Operationalizing Symptom Distress in Adults With Cancer: A Literature Synthesis

Sentinel and Networked Symptoms During Remission Induction Chemotherapy in Acute Lymphoblastic Leukemia Children

BACKGROUND

Children with acute lymphoblastic leukemia experience various adverse symptoms during remission induction. Elucidating the interrelationships among symptoms can facilitate precise and efficacious symptom management.

OBJECTIVE

This study aimed to elucidate symptom clusters and sentinel symptoms and to examine core and bridge symptoms within the symptom network in children with acute lymphoblastic leukemia during remission induction.

METHODS

A cross-sectional survey of 226 children aged 8 to 16 years with a new diagnosis of acute lymphoblastic leukemia during remission induction chemotherapy was conducted using the Chinese version of the Memorial Symptom Assessment Scale 10-18. Symptom clusters and sentinel symptoms were identified using exploratory factor analysis and Apriori algorithm. Core and bridge symptoms were identified using network analysis.

RESULTS

Five symptom clusters and sentinel symptoms were identified: gastrointestinal (constipation as the sentinel symptom), emotional (feeling sad as the sentinel symptom), and somatic (cough as the sentinel symptom); however, the sentinel symptoms of neurological and self-image impairment symptom clusters were not specified. In symptom network, feeling sad and nausea were core symptoms, whereas dizziness and lack of energy were the bridge symptoms.

CONCLUSIONS

The somatic symptom cluster should be prioritized for intervention during remission induction. Network analysis and sentinel symptom analysis must be extended to the symptom research in pediatric cancer to provide a scientific basis for symptom management.

IMPLICATIONS FOR PRACTICE

Nurses should aim to identify and intervene with sentinel and networked symptoms to ensure that children are effectively supported during the remission induction, reducing symptom burden and improving quality of life.

Changes in Fatigue, Psychological Distress, and Quality of Life After Chemotherapy in Women with Breast Cancer: A Prospective Study

BACKGROUND

Chemotherapy leads to various symptoms and psychological distress, which contribute to a significant decrease in the quality of life of the patients.

OBJECTIVES

The aim of this study was to identify changes and interrelationships in the fatigue-depression-anxiety symptom cluster and quality of life during the cancer care trajectory in women with breast cancer.

METHODS

Fifty women participated in the study and completed questionnaires at 3 different times: prechemotherapy, postchemotherapy, and 6 months after the completion of chemotherapy. The assessment tools were the Functional Assessment of Cancer Therapy-Fatigue Scale, Hospital Anxiety and Depression Scale, and Functional Assessment of Cancer Therapy-Breast Cancer version 4 Scale. Data were analyzed using descriptive and repeated-measures analysis of variance statistics.

RESULTS

A significant increase in fatigue (F = 41.95, P < .001) and psychological distress (F = 26.55, P < .001) from prechemotherapy to postchemotherapy was noted. Improvement was observed 6 months after the completion of chemotherapy. A positive or negative change in fatigue was associated with the same in psychological distress. Quality of life (F = 65.22, P < .001) also showed similar change patterns as observed with fatigue and psychological distress. Fatigue had a greater impact on quality of life at postchemotherapy, but psychological distress had a greater impact at prechemotherapy and at the 6-month follow-up.

CONCLUSION

These results suggest that chemotherapy is highly associated with the fatigue-depression-anxiety symptom cluster and quality of life in women with breast cancer.

IMPLICATIONS FOR PRACTICE

Nursing intervention is needed to relieve the intensity of the fatigue-depression-anxiety symptom cluster and thus improve the quality of life of patients undergoing chemotherapy from before treatment to follow-up.

Modifiable pathways from pain to functional status: Confirmatory baseline results from a randomised trial of African American patients with cancer pain

OBJECTIVE

This study tested a model of cancer-related pain and functional status in African American patients, including beliefs about the ability to control pain as a key determinant of distress and functional status.

METHODS

Baseline data from a randomised clinical trial consisting of clinical and patient-reported outcomes were used. Participants were 228 African American patients experiencing moderate to severe pain within the past 2 weeks. The model comprised four latent constructs: pain, perceived control over pain, pain-related distress and functional status. Confirmatory factor analysis was used to validate the factor structure of the measurement model. Structural equation modelling was used to estimate direct and mediated effects.

RESULTS

The measurement model fit well (RMSEA = 0.06, SRMR = 0.05) with all loadings significant (p < 0.05). The structural model also fit well (RMSEA = 0.04, SRMR = 0.05). The complex mediated pathway from pain to functional status through perceived control over pain and pain-related distress was strong and significant (specific indirect effect = -0.456, p = 0.004). Mediation by perceived control accounted for a 47% reduction of the effects of pain on functional status.

CONCLUSION

If these results hold up longitudinally, interventions to increase perceived control over pain have the potential to improve functional status by decreasing pain-related distress.

Measuring therapeutic response in chronic graft-versus-host disease. National Institutes of Health consensus development project on criteria for clinical trials in chronic graft-versus-host disease: IV. The 2014 Response Criteria Working Group report

In 2005, the National Institutes of Health (NIH) Chronic Graft-versus-Host Disease (GVHD) Consensus Response Criteria Working Group recommended several measures to document serial evaluations of chronic GVHD organ involvement. Provisional definitions of complete response, partial response, and progression were proposed for each organ and for overall outcome. Based on publications over the last 9 years, the 2014 Working Group has updated its recommendations for measures and interpretation of organ and overall responses. Major changes include elimination of several clinical parameters from the determination of response, updates to or addition of new organ scales to assess response, and the recognition that progression excludes minimal, clinically insignificant worsening that does not usually warrant a change in therapy. The response definitions have been revised to reflect these changes and are expected to enhance reliability and practical utility of these measures in clinical trials. Clarification is provided about response assessment after the addition of topical or organ-targeted treatment. Ancillary measures are strongly encouraged in clinical trials. Areas suggested for additional research include criteria to identify irreversible organ damage and validation of the modified response criteria, including in the pediatric population.

Symptom distress in older adults following cancer surgery

BACKGROUND

Symptom distress remains a significant health problem among older adults with cancer following surgery. Understanding factors influencing older adults' symptom distress may lead to early identification and interventions, decreasing morbidity and improving outcomes.

OBJECTIVE

We conducted this study to identify factors associated with symptom distress following surgery among 326 community-residing patients 65 years or older with a diagnosis of thoracic, digestive, gynecologic, and genitourinary cancers.

METHODS

This secondary analysis used combined subsets of data from 5 nurse-directed intervention clinical trials targeting patients after surgery at academic cancer centers in northwest and northeastern United States. Symptom distress was assessed by the Symptom Distress Scale at baseline and at 3 and 6 months.

RESULTS

A multivariable analysis, using generalized estimating equations, showed that symptom distress was significantly less at 3 and 6 months (3 months: P < .001, 6 months: P = .002) than at baseline while controlling for demographic, biologic, psychological, treatment, and function covariates. Thoracic cancer, comorbidities, worse mental health, and decreased function were, on average, associated with increased symptom distress (all P < .05). Participants 75 years or older reported increased symptom distress over time compared with those aged 65 to 69 years (P < .05).

CONCLUSIONS

Age, type of cancer, comorbidities, mental health, and function may influence older adults' symptom distress following cancer surgery.

IMPLICATIONS FOR PRACTICE

Older adults generally experience decreasing symptom distress after thoracic, abdominal, or pelvic cancer surgery. Symptom management over time for those with thoracic cancer, comorbidities, those with worse mental health, those with decreased function, and those 75 years or older may prevent morbidity and improve outcomes of older adults following surgery.

Evolution of cancer-related symptoms over an 18-month period

CONTEXT

Previous studies have revealed inconsistent findings about the longitudinal evolution of cancer-related symptoms. In addition, the contribution of medical factors (e.g., cancer site, and treatments) in explaining the changes in these symptoms is yet to be established.

OBJECTIVES

This prospective study investigated longitudinal changes of five symptoms (i.e., depression, anxiety, insomnia, fatigue, and pain) in patients scheduled to undergo surgery for cancer (N=828).

METHODS

The patients completed the Hospital Anxiety and Depression Scale, the Insomnia Severity Index, the Multidimensional Fatigue Inventory, and a pain questionnaire at baseline and after 2, 6, 10, 14 and 18 months.

RESULTS

Several time changes were statistically significant but effect sizes only revealed one change of a medium magnitude, that is, a reduction of anxiety from T1 to T2 (d=-0.58). Women with breast or gynecological cancer were the only subgroups to exhibit significant changes (i.e., reduction of a small magnitude of anxiety symptoms from T1 to T2; ds=-0.27 and -0.30, respectively). However, numerous differences were found across adjuvant treatments, including greater variations in depression and insomnia scores in the chemotherapy group (ds=-0.71 to 0.20) and a transient increase in fatigue symptoms in patients receiving "all" adjuvant treatments (ds=-0.24 to 0.37).

CONCLUSION

The severity of cancer-related symptoms varies during the cancer care trajectory, especially anxiety scores, which importantly decrease during the first few months after the surgery. This study also suggests that treatment regimens better account for individual differences than cancer site in the evolution of symptoms.

Symptom self-management strategies in patients with non-metastatic prostate cancer

AIMS AND OBJECTIVES

To explore the association between symptoms, symptom distress and symptom self-management and to identify effective strategies of symptom self-management in men with non-metastatic prostate cancer following radical prostatectomy or radiation therapy.

BACKGROUND

Men receiving treatments for localised prostate cancer experience symptoms of urinary incontinence, urinary obstruction/irritation, bowel difficulties and sexual dysfunction. Understanding patients' symptom experiences and identifying strategies that they use to manage these symptoms are imperative for symptom management planning.

DESIGN

A descriptive, cross-sectional study was conducted with a sample of 53 men, who were within three months of the initiation of their treatment.

METHODS

The Symptom Indexes and the Strategy and Effectiveness of Symptom Self-Management questionnaires were used to measure symptoms, symptom distress and symptom self-management. Descriptive statistics, t-tests, correlations and multiple regressions were used to analyse the data.

RESULTS

Symptoms were significantly correlated with symptom-related distress (r = 0·67, p < 0·01). Frequency of symptoms was significantly associated with symptom self-management strategies for urinary (β = 0·50, p < 0·01), bowel (β = 0·71, p < 0·01) and sexual problems (β = 0·28, p = 0·05). The most effective strategies were as follows: pads and doing Kegel exercise for managing urinary problems, rest and endurance for bowel symptoms, and expressing feelings and finding alternative ways to express affection for management of sexual dysfunction.

CONCLUSIONS

Assessing symptom self-management among men with newly diagnosed prostate cancer can help healthcare providers develop strategies that will enhance health-related quality of life.

RELEVANCE TO CLINICAL PRACTICE

Results provide information on effective strategies that patients with prostate cancer found to reduce their symptoms. The strategies used provide a foundation for developing and testing interventions for personalised symptom management.

High perceived stress is linked to afternoon cortisol levels and greater symptom distress in patients with localized prostate cancer

BACKGROUND

Patients treated with radical prostatectomy (RP) or radiation therapy (RT) for prostate cancer can experience stress and symptoms that impact quality of life.

OBJECTIVE

The objectives of this study were to describe cortisol levels, perceived stress, symptoms, and symptom distress; compare differences in variables measured between RP and RT; and identify associations among cortisol levels, perceived stress, symptoms, and symptom distress in patients treated for localized prostate cancer.

METHODS

A descriptive, cross-sectional study was conducted with 53 patients (RP n = 24, RT n = 29). Data from saliva, questionnaires, and interviews were collected within 3 months of treatment. Saliva samples were collected at 4 times over 2 consecutive days. Data were analyzed using descriptive statistics, correlations, and regressions.

RESULTS

A robust diurnal rhythm of cortisol secretion with heightened levels in the early morning and lowered levels late in the day was found. On average, the entire sample had moderate symptoms and symptom distress for urinary, bowel, and sexual dysfunction. The RP group reported significantly more urinary and sexual dysfunction symptoms and fewer bowel symptoms than did the RT group. Perceived stress was positively correlated with higher afternoon cortisol levels and greater symptom distress.

CONCLUSION

Moderate symptoms and symptom distress found in our sample indicate the need for interventions to address these outcomes in men treated for prostate cancer. Self-reported perceived stress can be used to assess the stress level and symptom distress in clinic setting.

IMPLICATIONS FOR PRACTICE

Patients treated for prostate cancer with RP or RT should be assessed for symptoms and symptom distress and targeted for early symptom management interventions.

A meta-synthesis of women's symptoms experience and breast cancer

The aim of this paper is to examine the symptom experience of women with breast cancer using meta-synthesis. Women with breast cancer may experience many symptoms resulting from the primary disease and/or treatment of the disease. It is very important the overall symptom experience from the patients' perspective is captured and understood by health professionals. The question developed was 'What is the symptom experience of women with breast cancer from time of diagnosis to completion of treatment'. The meta-synthesis process as developed by Sandelowski and Barroso was used to collect and analyse the data. The overarching idea emerging from this meta-synthesis is that the symptoms experience for women with breast cancer has effects on the very 'self' of the individual. Emerging is women's need to consider the existential issues that they face while simultaneously dealing with a multitude of physical and psychological symptoms. This meta-synthesis develops a new, integrated, and more complete interpretation of findings on the symptom experience of women with breast cancer. The results offer the clinician a greater understanding in depth and breadth than the findings from individual studies on symptom experiences.

Understanding distress and distressing experiences in patients living with multiple myeloma: an exploratory study

PURPOSE

The aim of this study was to gain greater insight into the symptoms and distressing experiences of patients living with myeloma.

METHODS

A qualitative interview evaluation of distressing experiences in patients with myeloma, following a grounded theory approach, was used. Sampling was purposive, with particular attention to diversity in age and ethnic minority patients.

RESULTS

Fifteen patients were interviewed. Key findings suggest that (a) many individual symptoms were not considered as particularly distressing beyond the acute phase of the disease and its treatment, except when they occurred in a context that was threatening to the patients; (b) visible symptoms that showed to other people one's disease condition may be particularly distressing, and (c) the conditioning phase of the transplant was particularly stressful and a violation to one's body, described by some patients as 'being somehow dead'.

CONCLUSION

The personal meaning ascribed to symptoms and treatments as well as the context in which they occur are important determinants of distress. Such patient meanings and contexts should be explored by health professionals in-depth, in order to prepare patients for the experience and support them more fully.

Predictors of psychosocial adjustment during the postradiation treatment transition

The aim of this study was to examine the role of cognitive appraisal in predicting psychosocial adjustment during the postradiation treatment transition. A predictive correlational design was used in a convenience sample of 80 patients with breast, lung, and prostate cancer who were receiving radiation therapy. Two weeks prior to completion of treatment, participants completed instruments to measure symptom distress, uncertainty, cognitive appraisal, social support, and self-efficacy for coping. The Psychosocial Adjustment to Illness Scale was administered 1 month after therapy. Adjustment was significantly correlated with all independent variables, age, and comorbidity. Young age and high amounts of threat appraisal, harm/loss appraisal, uncertainty, and symptom distress were significantly associated with poor adjustment. The model predicted 52% of the variability in adjustment. Cognitive appraisal was not a significant explanatory variable for adjustment when controlling for uncertainty, cancer stage, age, and symptom distress. Symptom distress was the only significant predictor of adjustment.

Breast cancer survivors' experiences of lymphedema-related symptoms

CONTEXT

As a serious chronic condition from breast cancer treatment, lymphedema or a syndrome of persistent swelling and symptoms is caused by chronic accumulation of lymph fluid in the interstitial spaces of the affected limb or surrounding areas. Although significant prevalence of ongoing multiple symptoms has been reported, little is known about how survivors with lymphedema perceive and respond to lymphedema-related symptoms in their daily lives.

OBJECTIVES

The purpose of this study was to explore and describe breast cancer survivors' lymphedema-related symptom experiences.

METHODS

This study used a descriptive phenomenological method. Thirty-four participants were recruited in the United States. Three in-depth interviews were conducted with each participant; a total of 102 interviews were completed, audio taped, and transcribed. Interview transcripts and field notes were the data sources for this analysis, which was part of three larger studies. Data were analyzed to identify the essential themes within and across cases.

RESULTS

Four essential themes were revealed: living with perpetual discomfort, confronting the unexpected, losing pre-lymphedema being, and feeling handicapped. Participants experienced multiple symptoms on a daily basis. Distress was heightened when women expected symptoms to disappear, but instead, they remained as a "perpetual discomfort." Moreover, distress was intensified when symptoms evoked unexpected situations or when symptoms elicited emotional responses powerful enough to change perceived personal identity.

CONCLUSIONS

Findings suggest that symptom distress may encompass temporal, situational, and attributive dimensions. Prospective studies are needed to examine lymphedema-related symptom distress in terms of these dimensions so that more specific interventions can be developed to target distress occurring in each dimension.

Bowel problems, self-care practices, and information needs of colorectal cancer survivors at 6 to 24 months after sphincter-saving surgery

The aim of this study was to describe bowel problems, self-care practices, and information needs of patients who have recovered from the acute effects of sphincter-saving surgery for colorectal cancer. A retrospective, descriptive survey was conducted using a structured telephone interview and mailed questionnaires. The sample consisted of 101 patients who had undergone sphincter-saving surgery for colorectal cancer in the last 6 to 24 months. Most participants (71.3%) reported a change in bowel habits after surgery. The 6 most frequently reported gastrointestinal problems were incomplete evacuation (75.2%), excessive flatus (75.2%), urgency (73.3%), straining (61.4%), perianal soreness or itching (49.5%), and bloating (43.6%). Incontinence of feces (varying from smears to complete bowel action) was reported by 37.6% of participants. The most frequently reported information needs were related to diet (50.5%) and managing conditions such as diarrhea (31.7%), bloating/wind/gas (28.7%), pain (21.8%), and incomplete emptying of the bowel (18.8%). Patients who had recovered from the acute effects of sphincter-saving surgery for colorectal cancer reported a wide range of bowel problems and ongoing concerns about managing symptoms. Findings from this study provide valuable information to guide the development of educational resources to prevent or better manage bowel problems after surgery.

Examining pain-related distress in relation to pain intensity and psychological distress

Despite frequent use of the term symptom distress in the pain literature, symptom distress is often confused with symptom intensity and psychological distress, contributing to inadequate assessment of symptoms and less than ideal symptom management. In this article we address these issues and propose a hybrid model, combining Price's interaction of pain sensation, pain unpleasantness, and secondary pain affect model with an information processing model. Recommendations on methods and techniques to reduce this confusion would assist healthcare professionals and researchers to better distinguish among these terms as they manage patient symptoms and design symptom management studies. Thus, the purpose of this article is to examine the terms symptom distress, symptom intensity, and psychological distress using pain as the example symptom.

The symptom experience in the first 100 days following allogeneic hematopoietic stem cell transplantation (HSCT)

GOALS OF WORK

Despite advances in allogeneic hematopoietic stem cell transplantation (HSCT), post-transplant complications are common, and patients' symptom experience has not been well documented.

PURPOSE

To characterize the symptom experience of adult patients pre-transplantation and days 0, 30, and 100 after allogeneic HSCT.

METHODS

Data from 76 participants enrolled in a prospective health-related quality of life (HRQL) study were used. Symptom occurrence, distress, and clusters were determined based on the 11 symptoms of the Symptom Distress Scale (SDS).

RESULTS

Participants were on average 40 years old (SD +/- 13.5). The majority (54%) received reduced intensity conditioning. Prevalent symptoms included fatigue (68%) and worry (68%) at baseline, appetite change (88%) at day 0, and fatigue at days 30 (90%) and 100 (81%). Participants reported the following symptoms as severely distressing: worry (16%) [baseline], insomnia (32%) [day 0], appetite change (22%) [day 30], and fatigue (11%) [day 100]. The total SDS score was highest at day 0 (M = 26.6 +/- 7.6) when the highest number of symptoms were reported [median = 8 (1-11)]. Symptoms formed clusters comprised of fatigue, appearance change, and worry at baseline, and fatigue, insomnia, and bowel changes at days 0 and 30. Compared to those with low symptom distress, participants with moderate/severe symptom distress reported poorer HRQL.

CONCLUSION

Allogeneic HSCT patients present for transplantation with low symptom distress yet experience multiple symptoms and high symptom distress after HSCT conditioning. Understanding the symptom experience of allogeneic HSCT patients can guide management strategies and improve HRQL.

Symptoms and symptom distress in localized prostate cancer

For over a decade, symptom distress has been a key concept in several studies of cancer. However, the definition of symptom distress is still unclear, and there are few measures targeting symptom distress, in general, and specific cancers, in particular. Prostate cancer is the sixth most common cancer worldwide and the second leading cause of death in American men. Many men with clinically localized prostate cancer may experience unique and multidimensional symptoms that occur from diagnosis through treatment, and thereafter. These symptoms associated with the disease and its treatments are in the form of physical and psychological sequelae such as urinary and bowel problems and sexual dysfunction. The purposes of this article are to (1) systematically review literature on symptoms and symptom distress in localized prostate cancer and (2) synthesize evidence of symptom distress applications and measurement in this group. A comprehensive, systematic review was conducted to identify original, data-based studies of symptoms and symptom distress in localized prostate cancer. Clarification of symptom distress and more comprehensive information about symptoms and symptom distress will provide nurses with a better foundation for developing self-management interventions aimed at ameliorating symptom distress and, ultimately, enhancing the quality of life of patients with localized prostate cancer.

Measuring symptom occurrence and symptom distress: development of the symptom experience index

AIM

This paper is a report of a study to assess reliability and construct validity of revised and refined version of the Adapted Symptom Distress Scale: the Symptom Experience Index (SEI).

BACKGROUND

The development of the SEI, a 41-item Likert Scale assessing 20 symptoms, was based on self-regulation theory and an integrative conceptual analysis of symptom assessment and management. The model emphasizes the difference between the occurrence of a symptom (or multiple symptoms) and the distress (emotional) response to the occurrence of a symptom. It is the distress from symptom occurrence that promotes a person to take action and use known coping strategies to prevent the symptom occurrence or alleviate the distress from the symptom.

METHOD

A contrast-group and test-retest approach was used to assess construct validity and reliability with a convenience sample of 158 patients at United States of America in 2003-2004.

RESULTS

The SEI demonstrated reasonable internal consistency with a Cronbach's alpha of 0.91 for symptom experience, 0.85 for symptom occurrence and 0.84 for symptom distress. Test-retest reliability was supported by high intra-class correlation coefficients (symptom experience r = 0.93; symptom occurrence r = 0.94; symptom distress, r = 0.92). Construct validity was supported by statistically significant differences between patients and healthy adults.

CONCLUSION

The SEI can be used as a baseline and outcome measure to assess the impact of multiple symptoms on patients, and the effectiveness of interventions to manage these symptoms.

Sildenafil reduces bother associated with erectile dysfunction: pooled analysis of five randomized, double-blind trials

Improvement in bother associated with erectile dysfunction (ED) is an important aspect of successful treatment of ED. Changes in erectile function and the bother associated with ED were assessed in this analysis of pooled data from five 12-week, multicenter, randomized, double-blind, placebo-controlled, flexible-dose studies of sildenafil. Men who received sildenafil (n=578, vs placebo, n=550) had significantly greater (least squares mean+/-s.e.) improvement in erectile function (EF) domain scores of the international index of erectile function (IIEF) (10.0+/-0.3 vs 1.0+/-0.3, P<0.0001) and in erection distress scale (EDS) total transformed score (18.8+/-0.8 vs 4.8+/-0.9, P<0.0001). Scores on individual questions of the EDS were 24-65% higher after treatment with sildenafil (vs 8-12%, for placebo). The change in EF domain score correlated positively with the change in total transformed EDS score (0.43, P<0.0001). Successful treatment of ED with sildenafil may reduce the bother associated with ED.

Coping with recurrent breast cancer: predictors of distressing symptoms and health-related quality of life

Little is known about how postmenopausal women with recurrent breast cancer cope with distressing symptoms and which factors predict health-related quality of life (HRQOL). In the present study, 56 consecutively enrolled patients completed questionnaires measuring symptom occurrence, coping capacity, coping efforts, and HRQOL at the time of recurrence. Results from this study illustrate that women with recurrent breast cancer suffer from multiple, concurrent, and interrelated symptoms of illness, anxiety, depression, and fatigue. Highly prevalent symptoms are lack of energy, difficulty sleeping, pain, worrying, problems with sexual interest, feeling sad, and dry mouth. The most frequently occurring symptom is problem with sexual interest, and the most severe symptom is worrying. The most distressing symptom experienced is pain. The majority of the women report 10-23 symptoms. Women who experience multiple symptoms also report higher levels of symptom distress. The experience of distressing symptoms is predicted by coping capacity, and the coping efforts experienced predict HRQOL. Patients with lower coping capacity report higher prevalence of symptoms, experience higher levels of distress, and experience worse perceived health, which in turn may decrease their HRQOL. To help women manage recurrent breast cancer, it is important to use multidimensional measurement to identify, evaluate, and treat distressing symptoms, and not assess single symptoms only. Care must be based upon the awareness of critical factors that exacerbate vulnerability to distress, as well as the ability to adapt to a recurrent breast cancer disease.

Symptom Burden: A Concept Analysis and Implications for Oncology Nurses

PURPOSE/OBJECTIVES

To analyze the concept of symptom burden and discuss implications for symptom research and symptom management.

DATA SOURCES

MEDLINE, CINAHL, PsycINFO, Cochrane Reviews, and published literature.

DATA SYNTHESIS

Through Rodgers's evolutionary method of concept analysis, attributes of symptom burden were identified as dynamic, multidimensional, quantifiable, subjective, and physiologic. The major antecedent was multiple symptoms related to worsening disease status. Consequences of symptom burden included decreased survival, poor prognosis, delay or termination of treatment, increased hospitalizations and medical costs, decreased functional status, and lowered self-reported quality of life. Symptom burden is defined as the subjective, quantifiable prevalence, frequency, and severity of symptoms placing a physiologic burden on patients and producing multiple negative, physical, and emotional patient responses.

CONCLUSIONS

Symptom burden is an important concept in the symptoms experience, separate from symptom distress and other related terms. The continued differentiation of symptom concepts is important for sound methodologic research and meaningful interventions that affect and improve patient experiences.

IMPLICATIONS FOR NURSING

Clarifying multiple symptom concepts in the symptoms experience, determining appropriate measurement methodologies for the concepts, and identifying appropriate strategies will lessen the burden of symptoms and contribute to improved quality of life and better patient outcomes.

Measuring therapeutic response in chronic graft-versus-host disease: National Institutes of Health Consensus Development Project on Criteria for Clinical Trials in Chronic Graft-versus-Host Disease: IV. Response Criteria Working Group report

The lack of standardized criteria for quantitative measurement of therapeutic response in clinical trials poses a major obstacle for the development of new agents in chronic graft-versus-host disease (GVHD). This consensus document was developed to address several objectives for response criteria to be used in chronic GVHD-related clinical trials. The proposed measures should be practical for use both by transplantation and nontransplantation medical providers, adaptable for use in adults and in children, and focused on the most important chronic GVHD manifestations. The measures should also give preference to quantitative, rather than semiquantitative, measures; capture information regarding signs, symptoms, and function separately from each other; and use validated scales whenever possible to demonstrate improved patient outcomes and meet requirements for regulatory approval of novel agents. Based on these criteria, we propose a set of measures to be considered for use in clinical trials, and forms for data collection are provided (). Measures should be made at 3-month intervals and whenever major changes are made in treatment. Provisional definitions of complete response, partial response, and progression are proposed for each organ and for overall outcomes. The proposed response criteria are based on current expert consensus opinion and are intended to improve consistency in the conduct and reporting of chronic GVHD trials, but their use remains to be demonstrated in practice.