Your SlideShare is downloading. ×
FACET - European Journal of Cancer Care
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×
Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply

FACET - European Journal of Cancer Care

483

Published on

0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total Views
483
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
1
Comments
0
Likes
0
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide
  • Notes
    The side-effects of chemotherapy treatment can influence patients’ quality of life, distress and adherence to treatment. By assessing the symptoms patients experience during chemotherapy, we can then develop strategies to manage them more effectively.
    Informal assessment is the most common way of assessing symptoms, but it is unsatisfactory for the following reasons:
    Patients prefer health professionals to initiate discussions
    Professionals fail to elicit patients’ concerns
    Assessment of psychosocial problems is particularly poor
    Poor continuity of care results from poor communication / agreement between professionals.
  • Notes
    Existing scales were found to be unsuitable for routine clinical assessment by patients. There are three main types:
    ‘Home-produced’ checklists:
    These lack validity and comprehensiveness. There is typically no scoring method and so they are unsuitable for quantifying change in symptom experience over time.
    Toxicity rating scales:
    Here, symptoms are rated by the clinician, rather than the patient. The scales are also limited to collecting information on the most common problems.
    Research scales:
    These are often lengthy, time consuming, and in formats inappropriate for clinical use.
    If you are already using a symptom assessment tool, how effective is it? Is it easy to apply and does it enable you to assess the outcome of managing side-effects?
  • Notes
    The Chemotherapy Symptom Assessment Scale (C-SAS)4 is a scale for the routine clinical assessment of the symptom experiences of patients receiving cytotoxic chemotherapy. The development of this assessment scale was the outcome of a descriptive study of the symptom experience of patients receiving chemotherapy for common cancers.
    In spring 1992, the Chemotherapy Unit at Worthing Hospital was selected as one of 30 new Nursing Development Units. With this came an unrestricted award of £80,000 over three years. A researcher was appointed in May 1993 and seven projects were identified.
    The main project was a descriptive study of the symptom experience of patients receiving chemotherapy for common cancers – breast, colorectal, ovarian and non-Hodgkin’s lymphoma. In total, 132 patients and all staff were involved. The research methodology for this study included the development of a patient self-report assessment questionnaire.
  • Notes
    In order to collect data for the initial descriptive study, we developed a patient self-report assessment scale – the Worthing Chemotherapy Questionnaire (WCQ75). Although this proved valid and reliable, with 75 questions it was too long and detailed for routine clinical use at every chemotherapy episode. However, all the patients who completed the WCQ75 felt more supported and satisfied with their care.
    This and the good response to our work from the cancer nursing community encouraged us to seek further funding to refine the scale into what is now the C-SAS.
    In 1996/97 we submitted a funding application, in collaboration with King’s College, London and Bromley Hospitals NHS Trust to the NHS South East Research and Development Project Grant Scheme. Our application was unsuccessful, so we revised and re-submitted it. This time it was successful and in 1999-2000, we were awarded £60,000. The funding was for the development and psychometric testing of C-SAS, an exhaustive process!
  • Notes
    The C-SAS, developed from the original questionnaire, now consists of 24 questions and is far more manageable for patients to use. There is also some room to document any extra symptoms the patient may have experienced.
    A pack is given to every patient at the beginning of their chemotherapy treatment. Depending on the chemotherapy regime, the pack will contain sufficient questionnaires for the patient to complete one after each episode of treatment.
    Patients bring the completed questionnaire with them when they next return for treatment. The questionnaire asks patients if they have ever experienced any of the side-effects listed and the extent to which they have been troublesome. Their responses provide a focus for discussion and treatment planning with clinical staff and are reviewed with patients at each treatment episode. Strategies to manage the symptoms can then be reviewed at their next appointment.
  • Notes
    Slides 6-9 provide an in-depth description of the research process involved in the development of the C-SAS.
    The number of items from the WCQ75 needed to be reduced for the scale to become more manageable.
    An up-to-date literature review was conducted and 267 studies were reviewed. This was to examine whether pooled items were supported by literature on chemotherapy side-effects and to identify further side-effects which should be included in the item selection process.
    A pilot study, with 72 patients receiving chemotherapy, was conducted in two outpatient facilities, Worthing and Southlands Hospitals NHS Trust, and Bromley Hospitals NHS Trust. This was undertaken to establish whether items in the C-SAS reflected patients’ experiences. It also identified additional symptoms experienced by patients. Equally, it was important to establish whether patients could complete the C-SAS within a reasonable time.
  • Notes
    Patients were asked to compare their symptom experience with the items on the scale and for their views on symptom assessment.
    Five focus groups involving 48 patients were held and patients were asked individually to rate pooled items through a questionnaire. Postal feedback was gained on the redrafted C-SAS from a sample of 25 patients.
    Data from focus groups showed that patients under-report symptoms for various reasons. These comments from two different patients undergoing chemotherapy illustrate some of the problems.
    “You think ‘What can they do about it?’ They are just general things they must have heard a million times before so I tend not to say anything.”
    “They are things you are warned about anyway…so you think there is no point saying anything because they know this is going to happen.”
  • Notes
    Health professionals were asked for their views on symptom assessment. A questionnaire was sent to 23 oncology health professionals – nurses, doctors and pharmacists. Their ratings of the importance of items for inclusion in a scale was combined with patients’ ratings to establish consensus.
    This meant that the number of items to be included in the C-SAS was reduced in a systematic way. Involving patients’ and expert health professionals’ opinion was crucial to the development of the final version of the C-SAS.
    The C-SAS was assessed for both validity - that the scale actually measured the expected symptoms and reliability - that the C-SAS would consistently measure symptoms experienced by patients.
  • Notes
    Content validity
    Content reliability was established through re-analysis of WCQ datasets with factor analysis and item endorsement analysis.
    Criterion validity
    The C-SAS was compared with the Rotterdam Symptom Checklist and Memorial Symptom Assessment Scale with 134 patients. (Mean rho = 0.69)
    Construct validity
    The degree to which the scale measured symptoms was developed through hypothesis testing. This was carried out with 40 patients and showed a statistically significant result.
    Test-retest reliability
    58 patients (mean kappa = 0.59)
    Internal consistency
    142 patients (mean alpha = 0.75)
  • Notes
    The C-SAS is the only chemotherapy assessment scale specifically designed for routine clinical use across a range of disease types and chemotherapy regimes. It was developed by a strongly collaborative clinical / academic team led by a small clinical unit.
    The C-SAS has undergone a process of development and testing far more rigorous than most scales. Most importantly, patients and health professionals were involved in its development. It assesses not only how severe the symptom is but how much it is bothering the patient. Therefore, symptom management focuses on what is most important to the patient.
    The C-SAS includes space for a nursing action plan, assisting not only better patient-nurse communication but better side-effect management and documentation. Neither is it restricted to use by nurses as it is also designed for multidisciplinary use. Another advantage is that it is designed so that a complete assessment fits on a single sheet of paper.
  • Notes
    Using the C-SAS empowers the patient in reporting side effects to health professionals. It also improves doctors’ and nurses’ knowledge of what the patient is experiencing during chemotherapy.
    Communication is improved all round, between doctors, nurses and patients.
    A good chemotherapy symptom assessment scale improves knowledge of the range and severity of side-effects experienced by patients. This is particularly true of less common problems. The C-SAS reduces under-reporting of side effects.
    It can also form the basis of a side-effects management file for each individual patient, helping in evidence-based symptom management.
    Designed for easy entry into computer database for clinical, audit or research purposes.
    There is the potential for development of a rich database of regime-specific side-effects.
  • Notes
    We were unsuccessful in securing funding for a formal evaluation of the C-SAS. Therefore, in 2002, we started using the C-SAS in clinical practice.
    There were problems initially with its introduction and its use was a bit inconsistent. We found that the action plan was not used and neither was there any consistency in its use. There were also problems entering the data onto the spreadsheet.
    However, following discussions at inpatient unit meetings, we developed packs to give out to patients at the beginning of their chemotherapy treatment. The packs contain information about about the patient’s chemotherapy regime, with sufficient questionnaires for each treatment episode. Effectively, these are patient held records. Patients are encouraged to bring them along when they attend for treatment. The action plan is now used and side-effect management can be assessed. After the full course of treatment has been completed, the data captured on the questionnaires can be entered onto the spread sheet.
  • Notes
    It was difficult initially, to get the commitment of all the staff and also, not all patients use it. Another problem was lack of time for the data entry required to develop a rich database of regime specific data. Another problem was lack of time for the data entry required to develop a rich database of regime specific data.
    It is never easy introducing change but the experience has been worth it. While the C-SAS does take more time to use, it is an easy-to-use, good assessment tool. It enable us to gain a better understanding of patients’ experiences and better knowledge of regime specific side-effects. We have seen an improvement in communication and it is a tool that all members of the multidisciplinary team can use and benefit from.
  • Notes
  • Notes
  • Footnotes
    1Clare Dikken, Worthing Hospital, UK.
    1Vivienne Brown, Worthing Hospital, UK.
    1John Sitzia, Worthing Hospital, UK.
    1Jayne Hughes, Worthing Hospital, UK.
    2Professor Alison Richardson, The Florence Nightingale School of Nursing and Midwifery, King’s College London, London, UK.
    3Helen Hannon, Chartwell Unit, Bromley Hospital PRUH, UK.
    3Catherine Oakley, Chartwell Unit, Bromley Hospital PRUH, UK.
    Correspondence address: Clare Dikken (e-mail: [email_address])
    4For further information about how to obtain a copy of the C-SAS: Vivienne Brown (e-mail: [email_address] )
  • Transcript

    • 1. FACET - European Journal of Cancer Care December 2003 slides available at: www.blackwellpublishing.com/journals/ecc Developing a chemotherapy symptom assessment scale Dikken C.1 Brown V.1 Sitzia J.1 Richardson A.2 Hughes J.1 Hannon H.3 & Oakley C.3 SlideOne *Click on “View”; “Notes Page” for explanatory notes Structured symptom assessment is important to the good management of side-effects during chemotherapy treatment. Why is it important to assess symptoms patients experience during chemotherapy?
    • 2. FACET - European Journal of Cancer Care December 2003 slides available at: www.blackwellpublishing.com/journals/ecc Developing a chemotherapy symptom assessment scale (continued) SlideTwo *Click on “View”; “Notes Page” for explanatory notes Existing assessment scales include: • ‘Home-produced’ checklists • Toxicity rating scales • Research scales
    • 3. FACET - European Journal of Cancer Care December 2003 slides available at: www.blackwellpublishing.com/journals/ecc Developing a chemotherapy symptom assessment scale (continued) SlideThree *Click on “View”; “Notes Page” for explanatory notes The Chemotherapy Symptom Assessment Scale (C-SAS) • What is it? • How was it developed? • Where was it developed?
    • 4. FACET - European Journal of Cancer Care December 2003 slides available at: www.blackwellpublishing.com/journals/ecc Developing a chemotherapy symptom assessment scale (continued) SlideFour *Click on “View”; “Notes Page” for explanatory notes Development of the C-SAS (1) • Data collection for the initial descriptive study through a self- report assessment scale (WCQ75) • Positive feedback from patients using the WCQ75 • Further refinement of the scale leads to the C-SAS
    • 5. FACET - European Journal of Cancer Care December 2003 slides available at: www.blackwellpublishing.com/journals/ecc Developing a chemotherapy symptom assessment scale (continued) SlideFive *Click on “View”; “Notes Page” for explanatory notes What is the C-SAS? • A self-assessment scale to measure side-effects of chemotherapy treatment • 24 questions • Administered following each chemotherapy episode
    • 6. FACET - European Journal of Cancer Care December 2003 Developing a chemotherapy symptom assessment scale (continued) SlideSix *Click on “View”; “Notes Page” for explanatory notes Development of the C-SAS (2) • Exploration of WCQ item pool. • Literature review • Pilot study slides available at: www.blackwellpublishing.com/journals/ecc
    • 7. FACET - European Journal of Cancer Care December 2003 Developing a chemotherapy symptom assessment scale (continued) SlideSeven *Click on “View”; “Notes Page” for explanatory notes Development of the C-SAS (3) • Patient involvement slides available at: www.blackwellpublishing.com/journals/ecc
    • 8. FACET - European Journal of Cancer Care December 2003 Developing a chemotherapy symptom assessment scale (continued) SlideEight *Click on “View”; “Notes Page” for explanatory notes Development of the C-SAS (4) • Health professional involvement • Item consensus generation slides available at: www.blackwellpublishing.com/journals/ecc
    • 9. FACET - European Journal of Cancer Care December 2003 Developing a chemotherapy symptom assessment scale (continued) SlideNine *Click on “View”; “Notes Page” for explanatory notes Validity and reliability of the C-SAS Validity: • Content • Criterion • Construct Reliability: • Test-retest reliability • Internal consistency slides available at: www.blackwellpublishing.com/journals/ecc
    • 10. FACET - European Journal of Cancer Care December 2003 Developing a chemotherapy symptom assessment scale (continued) SlideTen *Click on “View”; “Notes Page” for explanatory notes Why is the C-SAS innovative? (1) • Specifically designed for the purpose • Rigorous development • Patients and health professionals were involved in its development slides available at: www.blackwellpublishing.com/journals/ecc
    • 11. FACET - European Journal of Cancer Care December 2003 Developing a chemotherapy symptom assessment scale (continued) SlideEleven *Click on “View”; “Notes Page” for explanatory notes slides available at: www.blackwellpublishing.com/journals/ecc Why is the C-SAS innovative? (2) • Empowers • Improves knowledge • Improves communication • Individualised patient management
    • 12. FACET - European Journal of Cancer Care December 2003 Developing a chemotherapy symptom assessment scale (continued) SlideTwelve *Click on “View”; “Notes Page” for explanatory notes Introducing the C-SAS into clinical practice • Lack of funding for formal evaluation of the C-SAS • Teething problems on introduction slides available at: www.blackwellpublishing.com/journals/ecc
    • 13. FACET - European Journal of Cancer Care December 2003 Developing a chemotherapy symptom assessment scale (continued) SlideThirteen *Click on “View”; “Notes Page” for explanatory notes Introducing the C-SAS into clinical practice • Management of change • Time factor associated with use slides available at: www.blackwellpublishing.com/journals/ecc
    • 14. FACET - European Journal of Cancer Care December 2003 Developing a chemotherapy symptom assessment scale (continued) SlideFourteen *Click on “View”; “Notes Page” for explanatory notes Further reading • Brown V, Sitzia J, Richardson A, Hughes J, Hannon H, Oakley C. (2001) The development of the Chemotherapy Symptom Assessment Scale (C- SAS©): a scale for the routine clinical assessment of the symptom experiences of patients receiving cytotoxic chemotherapy. International Journal of Nursing Studies 38(5): 497- 510. • Buckingham R, Fitt J, Sitzia J. (1997) Patients' experiences of chemotherapy: side-effects of carboplatin in the treatment of carcinoma f the ovary. European Journal of Cancer Care. 6: 59- 71. • Dennison, S. (1995) An exploration of the communication that takes place between nurses and patients whilst cancer chemotherapy is being administered. Journal of Clinical Nursing 4: 227-233. • Dikken C, Sitzia J. (1998) Patients' experiences of chemotherapy: side-effects associated with 5- fluorouracil + folinic acid in the treatment of colorectal cancer. Journal of Clinical Nursing. 7: 371- 379. slides available at: www.blackwellpublishing.com/journals/ecc
    • 15. FACET - European Journal of Cancer Care December 2003 Developing a chemotherapy symptom assessment scale (continued) SlideFifteen *Click on “View”; “Notes Page” for explanatory notes Further reading (continued) • Given, B. (1991) Compliance and health promotion behaviours. In: Baird, S.B., McCorkle, R., Grant, M. (Eds.), Cancer Nursing: A Comprehensive Textbook. Philadelphia, W.B. Saunders, pp 61-73. • Holmes, S., Eburn, E. (1989) Patients’ and nurses’ perceptions of symptom distress in cancer. Journal of Advanced Nursing 14: 840-846. • Richardson, A. (1995) Fatigue in cancer patients: a review of the literature. European Journal of Cancer Care 4: 20-32. • Richardson, J.L., Marks, G., Levine, A. (1988) The influence of symptoms of disease and side-effects of treatment on compliance with cancer therapy. Journal of Clinical Oncology 6: 1746-1751. • Sitzia J, Hughes J, Sobrido L. (1995) A study of patients' experiences of side-effects associated with chemotherapy: pilot stage report. International Journal of Nursing Studies. 32(6): 580- 600. slides available at: www.blackwellpublishing.com/journals/ecc
    • 16. FACET - European Journal of Cancer Care December 2003 Developing a chemotherapy symptom assessment scale (continued) SlideSixteen *Click on “View”; “Notes Page” for explanatory notes Further reading (continued) • Sitzia J, Dikken C, Hughes J. (1997) Psychometric evaluation of a questionnaire to document side effects of chemotherapy Journal of Advanced Nursing. 25: 999- 1007. • Sitzia J, Dikken C. (1997) Survey of the incidence and severity of side effects reported by patients receiving six cycles of FEC chemotherapy. Journal of Cancer Nursing. 1: 61- 73. • Sitzia J, North C, Stanley J, Winterberg N. (1997) Side effects of CHOP in the treatment of non- Hodgkin's lymphoma Cancer Nursing. 20(6): 430- 439. • Sitzia J, Huggins L. (1998) Side effects of combination cyclophosphamide, methotrexate and 5-fluorouracil (CMF) chemotherapy for breast cancer. Cancer Practice. 6(1): 13- 21. • Tanghe A, Evers G, Paridaens R. (1998) Nurses’ assessment of symptom occurrence and symptom distress in chemotherapy patients. European Journal of Oncology Nursing (2):14-26 slides available at: www.blackwellpublishing.com/journals/ecc

    ×