The Memorial Symptom Assessment Scale: an instrument for the evaluation of symptom prevalence, characteristics and distress

Hematopoietic progenitor cell transplantation in breast cancer: current status and future directions

Breast cancer remains the second leading cause of cancer death despite numerous advances in medical science. In vitro, preclinical, and clinical trials have shown that chemotherapy dose intensity is an important component of therapy. Many clinical trials addressing the use of high-dose chemotherapy and hematopoietic cellular rescue have been conducted over the past decade. Early trials undertaken in heavily pretreated patients who had metastatic disease were associated with high treatment-related mortality rates; good response rates were noted but overall survivals were short. Subsequent technological advances, including the use of recombinant hematopoietic growth factors and peripheral blood progenitor cells as the source of cellular rescue, have dramatically lowered the morbidity and mortality of the procedure, as well as shortened hospital stay and markedly reduced cost. As a result, the high-dose chemotherapy approach has been used earlier in the disease course, both in patients with metastatic disease who were responding and in the adjuvant setting in patients at high risk for relapse. Results of many of these phase II trials are extremely encouraging, and phase III prospective, randomized trials comparing autotransplant to conventional approaches are currently under way. This review discusses past, current, and future initiatives of this modality. Included is a discussion of new preparative regimens, the addition of agents such as biochemical modifiers to enhance antitumor activity, and issues regarding timing of autotransplant, stem cell technology, use of allogeneic stem cells, and posttransplantation therapies.

Fatigue in ambulatory AIDS patients

Although preliminary reports indicate that fatigue is a common symptom of human immunodeficiency virus (HIV) disease, little empirical research has focused on its prevalence or characteristics among patients with acquired immunodeficiency syndrome (AIDS). We assessed the frequency of fatigue and its medical and psychological correlates, in a cross-sectional survey of ambulatory AIDS patients. Ambulatory patients with AIDS who participated in a study of quality life (N = 427) were classified into fatigue/no fatigue groups based on their responses to fatigue items on the Memorial Symptom Assessment Scale (MSAS) and the AIDS physical symptom checklist. Self-report inventories were also administered to assess psychological distress, depressive symptoms, and overall quality of life. Medical information was elicited through clinical interview and review of medical chart. Fifty-four percent of the patients endorsed both of the fatigue items from the MSAS and the AIDS physical symptom checklists, and were classified as having fatigue. Women were significantly more likely to report fatigue than men (chi square = 5.28, df = 1, P < 0.03), and patients reporting homosexual contact as their transmission risk factor were significantly less likely to report fatigue than were patients reporting injection drug use or heterosexual contact (chi square = 5.13, df = 2, P < 0.03). The presence of fatigue was significantly associated with the number of current AIDS-related physical symptoms [t(425) = 8.00, P < 0.0001], current treatment for HIV-related medical disorders (chi square = 12.51, df = 1, P < 0.0001), anemia [t(174) = -2.35, P < 0.02], and pain (chi square = 36.36, df = 1 P < 0.0001). Patients with fatigue also had significantly poorer physical functioning ability [Karnofsky: t(422) = -6.27, P < 0.0001], as well as greater degree of overall psychological distress and lower quality of life [F(5,418) = 23.79, P < 0.0001], as measured by the Brief Symptom Inventory, Beck Depression Inventory, Beck Hopelessness Scale, Functional Living Inventory for Cancer (modified for AIDS), and the MSAS Psychological Distress Subscale. Fatigue is a common symptom in ambulatory AIDS patients and is associated with significant physical and psychological morbidity.

Similarities and differences in assessing nausea on a verbal category scale and a visual analogue scale

The use of verbal category scales in assessing patient symptoms is evolving, but the extent to which reliability and precision are lost in using them as opposed to a visual analogue scale (VAS) remains uncertain. The present study analyzed the concordance between a four-point verbal category scale and a VAS in assessing nausea intensity in patients undergoing chemotherapy. The analysis of a total of 348 simultaneous ratings by 104 women over four cycles revealed good concordance between the scales. The means of the VAS ratings (range 0-100 mm) corresponding to the four verbal categories divided the scale in four almost equally large parts (no nausea = 0.7, mild = 24.8, moderate = 48.3, severe = 75.1). However, the VAS ranges were wide. On an individual level a one-step change in the verbal category was associated with an average change of 20 mm on the VAS. The choice of scale to use should be based on the need in the particular situation. When measuring intensity of nausea in patients, the VAS is a reasonable choice due to its possibly greater ability to detect changes over time. On the group level, findings on a four-point category scale and a VAS on the average seem similar.

Detailed quality of life assessment in patients treated with primary radiotherapy for squamous cell cancer of the base of the tongue

BACKGROUND

This study was conducted to evaluate quality of life in patients treated with primary radiotherapy (RT) for cancer of the base of tongue.

METHODS

From 1981 to 1990, 36 patients with primary squamous cell cancer of the base of tongue were managed with primary radiotherapy. Ages ranged from 35 to 71 years (median, 58 years), T Stage was: T1, n = 11; T2, n = 14; T3, n = 10; T4, n = 1. Thirty-one patients (86%) had palpable cervical lymph node metastases at initial examination (N1, n = 16; N2, n = 11; N3, n = 4). Patients received external beam RT to their primary site and necks, followed by a brachytherapy boost to the tongue. Those with neck nodes also had a neck dissection. The median follow-up is 5 years (minimum, 3 years). Actuarial 5-year local control was 85%; regional control was 96%; distant metastases-free survival was 87.5%; and overall survival, 85%. Twenty-nine of the 30 long-term survivors completed (1) Memorial Symptom Assessment Scale (MSAS), (2) Functional Assessment of Cancer Therapy (FACT), (3) Performance Status Scale for Head and Neck Cancer (PSS), and (4) a sociodemographic and economic questionnaire. At the time of cancer diagnosis, 62% were employed full-time, and 21% were employed part-time; 83% were earning > $20,000/year, and 59% were earning > $60,000/year.

RESULTS

At follow-up, annual incomes were similar to those at initial examination. Of those who had been working full-time, 72% were still in full-time work, and of those who had been working part-time, 83% were still in part-time work. Average PSS scores were 90 for eating in public, 96 for understandability of speech, and 68 for normalcy of diet. On the MSAS, the following symptoms had prevalence: > 30% xerostomia, difficulty swallowing, decreased energy, pain, worrying, insomnia, cough, drowsy, change in taste, and irritability. Scores on the FACT exceeded published values collected for a mixed cancer population.

CONCLUSIONS

The overwhelming majority of patients achieved excellent functional status and quality of life and could maintain their prediagnosis earning potential and employment status after primary radiation for advanced base of tongue cancer.

Monitoring of opioid therapy in advanced cancer pain patients

Until now, there have not been any parameters to monitor opioid therapy in cancer patients with pain. In this study, 325 consecutive advanced cancer patients were scheduled for a prospective longitudinal survey. After exclusions, 67 patients were surveyed. All included patients were advanced cancer patients with pain that required opioid therapy for more than 6 weeks before death. Opioid escalation, symptoms associated with opioid therapy, pain mechanism, and pain intensity were recorded. Indices were calculated to categorize the response to opioids. The opioid escalation index (OEI) was used to index the mean increase of the starting opioid dosage, expressed as a percentage or in mg. The length of the period of stable dose (MLD) and the effective analgesic score (EAS), that is, the analgesic consumption/pain relief ratio calculated at fixed intervals, were also used. Patients with a mean visual analogue scale score (VAS) of less than 4 and regular OEI and EAS were considered responsive; patients with a mean VAS less than 4 but with an OEI more than 5 or increases of more than 100% of EAS when compared to that calculated the week before were considered mildly responsive; and patients with a mean VAS more than 4 were considered unresponsive. Advanced age, female gender, and previous chemotherapy were all factors reducing OEI. Head and neck cancer was associated with a higher OEI. Regarding the influence of the opioid-related symptoms, an increased OEI was associated with the presence of confusion. Moreover the presence of confusion was associated with neuropathic pain. Neuropathic pain taken alone, however, did not influence this score. Gender-specific cancer, such as breast cancer, influenced the gender differences reported for MLD (significantly longer than that reported for males and other primary tumor). Good responsiveness was observed in 28 patients, partial responsiveness in 33 patients, unresponsiveness in six patients. Psychological factors were associated with poor pain relief, probably reducing the patient's compliance. The tools used in this study may be useful in monitoring the effects of opioid therapy in cancer pain patients. Simple numbers are easy to compare and make it possible to profile opioid responsiveness and differences among patients.

Surgical interruption of a midline dorsal column visceral pain pathway. Case report and review of the literature

A punctate midline myelotomy performed in a patient effectively eliminated residual, intractable pelvic pain, which remained after resolution of uterine cervical cancer. The authors describe the case history of the patient, in whom pain assessments were made, and a surgical procedure performed. Despite large doses of opiate analgesic medications, the patient experienced constant pressure pain in the right lower pelvis, with excruciating pain on bowel movement. Severe weight loss necessitated better pain control. A minimally invasive surgical procedure, a 5-mm deep puncture using a 16-gauge needle on either side of the median septum in the dorsal column of the spinal cord (T-8), resulted in no new neurological deficits. Narcotic medication was tapered, no pain was reported, and the patient resumed daily household activity. Midline myelotomy has typically been performed with the intention of eliminating the crossing fibers of the spinothalamic tract in the anterior white matter commissure. The punctate midline myelotomy described here was performed with the specific intention of interrupting a newly described visceral pain pathway that ascends to higher brain centers through the midline of the dorsal column. The effectiveness of the pain relief seen in this patient suggests that visceral pain of the pelvis in humans may be transmitted in the midline of the dorsal column, as has been recently reported in studies using rats. The effectiveness of the punctate midline myelotomy performed in this one case of pelvic visceral pain suggests that the surgery may eventually be effective in greatly reducing or replacing opiate narcotic medication for visceral pain management.

Measurement issues in the comprehensive assessment of cancer pain

OBJECTIVES

To examine issues related to the assessment of pain, symptoms and functional status in patients with cancer and the timing of assessment and appropriate tools to collect this information.

DATA SOURCES

Review articles, research studies book chapters, and government guidelines pertaining to measurement issues in the assessment of cancer pain.

CONCLUSIONS

Each component of the measurement process (ie, choice of an instrument to measure pain, timing and frequency of measurement measurement of symptoms accompanying pain or its treatment, and measurement of functional status) is important in developing an accurate and comprehensive assessment of cancer pain. This comprehensive assessment is a prerequisite to effective pain management.

IMPLICATIONS FOR NURSING PRACTICE

For pain to be evaluated and treated effectively, regular consistent assessment of pain by the clinician is imperative. This comprehensive assessment allows the clinician to choose modalities most likely to work for the individual patient.

Discordance between physicians' estimations and breast cancer patients' self-assessment of side-effects of chemotherapy: an issue for quality of care

Because side-effects of chemotherapy may be more diverse and patients' reactions more individualistic than tends to be acknowledged by clinicians, a survey was carried out among 50 breast cancer outpatients to document self-reported physical symptoms experienced during NCF (mitoxantrone + cyclophosphamide + 5-fluorouracil) adjuvant chemotherapy and to compare them with the clinicians' estimation in medical records. The questionnaire evaluated the prevalence, duration/severity and distress level of 17 symptoms. Symptom prevalence, assessed in 231 cycles, was high even for symptoms that do not usually focus clinicians' attention. Of these, hot flushes, stomach pain and muscular and articular pains lasted 1 week or more for nearly half of the cycles. Hot flushes, vomiting and stomach pain were the most distressing symptoms. The mean number of symptoms per cycle is significantly correlated with the global quality-of-life score. Concordance between patients' self-assessment and clinical reports, measured in 180 cycles, is moderately correct for vomiting and sore mouth and inadequate for the remaining symptoms even for hair loss (notified in 27% of cycles by clinicians vs 80% by patients) and nausea (38% vs 73%). A better understanding by physicians of cancer patients' problems is necessary to improve quality of care.

Pain in ambulatory AIDS patients. I: Pain characteristics and medical correlates

The characteristics and impact of pain were evaluated in a prospective cross-sectional survey of 438 ambulatory AIDS patients recruited from health care facilities in New York City. More than 60% of the patients reported 'frequent or persistent pain' during the 2 wks preceding the study. Patients with pain reported an average of 2.5 different pains. On the 0-10 numerical scale of the Brief Pain Inventory (BPI), mean pain intensity 'on average' was 5.4 (SD = 2.2; range = 0-10), and mean pain 'at its worst' was 7.4 (SD = 2.0; range = 1-10). The pain-related functional interference index (sum of the seven item BPI subscale) was 42.6 (SD = 17.2; range = 0.70). Demographic variables were not associated with the presence of pain, but the number of current HIV-related symptoms, treatment for HIV-related infections, and the absence of antiretroviral medications were significantly associated with the presence of pain. Female gender, non-Caucasian race, and number of HIV-related physical symptoms were significantly associated with pain intensity. Presence of pain and increasing pain intensity were significantly associated with greater impairment in functional ability (Karnofsky Performance Status, BPI functional interference index) and physical symptom distress (Memorial Symptom Assessment Scale). Results demonstrate high levels of pain and pain-related functional impairment among patients with AIDS. The presence and intensity of pain are associated with more advanced HIV disease and pain intensity is also associated with demographic factors (gender, race).

Pain in ambulatory AIDS patients. II: Impact of pain on psychological functioning and quality of life

The relationships among pain, psychological distress and other quality of life concerns were examined through a prospective cross-sectional survey of 438 ambulatory AIDS patients recruited from health care facilities in New York City. In this sample, 274 (62.6%) patients reported frequent or persistent pain during the prior 2 wks. Patients with and without pain completed a questionnaire packet that included measures of psychological symptom distress (Brief Symptom Inventory and the Psychological Distress Subscale of the Memorial Symptom Assessment Scale), depression (Beck Depression Inventory and Beck Hopelessness Scale), social support (Social Support Questionnaire), and overall quality of life (Functional Living Index-Cancer, modified for AIDS). Multivariate analyses (MANOVA, multiple regression) revealed significant associations between the presence and intensity of pain and scores on the measures of psychological distress, depression, hopelessness, and quality of life (P < 0.0001 for most analyses). Perceived adequacy of social support was also significantly associated with lower levels of psychological distress and depression, and better quality of life. These results demonstrate the significant relationships between pain, psychological well-being, and quality of life, and affirm the need to provide adequate treatment of pain in patients with AIDS.

An exploratory study of frequent pain measurement in a cancer clinical trial

The ideal methodology for quality of life (QOL) measurement in cancer clinical trials matches the evaluation to the anticipated outcomes, thereby increasing the likelihood that clinically relevant changes are captured. The present study explored the importance of such methodological 'tailoring' in a phase II trial of paclitaxel and recombinant human granulocyte-colony stimulating factor (rhG-CSF) for metastatic breast cancer. Prior to the trial, clinical observation suggested that frequent short-lived episodes of pain might occur during this treatment regimen. Twenty-one patients provided longitudinal data for at least three cycles of chemotherapy. To assess transient pain, a routine QOL assessment at baseline and every third cycle was supplemented with pain measurements twice weekly. The interval assessment included a multidimensional QOL instrument (Functional Living Index-Cancer) and measures of psychological state (Rand Mental Health Inventory), symptom distress (Memorial Symptom Assessment Scale), and performance status (Karnofsky Performance Status Score). The frequent pain measurements were acquired using visual analogue and categorical scales for pain intensity (Memorial Pain Assessment Card). From baseline to the end of cycle three, global pain scores declined and the results on other QOL measures were variable. The data obtained using these measures did not reveal the existence of episodic pains. In contrast, the twice weekly pain measurements clearly demonstrated transient severe pains in approximately half the patients. These data highlight the importance of specific measurement of troubling symptoms or other relevant QOL concerns at clinically appropriate intervals during the routine QOL assessment of clinical trials. The additional burden involved in these assessments is warranted if the information derived is highly relevant, would not be adequately captured otherwise and could improve therapy.

Development and testing of the symptom experience scale

The Symptom Experience Scale (SES) was designed to measure women's experience of symptoms associated with treatment for breast cancer. The SES, a modification of McCorkle's Symptom Distress Scale, was developed and tested in a sample of 252 women with breast cancer. Exploratory factor analysis yielded six factors, which used all 24 SES items and accounted for 83.2% of the variance. The factors were nausea and appetite, fatigue and sleep, concentration, appearance, bowel pattern, and pain. Cronbach's alpha internal consistency reliability coefficients ranged from 0.92 to 0.96; the alpha for the total SES was 0.94. Subscale to subscale correlations ranged from 0.21 to 0.56. Additional research is recommended with samples large enough to permit confirmatory factor analysis and determine the stability of the factor structure identified in the present study. Additional research also is recommended to determine the applicability of the SES for men and women of diverse ethnic groups with various types of cancer and other chronic illnesses.

Prevalence of symptoms among patients with advanced cancer: an international collaborative study. Symptom Prevalence Group

The aims of this study were (a) to estimate the prevalence of pain and eight other common symptoms in a large population of patients with advanced cancer from different palliative care centers, and (b) to assess the differences in prevalence of the symptoms by primary site. In 1990-1991, the prevalence of eight major symptoms and performance status were assessed prospectively among 1840 cancer patients in seven hospices in Europe, the United States, and Australia. The data were collected at each institution using structured data collection sheets from the World Health Organization's (WHO) Cancer and Palliative Care Unit. The prevalence of moderate to severe pain was 51%, ranging from 43% in stomach cancer to 80% in gynecological cancers. Nausea was most prevalent in gynecological (42%) and stomach (36%) cancers, and dyspnea (46%) in lung cancer. There were statistically significant differences in the prevalence of most symptoms depending on the primary site of cancer and the hospice. Population-based follow-up studies are needed to document the incidence and prevalence of symptoms throughout the course of the disease.

The impact of a hospice consultation team on the care of veterans with advanced cancer

To address the needs of patients with advanced cancer, all Veterans' Affairs hospitals were asked to establish teams of clinicians whose focus was to deliver expert palliative care. At the Philadelphia Veterans' Affairs Medical Center, our Hospice Consultation Team brought together professionals who had worked together informally in some of the outpatient oncology clinics. We conducted a prospective study of all consults received during the first year of the team's operation to determine whether or not the team approach would duplicate already available services or provide improved care. We identified 164 new medical/ nursing problems in 75 patients, 85% of which we were able to resolve. There were 152 new psychosocial/spiritual problems, but only 40%-61% were resolved. Of 22 patients followed in oncology clinics, new problems were identified and resolved in 21. We conclude that the expertise of the Hospice Consultation Team members along with the team process provided improved care to these patients.

Quality of life in patients with ovarian cancer: current state of research

Ovarian cancer is the most malignant cancer in women, where it is the fifth leading cause of cancer-related death. The disease and its treatment have considerable effects on the quality of life of patients with this cancer. This study reviews existing literature on quality of life in patients with ovarian cancer to demonstrate the importance of the topic, to comment on improvements achieved and to consider their implications for the implementation of optimal treatment. A literature search was carried out through MEDLINE and of published papers on quality of life in patients with ovarian cancer from 1976 to 1994. Twenty papers have been reviewed, of which, 10 were treatment-related assessments of quality of life and the remaining 10 dealt with different topics including psychometric issues in measuring health-related quality of life. Twenty-four instruments were employed to measure quality of life. Of these, the Rotterdam Symptom Checklist (RSCL) and The European Organisation for Research and Treatment of Cancer Core Quality of Life Questionnaire (EORTC QLQ-C30) were found to be the most appropriate. Although meta-analysis of results is impossible, it appears that debulking surgery followed by platinum-based chemotherapy could improve both quality of life and survival. In addition to effective and efficient treatment, psychological counselling, palliative and home care, nutritional support and pain relief are the most important areas for improving quality of life of patients with ovarian cancer. Knowledge and insight into the quality of life of patients with ovarian cancer are still limited, and a large carefully planned international study is required. Use of existing standard measures is preferable and agreement should be reached on a selected single instrument.

Development and validation of a patient needs assessment tool (PNAT) for oncology clinicians

The Patient Needs Assessment Tool (PNAT) is an interviewer-rated scale that may be completed through a simple structured interview and screens cancer patients for potential problems in physical and psychosocial functioning. The instrument provides separate scores for physical, psychological, and social status, and can potentially clarify the types of interventions needed to address specific areas of dysfunction. Reliability and validity was tested in two studies that used prescreened patient videotapes and other materials to assess the performance of the PNAT in groups of oncology nurses, physicians, and social workers. The data demonstrate that subscale scores for the physical, psychological, and social dimensions have good inter-rater reliability and internal consistency (intraclass correlation coefficients of 0.71-0.97). Criterion and construct validity was suggested through high correlations of each subscale with the evaluation of expert raters (correlation coefficients of 0.85-0.95) and with scores on validated patient-rated instruments appropriate to the functional area. These analyses suggest that the PNAT is a valid scale for the assessment of a range of functional disturbances in the cancer population.

A Circular Diagram for Representing Symptom Status in Advanced Cancer Patients

Symptom relief is the major goal of palliative care. Its assessment is essential and several methods have been described. To evaluate immediately the clinical situation, a circular diagram for a visual representation of the physical symptoms is proposed. Particular patterns derived from the given data emerge from the diagrams. Certain critical situations often observed in palliative care, especially in the last weeks of life, show specific patterns that are easily distinguished. Effective treatments may change the appearance of different pictures.

Palliative medicine and the medical oncologist. Defining the purview of care

The fusion of palliative medicine and medical oncology, in practice and in education, can provide a better standard of patient care, reduce the risk of oncologist burnout, and increase the likelihood of patient family and physician satisfaction. There need be no gulf between these disciplines, and only together do they represent truly comprehensive cancer care. The realization of this fusion will require the participation of individual clinicians, program directors, and the policy makers for cancer centers, professional organizations, and the health care regulatory authorities. It is a logical next step in the evolution of medical oncology.

Symptom assessment

Medical intervention aims to eliminate disease, to mitigate disease effect, and maximize quality of life. Throughout the course of illness, accurate symptom assessment is imperative if these goals are to be achieved. Symptom scales may facilitate this process in the clinical setting. Many valid scales are available for research, and investigators must be familiar with a methodology that can quantify the impact of therapies on symptoms, symptom distress, and overall QOL.