A SYNTHESIS OF LITERATURE ANO UTILIZATION}'§;_'-‘ } -
OF A FUNCTIONAL STATUS ASSESSMENT TOOL " :

FOR THE OLDER BREAST CANCER PATIENT

Scholarly Prolect fOr the Degree Of M S N '

MICHIGAN STATE UNIVERSITY
GAIL MADELINE BELL
1999

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A SYNTHESIS OF LITERATURE AND UTILIZATION
OF A FUNCTIONAL STATUS ASSESSMENT TOOL
FOR THE OLDER BREAST CANCER PATIENT
BY

GAIL MADELINE BELL

A SCHOLARLY PROJECT
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE IN NURSING

COLLEGE OF NURSING

1999

ABSTRACT
A SYNTHESIS OF LITERATURE AND UTILIZATION

OF A FUNCTIONAL STATUS ASSESSMENT TOOL
FOR THE OLDER BREAST CANCER PATIENT

BY

Gail Madeline Bell

Breast cancer is the second most common cause of
cancer death in women in the United States. Breast cancer
will affect one in nine women in their lifetimes. In the
elderly, breast cancer carries a substantial mortality. Age
is identified as a negative prognostic factor.

Breast cancer and its treatment can negatively effect
a patient's functional status. Assisting these patients in
the maintenance of their functional status is of great
importance to the health care profession. Once an older
patient’s functional status becomes altered, she is less
likely to return to her independent state after the
conclusion of treatment. The purpose of this scholarly
project is to complete a synthesis of literature and
develop a functional status assessment tool for older

breast cancer patients.

DEDICATION

This scholarly project
is dedicated
in loving memory to my
Mother:
Nancy Griggers

“The Wind Beneath My Wings”

iii

ACKNOWLEDGMENTS

I would like to express my sincere gratitude and
appreciation to my scholarly project committee, Barbara
Given (Chairperson), Louise Sealanders, and Gail Casper.
The time and advice given to accomplish this project did
not go unnoticed. Without your suggestions and expertise in
this area this scholarly project would never had been
accomplished.

I would like to thank my husband, Rob, and my
children, Christopher and Taylor, for all their love and
support through this Master's Program. I could never have
done this without you. Rob, you have been my greatest
support. You never let me quit and always made me believe I
could accomplish this goal. I would like to thank my
Father, Tom Griggers, for doing such a great job of raising
me and making me want to strive for more in my life. He
never let me forget that this goal is worth all the hard
work I put into it. I would like to thank my family, Diane,
Paul, Kim, Skip, Jackie, and Todd, for the all
encouragement and words of support. Everyone believed in me
and loved me through thick and thin. I could not have done
this without you. I would also like to thank my in-laws,
George and Ruth Bell, for the words of encouragement and
for the love you have always given so unselfishly.

iv

TABLE OF CONTENTS

Chapter 1. Problem Overview (Introduction) . . . . . . . 1
Conceptual Definitions . . . . . . . . . . . . . . . 1
Purpose . . . . . . . . . . . . . . . . . . . . . . 5
Objectives . . . . . . . . . . . . . . . . . . . . . 6

Chapter 2. Conceptual Framework . . . . . . . . . . . . 7

Chapter 3. Literature Review . . . . . . . . . . . . . . l7
Methodology . . . . . . . . . . . . . . . . . . . . 18
Treatment Options . . . . . . . . . . . . . . . . . 19
Caregiver Assistance . . . . . . . . . . . . . . . . 22
Treatment Regimen . . . . . . . . . . . . . . . . . 24

Summary . . . . . . . . . . . . . . . . . . . . 33
Psychological Effects . . . . . . . . . . . . . . . 34
Age, Comorbid Conditions, and Stage of Disease . . . 47

Summary . . . . . . . . . . . . . . . . . . . . 54
Summary . . . . . . . . . . . . . . . . . . . . . . 55
Strengths . . . . . . . . . . . . . . . . . . . . . 59
Limitations . . . . . . . . . . . . . . . . . . . . 61
Gaps in Literature . . . . . . . . . . . . . . . . . 62
Generalizations . . . . . . . . . . . . . . . . . . 62

Chapter 4. Project
Medical Outcomes Study (MOS) SF-36 . . . . . . . . . 67
Upper Body Strength of the Affected Arm . . . . . . 69
Symptom Experience . . . . . . . . . . . . . . . . . 69
Scoring . . . . . . . . . . . . . . . . . . . . . . 71

Chapter 5. Recommendations/ Implications for the Advanced
Practice Nurse
Research . . . . . . . . . . . . . . . . . . . . . . 79
Practice . . . . . . . . . . . . . . . . . . . . . . 85

List of References . . . . . . . . . . . . . . . . . . . 92

Appendix A: Functional Status Assessment Tool for the
Older Breast Cancer Patient . . . . . . . . 99

LIST OF TABLES

Table 1. Formulas for scoring and transforming scales . 73

Table 2. National norms for females by age group . . . . 75

vi

LIST OF FIGURES

Figure 1. King’s Conceptual Model . . . . . . . . . . . 10

Figure 2. Revised Conceptual Model for this Scholarly
Project . . . . . . . . . . . . . . . . . . . 13

vii

CHAPTER 1
PROBLEM OVERVIEW

Introduction

Breast cancer is the second most common cause of cancer
death in women in the United States. The incidence of
breast cancer diagnosis has been rising steadily at an
annual rate of 1.2% since 1940 (Murphy, Lawrence & Lenhard,
1995). Breast cancer incidence and mortality increase with
age (Morrow, 1994; Lickley, 1997), and will affect one in
nine women in their lifetimes. The women whose lives are
affected by breast cancer will live with this disease for
varying periods of time. These women will have to adjust to
the impact of breast cancer and to the consequences of its
treatments (Schag et al., 1993).

Conceptual Definitions

For the purpose of this project, breast cancer will be
defined as a malignant, solid tumor found in a woman's
breast (Murphy et al., 1995). In the research compiled for
this scholarly project there is no definitive definition
for breast cancer. Therefore, it is difficult to identify
if the breast cancer is primary, metastatic, localized,

etc.

Older woman will be defined as those aged 55 years and
older. The chance of being diagnosed with breast cancer
increases by 15% at the age of 55 (Murphy et al., 1995).

Functional status will be defined as the ability to
perform activities and tasks within a social, cultural, and
physical environment that are basic to the fulfillment of a
person's roles as a worker, parent, spouse or partner,
sibling, and friend to self and others (Baum & Edward,
1995).

In recent years, there have been many advances in the
treatment of breast cancer. Despite these advances many
breast cancer patients still do not receive the appropriate
treatment. These advances have not been translated into
better health outcomes for older women (Silliman, Balducci,
Goodwin, Holmes, & Leventhal, 1993).

Patients who are receiving outpatient chemotherapy,
radiation therapy, or both, experience negative
physiological reactions to treatment. These reactions may
include fatigue, nausea, vomiting, eye problems, shortness
of breath, diarrhea, and an array of other symptoms (Mor,
Masterson-Allen, Houts, & Siegel, 1992). As a result of
these reactions, the breast cancer patient's functional
status can be altered, which can adversely affect the

patient's life.

Patients receiving cancer treatment are encouraged to
relinquish daily responsibilities to family and friends if
possible. Normal daily activities can present a challenge
to a patient undergoing chemotherapy, radiation therapy, or
both. Activities such as bathing may become impossible
without assistance. The burden of care during recovery from
outpatient cancer treatment can be substantial. (Mor,
Masterson-Allen, Houts, & Siegel, 1992). An altered
functional status can impair a breast cancer patient for
the rest of her life.

Horton and Cox (1997) explain that in 1997 there was an
estimated incidence of 180,000 cases of breast cancer and a
mortality rate of 44,000. Morrow (1994) states,

Since 1960, the life expectancy of American women

of all races has increased from 73.1 years to 78.8

years, and the percentage of the population aged

65 and older has increased from 9.2% to 12.5%. The

combination of an aging population, a common

cancer, and an increase in incidence of the cancer

with advancing age, means that clinicians will

encounter increasing numbers of older women with

breast carcinoma in future years (p. 145).

Breast cancer in the elderly carries a substantial
mortality. Age is identified as a negative prognostic

3

factor (Sillman et al., 1993). In many studies, it is
indicated that the pattern of care for a woman with breast
cancer is strongly influenced by her age. In addition to
age, the areas that influence treatment efficacy and
effectiveness are comorbidity, impaired functional status,
lack of social support, and differences in host physiology
(Silliman et al., 1993).

In a review by Bergman et a1. (as cited in Morrow,
1994), of 2,268 breast cancer cases, women under the age of
75 received surgery 92% of the time, while only 81% of
older women received this intervention. Also, use of breast
conserving surgery decreased with increasing age. Goldberg
and co-authors (Morrow, 1994) reviewed data from the
Connecticut Tumor registry and Yale-New Haven Hospital to
find that the survival rate for approximately 4,000 women
over the age of 60 did not differ from that of women under
54 years of age. Therefore, it is recommended that breast
cancer therapy should be determined by a woman's
physiologic age and psychological needs rather than her
chronological age.

Substantial variations in breast cancer diagnosis,
treatment, and care exist. These variations become greater
with the increasing age of the patient. The overall health
of the older patient plays an important role in the

decision-making process for optimal treatment of primary

4

breast cancer. The issue of multiple or comorbid conditions
in older women is of great significance to health care
professionals. It has been found that the presence of three
or more comorbid conditions increases the death rate by
28-fold in a 3-year time frame and was unrelated to the
cancer. The greater the number of comorbid conditions an
older woman has the greater the effect on her health and
treatment outcomes (Lickley, 1997).

Given the current uncertainty about the relative
efficacy of treatments, the health care professional can
best serve the older patient with early stage breast cancer
by involving her in decision making and in individualizing
care on the basis of such factors as comorbidity, social
support, functional status, and patient preferences for
outcomes (Silliman et al., 1993).

As the elderly population and the probability of being
diagnosed with breast cancer increases, the more research
needs to be done in this area to expand the knowledge base.
Purpose

The purpose of this scholarly project is to do a
synthesis of the literature relative to functional status of
the older breast cancer patient. It is also the intent of
this project to identify the strengths, limitations, gaps,

and generalizations in the literature related to the

functional status and the functional status measures of
older breast cancer patients during and after treatment.
Objectives

This scholarly project is intended to synthesize
knowledge and understanding on the effects of treatment on
older breast cancer patients and their functional status, to
identify strengths, limitations, and gaps in existing
literature related to the functional status and functional
status measures of older breast cancer patients, to identify
what generalizations are made about breast cancer patients
during research studies, and to identify functional measures
that can be consistently utilized to assess the functional
status of the older breast cancer patient. It is also the
intention of this scholarly project to combine three
existing tools to assess the functional status of the older
breast cancer patient. This tool will be utilized by the

advanced practice nurse in the primary care facility.

CHAPTER 2

CONCEPTUAL FRAMEWORK

King (1981) states the “Theory of goal attainment
provides a theoretical baSe for nursing process as it
demonstrates a way for nurses to interact purposefully with
clients” (p. 176). King's theory is based on the overall
assumption that nursing is individuals interacting with
their environment leading to a state of health, which is an
ability to function in social roles (Fawcett, 1995). The
domain of nursing includes promotion of health,
maintenance, and restoration of health, and care of the
sick, injured, and dying (King, 1981). King states (1989a),
“The focus of this theory is the interpersonal system
because what nurses do with, and for, individuals is what
makes the difference between nursing and any other
profession.”[The focus of this theory is on] holism—that
is, the total human being interacting with another total
human being in a specific nursing situation” (p. 154-155).

The theory of goal attainment is a theory of nursing
that deals with phenomena called process and outcome. The
process that is essential is mutual goal setting. The

theory defines outcomes in the form of goals to be

7

obtained. The goals identified then become criteria by
which the effectiveness of nursing care can be measured
(King, 1989a). This theory also identifies that decision
making is a shared, collaborative process in which patient
and nurse exchange information, identify goals, explore
means to attain goals, and each individual moves forward to
attain goals (King, 1989a).

As the life expectancy of women continues to rise, so
does the incidence of being diagnosed with breast cancer.
The diagnosis of breast cancer and its treatment regimens
can alter a woman’s ability to function. The application of
King's Goal Attainment Theory can assist the advanced
practice nurse and the breast cancer patient in the
maintenance, restoration or improvement of the patient’s
functional status.

This theory utilizes the concepts of perception,
communication, interaction, growth and development, role,
self, space, stress, time, and transaction. The following
concepts are defined as: (a) Interaction—process of
communication and perception between person and environment
and between person and person identified by verbal and
nonverbal behaviors that are goal directed; (b)
Perception—each individual’s representation of reality; (c)
Communication—a process of exchanging information between
people either directly or indirectly; (d)

8

Transaction—purposeful interactions that lead to goal
attainment; (e) Role—a way a person is expected to conduct
their behavior when occupying a position in a social
system; (f) Stress—a dynamic state whereby an individual
interacts with the environment to maintain balance for
growth, development, and performance, which involves an
exchange of energy and information between the person and
the environment for regulation and control of stressors;

(g) Growth and Development—constant changes in an
individual at the cellular, molecular, and behavioral
levels of activities; (h) Self-a composite of feelings and
thoughts which form a person’s awareness of his/her
individual existence and what he/she is (Tomey & Alligood,
1998); (i) Time—the sequence of events moving onward to the
future; and (j) Space—existing in all directions and is the
same everywhere (King, 1981).

The major concepts of this theory work together for the
purpose of achieving goal attainment (see Figure 1). When
the advanced practice nurse and patient come together for a
purpose, they are perceiving each other and the situation,
making judgments, taking mental action, or making a
decision to act. These two individuals react to each other
and to the situation. Communication in any form is the
means by which information is given and provided in nursing
situations to identify concerns and problems and to share
information. This information assists patients and

9

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caregivers in making decisions that may lead to goal
attainment. Communication is accomplished through verbal
and nonverbal signs and symbols by which patients also
express their goals.

Interaction is the act of two or more people in mutual
presence. Interactions reveal how one person feels and
thinks about another person, how each perceives the other,
what each person's expectations are of the other, and how
each reacts to the actions of the other. Interactions are
observed in time and space as one person fulfills the role
that is helpful to another person and vice versa. A person
usually reacts to what another person thinks, feels,
perceives, and acts (King, 1981). Advanced practice nurses
and patients communicate information to each other so they
can engage in mutual goal setting and explore and agree on
means to achieve goals. The goal is to help the patient
maintain their health so they can function in their roles
(King,1981). Transactions are goal directed human
behaviors. Transaction is a process of interaction in which
human beings communicate with the environment to achieve
goals that are valued (King, 1981). The concepts,
perception, judgment, communication, and mutual goal
setting in a nurse-patient interaction are to lead to a
transaction. Transaction leads to goal attainment and
growth and development. Goal attainment leads to
satisfaction and effective nursing care. This theory

11

assists the nurse and patient by providing a systematic
approach to goal attainment. Health is not identified as a
concept but as an outcome variable. The outcome is an
individual’s state of health or the ability to function in
her roles (King, 1981).

As a woman receives treatment for breast cancer, her
functional status can be altered. An altered functional
status affects not only the patient's physical status, but
also her vitality, role functioning, social functioning,
mental health, general health perceptions, and ability to
cope with pain. The advanced practice nurse and patient
need to work together to identify mutual goals that can
assist this patient in the areas that are of concern.
Utilizing King's Goal Attainment Theory in breast cancer
patient care can provide valuable information and guidance
during this difficult time.

King's Goal Attainment Theory is an appropriate
theoretical framework to assist the advanced practice nurse
and older breast cancer patient in the maintenance,
restoration, or improvement of functional status before,
during, and after cancer treatment (See Figure 2). When the
advanced practice nurse and older breast cancer patient
meet for the first time, they each have their own
perceptions. At this time the assessment phase begins. The
advanced practice nurse brings special knowledge and skills
to this interaction. The patient brings knowledge of self,

12

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perceptions of the problem, concerns, and disturbances in
health (Tomey & Alligood, 1998; George, 1995). She also
contributes her perception of the situation and what she
sees as possible. Perception is the basis for gathering and
interpreting data and thus is the basis for assessment
(Tomey & Alligood, 1998). During this phase these two
individuals begin judging each other from the time they are
introduced. Communication is done verbally, nonverbally,
and through the functional assessment tool. Communication
is essential to verify the accuracy of perceptions. Without
communication, interaction and transaction can not occur
(Tomey & Alligood, 1998). Each individual involved in this
interaction brings personal knowledge, needs, goals,
expectations, perceptions, and past experiences that
influence this encounter (King, 1981). During this
interaction, information is exchanged, opinions verbalized,
emotions expressed, and expectations established. This step
moves the advanced practice nurse and older breast cancer
patient toward the planning phase. The concepts involved in
the planning process are decision making about goals and
exploring means to attain goals (King, 1981). Planning is
mutually setting goals and making decisions about how to
achieve these goals. This is part of transaction and
involves a mutual exchange with the patient (King, 1981).
Mutual goals cannot be established unless each person
involved is willing to move forward. Mutual goal setting

14

between an advanced practice nurse and patient is based on:
(a) the advanced practice nurse’s assessment of the
patient's concerns, problems, and disturbances in health;
(b) the advanced practice nurse’s and patient's perceptions
of the interference; and (c) the sharing of information
whereby each person functions to help the patient attain
the goals identified (Tomey & Alligood, 1998). Each
patient’s goal is individualized and established mutually
with the advanced practice nurse. Implementation occurs in
the activities that seek to meet the goals. Implementation
is a continuation of transaction. The concept involved is
the making of transactions (King, 1990a). Evaluation
involves descriptions of how the outcomes are identified as
goals are attained. Evaluation not only addresses the
attainment of the patient's goals, but also the
effectiveness of nursing care. This process moves the
advanced practice nurse and patient towards transaction and
goal achievement. When transaction is achieved, the
evaluation of the mutual goals related to functional status
is completed. Was the goal achieved? Were the outcome
measures appropriate indicators of functional status?

Could this plan of care have been revised to provide better
assistance? Transactions are valued by the patient because
the goal is meaningful and worth achieving. Through this
whole process the advanced practice nurse and patient are
moving towards transaction. Many times the advanced

15

practice nurse and patient never achieve transaction. This
process can stop at any point due to impeding factors.
Impeding factors can be the patient's unwillingness to set
mutual goals, poor prognosis, financial problems,
transportation issues, beliefs and values about the breast
cancer. When the goals of the advanced practice nurse and
the goals of the patient are incongruent, conflict can
occur. This situation can increase stress in both
individuals (King, 1981). Through the feedback system in
this theory, the advanced practice nurse and breast cancer
patient can continue to work towards the achievement of
their goal.

Theory is a construct that accounts for or organizes
some phenomenon (Barnum, 1998). Theory pulls out the
salient parts, separating the critical and necessary
factors or relationships from the accidental and
unessential factors (Barnum, 1998). King’s Theory of Goal
Attainment promotes interaction, assists the advanced
practice nurse and patient in mutual decision making, goal
setting, and goal attainment. Also, it gives the patient
control over her health problem, since every patient has
the right to participate in decisions that influence her

life and health (King, 1981).

16

CHAPTER 3

LITERATURE REVIEW

Breast cancer is the second leading cause of death due
to cancer among women in the United States. Also, it is the
most common neoplasm in North America (Ganz et al., 1993).
Although the number of new cases diagnosed has increased,
mortality due to breast cancer has remained unchanged over
the last decade (Hynes, 1994). Women over the age of 55 are
more vulnerable to the development of breast cancer. The
risk of breast cancer increases with age (Murphy et al.,
1995).

The reported incidence of breast cancer has increased
considerably over the last 50 years and will continue to do
so because of three major factors. These factors are: (a)
the reported incidence of breast cancer increases with age
and will continue to rise until at least the age of 85, (b)
the number of women in the older age groups of the U.S.
population is increasing rapidly relative to the number of
younger women, and (c) the reported age-adjusted incidence
of breast cancer is also increasing.

As people age, there is a increased likelihood of

functional disability and limited social resources,

17

especially in those of family and friends (Sillman et al.,
1993).
Methodology

The literature review for this scholarly project was
completed on Medline. The years researched were 1990—1998.
These years were chosen because during the 19905 there were
significant advancements in breast cancer treatment and
patient options (Sillman et al., 1993). Utilizing the most
recent information was important in establishing an
effective functional assessment tool for the older breast
cancer patient. The literature review was guided by the
Medical Outcomes Study (MOS) SF-36 functional status
measures (Ware, Stewart, & Hayes, 1988). These measures are
physical functioning, role physical, bodily pain, general
health perceptions, vitality, social functioning, role
emotional, and mental health. Research has identified the
SF-36 as an appropriate tool to measure functional status
across diverse medical populations. The eight different
areas that this tool measures is affected by breast cancer
and its treatments. This tool also provided important
information on how the advanced practice nurse can assist
the older breast cancer patient maintain, restore, or
improve her functional status.

The journals that were available on Medline were

searched in relation to the functional status of older

18

breast cancer patients. Certain journals were not excluded.
The array of journals that information was utilized from
were Medical, Nursing, Oncology, Advanced Practice, and
Occupational Therapy, to name a few. While researching the
literature, five common themes were identified that had a
great impact on the functional status of the older breast
cancer patient. These were treatment options, caregiver
assistance, age and stage of disease, treatment regimen, and
psychological effects on functional status. This provided a
more organized way for the reader to comprehend the
information and the significance of this problem.
Treatment Options

Cancer has evolved from a rapidly fatal illness to a
chronic condition. The cancer treatments that patients
receive can include modified radical mastectomy, node
dissection, lumpectomy, radiation, chemotherapy, hormonal
treatments, and potential reconstruction in the upper body.
As a result of cancer and the treatments received, a patient
is affected both physically and psychologically (Ganz et
al., 1993). Currently, the treatment of breast cancer is
being approached more aggressively over a longer period of
time. Primary therapy in breast cancer patients is often
being extended and no longer ends with the initial surgery.
Radiation and chemotherapy are two treatments that are used

for breast cancer. The optimal duration of

19

chemotherapy treatment for metastatic breast cancer is more
than three months and likely greater than six months but not
more than a year (Murphy et al., 1995).

Radiation therapy is administered five days a week for
a total of six weeks. Primary therapy can continue for an
additional two to three months if breast conservation
therapy is used. The most common side effect of radiation
therapy is fatigue. Fatigue causes difficulty in
concentrating, tiredness not relieved by resting, decreased
motivation, change in sleep patterns, inability to carry out
normal activities, and constant feelings of exhaustion and
of hopelessness. The most common side effects of
chemotherapy are fatigue, insomnia, nausea, hair thinning,
and pain. These side effects can have immediate and
long—term effects on a patient's functional status (Hoskins,
1997). Silliman, Balducci, Goodwin, Holmes, and Leventhal
(1993) state, “Breast cancer is a common and progressively
debilitating disease that can be readily treated if it is
diagnosed at an early stage. While considerable therapeutic
advances have been made, it appears that these advances have
not been translated into better health outcomes for older
women (i.e., those 65 years of age or older)” (p. 190). It
has been documented that when treated more aggressively,
older patients with cancer tend to respond comparably to

younger patients (Given, Given, & Stommel, 1994).

20

Breast cancer treatment has become highly complex. A
vast majority of breast cancer treatment is provided in
ambulatory settings. Multidisciplinary cancer care is
needed. Twenty—five years ago, surgery was the only option
for breast cancer patients. At the present time, women
receive surgery (mastectomy or segmental resection with
axillary node dissection), chemotherapy, radiation,
hormonal therapy, or a combination of these as a part of
their primary treatment. Because of this, the
rehabilitation of these individuals has become more complex
(Ganz, 1995).

Caregiver.Assistance

Treatment of patients with cancer is basically being
provided on an outpatient basis, which complicates and
strains the capacity of caregiver networks to meet patient
needs. This is especially true for patients who have
advanced disease. The amount of care that may be needed for
a patient may be considerable (Mor, Allen, Siegel, & Houts,
1992).

Family members are being called upon to assist in the
care of the cancer patient due to the strain on caregiver
networks. With little guidance and information from the
formal health care systems, families must assume
responsibilities for managing symptoms, administering

medications, utilizing equipment, monitoring for possible

21

complications, and assisting patients with self-care needs
(Given & Given, 1994).

Breast cancer itself and treatment regimens can cause
altered functional status. Patients are no longer staying in
the hospital for their entire treatment regimens.
Professional home care organizations are operating at near
capacity and are unable to handle the increasing volume of
cancer patients who require care outside the hospital.
Family members or friends are needed to assist in this care.
To maintain a patient’s functional status, symptom
management, administration of medications, observation of
complications, and assistance in self-care are a must. Home
care can assist in some aspects and educate the patient,
family, and friends related to the care needed, but they are
unable to provide all the care directly.

Ongoing patient care is a family responsibility that
should be provided at home (Mor, Allen, Siegel, & Houts,
1992). Therefore, limitations in physical functioning and
mental health become important areas for health care
professionals and families. It has been shown that if
emotional care is not provided in the home, the attempts to
improve symptom distress and physical functioning may only
be marginally successful (Given & Given, 1994). Family and
health care professionals are the people who monitor and
evaluate the impact of disease and treatment, and formulate
strategies for continuing care, rehabilitation, and

22

strategies for continuing care, rehabilitation, and
recovery following a course of therapy (Given et al. 1994).

In a study completed by Schag, et al. (1993)
rehabilitation needs were identified in the arm adjacent to
the operative breast. Patients complained of not being able
to dress, difficulty working, pain, difficulty with
recreational activities, and not being able to complete
activities of daily living. Problems with the arm were
weakness, swelling, lymphedema, and tightness, pulling, and
stretching in the chest wall, arm, and breast area. These
factors make it necessary for each breast cancer patient to
be assessed for functional limitations/deficits in relation
to rehabilitation requirements. While patients are
beginning their rehabilitation, the physiological stresses
are especially high. During this time the patient’s
functional status can be altered. This alteration can
continue with further scarring and restrictions.
Treatment Regimen

Hughes (1993) completed a study on the psychosocial and
functional status of breast cancer patients at the time of
diagnosis and during the initial phase of treatment. The
purpose of this study was to gain a better understanding of
the impact of diagnosis and treatment on a patient’s
physical state and psychosocial well-being. The sample size

for this study was 52 subjects. The sample group was one of

23

convenience at a breast clinic affiliated with a 1,000-bed
tertiary medical center. The inclusion criteria for this
study were patients had to have breast cancer in the early
stages of development, and the breast cancer was treatable
with either modified radical mastectomy or lumpectomy
followed by radiation treatment. The instruments utilized
in this study were Quality of Life Cancer II Version
Instrument (QLI) (Ferrans & Powers, 1985), Mishel
Uncertainty in Illness Scale-Community Form (MUIS-C)
(Mishel & Epstein, 1990), Medical Outcomes Study General
Health Survey-Short Form (GHS) (Ware et al., 1988), and the
Reaction to the Diagnosis of Cancer Questionnaire (RDCQ).
Patients were interviewed at the time of diagnosis before
treatment selection and approximately eight weeks after
surgery.

The results of this study identified overall
functional status scores from time 1 to time 2 unchanged,
but social functioning, role functioning, and physical
functioning were significantly decreased. However, pre- and
post-treatment mean scores for pain, mental health, and
overall health perceptions were not significantly
different. The study found that functional status declined
over the course of initial treatment. The ability to
function physically and meet normal role obligations was
significantly lower after surgery. The type of surgical
intervention was unrelated to functional status. A possible

24

explanation for this is that radiation therapy leads to
greater functional impairment than is typically assumed.
Patients undergoing radiation therapy five days a week for
five to six weeks experience varying degrees of fatigue in
addition to pain in the shoulder and swelling in the arm.
This type of treatment can be disruptive to a woman's
functioning while attempting to continue her regular
schedule.

A limitation in Hughes’s (1993) study is that caution
must be exercised when generalizing beyond this study. This
is because the subjects used in the study are not
representative of all breast cancer patients. Despite this
limitation, this study concludes that most breast cancer
patients are uncertain at the time of diagnosis that the
quality of their lives is not negatively affected by the
diagnosis and initial treatment, even though their
functional status does decline through the course of
treatment.

Being diagnosed with breast cancer can be threatening
to women on many levels. The woman's life is threatened by
the cancer. The surgical intervention is disfiguring and
there are threats to the woman's social and emotional well
being. The diagnosis of breast cancer represents a serious
crisis in the women diagnosed (Carver et al., 1993).

In 1992, Mor, Masterson-Allen, Houts and Siegel
completed a study on 629 patients with advanced cancer.

25

This study researched the changing needs of patients with
cancer at home. One hundred forty-four of the individuals
in this sample had breast cancer. Three hundred
seventy-eight of these patients were over age 60.
Twenty—three percent of the subjects in this study had a
diagnosis of breast cancer. Patient selection was completed
by targeting those individuals who were likely to
experience functional decline as a result of a treatment
regimen or disease progression, but had a chance of
surviving six months. Inclusion criteria in this study were
aged 21 years or older, cancer had to be nonlocalized,
recurrent, or inoperable, primary disease had to involve a
solid tumor of the gastrointestinal tract, genitourinary
organs, breast, lung, or head and neck, and patients with
Hodgkins or non—Hodgkins lymphoma were eligible. These
individuals were investigated during a course of outpatient
chemotherapy, radiation treatment, or both, and again three
to six months after the treatment was completed. The tools
utilized for this study were Katz's (1963) Index of
Activities of Daily Living (ADL) and the scale for
Instrumental Activities of Daily Living (IADL) (Lawton,
1971).

The results of this study were: (a) personal functional
status impairment was 7% at baseline and 16% at follow up
with a 13% new prevalence need, (b) instrumental impairment
(housework, shopping, and cooking) was 46% at baseline and

26

12% at follow up with a 25% new prevalence need, and (c)
transportation impairment was 54% at baseline and 47% at
follow up with a 27% new prevalence need. Cumulative 60% of
patients that completed both interviews needed assistance
with instrumental tasks. Ninety percent of these people who
had an impaired functional status at baseline later had
their functional status issue resolved.

The results of this study suggest that a substantial
proportion of patients have some type of altered functional
status during their treatment. Impaired functional status
may cause considerable disruption in the lives of patients
and their families. The patient's need to maintain
functional status is of great concern to oncologists
because impaired functional status may compromise a
patient's compliance with his or her health status or
treatment regimen and may affect future quality of life
(Mor, Masterson-Allen et al., 1992).

Given, Given, and Stommel (1994) completed a
longitudinal study on 111 patients 50 years of age and
older with solid tumors. Twenty-seven percent of the
individuals in this study had breast cancer. These patients
were selected from a convenience sample of adult patients
diagnosed with solid tumor or lymphoma that were receiving
treatment on an outpatient basis. These patients received
chemotherapy, radiation, hormonal treatment, or a
combination of these. Questionnaires were completed at

27

intake and at six months. The focus of the research was the
impact of age, treatment, and symptoms on the physical and
mental health of cancer patients. The tools utilized for
this study were ADLs, IADLs, and vigorous functioning from
the Medical Outcomes Study to measure physical functioning,
Center for Epidemiologic Studies Depression Scale (CES-D)
to measure depression, and a scale of 17 common symptoms
that measure symptom distress. The results of this study
explained that the number of symptoms experienced and the
changes of those experiences are variables explaining
patients’ levels of physical and mental health. The
patients' symptom experience at intake and the change in
symptom reports over time explain why each had an
independent effect on physical functioning and interacted
with gender to predict changes in patients' mental health.
Symptoms were found to play a significant role in
predicting changes in limitations of physical functioning
and mental health. The conclusion of this study was that
continuing care and rehabilitation professionals need to
develop strategies to focus on symptom management to
prevent an alteration in functional status in breast cancer
patients.

A study was completed by Mor, Allen, Houts, and Siegel
(1992) of 629 patients that had cancer and were receiving
radiation, chemotherapy, or both. This study describes the
physiological and social determinants of need and unmet

28

need for assistance in cancer patients with advanced
disease. Areas of need were examined by personal care,
instrumental tasks (housework, shopping, and cooking), and
transportation. Physiological factors (metastasis, disease
stage, and functional status) were associated with need for
assistance in all three areas. Inclusion criteria for this
study were survival prognosis of six months, were likely to
experience functional impairment because of treatment
complications or disease progression, age 21 years or
older, cancer had to be nonlocalized, recurrent, or
inoperable, primary disease had to involve a solid tumor of
the gastrointestinal tract, genitourinary organs, breast,
lung, or head and neck, and patients with Hodgkins or
non-Hodgkins lymphoma were eligible. The tools utilized for
this study were Katz's (1963) Index of Activities of Daily
Living (ADL) and the scale for Instrumental Activities of
Daily Living (IADL) (Lawton, 1971). Three hundred
thirty-nine of these patients were women. Two hundred
seventy were over age of 65 and 144 had breast cancer.
Three hundred forty-five of these patients were either
living alone, had three or fewer caregivers on whom they
could rely, or had low resiliency. The areas studied were
personal care, instrumental (housework, shopping, and
cooking), and transportation.

The study showed a patient's impaired functional status
was primarily associated with lack of social support.

29

Patients who had support systems that were not resilient
were twice as likely to have an unmet need for instrumental
activities and more than seven times as likely to have an
unmet transportation need. The percentage of patients who
verbalized impaired functional status related to these
three areas were personal 14%, instrumental 50.9%, and
transportation 58.3%. Identified impaired functional status
related to instrumental and transportation were 37% and 16%
respectively. Also, women were more likely to have
instrumental and transportation needs than men.
Instrumental needs (housework, shopping, and cooking) are
areas that cannot be left undone long term without
consequences. When the breast cancer patient is unable to
complete these tasks due to impaired functional status, it
is essential that she receive assistance to resolve this
problem. The patient cannot tolerate living with unmet
instrumental needs for an extended period of time.

Patients who had severe morbidity (three or more
symptoms, one or more days in bed, and restricted activity
every day) have increased odds of required assistance in
personal, instrumental, and transportation areas (Mor,
Allen et al., 1992). A patient with metastatic disease is
three times more likely to need help with personal
activities than a person with regional or local disease.
Morbidity is an important factor when predicting unmet
needs among cancer patients. The more the illness

30

interferes with the patient’s ability to perform tasks
independently, the greater the possibility that some need
will go unmet.

The results of this study suggest that there are a
large number of cancer patients receiving outpatient
treatment who are also impaired in daily functioning. Also,
the number of impaired patients who have inadequate help in
meeting their needs is substantial, ranging from 16% to
33%.

Cimprich (1992) states,

Over one million people in the United States are

diagnosed with cancer each year. In dealing with a

chronic and life threatening disease such as

cancer, individuals must direct attention to

multiple, and often competing demands imposed by

both the illness and its treatment. Directed
attention is needed to deal with informational
needs, the reality of treatment, therapeutic
self-care, and a myriad of adjustments in daily
life. Intense mental exertion in response to
multiple demands for attention can lead to
attentional fatigue characterized by a decline in

the capacity to direct attention (p. 199).

Cimprich (1992) completed a study examining the
capacity to direct attention in the initial phase of

31

treatment in a selected group of persons with cancer,
specifically women with breast cancer. Directed attention
is defined as the ability to focus attention on a task.
This study consisted of 32 women with newly diagnosed
breast cancer. All eligible women with Stage I or Stage II
cancer were recruited over a nine-month period. The
capacity for directed attention was measured by a battery
of tests that required inhibition of competing or
distracting stimuli, as well as a subjective measure of
perceived effectiveness in attentional functioning. The
battery of tests included Digit Span, Alphabet Backward,
Symbol Digit Modalities Test, and Letter Cancellation. The
patients received these tests on the day before discharge
in the hospital setting. These tests were completed in a
quiet setting. The battery of tests took 20 minutes to
complete. Attentional functioning can be affected by
uncertainty about the future and painful thoughts
associated with anticipated or actual losses. Also, illness
poses multiple limitations on normal functioning stemming
from physical discomfort and losses of privacy and domain.
The results of the Cimprich study indicate that women
with breast cancer experience decreased capacity for
directed attention following either mastectomy or breast
conservation surgery regardless of the extent of the
surgery. A possible explanation for lower scores is that
attentional fatigue may begin developing in the

32

pretreatment phase of illness when intense and prolonged
exertion of attentional effort is required. The diagnostic
phase of breast cancer can be associated with uncertainty
and conflict about treatment options. In this present study
an average of about one month elapsed between confirmation
of diagnosis and surgical treatment. Attentional demands
can increase in the time period between the diagnostic and
pretreatment phases of the illness. The patient's ability
to function socially, emotionally, mentally, and physically
can be greatly altered due to the inability to direct
attention and concentrate, thus altering the patient's
functional status.

A limitation of this study was that data was collected
only in the post-surgical period. Therefore, attentional
status in the pretreatment period was not assessed. Other
limitations were lack of a surgical control group, small
sample size, and the nature of the convenience sample.
Further studies need to be completed to understand better
the attentional deficits in diverse groups with cancer and

other illnesses.

Summary

Breast cancer treatment regimens can greatly alter a
patient’s functional status. Physical functioning was
decreased after initial treatment and surgical
intervention. Also, side effects such as fatigue, nausea,

33

vomiting, and diarrhea caused an alteration in functional
status (Mor, Masterson-Allen et al., 1992).

Lack of social support can affect a patient's
functional status (Mor, Allen et al., 1992). The lack of
health care resources and reimbursement issues require
family to assist these patients in conjunction with home
care. If patients do not have family or similar support
system, their potential to have impaired functional status
increases. Treatment regimens for breast cancer can
adversely affect a patient's functional status. Symptom
management, strategies to cope with adverse treatment side
effects, and assistance from family, support systems, or
the health care system are essential if the patient's
functional status is to be maintained during treatment.
Psychological Effects

A study was completed by Maunsell, Brisson, and
Deschenes (1993) on arm problems and psychological distress
after surgery for breast cancer. These patients were
interviewed at 3 months and 18 months after surgical
intervention. Two hundred thirty-three women participated
at the 3—month interview and 201 women participated at the
18-month interview. The decrease in subject number from the
first interview to the second was caused by 13 patients who
had died and 3 patients were too ill to complete the

interview. The criteria to be part of this study were

34

patients who underwent surgery for unilateral disease of
the breast, no distant metastasis at the time of diagnosis,
and had the ability to be interviewed within the study time
frame. Questions were asked about personal characteristics,
interpersonal relationships, perceptions of social and
professional support, daily activities, work outside the
home, stressful life events, and a history of depression.
The tools utilized for this study were Diagnostic Interview
Schedule (DIS) (Robins, Helzer, & Croughan, 1981, as cited
in Wing, Bebington, & Robins, 1981) and Psychiatric Symptom
Index (PSI) (Ilfeld, 1976).

The results at 3 months identified that 82% of patients
reported at least one functional deficit in the operated
arm. Problems most reported were loss of sensation (54%),
and pain (55%). Other problems identified were weakness
(26%), stiffness (40%), limitation in movement (24%), and
swelling (24%). At 18 months, 79% of patients reported at
least one problem in the operated arm. Once again loss of
sensation (49%) and pain (51%) were the most reported
problems. The other problems identified were weakness
(18%), stiffness (37%), limitation in movement (16%), and
swelling (27%). Patients who had axillary dissection had
significantly more problems than the women who did not
receive this surgical intervention. The proportion of women
with a high Psychiatric Symptom Index score increased with

the number of problems in the affected arm. At three months

35

the results were (a) no arm problems—17% high distress, (b)
1 to 2 arm problems—27% high distress, (c) 3 to 4 arm
problems—34% high distress, and d) 5 to 6 arm problems—50%
high distress. At 18 months the results were (a) no arm
problems—17% high distress, (b) 1 to 2 arm problems—25%
high distress, (c) 3 to 4 arm problems—54% high distress
and (d) 5 to 6 arm problems—70% high distress.

The results of this study showed that the patient's
overall quality of life was negatively affected by arm
problems 18 months after surgery (Maunsell et al., 1993).
The ability for these women to function independently has
been altered. Their overall quality of life is lower,
which causes psychological distress. Their lives have been
affected so it is difficult for them to function in their
social, cultural, and physical environments. It is also
difficult for these women to fulfill their specified
roles. Living with an altered functional status due to
surgical intervention and breast cancer greatly impacts a
person’s life.

A study was completed by Pascreta (1997) on the
nature and scope of depression and its relationship to
physical symptom distress and functional status among
women with breast cancer. The study consisted of 79 women.
Inclusion criteria for this study were English speaking,
first-time cancer diagnosis within the past 3 to 7 months,
and over the age of 21. Thirty-seven percent of the

36

participants were over age 60. The tools used were
Depressive Disorders Sections of the Diagnostic Interview
Schedule, Center for Epidemiological Studies of Depression
(CES—D) (Radloff, 1977), Symptom Distress Scale (SDS)
(McCorkle & Young, 1980), the Enforced Social Dependency
Scale (ESDS)(Benoliel, McCorkle, & Young, 1980), and the
Organic Mental Impairment Scale (Jacobs, Bernhard, &
Delgado, 1977).

The results of Pascreta’s (1997) study identified
that women with elevated depressive symptoms had more
physical symptom distress and an altered functional
status. Two variables accounted for 35% of the variance in
functional status—symptom distress 28% and depressive
symptoms 7%. The functional deficits measured and affected
were eating, dressing, walking, traveling, bathing, and
toileting. Cancer therapies used to treat breast cancer
can cause severe and life threatening side effects. As a
result of this fact, the inability to tend to self-care
needs and sometimes to be totally dependent on caregivers
is not uncommon. The most frequently reported symptoms
were fatigue, poor outlook, pain, adverse feelings about
appearance, insomnia, and poor concentration. Fatigue was
reported as the most common symptom.

The limitations in this study were the use of a
homogeneous sample and despite the fact that a study
objective was to determine the impact of study variables

37

on functional status outcomes, a cause-and-effect
relationship could not be assumed. This study suggests
that depression and symptom distress can affect functional
status. After being diagnosed with breast cancer, many
factors can affect a patient’s functional status. Health
care professionals need to be ready to assist these people
in their times of need. Nurses can teach management
strategies, such as how to schedule treatments, symptom
management, planning for periods of rest, and when to seek
support from family and friends (Hoskins, 1997).

In 1997 Jepson, Schultz, Luske, and McCorkle
completed a study examining the relationships between
survival time and enforced dependency in a group of
patients with cancer. The sample size for this study was
141 patients with solid tumors. Twenty-two of these
patients had a diagnosis of breast cancer. Measures
included medical history, demographic characteristics, and
five measures of psychosocial status, including enforced
personal and social dependency. Social dependency is
defined as help required from other people to perform
activities or roles that under normal circumstances could
be completed by the individuals themselves. Therefore,
social dependency is equivalent to functional status.
Inclusion criteria for this study were solid tumor
diagnosis, a complex nursing problem related to their
diagnosis at the time of discharge, a prognosis of

38

survival greater than 6 months, and lived within 30 miles
of a participating hospital. The tools utilized for this
study were the Symptoms of Distress Scale (SDS) (McCorkle
& Young, 1978), the Enforced Social Dependency Scale
(ESDS) (Benoliel, McCorkle, & Young, 1980), the Health
Perceptions Questionnaire, and the Center for
Epidemiological Studies-Depression Scale (CES-D) (Radloff,
1977). Survival time was measured from the date of
diagnosis to the date of death or last follow up.

The results of the Jepson et al. (1997) study reveal
that significant associations with survival were found for
all five psychosocial variables. High levels of symptom
distress, enforced personal and social dependency, and
depression were associated with shorter survival. The
functional limitations of the patients were physical
dependency, social dependency, and depression. These
findings suggested that survival might be improved by an
intervention focused on functional status. Therefore, it
can be speculated that efforts directed at maintaining the
patient's functional status may have positive outcomes,
including extended survival. This study supports the need
for outpatient staff to evaluate informal support systems
and care resources in addition to symptoms to determine
who should be referred for home care services. This study
suggests that survival rates may be directly related to
functional status. Creative strategies need to be

39

developed to broaden the range of interventions that
maintain a patient's desired level of independence, but
encourage dependence on others at appropriate times during
treatment.

A study completed by Polinsky (1994) was done on 223
breast cancer survivors 16 months to 32 years from their
original surgical intervention for breast cancer to assess
their current physical, psychosocial, and social
functional status. This study consisted of Reach to
Recovery Volunteers in southern California. The tools
utilized for this study were the 20-item Short-Form Survey
(SFHS) from the Medical Outcomes Study (MOS) (Stewart et
al., 1988), Breast Cancer-Specific Measure
(BCSM)(Polinsky, 1994), and Profile of Mood States (POMS)
(McNair, Lorr, & Doppleman, 1981). The results suggested
that physical functioning was high on the general
measures. The BCSM of long-term physical effects of
treatment identified many areas of change and concern.
These areas were uncomfortable clothing 59%, unattractive
body image 37%, caution with arm use 34%, arm weakness
43%, problems with blood drawing 40%, arm heaviness 36%,
and phantom breast syndrome 36%.

Social functioning was identified as high and less
than 5% identified a change in their social activities.
The areas that were avoided were traveling, visiting
people in the hospital, attending parties, staying

40

overnight at other people’s homes, and engaging in sports
activities previously enjoyed (Polinsky, 1994).

General psychological function was quite high in this
group. The areas that patients thought the most of related
to their breast cancer were recurrence (89%), angry
feelings related to having breast cancer (50%), anxiety
related to breast cancer (64%), nervousness related to
follow up appointments (58%), nervousness when having
diagnostic tests (72%), and nervousness when awaiting test
results of routine check-ups (74%). Also, there were
treatment-related problems that continued for many women.
These areas were conditioned nausea, vomiting, or both
from chemotherapy (39%), breast changes caused by
radiation treatment (57%), increased sensitivity to sun
due to radiation treatment (39%), and sensations such as a
tight band around the chest, severe itching, and muscle
twitching (20%) (Polinsky, 1994).

Sexual activity also was altered in Polinsky's (1994)
study. Forty-four percent identified dissatisfaction with
the level of sexual activity and lubrication, 55% with
orgasm, and 66% with being sexually aroused. Many studies
are completed on shorter term survivors, but it is
apparent that many of the short-term problems continue for
long-term survivors. Although breast cancer survivors
generally do well, there are concerns related to the
physical, psychological, and social effects. These

41

patients continue to have problems because of surgical
intervention, chemotherapy, or radiation treatment. It
appears that their functional status is permanently
altered because of breast cancer. They continue to have
physical problems, sexual problems, increased anxiety, and
symptoms caused by treatment. These patients are able to
function, but the problems identified in Polinsky’s (1994)
study should be of concern to the health care profession.
The ability to identify these problems will facilitate
compliance and provide a basis for educating breast cancer
survivors and health care professionals. This education
could possibly limit these issues and help develop
problem-solving strategies. It will also facilitate
patient compliance with appropriate comprehensive
follow—up care.

Tasmuth, von Smitten, and Kalso (1996) completed a
study on 93 patients who underwent radical and
conservative surgery for their breast cancer. This study
assessed the pain, neurological symptoms, edema of the
ipsilateral arm, anxiety, and depression in women treated
for breast cancer, as well as the impact of these symptoms
on daily life and how they evolved during the one year
follow up. The patients who participated in this study
underwent modified radical mastectomy with axillary
clearance (MRM) or breast-conserving surgery with axillary
clearance (BCT). These patients were seen four times, one

42

day before surgery, one month, six months, and one year
after surgery. The tools utilized in this study were
visual analogue scale for pain (Huskisson, 1974), State
and Trait Anxiety Inventory (STAI) (Spielberger, 1975),
and two questions were developed to evaluate depression.
These questions were developed following the style,
scoring, and response options of the STAI.

The results of the Tasmuth et al. (1996) study were
placed into five different categories: (a) post-treatment
symptoms, (b) pain in the breast region and in the
ipsilateral arm, (c) pain, (d) edema, numbness, strange
sensations, muscle weakness, phantom sensations, and
mobility of the arm, and (e) anxiety and depression.
Post—treatment symptoms showed that most patients had a
combination of symptoms in the breast area. These were
pain, numbness, edema, strange sensations, and phantom
sensations. In the ipsilateral arm the symptoms reported
were pain, numbness, edema, strange sensations, and muscle
weakness. One year after surgery, the percentage of
patients reporting at least one symptom in the breast scar
area was 83% MRM group and 82% BCT group.

Pain experienced in the breast region or ipsilateral
arm did not differ significantly between the two groups
(Tasmuth et al., 1996). Thirty percent of the patients
experienced breast pain for about 2 months before surgery
and about 10% had pain in the ipsilateral arm for about 5

43

months after surgery. One year after surgical
intervention, the incidence of chronic pain in the breast
region was 24% and in the ipsilateral arm 17%. Pain was
aggravated by sleeping on the operated side, reaching out,
working with the ipsilateral arm, housework, or
handicraft. One year after surgery, sleep was interrupted
because of pain in the breast region (18%) and because of
pain in the ipsilateral arm (31%).

Six months after surgery, full range of motion had
been restored in both groups, but was still significantly
reduced in 3% of the MRM group. Sixty-two percent of these
women worked. This is an important fact to be taken into
account when assessing a person's ability to return to
work that requires active use of the ipsilateral arm
(cleaning, carrying) (Tasmuth et al., 1996).

In the Tasmuth et al. (1996) study, anxiety and
depression played a significant role in the ability for
these women to function. Of these two groups of patients
more than half (MRM 57%, BCT 53%) reported experiencing
stressful events within the 6 months preceding surgery.
The patients who had these stressful events and could
correlate them with work had significantly higher levels
of trait anxiety and depression. The number of chronic
symptoms experienced in the operative site correlated
significantly with depression and anxiety one year after
surgery. The conclusion drawn from the Tasmuth, et al.

44

(1996) study, was that one year after surgical
intervention for breast cancer, most of these 93 women
still had treatment-related symptoms in the ipsilateral
arm and breast area. This study showed that the incidence
of chronic post-treatment pain was considerable and may
have affected functions that were important to women in
performing their activities at work and at home.

Surgical intervention for breast cancer can cause
physical problems, thus altering functional status.
Problems that could be experienced, such as pain, edema,
arm weakness, numbness, etc., are not usually discussed
before surgery. These patients are unaware and unprepared
for the issues they will face in the upcoming months to
years. These patients need to be informed of the possible
life-altering changes that will occur so plans can be made
to decrease the impact.

Zichi—Cohen, Kahn, and Steeves (1998) completed a
qualitative study to describe the mental and emotional
impact of breast cancer treatment with a focus on the ways
the body is experienced. The study consisted of 20 women
who underwent mastectomy or lumpectomy as treatment for
breast cancer. One interview was completed with the
interviewer asking, “Please tell me what it was like for
you to have breast cancer and your treatment” (p. 836).
This question was followed by probe questions to have the
women elaborate and give examples. The women interviewed

45

in the Zichi study identified three important areas of the
body. They were the body as a symbol or social expression,
the body as a way of being in the world, which includes
symptoms and sensations, and the body as a necessary
expression of existence. These three areas can help the
advanced practice nurse conduct a more focused assessment
to identify and meet the needs of breast cancer patients
by providing more effective care.

A limitation of this qualitative research is that it
is not generalizable in the standard use of the term. This
information may be applicable to other settings and
cancers, but that must be answered by the clinician or
researcher in that new setting.

Summary

Women that have breast cancer experience
psychological effects from the disease, treatment, symptom
distress, and side effects. These effects can alter a
woman’s functional status. Patients experience numbness,
weakness, pain, swelling, lymph edema, and an array of
other problems for varying periods of time. The
probability of experiencing depression and anxiety
increases the longer these patients experience these
problems. Symptom distress caused by treatment regimens,
when not relieved, also can lead to depression and thus

affects the patient’s functional status.

46

Age, Comorbid Conditions, and Stage of Disease

Kurtz, Given, Kurtz, and Given (1994) completed a
study on how age and survival status influence the
frequency and severity of patients' symptoms and
dependencies in functioning. This study was completed on
208 caregiver-patient dyads. These dyads were separated
into three groups by duration of survival. Group I was
composed of patients who survived 12 months or longer;
Group II of patients who survived between 6 and 12 months;
and Group III of patients who survived fewer than 6
months. The survival rate for each group was Group I—111;
Group II—35; and Group III—62. The percentage of breast
cancer patients that participated in this study was 24%.
The percentage of breast cancer patients in each group was
Group I-27.9%; Group II—25.7%; and Group III—16.1%.
Eighty-three breast cancer patients in this study were
over age 65. The tools utilized for this study were a
modified version of McCorkle's Symptom Distress Scale
(SDS) (McCorkle & Young, 1980), a scale derived from the
Medical Outcomes Study to measure loss of physical
functioning and ADLs (Filenbaum & Symer, 1981; Ware et
al., 1981), the Center for Epidemiological Studies for
Depression Scale (CES-D) (Radloff, 1977) and the
Caregivers Reaction Inventory (Given et al., 1992). The

most frequently identified symptoms for the patients aged

47

65 years and older were fatigue (81.3%), pain (71.9%),
poor appetite (65.6%), constipation (56.3%), weight loss
(53.1%), nausea (43.8%), insomnia (43.8%), diarrhea
(43.8%), and vomiting (37.5%).

The results of this study demonstrate that patient
depression, immobility, and dependency in ADLs were all
correlated. Also, all increased steadily with the client's
stage of illness. A further analysis was completed to
determine whether the increase in immobility and
dependency in ADLs were directly related to symptoms. The
results stated that symptoms were the only significant
predictor of dependency in ADL's, whereas symptoms and the
interaction of symptoms were significant for immobility.
The mere presence of symptoms is not the only factor
related to impact. An ability to manage the symptoms is
also important.

These results show the impact of symptoms on cancer
patients. Also, this study pointed out that as the demands
increased on caregivers during the later stages of
illness, an increase in physical and emotional support
from friends to caregivers did not occur.

Comorbid conditions can adversely affect a patient's
breast cancer treatment. With advanced breast cancer and a
significant number of comorbid conditions, a patient's
chances for successful treatment are significantly
decreased. Comorbid conditions need to be identified and

48

considered when making treatment decisions related to
breast cancer. Lickley (1994) identified a tool developed
by Greenfield and colleagues called the comorbidity index.
It rates 11 system categories, including circulation,
respiration, neurological, mental status, urinary,
feeding, ambulation, transfer, vision, hearing, and
speech. Each area is given a value. Complications and how
they affect functional status are also taken into account.
Each category is rated on a 3-point scale (0 represents no
comorbid conditions, 1 represents mild, controlled
comorbid conditions, and 2 represents moderate to severe
comorbid conditions). The chance of a 3—year death rate
unrelated to the cancer increases 28-fold in older
patients with 3 or more comorbid conditions.

Arathuzik (1994) completed a study on 24 patients
with metastatic breast cancer who were experiencing
physical pain. The purpose of this study was to examine
the effects of a combination of cognitive and behavioral
nursing interventions on pain perception, pain control,
and mood in patients with metastatic breast cancer
experiencing physical pain. Inclusion criteria for this
study were a confirmed diagnosis of metastatic breast
cancer, experiencing physical pain, oriented to person,
place, and time, and between the ages of 30 and 80.
Patients were randomly assigned to either of the two
treatment groups or to the control group. Three

49

instruments were utilized for this study. They were the
Johnson Pain Intensity-Distress Scales (1973), the pain
control scales developed by Rosenstiel (1981), and a
shortened version of the Profile of Mood States (Shacham,
1983). A pretest was given to each subject in the
treatment groups. The first treatment group received
instruction and practice time for either progressive
muscle relaxation exercise or guided imagery visualization
exercise aimed at reducing pain. The second treatment
group received the same instructions and practice with
cognitive coping skills included. All three groups were
able to continue taking narcotic analgesics. Thirty-three
percent of the subjects took strong narcotic analgesics,
29.2% received mild narcotic analgesics, and 25.5% were
receiving nonnarcotic analgesics. All the patients that
participated in this study had received one or more cancer
treatments including surgery (79.1%), chemotherapy (100%),
and radiation therapy to metastatic sites (66.7%).

Pain caused by breast cancer itself, surgical
intervention, and chemotherapy or radiation treatment can
greatly alter a person's functional status. Attempting to
alleviate or decrease her pain can give the cancer patient
the ability to maintain functional status. If a patient's
pain is tolerable, she may be able to perform essential

tasks to maintain her independence.

50

The result of Arathuzik's (1994) study was that the
combination of pain and coping strategies on the two
treatment groups did have an effect on the ability of
these patients to decrease pain. Both of the treatment
groups were significantly different from the control group
in their perceived ability to decrease pain as a result of
the interventions. This supports the idea that a
combination of interventions in addition to pain
analgesics can be helpful in decreasing a patient's pain.

McCorkle et al. (1994) completed a study to evaluate
the impact of home care services on the symptom distress,
mental health, enforced social dependency, and health
perceptions of cancer patients with advanced disease
following an acute care hospital stay. The sample size for
this study was 60. Seventeen subjects in this study had a
diagnosis of breast cancer. The inclusion criteria were
that the subjects had a solid tumor cancer diagnosis
(breast, colon, lung, or prostate), complex nursing
problem associated with their cancer at the time of
discharge, prognosis of greater than 6 months, and lived
within 30 miles of a participating hospital. This sample
was placed into two groups, patients receiving home care
and patients not receiving home care. Forty-nine patients
were in the home care group and eleven patients were in
the nonhome care group. Seventeen in the home care group
and two in the nonhome care group were breast cancer

51

patients. Forty-two of the patients in this study were
over age 65. The tools utilized in this study were Symptom
Distress Scale (SDS)(McCork1e & Young, 1980), Enforced
Social Dependency Scale, (McCorkle & Young, 1980), Health
Perception Questionnaire (Ware, 1976), and Mental Health
Status Inventory 5 (Viet & Ware, 1983).

The patients in the McCorkle et al. (1994) study were
interviewed on or about the date of discharge and three
months later. The care the patients received from nurses
was provided by certified home care agencies. Patients
were seen for an average of 7.31 weeks with a mean of
12.96 home visits.

The results of the McCorkle et al. (1994) study
showed that home care patients had greater symptom
distress at baseline than the nonhome care patients. It
also showed that home care patients had greater dependency
scores than the nonhome care patients. But the home care
patients had significant improvements in mental health,
dependency, and symptom distress. A decrease in any and
all of these factors can lead to increased functional
status. The home care patients remained unchanged on
health perceptions. The nonhome care patients showed no
significant change in symptom distress, mental health,
dependency, and health perceptions.

The McCorkle et al. (1994) study demonstrated that
home care interventions improve patients' mental status

52

and preserved their functional abilities. Home care
assisted these patients in the reduction of symptoms
caused by cancer treatment and the progression of the
disease. Health care professionals, patients, and family
members need to be made aware of the benefits of home
care. Limitations in this study were the small number of
subjects in the analysis and the lack of random assignment
of patients to the home care or nonhome care conditions.
The benefits of home care services demonstrated by this
study have important implications for health care policy.
At the present time, home care service funding is limited.
The results of this study underscore the importance of
increasing this funding for such services.

Breast cancer patients who are utilizing home care to
maintain their functional status have fewer mental health
issues. A person who has breast cancer can begin a vicious
cycle that in the end may never return them to their
previous level of functioning. As side effects cause a
patient's inability to care for self, family, and
household, these in turn cause depression and social
isolation, which are mental health problems that can be
avoided if the patient’s functional status can be
maintained. The maintenance of functional status is a very
important aspect that needs to be considered for the older

breast cancer patient if she is to recover completely.

53

Summary

The studies completed by Kurtz et a1. (1994),
Arathuzik (1994), and McCorkle et al. (1994) indicate that
when breast cancer patients receive treatment for their
disease, physical functioning and mental health are
affected. When a person's functional status is impaired,
it alters life and outside assistance may be warranted. If
a patient does not have family and friends to assist in
this area, community health care resources need to fill
this gap.

A process is needed in the oncology clinics where
these patients are seen to identify existing and potential
problems (Given & Given, 1994). This documentation could
provide the much needed evidence that cancer patients are
in need of assistance at home. Given and Given (1994)
suggest that health care professionals need to assess,
plan, implement, and evaluate the home care needs of
cancer patients and their families based on the type and
aggressiveness of initial and continuing therapy; the age
and comorbid conditions of the patient; the manner in
which families have chosen to organize home care and
caregiver needs; and the ability to manage symptoms,
monitor equipment, coordinate services, deliver physical
care, and address the patient's emotional needs. By
utilizing the nursing process, problem areas can be
identified before rehospitalization occurs. Not all people

54

have family or friends to take on the role of caregiver.
These people may require community resources to assist in
their care.

A possible solution and a way to ensure that
appropriate care is going to be provided at home is for
the advanced practice nurse to utilize her case management
role from the time of diagnosis. The advanced practice
nurse can assist the family in maximizing the use of home
care and community services. Many patients and family
members are not aware of community-based agencies such as
home health aides, transportation, or nutrition assistance
(Given & Given, 1994). Introducing the case management
role at the time of diagnosis could help educate families
about available community-based resources. As the elderly
population grows, so does the need to deliver appropriate
care and services for these individuals to remain
independent and maintain their functional status.
Utilizing the case management role can be an important
link to assist the elderly (Toran, 1994).

Summary

The literature states that the number of women in
older age groups is rising. The number of women diagnosed
with breast cancer is also increasing. Cancer has evolved
from a fatal illness to a chronic condition for many
people. While the complex treatment of breast cancer is
being approached more aggressively over a longer period of

55

time, it does not equate to better health outcomes for
older women. Also, cancer treatment is being provided more
in outpatient care settings. As a result of these factors
there will be an increasing number of women that will have
altered functional status caused by breast cancer
treatment.

When patients receive chemotherapy, radiation,
hormonal therapy, surgical intervention, or a combination
of these treatments, their lives and functional status are
affected. The studies have identified that patients
undergoing breast cancer treatment have impaired
functional status at some point in time. Hughes (1993)
identified that functional status declined over the course
of initial treatment with the ability to function
physically and meet normal role obligations being
significantly lower after surgery.

The diagnosis of breast cancer represents a serious
crisis for the patient. To maintain functional status
during treatment should be of great concern to
oncologists. Impaired functional status can compromise a
patient's compliance with health status and treatment.
Given, Given, and Stommel (1994) found that the number of
symptoms experienced and changes of those experiences are
variables explaining patients' level of physical and
mental health. Symptoms were found to play a significant
role in anticipating changes in limitations of physical

56

functioning and mental health. Therefore it is essential
for the health care profession to assist in symptom
management and to develop strategies to limit this
complication.

Cimprich’s (1994) study looked at the capacity to
direct attention during the initial phase of treatment.
The results of this study identified that women with
breast cancer had decreased capacity to direct attention
following either mastectomy or breast conservation
surgery. They were unable to pay attention and
concentrate, which affected their functioning in social,
emotional, mental, and physical roles. Maintaining
functional status during treatment of breast cancer is
very important but difficult if health care professionals
are not aware of the profound impact the disease and
treatments have on a patient's life.

Patients that undergo surgical intervention for
breast cancer have various problems with their arms after
treatment. A study completed by Maunsell et al. (1993)
found that women who are still experiencing problems with
their arms 18 months after surgical intervention have an
altered quality of life. Jepson et al. (1997) completed a
study to examine survival time and enforced dependency.
The results found that high levels of symptom distress,
enforced personal and social dependency, and depression
were associated with shorter survival. This study supports

57

that survival might be improved by implementing

interventions focused on functional status. Therefore, if
the patient is assisted in maintaining functional status,
positive outcomes, such as extended survival, may result.

Studies completed by Polinsky (1994) and Tasmuth et
al. (1996) identified multiple problems due to surgical
intervention. Common problems were pain, arm weakness,
anxiety, and depression. Short- and long-term survivors
experience many difficulties in relation to functional
status due to surgical intervention. Therefore it is
essential that patients be informed before surgery of
changes and issues that can occur as a result of
treatment.

Kurtz et al. (1994) completed a study on how age and
survival status influence the frequency and severity of
patient symptoms and dependencies in functioning. The
results identified that symptoms were the only significant
predictor in dependency in ADLs, whereas symptoms and the
interaction of symptoms were significant for immobility.
As a patient's cancer progresses, symptom distress
increases. Also, as a person ages the probability of
having comorbid conditions increases. The more comorbid
conditions a person has, the greater the probability of
impaired functional status. The ability to survive the
treatment and cancer itself decreases substantially with
an increased number of comorbid conditions.

58

McCorkle et al. (1994) completed a study to evaluate
the effect of home care services on patients with advanced
disease. The results of this study demonstrated that home
care interventions improved mental status and preserved
the patient's functional status abilities. Maintaining
functional status and minimizing symptom distress are
essential if these older patients are to be survivors of
breast cancer.

Not every individual has family or friends who can
care for that individual in a time of need. It has been
identified that if physical and emotional support is not
provided in the home, the attempts to improve symptom
distress and physical functioning are only marginally
successful. If a patient has unmet needs during her
rehabilitation, the likelihood of noncompliance with
treatment increases. This adversely affects patient
outcomes. If a family support system is not present,
professional assistance is required to provide this
necessary care. The health care profession must respond by
increasing the community health care resources and
assistance for breast cancer patients.

Strengths

The strengths of this literature for older breast

cancer patients are as follows. The research completed on

patients receiving chemotherapy, radiation, or both in

59

relation to their physical, mental health, and
psychosocial status provided sound evidence of the impact
they have on the older breast cancer patient. The
literature provided evidence that these three factors are
affected by the treatment regimens given to these
patients.

The research on physical functioning also showed the
impact it has on the older breast cancer patient. The
research provided valuable information on how the patient
is affected physically by breast cancer, surgical
intervention, and treatment regimens. The literature
informs the health care profession of the deficits that
can occur in this area.

The research and literature provided suggestions to
the health care profession on how to alleviate problems
that can affect functional status. Symptom management,
guided imagery, and changing pain medication doses or the
pain medication itself can assist in the alleviation of
these problems. Also, the literature identified ways to
assist in the maintenance of the breast cancer patient's
functional status.

The literature emphasized the importance of being
able to maintain functional status through assistance from
family, friends, home care, or a combination of these so
patients can be independent after surgical intervention or
treatment.

60

The tools that were utilized in the research studies
were reliable, valid, and well established (e.g., SF short
form, ESDS, DSD, CES-D, ADLs, and IADLs).

The literature informed the reader of the significant
impact that breast cancer can have on the older patient.
It informs health care professionals on how a patient's
functional status and the impact it can have on treatment
and prognosis over time needs to be continually assessed.
Limitations

The limitations of the literature review for the
older breast cancer patient are as follows. There were
limited studies completed on women with metastatic breast
cancer. The studies completed on breast cancer were on
women with early stage breast cancer, treatable breast
cancer, or solid tumors.

The studies that were completed solely on breast
cancer patients had a small number of subjects. This can
decrease the significance of the study. More studies need
to be completed on older women with larger subject numbers
to increase the validity of these studies.

There are not many studies completed on long-term
survivors of breast cancer. More research needs to be done
in this area. The one study about long-term survivors in
this scholarly project identified that these patients

continue to have multiple problems from surgical

61

intervention and treatment regimens.

The research studies identified limitations in the
arm on the operative side but no recommendations were
identified to rectify this problem. Information on
exercises and rehabilitation needs to be identified for
these patients.

Gaps in Literature

The one gap identified in the research literature was
the effects of long-term rehabilitation on the older
breast cancer patient. No research or information was
provided in this area. The rehabilitation needs of these
patients is of great importance to the health care
profession and research needs to be completed in this
area.

Generalizations

There are several generalizations within the
literature. Functional status is affected by surgical
intervention, treatment regimens, and age. If the
functional status in the older breast cancer patient is
impaired, the ability for her to return to an independent
state may be impossible. Most of the research completed on
older breast cancer patients is done on early stage breast
cancer and treatable breast cancer. These results are
generalized to “all” breast cancer patients. It has been

identified that studies completed on younger breast cancer

62

patients cannot be extrapolated to older breast cancer
patients (Silliman et al., 1993). The results in the
literature cannot be generalized to cover “all” older

breast cancer patients.

63

CHAPTER 4

PROJECT

According to the literature functional status is
compromised by stage of disease, treatment regimens,
psychological effects and comorbid conditions on the older
breast cancer patient. Due to this fact, a functional
status assessment tool is needed to measure the older
breast cancer patient's ability to function. The
information provided by this tool will assist the advanced
practice nurse and patient to set mutual goals to restore,
maintain or improve functional status.

With the information provided from the literature
review, in conjunction with King’s Goal Attainment Theory,
the Medical Outcomes Study (MOS) SF-36 (Ware, 1993), Upper
Body Strength of the Affected Arm (Satariano, Ragland &
DeLorenze, 1995) and The Symptom Experience (Given &
Given, 1996) tools were identified and combined to capture
the essence of functional status for the older breast
cancer patient. The combination of these tools provides
the advanced practice nurse with comprehensive information
on functional status. A woman who undergoes breast cancer
treatment has the potential to have an alteration in
functional status.

64

In King's Goal Attainment Theory the advanced
practice nurse and patient are in a reciprocal
relationship in which the nurse has special knowledge and
skills to communicate appropriate information to help the
patient set goals. The patient has information about self
and perceptions of problems or concerns that, when
communicated to the advanced practice nurse, will help in
mutual goal setting (King, 1981). Each patient’s goals are
individualized related to that patient’s concerns,
problems and disturbances in health (Tomey & Alligood,
1998). The advanced practice nurse and patient communicate
verbally, and nonverbally. The functional status
assessment tool for the older breast cancer patient
provides another way for these two people to communicate.
Communication is an essential concept in King's Goal
Attainment Theory. Without communication, interaction and
transaction cannot occur (Tomey & Alligood, 1998). The
utilization of this tool provides valuable information and
guidance during this difficult time.

With the information provided from the literature
review, the MOS (Medical Outcomes Study) SF-36 (Ware,
1993), Upper Body Strength of the Affected Arm (Satariano,
Ragland & DeLorenze, 1995), and The Symptom Experience
Tool (Given & Given, 1996) were combined to make the
functional status assessment tool for the older breast
cancer patient (See Appendix A). These tools were combined

65

for the following reasons:(a) The tool is easily self—
administered, (b) it is easily understood by the advanced
practice nurse and patient, (c) it covers a broad range of
health concepts, and (d) it provides important information
about a person’s ability to function.

King’s theory of goal attainment assisted in the
selection of these tools because of the following
characteristics:(a) The tools can be utilized in the Goal
Oriented Nursing Record process (GONR). The GONR serves as
a documentation system that assists the advanced practice
nurse and patient toward goal attainment. (b) Because this
tool is divided into 13 different sections, the advanced
practice nurse and patient can identify a broad range of
problem areas and mutually set goals that they identify as
important. A patient may have multiple problems, but is
only willing mutually to set goals related to one area.
The different sections in this tool makes this possible.
If a patient is not interested in mutually setting goals,
the ability to achieve goal attainment is minimal. (c)
This functional status assessment tool for the older
breast cancer patient focuses on the patient holistically.
It looks at many aspects of the patient’s ability to
function. It is not restricted to one area. In King's Goal
Attainment Theory focusing on holism is essential; and (d)
This tool promotes shared decision making between the
advanced practice nurse and patient.

66

After the tool is administered, the results need to
be discussed and decisions need to be made to proceed
toward goal attainment. When applying King's Goal
Attainment Theory collaborative decision making is
necessary throughout the entire process to achieve the
mutual goal(s).

Medical Outcomes Study (MOS) SF-36

The SF-36 is identified as a generic health measure
because it assesses health concepts that represent basic
human values that are relevant to everyone's functional
status and well-being (Ware, 1987, 1990a).

The Medical Outcomes Study SF-36 was constructed to
measure eight health attributes using eight multi-item
scales containing between two and ten items each. Ware
(1993) explains that the scales utilized in this tool are
Likerts method, but in fact, these scales are Likert-type.
The eight health attributes utilized in this tool are
physical functioning (PF), role limitations because of
physical health problems (RP), role limitations because of
emotional problems (RE), bodily pain (BP), vitality
(energy/fatigue) (V), social functioning (SF), general
mental health (psychological distress and psychological
well-being) (MH), and general health perceptions (GH)
(Ware & Sherbourne, 1992). The SF-36 permits scoring of a
set of eight scales displayed as a profile of health
status concepts. The scores are easy to compute and

67

considerable information is provided through their
interpretation (Ware & Sherbourne, 1992).

Ware (1993) explains that the SF-36 items and scales
are scored so that a higher score indicates a better
health state. For example, functioning scales are scored
so that a higher score indicates better functioning,
whereas the pain scales are scored so that a high score
indicates freedom from pain.

A study was completed on the MOS SF—36 to test data
quality, scaling assumptions, and reliability across
diverse patient groups. This study had 4,842 patients
enrolled in the longitudinal-panel component of the MOS
SF-36. The inclusion criteria into this study were: (a)
English speaking, (b) 18 years of age or older, and (c)
had an office visit with an enrolled clinician during a 9-
day screening period between February and November 1986.

The results of this study provide substantial
evidence that using the MOS SF-36 is appropriate across
diverse medical and psychiatric groups. The SF-36 is a
reliable and valid tool that is utilized widely with many
different patient populations (McHorney, Ware, Lu, &
Sherbourne, 1994; Ware, Kosinski, Bayliss, McHorney,
Rogers, & Raczek, 1995; Ware & Sherbourne, 1992; Stewart,
Hays & Ware, 1988; Stewart, Greenfield, Hays, Wells, Berry

& McGlynn, 1989; Ware & Kosinski, 1996).

68

Upper Body Strength of phe.Affepted Arm

Upper Body Strength of the Affected Arm(UBS) was
added to the Medical Outcomes Study SF-36 tool because
this condition can greatly alter the older breast cancer
patient’s functional status (see Appendix A). This section
consists of four items related to the physical functioning
of the affected arm. These items question the patient’s
ability to (a) lift an object greater than ten pounds, (b)
lift an object less than ten pounds, (c) push or pull
large objects, and (d) reach or extend arm above or below
shoulder level. This tool utilizes a Likert-type scale
with four possible answers to each question. They range
from 1- no difficulty to 4—a lot of difficulty. This
section will be scored utilizing the SF-36 scoring system.
Symptom Experience

McCorkle (1994) defines symptom distress as the
degree of discomfort from specific symptoms reported by
the patient. Studies completed by Given, Given and Stommel
(1994) and Given, Kurtz, Given, and Kurtz (1994)
demonstrate that symptom distress can affect functional
status of cancer patients. Careful management of symptoms
will have a positive impact on a patient’s ability to
function and perform her normal social roles.

McCorkle's symptom distress tool identifies to what
degree the patient is feeling symptoms and how this
affects the patient’s functional status. The symptom

69

experience tool does not measure the degree of the
distress but rather if the patient is experiencing the
symptoms at all. McCorkle's research studies identify that
symptoms caused by cancer treatment can affect a patient's
ability to function. Due to this fact the Symptom
Experience Tool was included in the Functional Status
Assessment Tool for the Older Breast Cancer Patient.

The Symptom Experience Tool (SE) was revised from its
original format to be included in this scholarly project.
Ten symptoms were identified that directly affected the
breast cancer patient. The Symptom Experience Tool scoring
system will be dichotomous (yes/no) due to the fact that
severity of the symptoms are not being looked at, but
rather the number of symptoms the patient is experiencing.
The scores will be summated at the end of this section. A
score of zero means that the patient is not having any
symptoms related to treatment regimens or breast cancer
itself and a score of 10 denotes the patient is
experiencing 10 symptoms affecting her ability to
function. Given and Given (1994) explain that when
symptoms of cancer treatment or disease progression are
large in number and unmanageable, it is a cause of great
distress for the patient and family.

This section will also be scored separately from the

SF-36 and the Upper Body Strength of the Affected Arm.

7O

Scoring

The SF-36 and the Upper Body Strength of the Affected
Arm (UBS) will be scored utilizing the SF-36 scoring
system. Each item in the SF-36 has a precoded item value
and a final item value. The final item value is the
recoding of response choices. Seven items in the SF-36 are
reverse scored. Reverse scoring is done to ensure that a
higher item value indicates better health on all SF-36
items and scales. SF-36 items that need to be reverse
scored are worded in such a way that a higher precoded
item value indicates a poorer health state (Ware, 1993).

The Upper Body Strength of the Affected Arm and the
Symptom Experience Tool are not in the original content of
the SF-36 tool. Due to this fact a precoded and final item
value needs to be established to utilize the SF-36 scoring
system. The Upper Body Strength of the Affected Arm
section is scored as 1—experiencing no difficulty,
2—experiencing a little difficulty, 3—experiencing some
difficulty, and 4—experiencing a lot of difficulty. The
scoring system of the Symptom Experience Tool will be
dichotomous (Yes—l/No-O). Even though the scoring system
is different this section will also be compared to
national norms.

For the purpose of this scholarly project the
precoded values and recoded values will be the same
number. This means that if the older breast cancer patient

71

is having a lot of difficulty with upper body strength in
the affected arm the four questions for this section
values precoded and recoded for each question would be a
four. As for the Symptom Experience Tool the precoded and
recoded value for any question marked “yes” is one.

After recoding for the SF-36, Upper Body Strength of
the Affected Arm and the Symptom Experience Tool is
completed, a raw score is computed for each scale. This
score is the simple algebraic sum of responses for all
items in that scale (See Table 1). The next step is to
transform each raw score to a 0-100 scale using the

following formula:

Transformed Scale = (Actual raw score - lowest possible raw score) x 100

 

possible raw score range

Although this final step is optional, is it strongly
recommended because transformed scale scores can be
compared with norms derived from the Medical Outcomes
Study (MOS) (Ware, 1993). Ware (1993) explains two reasons
to adhere to the standards of content and scoring
described in the SF-36 manual. First, they are most likely
to produce scores with the same reliability and validity

as reported in other Medical Outcome Study (MOS)

publications. Second, the comparisons of results across

72

Table 1.

Sca
1e

PF

RP
BP
GH

SF
RE
MH
UBS
SE

Note. =

Formulas for scoring and transforming scales

Sum final item value

3a+3b+3c+3d+3e+3f+3g+3h+
3i+3j

4a+4b+4c+4d

7+8
l+1la+1lb+11c+11d
9a+9e+9g+9i

6+10

5a+5b+5c
9b+9c+9d+9f+9h
12a+12b+12c+12d

l3a+13b+13c+13d+13e+13f+13g

+13h+13i+13j

Lowest
and
highest
possible
raw
scores

10,30

4,8
2,12
5,25
4,24
2,10
3,6
5,30
4,16
0,10

Possib
1e raw
score
range

20

10
20
20

25
14
10

SF-36 Health Survey Manual & Interpretation Guide

 

(6:18) by J. E. Ware,1993, Boston, Massachusetts: Nimrod
Press. Copyright 1993 by John E. Ware. Reprinted with
permission.

73

studies are made possible to benefit all who use these
content and scoring standards.

When scoring algorithms are used, the national norms
(see Table 2) in the SF-36 manual are the appropriate way
to interpret these scores. Each section of the tool is
scored separately. Questions referring to upper body
strength of the affected arm and symptom experience do not
have norms with which to compare their scores. These
questions are not a part of the SF—36; therefore, national
norms have not been developed in these areas. This issue
will be discussed in Chapter 5.
Recommendations/Implications.

Due to the fact each section in this tool is unique,
it is difficult to summate all 13 areas and decide if the
patient has an alteration in overall functional status.
Each section will need to be considered separately and
compared to national norms to determine if the patient is
having a problem in this area.

The Advanced Practice Nurse's Use of the Functional Status
Assessment Tool for the Older Breast Cancer Patient

This tool will be administered every three months for
one year. A baseline score will established between two
and three weeks after the patient has had surgical
intervention. The initial scores received from the patient
will be compared to national norms and the patient's own
satisfaction with her ability to function. A plan of care

74

Table 2. National Norms for Females by Age Group

 

 

 

 

 

Ages 55'“ PF RP up CH vr SF RE MH
Females (N=164)
Mean 73 09 71 61 66 64 62.87 58 08 79 43 79 51 73 40
25 th Percentile 60.00 33.33 51.00 46.“) 40.00 62.50 66.67 64.00
50th Percentile (median) 85.“) 100.00 72.“) 67.1!) 65.1” 11”.“) 100.00 76.“)
75th Percentile 95 00 100 00 84 00 82.“) 77 50 100 00 100 00 88 00
Standard Deviation 26.73 39.84 25.26 23.37 23.42 27.02 34.64 19.74
Range 0-100 0- 100 0- 100 5-100 0-95 0— 100 0100 0-100
96 Ceiling 13.3 59.8 17.2 5.5 0.0 54.5 67.7 5.2
% Flow 1.2 17.9 2.1 0.0 1.2 ‘ 1.5 12.7 0.5
Ages 65 & over 111‘ ltl’ 0P CH VT SF RE MH
Females (N=413)

Mean 61.86 56.11 63.44 61.64 55.46 77.00 73.38 74.71

...................................................................................

25111 Percentile 40.00 0.00 41.00 45.00 40.00 62.50 33.33 64.00
50th Percentile (median) 66.70 75.00 62.00 62.00 55.00 87.50 100.00 80.00
75th Percentile 85.00 100.00 84.00 77.00 75.00 100.00 100.0) 88.00

.....................................................................................

Standard Deviation 28.95 42.53 27.12 22.08 23.51 27.69 39.66 19.88
Range 0-100 0-100 0-100 10-100 0-100 0-100 0-100 4-100
96 Ceiling 7.3 40.0 21.0 3.1 0.8 48.3 64.3 6.8

96 Floor 2.8 27.9 2.4 0.0 2.2 2.2 18.5 0.0

.................................................................................

75

will then be established utilizing the advanced practice
nurse’s assessment and the above comparison. Comparing the
initial and previous scores with those obtained at the
current office visit will be important. If the patient’s
scores experience a 10% decrease over time, her function
is decreasing. There is no discussion in the literature
about what is identified as a clinically significant
decline in functional status. Due to this fact, the
advanced practice nurse’s assessment and the patient’s
satisfaction with functioning is important. The decline in
scores will alert the advanced practice nurse to problems
and open discussions with the patient. The advanced
practice nurse and patient will need to problem solve and
develop strategies to prevent the continuing decline in
score. This tool could be useful in justifying referrals
to home care for those patients with decreasing functional
status scores.

This tool can assist the advanced practice nurse and
patient in identifying problem areas related to functional
status. It is important to involve the patient in decision
making and developing goals related to her functional
status. With this tool divided in sections, the advanced
practice nurse and patient can identify problem areas and
mutually decide what areas need to be worked on. A patient

may have many problem areas, but may only choose to work

76

on one at time. King's Goal Attainment Theory involves the

patient in her care and promotes interaction.

77

CHAPTER 5

RECOMMENDATIONS/IMPLICATIONS FOR THE
ADVANCED PRACTICE NURSE

As the older breast cancer patient receives cancer
treatment, it is important for the advanced practice nurse
to monitor her functional status. If the older breast
cancer patient's functional status is altered during
cancer treatment, the ability for her to return to her
previous functioning may be compromised.

The intentions of this scholarly project are to:(a)
Expand knowledge and understanding on the effects of
treatment on older breast cancer patients and their
functional status, (b) identify measures that can be
consistently utilized to assess the functional status of
the older breast cancer patient, and (c) utilize a
functional status assessment tool for the older breast
cancer patient that can be applied by the advanced
practice nurse in the primary care facility.

Throughout the literature review, functional status
measures were identified. Understanding and knowledge were
also increased in the area of older breast cancer

patients. Three tools were identified and combined to make

the Functional Status Assessment Tool for the Older Breast

78

Cancer Patient. These three tools were the Medical
Outcomes Study (MOS) SF-36 (Ware, 1993), the Symptom
Experience Tool (Given & Given, 1996), and Upper Body
Strength of the Affected Arm (Satariano, Ragland,&
DeLorenze, 1995). These combined tools provide the
advanced practice nurse with the ability to assess, plan,
implement and evaluate the older breast cancer patient's
ability to function. The advanced practice nurse will
assist in the restoration, maintenance, or improvement of
this patient's functional status.

This chapter of the scholarly project will identify
recommendations for future research and implications for
advanced practice.

Research

Information provided from the literature review
informs the reader that more studies need to be completed
on the older breast cancer population. Also, the research
completed on older breast cancer patients should not be
extrapolated to “all” breast cancer patients. Due to the
fact that more research needs to be done in this area,
three tools were combined to measure the functional status
of the older breast cancer patient. These tools are the
Medical Outcomes Study (MOS) SF-36 (Ware, 1993), the
Symptom Experience Tool (Given & Given, 1996) and Upper
Body Strength of the Affected Arm (Satariano, Ragland &
DeLorenze, 1995). The Functional Status Assessment Tool

79

for the Older Breast Cancer Patient can provide valuable
information about this population and be of great
assistance to the advanced practice nurse in the primary
care facility. Information provided by research can help
the advanced practice nurse gain the knowledge necessary
to provide the best possible care to the older breast
cancer patient.

Due to the fact that these tools have never been
combined to assess the functional status of the older
breast cancer patient, the first research study must be
longitudinal to develop the psychometrics on the tool
itself. For the information provided by this tool to be
valued and meaningful in research, reliability and
validity must be established (Polit & Hungler, 1995). This
reliability and validity must also be established before
the tool can be utilized to measure the functional status
of the older breast cancer population in the primary care
facility.

Reliability identifies the degree of consistency or
dependability with which an instrument measures the
attribute it is designed to measure (Polit & Hungler,
1995). To assess the stability of the functional status
assessment tool, procedures that evaluate test-retest
reliability need to be completed (Polit & Hungler, 1995).
The researcher would administer the functional status
assessment tool to a sample of older breast cancer

80

patients on two occasions and then compare the scores
(Polit & Hungler, 1995). The comparison procedure is
performed by computing a reliability coefficient. This
coefficient represents a numerical index of the magnitude
of the test's reliability (Polit & Hungler, 1995). The
reliability coefficients can be used as an important
indicator of the quality of the instrument (Polit &
Hungler, 1995).

Another indicator of reliability is internal
consistency. Internal consistency must be established
before a tool can be used for research purposes (Brink &
Wood, 1995). Internal consistency is established through
Cronbach's Alpha. Cronbach's Alpha is a reliability index
that estimates the internal consistency or homogeneity of
a measure composed of several items or subparts (Polit &
Hungler, 1996). Cronbach’s Alpha correlates each
individual item with each item and the overall score. This
procedures gives an overall measure of the consistency
with which the score on an item can be used to predict the
overall attribute being measured (Brink & Wood, 1995).
These procedures can establish the reliability of the
Functional Status Assessment Tool for the Older Breast
Cancer Patient.

Validity is the degree to which an instrument
measures what it is intended to measure. Validity of a

tool is extremely difficult to establish (Polit & Hungler,

81

1995). To test if the Functional Status Assessment Tool
for the Older Breast Cancer Patient is valid, the
criterion—related approach would be utilized. The key
issue to utilizing this approach is whether the instrument
is a useful predictor of subsequent behaviors,
experiences, or conditions (Polit & Hungler, 1995).
Criterion Validity demonstrates that test scores are
systematically related to one or more outcome criteria
(Ware, 1993). Validity for the Upper Body Strength of the
Affected Arm Tool will be established by utilizing the
following measures: (a) passive range of motion (ROM) with
resistence to the muscles, and (b) active range of motion
(ROM). An independent advanced practice nurse will
complete the active and passive ROM assessment. The
results of the assessment will be compared to the
information obtained from the tool. To establish validity
a correlation between the assessment and the tool need to
be identified. This correlation identifies to the advanced
practice nurse that this tool is measuring what it is
suppose to. Validity is not an all—or-nothing
characteristic for an instrument. Validity is not proved,
established, or verified but rather supported to a greater
or lesser degree by evidence. Validation is a never-ending
process. The more evidence that can be gathered that an
instrument is measuring what it is supposed to be
measuring, the more confidence researchers will have in

82

the validity of the instrument (Polit & Hungler, 1995). It
must be identified that this tool measures functional
status of the older breast cancer patient at various
stages during the treatment and disease trajectory. This
tool must be able to reveal the two distinct groups of
patients, those who are experiencing functional status
changes and those who are not.

During the development of the psychometrics for the
functional assessment tool for the older breast cancer
patient, national norms need to be established in the
areas of upper body strength of the affected arm and
symptom experience. At the present time, this information
is not available but it is needed to score adequately the
functional status assessment tool for the older breast
cancer patient. This tool is scored utilizing the Medical
Outcomes Study (MOS) SF-36 scoring system. The SF-36
scores are compared to national norms. If national norms
are not established for the Functional Status Assessment
Tool for the Older Breast Cancer Patient, the ability to
score the tool and to signify its worth are nonexistent.

After the Functional Status Assessment Tool for the
Older Breast Cancer Patient has been identified as
reliable and valid, qualitative and quantitative research
needs to be completed. Qualitative and quantitative
research are two broad approaches to gathering and
analyzing scientific data (Polit & Hungler, 1995). These

83

two different approaches provide a different emphasis on

the information collected. The health care profession

needs to be informed of the older breast cancer patient's
measurable attributes of the human experience. Medical
professionals must also be aware of the dynamic, holistic,
and individual aspects of the human experience, which are
attempted to be captured in there entirety within the
context of those who are experiencing them (Polit &

Hungler, 1995). Each aspect of research can provide

valuable information about the older breast cancer

population.

Research studies need to be completed solely on older
breast cancer patients. The following research questions
need to be asked about this population:

1. What are the effects of chemotherapy and radiation on
the older breast cancer patient’s overall functional
status during and three months after a treatment
regimen?

2. During treatment regimens, does the older breast
cancer patient’s functional status of the affected
arm differ when physical therapy is and is not
provided?

3. How effective are rehabilitation's broad range of
services in improving the older breast cancer
patient's overall functional status during and three
months after treatment regimens?

84

4. What is the relationship between the actual decline
in scores of the Functional Status Assessment Tool
for the Older Breast Cancer Patient and their ability
to function in their daily activities?

This information from further research can bring
about positive alterations in the breast cancer patient's
survival, independence, and health behaviors, and/or in

the health care system itself.

Practice

The literature review identified that an older breast
cancer patient's functional status can be altered during
treatment of their disease. This scholarly project
combined three existing tools to measure the functional
status of the older breast cancer patient. The tools
utilized were the Medical Outcomes Study (MOS) SF-36
(Ware, 1993), Symptom Experience Tool (Given & Given,
1996), and Upper Body Strength of the Affected Arm
(Satariano, Ragland & DeLorenze, 1995). This tool will be
identified as the Functional Status Assessment Tool for
the Older Breast Cancer Patient.

The functional status assessment tool for the older
breast cancer patient will be administered to patients
that have been diagnosed and treated for breast cancer in
the last year. This tool will be administered every three
months for one year. The administration will begin at the

85

earliest convenient visit to the primary care facility.
The tool’s intentions and importance will be explained to
the patient. If the patient agrees to complete this tool,
she will be given two options: (a) the tool can be filled
out at home and brought back to the primary care facility,
or (b) the tool can be completed prior to the patient's
next office visit in the primary care facility.

After the tool is completed by the patient, the
advanced practice nurse will compile the scores. The
initial scores will be compared to national norms. The
patient’s functional status will be determined by
comparing initial scores to national norms, the advanced
practice nurse's assessment, and how the patient feels she
is functioning. Each time the patient fills out the tool,
it will be compared to previous scores. A 10% decrease
from previous scores will indicate that the patient's
functional status has declined and a plan of care will
need to be established.

The advanced practice nurse will take the information
obtained from the tool and discuss the results with the
patient. At this time, the advanced practice nurse and
patient will identify problem areas. The patient will
identify the areas she is willing to work on. To set goals
mutually the advanced practice nurse's and patient's goals
need to be congruent. The patient may only identify one
area of concern, however, there may be several problem

86

areas. The advanced practice nurse cannot force the
patient to work on these areas. After problem areas have
been identified, the advanced practice nurse and patient
mutually set goals. A plan of care is then developed to
restore, maintain, or improve functional status.

Each plan of care and follow-up care is
individualized for every patient. Each patient that has a
decreased ability to function, as identified by the
functional status assessment tool, needs a plan of care
developed including follow-up care. The progress or
digression of this patient needs to be monitored closely.
At follow-up visits, the plan of care may need to be
changed. The advanced practice nurse’s case management
role may need to be utilized to initiate care of the
patient at home and provide new interventions.

If the functional status assessment tool for the
older breast cancer patient identifies physical
functioning and upper body strength of the affected arm as
problems areas, the advanced practice nurse will need to
initiate a consultation for rehabilitation medicine. If
bodily pain is the issue, collaborating with the physician
in the primary care facility or the patient's oncologist
would be warranted. The advanced practice nurse would
initiate interventions, such as prescribing pain
medication, teaching the patient relaxation techniques, or
the importance of music therapy. If this patient's pain

87

could not be managed by the advanced practice nurse. a
consultation with the patient's oncologist or the pain
clinic may be needed to serve this patient better.

Complications caused by breast cancer treatment can
occur at any time during and after the older breast cancer
patient’s treatment. The functional status assessment tool
can assist in identifying these complications. The
advanced practice nurse can then develop a plan of care to
assist in the resolution of these issues. Complications,
such as severe pain or depression, can be out of the realm
of the advanced practice nurse's practice. Consulting
another physician to manage these problems may be the role
the advanced practice nurse plays in this aspect of
patient care.

The interventions developed in the breast cancer
patient’s plan of care need to be realistic. The patient’s
health condition, her ability to complete the tasks,
available support systems, and other comorbid conditions
must be taken into account. The functional status
assessment tool may identify a patient with a 5% decrease
in physical functioning and a 10% decrease in social
functioning. The advanced practice nurse is informed from
the patient that she lives alone and is not going out
because it is too difficult to get dressed. Interventions
for this patient would be an evaluation from
rehabilitation medicine, arm exercises, and a referral for

88

a home health aide to assist in morning care. The
interventions assist in the resolution of this problem as
well as achievement of goals and expected outcomes.
Evaluation of the plan of care for a patient is
essential. The advanced practice nurse must identify the
success of this care plan. Were any aspects more helpful
than others? Did the patient achieve the expected
outcome?. Were the goals for the advanced practice nurse
and the patient achieved? If not, what could have helped
this patient achieve her goals? If this patient’s goals
have not been achieved, a new plan of care must be
established. At this time, the advanced practice nurse
could collaborate with the physician of the primary care
facility, an expert advanced practice nurse in the area of
breast cancer, or the patient's oncologist to problem
solve and develop a plan of care to assist this patient.
The functional status assessment tool for the older
breast cancer patient is divided into 13 sections. Each
patient's expected outcomes are individualized related to
her own problems. The overall expected outcome for this
patient is to be able to function independently or with as
little assistance as the patient feels is necessary.

The maintenance, restoration, or improvement of
functional status for the older breast cancer patient
during and after treatment is very important. If
functional status is altered, the ability to return to the

89

previous level of functioning may be compromised. The
utilization of the functional status assessment tool for
the older breast cancer patient, if used properly,
provides valuable information to the advanced practice
nurse to identify problem areas, develop a plan of care
with interventions, and utilize her role characteristics

to help this patient regain her ability to function.

90

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91

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APPENDIX A

98

APPENDIX A

Functional Status Assessment Tool for the
Older Breast Cancer Patient

Medical Outcomes Study (MOS) SF-36

1.

In general, would you say your health is:

Excellent Very good Good Fair Poor
1 2 3 4 5

Compared to one year ago, how would you rate your

health in general now?

Much better now than one year ago
Somewhat better now than one year ago
About the same as one year ago

Somewhat worse now than one year ago

(flwal-J

Much worse now than one year ago

The following items area about activities you might do
during a typical day. Does your health now limit you in
these activities? If so how much.

Vigorous activities, such as running, lifting heavy

objects, participating in strenuous sports.

Yes, limited a lot (1)
Yes, limited alittle (2)
No, not limited at all (3)

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b)

Moderate activities, such as moving a table, pushing a

vacuum cleaner, bowling, or playing golf.

Yes, limited a lot (1)
Yes, limited a little (2)
No, not limited at all (3)

Lifting or carrying groceries.

Yes, limited a lot (1)
Yes, limited a little (2)
No, not limited at all (3)

Climbing several flights of stairs.

Yes, limited 3 lot (1)
Yes, limited alittle (2)
No, not limdted at all (3)

Climbing one flight of stairs.

Yes, limited a lot (1)
Yes, limited a little (2)
No, not limited at all (3)

Bending, kneeling or stooping.

Yes, limited a lot (1)
Yes, limited a little (2)
No, not limited at all (3)

Walking more than a mile.

Yes, limited a lot (1)
Yes, limited a little (2)
No, not limited at all (3)

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h) Walking several blocks.

Yes, limited a lot (1)
Yes, limited a little (2)
No, not limited at all (3)

1) Walking one block.

Yes, limited a lot (1)
Yes, limited a little (2)
No, not limited at all (3)

j) Bathing or dressing yourself.

Yes, limited a lot (1)
Yes, limited a little (2)
No, not limited at all (3)

4. During the past 4 weeks, have you had any of the

following problems with your work or other regular

daily activities as a result of your physical health?

Yes (1) No

(2)

a) Cut down on the amount of time you
spend on work or other activities.

 

b) Accomplished less than you would
like.

 

c) Were limited in the kind of work
or other activities.

 

d) Had difficulty performing the work
or other activities (for example, it
took extra time).

 

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5.

During the past 4 weeks, have you had any of the
following problems with your work or other regular
daily activities as a result of any emotional problems
(such as feeling depressed or anxious)?

Yes (1) No (2)

a) Cut down on the amount of time you

spent on work or other activities.

 

b) Accomplished less than you would

like.

 

c) Didn't do work or other activities
as carefully as usual.

 

During the past 4 weeks to what extent has your
physical health or emotional problems interfered with
your normal social activities with family, friends,

neighbors, or groups?

Not at Slightly Moderately Quite Extremely

all
(1) (2) (3) (4) (5)

 

 

 

How much bodily pain have you had during the past 4

weeks?

very Very
None Mild Mild Moderate Severe Severe
(1) (2) (3) (4) (5) (6)

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8. During the past 4 weeks, how much did pain interfere
with your normal work (including work outside the home

and housework)?

Not at A little Moderately Quite Extremely
all bit. (3) (4) (5)
(1) (2)

 

 

 

 

 

9. These questions are about how you feel and how things
have been with you during the past 4 weeks. For each
question, please give the one answer that comes closet
to the way you have been feeling. How much of the time
during the past 4 weeks

a) did you feel full of pep?

 

 

 

A None

All of Mbst A good Some little of
the of the bit of of the of the the
time time the time time time time
(1) (2) (3) (4) (5) (6)

b) have you been a very nervous person?

A None

Adl of Mest A.good Some little of
the of the bit of of the of the the
time time the time time time time

(1) (2) (3) (4) (5) (6)

 

 

 

 

 

c) have you felt so down in the dumps nothing could cheer

you up?
A None
Adl of Mest A good Some little of
the of the bit of of the of the the
time time the time time time time

(1) (2) (3) (4) (5) (6)

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d)

All of

 

 

 

 

 

 

have you felt calm and peaceful?

 

A None
Mbst A good Some little of
the of the bit of of the of the the
time time the time time time time
(1) (2) (3) (4) (5) (6)
e) did you have a lot of energy?
A None
.All of Most A.good Some little of
the of the bit of of the of the the
time time the time time time time
(1) (2) (3) (4) (5) (6)
f) have you felt downhearted and blue?
A None
All of Most A good Some little of
the of the bit of of the of the the
time time the time time time time
(1) (2) (3) (4) (5) (6)
g) did you feel worn out?
A None
All of Mbst A good Some little of
the of the bit of of the of the the
time time the time time time time
(1) (2) (3) (4) (5) (6)
h) have you been a happy person?
A None
All of Most A good Some of little of
the of the bit of the of the the
time time the time time time time
(1) (2) (3)

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(4)

(5)

(6)

i) did you feel tired?

None

.All of Most A good Some of little of
the of the bit of the of the the
time time the time time time time

(1) (2) (3) (4)

(6)

10. During the past 4 weeks, how much of the time has your

physical health or emotional problems interfered with

your social activities (like visiting friends,

relatives, etc.)?

None

.All of Mbst A.good Some little of
the of the bit of of the of the the
time time the time time time time

(1) (2) (3) (4)

 

 

 

 

(6)

11. How TRUE or FALSE is each of the following statements

 

 

 

 

for you?

a) I seem to get sick a little easier than other people.

Definitely Mbstly' Don't Mbstly Definitely
true true Know false false
(1) (2) (3) (4) (5)

b) I am as healthy as anybody I know.

Definitely Mbstly' Don't IMostly Definitely
true true Know false false

(1) (2) (3) (4)

105

(5)

c) I expect my health to get worse.

Definitely Mbstly' Don't Mostly Definitely
true true Know false false
(1) (2) (3) (4) (5)

 

 

d) My health is excellent.

Def 1 ni tely Mostly Don ’ t Mostly Def ini tely
true true Know false false
(1) (2) (3) (4) (5)

Upper Body Strength of the Affected Arm

12. Physical functioning of the affected arm.

These are activities that you may do during a typical day
with your affected arm. Does your health now limit you in
these activities. If so how much?

a) lifting objects heavier than 10 lbs.
No A.little Some .A lot of
difficultly* difficulty difficulty difficulty
(4) (3) (2) (1)

 

 

 

b) lifting objects weighing less than 10 lbs.
No A.little Some A lot of
difficultly' difficulty difficulty difficulty
(4) (3) (2) (1)

 

 

 

 

c) pushing or pulling large objects like a living room
chair.

No .A little Some A.lot of
difficultly difficulty difficulty difficulty
(4) (3) (2) (1)

106

d. reaching or extending arms above or below shoulder
level.

No A little Some A.lot of
difficultly' difficulty difficulty difficulty
(4) (3) (2) (1)

Symptom Experience

13. Have you experienced any of the following symptoms in

the last two weeks.

(1) (0)

1. Nausea Yes No
2. Trouble sleeping Yes No
3. Fatigue Yes No
4. Diarrhea Yes No
5. VOmiting Yes No
6. Difficulty concentrating Yes ‘No
7. Weakness Yes No
8. Poor appetite Yes No
9. Arm Swelling Yes No
10. Limitations in arm movement Yes No

Note. From Ware, J., & Sherbourne, C. (1992). The MOS
36-item short-form survey (SF-36). Medical gare, 30(6),
473—483., Vinokur, A,. Threatt, B., Vinokur-Kaplan, D., &
Satariano, W. (1990). The process of recovery from breast
cancer for younger and older patients. Cancer. 65
1242-1254., Satariano, W., Ragland, D., & DeLorenze, G.
(1995). Limitations in upper body strength associated with
breast cancer: A comparison of black and white women.
Journal of Clinical Epidemiology, 49(5), 535-544. and
Given, B. & Given, C. (1996). Wave I Patient Without
Caregiver Telephone Interview (Michigan State University.
Grant #2). Lansing, Michigan: Research Study.

 

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