Worst Pain Severity Profiles of Oncology Patients Are Associated With Significant Stress and Multiple Co-Occurring Symptoms

The Use of Biomarkers in Precision Health Symptom Science-Opportunities and Challenges

OBJECTIVES

Precision health symptom science applies person-centered approaches to elucidate interindividual differences in patients' symptom experiences and incorporates omics methods with social, societal, and environmental determinants of health to develop symptom management strategies. By filling scientific gaps related to patients' symptom experiences and their underlying mechanisms, interventions can be developed to improve quality of life and outcomes. The purposes of this article are to describe symptom phenotype development; review analytical approaches to identify a symptom phenotype; and discuss common and emerging methods for biomarker discovery and their implications in precision health symptom science.

METHODS

Peer-reviewed research studies, review articles, and scientific expertise were synthesized to provide a broad overview of several methods of biomarker discovery and their implications for precision health symptom science.

RESULTS

Approaches to symptom phenotype development and analytical methods for phenotype identification were reviewed. Common (ie, genomic, epigenomic, transcriptomic, proteomic, metabolomic, microbiome) and emerging (ie, polygenic risk scores, microRNA, epigenetic clocks, allostatic load, wearables) methods for biomarker discovery were described. Each method provides unique information to improve our understanding of the complex biological processes that underlie symptoms and may be used for risk prediction, screening, surveillance, and treatment response.

CONCLUSIONS

While the exemplar approaches to conducting precision health symptom science were shared through an oncology lens, they are generalizable across acute and chronic conditions.

IMPLICATIONS FOR NURSING PRACTICE

Symptom biomarker identification is inherently complex and the methods for biomarker collection, processing, measurement, and analysis are continually evolving. Therefore, symptom scientists need to form transdisciplinary teams with experts in omics methodologies and bioinformatics. Despite the challenges, symptom scientists are well suited to lead the way in precision health symptom science to reduce symptom burden and improve quality of life among patients with various chronic conditions.

Psychological Symptom Cluster Severity Profiles Are Associated With Higher Levels of Stress and Worse Quality of Life in Postmenopausal Women With Breast Cancer

BACKGROUND

Although common, the severity of the psychological symptom cluster (PSC) (ie, co-occurrence of anxiety, depression, fatigue, sleep disturbance) varies among women with breast cancer. In addition, the impact of various types of stress and other risk factors on its severity are understudied, and the influence of the PSC on quality of life (QOL) outcomes remains poorly characterized.

OBJECTIVE

To identify subgroups of postmenopausal women with breast cancer with distinct PSC severity profiles following surgery and evaluate whether these subgroups differed in terms of demographic and clinical characteristics, symptoms, social and posttraumatic stress, and QOL.

METHODS

Following surgery, 159 postmenopausal women with early-stage, hormone receptor-positive breast cancer completed assessments of anxiety, depression, fatigue, sleep disturbance, cognitive function, physical symptoms, stress, and QOL. Latent profile analysis was used to identify subgroups of women based on the severity of the prespecified PSC. Parametric and nonparametric tests were used to evaluate for subgroup differences.

RESULTS

Three distinct PSC severity subgroups were identified (ie, Lower [71.7%], Moderate [23.9%], Higher [4.4%]). Compared with the Lower subgroup, the Moderate subgroup was less likely to have received prior radiation, and the Moderate and Higher subgroups had worse perceived cognitive function, higher symptom burden, higher posttraumatic stress, and lower QOL. Clinically relevant sleep disturbance was common across PSC subgroups.

CONCLUSIONS

PSC severity is associated with higher posttraumatic stress and poorer QOL following breast surgery. Sleep disturbance is a common problem and may be undertreated.

IMPLICATIONS FOR PRACTICE

Assessments of posttraumatic stress and sleep disturbance are needed for timely intervention.

Worse Morning Energy Profiles Are Associated with Significant Levels of Stress and Decrements in Resilience in Patients Receiving Chemotherapy

OBJECTIVES

Evidence suggests that lower levels of morning energy are associated with higher levels of stress and lower levels of resilience in patients receiving chemotherapy. Study purposes were to identify subgroups of patients with distinct morning energy profiles; evaluate for differences among the profiles in demographic and clinical characteristics, as well as measures of stress, resilience, and coping.

METHODS

A total of 1,343 outpatients receiving chemotherapy completed a demographic questionnaire and measures of global, cancer-related, and cumulative life stress, and resilience at study enrollment. Morning energy was assessed using the Lee Fatigue Scale at six time points over two cycles of chemotherapy. Latent profile analysis was used to identify subgroups of patients with distinct morning energy profiles. Differences among the subgroups were evaluated using parametric and nonparametric tests.

RESULTS

Three morning energy profiles were identified (i.e., High (17.3%), Low (60.3%), Very Low (22.4%)). Compared to High class, the other two morning energy classes were less likely to be employed; had a lower functional status and a higher comorbidity burden; and were more likely to self-report depression and back pain. For all three types of stress, significant differences were found among the three classes with scores that demonstrated a dose response effect (i.e., High < Low < Very Low; as decrements in morning energy increased, stress scores increased). Compared to High class, Very Low class reported higher rates of physical and sexual abuse. The resilience scores exhibited a dose response effect as well (i.e., High > Low > Very Low). Patients with the two worst energy profiles reported a higher use of disengagement coping strategies.

CONCLUSIONS

Findings highlight the complex relationships among decrements in morning energy, various types of stress, resilience, and coping in patients undergoing chemotherapy.

IMPLICATIONS FOR NURSING PRACTICE

Clinicians need to assess for stress and adverse childhood experiences to develop individualized management plans to increase patients' energy levels.

Essential Components of an Electronic Patient-Reported Symptom Monitoring and Management System: A Randomized Clinical Trial

Importance

Multicomponent electronic patient-reported outcome cancer symptom management systems reduce symptom burden. Whether all components contribute to symptom reduction is unknown.

Objective

To deconstruct intervention components of the Symptom Care at Home (SCH) system, a digital symptom monitoring and management intervention that has demonstrated efficacy, to determine which component or combination of components results in the lowest symptom burden.

Design, Setting, and Participants

This randomized clinical trial included participants who were older than 18 years, had been diagnosed with cancer, had a life expectancy of 3 months or greater, were beginning a chemotherapy course planned for at least 3 cycles, spoke English, and had daily access and ability to use a telephone. Eligible participants were identified from the Huntsman Cancer Institute, University of Utah (Salt Lake City), and from Emory University Winship Cancer Institute, including Grady Memorial Hospital (Atlanta, Georgia), from August 7, 2017, to January 17, 2020. Patients receiving concurrent radiation therapy were excluded. Dates of analysis were from February 1, 2020, to December 22, 2023.

Interventions

Participants reported symptoms daily during a course of chemotherapy and received automated self-management coaching with an activity tracker without (group 1) and with (group 2) visualization, nurse practitioner (NP) follow-up for moderate-to-severe symptoms without (group 3) and with (group 4) decision support, or the complete SCH intervention (group 5).

Main Outcomes and Measures

The primary outcome, symptom burden, was assessed as the summed severity of 11 chemotherapy-related symptoms rated on a scale of 1 to 10 (with higher scores indicating greater severity), if present.

Results

The 757 participants (mean [SD] age, 59.2 [12.9] years) from 2 cancer centers were primarily female (61.2%). The most common cancer diagnoses were breast (132 [17.4%]), lung (107 [14.1%]), and colorectal (99 [13.1%]) cancers; 369 patients (48.7%) had metastatic disease. The complete SCH intervention including automated self-management coaching and NP follow-up with decision support (group 5) was superior in reducing symptom burden to either of the self-management coaching groups, as shown by the mean group differences in area under the curve (group 1, 1.86 [95% CI, 1.30-2.41] and group 2, 2.38 [95% CI, 1.84-2.92]; both P < .001), and to either of the NP follow-up groups (group 3, 0.57 [95% CI, 0.03-1.11]; P =.04; and group 4, 0.66 [95% CI, 0.14-1.19]; P = .014). Additionally, NP follow-up was superior to self-management coaching (group 1 vs group 3, 1.29 [95% CI, 0.72-1.86]; group 1 vs group 4, 1.20 [95% 12 CI, 0.64-1.76]; group 2 vs group 3, 1.81 [95% CI, 1.25-2.37]; and group 2 vs group 4, 1.72 [95% CI, 1.17-2.26]; all P < .001), but there was no difference between the 2 self-management coaching groups (-0.52 [95% CI, -1.09 to 0.05]; P = .07) or between the 2 NP groups (-0.10 [95% CI, -0.65 to 0.46]; P = .74).

Conclusions and Relevance

In this randomized clinical trial of adult participants undergoing chemotherapy treatment for cancer, the complete intervention, rather than any individual component of the SCH system, achieved the greatest symptom burden reduction. These findings suggest that a multicomponent digital approach to cancer symptom management may offer optimal symptom burden reduction.

Trial Registration

ClinicalTrials.gov Identifier: NCT02779725.

Prevalence and risk factors for anxiety in patients with early- and middle-stage lung cancer: a cross-sectional study

Objective

Lung cancer is a leading cause of cancer-related morbidity and mortality worldwide, with patients frequently experiencing significant psychological distress, particularly anxiety. Despite the high prevalence of anxiety in patients with cancer, there is limited comprehensive research focusing on the specific factors influencing anxiety in patients with early- and middle-stage lung cancer within the context of Chinese medicine hospitals. Therefore, we aimed to investigate the epidemiology and factors influencing anxiety disorders in patients with early- and middle-stage primary bronchial lung cancer through a cross-sectional study.

Methods

A total of 340 patients with early and middle-stage lung cancer admitted to the outpatient ward of the oncology department at Guang'anmen Hospital from June 2023 to December 2023 were included in this study. Survey data, including the patients' general condition questionnaire, Generalized Anxiety Scale (GAD-7), Hospital Anxiety and Depression Scale (HADS), and Mental Toughness Scale (CD-RISC-10), were collected and recorded in a database using a two-person input format. Data analysis was performed using SPSS 27.0 software.

Results

Out of the 340 patients with early- and middle-stage lung cancer included in this study, 133 had anxiety, resulting in an overall anxiety detection rate of 39.12%. The chi-square test showed that statistically significant differences in religion, marital status, surgical treatment, tobacco use, and alcohol history between the anxious and non-anxious groups (p < 0.05). Moreover, statistically significant differences were observed in per capita annual family income, pathological type, VAS score, targeted therapy, treatment stage, and mental toughness level (p < 0.001). Other factors were not significantly correlated with anxiety onset. Multivariate logistic regression analysis showed that higher per capita family income and completed treatment independently acted as protective factors against anxiety onset in patients with early- and middle-stage lung cancer. Conversely, rare pathological types, increased pain severity, and lower levels of mental toughness were identified as independent risk factors for anxiety onset in these patients.

Conclusion

Anxiety was prevalent in patients with early- and middle-stage lung cancers. Rare pathological types, increased pain severity, and lower levels of mental toughness were independent risk factors for anxiety. Therefore, clinicians and psychologists should pay more attention to patients with rare types of tumors, actively manage their pain symptoms, and consider implementing mental resilience training to improve patients' mental toughness.

Prevalence and biopsychosocial indicators of fatigue in cancer patients

INTRODUCTION

Symptoms of cancer-related fatigue (CRF) can have a significant impact on patients' quality of life and treatment adherence. We aimed to investigate the relationship between CRF and multiple psychosocial and somatic indicators within a large mixed cancer sample.

METHODS

In this cross-sectional study, N = 1787 outpatients with cancer were assessed for CRF, pain, anxiety, and depression using validated screening instruments. We further obtained clinical parameters (Hb, CRP, creatinine, leukocytes, ASAT, and ALAT), sociodemographic data (age, gender, income, education level, marital status, parenthood, and living area), and lifestyle factors. Multivariate linear regression models were applied to estimate the impact of each indicator on CRF.

RESULTS

Overall, 90.6% of patients experienced some CRF, with 14.8% experiencing severe CRF. No gender difference was found in the prevalence of CRF. Patients with higher levels of pain, depressive symptoms, and lower Hb levels had significantly higher levels of CRF (ps <0.001). Lower levels of CRF were observed in patients who had children (p = 0.03), had less education (p < 0.001), and were physically active for more than 2 h per week before their oncological diagnosis (p = 0.014). The latter was only a significant indicator in the male subsample.

CONCLUSION

The present results demonstrate a high prevalence of CRF and highlight that not only somatic and psychosocial factors, but also lifestyle factors prior to diagnosis appear to be associated with the etiology and persistence of CRF. To effectively treat CRF, a biopsychosocial, personalized approach is recommended.

Exploration of the Relationships Between Stress and Distinct Pain and Sleep Disturbance Profiles in Patients Undergoing Chemotherapy

BACKGROUND

Unrelieved pain and sleep disturbance are common symptoms in oncology patients. Increased stress may be an underlying cause for both symptoms.

OBJECTIVES

The purposes of this study were to identify subgroups of outpatients with distinct pain and sleep disturbance profiles and to evaluate differences among these subgroups in demographic and clinical characteristics. Differences in global stress, cancer-specific stress, and cumulative life stress, as well as resilience and coping, were evaluated.

METHODS

Patients (N = 1343) completed self-report questionnaires for demographic and clinical characteristics and stress, resilience, and coping. Latent profile analysis was used to identify subgroups of patients with distinct pain and sleep disturbance profiles. Differences among the subgroups were determined using parametric and nonparametric tests.

RESULTS

Three distinct profiles were identified (ie, No Pain + Moderate Sleep Disturbance (SD) (27.6%), Moderate Pain + Moderate SD (38.6%), Severe Pain + High SD (33.8%)). Compared with the other 2 classes, Severe Pain + High SD class was younger, had fewer years of education, was more likely to be female, more likely to live alone, less likely to be employed, and had a higher level of comorbidity. This class had the highest stress scores and was more likely to report higher rates of adverse childhood experiences.

CONCLUSION

Over 70% of our sample reported clinically meaningful levels of both symptoms, and 33.8% reported relatively high rates of adverse childhood experiences.

IMPLICATION FOR PRACTICE

Clinicians need to perform routine assessments, particularly of adverse childhood experiences, and initiate appropriate referrals.

Increased Stress Is Associated With Severe Pain and Decrements in Cognitive Function in Patients Receiving Chemotherapy

OBJECTIVES

Purposes were to identify subgroups of adult oncology patients (n = 1342) with distinct joint profiles of worst pain and cognitive function (CF) and evaluate for differences in demographic and clinical characteristics, as well as the severity of three distinct types of stress, resilience, and coping.

DATA SOURCES

Measures of pain and CF were evaluated six times over two cycles of chemotherapy. The other measures of demographic and clinical characteristics, stress, resilience, and coping were completed at enrollment (ie, prior to the second or third cycle of chemotherapy).

RESULTS

Using latent profile analysis, four distinct profiles were identified (ie, no pain + moderate CF [27.6%], moderate pain + high CF [22.4%] moderate pain and moderate CF [32.4%, both moderate], severe pain and low CF [17.5%, both severe]). Both moderate and both severe classes reported higher global, cancer-specific, and cumulative life stress, lower levels of resilience, and greater use of disengagement coping strategies. The Both severe class had higher occurrence rates for a number of adverse childhood experiences (ie, family violence in childhood, physical abuse at <16 years, forced sex at <16 years). Risk factors associated with membership in the two worst profiles included: being female, having a lower annual income, having a higher comorbidity burden, and having a poorer functional status.

CONCLUSION

Findings suggest that 72.4% of the patients reported pain scores in the moderate to severe range and 77.6% reported low to moderate levels of CF. Clinicians need to assess for both symptoms and various types of stress on a routine basis.

Higher Lifetime Stress and Symptom Burden Contribute to the Occurrence of Shortness of Breath

OBJECTIVES

Among four classes of patients with distinct shortness of breath profiles, evaluate for differences in levels of global, cancer-specific, and cumulative life stress, as well as resilience; evaluate for differences in the occurrence rates for various stressful life events, and evaluate for differences in the severity of common co-occurring symptoms.

DATA SOURCES

Outpatients (N = 1338) completed questionnaires six times over two cycles of chemotherapy. The occurrence of shortness of breath was assessed using the Memorial Symptom Assessment Scale. Latent class analysis was used to identify subgroups of patients with distinct shortness of breath profiles. Differences among the classes were evaluated using parametric and nonparametric tests.

CONCLUSION

Shortness of breath classes were labeled based on their distinct occurrence trajectories: None (70.5%), Decreasing (8.2%), Increasing (7.8%), and High (13.5%). Compared to None class, Decreasing and High classes had higher global and cancer-specific stress scores. The High class reported higher occurrence rates for several adverse childhood experiences. Compared to None class, Decreasing and High classes had higher depression, anxiety, and morning fatigue scores and lower morning energy and cognitive function scores.

IMPLICATIONS FOR NURSING PRACTICE

Given the additive or synergistic relationships between stress, co-occurring symptoms, and shortness of breath, multimodal interventions that include stress management, exercise training, and/or symptom management may decrease shortness of breath in oncology patients.

Neuroendocrine mechanisms in oxaliplatin-induced hyperalgesic priming

ABSTRACT

Stress plays a major role in the symptom burden of oncology patients and can exacerbate cancer chemotherapy-induced peripheral neuropathy (CIPN), a major adverse effect of many classes of chemotherapy. We explored the role of stress in the persistent phase of the pain induced by oxaliplatin. Oxaliplatin induced hyperalgesic priming, a model of the transition to chronic pain, as indicated by prolongation of hyperalgesia produced by prostaglandin E 2 , in male rats, which was markedly attenuated in adrenalectomized rats. A neonatal handling protocol that induces stress resilience in adult rats prevented oxaliplatin-induced hyperalgesic priming. To elucidate the role of the hypothalamic-pituitary-adrenal and sympathoadrenal neuroendocrine stress axes in oxaliplatin CIPN, we used intrathecally administered antisense oligodeoxynucleotides (ODNs) directed against mRNA for receptors mediating the effects of catecholamines and glucocorticoids, and their second messengers, to reduce their expression in nociceptors. Although oxaliplatin-induced hyperalgesic priming was attenuated by intrathecal administration of β 2 -adrenergic and glucocorticoid receptor antisense ODNs, oxaliplatin-induced hyperalgesia was only attenuated by β 2 -adrenergic receptor antisense. Administration of pertussis toxin, a nonselective inhibitor of Gα i/o proteins, attenuated hyperalgesic priming. Antisense ODNs for Gα i 1 and Gα o also attenuated hyperalgesic priming. Furthermore, antisense for protein kinase C epsilon, a second messenger involved in type I hyperalgesic priming, also attenuated oxaliplatin-induced hyperalgesic priming. Inhibitors of second messengers involved in the maintenance of type I (cordycepin) and type II (SSU6656 and U0126) hyperalgesic priming both attenuated hyperalgesic priming. These experiments support a role for neuroendocrine stress axes in hyperalgesic priming, in male rats with oxaliplatin CIPN.

Distinct Worst Pain Profiles in Oncology Outpatients Undergoing Chemotherapy

BACKGROUND

While pain is a significant problem for oncology patients, little is known about interindividual variability in pain characteristics.

OBJECTIVE

The aims of this study were to identify subgroups of patients with distinct worst pain severity profiles and evaluate for differences among these subgroups in demographic, clinical, and pain characteristics and stress and symptom scores.

METHODS

Patients (n = 934) completed questionnaires 6 times over 2 chemotherapy cycles. Worst pain intensity was assessed using a 0- to 10-point numeric rating scale. Brief Pain Inventory was used to assess various pain characteristics. Latent profile analysis was used to identify subgroups of patients with distinct pain profiles.

RESULTS

Three worst pain profiles were identified (low [17.5%], moderate [39.9%], severe [42.6%]). Compared with the other 2 classes, severe class was more likely to be single and unemployed and had a lower annual household income, a higher body mass index, a higher level of comorbidity, and a poorer functional status. Severe class was more likely to have both cancer and noncancer pain, a higher number of pain locations, higher frequency and duration of pain, worse pain quality scores, and higher pain interference scores. Compared with the other 2 classes, severe class reported lower satisfaction with pain management and higher global, disease-specific, and cumulative life stress, as well as higher anxiety, depression, fatigue, sleep disturbance, and cognitive dysfunction scores.

CONCLUSIONS

Unrelieved pain is a significant problem for more than 80% of outpatients.

IMPLICATIONS FOR PRACTICE

Clinicians need to perform comprehensive pain assessments; prescribe pharmacologic and nonpharmacologic interventions; and initiate referrals for pain management and psychological services.

Perturbations in Neuroinflammatory Pathways Are Associated With a Worst Pain Profile in Oncology Patients Receiving Chemotherapy

Unrelieved pain occurs in 55% of cancer patients. Identification of molecular mechanisms for pain may provide insights into therapeutic targets. Purpose was to evaluate for perturbations in neuroinflammatory pathways between oncology patients with and without severe pain. Worst pain severity was rated using a 0 to 10 numeric rating scale six times over two cycles of chemotherapy. Latent profile analysis was used to identify subgroups of patients with distinct pain profiles. Pathway impact analyses were performed in two independent samples using gene expression data obtained from RNA sequencing (n = 192) and microarray (n = 197) technologies. Fisher's combined probability test was used to identify significantly perturbed pathways between None versus the Severe pain classes. In the RNA sequencing and microarray samples, 62.5% and 56.3% of patients were in the Severe pain class, respectively. Nine perturbed pathways were related to neuroinflammatory mechanisms (i.e., retrograde endocannabinoid signaling, gamma-aminobutyric acid synapse, glutamatergic synapse, Janus kinase-signal transducer and activator of transcription signaling, phagosome, complement and coagulation cascades, cytokine-cytokine receptor interaction, chemokine signaling, calcium signaling). First study to identify perturbations in neuroinflammatory pathways associated with severe pain in oncology outpatients. Findings suggest that complex neuroimmune interactions are involved in the maintenance of chronic pain conditions. Perspective: In this study that compared oncology patients with none versus severe pain, nine perturbed neuroinflammatory pathways were identified. Findings suggest that complex neuroimmune interactions are involved in the maintenance of persistent pain conditions.

Co-occurring Fatigue and Lymphatic Pain Incrementally Aggravate Their Negative Effects on Activities of Daily Living, Emotional Distress, and Overall Health of Breast Cancer Patients

BACKGROUND

Fatigue and lymphatic pain are the most common and debilitating long-term adverse effects of breast cancer treatment. Fatigue and pain independently have negative effects on quality of life, physical functions, and cancer recurrence-free survival. The interactions between fatigue and pain may aggravate their negative effects.

OBJECTIVES

Examine the effects of co-occurring fatigue and lymphatic pain on activities of daily living (ADLs), emotional distress, and overall health of breast cancer patients.

METHODS

A cross-sectional and observational design was used to enroll 354 breast cancer patients. Valid and reliable instruments were used to assess fatigue, lymphatic pain, ADLs, emotional distress, and overall health. Descriptive statistics and multivariable regression models were used for data analysis.

RESULTS

After controlling for demographic and clinical factors, patients with co-occurring fatigue and lymphatic pain had higher odds of having impaired ADLs (OR = 24.43, CI = [5.44-109.67], P < .001) and emotional distress (OR = 26.52, CI = [9.64-72.90], P < .001) compared to patients with only fatigue and only lymphatic pain. Patients with co-occurring fatigue and lymphatic pain had 179% increase in impaired ADL scores (B = 8.06, CI = [5.54-10.59]) and 211% increase in emotional distress scores (B = 9.17, CI = [5.52-12.83]) compared to those without co-occurring fatigue and lymphatic pain. Patients with co-occurring fatigue and lymphatic pain had a 34% decrease (B = -26.29, CI = [-31.90 to -20.69]) and patients with only fatigue had a 33% decrease in overall health scores (B = -25.74, 95% CI = [-34.14 to -17.33]), indicating poor overall health.

CONCLUSIONS

Fatigue and lymphatic pain affected 66.4% of breast cancer patients. Findings from this study suggest that co-occurring fatigue and lymphatic pain have negative effects on breast cancer patients' ADLs, emotional distress, and overall health. The synergistic interactions between fatigue and lymphatic pain incrementally aggravated their negative effects on ADLs and emotional distress. Findings of the study highlight the need to evaluate the underlying mechanisms for co-occurring fatigue and lymphatic pain and develop interventions that target both fatigue and lymphatic pain to improve breast cancer patients' the quality of life.