Recovery Clinical Trial
Official title:
An Interpretative Phenomenological Analysis of 'Recovery' Following Complete Cytoreductive Surgery.
Complete cytoreductive surgery (CCRS) is an extensive, and potentially curative, procedure
utilised for peritoneal malignancies including Pseudomyxoma peritonei (PMP). This study aims
to provide a nuanced understanding of the lived experience of recovery following CCRS over
time, with the view to inform future supportive measures for CCRS patients in particular.
This study also provides the opportunity to longitudinally examine patient perceptions of
'recovery' in the context of major illness and/or treatment; i.e. what it is to experience
recovery, what is important during recovery, perhaps how this changes over time, and what it
is to be 'recovered', if this is possible. A greater understanding of the term may have
implications in how it is used, or how patients following major illness are approached by
healthcare professionals.
Interpretive Phenomenological Analysis (IPA) will be utilised as the guiding methodology in
order to answer the study objectives. Potential participants will be approached by the
clinical nurse specialist (CNS) involved in the patient's care, and will be offered a
'research study pack', containing a participant information sheet (PIS). A maximum of ten
consenting participants will be interviewed on up to six occasions (although only five are
planned) across a timeframe of little more than a year, both before and after their surgery.
Interviews may take place face-to-face, or via telephone. Data analysis will involve a
cyclical process of identifying patterns within the interview transcripts of each participant
at each time point, across time points, and between participants. This design will provide an
effective means of gathering and analysing rich data from each participant, thus affording a
comprehensive insight into the meanings that participants attribute over time to their
recovery following CCRS.
This study has been devised in partial fulfilment of a doctorate degree at the University of
Southampton.
Complete cytoreductive surgery (CCRS), an extensive procedure increasingly used to treat, and
potentially cure, advanced cancers of the peritoneal cavity, including Pseudomyxoma Peritonei
(PMP). In a process that can last fourteen hours a typically sizeable number of peritoneal
organs or tissues (upon which cancerous cells present) are targeted for tumour nodule
removal, or are resected or excised. CCRS is concluded by the administration of hyperthermic
intraperitoneal chemotherapy (HIPEC), a warm chemotherapy solution which is gyrated across
the peritoneal cavity for one to two hours.
Despite the magnitude of the procedure, CCRS offers the potential of prolonged survival, or
indeed cure, particularly for those diagnosed with PMP. Accumulated 10-year survival rates
for 1904 PMP patients after CCRS, in countries including the United Kingdom (UK), indicated
survival rates of 74%.
Empirical studies conclude that 'recovery' from the procedure, to preoperative or reference
population quality of life scores, across the domains of physical, emotional and psychosocial
health, typically occurs 3 - 12 months postoperatively. Notably, however, the dominant
paradigm of inquiry adopted in this field is positivist, with survey work accounting for
31/36 of the fully published studies located through a systematic literature search to have
examined the impact of CCRS on patients. Such work is limited in its ability to explicate the
personal meaning that people may attribute to their lived experience of recovery. Moreover,
the remaining five studies have not acquired an understanding of personal meaning over time,
across the course of postoperative recovery, in what is likely to be a profound example of
postoperative experience with implications beyond those highlighted by positivistic work.
This study aims to fill this gap in the knowledge base by providing a nuanced understanding
of the lived experience of recovery over time, from the perspective of patients who have
undergone CCRS surgery, with the view to inform future supportive measures for CCRS patients
in particular.
There is also a secondary motive for conducting this study.
Recovery is a term used frequently in literature to describe the process that CCRS patients
undergo. On occasion, authors insinuate that their study participants (or at least some)
experience a complete recovery.
However, the dictionary definition of recovery is 'a return to a normal state of health,
mind, or strength', and it is perhaps questionable whether such a definition applies a
completely adept description to patients who have experienced CCRS, or indeed any major
illness, injury or treatment. Do survivors ever truly recover? Is it not a 'new normal' to
some degree? There are increasing reasons to doubt that the definition holds true in such
cases, on physical, emotional or psychosocial bases.
For instance, many examples of literature within the field of survivorship following major
illness such as cancer, seem to indicate that many survivors continue to experience issues
pertaining to their illness, even years after it is diagnosed or treated. Foster et al.
(2009) found that 20-30% of survivors, five or more years after their treatment, consistently
reported problems associated with cancer and its treatment. Elliott et al. (2011) found in an
online survey of 4892 individuals, of whom 780 were cancer survivors, that survivors 'were
significantly more likely to report poor[er] health outcomes … than those with no history of
cancer or a chronic condition' (p11). These works are quantitative in nature, and it may be
that qualitative work, particularly as it increases in number, will highlight further changes
that distinguish survivor's lives from their pre-illness lives. Ohlsson-Nevo (2011) for
example, lead with the theme that 'life is normal, and yet not' to describe the experiences
of colorectal cancer survivors.
Given the potential that many do not experience a recovery in the full sense, Foster and
Fenlon (2011) and Horikoshi and Futawatari (2017) speculate that cancer survivor experiences,
in particular, are more akin to a process of adaptation such as that necessitated by chronic
illness (previously discussed by the 'biographical disruption' work of Bury (1991), Charmaz
(1991) Dorsett (1991) and Frank (1997)).
This study provides the opportunity to longitudinally examine patient perceptions of the
concept of 'recovery': How do survivors of major illness or treatment define recovery as a
term, both as a process and as an outcome? Do such perceptions change over time? Even if they
are physically, emotionally or psychosocially 'recovered', do survivors think or live their
lives differently as a result of their experiences? In what ways do people not recover? Do
they consider themselves as recovered?
In conclusion, this study seeks a longitudinal and detailed understanding of the experience
of recovery from CCRS, beyond that currently recognised by empirical work. This will be
useful in informing supportive measures for CCRS patients as they 'recover', and furthermore
will increase our understanding of recovery as a concept.
The study utilises interpretive phenomenological analysis (IPA) as a methodological
framework, which is suitable in meeting such objectives in light of its three core
principles. In being phenomenological, this study acknowledges that the study of lived
experience is a valid means of understanding the recovery process. It encourages the
researcher to suspend their preconceptions as much as possible and to be fully receptive and
inquisitive to the experience as it is conveyed. In being hermeneutical, this study
acknowledges that researcher-led interpretation is necessary in fully understanding lived
experience, particularly in the context of the sensitive timeframe in which the research will
be performed, and in bringing to light the temporal changes that may occur as the study
progresses. Lastly, in being idiographic, this study recognises that individual lived
experiences of recovery following CCRS are likely to be unique and rich, and deserve in-depth
consideration. It also acknowledges that literature exists in the field, and that this may be
re-evaluated in the light of in-depth findings. An in-depth understanding of the experiences
of CCRS patients as they 'recover' from their surgery, and the meanings of 'recovery' to them
during this time, should therefore be attained through the use of IPA.
This study will implement a longitudinal interview-based design with sequential data
collection points running over an approximate 12-14 month period.
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