Gastrointestinal symptom representation in cancer symptom clusters: a synthesis of the literature

Symptom clusters, fear of disease progression, and quality of life in postoperative gastric cancer patients: a cross-sectional study

BACKGROUND

Gastric cancer is a common tumor globally. Surgery is the preferred treatment for gastric cancer. Yet, little is known about its symptom clusters, fear of disease progression, and quality of life (QoL). This study aims to investigate the severity of symptom clusters, fear of disease progression, and quality of life of postoperative gastric cancer patients; to analyze the correlation between symptom clusters, fear of disease progression, and quality of life of postoperative gastric cancer patients; and to provide theoretical bases for the development of an intervention plan to enhance the quality of life of postoperative gastric cancer patients.

METHODS

A convenience sampling method was used to select 158 postoperative gastric cancer patients from a tertiary hospital in Xiamen City from January 2023 to April 2023 for the study. Data were collected using the General Information Evaluation Form, M.D. Anderson Symptom Inventory-Gastrointestinal Cancer Module (MDASI-GI), Fear of Progression Questionnaire-Short Form (FoP-Q-SF), and Functional Assessment of Cancer Therapy-General (FACT-G). Data were analyzed with EpiData 3.1 and SPSS 26.0. Symptom clusters were extracted via exploratory factor analysis. Differences in QoL based on patient characteristics were analyzed using t tests or one-way analysis of variance (ANOVA). Pearson correlation and multiple linear regression analyses were used to explore relationships among symptom clusters, fear of disease progression, and QoL.

RESULTS

The overall quality of life score in the FACT-G scale was (52.32 ± 10.58), of which the social/family status score was (16.47 ± 3.62), the physical status score was (14.24 ± 5.66), the functional status was (11.35 ± 4.48), and the emotional status score was (10.25 ± 3.53). The fear of disease progression score of postoperative gastric cancer patients was (37.37 ± 6.37), of which the physical health dimension score was (21.58 ± 4.01), and the social/family dimension score was (15.74 ± 4.07). Two symptom clusters were identified: physical/emotional sickness and gastrointestinal symptom cluster. The results of Pearson correlation analysis showed that symptom cluster severity was negatively correlated with quality of life (r =  - 0.508, P < 0.01); symptom cluster severity was significantly positively correlated with fear of disease progression (r = 0.260, P < 0.01); and fear of disease progression was significantly negatively correlated with quality of life (r =  - 0.194, P < 0.05). Multiple linear regression analyses showed that the physical/emotional sickness symptom cluster, physical health fears, and physical state of postoperative gastric cancer patients were the affecting factors of quality of life (P < 0.001).

CONCLUSION

Two symptom clusters were identified in postoperative gastric cancer patients in mainland China. Fear of disease progression was at a medium-high level, and QoL was at a medium level. Common symptoms included fatigue, pain, and worry. The physical state, physical health, and the physical/emotional sickness symptom cluster affect the quality of life of postoperative gastric cancer patients. Targeted clinical interventions are necessary to improve QoL in postoperative gastric cancer patients.

Gut Microbiome and Symptom Burden in Obese and Non-Obese Women Receiving Chemotherapy for Breast Cancer

Purpose: Obese women with breast cancer experience high symptom burden, poor quality of life, and increased mortality compared to non-obese women with breast cancer. Obesity-related changes to the bacteria of the gut, the GI microbiome, may be one such mechanism for these differences in outcomes. The purpose of this work is to report symptom burden and GI microbiome composition between obese and non-obese women with breast cancer to identify potential microbial influences for symptom severity. Methods: 59 women with breast cancer (26 obese, 33 non-obese) provided symptom reports using the Memorial Symptom Assessment Scale and stool samples for 16S analysis one week after receiving chemotherapy. Symptom reports were summarized and examined for differences based on obesity. Fecal microbiome analysis was compared between groups using alpha-diversity (Shannon index), beta-diversity (Principal Coordinate Analysis with weighted UniFrac distances), and LASSO analysis of abundance of bacterial species. Results: While symptom burden was high, it did not differ based on obesity status. Alpha- and beta-diversity did not find significant differences based on obesity, but LASSO analysis identified eight bacteria to be significantly enriched in obese participants: Collinsella aerofacien, Prevotella 7, Coprobacillus cateniformis, Ruminococcus torques group, Agathobacter, Frisingicoccus, Roseburia inulinivorans, and Monoglobus pectinilyticus. Conclusions: Identifying biologic mechanisms driving symptoms is necessary for the development of therapies to reduce cancer-related symptom burden. While obesity may alter the GI microbiome and influence symptom burden in women with breast cancer, these effects may be outweighed by the effects of chemotherapy on the gut.

Symptom clusters of patients with advanced thyroid cancer: a cross-sectional study

PURPOSE

To investigate and analyze the symptom clusters of patients with advanced thyroid cancer and provide a basis for developing targeted symptom management measures.

METHODS

Patients who visited a multidisciplinary outpatient service for advanced thyroid cancer at a tertiary A hospital in Sichuan Province from April 2022 to April 2023 were selected using convenience sampling. A cross-sectional survey was conducted using the M.D. Anderson Symptom Inventory-Thyroid Cancer module (MDASI-THY). Symptom clusters were extracted by exploratory factor analysis.

RESULTS

Disturbed sleep had the highest incidence (75.7%) and severity (3.0 points), while mood distress had the highest incidence (63.5%) and severity (2.0 points) of symptom interference. Three symptom clusters were identified: mood-fatigue-sleep, digestive tract-sensation, and thyroid cancer-specific symptom clusters.

CONCLUSION

Patients with advanced thyroid cancer have multiple symptom clusters that seriously affect their daily lives. Health care professionals should conduct targeted observation and preventive treatment to reduce the burden of symptoms on patients.

Proton pump inhibitors may increase the risk of cisplatin-induced acute kidney injury in patients with nasopharyngeal carcinoma: a prospective cohort study

Cisplatin is the most commonly used platinum-based treatment for nasopharyngeal carcinoma (NPC). However, its clinical application is limited owing to its nephrotoxicity and gastrointestinal reactions. Proton pump inhibitors (PPIs) have been reported to increase nephrotoxicity risk in previous studies. We aimed to evaluate whether PPIs increase cisplatin-induced nephrotoxicity in patients with NPC. In total, 295 patients were included in this prospective cohort study: 145 in the PPIs group and 150 in the non-PPIs group. All patients underwent cisplatin-based induction chemotherapy, followed by cisplatin-based concurrent chemoradiotherapy. The PPIs group received 40 mg of intravenous esomeprazole sodium for 7 days in each chemotherapy cycle. Chi-squared test and logistic regression analyses with odds ratios and 95% confidence intervals were applied to assess the association between PPIs and the risk of acute kidney injury (AKI). AKI incidence in the PPIs group was significantly higher than that in the non-PPIs group (P = 0.005). After adjusting for various confounders including demographic features, clinical features, and renal function indices, PPIs use was significantly associated with a higher AKI risk (odds ratio: 2.775; 95% confidence interval 1.280-6.020; P = 0.010). The incidences of acute and chronic kidney diseases were similar between both groups (P > 0.05), whereas the incidence of nausea was lower in the PPIs group than in the non-PPIs group (P = 0.029). This study has shown that PPIs use may increase the risk of cisplatin-induced acute nephrotoxicity in patients with NPC.

Membrane Lipid Replacement for reconstituting mitochondrial function and moderating cancer-related fatigue, pain and other symptoms while counteracting the adverse effects of cancer cytotoxic therapy

Cancer-related fatigue, pain, gastrointestinal and other symptoms are among the most familiar complaints in practically every type and stage of cancer, especially metastatic cancers. Such symptoms are also related to cancer oxidative stress and the damage instigated by cancer cytotoxic therapies to cellular membranes, especially mitochondrial membranes. Cancer cytotoxic therapies (chemotherapy and radiotherapy) often cause adverse symptoms and induce patients to terminate their anti-neoplastic regimens. Cancer-related fatigue, pain and other symptoms and the adverse effects of cancer cytotoxic therapies can be safely moderated with oral Membrane Lipid Replacement (MLR) glycerolphospholipids and mitochondrial cofactors, such as coenzyme Q10. MLR provides essential membrane lipids and precursors to maintain mitochondrial and other cellular membrane functions and reduces fatigue, pain, gastrointestinal, inflammation and other symptoms. In addition, patients with a variety of chronic symptoms benefit from MLR supplements, and MLR also has the ability to enhance the bioavailability of nutrients and slowly remove toxic, hydrophobic molecules from cells and tissues.

Preliminary Analysis of Gut Microbiome and Gastrointestinal Symptom Burden in Breast Cancer Patients Receiving Chemotherapy Compared to Healthy Controls

BACKGROUND

Alterations in the naturally occurring bacteria of the gut, known as the gastrointestinal (GI) microbiome, may influence GI symptoms in women with breast cancer.

OBJECTIVE

This work aims to describe GI symptom occurrence, duration, severity, and distress and measures of the GI microbiome among women with breast cancer receiving chemotherapy compared to age- and sex-matched healthy controls.

INTERVENTIONS/METHODS

22 women with breast cancer receiving chemotherapy and 17 healthy control women provided stool specimens and GI symptom data using the modified Memorial Symptom Assessment Scale (MSAS). The fecal microbiome was profiled by metagenomic sequencing of 16S Ribosomal RNA (rRNA). GI microbiome was compared between groups using alpha-diversity (Observed OTU number and Shannon index), beta-diversity (UniFrac distances), and relative abundance of select genera.

RESULTS

GI symptoms with high symptom reports among breast cancer patients included nausea, diarrhea, flatulence, dry mouth, taste change, and poor appetite. Indices of differential abundance (beta diversity) significantly distinguished between breast cancer patients and healthy controls. Unique bacterial features differentiating the 2 groups were Prevotella_9, Akkermansia, Lachnospira, Lachnospiraceae_NK4A136, Lachnoclostridium, and Oscillibacter.

CONCLUSIONS

Gut bacteria are associated with GI inflammation and mucus degradation, suggesting the potential role of the GI microbiome in GI symptom burden. Understanding the influence of GI bacteria on gut health and symptoms will help harness the enormous potential of the GI microbiome as a future diagnostic and therapeutic agent to reduce the symptom burden associated with chemotherapy.

Co-occurrence of symptoms after radiochemotherapy in locally advanced cervix cancer patients: a cluster analysis

BACKGROUND

State of the art combined radiochemotherapy and image-guided brachytherapy for locally advanced cervical cancer (LACC) has shown improved disease control and survival as well as a significant reduction of organ related morbidity. However, LACC cancer survivors are still experiencing a spectrum of symptoms. The aim of this study was to identify co-occurring symptoms in cervix cancer survivors by using patient-reported outcome and physician assessed morbidity.

MATERIALS AND METHOD

EMBRACE I is a multicenter prospective observational study with 1416 LACC patients (2008-2015). Information on physician-assessed morbidity and patient-reported outcome was assessed at baseline and at regular follow-ups up with the CTCAE v.3 and EORTC-C30/CX24, respectively. Patients with at least 2 years of follow-up were included and data from 3 months to 2 years was used in the analysis. Factor analysis was used on both EORTC and CTCAE data with symptoms and follow-ups as observations. The extracted factors represent clusters of symptoms. Subsequently, regression models were built to investigate associations between the symptom clusters and QOL.

RESULTS

The analysis included 742 patients. Despite the differences in the definition of physician-assessed and patient-reported symptoms, similar clusters are identified by the two assessment methods. Three main organ-related clusters are recognized for urinary, gastro-intestinal and vaginal morbidity. Furthermore, a general symptoms cluster where fatigue, pain, insomnia, neuropathy, and hot flashes have large weights is found. Lastly, a cluster with nausea, vomit and lack of appetite is also identified. The general, gastrointestinal and nausea clusters show significant associations with general QOL.

CONCLUSIONS

This analysis on both PRO and physician-assessed morbidity found a cluster associated with general symptoms and organ-related symptom clusters (urinary, gastrointestinal, vaginal). This shows that LACC survivors experience a variety of co-occurring symptoms. Our analysis also shows that the cluster of general symptoms is associated with a decrease in QOL.

Systemic Diseases and Gastrointestinal Cancer Risk

Importance

Gastrointestinal (GI) cancers are the second leading cause of cancer-related deaths worldwide.

Observations

The global challenges GI cancers pose are high, especially in middle- and low-income countries. Patients with these cancers present with symptoms of poor appetite, weight loss, heartburn, abdominal pain, fatigue and anaemia. Several risk factors contribute to GI cancers, including age, gender, obesity, pathogenic infections, smoking cigarettes, alcohol consumption and dietary habits. Most of these cancers are sporadic. However, some patients are at high risk due to a family history of GI cancers. Systemic diseases affect multiple organs, and their chronic occurrence elicits inflammatory responses at various sites. These diseases also contribute to GI cancers.

Conclusion and Relevance

In this review, we discuss that untreated systemic diseases, including diabetes, hepatitis, acquired immune deficiency syndrome, ulcers and hypertension, can potentially lead to GI cancers if they remain untreated for a longer period. Systemic diseases initiate oxidative stress, inflammatory pathways and genetic manipulations, which altogether confer risks to GI cancers. Here, we describe the association between systemic diseases and their underlying mechanisms leading to GI cancers.

Symptom burden survey and symptom clusters in patients with cervical cancer: a cross-sectional survey

PURPOSE

The purpose of this study is to determine the incidence and severity of symptoms of patients with cervical cancer within 6 months after radiotherapy and chemotherapy, form a symptom burden report, evaluate the distribution characteristics of symptoms, identify symptom clusters, and provide a basis for clinical doctors and nurses to improve the symptom management of patients with cervical cancer after radiotherapy and chemotherapy.

METHODS

The patients with cervical cancer within 6 months after radiotherapy and chemotherapy were recruited to investigate their symptom burden. Exploratory factor analysis was used to identify symptom clusters.

RESULTS

A total of 250 patients participated in the study. The study found that the most common symptom among the 40 symptoms was fatigue, and the most serious symptom was nocturia. Based on the occurrence rate and severity of symptoms, nine symptom clusters were identified, including psycho-emotion-related symptom cluster, pain-disturbed sleep-related symptom cluster, menopausal symptom cluster, tinnitus-dizziness-related symptom cluster, urinary-related symptom cluster, dry mouth-bitter taste-related symptom cluster, intestinal-related symptom cluster, memory loss-numbness-related symptom cluster, and emaciation-related symptom cluster. The three most serious symptom clusters are pain-disturbed sleep-related symptom cluster, urinary-related symptom cluster, and memory loss-numbness-related symptom cluster.

CONCLUSION

The symptoms of patients with cervical cancer within 6 months after radiotherapy and chemotherapy are complex, and nine symptom clusters can be identified according to the incidence and severity of symptoms. We can find the potential biological mechanism of each symptom cluster through the discussion of previous mechanism research and clinical research. The number of symptom clusters and the number of symptoms within the symptom cluster are closely related to the symptom evaluation scale selected for the study. Therefore, the symptom cluster study urgently needs a targeted symptom evaluation scale that can comprehensively reflect the patient's condition.

The core symptom in multiple myeloma patients undergoing chemotherapy: a network analysis

BACKGROUND

During chemotherapy for multiple myeloma, symptoms include those related to the disease, as well as adverse effects of the treatment. Few studies have explored the relationships between these symptoms. Network analysis could identify the core symptom in the symptom network.

OBJECTIVE

The aim of this study was to explore the core symptom in multiple myeloma patients undergoing chemotherapy.

METHODS

This was a cross-sectional study in which sequential sampling was used to recruit 177 participants from Hunan, China. Demographic and clinical characteristics were surveyed using a self-developed instrument. The symptoms of chemotherapy-treated multiple myeloma, including pain, fatigue, worry, nausea, and vomiting, were measured using a questionnaire with good reliability and validity. The mean ± SD, frequency, and percentages were used as descriptive statistics. Network analysis was used to estimate the correlation between symptoms.

RESULTS

The results showed that 70% of multiple myeloma patients using chemotherapy exhibited pain. In the network analysis, worrying was the dominant symptom, and the strongest relationship was between nausea and vomiting in chemotherapy-treated multiple myeloma patients' symptoms.

CONCLUSION

Worrying is the core symptom of multiple myeloma patients. Interventions could be most effective if there is a symptom management focus on worrying when providing care to chemotherapy-treated multiple myeloma patients. Nausea combined with vomiting could be better managed, which would decrease the cost of health care. Understanding the relationship between the symptoms of multiple myeloma patients undergoing chemotherapy is beneficial for precise symptom management.

IMPLICATIONS FOR PRACTICE

Nurses and health care teams should be a priority to intervene in the worrying for chemotherapy-treated multiple myeloma patients to maximize the effectiveness of an intervention. Except, nausea and vomiting should be managed together in a clinical setting.

Evaluation of the Effect of Self-Efficacy on Symptoms in Gastrointestinal Cancer Patients

Objective: The incidence of gastrointestinal cancer is increasing day by day and is among the highest 10 cancer types in the world. This study was conducted to evaluate the effects of self-efficacy of patients with gastrointestinal system cancer on symptom clusters. Methods: This cross-sectional study was conducted with 105 patients treated for gastrointestinal system cancer in a hospital located in the south of Turkey. In the study, patients over 18 years of age without hearing or speech impairment were included. To determine symptom clusters, Latent Profile Analysis and comparison of self-efficacy scale items by symptom clusters were performed with Chi-square, ANOVA, and Kruskal Wallis test. Results: The mean age of the patients was 58.83 ± 13.1 years; of the patients, 37.1% had colon ca, 21.9% had rectum ca. The patients had higher mean scores of fatigue, pain, feeling distressed, feeling sad, dry mouth, sleep disturbance, loss of appetite and nausea in the last week. The patients had higher mean scores of fatigue, pain, feeling distressed, feeling sad, dry mouth, sleep disturbance, loss of appetite and nausea in the last week. Three symptom clusters were determined by latent profile analysis; high, moderate, mild. It was determined that the level of self-efficacy was high in the symptom cluster which is low symptom severity and number of symptoms (p < .05). Conclusion: The number and the severity of symptoms are lower in patients with high self-efficacy perceptions.

Relationships Between Colorectal Cancer Survivors' Positive Psychology, Symptoms, and Quality of Life

This cross-sectional study examined colorectal cancer (CRC) survivors' symptom and symptom cluster characteristics (occurrence, frequency, and severity), positive psychology (benefit-finding and post-traumatic growth), and quality of life (QoL), and determined whether positive psychology moderates symptoms and QoL relationship during acute cancer survivorship, time from diagnosis to treatment completion. A total of 117 CRC survivors completed demographics, symptoms, QoL, and positive psychology questionnaires. Descriptive statistics, multiple linear regression, and moderation analyses were performed. Participants reported high QoL (94%, M = 5.15) and moderate-high positive psychology (75%, M = 3.21). Nineteen symptoms and five symptom clusters were inversely related to QoL (p < .05). Positive psychology (M = ~≥3.24) moderated the relationship of QoL (p < .05) with symptoms occurrence (n = 10), symptom severity (n = 1), and with the generalized symptom cluster (weakness, fatigue, dizziness, drowsy, sleep disturbances, and pain). Positive psychology aids in symptom management and improves QoL. Nurses are poised to identify, prevent, promote, and advocate self-management skills to improve health-related outcomes.

Patient-reported gastrointestinal symptoms following surgery for gastric cancer and the relative risk factors

Purpose

The study aims to assess the incidence of short-term patient-reported postoperative gastrointestinal symptoms (PGISs) after gastric cancer surgery and explore the relative risk factors for the symptoms.

Methods

Patients with radical gastrectomy were included for this retrospective and observational study. Symptoms extracted from the MD Anderson Symptom Inventory Gastrointestinal Cancer Module (MDASI-GI) were collected in postdischarge week (PDW) 1 and postoperative month (POM) 1. The distributing states of symptoms were analyzed in PDW1 and POM1. Logistic regression models were used to identify risk factors for PGISs.

Results

Among 356 patients with complete interviews, 156 (43.8%) patients reported abdominal distention in PDW1, which was significantly higher than patients in POM1 [103 (28.9%), p &lt; 0.001]. Pain (15.2% vs. 9.8%), dysphagia (5.6% vs. 7.0%), diarrhea (3.7% vs. 3.4%), and vomiting (2.5% vs. 2.8%) had no significant differences between PDW1 and POM1. Logistic models found that risk factors for PGISs were total gastrectomy [odds ratio (OR): 1.948; 95% CI: 1.097–3.459; p = 0.023] and disturbed sleep (OR: 3.116; 95% CI: 1.831–5.303; p &lt; 0.001) in PDW1 and female gender (OR: 1.726; 95% CI: 1.071–2.782; p = 0.025), total gastrectomy (OR: 1.729; 95% CI: 1.055–2.834; p = 0.030), and disturbed sleep (OR: 3.533; 95% CI: 1.757–7.106; p &lt; 0.001) in POM1.

Conclusions

The main symptom after gastric cancer surgery was abdominal distention. The relative risk factors for gastrointestinal symptoms after gastric cancer surgery were total gastrectomy and disturbed sleep. Timely symptom intervention may improve the quality of life of postgastrectomy patients.

Symptom clusters in outpatients with cancer using different dimensions of the symptom experience

PURPOSE

Relatively few studies have evaluated for symptom clusters across multiple dimensions. It is unknown whether the symptom dimension used to create symptom clusters influences the number and types of clusters that are identified. Study purposes were to describe ratings of occurrence, severity, and distress for 38 symptoms in a heterogeneous sample of oncology patients (n = 1329) undergoing chemotherapy; identify and compare the number and types of symptom clusters based on three dimensions (i.e., occurrence, severity, and distress); and identify common and distinct clusters.

METHODS

A modified version of the Memorial Symptom Assessment Scale was used to assess the occurrence, severity, and distress ratings of 38 symptoms in the week prior to patients' next cycle of chemotherapy. Symptom clusters for each dimension were identified using exploratory factor analysis.

RESULTS

Patients reported an average of 13.9 (±7.2) concurrent symptoms. Lack of energy was both the most common and severe symptom while "I don't look like myself" was the most distressing. Psychological, gastrointestinal, weight gain, respiratory, and hormonal clusters were identified across all three dimensions. Findings suggest that psychological, gastrointestinal, and weight gain clusters are common while respiratory and hormonal clusters are distinct.

CONCLUSIONS

Psychological, gastrointestinal, weight gain, hormonal, and respiratory clusters are stable across occurrence, severity, and distress in oncology patients receiving chemotherapy. Given the stability of these clusters and the consistency of the symptoms across dimensions, the use of a single dimension to identify these clusters may be sufficient. However, comprehensive and disease-specific inventories need to be used to identify distinct clusters.

A Review of the Clinical Implications of Cachexia, Sarcopenia, and BMI in Patients with Peritoneal Carcinomatosis Receiving Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

Simple Summary

Patients with peritoneal carcinomatosis from varying cancers may be affected by weight loss and decreased muscle mass, the hallmarks of cachexia. These patients can undergo surgical management via cytoreductive surgery and hyperthermic intraperitoneal chemotherapy to improve their overall survival. Here, we review the current literature investigating the impact of sarcopenia, cachexia, and body mass index on outcomes in a patient population that undergo surgical treatment. The results vary across the studies suggesting that further investigation is necessary to better understand the impact of these entities on postoperative outcomes and survival.

Abstract

Peritoneal carcinomatosis (PC) is the dissemination of cancer throughout the peritoneal cavity. Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is the surgical treatment of choice in highly selected patients. The aim of this narrative review was to assess the impact of cachexia, sarcopenia, and body mass index (BMI) on patient outcomes for patients undergoing CRS and HIPEC for peritoneal carcinomatosis. A narrative review was performed and articles pertaining to cachexia, sarcopenia, BMI, peritoneal carcinomatosis, and CRS/HIPEC were reviewed and selected. In total, 3041 articles were screened and seven original studies met the inclusion criteria. In summary, obesity was found to not be a contraindication to surgery, but the impact of BMI was variable across the spectrum. Decreased skeletal muscle mass was found to be associated with poorer postoperative outcomes in three studies and with worse overall survival in two. With limited data, evaluating the impact of BMI, sarcopenia, and cachexia on patients with PC undergoing CRS and HIPEC was difficult as most studies included heterogeneous cancer patient populations; thus, postoperative outcomes and survival were inconsistent across studies. More research is needed to better understand its impact and to better generalize the results for each cancer subset treated with CRS and HIPEC across diverse patient populations.

Symptom clusters in 1330 survivors of 7 cancer types from the PROFILES registry: A network analysis

Background

Research into the clustering of symptoms may improve the understanding of the underlying mechanisms that affect survivors' symptom burden. This study applied network analyses in a balanced sample of cancer survivors to 1) explore the clustering of symptoms and 2) assess differences in symptom clustering between cancer types, treatment regimens, and short‐term and long‐term survivors.

Methods

This study used cross‐sectional survey data, collected between 2008 and 2018, from the population‐based Patient Reported Outcomes Following Initial Treatment and Long Term Evaluation of Survivorship registry, which included survivors of 7 cancer types (colorectal cancer, breast cancer, ovarian cancer, thyroid cancer, chronic lymphocytic leukemia, Hodgkin lymphoma, and non‐Hodgkin lymphoma). Regularized partial correlation network analysis was used to explore and visualize the associations between self‐reported symptoms (European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire) and the centrality of these symptoms in the network (ie, how strongly a symptom was connected to other symptoms) for the total sample and for subgroups separately.

Results

In the total sample (n = 1330), fatigue was the most central symptom in the network with moderate direct relationships with emotional symptoms, cognitive symptoms, appetite loss, dyspnea, and pain. These relationships persisted after adjustments for sociodemographic and clinical characteristics. Connections between fatigue and emotional symptoms, appetite loss, dyspnea, and pain were consistently found across all cancer types (190 for each), treatment regimens, and short‐term and long‐term survivors.

Conclusions

In a heterogenous sample of cancer survivors, fatigue was consistently the most central symptom in all networks. Although longitudinal data are needed to build a case for the causal nature of these symptoms, cancer survivorship rehabilitation programs could focus on fatigue to reduce the overall symptom burden.

In a sample of 1330 survivors, fatigue is found to be the most central symptom (ie, the symptom most strongly connected to other symptoms) in the network with moderate direct relationships with emotional symptoms, cognitive symptoms, appetite loss, dyspnea, and pain. Connections between fatigue and emotional symptoms, appetite loss, dyspnea, and pain were consistently found across all cancer types (colorectal cancer, breast cancer, ovarian cancer, thyroid cancer, chronic lymphocytic leukemia, Hodgkin lymphoma, and non‐Hodgkin lymphoma, n = 190 for each group), treatment regimens, and short‐term and long‐term survivors.

Distress among cancer patients attending rehabilitation in the community

Purpose

The aim of this study is to identify sources of distress among cancer patients attending rehabilitation in the community.

Methods

Participants were 430 patients recruited from a cancer rehabilitation center in Singapore between 2017 and 2018, who had rated their distress using the distress thermometer (DT) and indicated associated problems on the problem list. Chi-square tests were used to detect differences in the reported symptoms among three age groups. Exploratory factor analysis was used to identify symptom clusters. Partial correlational analysis was then performed to examine the relationship between distress, symptom clusters, and age controlling for gender and cancer type.

Results

About 30% of the participants reported distress ≥ 5 on the DT (mean 3.3 ± 2.5), and the mean number of problems endorsed was 8 ± 6. A higher total number of reported problems (r = .63) and younger age (r =  − .21) were associated with increased distress. The younger age group also reported more problems surrounding emotions, finance, work/school, children-related issues, and physical symptoms such as sleep and nausea. Of the 12 factors identified, 9 psychosocial and physical symptom clusters correlated with distress (r ranging from .12 to .41). All results were statistically significant after adjustment (p ≤ 0.05).

Conclusion

Younger survivors are more at risk of distress and report greater role functioning concerns related to childcare, partner relationship, and work participation. Age-tailored and multimodal interventions may be necessary to adequately address age-related differences and help coordinate management of multiple symptom clusters across physical and psychosocial concerns.

Self-reported late effect symptom clusters among young pediatric cancer survivors

PURPOSE

Most survivors of childhood cancer experience subsequent chronic conditions but little is known about concurrent symptoms. This study seeks to identify late effect symptom clusters among young pediatric cancer survivors.

METHODS

Survivors ≥ 18 or parents of survivors < 18 years enrolled in an institutional cohort study indicated (yes/no) if they experienced certain symptoms after treatment. The sample was randomly divided in half for exploratory factor analyses to identify symptom clusters followed by confirmatory factor analyses. Symptoms with ≥ 10% prevalence were included. Cluster structure generalizability across subgroups was examined using congruence coefficients.

RESULTS

The sample included 579 survivors (74% non-Hispanic white, 45% leukemia, 12.8 ± 4.5 years at survey, 5.9 ± 3.5 years since therapy). Respondents averaged three symptoms. Three clusters were identified: (1) gastrointestinal: abdominal pain, diarrhea, constipation, nausea, vomiting (Cronbach's α = 0.74); (2) psychological: depression, anxiety, memory problems, anger management problems, sleep problems (α = 0.71); and (3) neurologic: problems walking, numbness/tingling, fatigue, back pain, chronic pain, weakness/inability to move legs (α = 0.71). Confirmatory factor analysis confirmed the three-cluster structure (standardized root mean square residual: 0.09; parsimonious goodness of fit: 0.96; Bentler-Bonett normed fit index: 0.95). The gastrointestinal and psychological clusters were generalizable across most subgroups while the neurologic cluster varied across age and race/ethnicity subgroups.

CONCLUSION

Three distinct late effect symptom clusters were identified in young childhood cancer survivors with gastrointestinal and psychological clusters remaining relatively stable across subgroups. Future studies should focus on the characteristics of patients who experience these symptoms, especially those with high symptom burden, and the synergistic impact on quality of life.

Characteristics of Cancer Symptom Clusters Reported through a Patient-Centered Symptom Cluster Assessment

In the scope of symptom cluster research, few investigators have obtained patients' perceptions of their symptom clusters, even though this information is central to designing effective interventions. In this cross-sectional study, 38 adults with cancer completed measures of demographics, health outcomes (functional status, well-being, quality of life) and a symptom cluster assessment that captured symptom occurrence, severity, distress, clustering, a priority cluster, causal attributions, duration, directional relationships, and cluster interference with daily life. Participants described 72 distinct symptom clusters. Symptoms were most frequently attributed to the cancer diagnosis. Participants' priority symptom cluster typically included two symptoms of continuous duration and one intermittent symptom. Temporal order and direction of symptom relationships varied, with 75 different relationships described among symptom pairs. Greater symptom cluster burden and interference were related to poorer health outcomes. This patient-centered view of symptom clusters revealed substantial variability in symptom cluster characteristics with important implications for symptom management.

A Proposed Theory of Symptom Cluster Management

Background

Symptom cluster management is in its early stages in many chronic and debilitating illnesses. The development of a proposed theory should be an initial step in advancing this area of interest.

Objective

This article presents the development of a Proposed Theory of Symptom Cluster Management.

Methods

The concept analysis, statement synthesis, and theory synthesis by Walker and Avant were used in the development of this proposed theory. A search from July to September 2020 for published empirical and theoretical articles was conducted in scientific databases, expanded on the web, and secondary references from identified articles.

Results

The Proposed Theory of Symptom Cluster Management is both a descriptive and explanatory theory. The defining characteristics of symptom cluster management include the basic and effectiveness components. Antecedents for symptom cluster management include socio-demographic characteristics, symptom cluster characteristics, individual clinical characteristics, individual illness factors, and situational factors or symptom experience. The consequences are clustered as personal-related, health-related, social-related outcomes, and existential outcomes. Measurement tools for the antecedents and outcomes in symptom cluster management and the analytical and statistical strategies were considered. Relational statements were also identified. Theoretical assertions were advanced.

Conclusion

The Proposed Theory of Symptom Cluster Management may provide a holistic approach because it integrates both the symptom cluster and management strategies. The concepts, statements including the complete representation of the proposed theory identified in this article, may provide cues to policymakers and clinical researchers towards the development of tailored interventions and programs.

The Influence of Multiple Chronic Conditions on Symptom Clusters in People With Solid Tumor Cancers

BACKGROUND

People with cancer who also have multiple chronic conditions (MCCs) experience co-occurring symptoms known as symptom clusters.

OBJECTIVE

To describe MCC and symptom clusters in people with cancer and to evaluate the relationships between MCCs and symptom severity, symptom interference with daily life, and quality of life (QoL).

METHODS

Weekly over a 3-week chemotherapy cycle, 182 adults with solid tumor cancer receiving chemotherapy completed measures of symptom severity, symptom interference with daily life, and QoL. Medical records reviewed to count number of MCCs in addition to cancer. Exploratory factor analysis was performed to identify symptom clusters. The relationships between the number of MCCs and the outcomes (symptom severity and symptom interference with daily life and QoL) at each time point were examined using the χ2 test. Longitudinal changes in outcomes were examined graphically.

RESULTS

The number of MCCs ranged from 0 to 9, but most participants (62.1%) had 2 or fewer MCCs. Obesity was the most prevalent chronic condition. Four symptom clusters were identified: nutrition, neurocognitive, abdominal discomfort, and respiratory clusters. At each time point, no significant differences were found for MCCs and any outcome. However, symptom severity in all the symptom clusters, symptom interference with daily life, and QoL demonstrated a worsening in the week following chemotherapy.

CONCLUSION

A majority of our sample had 2 or fewer MCCs, and MCCs did contribute to patient outcomes. Rather, timing of chemotherapy cycle had the greatest influence of patient outcomes.

IMPLICATIONS FOR PRACTICE

Additional support on day 7 of chemotherapy treatment is needed for people with MCCs.

Effect of Electrical Stimulation on Gastrointestinal Symptoms in Lung Cancer Patients during Chemotherapy: A Randomized Controlled Trial

Objective:

The objective was to evaluate the effects of transcutaneous acupoint electric stimulation (TAES) and gastric electrical stimulation (GES) on cancer patients with chemotherapy-induced gastrointestinal (GI) symptoms.

Methods:

A total of 122 lung cancer patients receiving chemotherapy were assigned randomly to the following two groups: control group (usual care group, n = 61) and intervention group (TAES plus GES, n = 61). TAES involved two acupoints such as Neiguan (PC6) and Zusanli (ST36). GES was performed at gastric pacing sites on the body surface such as the places of projection of gastric antrum and corpus on the body surface. GES was performed on these sites for 14 days continuously (25 min every time, once daily). The effects of TAES and GES on GI symptoms were assessed using the Memorial Symptom Assessment Scale on the day prior to chemotherapy (time point 1) and days 14 (time point 2) and 28 (time point 3) after chemotherapy.

Results:

No significant differences in the demographic and disease-related variables were detected between the two groups. Differences in symptom occurrence and severity at time point 1 were not statistically significant between the two groups (both P > 0.05). At time points 2 and 3, GI symptoms such as loss of appetite, nausea, vomiting, diarrhea, and constipation in the stimulation group had statistically significantly improved compared with the control group (all P < 0.05).

Conclusions:

TAES and GES were efficacious in relieving GI discomfort in lung cancer patients after chemotherapy. TAES combined with GES is a safe and easy-to-use tool to manage GI symptoms in practice.

Symptom Clusters and Quality of Life in Cervical Cancer Patients Receiving Concurrent Chemoradiotherapy: The Mediating Role of Illness Perceptions

OBJECTIVES

Although studies shows that symptom clusters and illness perceptions are negatively associated with quality of life (QoL), it is unclear how these variables of cervical cancer patients who receive concurrent chemoradiotherapy (CCRT) relate to each other. This study aimed to identify the symptom clusters in cervical cancer patients who receive CCRT and evaluate the mediating effect of illness perceptions on the relationship between symptom clusters and QoL.

METHODS

A cross-sectional survey was conducted on 286 cervical cancer patients receiving CCRT from October 2019 to October 2020. M.D. Anderson Symptom Inventory, Brief Illness Perception Questionnaire, and Functional Assessment Cancer Therapy-Cervix were applied to investigate the symptom clusters, illness perceptions and QoL of the participants, respectively. Exploratory factor analysis was conducted to identify symptom clusters. The relationships among symptom clusters, illness perceptions, and QoL were analyzed with the structural equation modeling.

RESULTS

A total of four symptom clusters were identified, including psychological status symptom cluster, therapy side-effect symptom cluster, sickness symptom cluster, and gastrointestinal symptom cluster (χ² = 1,552.282, Df = 78, P < 0.001). Symptom clusters, illness perceptions, and QoL were significantly correlated. Symptom clusters had significant direct (β = -0.38, P < 0.001) and indirect effects (β = -0.21, P < 0.001) on QoL.

CONCLUSION

Illness perceptions played a significant mediating role between symptom clusters and QoL in cervical cancer patients receiving CCRT. Strategies like prompting effective symptom management for the purposes of alleviating illness perceptions may contribute to improving their QoL.

Cachexia Anorexia Syndrome and Associated Metabolic Dysfunction in Peritoneal Metastasis

Patients with peritoneal metastasis (PM) of gastrointestinal and gynecological origin present with a nutritional deficit characterized by increased resting energy expenditure (REE), loss of muscle mass, and protein catabolism. Progression of peritoneal metastasis, as with other advanced malignancies, is associated with cancer cachexia anorexia syndrome (CAS), involving poor appetite (anorexia), involuntary weight loss, and chronic inflammation. Eventual causes of mortality include dysfunctional metabolism and energy store exhaustion. Etiology of CAS in PM patients is multifactorial including tumor growth, host response, cytokine release, systemic inflammation, proteolysis, lipolysis, malignant small bowel obstruction, ascites, and gastrointestinal side effects of drug therapy (chemotherapy, opioids). Metabolic changes of CAS in PM relate more to a systemic inflammatory response than an adaptation to starvation. Metabolic reprogramming is required for cancer cells shed into the peritoneal cavity to resist anoikis (i.e., programmed cell death). Profound changes in hexokinase metabolism are needed to compensate ineffective oxidative phosphorylation in mitochondria. During the development of PM, hypoxia inducible factor-1α (HIF-1α) plays a key role in activating both aerobic and anaerobic glycolysis, increasing the uptake of glucose, lipid, and glutamine into cancer cells. HIF-1α upregulates hexokinase II, phosphoglycerate kinase 1 (PGK1), pyruvate dehydrogenase kinase (PDK), pyruvate kinase muscle isoenzyme 2 (PKM2), lactate dehydrogenase (LDH) and glucose transporters (GLUT) and promotes cytoplasmic glycolysis. HIF-1α also stimulates the utilization of glutamine and fatty acids as alternative energy substrates. Cancer cells in the peritoneal cavity interact with cancer-associated fibroblasts and adipocytes to meet metabolic demands and incorporate autophagy products for growth. Therapy of CAS in PM is challenging. Optimal nutritional intake alone including total parenteral nutrition is unable to reverse CAS. Pressurized intraperitoneal aerosol chemotherapy (PIPAC) stabilized nutritional status in a significant proportion of PM patients. Agents targeting the mechanisms of CAS are under development.

A Cognitive-Behavioral Intervention for the Symptom Clusters of Chinese Patients With Gastrointestinal Tract Cancer Undergoing Chemotherapy: A Pilot Study

BACKGROUND

Patients with gastrointestinal tract (GIT) cancer undergoing chemotherapy often experience several symptoms that constitute symptom clusters and can cause patients to suffer. Effective interventions are lacking for this kind of patients.

OBJECTIVE

The aims of this study were to test the feasibility and acceptability of a cognitive-behavioral (CB) intervention developed for Chinese patients with GIT cancer undergoing chemotherapy and to estimate the efficacy of the intervention for symptom clusters.

METHODS

In this pilot, quasi-randomized controlled trial, 40 patients were assigned to the CB intervention or control group. The CB intervention, considering characteristics of patients and Chinese culture, contained 4 sections including cognitive reframing, cancer-diet education, relaxation, and exercise techniques. Symptom clusters, illness perception, anxiety, and depression were measured.

RESULTS

Thirty-nine patients (97.5%) completed the study program and expressed willingness to follow the intervention. Compared with the control group, all outcomes were improved (all P < .05) in the CB group after the intervention, except for the gastrointestinal symptom cluster (t = 0.25, P = .802). In the CB group, the scores of all outcomes (all P < .05) decreased except for depression (t = 1.76, P = .095).

CONCLUSION

The CB intervention is partially feasible and acceptable. It may also help to improve part of the symptom clusters of Chinese patients with GIT cancer undergoing chemotherapy. However, some modifications are needed in future studies to better test effectiveness.

IMPLICATIONS FOR PRACTICE

Symptom management remains a major problem in clinical nursing. Such a CB intervention can be beneficial to the clinical management of symptom clusters.

The effectiveness of non-pharmacological interventions in the management of symptom clusters in adult cancer patients: a systematic review protocol

REVIEW QUESTION/OBJECTIVE

To what extent are non-pharmacological interventions effective in reducing symptom clusters in terms of presence, frequency and severity, compared with standard care?More specifically, the objectives are to: CENTER CONDUCTING THE REVIEW:: The Hanoi Medical University Nursing Research Center for Evidence Based Health Care: a Collaborating Centre of the Joanna Briggs Institute; and Centre for Evidence-based Healthy Aging: an Affiliate Centre of the Joanna Briggs Institute, School of Nursing, Queensland University of Technology, Australia.

Prevalence, Duration, Severity, and Distress of Chemotherapy-Related Gastrointestinal Symptoms in Patients With a Hematologic Malignancy

PURPOSE/OBJECTIVES

To describe prevalence, duration, severity, and distress of chemotherapy-related gastrointestinal (GI) symptoms, and evaluate inclusion of clinically relevant GI symptom items on cancer symptom questionnaires.
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DESIGN

Longitudinal descriptive design.
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SETTING

Inpatient and outpatient hematology settings.
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SAMPLE

105 adults with a hematologic malignancy receiving their third or subsequent cycle of chemotherapy. 
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METHODS

Participants completed weekly assessments of 19 GI symptoms during a three-week period of chemotherapy. Descriptive statistics were calculated to summarize GI symptom prevalence, duration, severity, and distress ratings at each week. Findings were compared to item content of 12 cancer multisymptom questionnaires identified in the literature.
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MAIN RESEARCH VARIABLES

GI symptom prevalence, duration, severity, and distress.
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FINDINGS

Participants reported an average of three to five GI symptoms at each time point that were typically experienced as mild to moderate in duration, severity, and distress. Only 3 of 11 clinically relevant GI symptoms were included on more than half of the cancer symptom questionnaires. 
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CONCLUSIONS

Patients receiving chemotherapy experience a moderate GI symptom burden across a wide range of potential GI symptoms.
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IMPLICATIONS FOR NURSING

Future research should include measures of clinically relevant GI symptoms that may be emerging with new cancer therapies and toxicity prevention protocols.

Cancer Cachexia: Cause, Diagnosis, and Treatment

Patients with cancer frequently experience unintended weight loss due to gastrointestinal (GI) dysfunction caused by the malignancy or treatment of the malignancy. However, others may present with weight loss related to other symptoms not clearly associated with identifiable GI dysfunction such as anorexia and early satiety. Cancer cachexia (CC) is a multifactorial syndrome that is generally characterized by ongoing loss of skeletal muscle mass with or without fat loss, often accompanied by anorexia, weakness, and fatigue. CC is associated with poor tolerance of antitumor treatments, reduced quality of life (QOL), and negative impact on survival. Symptoms associated with CC are thought to be caused in part by tumor-induced changes in host metabolism that result in systemic inflammation and abnormal neurohormonal responses. Unfortunately, there is no single standard treatment for CC. Nutrition consequences of oncologic treatments should be identified early with nutrition screening and assessment. Pharmacologic agents directed at improving appetite and countering metabolic abnormalities that cause inefficient nutrient utilization are currently the foundation for treating CC. Multiple agents have been investigated for their effects on weight, muscle wasting, and QOL. However, few are commercially available for use. Considerations for choosing the most appropriate treatment include effect on appetite, weight, QOL, risk of adverse effects, and cost and availability of the agent.

Distress-Based Gastrointestinal Symptom Clusters and Impact on Symptom Interference and Quality of Life in Patients with a Hematologic Malignancy Receiving Chemotherapy

BACKGROUND/SIGNIFICANCE

People with cancer can experience co-occurring related symptoms, labeled symptom clusters. Gastrointestinal (GI) symptoms are common side effects of chemotherapy, but little research has investigated GI symptom clusters. A further gap in symptom cluster research is the lack of studies reporting symptom clusters based on symptom distress ratings.

PURPOSE

To identify distress-based GI symptom clusters and to investigate their relationship to symptom interference with daily life and quality of life (QoL).

SUBJECTS

About 105 adults with hematologic malignancy receiving chemotherapy.

METHODS

On Day 1 of a cycle of chemotherapy, participants completed a modified version of the Memorial Symptom Assessment Scale assessing 30 clinically relevant symptoms, the M.D. Anderson Symptom Inventory Symptom Interference with Daily Life subscale, and the Fox Simple Quality of Life Scale. Exploratory factor analysis was used to identify distress-based symptom clusters. Symptom clusters with ≥50% GI symptoms were labeled GI symptom clusters. Linear mixed modeling explored relationships between GI symptom clusters and symptom interference with daily life and QoL.

RESULTS

Of the six distress-based symptom clusters found, the bloating cluster and appetite cluster were identified as GI symptom clusters. Both the bloating cluster and the appetite cluster were significantly related to symptom interference with daily life, but only the appetite cluster was significantly related to QoL.

CONCLUSIONS

This research demonstrates the existence of distress-based GI symptom clusters and their relationship to symptom interference and QoL. Future work should explore predictors of distress-based symptom clusters and interventions to manage them.

Advancing Symptom Science Through Symptom Cluster Research: Expert Panel Proceedings and Recommendations

An overview of proceedings, findings, and recommendations from the workshop on "Advancing Symptom Science Through Symptom Cluster Research" sponsored by the National Institute of Nursing Research (NINR) and the Office of Rare Diseases Research, National Center for Advancing Translational Sciences, is presented. This workshop engaged an expert panel in an evidenced-based discussion regarding the state of the science of symptom clusters in chronic conditions including cancer and other rare diseases. An interdisciplinary working group from the extramural research community representing nursing, medicine, oncology, psychology, and bioinformatics was convened at the National Institutes of Health. Based on expertise, members were divided into teams to address key areas: defining characteristics of symptom clusters, priority symptom clusters and underlying mechanisms, measurement issues, targeted interventions, and new analytic strategies. For each area, the evidence was synthesized, limitations and gaps identified, and recommendations for future research delineated. The majority of findings in each area were from studies of oncology patients. However, increasing evidence suggests that symptom clusters occur in patients with other chronic conditions (eg, pulmonary, cardiac, and end-stage renal disease). Nonetheless, symptom cluster research is extremely limited and scientists are just beginning to understand how to investigate symptom clusters by developing frameworks and new methods and approaches. With a focus on personalized care, an understanding of individual susceptibility to symptoms and whether a "driving" symptom exists that triggers other symptoms in the cluster is needed. Also, research aimed at identifying the mechanisms that underlie symptom clusters is essential to developing targeted interventions.

Cancer Symptom Cluster Management

OBJECTIVES

To discuss the importance of cancer symptom clusters in clinical practice, review evidence for symptom cluster interventions, and make recommendations for symptom cluster identification, patient education, and management in clinical practice.

DATA SOURCES

Primary research and review articles identified through CINAHL, PubMed, and PsycINFO databases.

CONCLUSION

Several studies have investigated interventions for multi-symptom management or have evaluated the secondary effects of a single-symptom intervention on related symptoms. To date, only five studies have tested an intervention designed to manage a specific cancer symptom cluster. Those studies used nonpharmacologic approaches (psycho-education, cognitive-behavioral strategies, and acupressure) to address the pain, fatigue, and sleep disturbance symptom cluster, or the respiratory distress symptom cluster with some initial evidence of success. Further development and efficacy testing of symptom cluster interventions is needed.

IMPLICATIONS FOR NURSING PRACTICE

Clinical practice can be guided by knowledge of individual and multi-symptom management, and clinical judgment regarding possible etiologies of cancer symptom clusters. Clinicians should be aware of co-occurring symptoms in their patients, educate and involve patients in identifying symptom clusters and aggravating/alleviating factors, and coordinate treatment recommendations using strategies that are likely to be beneficial across symptoms.

Assessment of Multiple Co-Occurring Cancer Symptoms in the Clinical Setting

OBJECTIVES

To discuss multiple co-occurring cancer symptoms, review symptom assessment instruments, identify innovative methods to integrate symptom assessment and management in the clinical setting, and examine barriers and facilitators for implementation of symptom assessment and use of clinical practice guidelines.

DATA SOURCES

Peer-reviewed articles, guidelines, systematic reviews, and web-based resources.

CONCLUSION

Despite the availability of brief, reliable, and valid instruments, symptom assessment has not been integrated as a routine aspect of clinical care. New technologies and changes in health policy provide an optimal environment to integrate electronic symptom assessment and management into cancer care.

IMPLICATIONS FOR NURSING PRACTICE

Oncology nurses play a key role in early identification and management of distressing symptoms.

Cachexia-anorexia syndrome in patients with peritoneal metastasis: an observational study

Background: Little is known about the nutritional status of patients with peritoneal metastasis (PM), in particular about the evolution of the so-called anorexia-cachexia syndrome in these patients. The objective of the study was to assess nutritional status in PM patients at the end of life, including metabolic aspects. Methods: Observational study. Prospective nutritional status assessment in 87 PM patients, including Subjective Global Assessment: (SGA), physical examination (body mass index [BMI], bioelectrical impedance analysis [BIA], anthropometry and blood chemistry). Results: 85 % patients had received previous chemotherapy. Peritoneal carcinomatosis index was 16±11, Karnofsky 81±14 % and ascites volume 1,000±1,690 ml. SGA was reduced with 22.0±9.6 points, BMI normal with 25.3±5.8 kg/m² and resting metabolism was 1,527±248 kcal/day. Serum total protein and albumin were at the inferior normal limit (6.5±0.8 g/dl, respectively 3.7±0.8 g/dl) and C-reactive protein (CRP) was elevated (2.9±4.1 g/dl). Serum levels of protein (p=0.05), albumin (p=0.003) and transferrin (p=0.001) were higher in gastrointestinal than in ovarian PM patients. When patients were grouped according to time from first assessment to death, serum protein and albumin decreased until end of life, whereas ascites volume, resting metabolism and CRP increased. Conclusion: Both increased resting metabolism and decreased caloric intake contribute to the development of the cachexia-anorexia syndrome in PM patients. End of life is caused by energetic dysbalance and exhaustion.

Systematic bias in cancer patient-reported outcomes: symptom 'orphans' and 'champions'

INTRODUCTION

Patient-reported outcomes are an integral part of modern healthcare. We report a comparison of symptom item content from several validated cancer instruments to that of a published checklist, and identify the important differences this revealed.

METHODS

We defined orphans as any symptom not assessed in any of the six selected instruments; champions, in contrast, were present in all six. An empirically derived cancer multisymptom checklist was used.Three symptom categories were identified Orphan-absent from all 6,Champion-present in all 6,Intermediate-underreported. The contents of each validated instrument were cross-referenced against the checklist.

RESULTS

Eighteen (39%) checklist symptoms were orphans. Five (11%) were champions: fatigue, pain, anorexia, dyspnoea and nausea. Of the 46 checklist symptoms, 23 (50%) were inconsistently recorded. All 18 orphan symptoms were clinically important checklist symptoms. Common gastrointestinal and neuropsychological symptoms that pose great clinical management challenges were among the orphan symptoms.

CONCLUSIONS

Of 46 checklist cancer symptoms, over a third were orphans. All orphan symptoms were rated as clinically important and distressing by checklist. Only 5 checklist symptoms were champions: fatigue, pain, anorexia, dyspnoea and nausea. Important-but usually omitted-symptoms included early satiety (6 of 6) and weight loss (5 of 6). The bias appears to disproportionately affect gastrointestinal and neuropsychiatric symptoms. Symptom studies should specifically report the limitations and account for the inherent item bias of any instrument used.

Examining patterns of multivariate, longitudinal symptom experiences among older adults with type 2 diabetes and cancer via cluster analysis

PURPOSE

Diabetes and cancer are chronic conditions that produce symptoms, some unique to each condition and others common to both. Previous studies have reported on subgroups of patients who experience distinct combinations of symptoms in cross-sectional samples and the univariate longitudinal trajectories of individual symptoms. The literature currently lacks examples of research that take a multivariate longitudinal perspective to understanding patients' symptom experiences. The purpose of this study was to identify subgroups of patients who share distinct multivariate longitudinal profiles with respect to how symptom severity changes over time for a set of five symptoms (pain, fatigue, change in appetite, nausea, and numbness and tingling).

METHODS

This exploratory study included 43 participants with pre-existing diabetes from eight community-based cancer centers who were receiving chemotherapy for a solid tumor. Using baseline and 8-week data, a model-based cluster analysis with Bayesian regularization was used to identify subgroups.

RESULTS

Two groups were identified. Group 1 experienced mild symptoms that changed very little at 8 weeks; group 2 experienced mild to moderate symptom severity, with small increases in fatigue, nausea, and numbness and tingling. Effect size confidence intervals suggest that level of depression, length of time with diabetes, and severity of diabetes at baseline may differ between groups.

CONCLUSIONS

More research in this area is needed to further test this model, address limitations associated with analyzing a small sample, and explore factors that may be associated with changes in the overall symptom experience for patients with diabetes and cancer.

Cancer symptom clusters: an exploratory analysis of eight statistical techniques

CONTEXT

Statistical methods to identify symptom clusters (SC) have varied between studies. The optimal statistical method to identify SC is unknown.

OBJECTIVES

Our primary objective was to explore whether eight different statistical techniques applied to a single data set produced different SC. A secondary objective was to investigate whether SC identified by these techniques resembled those from our original study.

METHODS

We reanalyzed a symptom data set of 1000 patients with advanced cancer. Eight separate cluster analyses were conducted on both prevalence and severity of 38 symptoms. Hierarchical cluster analysis identified clusters at r-values of 0.6, 0.5, and 0.4. For prevalence and severity, the Spearman correlation and Kendall tau-b correlation, respectively, measured the similarity (distance) between symptom pairs. Sensitivity analysis of the prevalence data was done with Cohen kappa coefficient as a similarity measure. The K-means clustering method validated clusters.

RESULTS

Hierarchical cluster analysis identified similar cluster configurations from the 38 symptoms using an r-value of 0.6, 0.5, or 0.4. A cutoff point of 0.6 yielded seven clusters. Five of them were identical at all three r-values used: (1) fatigue/anorexia-cachexia: anorexia, dry mouth, early satiety, fatigue, lack of energy, taste changes, weakness, and weight loss (>10%); (2) gastrointestinal: belching, bloating, dyspepsia, and hiccough; (3) nausea/vomiting: nausea and vomiting; (4) aerodigestive: cough, dysphagia, dyspnea, hoarseness, and wheeze; (5) neurologic: confusion, hallucinations, and memory problems. Regardless of the threshold, there were always some symptoms (e.g., pain) that did not cluster with any others. Seven clusters were validated by K-means analysis.

CONCLUSION

Seven SC identified from both prevalence and severity data were consistently present irrespective of the statistical analysis used. There were only minor variations in the number of clusters and their symptom composition between analytical techniques. All seven clusters originally identified were confirmed. Four consistent SC were found in all analyses: aerodigestive, fatigue/anorexia-cachexia, nausea/vomiting, and upper GI. Our results support the clinical importance of the SC concept.

The role of thalidomide and placebo for the treatment of cancer-related anorexia-cachexia symptoms: results of a double-blind placebo-controlled randomized study

OBJECTIVES

To determine the effects of thalidomide and placebo on anorexia-cachexia and its related symptoms, body composition, resting metabolic rate, and serum cytokines and their receptors in patients with advanced cancer.

METHODS

Included in the study were patients with advanced cancer with weight loss greater than 5% in 6 months and who reported anorexia, fatigue, and one of the following: anxiety, depression, or sleep disturbances. Patients on chemotherapy within 2 weeks prior or during the study were excluded from the study. Patients were randomly assigned to either 100 mg thalidomide or placebo once a day for 14 days. The Edmonton Symptom Assessment Scale (ESAS), Functional Assessment of Anorexia/Cachexia Therapy (FAACT), Functional Assessment of Cancer Illness Therapy (FACIT-F), Hospital Anxiety Depression Scale (HADS) Pittsburgh Sleep Quality Index (PSQI) were utilized, and in addition body composition, Resting Energy Expenditure (REE), and serum cytokine levels were assessed.

RESULTS

Of the 31 patients entered in the study, 15 were assigned to the thalidomide group and 16 to the placebo group. However only 21/31 patients were able to complete the study. Compared with their baseline values, both the thalidomide and the placebo groups showed significant reduction in cytokines. Tumor necrosis factor (TNF)-α (p=0.04) and its receptors TNFR1 (p=0.04), TNFR2 (p=0.04), and interleukin (IL)-8 (p=0.04) were statistically significant in the thalidomide group. In the placebo group, TNF-α (p=0.008), TNFR1 (p=0.005), TNFR2 (p=0.005), IL-RA (p=0.005), IL-6 (p=0.005), and IL-8 (p=0.005) were statistically significant. However, improvement in these symptoms and cytokine levels were not significantly different in the thalidomide group compared with the placebo group. None of the patients withdrew from the study because of toxicity of either thalidomide or placebo.

CONCLUSIONS

Based on the poor accrual rate and attrition observed in this study, it is important that future research on thalidomide as a treatment for cancer-related anorexia-cachexia symptoms (ACS) in patients with advanced cancer use less stringent entry criteria and less exhaustive outcome measures.