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European Journal of Oncology Nursing 16 (2012) 453e459

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European Journal of Oncology Nursing

journal homepage: www.elsevier .com/locate/ejon

A description of the nutritional status and quality of life of Australiangynaecological cancer patients over time

Mary Ryan a,b,*, Kate White b,c,d, Jessica K. Roydhouse b,c, Judith Fethney b

aRoyal Hospital for Women, Barker St, Randwick NSW 2031 AustraliabCancer Nursing Research Unit, Sydney Nursing School (MO2), University of Sydney, Sydney NSW 2006, Australiac Sydney Cancer Centre, Royal Prince Alfred Hospital, Missenden Road, Camperdown NSW 2050, Australiad School of Nursing, Midwifery and Postgraduate Medicine, Edith Cowan University, 270 Joondalup Drive, Joondalup WA 6027, Australia

Keywords:Gynaecological cancerNutritionPhysical activityQuality of life

* Corresponding author. Gynaecological CancerWomen, Locked Bag 2000, Randwick NSW 2031, Ausfax: þ61 2 9382 6274.

E-mail addresses: mary.ryan@sydney.edu.au (M. Rau (K. White), jessica.roydhouse@sydney.edu.au (J.K.sydney.edu.au (J. Fethney).

1462-3889/$ e see front matter Crown Copyright � 2doi:10.1016/j.ejon.2011.10.007

a b s t r a c t

Purpose of the research: To describe the quality of life, nutritional status and physical activity of womenwith gynaecological cancer over three time points.Methods and sample: Women referred to a major gynaecological cancer service in Sydney for initialtreatment were invited to complete validated questionnaires at baseline, three and six months afterdiagnosis. Quality of life was assessed using the 36-item Short Form Health Survey (SF36) and theSymptom Distress Scale. Nutritional status was assessed using the Patient Generated-Subjective GlobalAssessment and physical activity was assessed using the International Physical Activity Questionnaireshort form.Effect sizes corrected for correlation were calculated using Cohen’s d and Friedman’s test was used tocompare scores. Complete case analysis was used.Key results: Forty women were recruited and twenty-three (58%) completed assessment measures for allthree time points. No important clinical or demographic differences existed between women whocompleted all measures and those who did not.Over the duration of the study, the number of well-nourished women increased from 16 to 21, while thenumber of malnourished women decreased from 7 to 2. Improvements in SF36 scores were seen in allaspects except general health, which declined (p> 0.05). Statistically significant (p< 0.05) improvementswere seen for role physical, vitality, social functioning and role emotional. The median number ofminutes of physical activity per week was highest at diagnosis and declined after that.Conclusions: This study indicates the importance of assessing nutritional status at diagnosis for womenwith gynaecological cancer.

Crown Copyright � 2011 Published by Elsevier Ltd. All rights reserved.

Introduction

Gynaecological cancers contribute significantly to the femalecancer burden. Globally, gynaecological cancers comprised 19% ofnew female cancer cases in 2002 (Sankaranarayanan and Ferlay,2006). In Australia, gynaecological cancers are the fourth mostcommon form of female cancer (Lancaster, 2010). Uterine cancer isthe most common gynaecological cancer in Australian women,followed by ovarian, cervical, and vulval (Commonwealth

Centre, Royal Hospital fortralia. Tel.: þ61 2 9382 6229;

yan), kate.white@sydney.edu.Roydhouse), judith.fethney@

011 Published by Elsevier Ltd. All

Government, 2007). A recent assessment of the global cervicalcancer burden estimated that 530,000 women developed cervicalcancer and 275,000 died of cervical cancer. Furthermore, cervicalcancer was identified as the thirdmost common cancer, after breastand colorectal, as well as the fourth most common cause of cancerdeath (Arbyn et al., 2011).

Malnutrition is a problem for cancer patients in many tumourgroups (von Meyenfeldt, 2005) and has been shown to haveanegative impact onquality of life, response to treatment,morbidityand mortality (Van Cutsem and Arends, 2005). Studies havedemonstrated the importance of nutrition forquality of life in cancerpatients (Nourissat et al., 2008; Ravasco et al., 2004; Tong et al.,2009), and this has led to the suggestion of incorporating nutritionguidelines into oncology care (Marin Caro et al., 2007) and to theimplementation of nutritional screening so thatmalnutrition can beidentified early and intervention commenced (Davies, 2005).

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M. Ryan et al. / European Journal of Oncology Nursing 16 (2012) 453e459454

A hospital-based study in the USA found malnutrition in 54% ofgynaecological cancer patients, which was associated with longerstays in hospital (Santoso et al., 2000). Other authors have alsoreported thatmalnutrition at the time of cancer diagnosis is a factorin greater length of stay in hospital for gynaecological cancerpatients (Laky et al., 2010). This is of concern, as moderatemalnutrition has been found to be highly prevalent in womenwithovarian cancer at the time of diagnosis (Laky et al., 2007) andweight loss and low nutrient intake prior to treatment have beenidentified in uterine cervical cancer patients (Lisboa et al., 2008).Furthermore, well-nourished ovarian cancer patients had bettersurvival outcomes than those who were moderately to severelymalnourished (Gupta et al., 2008) and improved nutritional statuswas associated with better survival (Gupta et al., 2010).

Although treatment such as chemotherapy or radiotherapy mayaffect nutritional status in patients receiving anticancer therapies,studies on the impact of treatment on the nutritional status ofgynaecological cancer patients remain limited. The side effects ofthese treatments can include nausea, vomiting, bowel problemsand loss of appetite (Cancer Council Victoria, 2009, 2010), all ofwhich have implications for nutritional intake. Investigating theimpact of gynaecological cancer treatment on nutritional status isthus an important area for research. The study reported in thispaper is the first phase of a larger programme of research seeking todesign and implement nursing interventions to reduce the impactof cancer treatment on the overall quality of life of female patients.The part of the programme described in this paper had thefollowing aim:

1. To explore the quality of life, cancer symptoms, nutritionalstatus and activity levels of women with gynaecologicalcancers from diagnosis to 6 months post diagnosis.

The second part of the study, which is currently ongoing, focuseson the development and pilot testing of an intervention to mini-mise the impact of gynaecological cancer treatment for women; weaim to report the findings, once obtained, at a later date.

Methods

Research design

The research design was an exploratory, prospective cohortstudy.

Participants

The sample was drawn from women newly referred toa gynaecological cancer centre for initial gynaecological cancertreatment at the Royal Hospital forWomen, a major tertiary referralhospital in Sydney, Australia. At the time of study development, itwas estimated that 300 women were referred to this serviceannually.

The following criteria had to be met for inclusion in the study:female, over 18 years of age, fluency in English, ability to giveconsent and newly diagnosed with a gynaecological cancer.Womenwith a history of a severe psychological illness or conditionwhich could interfere with the ability to understand the require-ments of the study were not eligible. Ethics approval was obtainedfrom the Human Research Ethics Committee of the South EasternSydney and Illawarra Area Health Service. The sample wasconsidered as a whole: that is, there were no subgroups based ontype of cancer treatment. However, all participants in the study hadreceived some form of cancer treatment (i.e. either adjuvant

treatment including chemotherapy, or chemotherapy plus radio-therapy as well as surgery).

Procedure

All new patients referred to the centre were identified by thenurses working in the clinic, and eligible women were given aninformation sheet. Data collection commenced once writteninformed consent was obtained, and was undertaken at three timepoints which were scheduled to coincide with regular visits to thecentre for medical follow up and obviate the need for extra visits tothe centre. First, following consent (T1), demographic data werecollected and baseline questionnaires completed. Questionnaireswere completed again when the women were referred back to thecentre for a follow up visit (T2), which was either post surgical forwomen not having adjuvant treatment or mid course for womenhaving adjuvant treatment. T2 was generally 3 months after diag-nosis. Final questionnaires were completed at 6 months postdiagnosis, which was either 3 months post adjuvant treatment or 6months post surgery (T3).

Instruments

Four validated tools were used: the 36-item short form healthsurvey version 2 (SF36), the Patient Generated-Subjective GlobalAssessment (PG-SGA), the Symptom Distress Scale (SDS) and theInternational Physical Activity Questionnaire short form (IPAQ).

Basic demographic data were collected at the time of recruit-ment and updated as appropriate at all time points. These dataincluded age, educational attainment, diagnosis, relationshipstatus, employment status, treatment and medical history.

SF36

The SF36 is an internationally used generic quality of lifemeasure that has been tested extensively. While not specificallydesigned for cancer patients, Luckett and colleagues found theperformance of the SF36 to be similar to that of the cancer-specificFunctional Assessment of Cancer Therapy e General (FACT-G) ina group of gynaecological cancer patients, but noted that very fewstudies have compared the two questionnaires directly (Luckettet al., 2010). Scores are usually transformed to 0e100, with lowerscores indicating poorer health and higher scores indicating betterhealth (Ware et al., 2007).

Previous studies have established content, criterion andconstruct validity, and reliability tests have usually shown coeffi-cients of >0.80 (Ware et al., 2007). There are a small number ofstudies directly comparing the SF36 to cancer-specific measures ingynaecological cancer patients (Luckett et al., 2010). Furthermore,the SF36 is frequently used as a QOL assessment tool in studies ofovarian cancer patients (Arriba et al., 2010), and has been used toassess QOL in gynaecological cancer survivors (Wenzel et al., 2002;Zeng et al., 2011), women undergoing surgery for endometrial orovarian cancers (Gil et al., 2007) and newly diagnosed ovariancancer patients (von Gruenigen et al., 2006).

PG-SGA

The PG-SGA is a sensitive, specific tool with reliability (stand-ardised alpha) of 0.64 and established concurrent validity (Baueret al., 2002) which has been used to measure nutritional statusand identify malnutrition in cancer patients (Bauer et al., 2002;Isenring et al., 2003). It is appropriate and feasible for assessingmalnutrition in a gynaecological cancer patient population, where

M. Ryan et al. / European Journal of Oncology Nursing 16 (2012) 453e459 455

it correlates with other measures such as total body potassium(Laky et al., 2008).

The PG-SGA uses the categories of weight, food intake, symp-toms, activities and function to produce a global assessment ofwell-nourished or anabolic (A), moderate or suspected malnutri-tion (B) or severe malnutrition (C). In addition, scores are givenwithin specific categories (e.g. unchanged weight is 0), and nutri-tional triage recommendations are made using these category-specific scores (0e1: indicates no intervention; 2e3: patient andfamily education with intervention as indicated by the symptomsurvey; 4e8: requires intervention by a dietitian in conjunctionwith a nurse or physician as indicated by the symptom survey; and�9 suggests a critical need for intervention) (McCallum, 2000).

SDS

The SDS is a tool for evaluating cancer-related symptoms anddistress. The SDS measures the frequencies of symptoms such asnausea, pain, appetite and insomnia using a five-point Likert-typescale where one indicates infrequent or nonexistent symptoms andfive indicates frequent symptoms (McCorkle and Young, 1978). TheSDS has been shown to be reliable (alpha¼ 0.79e0.89) and hasestablished convergent, discriminant, face and content validity(McCorkle, 1987). The SDS has been used in studies of QOL inwomen with ovarian cancer (McCorkle et al., 2009; Schulman-Green et al., 2008).

IPAQ

The IPAQ short form comprehensively assesses adult physicalactivity. A 12-country study found it to have acceptable reliabilityand validity across diverse adult population samples (repeatability:Spearman’s r¼ 0.8, criterion validity: r¼ 0.3) (Craig et al., 2003).The IPAQ short form asks respondents howmany days and hours orminutes per day were spent engaging in vigorous activity (e.g.aerobics), moderate activity (e.g. doubles tennis), walking duringthe past seven days, as well as howmuch time was spent sitting forthe past seven days. For the purposes of analysis, the minimumduration of activity is ten minutes; the IPAQ scoring protocolindicates that durations less than that should be re-coded to zero(“Guidelines for Data Processing and Analysis of the InternationalPhysical Activity Questionnaire (IPAQ) e Short and Long Forms,”2005).

There does not appear to be one best or preferred measure forassessing activity in cancer patients, and a range of measures havebeen used in previous studies (Bernardo et al., 2010; Devoogdtet al., 2010; Stephenson et al., 2009; Zakashansky et al., 2007).The IPAQ has been used to assess activity in breast cancer survivors(Rogers et al., 2011). Assessment of the IPAQ in breast cancerpatients found it to be less valid, sensitive and specific than theseven day Physical Activity Recall measure (Johnson-Kozlow et al.,2006).

Statistical analysis

SPSS version 18 was used for all analyses, excluding effect sizeswhich were obtained through an online effect size calculator(Cepeda, 2008). Effect sizes were calculated using Cohen’s d andwere corrected for correlation. Friedman’s test was used tocompare scores on SDS and SF36 measures across T1 (Baseline), T2(3 months post diagnosis) and T3 (6months post diagnosis); for thePG-SGA, Cochran’s Q was used as the data were categorical. Thesmall number of complete cases for the IPAQ precluded statisticaltesting.

For all analyses, a p-value of p< 0.05 was considered statisticallysignificant. As an indicator of clinical significance, effect sizes arereported for the SF36 and SDS, and SF36 values at all time points areassessed against Australian norms (Hawthorne et al., 2007) usingone-sample t-tests. These norms were included as they providea standard against which the gynaecological sample can becompared. Effect sizes presented are between T1 (diagnosis) and T3(6 months post diagnosis). In order to determine a clinically rele-vant effect size, the 0.5 criterion reported in Norman, Sloan andWyrwich (Norman et al., 2003) was used. Across a range of differentmeasures, including the SF36, these authors determined thatdiscrimination for changes in health-related quality of life forchronic diseases appeared to be approximately half a SD. Due to theexploratory nature of the study, the chance of Type I errors arisingdue to multiple comparisons was seen as not of major concern, astechniques to minimise such errors may be overly conservative andnot reveal potentially interesting findings.

Results

Demographic data

Forty women consented to participate in the study, 31 (78%)completed the second survey and 23 (58%) completed the third andfinal survey. Several reasons were identified for the attrition seenby T3. Some of thewomen from rural settings (N¼ 5) did not returnto the study centre within the data collection period, and otherswho were sent reminder letters did not make further contact withthe investigators (N¼ 7). Two women who were diagnosed withrecurrent disease declined any further participation; 2 womenfound the process of completing the questionnaires too arduousand 1 woman died within 6 months of being diagnosed.

Comparison of baseline (diagnosis) characteristics showed nostatistically significant differences (p> 0.05) in demographic orclinical characteristics (cancer type, weight loss/gain, and malnu-trition status as measured by PG-SGA) of completers compared tothose lost to follow-up. Therefore, results are based on completecases only. The number of complete cases varied by questionnaire,and the number of complete cases for each questionnaire isprovided below. Table 1 presents the participants’ demographiccharacteristics.

Most women (65%) were born in Australia and nearly all spokeEnglish as the primary language at home (95%). Just over half weremarried (52%), almost all had children (90%) and a minority (23%)had attained at least an undergraduate degree. More than half(62%) were currently employed. The two most common types ofcancer among participants were ovarian (45%) and endometrial(27%) cancer.

Quality of life

The mean scores on all SF36 scales at all time points, with theexception of General health at baseline, were lower than the meanAustralianpopulationnorms (Table 2).With the exceptionof generalhealth, all SF36 scores at T1 and T2 were statistically significantlylower than the Australian norms. Effect sizes between T1 and T2scores and the Australian norms ranged from�0.12 (general health)to �1.12 (role physical), with most falling above �0.80, indicatingconsiderable discrepancy in self reported quality of life betweenwomen with gynaecological cancer and the general population inthe first three months following diagnosis. At T3, role physical,bodily pain andmental healthwere still significantly lower than theAustralian norms,with bodily pain andmental health also having aneffect size >0.5. Within the gynaecological sample in this study,statistically significant (p< 0.05) improvements were seen for

Table 3Nutritional status and symptoms as measured by PG-SGA.a

Measure T1 N(%) T2 N (%) T3 N (%)

Nutritional statusWell-nourished or

anabolic (PG-SGA A)16 (70%) 17 (74%) 21 (91%)

Moderate or suspectedmalnutrition (PG-SGA B or C)

7 (30%) 6 (26%) 2 (9%)

No intervention required(PG-SGA total score 0e1)

2 (9%) 4 (17%) 7 (30%)

Patient and family educationneeded (PG-SGA total score 2e3)

9 (39%) 10 (44%) 12 (52%)

Intervention required(PG-SGA total score 4e8)

6 (26%) 6 (26%) 2 (9%)

Critical need for improved symptommanagement (PG-SGA total score �9)

6 (26%) 3 (13%) 2 (9%)

Nutrition impact symptomsb

No problems eating 15 (65%) 20 (87%) 19 (83%)No appetite 5 (22%) 3 (13%) 1 (4%)Nausea 2 (9%) 5 (22%) 1 (4%)Constipation 4 (17%) 1 (4%) 1 (4%)Mouth sores 0 (0%) 1 (4%) 1 (4%)Things taste funny 0 (0%) 4 (17%) 1 (4%)Problems swallowing 1 (4%) 0 (0%) 1 (4%)Pain 1 (4%) 0 (0%) 0 (0%)Vomiting 0 (0%) 0 (0%) 0 (0%)Diarrhoea 0 (0%) 1 (4%) 0 (0%)Dry mouth 1 (4%) 0 (0%) 0 (0%)Smells bother me 1 (4%) 2 (9%) 0 (0%)Feel full quickly 6 (26%) 2 (9%) 2 (9%)

Activities/functiona

Normal, no limitations 7 (30%) 5 (22%) 14 (61%)Not normal, but fairly normal activities 9 (39%) 17 (74%) 7 (30%)In bed/chair less than half the day 6 (26%) 1 (4%) 1 (4%)In bed/chair most of the day 1 (4%) 0 (0%) 1 (4%)Pretty much bedridden 0 (0%) 0 (0%) 0 (0%)

a Percentages may not sum to 100 due to rounding.b Number in columns indicates a positive response to the question.

Table 1Key demographic characteristics of participants (n¼ 40).

Characteristic N (%)a

Mean age in years (SD) 57 (14.1)Range 31e92 years

Country of birthAustralia 26 (65%)Overseas 14 (35%)

English is the primary language spoken at homeYes 38 (95%)No 2 (5%)

Relationship statusMarried 21 (53%)Single 5 (13%)Widow 4 (10%)Partnership 3 (8%)Other 7 (18%)

Have childrenYes 36 (90%)No 4 (10%)

Educational attainmentb

Primary school 1 (3%)High school e year 10 9 (23%)High school e year 12 13 (33%)College certificate/diploma 7 (18%)Undergraduate degree 7 (18%)Postgraduate degree 2 (5%)

Employment statusCurrently employed 25 (63%)Not in paid employment 15 (38%)

Cancer typeOvarian 18 (45%)Endometrial 11 (28%)Cervical 9 (23%)Other 2 (5%)

a Percentages may not sum to 100 due to rounding.b Missing data, so valid percentages reported.

M. Ryan et al. / European Journal of Oncology Nursing 16 (2012) 453e459456

physical functioning, role physical, vitality, social functioning androle emotional. Clinically significant improvements fromT1 toT3, asshown by effect size (Table 2), were seen for physical functioning,role physical, vitality and social function. General health was theonly aspect for which a decline was seen, albeit one which was notstatistically significant (p> 0.05).

With the SDS, there was a statistically significant reduction incancer-related symptoms, although the effect size was smaller thanthose for the SF36 (Table 2).

Table 2Quality of life at T1, T2 and T3, as measured by SF36 and SDS.

Measure N T1 M (SD) T2 M (SD) T3 M (SD)

SF36Physical functioning 24 67.7 (27.2)c 69.2 (20.7)c 82.9 (15.6)Role physical 24 51.0 (34.0)c 57.6 (23.7)c 73.2 (24.7)c

Bodily pain 24 51.5 (28.1)c 55.3 (18.3)c 63.7 (24.2)c

General health 24 74.1 (18.5) 66.7 (19.7) 65.7 (21.6)Vitality 24 48.7 (26.0)c 49.0 (21.1)c 58.8 (20.7)Social functioning 24 59.4 (35.0)c 64.1 (21.3)c 78.1 (22.5)Role emotional 24 72.2 (28.5)c 69.8 (22.6)c 86.5 (18.0)Mental health 24 63.7 (13.8)c 69.4 (15.3)c 69.2 (12.5)c

SDSTotal score 24 24.0 (6.4) 25.1 (6.2) 22.1 (5.5)

a Corrected for correlation between means between T1 and T3.b From a general population sample (Hawthorne et al., 2007).c Difference between the mean value at this time point and the Australian populationd Clinically relevant as per the criterion of Norman et al. (2003).

Nutritional status

Table 3 presents additional details of nutritional status andsymptoms, as assessed by PG-SGA. At T1, 16 women (70%) werewell-nourished; at T2, 17 women (74%) were and 21 women (91%)were at T3. The difference was not statistically significant(Cochran’s Q¼ 3.82, df¼ 2, p¼ 0.15). The number of womenrequiring some form of nutritional intervention decreased from T1to T3, albeit not significantly (Cochran’s Q¼ 4.75, df¼ 2, p¼ 0.09).The number of women describing activities and function as“Normal, no limitations” decreased from T1 to T2 but increased

Friedman’s c2 (df), p-value Effect size(Cohen’s d)a

Australian norm M (SD)(SF36 only)b

7.08 (df¼ 2), p¼ 0.029 0.55d 84.64 (21.86)11.58 (df¼ 2), p¼ 0.003 0.62d 84.41 (25.13)2.42 (df¼ 2), p¼ 0.30 0.40 76.45 (21.24)5.74 (df¼ 2), p¼ 0.06 �0.44 71.90 (21.88)11.28 (df¼ 2), p¼ 0.004 0.53d 61.12 (20.80)12.34 (df¼ 2), p¼ 0.002 0.60d 86.19 (22.33)9.41 (df¼ 2), p¼ 0.009 0.45 91.59 (17.50)2.61 (df¼ 2), p¼ 0.27 0.34 80.63 (16.99)

6.40 (df¼ 2) p¼ 0.04 �0.25 n/a

norm for that domain is statistically significant (SF36 only).

M. Ryan et al. / European Journal of Oncology Nursing 16 (2012) 453e459 457

beyond T1 levels at T3; in contrast, the number describing activitiesand functions as “Not normal, but fairly normal activities” increasedfrom T1 to T2 but fell below T1 levels at T3.

Physical activity

Compared to T1, vigorous and moderate and total activitydecreased by T3, but walking increased from T1 toT3. Sitting, whichshowed an increase at T2, had returned to baseline levels by T3. Thedecline from T1 to T2 was particularly marked for vigorous activity,but walking increased from T1 to T2, as did time spent sitting(Table 4).

Although IPAQ guidelines recommend converting minutes ofexercise per week into metabolic equivalent minutes (MET-minutes) per week and then categorising activity levels into Low,Moderate and High (“Guidelines for Data Processing and Analysis ofthe International Physical Activity Questionnaire (IPAQ) e Shortand Long Forms,” 2005), the small number of complete casesprecluded going beyond descriptive analysis.

Discussion

Nutritional status and quality of life were poorest at diagnosisand improved over time. In contrast, physical activity was highestat diagnosis and declined in the following three months, and mostactivity had not improved by six months. The type of activityundertaken also changed, with a shift from vigorous and moderateactivity to walking. The shift to walking may indicate the need tomodify exercise due to symptom distress and/or post surgicalinstruction to avoid vigorous activity. Health-based quality of life,as measured by the SF36, improved by 6 months post-diagnosis.Five of the 8 measures improved statistically, and 4 of the 8improved clinically. Compared to the normative sample, at T1 andT2 the gynaecological sample had statistically and clinicallysignificantly lower SF 36 scores with the exception of generalhealth, indicating worse perceptions of their health-based qualityof life at diagnosis and 3 months post-diagnosis, although scoreswere more similar to the Australian norms by T3. On the SF36, thelargest improvements were seen in role physical, social functioning,physical functioning and vitality. These results also highlight areaswhere clinical improvement was not seen, specifically in relation tomental health, role emotional, general health and pain.

It is worth mentioning that all of the women recruited were onsome form of treatment following diagnosis up until, and in somecases beyond, the 3 months timepoint (T2). Universally thesewomen were receiving cytotoxic agents. Some women (N¼ 6)received a combination of radiation and cytotoxic therapy. By thetime the women filled out their 6 month questionnaires, most hadbeen off treatment for some time and therefore we suggest thattheir improved physical health can be attributed to two factors: 1)completion of debilitating treatment which created side effects and2) having the cancer treatment, therefore the symptoms associatedwith the presence of the cancer either no longer existed or were

Table 4Time spent (hours) in physical activity and sitting at T1, T2 and T3, as measured by IPAQ

Activity type T1

Na Median (IQR)

Vigorous(total h/wk)

6 4.0 (2.8e9.5)

Moderate (total h/wk) 14 5.5 (2.9e11.0)Walking (total h/wk) 29 3.0 (1.4e8.0)Total activity (total h/wk) 5 24.3 (15.6e49.5)Sitting (total h/day) 29 4.0 (3.0e7.0)

a Valid responses.

somewhat alleviated. Additionally, any woman who was assessedas malnourished or at risk of malnutrition at any point in time waseither referred to a dietitian or provided with some form of dietarycounselling. The intervention received beyond diet counsellingincluded the recommendation for including high protein energydrinks and following a high protein diet where indicated.

Research in other types of cancer has highlighted the impor-tance of nutritional screening and intervening when required. Forexample, preventing weight loss in patients undergoing activecancer treatment is emphasised (Brown et al., 2003). Studies inpatients with a diagnosis of head and neck cancer have under-scored the need for early nutritional interventions (Capuano et al.,2010; Larsson et al., 2005), including pre-treatment interventions,as malnutrition (Capuano, et al., 2010) and weight loss (Larssonet al., 2005) are commonly identified prior to treatment. Malnu-trition has also been associated with poor quality of life in patientswith advanced colorectal cancer (Gupta et al., 2006), particularlythose undergoing radiotherapy where changes in nutritional statushave been associated with adverse changes in quality of life(Ravasco et al., 2005). Furthermore, by including dietary counsel-ling during treatment improvements in quality of life and nutri-tional status have been demonstrated for patients with colorectalcancer (Ravasco et al., 2005). Studies linking nutritional status andsurvival in ovarian cancer patients specifically (Gupta et al., 2008,2010), suggest that early nutritional intervention has the poten-tial to benefit this group of women, althoughmorework in this areais needed before definitive conclusions can be drawn. The findingsdescribed by Gupta and colleagues (2008, 2010) hold importantimplications for the study reported here, which identified 30% (7 of23) of women with ovarian cancer who were malnourished or atrisk of malnutrition at the time of diagnosis.

This study had several limitations. One limitation is that thenumber of complete cases obtained from the IPAQ was very smalland so changes in activity could not be tested statistically. Anotherlimitation was the small sample size, as recruiting sufficientnumbers of participants was a challenge for this study. Completingthe study within eighteen months, as per funding body require-ments, narrowed the window of time available for recruitment.Furthermore, during the course of the study it was identified thatmany women attending the centre at which the study was con-ducted came from rural areas. We were initially concerned aboutrecruiting women from rural areas to participate, and althoughwomen from rural areas were approached to participate in thestudy our concerns about the potential difficulties for follow up atT2 and T3 were soon realised. While most of the tools could havebeen completed over the phone or posted to the participants, thesecond part of the PG-SGA requires a physical assessment, whichpresents a challenge when working with patients coming fromrural areas. Arrangements to capture T2 and T3 data from theparticipants when they attended the study centre for their followup visits helped, but were not successful in yielding a completeresponse rate. In future the use of tools that could be completed athome or with assistance via telephone for example would be

.

T2 T3

Na Median (IQR) Na Median (IQR)

8 2.8 (1.1e4.5) 11 3.0 (1.5e7.5)

13 5.0 (2.3e6.5) 15 3.0 (1.0e9.0)30 3.5 (1.3e8.5) 20 3.8 (2.5e8.3)6 9.9 (8.2e28.4) 10 14.8 (9.0e25.5)

25 5.0 (3.0e7.0) 20 4.0 (3.0e5.0)

M. Ryan et al. / European Journal of Oncology Nursing 16 (2012) 453e459458

beneficial. Alternatively, developing links with colleagues in ruralareas who are interested in participating in the study couldimprove the return rate of follow up data.

Although the measures used to assess nutritional status, phys-ical activity and quality of life were validated, the validation testingdid not appear to have occurred in a gynaecological cancer patientpopulation. Nonetheless, all these measures save the IPAQ havebeen used in gynaecological cancer populations. The paucity ofvalidation studies for such instruments in gynaecological cancerpatient populations is a limitation, and future work in this areawould be beneficial.

However, this study contributes to the discipline by providingdata about nutritional status and quality of life in gynaecologicalcancer patients, a topic about which relatively little research hasbeen undertaken.

In summary, this study has found that nutritional status andimpact symptoms such as anorexia and early satiety as well asquality of life were poorest at diagnosis, although physical activitywas highest. These findings suggest the importance of earlymalnutrition screening and the development of individualisedinterventions which have the potential to maximise nutrition andquality of life outcomes in women diagnosed with a gynaecologicalcancer.

Conflict of interestThis study was funded by the Cancer Institute of NSW through

a Clinical Research Grant. Professor Kate White’s Chair of CancerNursing is partially funded by the Cancer Institute NSW througha different funding stream.

Dr Mary Ryan is the recipient of a National Health and MedicalResearch Council (NHMRC) NICS-CA-NCGC Fellowship(2009e2011), which is supported by NHMRC and CA-NCGC. Thework reported in this paper informed Dr Ryan’s Fellowship projectand some of this work was undertaken during the Fellowshipprogram. The views expressed herein are those of the authors andare not necessarily those of the NHMRC or CA-NCGC.

Acknowledgement

This study was funded by the Cancer Institute NSW. The CancerInstitute NSW had no role in study design, data collection, analysisand interpretation, or the writing of the manuscript and the deci-sion to submit the manuscript for publication. We would like tothank all of the women who participated in the study, withoutwhom this work would not have been possible, as well as JenniferDuggan, Natalie D’Abrew, Viola Heinzelmann-Schwarz and Clau-dette Knight for their assistance with the study.

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