Use of a single-item screening tool to detect clinically significant fatigue, pain, distress, and anorexia in ambulatory cancer practice

Patient-reported outcome measures suitable to assessment of patient navigation

BACKGROUND

Patient-reported outcomes (PROs) are measures completed by patients to capture outcomes that are meaningful and valued by patients. To help standardize PRO measures in patient navigation research and program evaluation, the Patient-Reported Outcomes Working Group (PROWG) was convened as part of the American Cancer Society's National Patient Navigator Leadership Summit.

METHODS

The PROWG consisted of clinicians, researchers, and program managers from a variety of perspectives who developed a set of recommended PRO measures across the cancer continuum (ie, screening, diagnostic follow-up, treatment, survivorship, end of life) as well as those useful for assessing family caregivers. Measures were recommended based on face validity, responsiveness to navigation, reliability, and construct validity in relevant populations. Other considerations included readability, existence of multiple language versions, the existence of norm groups, and respondent burden.

RESULTS

The PROWG reached consensus on measures for use in the domains of treatment adherence; perceived barriers to care; satisfaction with cancer care; satisfaction with patient navigation services; working alliance with patient navigator; perceived knowledge/competence/self-efficacy; functional assessment/symptom burden; global quality of life; specific quality-of-life symptoms (eg, depression, anxiety); and perceived cultural competency of the navigator. In domains where validated measures were found lacking, recommendations were made for areas of needed scale development.

CONCLUSIONS

These measures should guide research and programmatic evaluation of patient navigation.

Fatigue, dyspnea, and cough comprise a persistent symptom cluster up to five years after diagnosis with lung cancer

CONTEXT

Aggregates of concurrent symptoms, known as symptom clusters (SxCls), have been described in predominantly cross-sectional samples of lung cancer (LC) patients undergoing treatment.

OBJECTIVES

The objective of this study was to delineate SxCls in LC survivors up to five years after diagnosis, investigate their stability over time, and identify determinants of SxCl development and resolution.

METHODS

A sensitivity approach involving multiple exploratory and confirmatory analyses was applied to an eight-year prospective cohort study that annually assessed 2405 patients with LC for symptom burden with the Lung Cancer Symptom Scale and Linear Analogue Self-Assessment.

RESULTS

A single robust SxCl of fatigue, cough, and dyspnea was identified in 14.6%, 12.9%, 14.1%, 14.6%, and 15.4% of participants at Years 1-5 after diagnosis, respectively. Participants with the SxCl (SxCl (+)) were more likely to die than those without it; but this tendency diminished over time. SxCl persistence varied, with ≥40% of surviving patients annually transitioning to or from the SxCl(+) state until Year 4, after which the SxCl became increasingly stable. The SxCl was more likely to develop among male survivors who underwent surgery, received radiation, and were current smokers.

CONCLUSION

A single SxCl comprising dyspnea, fatigue, and cough has a stable prevalence among LC survivors up to five years after diagnosis but is not stable among individuals. Initially, after diagnosis, the SxCl is associated with a greater risk of death; however, after Year 2, the SxCl becomes increasingly stable and provides a marker for parenchymal lung injury.

The value of a symptom cluster of fatigue, dyspnea, and cough in predicting clinical outcomes in lung cancer survivors

CONTEXT

Aggregates of concurrent symptoms, known as symptom clusters (SxCls), are reported to have prognostic capabilities beyond that of single symptom alone. A SxCl of fatigue, dyspnea, and cough has been delineated in a number of lung cancer cohorts.

OBJECTIVES

The objective of this study was to characterize this SxCl's predictive value for important clinical outcomes relative to that of its component symptoms.

METHODS

Analysis of an eight-year prospective cohort study that assessed 2405 patients with LC for self-reported symptom burden, employment status, and physical activity with the Baecke questionnaire, and overall quality of life (QoL) was undertaken using nested Cox and generalized linear multilevel mixed models. Models were adjusted for longitudinally assessed demographics, cancer progression and tobacco use, and cancer progression.

RESULTS

The SxCl, as well as its individual symptoms and symptom pairs, were all negatively associated with survival in Cox models of Years 1-3 after diagnosis. Only in Year 3 did the SxCl prognosticate survival (and then marginally) better than single symptoms or symptom pairs; fatigue was strongly associated (P≤0.0005) with survival at all time points. The SxCl was not predictive of participants' employment status, physical activity, or QoL, whereas the presence of fatigue, dyspnea, or their combination was strongly associated with these outcomes.

CONCLUSION

Fatigue and dyspnea are strongly associated with poor clinical outcomes in LC survivors; however, a SxCl that includes fatigue, dyspnea, and cough as part as its components does not appear to significantly improve their predictive capability.

Associations of positive and negative life changes with well-being in young and middle-aged adult cancer survivors

Both positive and negative changes are commonly reported by cancer survivors, and both may impact quality of life. Yet few studies have directly compared the associations of positive and negative changes across multiple life domains with multiple aspects of well-being. This study examined positive and negative changes and their conjoint relation to a range of well-being indices. We used correlational and regression analyses of data from 237 young to middle aged (X = 45.3 years) cancer survivors, several years after treatment. Measures included demographic and medical variables, medical post-cancer positive and negative changes on multiple life domains, and a range of positive and negative adjustment indices. Demographic factors, especially income, related to both positive and negative outcomes. On average, participants reported no change on most life domains, although modest amounts of both positive and negative changes were reported. Negative change, rather than positive change, was closely associated with cancer survivors' adjustment. Detailed measurement of both positive and negative changes - as well as lack of change - is important to advance understanding of cancer's impact on survivors.

Minimally important differences were estimated for six Patient-Reported Outcomes Measurement Information System-Cancer scales in advanced-stage cancer patients

OBJECTIVE

We combined anchor- and distribution-based methods to establish minimally important differences (MIDs) for six Patient-Reported Outcomes Measurement Information System (PROMIS)-Cancer scales in advanced-stage cancer patients.

STUDY DESIGN AND SETTING

Participants completed 6 PROMIS-Cancer scales and 23 anchor measures at an initial (n=101) assessment and a follow-up (n=88) assessment 6-12 weeks later. Three a priori criteria were used to identify usable cross-sectional and longitudinal anchor-based MID estimates. The mean standard error of measurement was also computed for each scale. The focus of the analysis was on item response theory-based MIDs estimated on a T-score scale. Raw score MIDs were estimated for comparison purposes.

RESULTS

Many cross-sectional (64%) and longitudinal (73%) T-score anchor-based MID estimates were excluded because they did not meet a priori criteria. The following are the recommended T-score MID ranges: 17-item Fatigue (2.5-4.5), 7-item Fatigue (3.0-5.0), 10-item Pain Interference (4.0-6.0), 10-item Physical Functioning (4.0-6.0), 9-item Emotional Distress-Anxiety (3.0-4.5), and 10-item Emotional Distress-Depression (3.0-4.5). Effect sizes corresponding to these MIDs averaged between 0.40 and 0.63.

CONCLUSIONS

This study is the first to address MIDs for PROMIS measures. Studies are currently being conducted to confirm these MIDs in other patient populations and to determine whether these MIDs vary by patients' level of functioning.

Use of the Distress Thermometer to discern clinically relevant quality of life differences in women with breast cancer

PURPOSE

The purpose of this study was to explore the ability of Distress Thermometer (DT) scores to discern important differences in quality of life scores among women with breast cancer.

METHODS

The National Comprehensive Cancer Network's DT, the Functional Assessment of Cancer Therapy-Breast (FACT-B), and a demographic questionnaire were completed by 111 women recently diagnosed with breast cancer.

RESULTS

Patients considered moderately to severely distressed (score ≥ 4 on DT) scored significantly lower on FACT-B QOL scales and subscales when compared to those in the group scoring 3 or below. For those scales for which minimally important differences (MIDs) have been established, differences between the two groups were 2-3 and a half times the established MID.

CONCLUSIONS

Moderately to severely distressed patients have significantly lower QOL than those with expected or mild distress. The DT provides a quick and easy screening tool to alert the healthcare team to clinically relevant alterations in patients' QOL.

Prospective neurocognitive function over 5 years after allogeneic hematopoietic cell transplantation for cancer survivors compared with matched controls at 5 years

PURPOSE

Research has documented cognitive deficits both before and after high-dose treatment followed by allogeneic hematopoietic cell transplantation (HCT), with partial recovery by 1 year. This study prospectively examined the trajectory and extent of long-term cognitive dysfunction, with a focus on 1 to 5 years after treatment.

PATIENTS AND METHODS

Allogeneic HCT recipients completed standardized neuropsychological tests including information processing speed (Trail Making A and Digit Symbol Substitution Test), verbal memory (Hopkins Verbal Learning Test-Revised), executive function (Controlled Oral Word Association Test and Trail Making B), and motor dexterity and speed (Grooved Pegboard). Survivors (n = 92) were retested after 80 days and 1 and 5 years after transplantation. Case-matched controls (n = 66) received testing at the 5-year time point. A Global Deficit Score (GDS) summarized overall impairment. Response profiles were analyzed using linear mixed effects models.

RESULTS

Survivors recovered significant cognitive function from post-transplantation (80 days) to 5 years in all tests (P < .0001) except verbal recall (P > .06). Between 1 and 5 years, verbal fluency improved (P = .0002), as did executive function (P < .01), but motor dexterity did not (P > .15), remaining below controls (P < .0001) and more than 0.5 standard deviation below population norms. In GDS, 41.5% of survivors and 19.7% of controls had mild or greater deficits (NcNemar test = 7.04, P = .007).

CONCLUSION

Although neurocognitive function improved from 1 to 5 years after HCT, deficits remained for more than 40% of survivors. Risk factors, mechanisms and rehabilitation strategies need to be identified for these residual deficits.

Long-term follow-up and individual item analysis of quality of life assessments related to laparoscopic-assisted colectomy in the COST trial 93-46-53 (INT 0146)

BACKGROUND

Postoperative outcomes of patients undergoing laparoscopic-assisted colectomy (LAC) have shown modest improvements in recovery but only minimal differences in quality of life (QOL) compared with open colectomy. We therefore sought to assess the effect of LAC on QOL in the short and long term, using individual item analysis of multi-item QOL assessments.

METHODS

QOL variables were analyzed in 449 randomized patients from the COST trial 93-46-53 (INT 0146). Both cross-sectional single-time and change from baseline assessments were run at day 2, week 2, month 2, and month 18 postoperatively in an intention-to-treat analysis using Wilcoxon rank-sum tests. Stepwise regression models were used to determine predictors of QOL.

RESULTS

Of 449 colon cancer patients, 230 underwent LAC and 219 underwent open colectomy. Subdomain analysis revealed a clinically moderate improvement from baseline for LAC in total QOL index at 18 months (P = 0.02) as well as other small symptomatic improvements. Poor preoperative QOL as indicated by a rating scale of ≤ 50 was an independent predictor of poor QOL at 2 months postoperatively. QOL variables related to survival were baseline support (P = 0.001) and baseline outlook (P = 0.01).

CONCLUSIONS

Eighteen months after surgery, any differences in quality of life between patients randomized to LAC or open colectomy favored LAC. However, the magnitude of the benefits was small. Patients with poor preoperative QOL appear to be at higher risk for difficult postoperative courses, and may be candidates for enhanced ancillary services to address their particular needs.

Metrics to assess quality of life after management of early-stage lung cancer

Quality of life (QOL) is a key clinical outcome in patients with lung cancer because of the debilitating nature of the disease and its treatments. In recent years, advances have been made in the assessment of QOL via patient-reported outcomes. A brief history of the evolution of QOL measures in oncology clinical trials and practice is given with specific reference to early-stage lung cancer. The role that QOL can play as a prognostic factor, especially among lung cancer patients, is delineated. The most commonly seen symptoms among lung cancer patients are listed. This review is intended to provide the clinical researcher with a summary of the alternative measures that are both valid and reasonable to consider when assessing QOL in early-stage lung cancer patients. Suggestions for QOL assessment in both a research setting and clinical environment are considered. A review of the most popular QOL assessments in general application to lung cancer and disease-specific measures is provided. An algorithm for selecting appropriate QOL assessments for lung cancer clinical research is provided. The primary conclusion from this work is that scientifically sound investigations into the QOL of early-stage lung cancer patients are feasible and encouraged so that the care of these patients can be optimized.

Chemotherapy-related cognitive impairment

Chemotherapy-related cognitive impairment (CRCI) was first described in the 1970s, but significant recognition of CRCI did not emerge with consistency until the late 1990s. Estimates of frequency now range from 17%-75%, and evidence suggests that CRCI, or "chemobrain" as it is referred to in the lay literature, is of significant concern to patients. A variety of potentially associated factors have been identified, including age, education level, intelligence, and social support; anxiety, depression, and fatigue; disease site, stage, and comorbidities; treatment regimen, timing, duration, and concomitant therapies; and hormonal levels, cytokine levels, damage to neural progenitor cells, and the presence of the apolipoprotein E 4 allele. Controversy exists as to the most suitable neurocognitive tests to evaluate this sequeal of treatment. Neuroimaging techniques are beginning to reveal affected areas of the brain. A neuropsychologist is essential for the assessment, diagnosis, and recommendation of appropriate management strategies for this patient population. Oncology nurses should be aware of available resources, such as relevant Web sites, support groups, neuropsychologists, and cognitive retraining programs, and provide support for patients concerned about or experiencing CRCI.

Immediate versus delayed self-reporting of symptoms and side effects during chemotherapy: does timing matter?

PURPOSE

The aim of this study was to examine how patients recall symptoms at a delayed self-report. Accurate insight into toxicity symptoms during chemotherapy is essential so that nurses and doctors can assess therapeutic tolerance and adjust supportive care accordingly.

METHOD

A non-experimental, longitudinal design was employed. Using the Therapy-Related Symptoms Checklist (TRSC), respondents (n = 142) reported their initial symptoms during the first 7 days of the chemotherapy cycle at two different times: (1) each day of the first seven days after the chemotherapy administration (immediate self-report), and (2) at their next hospital visit for chemotherapy (delayed self-report). We compared the number and severity of symptoms and side effects reported in the immediate and delayed self-reports.

RESULTS

Respondents reported significantly fewer symptoms and fewer severe symptoms in the delayed self-report. For 22 out of 25 symptoms the delayed-reported grade was significantly lower than the immediate-reported maximum grade. Compared to the immediate-reported median grade, significant differences occurred in only 10 out of the 25 symptoms. In all cases, except fatigue, the delayed-reported grade was significantly higher than the immediate-reported median grade.

CONCLUSIONS

This study indicates that delayed self-report of chemotherapy side effects is not an appropriate measure of actual symptoms and side effects experienced by patients. Delayed self-report gives a weaker insight into actual symptom burden. Fatigue is at particular risk to be minimized at the delayed self-report. Therefore it is recommended to assess chemotherapy-related symptoms and side effects by means of immediate self-report.

ASCPRO recommendations for the assessment of fatigue as an outcome in clinical trials

CONTEXT

Development of pharmacological and behavioral interventions for cancer-related fatigue (CRF) requires adequate measures of this symptom. A guidance document from the Food and Drug Administration offers criteria for the formulation and evaluation of patient-reported outcome measures used in clinical trials to support drug or device labeling claims.

METHODS

An independent working group, ASCPRO (Assessing Symptoms of Cancer Using Patient-Reported Outcomes), has begun developing recommendations for the measurement of symptoms in oncology clinical trials. The recommendations of the Fatigue Task Force for measurement of CRF are presented here.

RESULTS

There was consensus that CRF could be measured effectively in clinical trials as the sensation of fatigue or tiredness, impact of fatigue/tiredness on usual functioning, or as both sensation and impact. The ASCPRO Fatigue Task Force constructed a definition and conceptual model to guide the measurement of CRF. ASCPRO recommendations do not endorse a specific fatigue measure but clarify how to evaluate and implement fatigue assessments in clinical studies. The selection of a CRF measure should be tailored to the goals of the research. Measurement issues related to various research environments were also discussed.

CONCLUSIONS

There exist in the literature good measures of CRF for clinical trials, with strong evidence of clarity and comprehensibility to patients, content and construct validity, reliability, and sensitivity to change in conditions in which one would expect them to change (assay sensitivity), and sufficient evidence to establish guides for interpreting changes in scores. Direction for future research is discussed.

Single- vs. multiple-item instruments in the assessment of quality of life in patients with advanced cancer

Although multidimensional instruments are usually used to measure quality of life in advanced cancer patients, recent research suggests that single-item assessments can provide a reliable measure. Using the Functional Assessment of Cancer Therapy-General (FACT-G) instrument as a gold standard, we assessed the performance of the Edmonton Symptom Assessment System "feeling of well-being" (ESAS WB) item. We reviewed the data from 213 patients enrolled in six clinical trials. We determined the association between baseline ESAS WB and FACT-G total and subscale domain scores (Physical Well-being [PWB], Social/Family Well-being [SWB], Emotional Well-being [EWB], and Functional Well-being [FWB]. We also calculated the association between baseline (T1) and second (T2) observations of ESAS WB and of FACT-G total score. In addition, we predicted the change in FACT-G predicted by the ESAS WB score using regression analysis. Mean age was 60 (SD 12) years and 48% were female. The Spearman correlation coefficient of ESAS WB and FACT-G was -0.48 (P<0.0001). Correlations with FACT-G subscale domains were also highly significant, except for the SWB domain (P=0.08). The Pearson correlation coefficient for T1-T2 in ESAS WB and FACT-G for 146 patients was -0.36 (P<0.0001). The change in ESAS WB corresponding to FACT-G published minimally important difference was -0.24 for 3, -1.55 for 5, and -2.87 for 7, respectively. These results suggest that the single-item measure ESAS WB best reflects the total score on the FACT-G and PWB, EWB, and FWB domains but not on the SWB domain.

Quality criteria and user-friendliness in self-reported questionnaires on cancer-related fatigue: a review

OBJECTIVE

Cancer-related fatigue (CRF) is a distressing, persistent, subjective sense of tiredness or exhaustion that occurs in 70-100% of cancer patients. The purpose of this review was to provide an overview of the quality of research performed on existing CRF self-report questionnaires and compare their reported psychometric properties and user-friendliness.

METHODS

Database searches of CINAHL, Cochrane Library, EMBASE, MEDLINE, Scopus, PEDro, and PsycINFO were undertaken to find published scales. Standardized criteria were used to assess quality and user-friendliness.

RESULTS

Thirty-five articles were included that described 18 questionnaires-seven one-dimensional questionnaires and 11 multidimensional questionnaires. The mean item count was 20.8 (range: 3-83). The mean overall score of the one-dimensional questionnaires was 10.4 of a maximum of 18 points (range: 7.6-14.3). The mean overall score of the multidimensional questionnaires was 9.4 of a maximum of 18 points (range: 4.3-14.4).

CONCLUSION

Recommendations were made for the selection of a scale. We argue in favor of repeatedly reassessing psychometric properties of even established questionnaires to ensure they comply with evermore increasing stringent quality criteria.

A single set of numerical cutpoints to define moderate and severe symptoms for the Edmonton Symptom Assessment System

Symptom intensity in cancer and palliative care patients is frequently assessed using a 0-10 ranking score. Results are then often grouped into verbal categories (mild, moderate, or severe) to guide therapy. Numerical cutpoints separating these categories are often variable, with previous work suggesting different cutpoints across different symptoms, which is unwieldy for clinical use. The Edmonton Symptom Assessment Symptom (ESAS) assesses nine common symptoms using this 0-10 scale. The primary aim of this study was to examine the relationship between the numerical and verbal scores using the ESAS and to identify a single cutpoint to separate severe from nonsevere symptomatology. A second goal was to similarly identify a cutpoint to separate moderate or severe from none or mild symptom intensity. Consenting patients (n=400) completed both a standard ESAS and an identical form that replaced 0-10 with none, mild, moderate, and severe. Receiver operating characteristic curves were generated to identify the best fit between sensitivity and specificity. For the "severe" ranking, six symptoms had a best fit of 7, with sensitivity for the remaining three symptoms still greater than 80%. For the combined grouping of moderate or severe, results were less uniform. A cutpoint of either 4 or 5 would be supported by our data, with a greater sensitivity using 4 and improved specificity using 5 as the cutpoint. Across all ESAS symptoms, then, 7 or higher represents a severe symptom by patient definition, whereas a cutpoint of either 4 or 5 could reasonably define combined moderate and severe symptoms.

Fatigue

When fatigue is not addressed, there is a high probability that it will negatively affect the patient’s participation in healthy behaviors. It is well known that a patient’s active participation can improve recovery from any injury or illness. The first step is the assessment of a patient’s fatigue, with a follow up focus on fatigue management strategies. The clinical guidelines for cancer-related fatigue recommend fatigue assessment as the sixth vital sign. This recommendation is a good guideline for all provider/patient interactions and provides an overall picture of the patient’s health. While fatigue is often an expected symptom of chronic illness or cancer therapy, few patients are given a proactive approach to fatigue management. When fatigue is left untreated, the patient is set up for failure in all self-management behaviors. Fatigue is a manageable condition but requires the active and well-informed patient and a supportive, well-informed health care team.

Pretreatment quality of life is an independent prognostic factor for overall survival in patients with advanced stage non-small cell lung cancer

HYPOTHESIS

We conducted this pooled analysis to assess the prognostic value of pretreatment Quality of Life (QOL) assessments on overall survival (OS) in advanced non-small cell lung cancer (NSCLC).

METHODS

Four hundred twenty patients with advanced NSCLC (stages IIIB with pleural effusion and IV) from six North Central Cancer Treatment Group trials were included in this study. QOL assessments included the single-item Uniscale (355 patients), Lung Cancer Symptom Scale (217 patients), and Functional Assessment of Cancer Therapy-Lung (197 patients). QOL scores were transformed to a 0 to 100 scale with higher scores representing better status and categorized using the sample median or clinically deficient score (CDS, <or=50 versus >50). Cox proportional hazards models stratified by study were used to evaluate the prognostic importance of QOL on OS alone and in the presence of other prognostic factors such as performance status, age, gender, body mass index, and laboratory parameters.

RESULTS

Pretreatment QOL accessed by Uniscale was significantly associated with OS univariately (p < 0.0001). Uniscale (p < 0.0001; hazard ratio = 1.6 for the sample median and 2.0 for the CDS categorization) and body mass index were the only significant predictors of OS multivariately. The median survival of patients who had a Uniscale score less than or equal to the CDS (<or=50) was 5.7 versus 11.1 months for the >50 group; and 7.8 versus 13 months for the less than or equal to sample median (<or=83) group and >83 group, respectively. The Lung Cancer Symptom Scale and the Functional Assessment of Cancer Therapy-Lung total scores were not significant predictors of OS.

CONCLUSIONS

Pretreatment QOL measured by Uniscale is a significant and an independent prognostic factor for OS, and QOL should be routinely integrated as a stratification factor in advanced NSCLC trials.

Screening for emotional distress in cancer patients: a systematic review of assessment instruments

Screening for emotional distress is becoming increasingly common in cancer care. This systematic review examines the psychometric properties of the existing tools used to screen patients for emotional distress, with the goal of encouraging screening programs to use standardized tools that have strong psychometrics. Systematic searches of MEDLINE and PsycINFO databases for English-language studies in cancer patients were performed using a uniform set of key words (eg, depression, anxiety, screening, validation, and scale), and the retrieved studies were independently evaluated by two reviewers. Evaluation criteria included the number of validation studies, the number of participants, generalizability, reliability, the quality of the criterion measure, sensitivity, and specificity. The literature search yielded 106 validation studies that described a total of 33 screening measures. Many generic and cancer-specific scales satisfied a fairly high threshold of quality in terms of their psychometric properties and generalizability. Among the ultrashort measures (ie, those containing one to four items), the Combined Depression Questions performed best in patients receiving palliative care. Among the short measures (ie, those containing five to 20 items), the Center for Epidemiologic Studies–Depression Scale and the Hospital Anxiety and Depression Scale demonstrated adequate psychometric properties. Among the long measures (ie, those containing 21–50 items), the Beck Depression Inventory and the General Health Questionaire–28 met all evaluation criteria. The PsychoSocial Screen for Cancer, the Questionnaire on Stress in Cancer Patients–Revised, and the Rotterdam Symptom Checklist are long measures that can also be recommended for routine screening. In addition, other measures may be considered for specific indications or disease types. Some measures, particularly newly developed cancer-specific scales, require further validation against structured clinical interviews (the criterion standard for validation measures) before they can be recommended.

Evaluating cognitive, emotional, and physical fatigue domains in daily practice by single-item questions in patients with advanced cancer: a cross-sectional pragmatic study

To assess cancer-related fatigue (CRF), multidimensional questionnaires are required. The aim of this study was to evaluate single-item fatigue (SIF) screening questions-one for global fatigue and three for the fatigue domains (cognitive, emotional, and physical)-for their immediate use in daily oncology practice. Sixty-one fatigued patients with advanced cancer completed SIF assessments (visual analog scales for global fatigue and for fatigue in the cognitive, emotional, and physical domains, respectively), and the Brief Fatigue Inventory (BFI), the Fatigue Assessment Questionnaire (FAQ), the Hospital Anxiety and Depression Scale (HADS), and the European Organization for Research and Treatment of Cancer (EORTC) Quality-of-Life-C30 (QLQ-C30). SIF-global correlated with BFI (r=0.51), and the domain-SIFs correlated with their respective FAQ domains (cognitive r=0.59; affective r=0.45; physical r=0.33) and functional EORTC QLQ-C30 subscales (r=0.62; r=0.42; r=0.34). The SIF-emotional also correlated with HADS-Anxiety (r=0.43) and HADS-Depression (r=0.62). Principal component analysis (domain-SIF; respective FAQ and functional EORTC QLQ-C30 subscales) revealed three clusters and a two-factor model (cognitive/emotional, physical), explaining 74% of variability. Patients with one predominant SIF domain had more domain-tailored fatigue interventions than had patients with mixed SIFs. These data suggest that three simple SIF questions permit rapid assessment of the physical and cognitive and probably the emotional domains of CRF in patients with advanced cancer.

Pain and heart failure: unrecognized and untreated

BACKGROUND

Although evidence exists to support the presence of pain in advanced stages of heart failure (HF), the pain experience in the early phases of this progressive disease is poorly documented, and therefore, poorly understood. The current study was conducted to: 1) examine the prevalence of pain in cohort of patients with chronic HF (New York Heart Association class I-IV); and 2) determine the relationship between pain and QOL.

METHODS AND RESULTS

Data were obtained from 300 patients (mean age 54.2+/-12.7 years; 72% male; 65% Caucasians; time since HF diagnosis 4.6+/-4.8 years). Two-thirds of the patients (67%) reported some degree of pain; the prevalence of pain increased as functional class worsened (p<.009). Differences in QOL outcomes for patients experiencing pain vs. no pain were statistically significant for physical and overall QOL. Pain accounted for 20% of the variance in QOL (p<.001) even after adjusting for age, gender, and functional class.

CONCLUSIONS

Our findings suggest pain is present in a majority of patients with HF. Given the potential deleterious effects of untreated pain on QOL in patients with HF, it is important that healthcare providers assess patients for this often-unrecognized symptom.

Brief intervention for anxiety in primary care patients

To address the difficulty of assessing and managing multiple anxiety disorders in the primary care setting, this article provides a simple, easy-to-learn, unified approach to the diagnosis, care management, and pharmacotherapy of the 4 most common anxiety disorders found in primary care: panic, generalized anxiety disorders, social anxiety disorders, and posttraumatic stress disorder. This evidence-based approach was developed for an ongoing National Institute of Mental Health-funded study designed to improve the delivery of evidence-based medication and psychotherapy treatment to primary care patients with these anxiety disorders. We present a simple, validated method to screen for the 4 major disorders that emphasizes identifying other medical or psychiatric comorbidities that can complicate treatment; an approach for initial education of the patient and discussion about treatment, including provision of some simple cognitive behavioral therapy skills, based on motivational interviewing/brief intervention approaches previously used for substance use disorders; a validated method for monitoring treatment outcome; and an algorithmic approach for the selection of initial medication treatment, the selection of alternative or adjunctive treatments when the initial approach has not produced optimal results, and indications for mental health referral.

Morbidity associated with "self-rated health" in epithelial ovarian cancer survivors

Background

Epithelial ovarian cancer survivors (EOCSs) frequently report multiple complaints after their treatment. The objective was to study somatic and mental morbidity in EOCSs associated with their Self- Rated Health (SRH) assessed by a single item.

Findings were compared to age-matched controls from the general population.

Methods

In a cross -sectional follow-up design 189/287 (66%) EOCSs treated at The Norwegian Radiumhospital 1979–2003 responded to a mailed questionnaire on demographic data, and somatic and mental morbidity. SRH last week was rated on item #29 of the European Organization and Treatment of Cancer Quality of Life Questionnaire in 84/189 (97%) of responding EOCSs. For comparisons "good" and "poor" SRH groups were defined by the median score on the SRH item.

Results

EOCSs with "poor SRH" had higher level of somatic symptoms, anxiety, depression and fatigue than those with "good SRH" (p < .001). In multivariate analyses somatic symptoms, age and fatigue, were significantly associated with the SRH score in EOCSs, but not the cancer-related variables (FIGO stage, recurrence in < 6 months or chemotherapy ever). The model explained 70% of the variance in SRH in linear and 77% in logistic regression analyses. The distribution of the SRH scores in EOCSs did not differ significantly from that of normative controls; however a higher proportion of controls recorded a high SRH score.

Conclusion

SRH is strongly related to common somatic complaints, impairment and fatigue but not to cancer-related variables. A single question concerning SRH last week might be a quick screening method for collecting important information on symptoms in EOCSs, in addition to cancer – related questions.

Longitudinal screening and management of fatigue, pain, and emotional distress associated with cancer therapy

GOALS OF WORK

Fatigue, pain, and emotional distress are common symptoms among patients with cancer. We sought to learn about patient perceptions of these symptoms and their treatment.

MATERIALS AND METHODS

At a baseline assessment and two monthly follow-up assessments, we asked a diverse sample of patients with solid tumor or lymphoma (N = 99) about their fatigue, pain and distress, their treatment for these symptoms, and their satisfaction with treatment via standardized questionnaires and semistructured interviews.

MAIN RESULTS

In this observational study, patients reported fatigue, pain, emotional distress, and general quality of life at expected levels. Across all assessments, at least half of our sample experienced at least some fatigue, pain, or distress. On the whole, patients and providers do communicate about these concerns, and at least 75% of patients found these discussions helpful when they occurred.

CONCLUSIONS

Improved symptom identification and communication may optimize the detection of those at risk of morbidity and decreased quality of life because of excess symptom burden.