Distress with Breathing in People with Lung Cancer: A Systematic Review

A Peer Reviewed Publication of the College of Allied Health & Nursing at Nova Southeastern University Dedicated edicated to allied health professional practice and education http://ijahsp.nova.edu Vol. 7 No. 4 ISSN 1540-580X Distress with Breathing in People eople with Lung Cancer: A Systematic Review eview Elizabeth Quast Quast, B. Physiotherapy (Hons)1 Marie Williams, PhD2 1. 2. School of Health Sciences Associate Professor, School of Health Sciences University of South Australia Australia CITATION: Quast, E., Williams, M. Distress with Breathing in People with Lung Cancer: A Systematic Review Review. The Internet Journal of Allied Health Sciences and Practice. Oct 2009, Volume 7 Number 4. ABSTRACT While the prevalence of shortness of breath has been reported to be as frequent as pain in people with lung cancer, less attention has been paid to the distress associated with this symptom (dyspnea). This systematic review of the literature was undertaken to investigate how this symptom has been assessed and whether breathlessness in people with lung cancer is distressing. Using a pre-determined determined search strategy and inclusion criteria, thirty thirty-one primary studies were identified and included in this review. A variety of outcome measures have been used to assess the experience of dyspnea with domains including intensity, distress, quality of life, qualitative sensation and prevalence. The distress associated with breathl breathlessness essness appears to be variable, with some studies reporting it to be the most distressing sensation, while others report lower levels of distress. Overall the studies reflect a high prevalence of dyspnea in lung cancer patients, with subjects experiencing a moderate level of dyspnea intensity and interference with activities of daily living. Overall, the findings of this review indicate that dyspnea was a common symptom experienced by people with lung cancer with varying degrees of intensity and unpleasantn unpleasantness. ess. Thus, if dyspnea and pain are both distressing sensations for people with lung cancer, this has potential implications for both clinical and acade academic areas, with regards to both management strategies and further research. BACKGROUND There are currently in excess of 1.3 million people worldwide affected by lung cancer. 1 Lung cancer is the leading cause of cancer death in the United States, with an estimated 565,650 people dying from lung cancers in 2008. 2 Up to ninety percent of lung cancer ancer is related to active cigarette smoking, with the remaining ten percent mainly caused by passive smoking and exposure to medical radiation and environmental factors such asbestos and silica silica.1 People with lung cancer experience symptoms which vary between individuals, resulting in a range of symptoms which people might find distressing. 3 There are several common signs and symptoms associated with lung cancer, which can be classified as a result of the primary tumour, intra-thoracic spread, distant metastases, etastases, paraneoplastic syndromes or they may be non non-specific symptoms. 3 The most common signs and symptoms relating to a primary lung tumour, and therefore corresponding to early stage disease, are: cough, dyspnea (distress with breathing or breathing discomfort) haemoptysis (coughing up blood) and chest discomfort. Non Non-specific specific symptoms such as weight-loss loss or fatigue are also common in the initial stages of lung cancer. 3 Pain and dyspnea have been reported to be common distressing symptoms in people with cancer. Beckles et al (2003) report that while 6 to 25% of people with lung cancer will experience bone pain and 20 to 49% will experience chest pain, somewhere between 3 and 60% will experience dyspnea.3 While the incidence of dyspnea in people with lung cancer has been reported to be at least as frequent as pain, its presence is underappreciated and potentially not scrutinized or investigated to the same extent.4 For example, a preliminary search of the database Scopus reveals almost twice as much literature terature addressing pain and © The Internet Journal of Allied Health alth Sciences and Practice, 2009 Distress with Breathing in People with Lung Cancer: A Systematic Review 2 pain management in people with lung cancer, compared with that of dyspnea. The purpose of this paper is to systematically review primary studies of people with lung cancer in order to answer two specific questions: 1. 2. Which outcome measures have been used to assess breathlessness? What evidence is there that breathlessness is distressing? SYSTEMATIC SEARCH STRATEGY A systematic search process was undertaken to identify peer reviewed publications specifically investigating the sensation of breathlessness in people with lung cancer. When developing the review question, the PICO structure was used. PICO is an acronym for population, interventions, comparisons and outcomes. 5 The population of interest was adults with lung cancer, of any type or stage. Studies were limited to observation or epidemiological studies. As the intent of the systematic review was not to explore the evidence for management strategies for breathlessness, no intervention or comparator was specified for this question. The outcome of interest was data on the sensation of dyspnea or breathlessness. Three groups of search terms were identified. The first group of search terms included lung cancer and lung neoplasms, the second: dyspnea and breathlessness; and third: distress, perception and sensation. Each term within a group was separated by “or” and each group was separated by “and”. The database search was undertaken between late February and early March 2008. The databases (Ovid) Medline and Embase, Cochrane Library, CINAHL, PsycINFO and Scopus were searched using the default settings except in Ovid, where ‘advanced search’ was used. Table 1 presents the citations retrieved using the search strategy, and those which were retained in each database. ______________________________________________________________________________________________________ Table 1: Retrieved and retained citations in each database Database Date of Search Retrieved citations Retained citations MEDLINE 26/02/08 339 2 EMBASE 26/02/08 418 8 Cochrane Library 26/02/08 137 0 CINAHL 28/02/08 186 13 PsycINFO 28/02/08 174 2 Scopus 02/03/08 391 6 ______________________________________________________________________________________________________ During the first wave of the search, citations were retained if they met the following five criteria: 1. 2. 3. 4. 5. Must refer to distress/perception/sensation of dyspnea/breathlessness or symptoms, rather than psychological distress in the abstract or title Must not refer to any drugs for the treatment of breathlessness/dyspnea Subjects: must include lung cancer Language of publication: English Publication: peer reviewed journal article (no grey literature) The search identified 143 articles (...truncated)