Utilizing a Nurse-Led Approach to Promoting Health-Related Quality of Life in Women After Cancer

Background: Advances in the diagnosis, treatment and management of cancer have significantly improved survival rates and in some cases, such as early breast malignancies, transformed cancer from a fatal condition to a chronic and sometimes curable disease (Australian Institute of Health and Welfare (AIHW) in association with Cancer Australia and the Australian Association of Cancer Registries, 2008). In the case of breast cancer, survival rates are now 90% at 5 years and 80% twenty years after treatment (AIHW, 2017) and thus patients previously treated for cancer (or cancer survivors) represent a growing population in Australia (de Moor et al., 2013). Although survival rates are improving, survival can involve a number of treatment-related health problems including ovarian failure (Gupta et al., 2006), weight gain (Eakin et al., 2006), cognitive alterations (Evens & Eschiti, 2009), and fatigue (Bower et al., 2006). For many women after cancer, these physical and psychological sequelae can have a significant and negative impact on quality of life (American Cancer Society, 2017) and are not adequately addressed within current supportive cancer care services. Moreover, there is a need for support is particularly acute among rural and outer metropolitan survivors, who have restricted access to face-to-face services due to cost, time, geographical, and other barriers.

Aims: This National Health and Medical Research Council (NHMRC) Partnerships Project was awarded to develop, trial and evaluate clinical benefits and cost effectiveness of an e-health enabled structured health promotion intervention - The Women’s Wellness after Cancer Program (WWACP). The project aimed to develop and trial an e-health enabled multimodal intervention is to improve health related quality of life in women previously treated for target cancers and enhance accessibility for metropolitan and regional women. Primary outcomes for this project are to promote a positive change in health-related quality of life (HRQoL) in the women undertaking WWACP compared to women who receive usual care.

Methods: The single-blinded multi-center randomized controlled trial recruited a total of 351 women within 24 months of completion of chemotherapy and/or radiotherapy. Women were randomly assigned to either a usual care or intervention group. Women provided with the intervention were provided with an interactive iBook and journal, web interface, and three virtual consultations by experienced cancer nurses. A variety of methods were utilized, to enable positive self- efficacy and lifestyle changes. These include online coaching with a registered nurse trained in the intervention, plus written educational and health promotional information. The program has been delivered through the e-health enabled interfaces, which enables virtual delivery via desktop and mobile computing devices and was underpinned by Bandura’s social cognitive theory which emphasizes the notions of perceived control, planned behavior and self-efficacy. Importantly this enables accessibility for rural and regional women in Australia who are frequently geographically disadvantaged in terms of health care provision.

Results: The average age of women in this study was 53 years (SD = 8). Over two-thirds of the sample were married (77%), many were Australian born (69%), and over half had completed a university degree (59%). Most Australian states were represented with around three-quarters of participants coming for Queensland, New South Wales, and Victoria. One-way ANCOVAs (one-way between groups analysis of covariance) and effect size using Cohen’s d were conducted to determine a statistically significantly difference between the different HRQoL measures on the post intervention. After adjusting for the pre-intervention scores, there was a significant difference between the two groups on post-intervention the Short Form 36 (SF 36) domain Role Emotional (p =.011) and the Physical Component Score (p =.023). Moreover, medium effects were seen for SF 36 bodily pain (Cohen’s d = 0.33).

Conclusions: Women after acute hematological, breast and gynecological cancer treatments demonstrate good cancer survival rates and face residual health problems which are amenable to behavioral interventions. The conclusion of active treatment is a key 'teachable moment' in which sustainable positive lifestyle change can be achieved if patients receive education and psychological support which targets key treatment related health problems and known chronic disease risk factors.