Evidence-Based Practice for the Management of Musculoskeletal Symptoms in Breast Cancer Patients Undergoing Endocrine Therapy: A Multicultural Perspective
Phase: NA
Conditions: Breast Neoplasms, Aromatase Inhibitor-Associated Musculoskeletal Symptoms (AIMSS)
Sponsor: Yuling CAO

1
Official Title: Evidence-Based Practice Research on the Management of
Musculoskeletal Symptoms in Breast Cancer Patients Undergoing
Endocrine Therapy from a Multicultural Perspective
NCT Number: Pending
Document Date: April 17, 2023
Document Type: Study Protocol

Musculoskeletal Symptom Management Protocol
School of Nursing, Fudan University
2024.10.31

Table of Contents
1. Research Background
2. Research Objectives (Why)
3. Research Design
4. Intervention Plan
(1) Intervention Objectives
(2) Target Population (Who)
(3) Intervention Timing (When)
(4) Intervention Location (Where)
(5) Intervention Strategies
5. Intervention Content (What)
(1) Self-Monitoring and Reporting
(2) Diet and Nutrition Management
(3) Exercise and Rehabilitation
(4) Medication Adherence Management
6. Intervention Evaluation (How) — Evaluation Indicators and Tools
7. Intervention Process
8. Research Schedule
9. Appendix
(1) General Information Survey
(2) Modified Score for the Assessment and Quantification of Chronic Rheumatic
Affections of the Hands (M-SACRAH)
(3) Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)
(4) Informed Consent Form
(5) Knowledge, Attitude, and Practice (KAP) Survey
(6) Interview Guide
10. Attachments
(1) Patient Health Education Handbook
(2) Expert Review Scoring Form
11. References

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1. Research Background
With the continuous rise in global breast cancer incidence, the treatment and
management of breast cancer have become major research topics in the medical field.
Endocrine therapy is a common treatment for patients with hormone receptor-positive
breast cancer; however, this treatment is often accompanied by side effects, such as
musculoskeletal symptoms (e.g., pain and stiffness), which significantly impact
patients' quality of life. Furthermore, symptom management varies markedly across
different cultural backgrounds, influenced by local healthcare resources, nursing
practices, and cultural factors. Consequently, effectively addressing musculoskeletal
symptoms induced by endocrine therapy within a multicultural context has become an
urgent challenge.
To tackle this issue, the Evidence-Based Nursing Center at Fudan University has
launched the "Evidence-Based Practice Project for Managing Musculoskeletal
Symptoms in Breast Cancer Patients Undergoing Endocrine Therapy from a
Multicultural Perspective." This project aims to improve symptom management for
breast cancer patients across various cultural backgrounds through the clinical
application of scientific evidence, thereby enhancing the quality of nursing care.
Based on implementation science, this study explores how to effectively apply and
disseminate evidence-based nursing strategies in different regions and cultural
environments, fostering cross-cultural healthcare cooperation and advancing the
global optimization of breast cancer patient care.
2. Research Objectives (Why)
This study aims to identify best practices for managing musculoskeletal symptoms in
breast cancer patients undergoing endocrine therapy within a multicultural context
through a multi-center, parallel, randomized controlled implementation study. It also
seeks to evaluate the translation and application of scientific evidence across different
cultural backgrounds.
The specific objectives are as follows:
2.1 To investigate the current incidence of musculoskeletal symptoms among breast
cancer patients undergoing endocrine therapy in Shanghai (China), Dali (Yunnan,

2
China), and Jakarta (Indonesia), and to assess the knowledge, attitudes, and practices
(KAP) of oncology nurses in symptom management in these locations.
2.2 To conduct a multi-center, parallel, randomized controlled study guided by
implementation science, evaluating the effectiveness of interventions in managing
musculoskeletal symptoms for breast cancer patients undergoing endocrine therapy
across different cultural contexts. This study will also validate the translation of
scientific evidence in multicultural settings and explore the feasibility and scalability
of the interventions across diverse cultural and healthcare systems.
3. Research Design
This study employs a simple randomized controlled trial (RCT) design to assess the
effectiveness of musculoskeletal symptom management in breast cancer patients
undergoing endocrine therapy from a multicultural perspective.
3.1 Sample Size
The primary measurement tool for this study is the Western Ontario and McMaster
Universities Osteoarthritis Index (WOMAC), used to assess aromatase
inhibitor-related musculoskeletal symptoms in breast cancer patients. The sample size
estimation is based on effect size and standard deviation data from previous studies,
with a significance level of α=0.05 and a statistical power of 80%. The calculated
effect size is 0.78. Based on these parameters, each group requires 26 patients, with
an additional 20% to account for potential attrition, resulting in a total of 33 patients
per group.
Each research site will thus recruit 33 patients for both the intervention and control
groups.
3.2 Sampling Method
Patients will be screened and recruited on a consecutive enrollment basis, meaning
that all patients meeting the inclusion criteria will be enrolled sequentially during the
study period until the predetermined sample size is reached.
Upon enrollment, each patient will undergo a comprehensive baseline assessment,
and the research team will ensure that patients understand the study’s details and
voluntarily sign informed consent forms. After enrollment, patients will be assigned

3
to either the intervention or control group based on a computer-generated random
sequence. The intervention group will receive a management program for
musculoskeletal symptoms, while the control group will receive standard care.
3.3 Allocation Concealment
To prevent allocation bias, this study uses an allocation concealment technique. The
randomization sequence will be managed by an independent third party, ensuring that
the clinical research team is unaware of patient group assignments prior to allocation.
In practice, the randomization results will be sealed in opaque envelopes, which will
be opened by independent personnel after each patient’s enrollment to determine
group allocation. This blinding method minimizes potential bias and interference
during study implementation.
4. Intervention Plan
4.1 Intervention Objectives
4.1.1 Patient Outcomes

Target Population: Patients undergoing endocrine therapy following
early-stage breast cancer surgery.

Intervention Duration: The intervention will last for 6 months, with regular
follow-up and symptom assessment.

Expected Outcomes: Through intervention, patients' musculoskeletal
symptoms (e.g., pain, stiffness) are expected to significantly improve, with a
corresponding improvement in quality of life.
4.1.2 Practitioner Outcomes

Target Population: Nurses and clinical practitioners involved in managing
musculoskeletal symptoms in breast cancer patients.

Assessment Tool: The “Survey on Nurses' Knowledge, Attitude, and Practice
(KAP) Regarding Musculoskeletal Symptom Management in Breast Cancer
Patients Undergoing Endocrine Therapy in a Multicultural Context.” Pre- and
post-intervention comparisons will be conducted to assess knowledge,
attitudes, and practice skills.

4

Expected Outcomes: Nursing staff will demonstrate significant
improvements in knowledge, beliefs, and practical skills in managing
musculoskeletal symptoms, promoting evidence-based nursing practices.
4.1.3 System Outcomes

Expected Outcomes: This study aims to optimize and standardize the
management processes for musculoskeletal symptoms related to endocrine
therapy in breast cancer patients. By developing a standardized management
protocol, we expect to improve the quality and efficiency of clinical nursing,
supporting the advancement and optimization of clinical nursing systems.
4.2 Intervention Participants (Who)
4.2.1 Target Population
Patients undergoing endocrine therapy after early-stage breast cancer surgery.

Inclusion Criteria:
o
Pathologically confirmed hormone receptor-positive (HR+) breast
cancer patients.
o
Aged 18 years or older.
o
Currently receiving aromatase inhibitor therapy (e.g., anastrozole,
letrozole, exemestane) for at least 6 months.
o
Reports musculoskeletal symptoms induced by endocrine therapy
before enrollment.
o
Capable of understanding the study and willing to sign informed
consent.

Exclusion Criteria:
o
Patients with a history of fracture or surgery within the past 6 months.
o
Patients diagnosed with arthritis (e.g., rheumatoid arthritis).
o
Patients diagnosed with osteoporosis according to WHO criteria
(T-score ≤-2.5).
o
Patients with recurrent or metastatic breast cancer.
o
Patients with other primary malignancies.
o
Patients with severe heart, brain, liver, or kidney dysfunction, or
infectious diseases.

5
o
Patients with severe mental, cognitive, or behavioral disorders that
hinder understanding or participation in the study.
4.2.2 Intervention Team

Nursing Manager (1): Responsible for human resource management, task
allocation, and nursing supervision within the intervention team.

Project Coordinator (1): Manages project progress, coordinates
communication and cooperation among departments, and ensures adherence to
the study plan.

Recruitment, Intervention, and Follow-Up Staff (2-3): Responsible for
patient recruitment, intervention implementation, and follow-up management,
including patient enrollment, intervention execution, and periodic follow-up to
ensure data collection and sustained patient participation.
4.3 Intervention and Follow-Up Duration (When)
This study includes a baseline survey, a 3-month intervention period, and a 3-month
follow-up period, for a total duration of 6 months.
4.4 Intervention Location (Where)
4.4.1 Research Centers

Shanghai, China: Comprehensive Treatment Outpatient Clinic, Fudan
University Cancer Hospital

Dali, China: Breast Oncology Outpatient Clinic, First Affiliated Hospital of
Dali University

Jakarta, Indonesia: Breast Oncology Department, Dharmais Cancer Hospital
4.4.2 Intervention Implementation Sites
(1) Medical Institutions
At each research center, the intervention team implements the following measures:

Patient Training: Nurses provide personalized, face-to-face training to help
patients understand musculoskeletal symptoms related to endocrine therapy
and their management. Training content includes practical self-management
skills, such as pain monitoring, medication side effect management, and
guidance on diet and exercise.

6

Regular Assessment: Nurses guide patients to attend regular hospital
assessments of musculoskeletal symptoms during the intervention and
follow-up periods. Standardized assessment tools are used to document
symptom changes, and treatment plans are adjusted accordingly based on the
results.
(2) Home-Based Self-Management
Patients follow the intervention plan for self-management in their daily lives,
including the following components:

Self-Monitoring: Regularly record musculoskeletal symptoms, such as pain
intensity and stiffness.

Health Management: Follow the intervention guidance provided by nurses
for daily exercise, dietary adjustments, and medication management to ensure
consistent intervention adherence and continuous monitoring and control of
symptoms.

Data Feedback: Patients regularly submit self-management records to the
medical team for ongoing evaluation and adjustments.
4.5 Intervention Strategies
In this study, all research centers provide the same symptom management materials,
but each center uses different media formats based on local resources and cultural
context.
4.5.1 Shanghai and Dali, China
Patients manage their musculoskeletal symptoms through an app platform designed
by the research team. The app offers symptom management materials across four
main modules: Self-Monitoring and Reporting, Diet and Nutrition Management,
Medication Adherence Management, and Exercise and Rehabilitation. Patients can
record symptom changes, medication side effects, and daily diet and exercise plans on
the platform. The nursing team provides personalized feedback and guidance through
the platform, ensuring effective implementation of the intervention and continuous
monitoring of patients’ symptom management.
4.5.2 Jakarta, Indonesia
In Jakarta, the intervention is conducted offline. The nursing team provides patients

7
with the same symptom management content as the Chinese research centers,
including Self-Monitoring and Reporting, Diet and Nutrition Management,
Medication Adherence Management, and Exercise and Rehabilitation. Nurses
distribute written and audio materials, offering detailed guidance for home-based
self-management. Regular follow-ups and assessments are scheduled to ensure
effective intervention implementation and positive outcomes.
5. Intervention Content (What)
Table 1: Evidence Extraction Table
Category
Evidence
Grade
Risk
assessment
1. A thorough risk assessment of MS should be performed on the patient and
inform relevant risk factors
3b
2. Evaluation records should include age, BMI, hormone replacement therapy
history, paclitaxel chemotherapy history, tamoxifen treatment history, cancer
stage, date of last menstrual period, existing menopausal symptoms, or joint
related diseases (e.g., osteoarthritis, rheumatoid arthritis)
3b
Symptom
assessment
1. Commonly used assessment tools include the BPI-SF, M-SACRAH, PRAI,
BCPT-MS, AUSCAN, WOMAC and ect.
1b
Preventions
1. Bone mineral density testing is performed before aromatase inhibitor
treatment and once a year thereafter, and treatment with bisphosphonate or
denosumab is considered based on the evaluation results
5b
2. Instruct patients to take calcium and vitamin D supplements
5b
3. For patients without MS, routine education should be done to strengthen
patients' understanding of possible MS. Encourage the patient to participate in
exercise and manage weight
5b
4. Health education on the benefits and side effects of adjuvant endocrine
therapy should be strengthened to improve compliance with endocrine therapy
5b
Interventions
1. Symptomatic treatment with acetaminophen or non-steroidal
anti-inflammatory drugs
5b
2. Traditional Chinese medicine could be a treatment option
1a

8
3. Acupuncture is recommended to treat MS induced by aromatase inhibitors
1a
4. Night splinting and nonsteroidal anti-inflammatory drugs could be used to
relief carpal tunnel syndrome and stenosing tenosynovitis. If symptoms are
refractory to nonsurgical intervention, surgical intervention may be warranted
3b
5. Encourage moderate-intensity physical activity, 30 minutes a day, 5 times a
week
1a
6. A supervised exercise program, including aerobic exercise, resistance
training, or a combination of both, is recommended, and the exercise intensity
does not exceed 60% to 80% of the maximum heart rate, three times a week
for 30 minutes each time
1a
7. It is recommended to participate in yoga, Tai Chi, Health Qigong-Ba Duan
Jin or other activities
2b
Monitoring
1. Increase the frequency of MS monitoring and follow-up every 3 to 6 months
5b
Table 2: Audit Criteria Extraction Table
Evidence
Audit criteria
1. A thorough risk assessment of MS should be performed on the patient and
inform relevant risk factors
1. The nurse assesses the patient's
risk of MS, informs the relevant
risk factors, and records them.
2. Evaluation records should include age, BMI, hormone replacement
therapy history, paclitaxel chemotherapy history, tamoxifen treatment
history, cancer stage, date of last menstrual period, existing menopausal
symptoms, or joint related diseases (e.g., osteoarthritis, rheumatoid arthritis)
3. Commonly used assessment tools include the BPI-SF, M-SACRAH,
PRAI, BCPT-MS, AUSCAN, WOMAC and ect.
2. The nurse uses a professional
scale to assess the MS.
4. Bone mineral density testing is performed before aromatase inhibitor
treatment and once a year thereafter, and treatment with bisphosphonate or
denosumab is considered based on the evaluation results
3. The doctor tests the patient's
bone mineral density once a year
and gives treatment when
appropriate.
5. Instruct patients to take calcium and vitamin D supplements
4. The nurse instructs the patient
to take calcium and vitamin D
supplements.

9
6. For patients without MS, routine education should be done to strengthen
patients' understanding of possible MS. Encourage the patient to participate
in exercise and manage weight
5. The nurse delivers the patient
health education about MS.
7. Health education on the benefits and side effects of adjuvant endocrine
therapy should be strengthened to improve compliance with endocrine
therapy
8. Symptomatic treatment with acetaminophen or non-steroidal
anti-inflammatory drugs
6. The doctor prescribes
acetaminophen or non-steroidal
anti-inflammatory drugs,
traditional Chinese medicine,
acupuncture, night splinting
other treatments when
appropriate.
9. Traditional Chinese medicine could be a treatment option
10. Acupuncture is recommended to treat MS induced by aromatase
inhibitors
11. Night splinting and nonsteroidal anti-inflammatory drugs could be used
to relief carpal tunnel syndrome and stenosing tenosynovitis. If symptoms
are refractory to nonsurgical intervention, surgical intervention may be
warranted
12. Encourage moderate-intensity physical activity, 30 minutes a day, 5
times a week
7. The nurse instructs the patient
to participate in exercise.
13. A supervised exercise program, including aerobic exercise, resistance
training, or a combination of both, is recommended, and the exercise
intensity does not exceed 60% to 80% of the maximum heart rate, three
times a week for 30 minutes each time
14. It is recommended to participate in yoga, Tai Chi, Health Qigong-Ba
Duan Jin or other activities
15. Increase the frequency of MS monitoring and follow-up every 3 to 6
months
8. The nurse regularly monitors
patients for MS.
5. Intervention Content (What)
5.1 Self-Monitoring and Reporting
Nurses guide patients to record their status weekly using the "Patient Self-Monitoring
Record Form." The nursing team regularly collects this feedback data.

10
Table 3: Patient Self-Monitoring Record Form
Date
Type of
Musculoskeletal
Symptoms
Symptom
Location
Start and
End Time
Duration
VAS Score
Relief
Measures
Remarks
Note: VAS score ranges from 0 to 10, where 0 indicates no pain and 10 indicates
severe pain.
Instructions for Completion:

China (Shanghai, Dali): Patients enter self-monitoring data through the app
platform. By selecting “Symptom Monitoring” on the app, a musculoskeletal
symptom record form will automatically pop up. Patients enter information
sequentially to ensure accuracy and completeness. The system automatically
saves and submits data to the nursing team for timely evaluation and care plan
adjustments.

Indonesia: Patients use the "Patient Self-Monitoring Record Form" for manual
recording. Each week, they fill out the form, documenting symptom type,
location, start time, duration, VAS score, and relief measures. Patients submit
the completed form to the nursing team on time.
5.2 Diet and Nutrition Management
5.2.1 Daily Vitamin D Supplementation: It is recommended that patients take daily
vitamin D supplements.[1]

For patients aged 18 to 50 with limited sun exposure, a daily intake of
1500-2000 IU of vitamin D is advised.

For patients over 50, 1600-2000 IU is recommended to maintain serum
25(OH)D levels ≥30 ng/mL.[2]

11
5.2.2 Omega-3 Fatty Acid Intake: Patients are encouraged to consume foods rich in
omega-3 fatty acids[3] (e.g., salmon, flaxseed oil, fish oil supplements).
5.2.3 Weight Management for Obese Patients: Patients with obesity (BMI ≥30) are
advised to engage in weight management.[3]
5.3 Exercise and Rehabilitation
Patients are instructed to follow the standardized exercise and rehabilitation regimen[1,
4-6], with specific movements available in video format.
Figure 1: Exercise Demonstration Video Screenshots
Table 4: Standardized Exercise Rehabilitation Program
Aerobic Warm-up
Frequency: 5-7 times per week
Intensity: 60%-70% of maximum heart rate (220-age); RPE 3-4
Duration: 30-45 minutes
Repetitions: 5-10 times per set
Aerobic Warm-up for Young Group
Marching in place
Full-body stretch
Jumping jacks
Side steps with arm circles

12
Squat with alternating punches
Aerobic warm-up for the elderly group
Marching in place
Full-body stretch
Full-body stretch
Chest expansion exercise
Abduction exercise
Overhead reach
Lateral movement
Hip extension exercise
Calf raises
Functional Training
Frequency: 3-5 times per week
Intensity: RPE 3-4
Duration: 15-30 minutes
Repetitions: 8-12 times per set
Location
Content
Nerves, Muscles, Joints
Hand
Hand functional exercise
Quadriceps, Hamstrings,
Gastrocnemius, Soleus, Gluteus
Maximus, Hip Flexors
Wrist rotation
Flexor Carpi Radialis, Flexor
Carpi Ulnaris, Extensor Carpi
Radialis Longus, Extensor Carpi
Radialis Brevis
Arm
Active posterior deltoid stretch
Deltoid (posterior fibers)
Arm pull down stretch
Triceps Brachii, Latissimus Dorsi
Active triceps stretch
Triceps Brachii
Shoulder
Arm flexion with shoulder circles
Biceps Brachii, Deltoid, Rotator
Cuff muscles
Shoulder extension with reach
Deltoid, Latissimus Dorsi,
Trapezius
Hands behind head
Trapezius, Deltoid, Rhomboids
Prone Y extension
Trapezius, Rhomboids, Deltoids
Wall slides
Deltoids, Trapezius, Rotator Cuff
muscles
Hip and leg
Wall sit
Quadriceps, Hamstrings, Gluteus

13
Maximus
Standing left thigh stretch with
wall support
Quadriceps
Bent-over deadlift
Erector Spinae, Gluteus
Maximus, Hamstrings
Back
Lunge stretch
Quadriceps, Hamstrings, Gluteus
Maximus
Seated butterfly stretch
Adductor muscles, Sartorius
Flat back exercise
Erector Spinae, Rectus
Abdominis
Double knee to chest
Rectus Abdominis, Hip Flexors
Supine knee touch
Rectus Abdominis, Hip Flexors
Table 5: Exercise Demonstration Table
Major
Category
Sequence
Number
Body
Position
Exercise
Name
Exercise Image
Target Joint
Warm-Up for
Young Group
1
Frontal
Marching in
place
Shoulder, Hip,
Knee
2
Frontal
Full-body
stretch
Elbow,
Shoulder, Hip

14
3
Frontal
Jumping
jacks
Elbow,
Shoulder, Hip
4
Frontal
Side steps
with arm
circles
Elbow,
Shoulder, Hip
5
Lateral
Squat with
alternating
punches
Shoulder, Hip,
Knee
Warm-Up for
Elderly
Group
1
Frontal
Chest
Expansion
Exercise
Wrist, Elbow,
Shoulder

15
2
Frontal
Chest Stretch
Exercise
Elbow,
Shoulder, Hip
3
Frontal
Abduction
Exercise
Elbow,
Shoulder, Hip
4
Frontal
Overhead
reach
Elbow,
Shoulder, Hip
5
Frontal
Lateral
movement
Ankle, Hip,
Shoulder

16
6
Lateral
Hip
extension
exercise
Shoulder, Hip,
Knee
7
Lateral
Calf raises
Toe, Ankle,
Knee
Shoulder
Exercises
1
Frontal
Arm flexion
with
shoulder
circles
Elbow,
Shoulder, Hip

17
2
Frontal
Shoulder
extension
with reach
Wrist, Elbow,
Shoulder
3
Frontal
Hands
behind head
Elbow,
Shoulder, Hip
4
Frontal
Prone Y
extension
Elbow,
Shoulder, Hip

18
5
Frontal
Wall slides
Elbow,
Shoulder, Hip
Arm
Exercises
1
Frontal
Active
posterior
deltoid
stretch
Wrist, Elbow,
Hip
2
Lateral
Arm pull
down stretch
Elbow, Wrist,
Pinky Finger
3
Frontal
Active
triceps
stretch
Shoulder,
Elbow, Elbow
Hand
Exercises
1
Frontal
Hand
functional
exercise
Elbow, Wrist,
Finger

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2
Frontal
Wrist
rotation
Elbow, Wrist,
Pinky Finger
Body
Position
1
Lateral
Lunge
stretch
Ankle, Knee,
Hip
2
Lateral
Seated
butterfly
stretch
Shoulder, Hip,
Knee
3
Lateral
Flat back
exercise
Elbow,
Shoulder, Hip
4
Lateral
Double knee
to chest
Shoulder, Hip,
Knee

20
5
Lateral
Supine knee
touch
Shoulder, Hip,
Knee
Hip Exercises
1
Lateral
Wall sit
Hip, Knee,
Ankle
2
Lateral
Standing left
thigh stretch
with wall
support
Hip, Knee,
Ankle
3
Lateral
Bent-over
deadlift
Shoulder, Hip,
Knee
5.4 Medication Adherence Management
5.4.1 Guide patients to complete a weekly medication adherence assessment.[1]
Below is a line representing your adherence to prescribed endocrine medication over
the past week. A score of 0% indicates no medication taken, while 100% indicates
full adherence to the prescribed dose. Please mark "√" at the point on the line that best
reflects your medication intake.

21
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
5.4.2 The nursing team conducts biweekly telephone follow-ups during the
intervention period and monthly telephone follow-ups during the follow-up
period.[7, 8] The specific follow-up content is as follows:
(1) Self-Monitoring and Reporting

Do you regularly record changes in musculoskeletal symptoms?
Never (0) | Occasionally (1) | Often (2) | Always (3)

Do you encounter any difficulties or uncertainties when recording?
No (0) | Occasionally (1) | Often (2) | Always (3)

What was your most recent VAS score (0-10)?
Specify a score (0-10)

Has there been any change in symptoms?
No change (0) | Slight change (1) | Significant change (2) | Severe change (3)

What relief measures have you used, and how effective were they?
None (0) | Poor (1) | Moderate (2) | Good (3)

Have you experienced any new symptoms or worsening of existing symptoms?
No (0) | Slight worsening (1) | Significant worsening (2) | Severe worsening
(3)
(2) Diet and Nutrition Management

Has there been any change in your recent dietary habits?
No change (0) | Slight change (1) | Significant change (2) | Severe change (3)

Is your daily diet balanced?
Very unbalanced (0) | Unbalanced (1) | Balanced (2) | Very balanced (3)

Have you been taking supplements?
None (0) | Occasionally (1) | Often (2) | Daily (3)
(Follow up with specific types and dosages of supplements)

Are there any difficulties or questions regarding dietary management?
None (0) | Slight difficulty (1) | Moderate difficulty (2) | Severe difficulty (3)
(3) Exercise and Rehabilitation

Do you follow the recommended exercise program?
Never (0) | Occasionally (1) | Often (2) | Always (3)

22

Is the frequency and intensity of your exercise appropriate?
Not appropriate (0) | Fairly appropriate (1) | Appropriate (2) | Very appropriate
(3)

Do you experience discomfort or worsening of symptoms after exercise?
No discomfort (0) | Mild discomfort (1) | Moderate discomfort (2) | Severe
discomfort (3)

Do you feel fatigued after exercising?
Never (0) | Occasionally (1) | Often (2) | Always (3)

Do you need to adjust your exercise plan?
No adjustment needed (0) | Slight adjustment (1) | Moderate adjustment (2) |
Major adjustment (3)
(4) Medication Adherence Management

Do you take your medication on time and at the correct dose?
Never (0) | Occasionally (1) | Often (2) | Always (3)

Have you missed or incorrectly taken any doses?
No (0) | Occasionally (1) | Often (2) | Always (3)

Have you experienced any side effects from the medication, and did they
impact your adherence?
No side effects (0) | Mild side effects (1) | Moderate side effects (2) | Severe
side effects (3)

Have you interrupted endocrine therapy, and if so, what was the reason?
No interruption (0) | Occasionally (1) | Often (2) | Completely stopped (3)
(5) Referral

Have any abnormal symptoms or other health issues been detected during
monitoring?
None (0) | Mild abnormality (1) | Moderate abnormality (2) | Severe
abnormality (3)

Do you need to consult a doctor or undergo further testing?
No need (0) | Possibly needed (1) | Needed (2) | Urgently needed (3)
(If symptoms worsen or become uncontrollable, a referral to a relevant
department is recommended.)

23
6. Intervention Evaluation
Table 6: Evaluation of Intervention Effectiveness
Assessment
Tools
Baseline
T0
Intervention
Period
Follow-up
Period
M1
M2
M3
M4
M5
M6
General Information
Baseline Survey Form
✅
❌
❌
❌
❌
❌
❌
Biomarker - Bone
Density
Dual-Energy X-ray
Absorptiometry (DXA)
Scanner
✅
❌
❌
❌
❌
❌
✅
Grip Strength
Digital Hand Grip
Dynamometer
✅
✅
❌
✅
❌
❌
✅
Joint Function
WOMAC, M-SACRAH
✅
✅
❌
✅
❌
❌
✅
Intervention Implementa
tion Status
Review Indicators
✅
✅
❌
✅
❌
❌
✅
Practitioner Knowledge,
Attitude, and Practice
(KAP)
Questionnaire
✅
❌
❌
❌
❌
❌
✅
System Outcomes
Interview Guide
✅
❌
❌
❌
❌
❌
✅
Patient Intervention
Adherence
Follow-Up
Record Form
✅
❌
❌
✅
❌
❌
✅
Practitioner Compliance
Rate
Review Indicator Recor
d Form
✅
❌
❌
✅
❌
❌
✅
【Biomarker - Bone Density】
At months 0 and 6 of the intervention, bone density will be measured using
Dual-Energy X-ray Absorptiometry (DEXA). DEXA is widely recognized as the gold
standard for bone density assessment due to its high precision and reliability, making
it extensively used in clinical diagnosis and research. The primary measurement sites
include the lumbar spine and femoral neck, which reflect bone mineral content and
overall bone health.
According to the World Health Organization (WHO) bone density diagnostic
criteria[9], the T-score ranges are as follows:

Normal: T-score ≥-1

Low Bone Mass (Osteopenia): T-score between -1 and -2.5

Osteoporosis: T-score ≤-2.5

24
【Grip Strength】
Grip strength will be measured at months 0, 1, 3, and 6 by the exercise team. This
measurement primarily evaluates the forearm flexor and hand muscles, representing
forearm muscle strength. An electronic handgrip dynamometer will be used. The
subject stands with arms relaxed and hanging down, palms facing the thighs, and the
dominant arm (non-surgical side) abducted to a 30-degree angle. The participant grips
the dynamometer without swinging the arm, squatting, or allowing the dynamometer
to touch the body. Each participant will undergo three assessments, with the highest
value used for analysis. A 60-second rest interval is provided between each
measurement. Reference standards for grip strength are based on normal values from
a large-scale national health survey in China.
Figure 2: Reference Standard for Grip Strength
【Audit Record Table】
Table 7: Audit Record Table
Serial
Number
Audit criteria
Compliance Status
Remarks
1
The nurse assesses the patient's risk of MS, informs the
relevant risk factors, and records them.
□Compliant
□Non-compliant
2
The nurse uses a professional scale to assess the MS.
□Compliant

25
□Non-compliant
3
The doctor tests the patient's bone mineral density once
a year and gives treatment when appropriate.
□Compliant
□Non-compliant
4
The nurse instructs the patient to take calcium and
vitamin D supplements.
□Compliant
□Non-compliant
5
The nurse delivers the patient health education about
MS.
□Compliant
□Non-compliant
6
The doctor prescribes acetaminophen or non-steroidal
anti-inflammatory drugs, traditional Chinese medicine,
acupuncture, night splinting other treatments when
appropriate.
□Compliant
□Non-compliant
7
The nurse instructs the patient to participate in exercise.
□Compliant
□Non-compliant
8
The nurse regularly monitors patients for MS.
□Compliant
□Non-compliant

26
7. Intervention Flowchart
Figure 3: Intervention Flowchart

27
8. Research Schedule
Table 8: Intervention and Follow-Up Schedule for Managing Musculoskeletal
Symptoms in Breast Cancer Patients
Phase
Duration
Follow-Up Frequency
1
Intervention
Initiation
November 2024 -
December 2024
/
2
Intervention Period
3 months
Weekly Telephone Follow-Up
3
Follow-Up Period
3 months
Biweekly Telephone Follow-Up
9. Appendix
9.1 Baseline Survey Form - Musculoskeletal Symptom Form
Dear Patients,
In order to better understand your condition during endocrine therapy and to help us provide you
with appropriate treatment and care, we have designed the following questionnaire to assess your
physical and psychological status. The information you provide will serve as a valuable reference
for clinical medical and nursing work. We kindly ask that you fill out the questionnaire thoroughly,
reflecting your true situation. Some questions may be completed by medical personnel on your
behalf.
We sincerely thank you for your participation, support, and cooperation!

There are no right or wrong answers. Please respond based on how you usually feel and
act.

Please fill out the form based on your actual situation.

For items with a □, please place a "√" in the appropriate box.
□Outpatient □Inpatient
Outpatient/Inpatient Number: ___________
Enrollment/Follow-up Date: ___________
Investigator's Signature: ___________
I. General Information
1.Gender:
□Male
□Female
2.Age: _______ years
3.Height: _______ cm
Weight: _______ kg

28
4.Religious Belief:
□None
□Buddhism
□Christianity
□Islam
□Other
5.Do you regularly participate in religious activities or prayer?
□Never
□Occasionally
□Sometimes
□Frequently
6.How much does your religious belief influence your lifestyle?
□No influence
□Slight influence
□Some influence
□Significant influence
7.Educational Level:
□Primary school or below
□Middle school
□Technical school/High school
□College/University
□Graduate degree or higher
8.Employment Status:
□Unemployed
□Part-time job
□Full-time job
□Retired
□Homemaker
9.Marital Status:
□Single
□Married
□Divorced
□
Widowed
10.Living Situation:
□Stable
□Unstable
□Homeless
11.Medical Expenses:
□Fully self-paid
□Mostly self-paid
□Partially self-paid
□No self-payment
12.Economic Pressure:
□None
□Slight
□Some
□Significant
13.Understanding of your disease:
□Not at all
□Slightly
□Somewhat
□Very well
II. Medical History
1. Diagnosis Date: _______ Year _______ Month
2. Surgical Approach: ________________________
3. Pathological Type: ______________ (e.g., ductal carcinoma, lobular carcinoma, ductal
carcinoma in situ, lobular carcinoma in situ, inflammatory breast cancer, mucinous carcinoma,
medullary carcinoma) (may consult healthcare professionals for completion)
4. Comprehensive Treatment Plan:
□Chemotherapy: ____________
□Radiotherapy: __________
□Targeted Therapy: __________
□Other: __________

29
5. Tumor Stage:
□Stage 0
□Stage I
□Stage II
□Stage III
□Stage IV
□Unclear
6. Endocrine Therapy Medication Currently Administered (please specify the detailed regimen on
the line below): __________
Start Date of Endocrine Therapy: __________
□Anastrozole
□Letrozole
□Exemestane
□Ovarian function suppression medication
□Other: __________
7. Do you have any other chronic diseases? (select all that apply):
□Hypertension
□Diabetes
□Coronary heart disease
□Other: __________
□None
III. Menstrual and Fertility Status
1.Time Since Last Menstruation: _______ years (If within one year, fill in 0.5 years)
IV. Dietary Habits and Nutrition
(1) Dietary Habits and Nutrition
1.Do you take dietary supplements (e.g., fish oil, calcium tablets, vitamin D, etc.)?
□Yes, type and dosage: __________
□No
(2) Behavioral Habits
1.Do you smoke?
□Yes
□Used to, but quit
□No
2.Do you drink alcohol?
□Yes
□Used to, but quit
□No
3.Exercise frequency:
□Daily
□3-4 times per week
□1-2 times per week
□Rarely exercise
4.Exercise intensity:
□Light activity
□Moderate activity
□Intense activity
(3) Sleep Situation
1.Sleep quality in the past month:
□Very good
□Fairly good
□Fairly poor
□Very poor
V. Medication Adherence
The following line represents how closely you followed your prescribed medication regimen in
the past week. 0% means you did not take any medication, and 100% means you took the full
amount as prescribed. Please place a "√" on the line at the point that best reflects your adherence.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%

30
VI. Symptom Assessment
Type of Musculoskeletal Symptoms: _________________
Please rate the musculoskeletal symptoms you are experiencing using the VAS score. Mark "√" at
the point on the line that best reflects your symptom score. (Note: VAS score ranges from 0 to 10,
where 0 indicates no pain and 10 indicates severe pain.)
0
1
2
3
4
5
6
7
8
9
10
Hand Symptoms and Function Assessment
Please select your answers based on your actual situation in the past 48 hours (with scores
increasing from 0 to 100):
1. Pain experienced while inactive:
□0
□10
□20
□30
□40
□50
□60
□70
□80
□90
□100
2. Pain experienced during intense work:
□0
□10
□20
□30
□40
□50
□60
□70
□80
□90
□100
3. Severity of stiffness upon waking in the morning:
□0
□10
□20
□30
□40
□50
□60
□70
□80
□90
□100
4. Severity of stiffness after sitting, lying down, or resting:
□0
□10
□20
□30
□40
□50
□60
□70
□80
□90
□100
5. Difficulty in opening/closing doors:
□0
□10
□20
□30
□40
□50
□60
□70
□80
□90
□100
6. Difficulty in buttoning/unbuttoning clothes:
□0
□10
□20
□30
□40
□50
□60
□70
□80
□90
□100
7. Difficulty in turning a faucet on/off:
□0
□10
□20
□30
□40
□50
□60
□70
□80
□90
□100
8. Difficulty in pulling up/down a zipper:
□0
□10
□20
□30
□40
□50
□60
□70
□80
□90
□100
9. Difficulty in tying shoelaces:
□0
□10
□20
□30
□40
□50
□60
□70
□80
□90
□100
10. Difficulty in opening a jar:
□0
□10
□20
□30
□40
□50
□60
□70
□80
□90
□100
11. Difficulty in turning pages of a newspaper:
□0
□10
□20
□30
□40
□50
□60
□70
□80
□90
□100
12. Difficulty in writing:
□0
□10
□20
□30
□40
□50
□60
□70
□80
□90
□100
Knee and Hip Joint Symptoms and Function Assessment
Please select your answers based on your actual situation in the past 48 hours (with scores
increasing from 0 to 100):
1. Intensity of knee or hip pain while ambulating on a flat surface:
□0
□10
□20
□30
□40
□50
□60
□70
□80
□90
□100

31
2. Intensity of knee or hip pain during stair ascent or descent:
□0
□10
□20
□30
□40
□50
□60
□70
□80
□90
□100
3. Intensity of knee or hip pain during nocturnal rest:
□0
□10
□20
□30
□40
□50
□60
□70
□80
□90
□100
4. Intensity of knee or hip pain while seated or in a supine position:
□0
□10
□20
□30
□40
□50
□60
□70
□80
□90
□100
5. Intensity of knee or hip pain while in an upright position:
□0
□10
□20
□30
□40
□50
□60
□70
□80
□90
□100
6. Severity of stiffness in the knee or hip upon waking in the morning:
□0
□10
□20
□30
□40
□50
□60
□70
□80
□90
□100
7. Severity of stiffness in the knee or hip following periods of sitting or rest during the day:
□0
□10
□20
□30
□40
□50
□60
□70
□80
□90
□100
8. Difficulty experienced during stair ascent:
□0
□10
□20
□30
□40
□50
□60
□70
□80
□90
□100
9. Difficulty experienced during stair descent:
□0
□10
□20
□30
□40
□50
□60
□70
□80
□90
□100
10. Difficulty in transitioning from a seated to a standing position:
□0
□10
□20
□30
□40
□50
□60
□70
□80
□90
□100
11. Difficulty while maintaining an upright position
□0
□10
□20
□30
□40
□50
□60
□70
□80
□90
□100
12. Difficulty in bending forward to reach the ground
□0
□10
□20
□30
□40
□50
□60
□70
□80
□90
□100
13. Difficulty while ambulating on a flat surface
□0
□10
□20
□30
□40
□50
□60
□70
□80
□90
□100
14. Difficulty in entering and exiting a vehicle or boarding a bus
□0
□10
□20
□30
□40
□50
□60
□70
□80
□90
□100
15. Difficulty experienced during shopping activities
□0
□10
□20
□30
□40
□50
□60
□70
□80
□90
□100
16. Difficulty in donning socks
□0
□10
□20
□30
□40
□50
□60
□70
□80
□90
□100
17. Difficulty in doffing socks
□0
□10
□20
□30
□40
□50
□60
□70
□80
□90
□100
18. Difficulty in rising from a supine position in bed
□0
□10
□20
□30
□40
□50
□60
□70
□80
□90
□100
19. Difficulty while lying in bed
□0
□10
□20
□30
□40
□50
□60
□70
□80
□90
□100
20. Difficulty in exiting a bathtub or bathroom
□0
□10
□20
□30
□40
□50
□60
□70
□80
□90
□100
21. Difficulty in transitions between sitting and standing

32
□0
□10
□20
□30
□40
□50
□60
□70
□80
□90
□100
22. Difficulty in rising from a toilet seat
□0
□10
□20
□30
□40
□50
□60
□70
□80
□90
□100
23. Difficulty in performing heavy household chores
□0
□10
□20
□30
□40
□50
□60
□70
□80
□90
□100
24. Difficulty in performing light household chores
□0
□10
□20
□30
□40
□50
□60
□70
□80
□90
□100
9.2 The WOMAC (Western Ontario and McMaster Universities) Index of
Osteoarthritis
Overview:
The WOMAC (Westren Ontario and McMaster Universities) index is used to assess
patients with
osteoarthritis of the hip or knee using 24 parameters. It can be used to monitor the
course of the disease or to determine the effectiveness of anti-rheumatic medications.
Pain:
(1) walking
(2) stair climbing
(3) nocturnal
(4) rest
(5) weight bearing
Stiffness:
(1) morning stiffness
(2) stiffness occurring later in the day Physical function:
(1) descending stairs
(2) ascending stairs
(3) rising from sitting
(4) standing
(5) bending to floor
(6) walking on flat
(7) getting in or out of car
(8) going shopping
(9) putting on socks
(10) rising from bed

33
(11) taking off socks
(12) lying in bed
(13) sitting
(14) sitting
(15) getting on or off toilet
(16) heavy domestic duties
(17) light domestic duties
While the index was being developed performance of social functions and the status
of emotional function were also included. These were not included in the final
instrument.
Social function:
(1) leisure activities
(2) community events
(3) church attendance
(4) with spouse
(5) with family
(6) with friends
(7) with others
Emotional function:
(1) anxiety
(2) irritability
(3) frustration
(4) depression
(5) relaxation
(6) insomnia
(7) boredom
(8) loneliness
(9) stress
(10) well-being

34
Scoring and Interpretation
Response
Points
none
0
slight
1
moderate
2
severe
3
extreme
4
Alternatively a visual analogue scale (VAS) may be used ranging from 0 to 10. score
=
= SUM(points for relevant items) average score =
= (total score) / (number of items) Interpretation:
• minimum total score: 0
• maximum total score: 96
• minimum pain subscore: 0
• maximum pain subscore: 20
• minimum stiffness subscore: 0
• maximum stiffness subscore: 8
• minimum physical function subscore: 0
• maximum physical function subscore: 68

35
9.3 Modified Score for the Assessment and Quantification of Chronic
Rheumatoid Affections of the Hands (M-SACRAH)
PART 1: DIFFICULTIES PERFORMING DAILY ACTIVITIES
Think about the difficulties you have had in the past 48 hours doing the following
physical daily activities because of your finger joint problems. This means your
ability to move easily and do things yourself. (Please mark each answer with an “X”
on the line.)
QUESTION: How difficult was it for you...
PART 2: STIFFNESS
Think about the stiffness (not pain) you have had in the past 48 hours because of your
finger joint problems. Joint

36
stiffness is normally experienced as a limitation or reduction in the mobility of
your joints.
(Please mark each answer with an “X” on the line.)
PART 3: PAIN
Think about the pain you have had in the past 48 hours because of your finger joint
problems.
(Please mark each answer with an “X” on the line.)

37
9.4 Informed Consent Form
Study Title:
Evidence-Based Practice Research on the Management of Musculoskeletal Symptoms
in Breast Cancer Patients Undergoing Endocrine Therapy from a Multicultural
Perspective
Lead Institution:
School of Nursing, Fudan University
Collaborating Institutions:
Fudan University Shanghai Cancer Center; Dali University Affiliated Hospital;
Dharmais Cancer Hospital (Indonesia)
You are being invited to participate in a clinical research study. This informed consent
form provides information to help you decide whether to participate in this clinical
study. Please read it carefully, and if you have any questions, do not hesitate to ask
the researchers responsible for the study.
Your participation in this study is entirely voluntary.
This study has been reviewed and approved by the Ethics Committee of the institution
conducting the research.
Background and Purpose of the Study:
The purpose of this study is to help breast cancer patients undergoing endocrine
therapy better manage musculoskeletal symptoms related to their treatment. By
analyzing the current symptom management practices of patients from tertiary
hospitals in Shanghai (China), Dali (China), and Jakarta (Indonesia), we aim to
develop and evaluate a series of personalized management plans. These plans include
strategies for self-monitoring and reporting, medication adherence, diet and nutrition,

38
exercise and rehabilitation, and health education, with the goal of improving patients'
symptoms and quality of life. Through evidence-based practice research, we hope to
implement these management plans in different regions and enhance the overall
quality of breast cancer care through cross-cultural collaboration. This study seeks to
provide targeted nursing support for patients and promote international nursing
cooperation along the Belt and Road Initiative.
Study Procedures:
If you agree to participate in this study, you will be asked to:
1. If technically feasible, download and use the intelligent symptom management
app provided by the research team.
2. Regularly record your musculoskeletal symptoms, including data such as pain
levels and quality of life.
3. If you are unable to use the app due to technical issues or other reasons, the
research team will provide paper records or telephone follow-ups as an
alternative.
4. This study will last for six months, with three months of intervention and three
months of follow-up. During the intervention phase, you will participate in the
symptom management plan, and during the follow-up phase, you will be
contacted for follow-up once a month.
5. Your participation is voluntary, and you may withdraw at any time without
impacting the medical care you are currently receiving.
6. Additional information: During the course of the study, new information
related to the research methods may emerge. If this occurs, your study
physician or nurse will inform you promptly and discuss whether you wish to
continue participating. If you decide to continue, you may be required to sign
a new informed consent form. During the follow-up phase, your physician or
nurse may contact you via text messages, phone calls, or clinic visits to check

39
on your condition.
Potential Benefits:
While we cannot guarantee direct health benefits from participating in this study, we
hope that the intelligent symptom management plan will help improve your ability to
manage musculoskeletal symptoms. Furthermore, your participation will contribute to
the development of better symptom management tools for other breast cancer patients
undergoing endocrine therapy.
Costs and Compensation:
There will be no additional medical costs incurred by participating in this study. The
research team will reimburse you for any transportation costs associated with
participating in the study. All expenses related to data collection and analysis will be
covered by the research team.
The research team will make every effort to prevent and address any harm caused by
the study. If adverse events occur, a medical expert committee will assess whether
they are related to the study. If deemed study-related, the sponsor will provide
compensation and cover any necessary medical treatment in accordance with relevant
regulations.
Information and Consultation:
You are free to ask questions about the study at any time, and these questions will be
addressed promptly. If new information arises during the study that might affect your
decision to continue participating, your doctor or nurse will notify you immediately.
Privacy and Data Confidentiality:
We will maintain strict confidentiality regarding all of your personal information. All
health data provided, including symptoms recorded through the app or other means,

40
will be stored anonymously on encrypted servers, accessible only to the research team.
Upon completion of the study, all data will be destroyed in accordance with legal and
ethical guidelines, and will not be used for other studies. Your privacy will be
protected to the fullest extent possible.
Right to Withdraw:
You have the right to withdraw from the study at any time, without it affecting the
breast cancer treatment you are currently receiving. Upon withdrawal, your data will
no longer be used and will be destroyed as per legal and ethical requirements. If you
wish to withdraw, please contact the research team at any time.
Contact Information:
If you have any questions or require further information regarding this study, you may
contact the lead researcher:
Cao Yuling (Phone:+86 13961102420; Email: caoyulingedu@163.com).
Consent Statement:
I have read and understood the information provided above, and the research team has answered
my questions.
I understand that participation in this study is voluntary, and I can withdraw at any time without
affecting my medical care.
I agree to participate in this study.
Participant's Name: ________________________
Participant's Signature: _________________________
Date：_______ Month _______ Day _______ Year

41
I have accurately explained this document to the participant, who has read the informed consent
form thoroughly and has been given the opportunity to ask questions.
Researcher’s Name：________________________
Researcher’s Signature：_________________________
Date：_______ Month _______ Day _______ Year
(Note: If the participant is legally incapacitated, a legal representative must sign.)
9.5 Questionnaire on Nurses' Knowledge, Beliefs, and Practices Regarding the
Management of Musculoskeletal Symptoms in Breast Cancer Patients
Undergoing Endocrine Therapy in a Multicultural Context
We are conducting a study on the differences in nurses' knowledge, attitudes, and
practices regarding the management of musculoskeletal symptoms in breast cancer
patients undergoing endocrine therapy in a multicultural context. We sincerely invite
you to participate in this research. If you agree to take part, you will be asked to
complete a four-part questionnaire, which is expected to take approximately 15-20
minutes. Your participation will greatly contribute to our understanding and
improvement of the quality of care for breast cancer patients.
There are no known risks associated with this study. All data collected will be
anonymized and kept strictly confidential. You are free to withdraw from the study at
any time without providing any reason. We greatly appreciate your support and
participation.
---------------------------------------------------------------
------
Part I: Basic Information
1. Name of your workplace: ___________
2. Your gender [Single choice question]
A. Male
B. Female
3. Your age: ______
4. Years of nursing experience: _______ years

42
5. Your current professional title [Single choice question]
A. Nurse
B. Registered Nurse
C. Charge Nurse
D. Deputy Head Nurse
E. Head Nurse
F. Other: __________
6. Your highest academic degree [Single choice question]
A. Junior college and below
B. Bachelor's degree
C. Master's degree or Postgraduate diploma
D. Doctoral degree and above
7. The number of beds in your department is: ______
8. Your working city [Single choice question]
A. Shanghai
B. Dali
C. Indonesia
D. Other: __________
9. Are you familiar with the clinical guidelines for the management of
musculoskeletal symptoms among breast cancer patients with endocrine therapy?
[Single choice question]
A. Yes
B. No
10. Does your institution have an internal implementation plan or process for the
management of musculoskeletal symptoms among breast cancer patients with
endocrine therapy? [Single choice question]
A. Yes
B. No

43
11. Have you participated in training related to the management of musculoskeletal
symptoms among breast cancer patients with endocrine therapy? [Single choice
question]
A. Yes
B. No
12. If you have not received the relevant training, what are the reasons? [Multiple
choice question]
A. Heavy workload in the department, no time or energy
B. Lack of interest, training is not a concern
C. Unaware of such training notifications and information
D. Low seniority, no opportunity or quota to participate in training
13. If you have received the relevant training, what type of training have you received?
[Multiple choice question]
A. Training organized by the department
B. Training organized by the hospital
C. Training organized by external organizations
D. Other: __________
14. What are your main sources for acquiring knowledge about endocrine therapy for
breast cancer patients? [Multiple choice question]
A. Institutional education
B. Relevant books and literature
C. Academic conferences or lectures
D. Departmental business learning
E. Self-study due to personal interest or work requirements
F. Training courses
G. Have not yet paid attention to this knowledge area
15. Do you think it is necessary to learn and master more knowledge about the
management of musculoskeletal symptoms among breast cancer patients with
endocrine therapy? [Single choice question]

44
A. Yes
B. No
---------------------------------------------------------------
------
Part II: Knowledge (K)
1. Which of the following adverse reactions are most common in endocrine therapy
for breast cancer patients? [Multiple choice question]
A. Hot flashes and sweating
B. Musculoskeletal pain
C. Decreased bone density, increasing the risk of fractures
D. Vaginal dryness and decreased libido
E. Endometrial thickening, potentially increasing the risk of endometrial cancer
F. Liver function abnormalities, such as elevated transaminases
G. Cardiovascular events, such as thrombosis
2. Which factors may exacerbate musculoskeletal symptoms during endocrine therapy
for breast cancer patients? [Multiple choice question]
A. Weight gain
B. Prolonged sedentary behavior
C. Insufficient intake of calcium and vitamin D
D. Lack of regular exercise
3. What is the recommended daily calcium intake during endocrine therapy for breast
cancer patients? [Single choice question]
A.1000mg
B.1200mg
C.1500mg
D.2000mg
4. What is the recommended daily vitamin D intake during endocrine therapy for
breast cancer patients? [Single choice question]
A.400IU
B.800IU
C.1000IU

45
D.2000IU
5. Vitamin D is crucial for the skeletal health of breast cancer patients with endocrine
therapy. Which of the following is the primary function of vitamin D? [Single choice
question]
A. Promotes calcium absorption and maintains bone health
B. Enhances muscle function
C. Regulates the immune system
D. Improves cardiovascular health
6. Which of the following foods helps prevent osteoporosis? [Single choice question]
A. Milk and dairy products
B. Green leafy vegetables
C. Nuts and seeds
D. Fish (such as salmon)
7. Which mineral helps maintain bone health? [Single choice question]
A. Magnesium
B. Iron
C. Zinc
D. Calcium
8. Which of the following behaviors is most beneficial to bone health? [Single choice
question]
A. Vitamin D and calcium supplementation
B. Prolonged bed rest
C. Restricting fat intake
D. High-fiber diet
9. What is the recommended frequency for bone density tests in breast cancer patients
with endocrine therapy? [Single choice question]
A. Every 6 months
B. Annually
C. Every 2 years

46
D. Every 5 years
10. What is the purpose of regular bone density testing during endocrine therapy for
breast cancer patients? [Single choice question]
A. Monitoring blood sugar levels
B. Assessing bone health status
C. Measuring blood pressure
D. Checking vision
11. Which medication is commonly used to alleviate joint pain caused by endocrine
therapy for breast cancer? [Single choice question]
A. Nonsteroidal anti-inflammatory drugs (NSAIDs)
B. Calcium and vitamin D supplements
C. Bisphosphonates
D. Opioids
12. Which type of physical therapy can help breast cancer patients with endocrine
therapy to alleviate musculoskeletal symptoms? [Single choice question]
A. Yoga
B. Swimming
C. Specific exercises under the guidance of physical therapy
D. Heat therapy
13. How many minutes of moderate-intensity aerobic exercise should adults engage in
per week during endocrine therapy for breast cancer? [Single choice question]
A. 75 minutes
B. 150 minutes
C. 225 minutes
D. 300 minutes
14. Which of the following behaviors helps maintain bone health during endocrine
therapy for breast cancer? [Single choice question]
A. Engaging in regular moderate-intensity exercise
B. High-sugar diet

47
C. Prolonged bed rest
D. Restricting calcium intake
---------------------------------------------------------------
------Part III: Attitude (A)
1. Do you think managing the musculoskeletal symptoms of breast cancer patients is
important? [Single choice question]
A. Extremely important
B. Important
C. Moderately important
D. Unimportant
E. Extremely unimportant
2. Do you think nurses play a crucial role in managing the musculoskeletal symptoms
of breast cancer patients? [Single choice question]
A. Strongly agree
B. Agree
C. Uncertain
D. Disagree
E. Strongly disagree
3. What kind of knowledge do you think nurses need to have to manage
musculoskeletal symptoms caused by endocrine therapy for breast cancer? [Multiple
choice question]
A. Symptom recognition
B. Medication management
C. Physical therapy
D. Nutritional guidance
E. Exercise advice
F. Other: __________
4. Are you willing to receive training on the management of musculoskeletal
symptoms related to endocrine therapy for breast cancer? [Single choice question]
A. Very willing
B. Willing

48
C. Uncertain
D. Unwilling
E. Very unwilling
5. Do you think the current training is sufficient to meet the needs of patients with
endocrine therapy for breast cancer? [Single choice question]
A. Strongly agree
B. Agree
C. Uncertain
D. Disagree
E. Strongly disagree
6. What do you think are the main challenges in managing musculoskeletal symptoms
in actual work? [Multiple choice question]
A. Low patient compliance
B. Lack of professional knowledge
C. Lack of practical experience
D. Insufficient hospital support
E. Other: __________
7. Do you think it is necessary to establish a specialized management plan for
musculoskeletal symptoms? [Single choice question]
A. Strongly agree
B. Agree
C. Uncertain
D. Disagree
E. Strongly disagree
8. How much do you think musculoskeletal symptoms affect the quality of life of
breast cancer patients? [Single choice question]
A. Very significant
B. Significant
C. Moderate
D. Slight

49
E. Very slight
9. What do you think are the main responsibilities of nurses in managing
musculoskeletal symptoms? [Multiple choice question]
A. Assessing and monitoring symptoms
B. Providing education and guidance
C. Developing and implementing management plans
D. Collaborating with physicians and other healthcare team members
E. Other: __________
10. Do you believe that health education can effectively improve patient compliance
with musculoskeletal symptom management? [Single choice question]
A. Strongly agree
B. Agree
C. Uncertain
D. Disagree
E. Strongly disagree
---------------------------------------------------------------
------Part IV: Practice (P)
1. Do you actively assess the musculoskeletal symptoms of breast cancer patients in
your daily nursing practice? [Single choice question]
A. Never
B. Occasionally
C. Sometimes
D. Often
E. Always
2. Do you provide health education on musculoskeletal symptom management to
breast cancer patients and their families? [Single choice question]
A. Never
B. Occasionally
C. Sometimes
D. Often
E. Always

50
3. Do you tailor musculoskeletal symptom management plans to the individual
patient's situation in your actual work? [Single choice question]
A. Never
B. Occasionally
C. Sometimes
D. Often
E. Always
4. Do you regularly review and adjust the musculoskeletal symptom management
plans for patients? [Single choice question]
A. Never
B. Occasionally
C. Sometimes
D. Often
E. Always
5. Do you collaborate with other healthcare team members to jointly manage the
musculoskeletal symptoms of breast cancer patients? [Single choice question]
A. Never
B. Occasionally
C. Sometimes
D. Often
E. Always
6. Do you regularly participate in relevant training or learning to improve your
knowledge and skills in musculoskeletal symptom management? [Single choice
question]
A. Never
B. Occasionally
C. Sometimes
D. Often
E. Always

51
7. Do you proactively learn and apply new technologies and methods in
musculoskeletal symptom management in your work? [Single choice question]
A. Never
B. Occasionally
C. Sometimes
D. Often
E. Always
8. Do you record the patient's compliance in managing musculoskeletal symptoms?
[Single choice question]
A. Never
B. Occasionally
C. Sometimes
D. Often
E. Always
9. Do you participate in the establishment and (or) strict implementation of the unit's
processes and standards for managing musculoskeletal symptoms in breast cancer
patients? [Single choice question]
A. Never
B. Occasionally
C. Sometimes
D. Often
E. Always
10. Do you regularly assess and improve your nursing practice to enhance the quality
of care for breast cancer patients? [Single choice question]
A. Never
B. Occasionally
C. Sometimes
D. Often
E. Always

52
11. Do you share your experience and skills in managing musculoskeletal symptoms
with new nurses or interns? [Single choice question]
A. Never
B. Occasionally
C. Sometimes
D. Often
E. Always
---------------------------------------------------------------
------Thank you very much for your participation! Your answers will provide
valuable insights for our study!
9.6 Interview Guide
1. Intervention Implementation Process
o
Could you briefly describe the specific process of implementing the
intervention at your site?
o
Were there any aspects of the implementation that differed from your
initial expectations? Please explain in detail.
2. Facilitators of Intervention Implementation
o
In implementing the intervention, what specific factors (e.g., team
collaboration, resource support, patient engagement) do you believe
contributed positively to the smooth execution of the plan?
o
Have you observed any management processes or system support that
effectively enhanced the intervention outcomes?
3. Barriers to Intervention Implementation
o
What major difficulties or challenges did you encounter during
implementation? How did these challenges specifically affect the
execution of the intervention plan?
o
Do you believe there were any resource or condition limitations that
created obstacles in carrying out the plan? Additionally, were there
cultural or policy factors that acted as barriers?
4. Feedback from Patients and Team

53
o
How did the nursing team respond to the intervention during
implementation? Were there any factors that affected team
participation or execution?
o
What is your perception of patient acceptance of the intervention?
Were there any specific factors that influenced patient engagement?
5. Improvement and Sustainability of the Intervention
o
Based on your experience, what aspects of the intervention could be
further optimized or improved?
o
Do you believe this intervention has the potential for long-term
application in clinical practice? What factors might influence its
sustainability in the future?
10. Attachments
(1) Patient Health Education Handbook
(2) Expert Review Scoring Form

54
11. References
[1]
ABRAHAM J, CALDERA H, COLEMAN R, et al. Endocrine therapy and
related issues in hormone receptor-positive early breast cancer: a roundtable
discussion by the breast cancer therapy expert group (BCTEG) [J]. Breast
Cancer Res Treat, 2018, 169(1): 1-7.
[2]
Chinese Anti-Cancer Association, Committee on Clinical Research
Management, Chongqing Clinical Medicine Research Federation, Chongqing
Anti-Cancer Association, Oncology Endocrinology Committee. 中国女性早
期乳腺癌患者维生素D 缺乏管理专家共识（2023 版）[Expert Consensus on
Vitamin D Deficiency Management for Chinese Women with Early Breast
Cancer (2023 Edition)] [J]. Chinese Journal of Endocrine Surgery, 2024, (01):
1-11.
[3]
National Cancer Quality Control Center, Breast Cancer Expert Committee,
Beijing Breast Disease Prevention and Treatment Society, Health
Management Committee. 中国乳腺癌随诊随访与健康管理指南(2022 版)
[Guidelines for Breast Cancer Follow-up and Health Management in China
(2022 Edition)] [J]. Chinese Journal of Oncology, 2022, (01): 1-28.
[4]
LU G, ZHENG J, ZHANG L. The effect of exercise on aromatase
inhibitor-induced musculoskeletal symptoms in breast cancer survivors :a
systematic review and meta-analysis [J]. Support Care Cancer, 2020, 28(4):
1587-96.
[5]
BOING L, VIEIRA M C S, MORATELLI J, et al. Effects of exercise on
physical outcomes of breast cancer survivors receiving hormone therapy - A
systematic review and meta-analysis [J]. Maturitas, 2020, 141: 71-81.
[6]
SCRUTH E. Exercise Therapies for Preventing or Treating Aromatase
Inhibitor-Induced Musculoskeletal Symptoms in Early Breast Cancer [J]. Clin
Nurse Spec, 2021, 35(4): 167-8.
[7]
HYDER T, MARINO C C, AHMAD S, et al. Aromatase Inhibitor-Associated
Musculoskeletal Syndrome: Understanding Mechanisms and Management [J].
Front Endocrinol (Lausanne), 2021, 12: 713700.
[8]
GUPTA A, HENRY N L, LOPRINZI C L. Management of Aromatase
Inhibitor-Induced Musculoskeletal Symptoms [J]. JCO Oncol Pract, 2020,
16(11): 733-9.
[9]
World Health Organization.