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Corresponding author: Linda Sarna, RN, DNSc, FAAN, School of Nursing, University of California, Los Angeles, 700 Tiverton Ave, Los Angeles, CA 90095-6918 (e-mail: lsarna{at}sonnet.ucla.edu).
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Abstract |
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 Top Abstract Symptoms and Recovery After...Factors Potentially Influencing...MethodsResultsDiscussionReferences |
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Objectives To describe symptom severity during the first 4 months after thoracotomy for non–small cell lung cancer and factors associated with overall symptom severity at 1 and 4 months.
Methods Ninety-four patients were assessed at 1, 2, and 4 months after thoracotomy by using the Lung Cancer Symptom Scale, Brief Pain Inventory, Schwartz Fatigue Scale, Dyspnea Index, and Center for Epidemiology Studies–Depression Scale (CES-D). Clinically meaningful changes, decrease in the proportion of patients with severe symptoms, and relationships among symptoms were determined. Mixed effects models for repeated measures were used to evaluate changes in severity. Multiple regression models were used to examine correlates of overall symptoms.
Results Mean symptom severity significantly decreased over time for most symptoms. Only disrupted appetite, pain, and dyspnea had clinically meaningful improvement at 4 months. Severe symptoms included fatigue (57%), dyspnea (49%), cough (29%), and pain (20%). Prevalence of depressed mood decreased at 4 months. Most patients (77%) had comorbid conditions. Number of comorbid conditions and CES-D explained 54% of the variance in symptom severity at 1 month; comorbid conditions, male sex, neoadjuvant treatment, and CES-D score explained 50% of the variance at 4 months.
Conclusions Severe symptoms continued 4 months after surgery for some patients, indicating the need for support during recovery, especially for patients with multiple comorbid conditions and depressed mood.
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Notice to CE enrollees: A closed-book, multiple-choice examination following this article tests your understanding of the following objectives:
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Symptoms and Recovery After Thoracotomy |
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TopAbstractSymptoms and Recovery After...Factors Potentially Influencing...MethodsResultsDiscussionReferences |
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Common symptoms after thoracotomy include pain, dyspnea, and fatigue. Pain may persist 6 months13 to 1 year14,15 after surgery. Rogers and Duffy16 stated that the incidence of chronic mild to moderate pain after thoracotomy is "underrated" and affects approximately 50% of patients. Because of the extent of resection and the presence of comorbid conditions such as chronic obstructive pulmonary disease (COPD), dyspnea may continue or even be exacerbated after curative surgery. In a study of 142 long-term (disease-free for at least 5 years) lung cancer survivors, two-thirds of the patients reported at least 1 respiratory symptom; 39% reported dyspnea at rest and 36% reported multiple symptoms.17 Other than for cough, disease and treatment characteristics were not associated with differences in symptoms or pulmonary function.17 Although fatigue may be an expected part of the deconditioning that occurs after surgery and is a common symptom associated with cancer, few studies have reported the severity of fatigue after lung cancer surgery.18
In addition to physical symptoms, recovery also may be complicated by psychological symptoms. Compared with patients with other cancer diagnoses, patients with lung cancer have the highest level of emotional distress.19 Patients may be depressed at the time of surgery. In a study20 of 223 patients with NSCLC who had potentially curative surgical treatment, 14.8% met the criteria for clinical depression after surgery. Prevalence declined monthly over the 3-month assessment period (9.0%, 9.4%, 5.8%). Patients with poorer social support were at higher risk for depression.20 For some lung cancer survivors, depressed mood is an ongoing concern.21
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Factors Potentially Influencing Symptom Severity During Recovery |
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Treatment variables such as the extent of surgery, especially pneumonectomy, may influence the type and severity of some symptoms. For example, Nugent et al27 reported long-term impaired exercise performance in patients undergoing a pneumonectomy, and other investigators28 reported diminished QOL. Use of the less invasive video-assisted pulmonary resection may decrease morbidity,29 but current data, including information about the symptom profile, are limited.30
Compared with patients who have other types of lung surgery, patients who have video-assisted thoracic surgery may have quite different postoperative symptom severity and patterns. For some patients, video-assisted pulmonary resection may result in fewer symptoms; however, others who have this procedure when thoracotomy is not feasible because of poor health may have even more severe symptoms.31 Additionally, adjuvant chemotherapy or radiation treatment before or after lung cancer surgery, given to improve survival and reduce risk of recurrence, may increase symptom severity. In at least 1 study,13 preoperative adjuvant chemotherapy or radiation treatment did not influence functional health or QOL 6 months after surgery.
Health status factors are important considerations in the evaluation of symptoms because lung cancer is diagnosed more often in older persons than in younger persons,32 and comorbid conditions, especially conditions influenced by long-term smoking, may influence symptom severity during recovery.21 For example, cardiovascular and respiratory diseases, including COPD, are common comorbid conditions in patients with lung cancer.33 COPD has been associated with dyspnea after thoracotomy and with increased risk for perioperative mortality.34
Smoking status also may influence severity of symptoms. Although many patients with lung cancer already have stopped smoking at the time of diagnosis, former smoking as well as continued smoking may affect morbidity after surgery.35 In a cross-sectional survey25 of 1019 lung cancer survivors (24% current smokers, 22% with advanced-stage disease), statistically and clinically important differences in the signs and symptoms (eg, worse appetite, fatigue, cough, shortness of breath) were reported according to smoking status; current smokers had the most distress. Obesity has been reported among lung cancer survivors36 and may increase the severity of symptoms such as fatigue and dyspnea.
Patients seldom experience just a single symptom, and multiple symptoms, groups, or clusters of symptoms are the focus of current research in symptom management.37 Co-occurrence of symptoms, even if the symptoms do not have the same etiology, may complicate assessment and intervention after surgery, and has received little attention.
| Physical and psychological symptoms continue long after thoracotomy.
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This study had 4 specific aims:
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Methods |
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| Owing to late diagnosis, only a minority of patients with non–small cell lung cancer are candidates for curative resection.
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Sample and Setting
A convenience sample of patients was recruited from outpatient settings in tertiary care hospitals in 4 metropolitan areas: Los Angeles, California; Buffalo, New York; Boston, Massachusetts; and Atlanta, Georgia. Integrity of data across sites was ensured by maintaining a standardized protocol with consistent forms and with frequent communication among the investigators. After approval from the institutional review board at each of the participating institutions, patients were eligible to participate if they had received surgical treatment (thoracotomy) for early-stage (I, II, III) NSCLC, were 18 years old or older, and were able to read and understand English. Patients who had a second primary lung cancer or a history of a cured nonpulmonary cancer also were eligible.
Because the study was exploratory, the "rule of thumb" with 10 patients per covariate was used; the target enrollment in the study was 90 to 100 patients. A total of 97 patients were recruited. Three patients who initially agreed to participate did not meet the study criteria and were excluded from analysis. A total of 94 patients provided data at 1 month, 92 at 2 months, and 86 at 4 months. Reasons for dropping out of the study included health limitations (5 patients), having left the area (1), being lost to follow-up (1), and having no time to participate (1).
| The most common severe symptom at each time point was fatigue; the next most common was shortness of breath.
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Procedures
All potential participants were recruited via letters sent by the treating surgeon/oncologist or through responses to a flyer. Trained research assistants obtained each patient’s consent and made an appointment to assess the patient’s symptoms on the first postoperative visit after surgery (approximately 3–4 weeks after surgery). Because of constraints imposed by the institutional review boards, patients were required to approach us; we therefore cannot determine the pool of patients who potentially met the inclusion criteria at each site and who were not interested in participating. Participants received a small stipend for their time and efforts for each of the 3 interviews.
Data describing symptoms were collected at the first postoperative visit (1 month after surgery). At this time, patients provided demographic, disease/ treatment, and health status information and symptom appraisal. Follow-up assessments of symptoms were done 2 and 4 months after discharge, corresponding to follow-up care. At follow-up, participants were asked if they had any changes in their health or personal situation (including smoking cessation, participation in rehabilitation). Height was assessed at 1 month and weight was assessed at each time point for calculations of body mass index (BMI; calculated as weight in kilograms divided by height in meters squared). Data on diagnosis and treatment were abstracted from the clinical records.
Measures
Symptom Severity.
Five symptom measures were used to provide a comprehensive and detailed description of the symptoms during recovery from thoracotomy.
The Lung Cancer Symptom Scale (LCSS)38–40 provides an overview of symptom severity and was developed specifically for patients with lung cancer. A patient’s perception of the severity of 6 symptoms (loss of appetite, fatigue, cough, shortness of breath, hemoptysis, and pain), overall symptom severity, ability to carry out normal activities, and overall QOL during the past 4 weeks are recorded on 100-mm visual analog scales. Responses to each symptom range from "none" to "as much as it could be." Responses are summed for a mean overall score (possible range, 0–100); higher scores indicate greater symptom severity. Unadjusted cumulative mean scores were used as a measure of the mean severity of 6 symptoms (fatigue, appetite, shortness of breath, pain, cough, hemoptysis).
The LCSS is suitable for patients with different levels of symptoms and is sensitive for detecting change over time. An advantage of this instrument is its established parameters for detecting clinically meaningful differences in changes in symptoms.39,40 The concept of a clinically meaningful difference has been used in cancer clinical trials and QOL research to distinguish differences that are not just statistically significant but also correspond to clinically important outcomes.41 The LCSS has undergone extensive psychometric testing and has well-established reliability, validity, and normative scores for lung cancer populations.38
The American Thoracic Society Dyspnea Index42 was used to provide more detail about dyspnea. The index was used in a previous study of lung cancer survivors.17 This 5-item self-report describes difficulty with breathlessness according to level of activity; scores range from 0 (not troubled with breathlessness except with strenuous exercise) to 4 (too breathless to leave the house or breathless when dressing or undressing). Higher scores indicate more severe problems. Test-retest reliability greater than 0.70 and internal consistency greater than 0.75 have been reported.43
The Brief Pain Inventory (BPI) short-form44 was used to provide more detail about pain. Pain severity and interference with day-to-day activities during the past 24 hours were used. As recommended, pain severity was calculated by using the arithmetic mean of the 4 severity items (possible score, 0–40). Pain interference was calculated as the arithmetic mean of the 7 interference items (possible score, 0–70). Higher scores indicate more severe pain. Additionally, a single item "worst pain right now" was used to categorize pain severity as mild (scores, 1–4), moderate (scores, 5–6), and severe (scores, 7–10).
The Schwartz Cancer Fatigue Scale, version 6,45,46 was used to provide greater detail about fatigue. This 6-item self-report has been used successfully with patients with a variety of cancer diagnoses and treatments and is sensitive for detecting change over time. Respondents report about fatigue they experienced during the past 2 to 3 days. Internal consistency and validity have been reported.47 Scores range from 1 (not at all) to 5 (extremely) for each of 6 feelings associated with fatigue: tired, difficulty thinking, overcome, listless, worn out, and helpless. Total scores for the 6-item scale range from 6 to 30.
The Center for Epidemiological Studies Depression Scale (CES-D)48 has been used in multiple studies of patients with cancer49 to assess depressed mood. This 20-item self-report (possible score, 0–60) can be used to indicate potential depression (scores > 15). Responses are requested for feelings during the past week. Acceptable reliability and validity, including discrimination between normal and clinical samples, have been reported. The Cronbach 
for this study was 0.91.
Potential Predictors of Symptom Severity. Data describing the demographic characteristics of the sample, including age, sex, marital status, race/ethnicity, living situation (alone or with others), education, and employment status, were collected by using a self-report. Information also was collected about attendance at support groups after surgery. Information on health status included data on comorbid conditions, smoking status, and BMI.
The Charlson Comorbidity Index self-report,50,51 which has established reliability and validity in different samples of patients, was used to assess presence of comorbid conditions. The prevalence of each of 11 conditions individually and the extent of comorbid conditions as a summed score were determined. Responses were collapsed to 3 conditions (heart attack, heart failure, operation to unclog arteries) into a single summary for heart disease to allow for comparisons.
Smoking status (never, former, current smoker) at study entry was determined through responses to questions about tobacco history and current smoking status based on the Behavioral Risk Factor Survey52 and the Fagerström Test for Nicotine Dependence.53,54 Change in smoking status was evaluated 1 month and 4 months after thoracotomy. As recommended by the Society for Nicotine and Tobacco Research,55 biochemical validation of smoking status was obtained at the time of the interview by using a urine sample and a cotinine dipstick (NicAlert, for urine, Jant Pharmacal Corporation, Encino, California). Participants who described themselves as nonsmokers but had a score of 3 or higher on the dipstick test were reclassified as smokers. Concurrent use of nicotine replacement therapy medications was also determined to prevent false-positive readings with the dipstick.
BMI 1 month after thoracotomy and changes during the study period were evaluated. Height and weight (with participant fully clothed) were measured by using a protocol24 designed to ensure reliability. BMI was calculated at each assessment period, and patients were categorized as malnourished (BMI < 18.5), healthy weight (18.5–24.99), overweight (25–29.99), and obese (
30.0).56
| Depressed mood was associated with severity of symptoms at almost all time points.
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Treatment details, including the extent of surgery (lobectomy, segmental/wedge or sleeve resection, and pneumonectomy) and use of adjuvant treatment were collected by using a medical record form. These data and other clinical characteristics (histological findings, TNM staging), number of days in the hospital before discharge, and any complications during recovery were obtained from medical records. In some instances, TNM information in the operative report was translated to stage by using the American Joint Committee on Cancer staging manual.57
Data Analysis
Descriptive statistics, appropriate to level of measurement, were used to describe patients’ demographics, health status, treatment characteristics, and symptoms after surgery. The severity of symptoms was determined at each time point. Data for any patient with a symptom item rated zero on the LCSS were excluded when the mean raw scores for that symptom were calculated. Further, a cut point of greater than 25 mm on the visual analog scale was used to indicate the presence (or absence) of severe individual symptoms on the LCSS (appetite, fatigue, cough, dyspnea, pain, hemoptysis). Because of the small percentage of patients who reported any problems with hemoptysis, this symptom was subsequently removed from the analysis.
Mean BPI scores (severity and interference), total scores on the Schwartz Cancer Fatigue Scale, and total CES-D scores were determined. For the BPI, severity also was calculated by using the recommended categorical definitions to denote severe pain. Patients with CES-D scores greater than 15 were defined as having depressed mood (potential depression).
The percent change in mean symptom severity scores from 1 month to 4 months was calculated to describe the magnitude of changes. In a similar fashion, the percent changes in the proportion of patients with severe symptoms (LCSS symptoms rated 25) from 1 month to 4 months and with the presence/absence of depressed mood (CES-D > 15) were determined.
In order to determine statistically significant changes in symptom severity over time (1 month to 4 months), mixed effects models for repeated-measures analysis for continuous and ordinal outcomes were used. All repeated-measures analyses included time, demographic characteristics (age, sex), health status (presence of comorbid conditions, smoking status) and treatment factors (adjuvant treatment, type of surgery) as fixed effects and patient as random effect. Significant changes in severe symptoms, including depressed mood, adjusted for covariates, also were computed. Differences in the number of symptoms at each time point (defined as > 0 on the LCSS) were determined by using logistic regression. In addition to statistically significant changes, clinically meaningful differences in symptoms were determined by identifying those symptoms with reductions of 10 mm or greater in symptom scores from 1 month to 4 months, as recommended by Hollen et al58 and as used in another study25 of QOL of lung cancer survivors.
Multivariate regression was used to determine predictors associated with overall symptom severity (LCSS mean total score) at 1 month and 4 months after thoracotomy. For this model, in addition to demographic, health status, and treatment characteristics, mood (ie, total CES-D score) was considered a potential predictor of symptom severity.
Finally, the relationship among co-occurring symptoms from the LCSS (ie, pain, fatigue, dyspnea, cough, appetite) during recovery was determined separately for the presence of each symptom in comparison with all other symptoms. For example, for all patients reporting pain at each point, other symptoms related to pain were examined by using a correlation matrix of individual mean LCSS scores, including the presence of depressed mood (CES-D > 15). Symptoms significantly correlated (r > 0.30) with other symptoms, including depressed mood, were identified. Any group of 3 or more symptoms significantly related to the sentinel symptom was classified as a potential symptom cluster.59
SAS 9.1 software (SAS Institute Inc, Cary, North Carolina) was used for data analysis. Level of significance was set at P < .05.
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Results |
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TopAbstractSymptoms and Recovery After...Factors Potentially Influencing...MethodsResultsDiscussionReferences |
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). A total of 8 patients attended a support group during their postoperative recovery (1 attended 3 times, 2 attended twice, and 5 attended once).
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). Additionally, 12 patients (13%) had video-assisted thoracic surgery. A minority (21%) reported postoperative complications, most commonly atelectasis (13%). A minority of patients received neoadjuvant (12%) or postoperative adjuvant (11%) treatment.
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). Previous cancer diagnoses (excluding in situ skin and cervical cancer) included breast (n=4), bladder/kidney (n=4), prostate (n=2), thyroid (n=2), melanoma (n=2), second primary lung cancers (n=2), ovarian (n = 1), and not specified (n = 2). A total of 37% reported smoking at the time of diagnosis; 17% continued to smoke at the first postoperative visit at 1 month. Among the former smokers, 32% had quit within the past 6 months. The mean BMI at each time point was in the overweight category (BMI25).
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gives the unadjusted mean scores for severity of symptoms. Changes in severity of symptoms are indicated by the percent change in scores from 1 month to 4 months. According to adjusted repeated-measures analyses, all symptoms except cough and hemoptysis on the LCSS significantly decreased from 1 month to 4 months. Appetite, the second most severe symptom at 1 month, had the largest percent change in mean score (54% decrease) by 4 months; next, in order, was pain (45% decrease). Patients’ responses to how bad symptoms were did not decrease significantly from 1 month to 4 months after surgery.
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Table 4
also has data for BMI by quartiles. The range of BMI during recovery varied: 14.8 to 38.8 at 1 month, 11.3 to 41.4 at 2 months, and 14.8 to 41.7 at 4 months. From 1 month to 4 months, 50% of the patients reported weight gain and 30% reported weight loss.
Severe Symptoms
The frequency of patients with the most severe symptoms (rated 25 mm on the LCSS) decreased significantly over time for all symptoms except cough (Table 5). The most common severe symptom at each time point was fatigue; the next most common was shortness of breath. The frequency of patients with severe problems in appetite decreased the most; that of patients with severe cough decreased the least. The number of patients with depressed mood (CES-D> 15) decreased by 9% from 1 month to 4 months, but 26% of patients still had CES-D scores greater than 15 at 4 months. Severe fatigue, shortness of breath, and cough also remained persistent problems. Severe pain (according to the categorical definitions for severe pain from the BPI) was reported by 26% of patients at 1 month, 17% at 2 months, and 12% at 4 months. Changes in the proportion of patients in the severe BPI category significantly decreased at 4 months (odds ratio, 0.29; confidence interval, 0.43 to 0.75; P = .02).
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Predictors of Symptom Severity
Two separate multivariate regression models were used to examine characteristics associated with overall symptom severity (LCSS) at 1 month and 4 months after thoracotomy (Table 6). Both models explained a significant amount of the variance in symptom severity (50% at 1 month and 47% at 4 months). The number of cases in the second model differed from the number in the first model because some patients had dropped out of the study. Number of comorbid conditions and CES-D score were significantly associated with symptom severity at both time points. Younger age was associated with greater severity at 1 month only. Being male and receiving neoadjuvant treatment were each associated with overall symptom severity 4 months after surgery.
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). In several cases, symptom clusters (3 or more correlated symptoms) were identified. For example, pain was associated with severity of appetite disruptions, fatigue, cough, dyspnea, and depressed mood at 4 months.
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Discussion |
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Our finding of continued dyspnea, with a small proportion of patients who had extreme difficulty, differs from the results reported by Win et al.7 In their study, dyspnea improved at 3 months and returned to preoperative levels at 6 months. In that investigation,7 ongoing support was given to patients by a respiratory physician and a nurse during recovery. Win et al found that fatigue and pain improved to preoperative levels at 6 months; we did not collect data at 6 months after surgery.
Although we found statistically significant changes in the decrease in symptom severity, only 3 symptoms—appetite disruptions, dyspnea, and pain—met the threshold for clinically meaningful changes from 1 month to 4 months after surgery. Perhaps more clinically meaningful changes would have been detected if the change had been measured from the time of discharge or the study period had been extended to 6 months. Interpreting the LCSS scores for this sample by comparing the scores with population norms for this instrument is difficult because no standards exist for patients recovering from surgery. Compared with data from a report for LCSS (version 2)38 scores based on 144 patients with advanced-stage disease before treatment, our data suggest that on average, after thoracotomy, our patients had more dyspnea (shortness of breath normative score, 35.65) in the acute postoperative month but less dyspnea at 4 months.
Similarly, the patients with advanced-stage disease were more troubled by cough (normative score, 31.67) than our patients were, but had lower levels of fatigue than our patients did in the first 2 months after surgery (normative score, 40.45). Our patients’ mean pain scores at 4 months after thoracotomy were lower than the pain scores (normative score, 21.28) for the patients with advanced-stage disease. Further research with the LCSS in postoperative patients, including evaluation of an adequate sample of patients who have video-assisted thoracic surgery, will allow for creation of normative symptoms standards for recovery after surgery.
Our data indicate that even with the prospect of potentially curable lung cancer, depressed mood was evident for more than one-third of patients 1 month after surgery and for more than one-fourth 4 months after surgery. These data are only suggestive of depression; further clinical assessment is needed to evaluate clinical depression. Other research21 indicates that depressed mood is a continuing issue for lung cancer survivors that affects overall emotional well-being.
Predictors of Symptom Severity
Health status factors were important predictors of the severity of symptoms. Comorbid conditions might be expected in a sample of older patients with a strong history of tobacco use. Thus, the percentage of patients with comorbid conditions (77%) and the relationship between the conditions and symptom severity during recovery were not surprising. However, selection criteria for surgical candidates may vary. For example, a QOL study6 of patients with lung cancer provides data on healthier samples (eg, 52% had comorbid conditions). The most frequent comorbid conditions in our sample, emphysema/COPD and heart disease, are associated with tobacco use.61 As reported by others,62,63 for a minority of patients, smoking continues to be a concern during the postoperative course. Although current tobacco use was not associated with increased symptom severity in our study, our subsample of current smokers 1 month after surgery was small (17%).
We did not include weight in the regression models because it was not significant in any of the preliminary univariate analyses. Fluctuations in weight or the prevalence of overweight patients have not been reported in QOL studies of patients recovering from surgery. Many of our patients were overweight, and the fear of weight gain, often associated with smoking cessation, may be a concern for patients who quit smoking and should be addressed in intervention programs. Overweight also might result in difficulties with physical activity.
| The presence of symptoms at 4 months after resection highlights the need for rehabilitative support.
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CES-D scores were a significant predictor in both models of symptom severity 1 and 4 months after surgery. Because our sample was too small (n = 8), we could not determine if attendance at a support group was associated with changes in mood during recovery. Further research is warranted to evaluate the role of mood on symptom resolution.
Neoadjuvant treatment was linked with symptom severity at 4 months after surgery. Some of the symptoms that patients experienced may have been associated with the side effects of chemotherapy or radiation therapy. However, only a few of our patients received treatment before surgery. In a study by Handy et al,13 preoperative chemoradiation or adjuvant therapy did not negatively influence physical function or overall QOL 6 months after surgery. Because the benefits of adjuvant treatment for early-stage patients with NSCLC have been established,64 further research is needed to explore the special needs of this population during recovery.
Younger age was associated with increased symptom severity 1 month after thoracotomy, but not at 4 months. Our patients had a wide age range (32–86 years), but the mean of 63 years was similar to the age of a typical patient with lung cancer. Perhaps younger patients had less experience managing symptoms or rated them as more distressing.
Our finding that male sex was associated with increased symptom severity differs from the finding of Garces et al25 that women had more symptoms and distressed mood than men did. The men in our study may have differed from those in the study by Garces et al in other ways, such as having more comorbid conditions, that might account for this difference.
Co-occurrence of Symptoms
Interrelated symptoms (ie, clusters) are a focus of interest,22 and we found several constellations of multiple interrelated symptoms. Rather than conventional cluster analysis, we used a different approach: we identified sentinel symptoms first and then evaluated related symptoms. Depressed mood was associated with severity of other physical symptoms such as pain, fatigue, and dyspnea. These findings suggest an interrelationship of physical and psychological symptoms. Future studies are needed to determine if treatment for a single symptom has unintended consequences on other symptoms (eg, pain relief with narcotics and related anorexia) or if treatment of a sentinel symptom (eg, dyspnea) results in reduction of overall symptom distress.
Limitations
Our study had several limitations that should be considered in the interpretation of the results. We did not have symptom assessments before thoracotomy; we therefore could not determine the premorbid level of symptoms and evaluate recovery in light of these ratings. Some symptoms, especially those due to comorbid diseases, such as dyspnea, may have been present before surgery. Although preoperative level of symptoms has been used for comparison in other studies, our primary intent was to identify severe symptoms, regardless of premorbid condition, during recovery after thoracotomy. Additionally, the time of determining the severity of symptoms in patients who may have had neoadjuvant treatment and may be experiencing treatment-related symptoms must be carefully considered because it may confound assessments of symptom severity.
In this study, we evaluated patients who received a thoracotomy. Therefore, our sample may have been healthier than patients in other studies because it did not include any patients who might not have been offered or might not have been eligible for thoracotomy. Only a minority of our patients had had video-assisted thoracic surgery. Although we did not find statistically significant differences in severity of symptoms between patients who did and did not have video-assisted procedures, our study was not adequately powered to determine differences in symptom outcomes in these 2 groups. We expected that extent of surgery would be associated with significant differences in recovery, but the small number of patients who had pneumonectomy did not allow for meaningful comparisons. Although we did not focus on the immediate postoperative period, long-term recovery may be influenced by type of anesthesia, hours required for surgery, and other surgical factors that deserve further study.
The percentage of women in our study was slightly higher than the percentage of women in whom lung cancer is diagnosed. Because women score higher than men on surveys of symptoms and emotional distress,26 the higher percentage of women in our study might have inflated our findings of depressed mood.
Finally, we did not monitor the quality of care or programs in place at the different institutions that might make a difference in symptom management during recovery. Future research is needed to explore the impact of symptom management in the immediate postoperative period to see if differences in management make a difference in long-term recovery.
Clinical Implications
Our study revealed significant fatigue and dyspnea 4 months after thoracotomy. The inclusion of ongoing symptom assessment during recovery from lung cancer could provide information useful to patients and clinicians. Some researchers6 have argued that because of the precarious future for many patients with lung cancer, support for QOL and symptom relief for the short-term in these patients is even more important than for patients with higher expectations for long-term survivorship.
Currently, no recommendations or guidelines exist for routine rehabilitative support after lung cancer surgery. No normative data are available that we can use to compare our findings with projected symptom severity during the course of recovery after surgery. In this study, although the mean severity of several symptoms decreased from 1 month to 4 months after thoracotomy, the changes for cough and fatigue did not meet the threshold of clinically meaningful improvement. A minority of patients continued to experience severe problems with pain and with dyspnea.
Overall symptom severity was related to the extent of comorbid conditions and to depressed mood, 2 conditions that can be detected before surgery. These characteristics might identify a subpopulation of patients who require additional support and follow-up after thoracotomy. Some patients—those with continuing fatigue, for example—might benefit from conditioning exercises to promote recovery. Additional studies are needed to examine the influence of adjuvant treatment on changes in symptom severity and speed of postoperative recovery. Our data add to the limited research in this area and suggest many areas where research is needed.
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ACKNOWLEDGMENTS |
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FINANCIAL DISCLOSURES
None reported.
Now that you’ve read the article, create or contribute to an online discussion about this topic using eLetters. Just visit www.ajcconline.org and click "Respond to This Article" in either the full-text or PDF view of the article.
To learn more about treating patients with lung cancer in the critical care environment, visit http://ccn.aacnjournals.org and read the article by Collins and Garner, "Caring for Lung Cancer Patients Receiving Photodynamic Therapy" (Critical Care Nurse, April 2007).
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