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. Author manuscript; available in PMC: 2025 Jun 14.
Published in final edited form as: Oncol Nurs Forum. 2024 Jun 14;51(4):381–390. doi: 10.1188/24.ONF.381-390

Distress, Pain, and Nausea on Postoperative Day One and Fourteen in Women Recovering from Breast Conserving Surgery: A Repeated-Measure Study

Jennifer R Majumdar 1,2, Petra Goodman 3, Margaret Barton Burke 1, Jaime Gilliland 4, Nalini Jairath 3
PMCID: PMC11875513  NIHMSID: NIHMS2055865  PMID: 38950094

Abstract

Objectives

To determine the incidence and trajectory of distress, pain, and post-operative nausea and vomiting at baseline, and post-operative day (POD) 1 and 14 following breast-conserving surgery.

Sample and Setting

75 women over 18 undergoing breast-conserving surgery with sentinel lymph node biopsy for treatment of early-stage primary breast cancer at an ambulatory surgery center in a large Northeast metropolitan institution.

Methods and Variables

The prospective repeated measures design study measured distress, pain, and nausea and vomiting (PONV) with the Distress Thermometer with Problem List on POD 1 and POD14.

Results

Pain and distress scores were highest on POD1. The number of women reporting depression (an indicator of distress) increased between POD 1 and POD 14. Thematic analysis of free-text questions revealed that family concerns, fears and worries, and post-operative issues were all contributing factors to patients’ experience of pain and distress.

Implications for Nursing

Following breast conserving surgery, women experience pain and distress while recovering at home. Oncology nurses can utilize the results of this study to apply evidence-based practice to reduce the symptom burden in this population. Future nursing research should focus on developing innovative targeted interventions that can be utilized outside of the hospital setting.

Background

One in eight American women will experience breast cancer in their lifetime (Siegel Mph et al., 2024). With early screening and diagnosis, most women with breast cancer are diagnosed at an early stage (Stages I or II) when surgery remains the primary treatment (DeSantis et al., 2019) and the majority of patients with early-stage breast cancer are eligible for breast-conserving therapy consisting of breast-conserving surgery followed by adjuvant radiation therapy (J. Ji et al., 2022). In addition to the surgical removal of the breast tumor, these surgeries often include pathology procedures including lymph node removal that within approximately two week time frame provide diagnostic information that guide the next treatment steps (Goetz et al., 2019; Gradishar et al., 2019). Consequently, women undergoing breast-conserving surgery must cope with the typical symptoms of the surgical procedure including pain and post-operative nausea and vomiting (PONV) while also awaiting results, further compounding their already high levels of psychological distress related to a recent breast cancer diagnosis.

The National Comprehensive Cancer Network (NCCN) Guidelines for Distress Management state that psychological distress should be recognized, monitored, documented, and treated promptly at all stages of disease and in all settings (Riba et al., 2022). Distress extends along a continuum and includes the multifactorial, unpleasant experience of a psychological, social, spiritual, and/or physical nature that may interfere with one’s ability to cope effectively with cancer, its physical symptoms, and treatment (Riba et al., 2022). As more surgeries move to the outpatient setting, assessing, and treating symptoms of distress and associate symptoms following surgery moves from the hospital setting to the home adding new complexities.

Despite the urgent need to understand the incidence and trajectory of symptoms in the postoperative period, a scoping review demonstrated a significant gap in the current literature (Majumdar & Yermal, 2024). In fact, the majority of research literature addressing psychological distress, pain and PONV following breast cancer surgery focuses on patients undergoing total mastectomy procedures (Kant et al., 2018; McFarland et al., 2018; Schreiber et al., 2019). Additionally, psychological distress and symptoms during the immediate post-operative period (post-operative day 1) in these patients when the pain (Gan, 2017) and PONV (Wesmiller et al., 2017) are most acute, is rarely addressed and often not reported even if the data is collected (W. Ji et al., 2022; Kulkarni et al., 2017; Schreiber et al., 2019; Yang et al., 2019). Furthermore, data regarding the prevalence of pain following breast-conserving surgery ranges from as little as 9% to as high as 94% in other studies (Bruce et al., 2012; Killelea et al., 2018; Powell et al., 2016), underscoring the need for better characterization of the pain experience. Lastly, the research literature does not address the impact of the current standard of breast conserving surgery care, which includes home-based recovery with minimal or absent patient-provider interaction assessing distress and symptoms. Therefore, additional research is required to help guide oncology nursing practice and improve patient care.

The prospective study is based upon Lazarus and Folkman’s Transactional Model of Stress and Coping (TMSC), a widely-used conceptual framework used to understand how stress impacts patient outcomes (Lazarus & Folkman, 1984). The purpose of this study was to determine the incidence and trajectory of distress, pain, and post-operative nausea and vomiting at baseline and post-operative day (POD) 1 and 14 following breast-conserving surgery.

Methods

Study Design and Participants

The study presented is based on a subset of data from a prospective repeated measure study. The results related to the utilization of coping strategy and conceptual model will be reported separately. From August 15, 2020 to October 15, 2020 patients were consecutively recruited following surgery at an ambulatory surgical facility Memorial Sloan Kettering Cancer Center(Afonso et al., 2021). All women over 18 undergoing breast-conserving surgery with sentinel lymph node biopsy (SLNB) for treatment of early- stage (Stage I or II) primary breast cancer that selected English as their preferred language were invited to participate in the study. Patients diagnosed with unrelated severe medical or psychological comorbidities, who required transfer to another hospital for medical reasons, or had a previous cancer diagnosis were excluded from the study.

Procedures and Data Collection

The study was approved by the Memorial Sloan Kettering Cancer Center Institutional Review Board (X20-042). Participants were recruited on postoperative day one (POD1) by email and provided consent to participate and to access the electronic health record (EHR) for additional information. Demographic and predictor data abstracted from the electronic health records included: patient age, zip code, children at home, perceived social support, employment status, sick leave status, current smoker, history of PONV, and baseline distress thermometer score. Participants who completed the first questionnaire on POD1 were sent an additional questionnaire at postoperative day 14 (POD14), at which point they had received the additional diagnostic results from the SLNB and met with the surgeon.

Data for this study collected by email was managed via a secure Research Electronic Data Capture (REDCap) database. REDCap is a platform that allows for securely collecting research data using a web-based interface (Majumdar et al., 2023). All connections to REDCap are encrypted to ensure data were protected (Harris et al., 2019).

Instruments

On POD 0 in the post anesthesia care unit (PACU), pain was measured by a numerical rating scale (0-10) and PONV was collected by number of antiemetics administered. Patients undergoing general anesthesia received standard prophylactic antiemetics. In the PACU, antiemetics were only administered for the treatment of nausea or vomiting based upon standard of care treatment protocol.

At baseline prior to surgery, all patients completed the NCCN Distress Thermometer. On POD 1 and 14, participants completed the NCCN Distress Thermometer and Problem List (DT/PL) Version 2.2016 with “COVID-19” identified as an additional listed problem to collect levels of distress, pain, and nausea. The NCCN recommends including the Problem list to assist in identifying sources of patient distress and includes a comprehensive list of categories, including practical, family, physical, and emotional problems(Ownby, 2019).

The DT measures distress on a scale from 0 to 10, where 0 indicates no distress and 10 indicates extreme distress. The Distress Thermometer has been validated in patients with different types of cancer, in different settings, and different languages, cultures, and countries (Riba et al., 2019). A meta-analysis of 42 studies and over 14,000 patients indicated pooled sensitivity to be 81% (95% CI 0.79 – 0.82) and pooled specificity to be 72% (95% CI 0.71 – 0.72) with a cutoff score of 4 for identifying clinically significant levels of distress (Ma et al., 2014). In addition, when compared with the Hospital Anxiety and Depression Scale (HADS), the meta-analysis concluded that the cut-off score of 4 maximized the balance between pooled sensitivity (0.82, 95% CI 0.80 – 0.84) and pooled specificity (0.73, 95% CI 0.72 – 0.74) with an area under the curve of 0.8432. Thus, in this study, the patient-reported DT score of 4 or greater represented a moderate and clinically-relevant level of distress.

Data Analysis

All patients who accepted and completed the first questionnaire were included for the purpose of data analysis. Statistical analyses were conducted using IBM SPSS Statistics (Version 25). Percentages were reported for categorical variables and means, standard deviations, range, and median values with interquartile ranges for continuous variables. Repeated measures ANOVA was used to compare the distress thermometer scores across the data collection points. In addition, to assess whether there was a relationship between distress and lymph node pathology results at the three time points statistical analysis was performed using the Mann–Whitney U test. McNemar’s test was used to compare the prevalence of items on the Problem List.

The open-ended responses were analyzed by a qualitative methods specialist (QMS) (J.G.) in the Patient-Reported Outcomes, Community Engagement, and Language Core Facility at Memorial Sloan Kettering Cancer Center, and the primary investigator (J.M.). The data were analyzed using a matrix analysis approach, where responses to each item were coded for primary themes and subthemes. This approach has been previously used to characterize key thematic content in open-ended survey responses(Uscher-Pines et al., 2020; Vaismoradi et al., 2013).

Results

Sample Characteristics

The final sample consisted of 75 women. Of 123 potential participants, 75 (61%) responded and agreed to participate. The average age of the sample was 58.7 ± 9.51 years. Over half of the participants were employed (57.1%, n = 40), and the majority of those employed had access to sick leave (72.5%, n = 29). Table 1 provides complete descriptive information.

Table 1.

Sample Number and Percentages for Study Sample

Variable n %
Age in years
 18–39 2 2.6
 40–49 12 16.0
 50–69 54 71.1
 ≥70 8 10.5
Home state
 Connecticut 2 2.6
 New Jersey 9 11.8
 New York 64 84.2
 Florida 1 1.3
Children at home
 Yes 5 6.6
 No 70 93.4
Employed
 Yes 40 57.1
 No 35 42.9
Sick leave (if employed)
 Yes 29 72.5
 No 11 27.5
Social support
 Yes 67 89.3
 No 8 10.7
Current smoker
 Yes 23 32.9
 No 52 69.3
History of postoperative nausea and vomiting
 Yes 3 4.0
 No 72 96.0
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Distress Thermometer and Problem List

The highest frequency of clinically-relevant levels of distress (<4) were reported on POD1 (Figure 1).At baseline prior to the first surgical visit, 23% of patients (n=17) reported a DT score 4 or greater. On post-operative day 1, 85% (n=64) of patients reported a DT score of 4 or more. On post-operative day 14, 42% (n=26) of patients reported a DT score of 4 or more. The levels of distress were highest at POD 1, with a mean of 4.0 ± 2.9, followed by baseline, with a mean of 3.5 ± 2.9; they were lowest at POD 14, with a mean of 3.3 ± 2.5. According to the repeated ANOVA Greenhouse-Geisser tests, the mean scores for distress were not significantly different across the three time periods (F = 1.69, p = .195). The results indicated a higher median distress score in patients with positive pathology results (4.00) than in patients with negative pathology results (3.00) at POD 14, however the results were not significant (U=9, p = 0.059).

Figure 1.

Figure 1.

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Frequency of clinically-relevant levels of distress (≥4 on DT)

On post-operative day 1 (POD1), most of the participants in the study reported “worry” as a problem (70%, n = 49). In addition, about half of the participants (46.5%, n = 33) reported “concerns about treatment decisions”, fear (49.3%, n = 34), nervousness (56.7%, n = 38), sadness (40.3%, n = 27), fatigue (44.6%, n = 29), and sleep (56.7%, n = 38). One-third of the participants reported feeling swollen (34.8%, n = 23) and pain (38.5%, n = 25). Participants reported problems with constipation (20.3%, n = 13), work/school (19.1%, n = 13), changes in appearance (20%, n = 13), memory/concentration (20.6%, n = 13), and COVID-19 concerns (20.6%, n = 13). All problems decreased between the two data collection points (Figure 2), except for depression, “getting around”, and “sexual” which had higher frequencies at post-operative day 14.

Figure 2.

Figure 2

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Distress Thermometer Problem List Frequency at postoperative day 1 and 14

A McNemar’s test was used to assess the difference in distress based on whether the woman experienced or did not experience the problem POD 1 and 14. A total of 18 Distress Thermometer problems were significantly associated with distress at POD 1. Distress was significantly higher in participants with concerns about treatment decisions, fear, nervousness, sadness, worry, loss of interest, appearance, constipation, swelling, fever, getting around, indigestion, and memory (p < .001). Family/health issues and sleep were also associated with distress (p = .01). Work/school issues and sexual issues were also associated with higher levels of distress (p < .05).

Only nine problems were associated with distress at POD 14. Distress was significantly higher in patients reporting constipation (p < .001). Concerns about work/school, treatment decisions, dealing with a partner, fear, nervousness, sadness, worry, loss of interest, and breathing were also associated with higher levels of distress (p < .05). Breathing and dealing with a partner were not associated with higher distress at POD 1, but they were at POD 14.

Pain and Post-operative Nausea and Vomiting

While in the postoperative care unit following surgery, post-operative day zero (POD 0), most patients (66%, n = 42) experienced some pain, and about one-third of the participants experienced moderate to severe pain greater than 4 on the numeric pain scale (38.7%, n = 29). Most participants did not experience any nausea (97.3%, n = 73). On post-operative day 1 (POD1), 38.5% (n=25) reported pain and 7.9% (n=5) reported nausea as a problem causing distress. On post-operative day 14 (POD14), 34.5% (n=20) reported pain and 1.75% (n=1) reported nausea as a problem causing distress.

Open-ended Survey Questions

Twenty-nine patients provided responses to the open-ended survey questions. When asked to identify ‘other problems’ contributing to post-operative pain and distress, and to provide ‘additional information’ related to their survey responses, patients provided responses that fell into three domains: contributing factors to pain and distress, contributing factors to the improvement to pain and distress, and coping strategies. Domain 1, contributing factors to pain and distress, includes four themes: family concerns, fears and worries, post-operative issues, and other physical concerns. Domain 2, contributing factors to the improvement of pain and distress, includes one theme: observed improvement of symptoms and side effects over time. Supporting quotations can be found in Table 3.

Domain 1. Contributing factors to pain and distress

Family concerns were of importance to patients, highlighting family dysfunction, death of close relatives, and family health issues including other cancer diagnoses as factors that contributed to their post-operative pain and distress.

Fears and worries were common factors for pain and distress. Patients discussed concerns around navigating their cancer diagnosis and how to cope, including concerns about future longevity. Patients noted that their diagnosis has caused anxiety, adding that they’ve seen friends die from similar diagnoses and speculating about their own life trajectory. Patients also expressed concerns related to treatment of their cancer, including waiting for test results and dealing with side effects from adjuvant therapies. Surgical considerations were also of concern for patients. Some worried whether they had made the “right” surgical choice, while others were concerned about post-operative appearance and side effects such as lymphedema. Some patients also worried about returning to work after surgery and the possibility of disease recurrence. COVID-19 was also a prominent cause of fear and worry for patients, with several patients discussing concerns around increased susceptibility to infection and increased exposure during travel to and from appointments.

Post-operative issues concerning patients fell into three categories: at the surgical site, outside of the surgical site, and at the biopsy site. Concerns at the surgical site included general soreness, pain in breasts, scar tissue, stress from having a drain, and wound care. Concerns outside of the surgical site included sore throat from breathing tube, migraine, fever, and increased urination. Concerns at the biopsy site included fluid buildup where sentinel lymph nodes were removed.

Other physical concerns causing pain and distress for patients include the inability to engage in their “normal” activities, concerns around engaging in physical activity and not wanting to “overdo it”, increased fatigue and sleep issues, and medical concerns not related to cancer diagnosis, such as shingles.

Domain 2. Contributing factors to improvement of pain and distress

Patients shared that observing a general improvement of symptoms and side effects over time impacted their experience of pain and distress. Patients noted that issues related to sleep, pain, and anxiety have all improved, contributing to improved pain and distress scores.

Discussion

The purpose of this study was to determine the incidence and trajectory of distress, pain, and post-operative nausea and vomiting at baseline and post-operative day (POD) 1 and 14 following breast-conserving surgery.Our analysis underscores the importance of assessment and treatment of symptoms such as distress and pain following breast-conserving surgery. The majority of the participants reported levels of clinically relevant levels of distress greater than 4 (84.2%, n = 64) on postoperative day 1. On post-operative day 14, only 42% (n=26) of the participants reported a distress score of 4 or more. However, the large SD relative to the mean, for distress on POD1 and POD14, demonstrates that there is a considerable divergence of the levels of distress. These results demonstrate the variability in severity and the importance of assessment of patients experiencing and at high risk for severe distress symptoms in alignment with the current literature (Bruce et al., 2012; Killelea et al., 2018; Montgomery et al., 2010; Schreiber et al., 2019).

The inclusion of the problem list allowed participants to report aspects of their lives contributing to their levels of distress. A notable result was that the number of participants who depression increased between POD 1 and POD 14 and the number of participants who reported concepts related to “anxiety” (“nervousness” and “worry”) decreased between POD 1 and POD14. These results are in alignment with research on patients following breast cancer surgery demonstrating 33% of the participants reporting moderate to severe depression and 18% of the participants reporting severe anxiety(Karabulut Gul et al., 2023). This notable difference provides further guidance for developing and evaluating interventions targeting anxiety at POD1 and depression at POD14. In addition, over one-third of the participants described fatigue and sleep and swelling as problems at POD14, which represent additional symptoms for future researchers to explore and target.

Given the invasiveness of the surgery, mild levels of pain were an expected outcome; however, about one-third (38.7%, n = 29) experienced moderate to severe pain in the post-anesthesia care unit (PACU) on POD0. Furthermore, about one-eighth of the participants experienced severe pain (12%, n = 9). Also notably, 34% of the participants continued to identify pain as a problem at POD14, only a small decrease from the 38% who identified pain as a problem at POD1. Other researchers (Lötsch et al., 2018) have found that patients who experience higher levels of pain during the postoperative period are at higher risk of persistent and chronic pain, which supports the importance of identifying this higher risk population and providing effective interventions to treat their pain to help reduce long-term sequelae. Although the literature reported the frequency of pain varying between 9% and 94%, these results are in alignment with a similar sample of patients that reported 30% of a similar sample experienced pain 2 weeks after surgery (Schreiber et al., 2019). Furthermore, in the same study, almost 10% continued to experience pain 9 months after surgery (Schreiber et al., 2019). As health care providers move away from opioids to treat pain, the necessity of pain assessment and the importance of multimodal treatment of pain increases to ensure patient’s pain is being adequately managed. This ongoing pain may reduce mobility and social interaction and hinder a patient’s ability to fully recover from surgery and prepare for the next treatment phase. Furthermore, at home, one-third of patients reported pain as causing distress, which could also be related to concern over the pain being more severe than expected.

Only one woman reported postoperative nausea and vomiting (3%), which represents a much lower rate than the rate of nausea in this population reported by other researchers, with expected rates as high as 30% (Wesmiller et al., 2017, 2023). This encouraging result may reflect the implementation of standardized enhanced recovery protocols targeting PONV that included muti-modal intraoperative anti-emetics in high-risk patients undergoing outpatient surgeries (Majumdar et al., 2019, 2021, 2022).

The Distress Thermometer Problem List identified problems outside cancer affecting distress in this population that health care providers can address. Notably, about 20% of the participants reported problems with constipation, work/school, appearance, transportation, memory/concentration, and “COVID-19 concerns”. “Covid-19 concerns” was a relevant issue to this population and may have been higher because the study was conducted in a major metropolitan area at the center of the pandemic. By asking specific questions and bringing up these issues, providers can help patients deal with ongoing issues that patients may not feel is relevant to their health care providers. Even expressing concern about these issues and revealing to patients that these problems causing distress are expected may relieve some of the distress, discomfort, or fear related to unexpected side effects of surgery or medication. Furthermore, many issues may have relatively simple solutions; however, if providers do not know patients are experiencing these problems, they cannot help patients obtain relief.

Study Limitations

The study was completed at a single location; however, the sample included participants from multiple surrounding states. A longer longitudinal follow-up would provide additional data points to evaluate the severity of symptoms to target interventions. The participants only included women who could read and write in English and were computer literate. Finally, the Distress Thermometer only captured one element of a complicated set of psychological reactions, and a different instrument may have provided a complete understanding of the experience. However, the Distress Thermometer was a simple, already well-known instrument that reduced the respondent burden.

Implications for Nursing

The results provide vital information for oncology nurses that should influence and improve current nursing practice in three major categories: identification, assessment, and implementation. First, the results identify for clinician’s providing care for the population the incidence and severity of symptoms.. Second, the results provide guidelines for the additional assessment of symptoms outside of the standard periods. Finally, the results provide guidance for symptoms to target for interventions.

Participants in the study population faced physical, psychological, social, and logistical issues as they recovered from breast cancer surgery. The study findings, supporting that a significant proportion of participants experience pain and distress throughout the initial treatment period, can be used to guide clinical practice. Identifying the frequency and severity of symptoms can be useful both for clinicians and patients to set appropriate expectations. Even the reassurance that a symptom such as distress preoperatively is common can provide comfort. In addition, many patients may be expecting little or no pain 24 hours or 2 weeks following surgery, but describing the incidence ahead of the surgical period can help them set proper expectations of their recovery and help in their planning for the recovery period.

Next, the study identified both symptoms and periods of time throughout the perioperative period that requires additional assessment. Patients experienced distress, pain, and additional symptoms outside hospitalization, indicating the importance of developing new methods to assess and treat symptoms in outpatient procedures. The majority of patients experienced moderate levels of distress 24 hours following surgery, demonstrating a time point during which distress is not routinely captured in nursing assessment. In addition, the results indicated that 34% of participants continued to identify pain as a problem on POD 14. These results confirm that although breast-conserving surgery is less invasive and more conservative than other options, patients continue to experience pain afterward, justifying further assessment and intervention beyond the immediate postoperative period. This ongoing pain may reduce mobility and social interaction and hinder a patient’s ability to fully recover from surgery and prepare for the next treatment phase. In current practice, all outpatients receive a phone call from the institution 24 hours after surgery. This phone call could serve as an ideal time to assess distress and pain levels and provide resources if the patient reports high levels. This assessment also needs to employ standardized and validated measures that capture distress and pain, facilitating interventions.

Finally, the results demonstrate additional areas for implementation of evidence-based interventions to manage untreated pain, nausea, and distress. Most patients do not see their surgeons for follow-up until several weeks after surgery, when many symptoms may have already resolved themselves. However, although symptoms may resolve prior to follow-up, the extended experience of symptoms may increase anxiety when the woman needs future surgeries.

Conclusion

Following breast conserving surgery, women experience pain and distress while recovering at home. Oncology nurses can utilize the results of this study to apply evidence-based practice to reduce the symptom burden in this population. Future nursing research should focus on developing innovative targeted interventions that can be utilized outside of the hospital setting.

Table 2.

Themes from open-ended survey questions

Domain 1: Contributing factors to pain and distress
Theme Illustrative quotations
Family concerns “My biggest cause of distress is my dysfunctional nuclear family. Receiving a breast cancer diagnosis in the midst of having an upheaval with them wasn't great. It also caused issues between my partner and me.” – Patient 5

“My husband has chronic but stable health issues. I am concerned about being able to help him with his treatment issues. I plan to take it one step at a time and do the best I can.” – Patient 16
Fears and worries “Very anxious about having cancer. The word has always frightened me. Lost a close friend to breast cancer when she was 41.” – Patient 35

“My only concern was trying to deal with the radiation process and the sides effects that can occur. I was nervous about the breast incision/scar but when I saw it, my surgeon did an amazing job.” – Patient 18

“Mainly worried about lymphedema and future cancer appearing.” – Patient 10

“Having difficulty coping with giving up my career because I am scared to death to work with teenagers during a pandemic while waiting for radiation treatments.” – Patient 60
Post-operative issues “Fluid buildup from lymph node biopsy is uncomfortable Can't find comfortable, supportive bra and COVID-19 makes it harder.” – Patient 30

“Was not prepared for the level of wound care required. I felt underprepared and had to rely on phone calls and portal conversations. I was not prepared for what my breast looked like and how much tissue was exposed.” – Patient 69
Other physical concerns “I miss doing yoga but don't want to overdo it.” – Patient 65

“Had difficulty falling asleep and staying asleep. Would reach for my iPad even though I knew it was counterproductive.” – Patient 21
Domain 2: Contributing factors to the improvement to pain and distress
Theme Illustrative quotations
Observed improvement of symptoms and side effects over time “I feel good, almost like this never happened.” – Patient 3

“Feeling much better this week after doctors follow up visit. Still some swelling underarm but has greatly improved.” – Patient 40

“The sleep issues were concerning but they have stopped.” – Patient 74
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Knowledge Translation: Include three points indicating new knowledge or cutting-edge practice innovations that may influence practice.

  • On postoperative day one, most women experienced moderate levels of distress, a previously underrecognized time period of symptom severity.

  • One in three women continue to experience pain two weeks following breast conserving surgery, demonstrating the need for multimodal interventions.

  • Future research should develop targeted interventions to reduce distress in patients recovering from breast conserving surgery and other populations awaiting diagnostic test results.

Financial support and sponsorship

This work was supported in part by the National Institutes of Health/National Cancer Institute (NIH/NCI) with a Cancer Center Support Grant to Memorial Sloan Kettering Cancer Center [P30 CA008748], the Leslie B. Tyson Nursing Research Award, and the GERI and Me Nursing Grant.

Footnotes

Conflicts of interest

There are no conflicts of interest.

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