Research On Assessment Of Chemotherapy-induced Peripheral Neuropathy In Cancer Patients

Objective: To examine status and factors influencing oncology nurses' knowledge,attitude,and practice regarding Chemotherapy-induced peripheral neuropathy(CIPN)assessment and management,and to recognize barriers for CIPN assessment and management as well as their needs for continuing education on CIPN.To explore CIPN symptom experience,the interference with activities of daily lives(ADL),and coping style in cancer patients with CIPN by qualitative research.To translate Chemotherapy-induced Peripheral Neuropathy Assessment Tool(CIPNAT)into Chinese and evaluate its reliability and validity,so that we could develop the Chinese version of CIPNAT.And to investigate the characteristic of CIPN and interference with ADL,to identify the relationship among CIPN,psychological distress,sleep disturbance and hearth-related quality of life(HQOL)by quantitative analysis,so that we could provide theoretical guidance for the targeted intervention.Methods: 1.Knowledge,Attitude and Practice regarding Chemotherapy-induced Peripheral Neuropathy Assessment and Management among Oncology Nurses Through comprehensive review of literature,we developed an electronic survey of CIPN knowledge,attitude,and practice among oncology nurses.After releasing questionnaire on Sojump(A software which is popular in China to release questionnaire online)to Wechat group of Shaanxi Anti-Cancer Association Oncologic Nursing Committee,the members filled in it and forwarded it to their colleagues in the same setting.After participants filled questionnaire,the data was transmitted to back-stage database of Sojump,and all data can be output from the back-stage database.The statistical package for the Social Science(SPSS)version 20.0 was used to analyze the data,and descriptive statistics were applied to the research questions.Enumeration data were described by frequency and percentage,while the Measurement data were described by `x±s.Univariate and multivariate analysis were used to identify the factors influencing oncology nurses' knowledge,attitude and practice on CIPN assessment and management.2.Cancer Patients with Chemotherapy-induced Peripheral Neuropathy: A Qualitative Research of Symptom Experience and Coping Style Using semi-structured interviews,18 cancer patients with CIPN was selected following the guidance of colaizzis phenomenological method in qualitative research and the conversation data were analyzed.3.Quantitative research on CIPN(1)Localization and Evaluation for Reliability and Validity of Chemotherapyinduced Peripheral Neuropathy Assessment Tool.The Chinese version of CIPNAT was translated from the original scale that Pro.Togthagen of University of South Florida developed in 2008,back-translated and adjusted for cultural adaptation after getting permission from the author.The reliability and validity were tested in 260 cancer patients.Reliability was estimated using the Cronbach's ? coefficient and rest-retest reliability.Validity was evaluated by content validity,exploratory/confirming factor analysis,criterion-related validity and discrimination validity.(2)Research on Relationship among CIPN,Fall/Near falls,Psychological Distress,Sleep Disturbance and HQOL.The cross sectional,descriptive study included 179 patients who had received neurotoxic chemotherapy and reported at least one symptom of peripheral neuropathy in the first section of this part.Questionnaires including the Chinese version of CIPNAT,HADS,PSQI,SF-36 and a demographic survey were administered.And data were analyzed using descriptive statistics,independent-sample T test,binary logistic regression,multiple linear regression,pearson correlation analysis and structural equation model(SEM).Results: 1.Knowledge,Attitude and Practice regarding Chemotherapy-induced Peripheral Neuropathy Assessment and Management among Oncology Nurses(1)A total of 309 valid questionnaires were returned.The majority of participants were women from oncology unit in triple A hospitals,most of whom possessed college degree or above.And most participants(94.17%)recognized that CIPN is an important issue for patients.(2)Knowledge: The mean score for nurses' knowledge on CIPN is 9.16±1.93,only accounting for 57.25% of this domain,indicating that nurses' knowledge is poor.And many nurses had no idea which drug was neurotoxic.Attitude: Although most nurses took positive attitude to CIPN assessment and management,and believed nurses play an irreplaceable role in assessing CIPN in patients.Only 7.8% of the nurses,however,thought that they were familiar with CIPN and could assess it confidently.Practice: Nurses reported that routine CIPN assessment and management were performed infrequently.Only 62.5% of the nurses would frequently assess the occurrence of CIPN.And practice item with lowest score is deep tendon reflexes assessment,while what nurses practice most is gross motor.(3)Multivariate analysis indicated that nurses' knowledge,attitude,and practice are influenced by whether they believed CIPN is an important issue for patients or not.Besides,related training and professional title are also factors influencing practice on CIPN assessment and management.(4)Barriers for CIPN assessment: Only 7.77% of the nurses believed they can perform it well and no barrier stops them.Barriers cited for not routinely perform CIPN assessment mainly focused on the following items: do not know how to perform neurologic assessment(68.93%),have no access to questionnaires(57.93%),do not know how to evaluate(55.66%),and do not know which drugs are neurotoxic(36.57%).Nearly 90% have not ever participated in training on CIPN assessment.Group study held in working setting(76.38%)was the preferred way to expand nurse's knowledge,next is the academic workshop(71.20%).2.Cancer Patients with Chemotherapy-induced Peripheral Neuropathy: A Qualitative Research of Symptom Experience and Coping Style Four themes were concluded in this study.Theme 1: Diverse symptoms were present in CIPN patients,including numbness,neurotoxic pain,weak extremity,blurred vision,discomfort feelings,altered taste and reduced memory.Theme 2: Patients' activities of daily life were affected,including difficulty in fine motor skill,higher risk for fall and sleep disturbance.Theme 3: Patients' psychological burden was heavy,including anxiety and upset.Theme 4: Patients showed different coping style to manage CIPN,like keeping warm,massage,exercise,medicine,change or quit current chemotherapy regimen.3.Quantitative research on CIPN(1)Localization and Evaluation for Reliability and Validity of Chemotherapyinduced Peripheral Neuropathy Assessment Tool.(1)After forward-backward translated,regulated,and the content validity,the I-CVI was 0.89-1,S-CVI was 0.92;(2)Item analysis: no deleted items.The result of project analysis suggested that the items has good identification;The correlation coefficient between each item and total score was 0.32-0.70(p<0.01);Except for the subscale“Interfence with ADL” presenting with slight floor effects,the other subscale and the total scale showed neither floor effects nor ceiling effects.(3)Reliability: The Cronbach's ? coefficient(0.89 to 0.94)and test-retest reliability(0.89 to 0.93)were acceptable.(4)Validity: The correlation coefficient between subscales was 0.632,and the correlation coefficient between subscales and total score was 0.814-0.964(p<0.01);Exploratory factor analysis(EFA)identified 2 subscales in Subscale One“Patients' Experience” and Subscale Two “Interference with ADL”,and the cumulative variance contribution rate was 53.61% and 57.46% respectively.Confirmatory factor analysis(CFA)indicated the fit indices of the measurement were improved.Difference between the score of CIPNAT in patients receiving neurotoxic agents and non-neurotoxic agents is significant,indicating good discrimination validity;The correlation coefficient between CIPNAT score and NCI-CTC score was 0.783-0.873(p<0.01),which indicated that the CIPNAT scale had good criterion related validity.(2)Research on Relationship among CIPN,Fall/Near falls,Psychological Distress,Sleep Disturbance and HQOL.(1)Characteristic of Paticipants in This Study A total of 179 patients were collected.The majority of participants were married(92.2%),less educated(50.8%)and unemployed(50.8%),with gastric cancer(33.0%),colon cancer(35.7%),surgery(63.7%),advanced(III 34.6% ? IV 31.8%)and metastatic(70.9%)cancer and platium-based chemotherapy(65.9%).The duration of neurotoxic chemotherapy is 1-18,with an average of 5.51 ± 3.30 courses,and the cumulative dose of neurotoxic agents is 519.17±335.32 mg/m2.Besides,125,47 and 7 participants received low,moderate and high cumulative dose of neurotoxic agents respectively.Of them,78(43.6%)patients had neurotoxic pain,128(71.5%)patients had sleep disturbance,and the number of patients with anxiety and depression is 52 and 58 respectively.(2)Symptom and Interference of ADL of CIPN The most common symptom was “numbness in the fingers/hands”(72.1%),the most serious symptom is “sensitive to cold temperature”(5.51±2.00),the most distressing symptom is“tingling in the toes/feet ”(4.44±2.17)and “trouble with your balance”(4.39±2.13),and the most frequent symptom is “numbness in the toes/feet”.The average score of interference with ADL is 23.97±18.38.Exercise(54.2%)and walking(49.7%)were interfered most,and sexual life(12.8%)was interfered least.The severity of interference with clothing and walking is 4.29±2.16 and 4.19±2.07 respectively.The patients with high cumulative doses showed a significant of CIPNAT score,CIPN experience,interference with ADL,neurotoxic symptom number,severity of CIPN, numbness in the hands and feet,tingling sensation in the hands and feet,muscle or joint aches,and weakness in the arms or legs.And symptom severity increased substantially with cumulative dose of chemotherapeutic agents(3)CIPN and Fall/Near falls In this sample(n=179),30 patients had falls and near falls.Univariate logistic regression analysis identified potential risk factors for falls and near falls in patients with CIPN including depression,neuropathic pain,number of neuropathic symptoms,score of sensory/ motor neuropathy,severity of CIPN,CIPN experience and interference with activity of daily life,total score of Chemotherapy-Induced Peripheral Neuropathy Assessment Tool,severity of loss of balance and muscle weakness,as well as self-reported interference with walking.Multivariate logistic regression analysis showed number of neuropathic symptoms(OR=1.318,p=0.031),severity of loss of balance(OR=1.298,p=0.028)and interference with walking(OR=1.239,p=0.021)were independently associated with falls and near falls.(4)CIPN and Psychological Distress Nearly 30% of 179 patients have anxiety and depression in this study.Multiple linear regression showed total score of CIPNAT,sleep disturbance and combination of neurotoxic agents are the influencing factors for anxiety in patients with CIPN,and total score of CIPNAT and sleep disturbance are the influencing factors for depression in patients with CIPN.Pearson correlation analysis showed symptom experience and interference with ADL had positive and moderate correlation with anxiety and depression in CIPN patients.(5)CIPN and Sleep Disturbance The average score of PSQI is 8.81±4.38 in 179 patients with CIPN,which is lower than the average people(3.88±2.52)with significant differences.The number of CIPN patients with poor,general and good sleep quality is 100(56%),43(24%)and 36(20%)respectively.Multiple linear regression showed anxiety and total score of CIPNAT are the influencing factors for sleep quality in patients with CIPN.Pearson correlation analysis showed symptom experience and interference with ADL had positive correlation with other dimensions of PSQI except taking medicine to help sleep.(6)CIPN and HQOL HQOL in cancer patients was poor.Multiple linear regression showed KPS score,total score of CIPNAT,anxiety,depression and sleep disturbance are the influencing factors for HQOL in patients with CIPN.Pearson correlation analysis showed each dimension of CIPN had negative correlation with each dimension of HQOL.(7)Relationship among CIPN,Psychological Distress,Sleep Disturbance and HQOL.SEM showed that symptom experience of CIPN had direct positive effect on psychological distress(?=0.23,p<0.01);CIPN interference with ADL had direct positive effect on psychological distress and sleep disturbance(?=0.42,?=0.24,p<0.01),and direct negative effect on HQOL(?=-0.16,p<0.01);Psychological distress had direct positive effect on sleep disturbance(?=-0.34,p<0.01)and direct negative effect on HQOL(?=-0.70,p<0.01);sleep disturbance had direct negative effect on HQOL(?=-0.16,p<0.01);CIPN interference with ADL had indirect effect on HQOL via psychological distress and sleep disturbance.So psychological distress and sleep diaturbance are both direct and mediating variables.Conclusion: 1.Nurses' knowledge,attitude and practice towards CIPN assessment and management are affected by whether they believe CIPN is an important issue for patients.So raise the awareness on importance of CIPN and their knowledge regarding CIPN is the key to better practice.Educators are suggested to develop some specific training projects focused on basic knowledge of CIPN,CIPN assessment,related guidelines and prevention measures of CIPN,so that to improve nurses' ability to better assess and manage CIPN.Also,assessment tool for CIPN which is applicable for Chinese cancer patients needs to be developed.2.The Chinese version of CIPNAT has good reliability and validity.It can be applicable to assess CIPN comprehensively in China and help nurses better understand CIPN.3.CIPN presented diverse symptom and interference of ADL,so it remains a major issue in cancer survivors.With the increase of cumulative dose of neurotoxic agents,patients' experience of CIPN become more severious,and their ADL will be greatly limited.4.Patients with CIPN who reported more neuropathic symptoms,those with CIPN interfering with walking and those having trouble with balance may be at a higher risk of falls.To reduce the risk of falls or near falls,it is necessary to not only assess the symptoms of CIPN,but also provide balance and activity training.Recommendations in terms of aids and security environment at home for patients undergoing neurotoxic chemotherapy are also helpful to reduce the risk of falls.5.CIPN showed positive relation with anxiety/depression and negative correlation with sleep quality and HQOL.Also,CIPN is the risk factor for psychological distress,sleep disturbance and poor HQOL.6.Symptom experience of CIPN had direct effect on HQOL.CIPN interference with ADL had direct and/or indirect effect on HQOL,psychological distress and sleep disturbance,as midiated variables,can mediate the relationship between CIPN and HQOL.