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An Individualized Representational Intervention to Improve Symptom Management (IRIS) in Older Breast Cancer Survivors: Three Pilot Studies

Susan M. Heidrich

Roger L. Brown

Judith J. Egan

Oscar A. Perez

Cynthia H. Phelan

Hyune Yeom

Sandra E. Ward

symptom assessment
ONF 2009, 36(3), E133-E143. DOI: 10.1188/09.ONF.E133-E143

Purpose/Objectives: To test the feasibility and acceptability of an individualized representational intervention to improve symptom management (IRIS) in older breast cancer survivors and test the short-term effects of an IRIS on symptom distress.

Design: Two small randomized clinical trials and one pre-experimental study.

Setting: Oncology clinic and community.

Sample: 41 women with breast cancer (aged 65 years and older) in pilot study 1, 20 in pilot study 2, and 21 in pilot study 3.

Methods: In pilot study 1, women were randomized to the IRIS or usual care control. In pilot study 2, women were randomized to the IRIS or delayed IRIS (wait list) control. In pilot study 3, all women received the IRIS by telephone. Measures were collected at baseline, postintervention, and follow-up (up to four months).

Main Research Variables: Feasibility, acceptability, symptom distress, symptom management behaviors, symptom management barriers, and quality of life.

Findings: Across three pilot studies, 76% of eligible women participated, 95% completed the study, 88% reported the study was helpful, and 91% were satisfied with the study. Some measures of symptom distress decreased significantly after the IRIS, but quality of life was stable. Women in the IRIS group changed their symptom management behaviors more than controls.

Conclusions: Preliminary evidence supports the need for and feasibility of an IRIS.

Implications for Nursing: Nurses may help older breast cancer survivors manage their numerous chronic symptoms more effectively by assessing women's beliefs about their symptoms and their current symptom management strategies.

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    Boyle, D.M. (1992). Acknowledging the forgotten priority. Oncology Nursing Forum, 19(6), 841.
    Byrne, C., Smart, C.R., Chu, K.C., & Hartmann, W.H. (1994). Survival advantage differences by age: Evaluation of the extended follow-up of the Breast Cancer Detection Demonstration Project. Cancer, 74(1, Suppl.), 301-310.
    Clayton, M.F., Mishel, M.H., & Belyea, M. (2006). Testing a model of symptoms, communication, uncertainty, and well-being in older breast cancer survivors. Research in Nursing and Health, 29(1), 18-39.
    Cleeland, C.S., & Syrjala, K.L. (1992). How to assess cancer pain. In D. Turk & R. Melzack (Eds.), Pain assessment (pp. 360-387). New York: Guilford Press.
    Clough-Gorr, K.M., Ganz, P.A., & Silliman, R.A. (2007). Older breast cancer survivors: Factors associated with change in emotional well-being. Journal of Clinical Oncology, 25(11), 1334-1340.
    Daut, R.L., Cleeland, C.S., & Flanery, R.C. (1983). Development of the Wisconsin Brief Pain Questionnaire to assess pain in cancer and other diseases. Pain, 17(2), 197-210.
    Deimling, G.T., Bowman, K.F., Sterns, S., Wagner, L.J., & Kahana, B. (2006). Cancer-related health worries and psychological distress among older adult, long-term cancer survivors. Psycho-Oncology, 15(4), 306-320.
    Deimling, G.T., Sterns, S., Bowman, K.F., & Kahana, B. (2005). The health of older-adult, long-term cancer survivors. Cancer Nursing, 28(6), 415-424.
    Dodd, M., Janson, S., Facione, N., Faucett, J., Froelicher, E.S., & Humphreys, J., et al. (2001). Advancing the science of symptom management. Journal of Advanced Nursing, 33(5), 668-676.
    Donovan, H.S., & Ward, S. (2001). A representational approach to patient education. Journal of Nursing Scholarship, 33(3), 211-216.
    Donovan, H.S., Ward, S.E., Song, M.K., Heidrich, S.M., Gunnarsdottir, S., & Phillips, C.M. (2007). An update on the Representational Approach to Patient Education. Journal of Nursing Scholarship, 39(3), 259-265.
    Duke University Center for the Study of Aging and Human Development. (1978). Multidimensional functional assessment: The OARS methodology. Durham, NC: Duke University.
    Einhorn, G.W. (1994). Total quality pain management: A computerized quality assessment tool for postoperative pain management. Analgesia, 5, 10-13.
    Gibson, S.J. (1997). The measurement of mood states in older adults. Journal of Gerontology: Psychological Sciences, 52(4), P167-P174.
    Gordon, D.B., Pellino, T.A., Miaskowski, C., McNeil, J.A., Paice, J.A., Laferriere, D., et al. (2002). A 10-year review of quality improvement monitoring in pain management: Recommendations for standardized outcome measures. Pain Management Nursing, 3(4), 116-130.
    Gunnarsdottir, S., Donovan, H.S., Serlin, R.C., Voge, C., & Ward, S.E. (2002). Patient-related barriers to pain management: The Barriers Questionnaire II (BQ-II). Pain, 99(3), 385-396.
    Heidrich, S.M. (1996). Mechanisms related to psychological well-being in older women with chronic illnesses: Age and disease comparisons. Research in Nursing and Health, 19(3), 225-235.
    Heidrich, S.M., Egan, J.J., Hengudomsub, P., & Randolph, S.M. (2006). Symptoms, symptom beliefs, and quality of life in older breast cancer survivors: A comparative study. Oncology Nursing Forum, 33(2), 315-322.
    Heidrich, S.M., Forsthoff, C.A., & Ward, S.E. (1994). Psychological adjustment in adults with cancer: The self as mediator. Health Psychology, 13(4), 346-353.
    Hewson, P.W., & Thorley, R.T. (1989). The conditions of conceptual change in the classroom. International Journal of Science Education, 11(5), 541-553.
    Irwin, M., Artin, K.H., & Oxman, M.N. (1999). Screening for depression in the older adult: Criterion validity of the 10-item Center for Epidemiological Studies Depression Scale (CES-D). Archives of Internal Medicine, 159(15), 1701-1704.
    Keating, N.L., Norredam, M., Landrum, M.B., Huskamp, H.A., & Meara, E. (2005). Physical and mental health status of older long-term cancer survivors. Journal of the American Geriatrics Society, 53(12), 2145-2152.
    Kohout, F.J., Berkman, L.F., Evans, D.A., & Cornoni-Huntley, J. (1993). Two shorter forms of the CES-D (Center for Epidemiological Studies Depression) depression symptoms index. Journal of Aging and Health, 5(2), 179-193.
    Leventhal, H., & Diefenbach, M. (1991). The active side of illness cognition. In J. Skelton & R. Croyle (Eds.), Mental representation in health and illness (pp. 247-272). New York: Springer-Verlag.
    Ludman, E.J., Simon, G.E., Grothaus, L.C., Luce, C., Markley, D.K., & Schaefer, J. (2007). A pilot study of telephone care management and structured disease self-management groups for chronic depression. Psychiatric Services, 58(8), 1065-1072.
    Oncology Nursing Society and Geriatric Oncology Consortium. (2007). Cancer care for older adults [Position statement]. Oncology Nursing Forum, 34(3), 623-624.
    Peer, P.G., Verbeek, A.L., Mravunac, M., Hendriks, J.H., & Holland, R. (1996). Prognosis of younger and older patients with early breast cancer. British Journal of Cancer, 73(3), 382-385.
    Posner, G.J., Strike, K.A., Hewson, P.W., & Gertzog, W.A. (1982). Accommodation of a scientific conception: Toward a theory of conceptual change. Science Education, 66(2), 211-227.
    Ries, L.A.G., Melbert, D., Krapcho, M., Stinchcomb, D.G., Howlader, N., Horner, M.J., et al. (2008). SEER cancer statistics review, 1975-2005. Retrieved April 10, 2009, from
    Ryff, C.D. (1989). Happiness is everything, or is it? Explorations on the meaning of psychological well-being. Journal of Personality and Social Psychology, 57(6), 1069-1081.
    Ryff, C.D., & Keyes, C.L. (1995). The structure of psychological well-being revisited. Journal of Personality and Social Psychology, 69(4), 719-727.
    Serlin, R.C., Mendoza, T.R., Nakamura, Y., Edwards, K.R., & Cleeland, C.S. (1995). When is cancer pain mild, moderate or severe? Grading pain severity by its interference with function. Pain, 61(2), 277-284.
    Shacham, S. (1983). A shortened version of the Profile of Mood States. Journal of Personality Assessment, 47(3), 305-306.
    Sherwood, P., Given, B.A., Given, C.W., Champion, V.L., Doorenbos, A.Z., & Azzouz, F. (2005). A cognitive behavioral intervention for symptom management in patients with advanced cancer. Oncology Nursing Forum, 32(6), 1190-1198.
    Song, M.K., Kirchhoff, K.T., Douglas, J., Ward, S., & Hammes, B. (2005). A randomized, controlled trial to improve advance care planning among patients undergoing cardiac surgery. Medical Care, 43(10), 1049-1053.
    Spielberger, C.D., Gorsuch, R.L., & Lushene, R.E. (1970). STAI manual for the State-Trait Anxiety Inventory. Palo Alto, CA: Consulting Psychologists.
    Stone, A.A., Schwartz, J.E., Neale, J.M., Shiffman, S., Marco, C.A., & Hickcox, M. (1998). A comparison of coping assessed by ecological momentary assessment and retrospective recall. Journal of Personality and Social Psychology, 74(6), 1670-1680.
    Ward, S., Donovan, H., Gunnarsdottir, S., Serlin, R.C., Shapiro, G.R., & Hughes, S. (2008). A randomized trial of a representational intervention to decrease cancer pain (RIDcancerPain). Health Psychology, 27(1), 59-67.
    Ward, S., Donovan, H.S., Owen, B., Grosen, E., & Serlin, R. (2000). An individualized intervention to overcome patient-related barriers to pain management in women with gynecologic cancers. Research in Nursing and Health, 23(5), 393-405.
    Ward, S.E., Goldberg, N., Miller-McCauley, V., Mueller, C., Nolan, A., Pawlik-Plank, D., et al. (1993). Patient-related barriers to management of cancer pain. Pain, 52(3), 319-324.
    Ware, J.E., Jr. (2000). SF-36 Health Survey update. Spine, 25(24), 3130-3139.
    Ware, J.E., Jr., & Sherbourne, C.D. (1992). The MOS 36-item short-form health survey (SF-36): Conceptual framework and item selection. Medical Care, 30(6), 473-483.
    Yancik, R., Wesley, M.N., Ries, L.A., Havlik, R.J., Edwards, B.K., & Yates, J.W. (2001). Effect of age and comorbidity in postmenopausal breast cancer patients aged 55 years and older. JAMA, 285(7), 885-892.
    Yeom, H., & Heidrich, S.M. (2006). Communication difficulties and physical and mental health in older breast cancer survivors. Gerontologist, 46(1), 412.