Symptom clusters in patients with metastatic cancer: a literature review

Effects of Auricular Acupressure on Fatigue, Sleep Quality, Physical Activity, and Quality of Life in Pancreatic Cancer Patients Undergoing Chemotherapy: A Randomized Controlled Trial

BACKGROUND

Patients with pancreatic cancer exhibit various symptoms and numerous physiological and psychological complications. Therefore, designing intervention measures to alleviate symptoms is crucial.

OBJECTIVE

This study explored the effectiveness of a 4-week auricular acupressure intervention for reducing fatigue and improving quality of life, sleep quality, and physical activity in patients receiving chemotherapy for pancreatic cancer.

METHODS

This randomized controlled trial was conducted at a medical center in northern Taiwan. The study participants comprised 80 patients undergoing chemotherapy for pancreatic cancer. The experimental group received auricular acupressure therapy for 4 weeks, which targeted the shenmen (TF4), sympathetic (AH6), liver (CO12), spleen (CO13), and subcortex (AT4) acupoints, and the control group received routine care. The European Organization for Research and Treatment of Cancer Quality of Life Group Core Questionnaire-C30, European Organization for Research and Treatment of Cancer Quality of Life Group Core Questionnaire-PAN26, Brief Fatigue Inventory-Taiwanese version, Pittsburgh Sleep Quality Index, and 3-day Physical Activity Record were used for assessment.

RESULTS

After auricular acupressure therapy for 4 weeks, the experimental group exhibited significant improvements in insomnia symptoms during weeks 1 to 4, as measured using the European Organization for Research and Treatment of Cancer Quality of Life Group Core Questionnaire-C30 (all P < .01), and improvements in sleep quality by week 4, as measured using the Pittsburgh Sleep Quality Index ( P < .036).

CONCLUSIONS

After auricular acupressure therapy for 4 weeks, significant improvements were observed in patients' sleep quality and quality of life in terms of insomnia.

IMPLICATIONS FOR PRACTICE

Auricular acupressure can improve sleep quality and other aspects of quality of life among patients undergoing chemotherapy for pancreatic cancer. The study findings indicate the potential of auricular acupressure as an adjunctive cancer care treatment.

The development of medical infographics to raise symptom awareness and promote communication to patients with cancer: A co-creation study

Objective

The study aims to develop medical infographics that have a potential to raise symptom awareness and promote symptom communication between patients diagnosed with cancer and healthcare professionals.

Methods

This study comprised four phases: 1) development of medical infographics, 2) user testing with healthcare professionals and patients, 3) selection of specific medical infographics, and 4) interviews on these specific medical infographics with patients using the think-aloud method.

Results

Design students created 22 medical infographics conveying information about six symptoms and concerns. Patients (n = 28) with cancer said that the colourful infographics evoked individual emotional responses and associations, and they facilitated their narratives of experiences with symptoms. Healthcare professionals (n = 29) thought the infographics were eye-catching and may promote dialogue on symptoms.

Conclusions

The design of medical infographics must target a specific population. When introduced, the use of medical infographics may be influenced by the physical surroundings. Medical infographics can facilitate symptom communication by creating symptom awareness and providing patients with the vocabulary to describe their symptoms and concerns.

Innovation

Medical infographics are engaging visual messages with the potential to help prepare cancer patients to communicate their symptom experiences and reduce the feeling of being alone in experiencing certain symptoms.

The prevalence and risk of symptom and function clusters in colorectal cancer survivors

PURPOSE

Our purpose was to describe the prevalence and predictors of symptom and function clusters in a diverse cohort of colorectal cancer survivors.

METHODS

We used data from a cohort of 909 adult colorectal cancer survivors. Participants were surveyed at a median of 9 months after diagnosis to ascertain the co-occurrence of eight distinct symptom and functional domains. We used factor analysis to identify co-occurring domains and latent profile analysis (LPA) to identify subgroups of survivors with different symptom and function clusters. Multinomial logistic regression models were used to identify risk/protective factors.

RESULTS

Factor analysis demonstrated a single underlying factor structure that included all eight health domains with depression and anxiety highly correlated (r = 0.87). The LPA identified three symptom and function clusters, with 30% of survivors in the low health-related quality of life (HRQOL) profile having the highest symptom burden and lowest functioning. In multivariable models, survivors more likely to be in the low HRQOL profile included being non-White, female, those with a history of cardiac or mental health conditions, and chemotherapy recipients. Survivors less likely to be in the low HRQOL profile included those with older age, greater financial well-being, and more spirituality.

CONCLUSION

Nearly one-third of colorectal cancer survivors experienced a cluster of physical and psychosocial symptoms that co-occur with clinically relevant deficits in function.

IMPLICATIONS FOR CANCER SURVIVORS

Improving the identification of risk factors for having the highest symptom and lowest function profile can inform the development of clinical interventions to mitigate their adverse impact on cancer survivors' HRQOL.

Symptom Clusters in Head and Neck Cancer: A Systematic Review and Conceptual Model

OBJECTIVE

The two approaches to symptom-cluster research include grouping symptoms and grouping patients. The objective of this systematic review was to examine the conceptual approaches and methodologies used in symptom-cluster research in patients with head and neck cancer.

DATA SOURCES

Articles were retrieved from electronic databases (CINAHL, MEDLINE via Ovid, APA PsycINFO, Scopus, Embase, and Cochrane Central Register of Controlled Trials-CENTRAL), five grey literature portals, and Google Scholar. Seventeen studies met the eligibility criteria. Eight studies grouped symptoms to identify symptom clusters, of which two used qualitative methods. The number of symptom clusters ranged from two to five, and the number of symptoms in a cluster ranged from 2 to 11. Nine studies grouped patients based on their experiences with multiple symptoms. Cluster analysis and factor analysis were most commonly used. Despite variable names and composition of symptom clusters, synthesis revealed three prominent symptom clusters: general, head and neck cancer-specific, and gastrointestinal. Being female and quality of life were significantly associated with high symptom group or cluster severity. Biological mechanisms were sparsely examined.

CONCLUSION

Symptom cluster research in head and neck cancer is emerging. Consensus on nomenclature of a symptom cluster will facilitate deduction of core clinically relevant symptom clusters in head and neck cancer. Further research is required on understanding patients' subjective experiences, identifying predictors and outcomes, and underlying mechanisms for symptom clusters.

IMPLICATIONS FOR NURSING PRACTICE

Identification of clinically relevant symptom clusters would enable targeted symptom assessment and management strategies, thus improving treatment efficiencies and patient outcomes.

Physical activity preferences before and after participation in a 6-month physical activity intervention among women with metastatic breast cancer

OBJECTIVE

This secondary analysis of the ABLE Trial (ClinicalTrials.gov NCT03148886) aimed to assess physical activity preferences before and after a 6-month physical activity intervention for women recently diagnosed with metastatic breast cancer and to investigate demographic and clinical correlates of these preferences.

METHODS

Forty-nine patients participated in the ABLE Trial, a single-arm, unsupervised 6-month physical activity intervention with activity trackers. At baseline and 6 months, physical activity preferences, physical activity level, clinical variables, demographics and social vulnerability were assessed.

RESULTS

At baseline, 49 participants were included, among whom 85% were interested in receiving physical activity counselling and 89% were interested in following a physical activity programme designed for metastatic breast cancer. At the end of the study, more participants preferred practising in a community fitness centre (66%) rather than at home (19% vs. 44% at baseline, p = .03). A higher social vulnerability score and not being treated by chemotherapy at baseline were significantly associated with lower desire to receive physical activity counselling (p = .01 and p = .04 respectively).

CONCLUSIONS

This study will help design future studies within patients with metastatic breast cancer in accordance with their preferences. Designing tailored physical activity interventions according to the participant's preferences may be one key to success for adherence.

Estimating the Frequency, Severity, and Clustering of SPADE Symptoms in Chronic Painful Chemotherapy-Induced Peripheral Neuropathy

BACKGROUND

Patients undergoing treatment for cancer commonly experience symptoms such as sleep disturbance, pain, anxiety, depression, and low energy/fatigue (SPADE), subsequently altering physical function and complicating effective symptom management. However, little is known about the frequency, severity, and clustering of SPADE symptoms in individuals with chronic painful chemotherapy-induced peripheral neuropathy (CIPN). Aims/Design: The purpose of this cross-sectional, secondary analysis was to describe the frequency, severity, and clustering of SPADE symptoms and their association with physical function in individuals with chronic painful CIPN. Participants/Subjects: Sixty individuals with chronic painful CIPN were recruited from five academic and community oncology outpatient center to participate in a randomized controlled pilot trial designed to test the efficacy of a cognitive behavioral therapy-based pain management program.

METHODS

Participants completed the 0-10 Average CIPN Pain Numerical Rating Scale and Patient-Reported Outcome Measurement Information System measures for sleep-related impairment, anxiety, depression, fatigue, and pain interference via tablet before being randomly assigned to a study arm. The frequency, severity, and clustering of SPADE symptoms were calculated via descriptive statistics and Partitioning Around Medoids cluster analysis. Spearman rank correlation was performed to determine the association between number of SPADE symptoms and pain interference severity.

RESULTS AND CONCLUSIONS

Participants (n = 59) experienced numerous SPADE symptoms. 66.1% of participants experienced at least two SPADE symptoms concurrently. The cluster analysis revealed high (n = 36) and low (n = 23) severity subgroups. There was a moderate correlation (r = 0.48) between the number of SPADE symptoms and pain interference severity. Determining the clustering of SPADE symptoms in individuals with chronic painful CIPN may lead to targeted multifaceted interventions to improve physical function.

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.

A review of the literature on symptom clusters in studies that included oncology patients receiving primary or adjuvant chemotherapy

AIMS AND OBJECTIVES

To summarise the current state of knowledge of symptom clusters research from studies that included, as part of their sample, patients who were receiving primary or adjuvant chemotherapy.

BACKGROUND

Since the concept of a symptom cluster was first introduced into the oncology literature in 2001, only four comprehensive reviews of symptom clusters research in oncology patients were identified that provide insights into this important concept in symptom management research.

DESIGN

A comprehensive review of the literature.

METHODS

A comprehensive literature search was conducted for the years 2000 to 2016. Only 19 studies met the inclusion criteria for this literature review. These studies were evaluated in terms of the symptom assessment instruments used; the statistical analysis methods used; the symptom dimension(s) used to create the symptom cluster(s); the number and types of symptom clusters identified; and whether the specific symptom clusters changed over time.

RESULTS

The number of symptom clusters identified ranged from one-seven. The majority of the studies used some type of factor analysis to create the symptom clusters. The most common symptom dimension used to create the clusters was symptom severity. A "gastrointestinal symptom cluster" was the most common symptom cluster identified. Across the eight longitudinal studies, for half of these studies the symptom clusters remained relatively stable over time.

CONCLUSIONS

Additional research is needed in oncology patients to address the assessment of symptom clusters, the specific nature of symptom clusters and whether symptom clusters change over time.

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.

Physical activity interests and preferences of cancer patients with brain metastases: a cross-sectional survey

BACKGROUND

Physical activity has been shown to positively impact cancer-related fatigue, physical functioning and quality of life outcomes in early stage cancer patients, however its role at the end stage of cancer has yet to be determined. Brain metastases are amongst the most common neurological complications of advanced cancer, with significant deterioration in fatigue and quality of life. The purpose of the present study was to examine the physical activity interests and preferences of cancer patients with brain metastases initiating palliative whole brain radiotherapy.

METHODS

Thirty-one patients aged 18 years or older, cognitively intact, diagnosed with brain metastases, and with Palliative Performance Scale scores of greater than 30%, were recruited from a multidisciplinary outpatient brain metastases clinic. An interviewer-administered survey was used to assess physical activity interests and preferences of participants who were embarking upon palliative whole brain radiotherapy.

RESULTS

87% (n = 27) of participants felt that physical activity was important, however there was limited interest in participating in a structured program at the onset of palliative whole brain radiotherapy. Lung cancer diagnosis was associated with being less interested in participating in a physical activity program, and feeling less able to participate in a physical activity program at the onset of palliative whole brain radiotherapy.

CONCLUSIONS

Cancer patients with brain metastases demonstrate limited interest and varied preferences for physical activity during palliative whole brain radiotherapy. Additional pilot work with this patient population is needed before physical activity interventions can be tested in clinical research.

Symptom Clusters in Advanced Cancer Patients: An Empirical Comparison of Statistical Methods and the Impact on Quality of Life

CONTEXT

Symptom clusters in advanced cancer can influence patient outcomes. There is large heterogeneity in the methods used to identify symptom clusters.

OBJECTIVES

To investigate the consistency of symptom cluster composition in advanced cancer patients using different statistical methodologies for all patients across five primary cancer sites, and to examine which clusters predict functional status, a global assessment of health and global quality of life.

METHODS

Principal component analysis and exploratory factor analysis (with different rotation and factor selection methods) and hierarchical cluster analysis (with different linkage and similarity measures) were used on a data set of 1562 advanced cancer patients who completed the European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire-Core 30.

RESULTS

Four clusters consistently formed for many of the methods and cancer sites: tense-worry-irritable-depressed (emotional cluster), fatigue-pain, nausea-vomiting, and concentration-memory (cognitive cluster). The emotional cluster was a stronger predictor of overall quality of life than the other clusters. Fatigue-pain was a stronger predictor of overall health than the other clusters. The cognitive cluster and fatigue-pain predicted physical functioning, role functioning, and social functioning.

CONCLUSIONS

The four identified symptom clusters were consistent across statistical methods and cancer types, although there were some noteworthy differences. Statistical derivation of symptom clusters is in need of greater methodological guidance. A psychosocial pathway in the management of symptom clusters may improve quality of life. Biological mechanisms underpinning symptom clusters need to be delineated by future research. A framework for evidence-based screening, assessment, treatment, and follow-up of symptom clusters in advanced cancer is essential.

Opportunities for targeting the fatigue-anorexia-cachexia symptom cluster

Cancer patients experience multiple symptoms throughout their illness trajectory. Symptoms consistently occurring together, known as symptom clusters, share common pathophysiologic mechanisms. Understanding and targeting such symptom clusters may allow for more effective and efficient use of treatments for a variety of symptoms. Fatigue-anorexia-cachexia is one of the most prevalent symptom clusters and significantly impairs quality of life. In this review, we explore the fatigue-anorexia-cachexia symptom cluster and focus on current and emerging therapies with an emphasis on pharmacologic management.

What bothers lung cancer patients the most? A prospective, longitudinal electronic patient-reported outcomes study in advanced non-small cell lung cancer

PURPOSE

Patients with advanced non-small cell lung cancer (aNSCLC) face a significant symptom burden. Little is known about the frequency and severity of symptoms over time, so we longitudinally characterized patients' symptoms using the Patient Care Monitor (PCM) version 2.0, an electronic symptom-assessment tool.

METHODS

Ninety-seven patients with aNSCLC completed the PCM at up to four clinic visits. We analyzed symptom data by incidence, severity, type (functional vs. nonfunctional), proximity to death, and cancer anorexia-cachexia syndrome status (CACS).

RESULTS

Functional concerns predominated, even in the non-CACS group. Average severity among the top 5 symptoms was worse for functional than nonfunctional items (mean difference 0.62, 95% CI 0.22-1.01, P = 0.003). Severe dyspnea and fatigue were the most prevalent nonfunctional symptoms; moderate/severe dyspnea was reported by at least 29% of patients, and fatigue by over 50%. Depression was reported infrequently, with over half of patients at each visit reporting "none"; moderate or severe depression was reported in only 2.5-9.3 and 3.4-6.2% of patients, respectively. The average number of moderate/severe symptoms increased with proximity to death; 84% reported moderate/severe fatigue in the last 3 months of life, compared to 48% at ≥ 12 months from death (P = 0.007).

CONCLUSIONS

Patients with aNSCLC face a significant symptom burden, which increases with proximity to death. Symptom type and severity vary by proximity to death, but even patients without overt CACS report significant functional symptoms throughout. We recommend an individualized approach to palliative symptom intervention in advanced lung cancer, based on detailed symptom assessment and tracking.