delegation, priority setting, pacing oneself, and planning activities at times of peak energy) benefited a diverse sample of 396 men and women. The ECAM group reported less fatigue, distress, and impact than a comparison group. Given the positive result, it is essential to identify patient characteristics that will enable busy clinicians to target individuals most likely to benefit from this intervention. The secondary analysis included 111 participants in the ECAM group who completed measures at all three data points. Multiple regression with residual analysis was used to create a dichotomous variable indicating high or low change in fatigue scores. Change scores indicated greater or less benefit from the ECAM intervention. Chi-square and t-tests were used to evaluate demographic (age, education, marital, or work status), clinical (diagnosis, disease stage, performance status, treatment type, or side effects), and behavioral characteristics (baseline function in usual activities, sleep disturbance, and mood disturbance) as candidate predictors of benefit from the intervention. Only cancer treatment group (p = .001) and functional performance of household duties (.01) distinguished the groups with greater or less benefit from the intervention. More than two thirds of those in the high benefit group (71%) had been treated with RT compared with 29% of those receiving CTX/concurrent therapy. Persons in the high benefit group had significantly better baseline performance of household activities than the low benefit group. The findings indicate that persons receiving less intensive therapy, such as RT, and those who start out with higher baseline functioning are most likely to benefit from the ECAM intervention. The results suggest that persons treated with intensive therapy or whose usual functioning is compromised at the start of therapy may require more intensive or more comprehensive symptom management.

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FACTORS ASSOCIATED WITH FATIGUE IN WOMEN BEFORE AND AFTER SURGERY FOR BREAST CANCER. Grace Dean, RN, PhD, City of Hope, Duarte, CA; Linda Sarna, RN, DNSc, FAAN, University of California, Los Angeles, Los Angeles, CA; and Marcia Grant, RN, DNSc, FAAN, City of Hope, Duarte, CA.

Significance: While significant literature supports the occurrence and distress of cancer treatment-related fatigue and fatigue in advanced cancer, little evidence is available on the newly diagnosed cancer patient.
Purpose: This study explored the occurrence of fatigue and relationship of mood and symptom distress on fatigue in women before and one month after surgery for breast cancer.
Theoretical Framework: Piper’s Integrated Fatigue Model was used to guide this study.
Methods: A descriptive prospective one group pre-post design was used to describe changes in, and relationships between fatigue, mood, and symptom distress. Twenty women scheduled for breast cancer surgery were recruited from a cancer center in Southern California. Data were collected on fatigue (Piper Fatigue Scale, Profile of Mood States fatigue and vigor subscales), mood (Hospital Anxiety and Depression Scale), and symptom distress (Symptom Distress Scale = SDS). Higher scores indicate more fatigue, negative mood, and more symptom distress.
Data Analysis: Descriptive statistics, correlations, and paired t-tests were used for the analysis.
Findings and Implications: Mean scores for fatigue revealed nonsignificant differences (4.63 pre-op to 4.68 postop; p = 0.94). Mean scores for anxiety decreased significantly (9.25 pre-op to 7.26 postop; p < 0.02). Anxiety subscale scores of 11 or greater (need further evaluation) were found in 10 (50%) participants pre-operatively and only 4 (20%) participants postoperatively. Mean scores for depression revealed nonsignificant differences (5.50 pre-op to 5.42 postop; p < 0.79). Depression subscale scores of 11 or greater (need further evaluation) were found in 3 (15%) participants pre-operatively and 2 (10%) participants postoperatively. Mean scores for the SDS demonstrated nonsignificant differences (23.05 pre-op to 23.89 post-op; p < 0.84). Three symptoms reported with greater frequency and varying levels of distress both pre- and post-operatively were outlook, insomnia, and fatigue. Fatigue, mood, and symptom distress were moderately to highly correlated. These results confirm previous research findings on newly diagnosed women with breast cancer (Cimprich, 1999). (This research was supported by the Sigma Theta Tau/Oncology Nursing Foundation Grant.)

140
FACTORS INFLUENCING FATIGUE DURING AND AFTER CHEMOTHERAPY: RESULTS OF A FEASIBILITY SLEEP INTERVENTION STUDY. Ann Berger, PhD, RN, AOCN^®, and Barbara Piper, DNS, RN, AOCN^®, FAAN, University of Nebraska Medical Center, Omaha, NE; and Patti Higginbotham, MSN, RN, OCN^®, Alegent Health, Omaha, NE.

Significance: The number of women undergoing adjuvant breast cancer chemotherapy continues to increase due to the aging of baby boomers and use of more aggressive first-line therapies. Previous descriptive research has found that symptoms, physical functioning, psychological status, activity/rest, and sleep/wake patterns are associated with fatigue in women during and after treatments.
Purpose: A behavioral intervention promoting quality sleep was tested to determine its impact on sleep and fatigue during and after adjuvant breast cancer chemotherapy.
Theoretical Framework: Piper’s Integrated Fatigue Model.
Methods: Prospective, repeated measures, feasibility design; enrolled 25 post-op women with stage I or II breast cancer receiving four cycles of Adriamycin-based chemotherapy. Mean age 54.3, most were married, employed full or part time, with some college education. After the four cycles of Adriamycin-based chemotherapy, 21 women remained in the study until the last measurement, of which 8 also had 4 cycles of Taxol, 10 also had radiation, and 18 were taking Tamoxifen. Instruments used had adequate reliability and validity, and included symptom experience scale, MOS- SF-36, wrist actigraph, Pittsburgh Sleep Quality Index, Morin Sleep Diary, and Piper Fatigue Scale. SPSS was used to test relationships among variables at 8 times over 1 year beginning with the first treatment.
Findings: During all 4 cycles of chemotherapy, night awakenings combined with symptoms at cycles 1 and 2, sleep latency at cycle 3, and anxiety at cycle 4 contributed significantly to fatigue in tensity (p< .05–.007). At all times after chemotherapy, symptoms contributed significantly to fatigue. Symptoms combined with length/naps were significant 30 days afterwards; physical functioning status and depression were significant 60 and 90 days after and 1 year after the first chemotherapy treatment (p < .05–.003). Additional contributors to later fatigue combined with symptoms at various times were decreased sleep efficiency, sleep quality, increased night awakenings, or anxiety.
Implications: Interventions that focus on reducing disruptions from symptoms and maintain physical functioning, psychological status, activity/rest, and sleep/wake patterns are most likely to modify fatigue during and after chemotherapy. Interventions should be tailored and contain elements from each of these areas, with particular emphasis on symptoms, especially sleep disturbances.

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EVALUATING THE CLINICAL IMPORTANCE OF A FATIGUE ASSESSMENT TOOL: A PILOT STUDY. Maureen Quick, RN, BSN, OCN^®, Self-Employed, Contracted Consultant for Oncology Education Services, Inc., Bloomington, MN; and Elizabeth Kraatz, RN, PhD, AOCN^®, University of Minnesota School of Nursing, Minneapolis, MN.

Patients can experience a multitude of symptoms related to their cancer and cancer treatment. Pain, nausea, and vomiting have been the focus of considerable research over the years. Providing evidence-based clinical interventions has improved patient care and successful management of these side effects is a hallmark of cancer nursing. In recent years, fatigue has been recognized as a prevalent and often debilitating symptom for cancer patients. Despite the increased recognition of cancer-related fatigue (CRF), it is often not assessed in the clinical setting. Clinicians do not always recognize fatigue as a critical symptom and perceive a lack of effective therapy. Assessment of fatigue is also difficult because it is complex and multi-dimensional.
A study was designed to evaluate the clinical importance of a patient fatigue assessment tool for nurses in the clinical setting. The purpose was to identify whether assessing fatigue and potential contributing factors is beneficial in assisting nurses in identifying interventions to minimize the impact of CRF. The fatigue assessment tool is a survey that includes questions about the onset, intensity, and duration of fatigue as well as known factors that contribute to the experience and severity of fatigue. A pilot study conducted at four outpatient oncology clinics in a large urban area included a sample of 112 cancer patients and 24 oncology nurses. Patients were asked by their clinic nurses to be participants in the study and complete a fatigue assessment tool. At the end of data collection, the nurses were asked to complete a questionnaire evaluating the utility of the fatigue assessment tool in clinical practice. Data collection is complete and will be analyzed using the SPSS statistical program.

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WOMEN RECEIVING ADJUVANT CHEMOTHERAPY FOR BREAST CANCER: IMPACT ON QUALITY OF LIFE AND FATIGUE. Katherine Byar, RN, BSN, and Ann Berger, RN, PhD, AOCN^®, University of Nebraska Medical Center, Omaha, NE.

Significance: As more women receive adjuvant chemotherapy for breast cancer, there is a growing recognition of the potential long-term side effects such as increased fatigue, decreased stamina, and loss of energy that impact quality of life (QOL).
Purpose: The first was to determine the domains of QOL most affected by chemotherapy. The second was to determine relationships between fatigue and QOL domains. The third was to examine relationships between demographic variables and QOL domains.
Conceptual Framework: Components of the Piper’s Integrated Fatigue Model.
Methods: Prospective repeated measures study. Caucasian women (n = 25) following surgery for stage I or II breast cancer, followed by Adriamycin-based chemotherapy (8 received Taxol, 10 received radiation, 18 received Tamoxifen).
Reliable and Valid Instruments: Piper Fatigue Scale (PFS), Medical Outcomes Short Form-SF-36, Fatigue Intensity (Item #7 on the PFS), Symptom Experience Scale (SES). Data collected at eight times; two days prior to and seven days following four chemotherapy treatments, then for seven days at 30, 60, and 90 days following the last chemotherapy treatment, and one-year after the first treatment.
Results: At the beginning of the first chemotherapy, six domains of QOL were significantly below population norms, mental and general health was WNL. Sixty days after the chemotherapy was completed, physical (X = 70.71) and role-physical (X = 47.62) domains, were still significantly below norms, with other domains returning to norms, except mental (X = 80.38) which was higher. At one-year, five domains returned to norms, and mental, social, and general health was higher than norms.
Women who reported higher fatigue at the beginning of the first chemotherapy had lower mental functioning (r = -0.433, p < 0.05). Sixty days after chemotherapy, women reporting higher fatigue had lower functioning for all QOL domains except bodily pain (r = -0.784 to 0.785, p < 0.01). One year after the first treatment, women who reported higher fatigue had lower social functioning, vitality, general health, and more pain (r = -0.625 to –0.597, p < 0.01). No demographic variables were associated with significant differences in the QOL domains.
Implications: Data regarding QOL and fatigue is important so nurses can determine the most effective intervention to improve outcomes and individualize care.

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THE INFLUENCE OF CAREGIVER AGE AND GENDER, AND PATIENT CLINICAL FACTORS ON FAMILY CAREGIVERS’ PERCEPTIONS OF AND INVOLVEMENT IN CANCER PAIN MANAGEMENT. Patsy Yates, PhD, RN, Helen Skerman, MsocSc, and Helen Edwards, PhD, RN, Queensland University of Technology, Brisbane, Queensland, Australia; Sanchia Aranda, PhD, RN, and Peter MacCallum, Sancha Cancer Institute, Melbourne, Victoria, Australia; and Robyn Nash, MHlthSc, Queensland University of Technology, Brisbane, QLD, AU.

Many family caregivers are actively involved in managing their relative’s cancer pain; however little is known about their pain management experiences and their impact on caregivers and patients. Based on the PRECEDE model of health behavior, the purpose of this study was to identify factors which may influence family caregivers’ experiences with cancer pain management. A consecutively recruited cohort of 75 family members attending outpatient oncology clinics with a relative who had experienced cancer pain in the past month completed a self-administered survey. The sample had a mean age of 55 years (SD = 13.5), with 75% being female. 68% of the sample rated their family member’s average pain in the past week as 5 or higher on an 11-point numeric rating scale. The survey comprised measures of: 1) demographics/medical characteristics, 2) pain knowledge, 3) concerns about addiction, side effects, progression, tolerance, 4) perceived difficulty communicating regarding pain, and 5) pain management actions. On a scale from 0 = none to 10 = a great deal, family caregiver’s mean knowledge score was 5.5 (SD = 2.5), while their mean preparedness and confidence scores were 7.8 (SD = 2.5) and 6.8 (SD = 2.9), respectively. All family caregivers (100%) stated they wanted t