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   Table of Contents - Current issue
Coverpage
October-December 2019
Volume 6 | Issue 4
Page Nos. 315-445

Online since Wednesday, August 7, 2019

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EDITORIAL  

Qigong Exercise and Tai Chi in Cancer Care p. 315
Pei-Shiun Chang, Tish Knobf
DOI:10.4103/apjon.apjon_34_19  
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REVIEW ARTICLE Top

Characterization of Internal Validity Threats to Phase III Clinical Trials for Chemotherapy-Induced Peripheral Neuropathy Management: A Systematic Review Highly accessed article p. 318
Deborah Lee, Grace Kanzawa-Lee, Robert Knoerl, Gwen Wyatt, Ellen M. Lavoie Smith
DOI:10.4103/apjon.apjon_14_19  
Objective: The recent American Society of Clinical Oncology (ASCO) Clinical Guidelines for chemotherapy-induced peripheral neuropathy (CIPN) management (48 Phase III trials reviewed) only recommend duloxetine. However, before concluding that a CIPN intervention is ineffective, scientists and clinicians should consider the risk of Type II error in Phase III studies. The purpose of this systematic review was to characterize internal threats to validity in Phase III CIPN management trials. Methods: The PubMed, CINAHL, EMBASE®, and Scopus databases were searched for Phase III clinical trials testing interventions for CIPN management between 1990 and 2018. The key search terms were neoplasms, cancer, neuropathy, and CIPN. Two independent researchers evaluated 24 studies, using a modified Joanna Briggs Institute Checklist for Randomized Control Trials developed by the authors specific for CIPN intervention trials. Results: Two studies exhibited minimal or no design flaws. 22/24 Phase III clinical trials for CIPN have two or greater design flaws due to sample heterogeneity, malapropos mechanism of action, malapropos intervention dose, malapropos timing of the outcome measurement, confounding variables, lack of a valid and reliable measurement, and suboptimal statistical validity. Conclusions: Numerous CIPN interventions have been declared ineffective based on the results of Phase III trials. However, internal validity threats to numerous studies may have resulted in Type II error and subsequent dismissal of a potentially effective intervention. Patients may benefit from rigorous retesting of several agents (e.g., alpha-lipoic acid, duloxetine, gabapentin, glutathione, goshajinkigan, lamotrigine, nortriptyline, venlafaxine, and Vitamin E) to expand and validate the evidence regarding ASCO's recommendations for CIPN management.
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MINI REVIEW Top

Impact of the Enhanced Recovery Program after Hepato-Pancreato-Biliary Surgery p. 333
Maria Kapritsou
DOI:10.4103/apjon.apjon_15_19  
Enhanced Recovery after Surgery (ERAS) is a multicentric program that includes the fields of nursing and anesthesia, nutrition and fluid management, and minimally invasive surgery. ERAS protocols focus on reducing the postoperative complications and stress response, optimizing the postoperative recovery. They have been implemented in many surgical fields, such as cardiac, gastric, and urologic, as they were shown to be effective in reducing morbidity and the overall health costs and in improving patient satisfaction. The aim of this minireview was to investigate the impact of ERAS programs on patients' postoperative outcome after hepato-pancreato-biliary surgery.
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ORIGINAL ARTICLES Top

Improving Information Provision on Chemotherapy-Induced Alopecia and Scalp Cooling: A Comprehensive Approach Including A Website and Web-Based Decision Tool p. 336
Corina van den Hurk, Paulien Keizer-Heldens, Ilse Raats, Kim Hoeijmakers, Floortje Mols
DOI:10.4103/apjon.apjon_19_19  
Objective: Alopecia is a frequently occurring side effect of chemotherapy and has high impact on many patients. Currently, scalp cooling is the only method to prevent this chemotherapy-induced alopecia (CIA) and it is effective in about half of the patients. Since determinants of the success are largely unknown, all patients should be prepared for potential hair loss. The objective was to provide up-to-date online information about CIA and scalp cooling to support patients in coping with CIA and in their choice regarding scalp cooling. Methods: Essential aspects of delivering information and lack of information were identified during focus groups, interviews, and a questionnaire survey among cancer patients, and in discussions with nurses. Results: The obtained information was used to develop a website (www.scalpcooling.org) and a web-based tool. It combines scientific evidence and practical advice about CIA and regrowth of hair, scalp-cooling tolerance, efficacy and safety, as well as an overview of possible advantages and disadvantages. The web-based tool provides tailored information about the probability of CIA with and without scalp cooling in particular chemotherapy regimens. Besides, the tool offers patients' support in decision-making by allowing them to reflect and consider their values and opinions about scalp cooling. Conclusions: This comprehensive information is useful during nursing consultations.
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Educating Healthcare Employees about Advance Care Planning p. 343
Catherine A Glennon, Wendy Thomas, Katherine Black, Madison Herrig, Jane Ishikawa, Isabel Reedy
DOI:10.4103/apjon.apjon_27_19  
The objective of this descriptive article is to provide a background of current research and data on advance care planning. Additionally, a proposed and detailed education initiative for increasing completion and understanding of advance care planning documents is presented.
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Measuring Acculturation of Pakistani Women: A Psychometric Evaluation of Urdu Version of the Short Acculturation Scale p. 349
Dorothy N. S Chan, Winnie K. W So
DOI:10.4103/apjon.apjon_28_19  
Objectives: The purpose of the study was to translate and validate the psychometric properties of the Short Acculturation Scale-Urdu version (SAS-U) for Pakistani women in Hong Kong. Methods: This is a methodological study, and a convenience sample of 263 Pakistani women was recruited to participate in the study. The SAS was translated from English to Urdu using forward and backward translation and reviewed by an expert panel for semantic equivalence and content validity. Face validity was done by five bilingual Pakistani women. Construct validity was established by confirmatory factor analysis (CFA). Convergent validity was examined by the bivariate correlation of proxy indicators such as language preference, with the overall and subscales of SAS-U. Reliability was established by internal consistency and test–retest reliability. IBM SPSS Statistics for Windows version 22.0 and LISREL version 8.80 were used for data analysis. Results: The translated SAS-U had good content validity and face validity. CFA revealed that the second-order model with three first-order factors and the results was supported by the following indices: root mean square error of approximation = 0.055, standardized root mean square residual = 0.031, χ2/df = 1.80, nonnormed fit index = 0.99, and comparative goodness-of-fit index = 1.00. Language preference correlated significantly with the overall and subscales of SAS-U (r > 0.6, P < 0.01). SAS-U demonstrated high internal consistency (Cronbach's alpha = 0.96) and acceptable test–retest reliability (weighted kappa = 0.68–0.93). Conclusions: The results provide support for the psychometric properties of the SAS-U – it is a reliable and valid instrument for measuring levels of acculturation among Pakistani women in Hong Kong.
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Scope of Practice, Role Legitimacy, and Role Potential for Cancer Care Coordinators p. 356
Stacey Panozzo, Anna Collins, Sue-Anne McLachlan, Rosalind Lau, Brian Le, Mary Duffy, Jennifer A Philip
DOI:10.4103/apjon.apjon_29_19  
Objective: The cancer care coordinator (CCC) role has become a priority in providing coordinated, patient-centered, supported care for patients, and their families experiencing cancer. The CCC role exists with heterogeneity across tumor streams, clinical disciplines, and institutions. This study explored CCCs perceptions and experiences of their role, scope of practice, and potential for future role development. Methods: This research used a mixed methods design. Focus groups and individual interviews were conducted with a purposive sample of 16 CCCs from two tertiary public teaching hospitals in Melbourne, Australia. A thematic analysis approach was used. A quantitative record of relative time spent on tasks was also collected. Results: Three major themes were identified: (1) Perceptions of role legitimacy, (2) Structure and funding of the role determines scope of practice, and (3) Reflections on the potential for the role. Variability was evident in predominant tasks undertaken, integration into the unit, level of patient contact, and regard from other professional colleagues. Variability appears to relate to employment time assigned to the role, and history and structure of the role. Conclusions: The findings underline the need when establishing and reviewing CCC roles for explicit attention to be given to the reporting, integration, structural, and collegiate support for the role as this will profoundly influence its success.
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Physical Symptoms, Unmet Needs, and Quality of Life in Thai Cancer Survivors after the Completion of Primary Treatment p. 363
Kanaungnit Pongthavornkamol, Pichitra Lekdamrongkul, Pimchan Pinsuntorn, Alex Molassiotis
DOI:10.4103/apjon.apjon_26_19  
Objectives: This study investigated physical symptoms, unmet supportive care needs, and quality of life (QoL) perception among different types of Thai cancer survivors who had completed first-line treatment. Methods: A cross-sectional study recruited breast, gynecological, colorectal, lung, and head and neck cancer survivors (n = 236) who were attending follow-up visits at a regional cancer hospital in central Thailand. Data were collected by the Physical Symptom Concerns Survey, the Cancer Survivors' Unmet Needs Scale, and a single item measuring global QoL. Descriptive statistics, one-way analysis of variance (ANOVA), and Welch's ANOVA were used for data analysis. Results: Cancer survivors generally perceived good QoL, with significantly low QoL for lung cancer survivors (P < 0.001). There were no differences in symptom experiences among the five cancer groups, except for pain, which was significantly higher in lung cancer survivors than in the other four groups. The most frequently reported symptoms across all groups were numbness in the hands/feet, sleep disturbances, fatigue, and pain. The top unmet supportive care need among all participants was related to concerns of cancer recurrence (44.5%). Head and neck cancer survivors reported the highest number of unmet needs among the five cancer groups. Conclusions: This study mapped the unmet supportive care needs in Thai cancer patients and showed that patients with head and neck cancer and lung cancer were strongly affected. A survivorship care plan focusing on managing physical symptoms and providing supportive and psychosocial care should be developed to meet the needs of each cancer survivor group and to enhance QoL after the completion of treatment.
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Iranian Cancer Patients Perceptions of Barriers to Participation in Decision-Making: Potential Impact on Patient-Centered Care p. 372
Naism Aminaie, Jila Mirlashari, Rebecca H Lehto, Marzieh Lashkari, Reza Negarandeh
DOI:10.4103/apjon.apjon_11_19  
Objective: The purpose of this study was to explore perceptions about barriers to decision-making in Iranian patients with cancer about their care. Methods: Utilizing a qualitative approach, semi-structured interviews were conducted with 15 cancer patients. Results: Data analysis revealed four central categories reflecting patient perceptions about barriers that included medical dominance (uninformed decision-making, perceived inability to disagree secondary to despair, and patient objectification), healthcare system mistrust (physician, nurse, and medical center facility and equipment), healthcare system characteristics (services and facilities' limitations, poor communication, healthcare setting compulsion), and cultural barriers (feeling unfamiliar, insecurity in an unfamiliar environment, language barriers, limited attention to religious beliefs). Conclusions: Barriers may impact the perceived ability of Iranian patients' with cancer ability to participate in decision-making regarding their care. Such barriers contain the potential to disrupt patient-centered care. Perceptions about barriers articulated by patients are modifiable. While some Iranian healthcare systems may have problematic challenges, targeted allocation of resources and education of healthcare providers convey strong possibilities to enhance patient-centered care.
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Improving the Workflow Efficiency of an Outpatient Pain Clinic at a Specialized Oncology Center by Implementing Lean Principles Highly accessed article p. 381
Ahmad Al Hroub, Abdullah Obaid, Rawya Yaseen, Aqel El-Aqoul, Naser Zghool, Hussien Abu-Khudair, Darwish Al Kakani, Aladeen Alloubani
DOI:10.4103/apjon.apjon_21_19  
Objective: Adult outpatient oncology pain clinics face many challenges due to the increased number of patients, the restriction of electronic appointment systems, overcrowding, waiting time, and patient dissatisfaction. This project aimed to improve clinic time efficiency, decrease clinic waiting time, and improve patient satisfaction. Methods: Lean thinking concepts and their tools, for example, value-stream mapping and value added (VA)/non-VA (NVA) analysis were used. Electronic appointment system slots were stratified based on patient visit type. A total of 187 patients were included in a time-motion survey at three different occasions: preintervention (n = 67) and two consecutive quarter postintervention time points (n = 64, n = 56). Simultaneously, patient satisfaction was reported quarterly by a quality management office. Results: The pain clinic workflow became more efficient; the mean clinic waiting time decreased from 72.5 min at preintervention to 19.5 and 21 min at the two postintervention quarters, respectively. Moreover, patient satisfaction improved from 75% at the preintervention to 100% and 96.7% at the two postintervention quarters. Conclusions: Redesigning the process of an electronic appointment system using lean thinking considerably decreases patients' waiting time, improves patient satisfaction, improves resource utilization, allows proper scheduling based on patient visit types, eliminates unnecessary waste processes, and reallocates health-care providers' time toward direct, individualized patient care.
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Visiting Nurses' Perspectives on Practices to Achieve End-of-Life Cancer Patients' Wishes for Death at Home: A Qualitative Study p. 389
Noriko Teruya, Yoko Sunagawa, Haru Sunagawa, Takehiko Toyosato
DOI:10.4103/apjon.apjon_18_19  
Objective: This study aimed to clarify visiting nurses' perspectives on critical practices to ensure they could advocate for patients who prefer to die at home. Methods: Sixteen nurses, working at home-visit nursing agencies in Japan, participated in this study. Data were generated by interviews with the nurses and participant observations from nursing home-visits for six end-of-life cancer patients and were analyzed using content analysis. Results: Five themes emerged: (1) nursing assessment, (2) support for comfortable daily life of the patient and their family, (3) advocating for the patient's views about continuing homecare until death, (4) supporting the patient's preparedness for death, and (5) coordination with other health professionals and related facilities for a comfortable environment for the patient. In addition, the nurses sometimes used humorous responses to death-related work to change the patient's melancholy thoughts. Conclusion: The present study found that the participants advocated for the patient's views about continuing homecare until death while coordinating views between the patient and their family; they further supported the patient's daily life while helping them prepare for death to achieve their wish for death at home. In addition, our study uncovered the visiting nurses' unconscious practical wisdom of using humorous responses to death-related work to alleviate the patients' feelings of hopelessness. To develop practical wisdom for using humor effectively in end-of-life care, nurses need to verbalize unconscious practices, and accumulate empirical knowledge about nursing interventions using humor, including cultural attitudes, through case study analysis.
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Physiological Factor Evaluation of the Warm Humidification of Anesthetic Gas Nursing Care p. 397
Hyosun Park, Nayeon Shin
DOI:10.4103/apjon.apjon_23_19  
Objective: This study aimed to evaluate the effects of warm humidification of anesthetic gas nursing care on physiological factors in elderly patients during laparoscopic cancer surgery. Methods: Sixty elderly laparoscopic surgical patients were recruited from a medical center in Korea. The participants' physiological factors (blood pressure, body temperature, and leukocyte and neutrophil counts) were measured four times. Results: After warm humidification of anesthetic gas nursing care, there were significant differences in body temperatures. Conclusions: These findings indicate that warm humidification of anesthetic gas nursing care is effective in maintaining body temperature. Thus, this type of nursing care can be effective in elderly cancer patients undergoing laparoscopic surgery.
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Effects of Health Belief Model-Based Education on Health Beliefs and Breast Self-Examination in Nursing Students p. 403
Aygül Kissal, Bahtısen Kartal
DOI:10.4103/apjon.apjon_17_19  
Objective: This study was carried out to investigate the effect of an education program based on the health belief model (HBM) on nursing students' health beliefs and on their practices of breast self-examination (BSE). Methods: This research was a semi-experimental intervention study with a single group, pretest and posttest design. The sample of the research consisted of 48 students in the 3rd year of study. Data were collected before the education program and 6 months and 1 year after the training. A sociodemographic information form, the breast cancer knowledge form, the HBM scale, and the BSE proficiency rating instrument were used. Descriptive statistics and repeated measures ANOVA were used to examine the relationships among the variables. Results: Implementing the educational program was found to be statistically insignificant for the HBM. Knowledge about breast cancer and BSE skills increased after the training. The percentage of students practicing regular BSE was determined as 14.6% before training, 45.8% after 6 months, and 28.1% after 1 year. Conclusions: The education provided to the students increased their HBM scores, knowledge about breast cancer, and BSE skills. However, the frequency of regular BSE was still quite low after training.
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Dhikr Therapy for Reducing Anxiety in Cancer Patients p. 411
Ririn Afrian Sulistyawati, Probosuseno , Sri Setiyarini
DOI:10.4103/apjon.apjon_33_19  
Objective: Anxiety in cancer patients can affect recovery time, medication adherence, and patient quality of life. Some studies show that dhikr therapy can improve relaxation and can reduce anxiety, but research on dhikr therapy in cancer patients is still not widely done. This study aims to determine the effect of dhikr therapy on reducing anxiety in cancer patients. Methods: This study used a quantitative method with a quasi-experimental-nonequivalent control group design. The study was conducted in April–May 2018, with respondents 20 people in the intervention group and 20 people in the control group. Dhikr therapy is given once a day in the intervention group with a minimum time of 10 min. Anxiety was measured using the Visual Analog Scale for Anxiety. The effect of dhikr therapy was measured using the Mann–Whitney and effect size (ES). Results: There were a statistically significant differences in the anxiety level of patients in the intervention group and the control group, with a value of P = 0.001 (P < 0.05) and ES = 0.87 (ES > 0.5) indicating the influence of dhikr therapy in reducing patient anxiety. Conclusions: Dhikr therapy has a great effect on reducing anxiety in cancer patients.
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Oral Care Protocol for Chemotherapy- and Radiation Therapy-Induced Oral Complications in Cancer Patients: Study Protocol p. 417
Radhika R Pai, Ravikiran Ongole, Sourjya Banerjee, Krishna Prasad, Linu Sara George, Anice George, Baby S Nayak
DOI:10.4103/apjon.apjon_30_19  
Objective: The purpose of this study is to describe a randomized control trial protocol that assesses the effectiveness of an oral care protocol on chemotherapy- and radiation therapy-induced oral complications in cancer patients. Methods: This study is a randomized, outcome assessor blinded study. For Phase I training phase, one group pretest-posttest design will be implemented for training the staff nurses on oral care in cancer patients and for Phase II Intervention Phase, randomized clinical trial will be used to determine the effectiveness of oral care protocol. Twenty-five staff nurses working in radiation oncology areas hospital will be trained about oral care in cancer patients. Seventy newly diagnosed patients with head and neck cancer admitted to the oncology wards of a tertiary care hospital in South India will be enrolled. Patients will be randomly allotted to a control and intervention group. The primary outcome variables are oral complications and oral health assessment. Results: The results of the preliminary survey conducted among 158 staff nurses showed that 81 (51.3%) of the staff nurses had poor knowledge regarding oral care of cancer patients and majority 128 (81.0%) of them suggested for training in the specific area of oral care of cancer patients. A pilot study conducted by the principal investigator to determine the feasibility of the study among 9 participants (4 experimental and 5 control) revealed that there was slight difference found in the incidence of oral complications among the group in relation to weeks of assessment. Conclusions: The present study may give data regarding the occurrence of oral complications in head and neck cancer patients, and even, it can enlighten on the effectiveness of oral care protocol on oral complications. If this protocol is found effective, then this protocol can be made part of daily nursing care to improve the patient outcome.
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The Relationship between Depressive Symptoms and Demographic-Medical Characteristics among Elder People with Cancer p. 424
Sepideh Ladaninejad, Ehteramsadat Ilali, Nouroeddin Mousavinasab, Zohreh Taraghi
DOI:10.4103/apjon.apjon_13_19  
Objective: Cancer is one of the most common life-threatening diseases and a great source of stress in patients. The risk factors of depression differ in elder people compared to other age groups. The present study was designed to determine the relationship between depressive symptoms and demographic-medical characteristics among elder people with cancer. Methods: This cross-sectional correlational study recruited 200 elder people with cancer. The eligible patients completed the demographic-medical characteristics questionnaire, the Geriatric Depression Scale, the Abbreviated Mental Test, the Activities of Daily Living Scale, and the Multidimensional Perceived Social Support Scale. The findings were analyzed in SPSS software version 21.0 using the Kruskal–Wallis and Mann–Whitney tests. Results: A total of 50% of the elder people in this study had mild depression, 18.5% had moderate depression, and 2.5% had severe depression. A significant relationship was observed between depression in the elder people and their marital status (P = 0.025), living arrangement (P = 0.013), and income (P = 0.021). Depression also had a significant relationship with diabetes (P = 0.044) and respiratory diseases (P = 0.040). A significant relationship was also observed between depression and colon cancer (P = 0.007), and the mean depression was lower in the patients with colon cancer compared to those with other cancers. Depression had a significant relationship with complications, including pain (P = 0.001), nausea (P < 0.001), vomiting (P = 0.001), hair loss (P < 0.001), and shortness of breath (P = 0.028). Conclusions: Given the high prevalence of depression in this age group, screening and counseling-supportive interventions are recommended for helping prevent depression and come to terms with cancer.
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Health Belief Model-based Intervention on Women's Knowledge and Perceived Beliefs about Warning Signs of Cancer p. 431
Iman Sharifikia, Camelia Rohani, Fatemeh Estebsari, Mahsa Matbouei, Fatemeh Salmani, Azam Hossein-Nejad
DOI:10.4103/apjon.apjon_32_19  
Objective: Early detection of cancers essentially depends on knowledge of the warning signs. This study, therefore, aimed at investigating the effect of Health Belief Model (HBM)-based educational intervention on the knowledge and perceived beliefs of women about the warning signs of cancer. Methods: This experimental study with intervention (n = 80) and control (n = 80) groups was performed at four urban health centers affiliated to the university. Data collection was done in two phases, before and one month after the educational intervention, using three instruments, a demographic-clinical information questionnaire, the awareness questionnaire on cancer warning signs, and the cancer warning signs-HBM questionnaire. Results: The results of the multivariate repeated-measures analyses of variance indicated that the hypothesis of this study was confirmed. It means that “women's knowledge and their perceived beliefs of cancer warning signs” improved after HBM-based educational intervention in the intervention group, compared to the controls over time. Thus, the “level of knowledge” and perceived beliefs of the women in the intervention group compared to the controls increased, in terms of perceived “sensitivity,” “severity,” “benefits,” “barriers,” “cue to action,” and “self-efficacy” over time (P < 0.001). Conclusions: It could be hoped that this intervention would be effective for improving the performance of women in health-promoting behaviors of cancer prevention. It is recommended that health-care providers plan for HBM-based educational interventions, based on educational needs of the target groups at different community levels.
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Preoperative Anxiety in Patients Undergoing Outpatient Cancer Surgery p. 440
Jennifer Ross Majumdar, Emily A Vertosick, Bevin Cohen, Melissa Assel, Marcia Levine, Margaret Barton-Burke
DOI:10.4103/apjon.apjon_16_19  
Objective: Our primary research aim was to determine the prevalence of preoperative anxiety in patients undergoing outpatient cancer surgery. Our secondary aim was to examine the association between preoperative anxiety and negative intraoperative and postoperative outcomes in patients undergoing outpatient cancer surgery, including increased anesthesia requirements, postoperative nausea and vomiting (PONV), extended overnight stay, total length of stay (LOS), transfer to hospital, surgical complications, and postoperative visits to urgent care centers (UCC). Methods: We conducted a retrospective cohort study to investigate the prevalence of preoperative anxiety and its association with postoperative outcomes in patients undergoing outpatient cancer surgery. Our retrospective cohort included 10,048 outpatient procedures performed on 8683 patients at a large comprehensive cancer center between January 1, 2016, and April 30, 2018. Results: The analysis included 8665 patients undergoing procedures at an outpatient facility over 16 months; 16.7% had preoperative anxiety. In patients with preoperative anxiety, higher rates of adverse outcomes were seen, including PONV (adjusted difference 1.8%, 95% confidence interval [CI] 0.12%, 3.4%, P = 0.029), unplanned overnight admission (adjusted difference 1.1%, 95% CI 0.07%, 2.0%, P = 0.021), and urgent care visits within 30 days (adjusted difference 1.5%, 95% CI 0.44%, 2.6%, P = 0.002). Conclusions: Even assuming a causal relationship between preoperative anxiety and postoperative outcomes, preventing one instance of PONV would require treating at least 30 patients for anxiety, and preventing longer-term outcomes such as urgent care visits or readmissions within 30 days would require treating even larger numbers of patients. Future studies should attempt to elucidate the causal pathway between preoperative anxiety and postoperative adverse events in outpatients undergoing outpatient cancer surgery.
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