Symptoms in patients with lung carcinoma

Perspectives of patients with advanced or metastatic non-small cell lung cancer on symptoms, impacts on daily activities, and thresholds for meaningful change: a qualitative research study

Introduction

Advanced or metastatic non-small cell lung cancer (NSCLC) is associated with significant symptom burden. It is important to understand the impact of these disease-and treatment-related symptoms on patients' daily lives and explore from a patient perspective what constitutes a meaningful change in NSCLC symptoms.

Methods

Patient experience of advanced or metastatic NSCLC was explored in this prospective, non-interventional qualitative research study recruiting patients from the United States (US). Interviews were conducted to explore the most important symptoms, daily life impacts, and patients' perspectives of what constitutes meaningful change when considering their current symptoms versus 6-12 months prior, based on the Patient Global Impression of Severity (PGI-S) and Patient Global Impression of Change (PGI-C) items.

Results

Between February and April 2022, 19 US-based patients with Stage IV NSCLC were recruited; 95% were female, 63% were White, 79% had been diagnosed >1 year prior, and 63% were receiving targeted therapy. Over half the patients indicated their most important symptoms were fatigue, shortness of breath, and cough. Patient differentiation between whether symptoms were disease- or treatment-related lacked concordance, and often patients were unable to distinguish the two. The most frequently mentioned impacts of these symptoms on patients' daily lives were difficulty walking, sleep disturbance, anxiety/depression, impact on relationships, and difficulty doing daily tasks. Most patients considered a one-point change on the PGI-S or PGI-C to be meaningful based on rating their symptom severity at the time of the interview compared with 6-12 months before the interview.

Conclusion

Based on their own symptom experience, patients with advanced or metastatic NSCLC indicated a one-point threshold for meaningful change, whether improvement or worsening. This suggests a one-point change on the PGI-S or PGI-C may be a potential anchor for patient-reported outcome (PRO) endpoints used in clinical trials. It is important to use PRO instruments that capture the symptoms and impacts identified as most important to patients. These findings highlight the importance of using qualitative methods to assess disease-related symptoms, treatment-related side effects, and the impacts on daily life for patients with advanced or metastatic NSCLC, underscoring how qualitative assessments can complement quantitative PRO instruments for evaluating clinical trials.

Evaluating the Content Validity, Clarity, and Relevance of Two Patient-Reported Outcomes for Use With Adults With EGFR-Mutated NSCLC

Introduction

NSCLCs account for most lung cancers; approximately 30% involve a mutation in the EGFR gene. This study sought to identify one or more patient-reported outcome (PRO) measures relevant for use in clinical trials to assess symptoms and health-related quality of life in this population.

Methods

Patients with NSCLC from the United States, Europe, and Asia and including those with an exon 20 insertion mutation and other EGFR mutations participated in a combination of concept elicitation and cognitive debriefing interviews to report symptoms and impacts of their NSCLC and provide feedback on the clarity and relevance of several PRO measures.

Results

A total of 30 individuals participated (mean age = 57 years, 87% female, 80% white). The most often reported symptoms included fatigue, shortness of breath, cough, and weight loss. Individuals with the exon 20 insertion mutation (n = 21) more frequently reported negative impacts on daily life, physical functioning, and social functioning but less frequently reported negative impacts to emotional functioning. The PROMIS Short-Form version 2.0—Physical Function 8c and the NSCLC Symptom Assessment Questionnaire were deemed clear, relevant, and easy to complete. The concepts identified during the concept elicitation portion of the interviews were mapped to the content of each PRO, and all items within both PROs were endorsed by at least 20% of the participants.

Conclusions

These results support the content validity, clarity, and relevance of the PROMIS Short-Form version 2.0—Physical Function 8c and the NSCLC Symptom Assessment Questionnaire in a population with EGFR-mutated NSCLC. Both would be appropriate for inclusion in future studies.

Sensations, symptoms, and then what? Early bodily experiences prior to diagnosis of lung cancer

Lung cancer (LC) generally lacks unique core symptoms or signs. However, there are a multitude of bodily sensations that are often non-specific, not easily understood, and many times initially not recognized as indicative of LC by the affected person, which often leads to late diagnosis. In this international qualitative study, we inductively analyzed retrospective accounts of 61 people diagnosed with LC in Denmark, England and Sweden. Using the bodily sensations they most commonly spoke about (tiredness, breathlessness, pain, and cough), we constructed four sensation-based cases to understand the pre-diagnostic processes of reasoning and practice triggered by these key indicators of LC. We thereafter critically applied Hay's model of sensations to symptoms transformation, examining its central concepts of duration, disability and vulnerability, to support understanding of these processes. We found that while duration and disability are clearly relevant, vulnerability is more implicitly expressed in relation to perceived threat. Tiredness, even when of long duration and causing disability, was often related to normal aging, rather than a health threat. Regardless of duration, breathlessness was disturbing and threatening enough to lead to care-seeking. Pain varied by location, duration and degree of disability, and thus also varied in degree of threat perceived. Preconceived, but unmet expectations of what LC-related cough and pain would entail could cause delays by misleading participants; if cough lasted long enough, it could trigger health care contact. Duration, disability, and sense of threat, rather than vulnerability, were found to be relevant concepts for understanding the trajectory to diagnosis for LC among these participants. The process by which an individual, their family and health care providers legitimize sensations, allowing them to be seen as potential symptoms of disease, is also an essential, but varying part of the diagnostic processes described here.

Relationships of Symptom Groups and Functioning Domains in Patients with Advanced-Stage Non-Small Cell Lung Cancer Undergoing Treatment: A Cross-Sectional Study

The purpose of this study was to describe the symptoms experienced by patients with non-small cell lung cancer (NSCLC), examine whether different symptom groups significantly affected different functioning domains in these patients, and determine the effect of the "lack of energy" and "pain" symptom groups on the different functioning domains of health-related quality of life (HRQOL). From a single tertiary institution, this cross-sectional study enrolled 135 consecutive NSCLC patients who were mostly undergoing chemotherapy and were in the advanced stage (National University Hospital, Daegu, South Korea). Clinical and self-reported demographic information and data on different functioning domains (from the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire C30 (EORTC QLQ-C30)), symptom experience (from the EORTC QLQ-LC13), and the Symptom Distress Scale (SDS) were examined. The four most common symptoms were fatigue (69%), pain (47%), dyspnea (38%), and lack of appetite (36%). The "pain" symptom group was negatively associated with physical, emotional, cognitive, and role functioning. The "lack of energy" symptom group was negatively associated with physical, role, emotional, social, and cognitive functioning. The "lack of energy" symptom group explained the most variance for physical and role functioning, and the "pain" symptom group explained the most variance for emotional functioning. Impaired concentration explained the most variance for cognitive functioning.

Palliative care needs and utilisation of different specialist services in the last days of life for people with lung cancer

OBJECTIVES

To (a) compare palliative care needs of lung cancer patients on their final admission to community-based and inpatient palliative care services; and (b) explore whether and how these care needs affect their utilisation of different palliative care services in the last days of life.

METHODS

Descriptive study involving 17,816 lung cancer patients who received the last episode of palliative care from specialist services and died between 1 January 2013 and 31 December 2018.

RESULTS

Both groups of patients admitted to community-based and inpatient palliative care services generally experienced relatively low levels of symptom distress, but high levels of functional impairment and dependency. "Unstable" versus "stable" palliative care phase (Odds ratio = 11.66; 95% Confidence Interval: 9.55-14.24), poorer functional outcomes and severe levels of distress from many symptoms predicted greater likelihood of use of inpatient versus community-based palliative care.

CONCLUSIONS

Most inpatient palliative care admissions are not associated with high levels of symptom severity. To extend the period of home care and rate of home death for people with lung cancer, additional investment is required to improve their access to sufficiently skilled palliative care staff, multi-disciplinary teams and 24-hour home support in community settings.

Association Between Heart Rate and Reversibility of the Symptom, Refractoriness to Palliative Treatment, and Survival in Dyspneic Cancer Patients

CONTEXT

Dyspnea is one of the most distressing symptoms for terminally ill cancer patients and a predictor of poor prognosis. Identification of simple clinical signs, such as heart rate, indicating clinical course of each patient is of value.

OBJECTIVES

To explore the potential association between heart rate and reversibility of the symptom, treatment response to palliative intervention, and survival in terminally ill cancer patients with dyspnea at rest.

METHODS

This is a secondary analysis of a multicenter prospective cohort study of patients with advanced cancer to validate multiple prognostic tools. In the patients with dyspnea at rest at the baseline, we examined a potential association between heart rate and the reversibility of dyspnea and refractoriness to palliative treatment using logistic regression analysis. Survivals were compared using the Cox proportional hazards model among four groups with different levels of the heart rate (≤74, 75-84, 85-97, and ≥98).

RESULTS

A total of 2298 patients were enrolled, and 418 patients (18%) had dyspnea at rest. Reversibility of dyspnea was significantly higher in the patients with lower heart rate (P for trend = 0.008), and the refractoriness to palliative treatment tended to be higher in the patients with higher heart rate (P for trend = 0.101). The median survival for each heart rate quartile groups was significantly higher in the lower heart rate group (24 vs. 21 vs. 14 vs. 9 days; heart rate ≤74, 75-84, 85-97, and ≥98, respectively; log-rank P < 0.001).

CONCLUSION

Heart rate may help clinicians to make the prediction of the patient's clinical course more accurate.

Feasibility and Utility of Incorporating Patient-Reported Outcomes into Surveillance Strategies for Advanced Lung Cancer

PURPOSE

To identify and to describe patient-reported outcomes (PROs) in lung cancer patients and to evaluate the feasibility and utility of PROs into surveillance strategies, a review was carried out.

PATIENTS AND METHODS

A systematic search in bibliographic databases evaluating the instruments used in PROs of non-small-Cell lung cancer (NSCLC) patients was done.

RESULTS

From August 2014 to August 2019, 33 studies were included in this review and 16,491 patients were evaluated. PROs were divided into 6 different categories: 1) PROs as a guide in therapeutic choice, 2) PROs as indicator of disease progression, 3) agreement between PROs and the evaluated parameters, 4) PROs to evaluate the effects of immunotherapy, 5) need to deepen the knowledge of PROs, and 6) use of new electronic PROs.

CONCLUSION

The most frequently used instruments are EORTC QLQ-30 (16, 50%) and EORTC LC-13 (14, 43.75%) and in some studies (37.5%) they are used together. For different reasons (disease progression, adverse event, death, incomplete participation, etc.), the completion of these instruments decreased over time from baseline to subsequent measurements. This review demonstrates that PROs can play an important role as part of health care, and that routine use implementation could improve patient management in addition to the traditionally collected outcome.

Patterns of Suffering in Palliative Care: A Descriptive Study

Suffering experiences are common phenomena in palliative care. In this study, we aim to explore the different patterns of suffering in palliative care. Adult palliative care patients were recruited from the University of Malaya Medical Centre. Suffering scores were charted 3 times a day for a week. The characteristics of the suffering charts were analyzed using SPSS. The patterns of suffering were analyzed using structural pattern recognition. A total of 53 patients participated. The overall trends of suffering were downward (64%), upward (19%), and stable (17%). Median minimum and maximum suffering scores were 2/10 and 6/10, with an average of 3.6/10. Nine patterns of suffering were recognized from categorizing two key characteristics of suffering (intensity and fluctuation)-named S1 to S9. Understanding the different patterns of suffering may lead to better suffering management.

Association of baseline symptom burden with efficacy outcomes: Exploratory analysis from the randomized phase III REVEL study in advanced non-small-cell lung cancer

OBJECTIVES

The REVEL study demonstrated improved efficacy with ramucirumab plus docetaxel versus placebo plus docetaxel for previously treated advanced/metastatic non-small-cell lung cancer (NSCLC) without further detriment to patient quality of life, symptoms, or functioning. This post hoc analysis explored the association between baseline Lung Cancer Symptom Scale (LCSS) Average Symptom Burden Index (ASBI) and efficacy.

MATERIALS AND METHODS

Baseline ASBI scores were the average of the 6 LCSS symptom components. Low and high symptom burden (LSB ≤ median, HSB > median) were analyzed across and by treatment arms for effects on overall survival (OS), progression-free survival (PFS), and objective response rate (ORR) using the Kaplan-Meier method and Cox proportional hazards model.

RESULTS

Baseline LCSS compliance was approximately 78% in both REVEL treatment arms. Patients with LSB versus HSB had fewer poor prognostic factors. The HSB patient population significantly overlapped with previously identified aggressive disease subgroups (rapidly progressing disease or refractory to first-line treatment). Patients with LSB versus HSB had significantly improved OS (P < 0.0001), PFS (P < 0.0001), and ORR (P = 0.0003) regardless of treatment, with superior ORR and PFS but not OS in the ramucirumab plus docetaxel arm. Patients with HSB treated with ramucirumab plus docetaxel versus docetaxel had improved OS (median, 7.39 vs. 5.95 months; HR 0.749 [95% CI 0.610-0.920]; P = 0.0308), PFS (median, 4.01 vs. 2.63 months; HR 0.749 [0.619-0.907]; P = 0.0202), and ORR (18% vs. 11%; P = 0.0458). Of patients with rapidly progressing disease, 57% (92/162) also had HSB.

CONCLUSIONS

Baseline ASBI may be an independent prognostic factor in this large second-line cohort of patients with advanced NSCLC. The preservation of improved PFS and OS in the HSB cohort suggests that the addition of ramucirumab to docetaxel provides benefit in patients with greater symptom burden, consistent with previous data on REVEL patients with aggressive disease.

Pain distress: the negative emotion associated with procedures in ICU patients

PURPOSE

The intensity of procedural pain in intensive care unit (ICU) patients is well documented. However, little is known about procedural pain distress, the psychological response to pain.

METHODS

Post hoc analysis of a multicenter, multinational study of procedural pain. Pain distress was measured before and during procedures (0-10 numeric rating scale). Factors that influenced procedural pain distress were identified by multivariable analyses using a hierarchical model with ICU and country as random effects.

RESULTS

A total of 4812 procedures were recorded (3851 patients, 192 ICUs, 28 countries). Pain distress scores were highest for endotracheal suctioning (ETS) and tracheal suctioning, chest tube removal (CTR), and wound drain removal (median [IQRs] = 4 [1.6, 1.7]). Significant relative risks (RR) for a higher degree of pain distress included certain procedures: turning (RR = 1.18), ETS (RR = 1.45), tracheal suctioning (RR = 1.38), CTR (RR = 1.39), wound drain removal (RR = 1.56), and arterial line insertion (RR = 1.41); certain pain behaviors (RR = 1.19-1.28); pre-procedural pain intensity (RR = 1.15); and use of opioids (RR = 1.15-1.22). Patient-related variables that significantly increased the odds of patients having higher procedural pain distress than pain intensity were pre-procedural pain intensity (odds ratio [OR] = 1.05); pre-hospital anxiety (OR = 1.76); receiving pethidine/meperidine (OR = 4.11); or receiving haloperidol (OR = 1.77) prior to the procedure.

CONCLUSIONS

Procedural pain has both sensory and emotional dimensions. We found that, although procedural pain intensity (the sensory dimension) and distress (the emotional dimension) may closely covary, there are certain factors than can preferentially influence each of the dimensions. Clinicians are encouraged to appreciate the multidimensionality of pain when they perform procedures and use this knowledge to minimize the patient's pain experience.

Patient-Reported Outcomes in OAK: A Phase III Study of Atezolizumab Versus Docetaxel in Advanced Non-Small-cell Lung Cancer

BACKGROUND

The randomized phase III OAK (a study of atezolizumab compared with docetaxel in participants with locally advanced or metastatic non-small-cell lung cancer [NSCLC] who have failed platinum-containing therapy) trial investigated the anti-programmed cell death ligand 1 (PD-L1) antibody atezolizumab for advanced or metastatic, previously treated, NSCLC. Atezolizumab significantly improved overall survival (OS) compared with docetaxel (hazard ratio [HR], 0.73; 95% confidence interval [CI], 0.62-0.87; P = .0003; median OS, 13.8 vs. 9.6 months, respectively). Patient-reported outcomes (PROs) were collected to evaluate disease-related symptoms and health-related quality of life (HRQoL) to support the finding of a survival benefit.

PATIENTS AND METHODS

The first 850 patients were randomized to receive atezolizumab (1200 mg every 3 weeks) or docetaxel (75 mg/m² every 3 weeks). PROs were collected on day 1 of cycle 1, day 1 of every subsequent cycle, and at the end-of-treatment visit for patients who completed ≥ 1 baseline and 1 postbaseline PRO assessment. The European Organisation for the Research and Treatment of Cancer QoL questionnaire and lung cancer module were used to assess PROs.

RESULTS

Atezolizumab delayed the time to deterioration (TTD) in physical function (HR, 0.75; 95% CI, 0.58-0.98) and role function (HR, 0.79; 95% CI, 0.62-1.00) and numerically improved patients' HRQoL from baseline compared with docetaxel. Atezolizumab also prolonged the TTD in chest pain (HR, 0.71; 95% CI, 0.49-1.05; P = .0823), although both arms showed an objective reduction relative to baseline. Overall, the patients had no clinically significant worsening in treatment-related symptoms, although the scores favored atezolizumab.

CONCLUSION

These PRO data support the clinical benefit of atezolizumab in patients with previously treated advanced or metastatic NSCLC. Atezolizumab prolonged the TTD of patients' limitations in role and physical functions compared with docetaxel.

A qualitative exploration of distress associated with episodic breathlessness in advanced lung cancer

PURPOSE

Breathlessness is a distressing symptom, particularly common in those with advanced lung cancer. Previous research has identified the symptom occurrence of episodic breathlessness, identifying average frequency, duration and severity of episodes, but has not explored the distress specifically associated with these episodes. This study explored the distress associated with episodic breathlessness for adults with advanced cancer and the relative impact of three elements; frequency, duration or severity.

METHODS

Semi-structured interviews were conducted with four participants with advanced lung cancer. Analysis adopted an interpretative phenomenological approach.

RESULTS

A complex relationship existed between distress caused by episodic breathlessness and its frequency, duration and severity for study participants. Episodic breathlessness had a significant impact on participant's perceptions of self and previous experience effected how distressed they were by their breathlessness. The emotional work created by the symptom was considerable for individuals.

CONCLUSION

The study highlights the importance of recognizing symptoms as a combination of different experiences that may each cause different levels of distress. Initial evidence is provided that the emotional work involved for patients to self-manage each separate element of breathlessness should be considered in its treatment.

The Roles of Dyadic Appraisal and Coping in Couples With Lung Cancer

Given the high symptom burden and low survivability of lung cancer, patients and their spouses have been found to experience poor mental health. The current study examined the roles of dyadic appraisal and dyadic coping on the mental health of 78 couples living with non-small cell lung cancer. Multilevel modeling revealed that spouses, on average, reported significantly worse mental health than patients. Dyadic appraisal and dyadic coping played important roles in predicting mental health, controlling for known developmental and contextual covariates. Dyadic appraisal of the patient's pain and fatigue was significantly associated with spouse mental health, albeit in opposite directions. Dyadic coping significantly predicted patient mental health. The study underlines the need to incorporate routine screening of both patient and spouse mental health, and highlights the complex role of appraisal within the couple in a life-threatening context. Viewing the couple as a unit, rather than separate individuals, raises important awareness about the role of disparate illness appraisals and coping strategies within the dyad on the health of both members. Nurses are particularly well situated to engage in a collaborative family-focused approach to the couple with cancer that promotes communication and health.

The differential diagnosis of tiredness: a systematic review

Background

Tiredness is one of the most frequent complaints in primary care. Although often self-limiting and frequently associated with psychosocial stress, patients but also their physicians are often uncertain regarding a serious cause and appropriate diagnostic work-up. We conducted a systematic review and meta-analysis of studies reporting on differential diagnosis of fatigue in primary care.

Methods

MEDLINE, EMBASE and conference abstracts were searched for primary care based studies of patients presenting with tiredness. Twenty-six studies were included. We report on anaemia, malignancy, serious organic disease, depression and the chronic fatigue syndrome (CFS) as causes of tiredness as presenting complaint.

Results

We found considerable heterogeneity of estimates which was reduced by limiting our analysis to high quality studies. Prevalences were as follows-anaemia: 2.8 % (CI (confidence interval) 1.6–4.8 %); malignancy: 0.6 % (CI 0.3–1.3 %); serious somatic disease: 4.3 % (CI 2.7–6.7 %); depression 18.5 % (CI 16.2–21.0 %). Pooling was not appropriate for CFS.

In studies with control groups of patients without the symptom of tiredness, prevalence of somatic disease was identical to those complaining of tiredness. Depression, however, was more frequent among those with tiredness.

Conclusions

Serious somatic disease is rare in patients complaining of tiredness. Since prevalence is similar in patients without tiredness, the association may not be causal. Extensive investigations are only warranted in case of specific findings from the history or clinical examination. Instead, attention should focus on depression and psychosocial problems.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-016-0545-5) contains supplementary material, which is available to authorized users.

Translation and evaluation of Chinese version of the symptom experience index

Symptom assessment is crucial for patient care through the entire disease trajectory. Patients often experience multiple symptoms concurrently. The symptom experience index is reliable and valid as an instrument developed in the USA for assessing multiple symptoms and distress. The aim of the study was to translate and evaluate the Chinese version of the instrument in healthy adults and oncology patients. This is a psychometric study with a cross-sectional design. To ensure the semantic equivalence and content validity, an integrative translation method was employed to translate the English version into Chinese language. The participants were recruited during 2014 from a large university, two university-affiliated hospitals and a community in Changchun, China. The Chinese version demonstrated high internal consistency, test-retest reliability and content validity. Construct validity was supported by factor analysis and significant differences of symptom experience scores between healthy and oncology groups. Participants' acceptance of the Chinese version and its ability to collect adequate data among Chinese population provided evidence for using this version among Chinese population. This study provided initial evidence to support the psychometric properties of the Chinese version. The Chinese version demonstrated adequate reliability and validity to assess multiple symptom experience by Chinese populations.

Quality of life results from the phase 3 REVEL randomized clinical trial of ramucirumab-plus-docetaxel versus placebo-plus-docetaxel in advanced/metastatic non-small cell lung cancer patients with progression after platinum-based chemotherapy

OBJECTIVES

REVEL demonstrated that ramucirumab+docetaxel (RAM+DTX) improved overall survival, progression-free survival, and objective response rate in patients with advanced/metastatic non-small cell lung cancer with progression after platinum-based chemotherapy. This analysis examined quality of life (QoL) as assessed by the Lung Cancer Symptom Scale (LCSS) and clinician-reported functional status.

MATERIALS AND METHODS

The LCSS includes 6 symptom and 3 global items measured on a 0-100-mm scale; higher scores represent greater symptom burden. LCSS and ECOG PS data were collected at baseline, every 3-week cycle, the summary visit, and at the 30-day follow-up. LCSS total score and Average Symptom Burden Index (ASBI) were calculated. The primary analysis compared time to deterioration (TtD) between treatment arms for all individual items and summary scores, defined as increase from baseline by ≥ 15 mm using the Kaplan-Meier method and Cox regression. TtD to ECOG PS ≥ 2 was analyzed.

RESULTS

There were 1253 patients randomized to receive RAM+DTX or placebo+docetaxel (PL+DTX). Across all assessments, LCSS compliance was approximately 75% and balanced across arms. The mean (SD) baseline LCSS total score was 27.3mm (17.08 mm) on RAM+DTX and 29.6mm (17.59 mm) on PL+DTX. At 30-day follow-up, mean (SD) LCSS total score was 32.0 (19.03) on RAM+DTX and 32.5 (19.87) on PL+DTX. The TtD for all LCSS scores was similar between treatment arms. Stratified HRs (95% CI) for LCSS total score and ASBI were HR=0.99 (0.81, 1.22), p=0.932 and HR=0.93 (0.75, 1.15), p=0.514 with approximately 70% of patients censored. TtD to PS ≥ 2 was similar between treatment arms (HR=1.03 [95% CI: 0.85, 1.26], p=0.743) with approximately two-thirds of the patients censored.

CONCLUSION

In addition to improvement of clinical efficacy outcomes demonstrated in REVEL, these results suggest that adding ramucirumab to docetaxel did not impair patient QoL, symptoms, or functioning.

Content Validity of the Lee Chronic Graft-versus-Host Disease Symptom Scale as Assessed by Cognitive Interviews

The Lee Chronic Graft-versus-Host Disease (cGVHD) Symptom Scale has been recommended for use by the 2005 and 2014 National Institutes of Health (NIH) Consensus Conferences to capture cGVHD symptoms. Although the cGVHD Symptom Scale was previously validated, this study aims to reexamine the instrument's content validity by exploring the clarity, comprehensibility, relevance, and ease of use in a contemporary cGVHD sample, toward Food and Drug Administration (FDA) qualification of this patient-reported outcomes (PRO) instrument as a drug development tool. Attaining FDA qualification means that an instrument has been judged to be a reliable and valid measure of clinical benefit. Twenty adult patients with a median age of 58 year (range, 31 to 79 years) participated. The median duration of cGVHD was 33 months (range, 0 to 134.4 months), and current NIH severity score was mild in 1 patient, moderate in 10 patients, and severe in 9 patients, with a median of 5.5 treatments (range, 0 to 14) ever used for cGVHD. The median summary score was 23 (range, 8 to 51), and the median time to complete the scale was 2 minutes, 7 seconds (range, 1 minute, 8 seconds to 4 minutes). Symptoms of cGVHD were well captured on the Lee cGVHD Symptom Scale, although 4 additional symptoms/signs were mentioned by 15% of the participants. Participants mostly reported that item wording was clear and provided accurate definitions of specific terminologies; however, 7 participants (35%) reported finding 1 or more items in the skin domain unclear, reporting, for example, that rashes and itchy skin seemed synonymous. Two of 19 participants (10.5%) described how their answers would have changed had they been asked about their symptoms within the past month instead of within the past week, owing to recently resolved symptoms. All participants were able to accurately explain the concept of "bother" in their own words and distinguish it from symptom severity or other related symptom attributes. In summary, participants found the Lee GVHD Symptom Scale to be a comprehensive and understandable way to report their cGVHD symptom experience. Future work will focus on options for the recall period, the phrasing of skin items, and whether some very rare symptoms (eg, feeding tube, use of oxygen) should continue to be a part of the scale.

Trajectories of Symptom Occurrence and Severity From Before Through Five Months After Lung Cancer Surgery

CONTEXT

Limited information is available about lung cancer patients' symptoms in the pre- and postoperative periods.

OBJECTIVES

Study purposes were to evaluate for changes in symptom occurrence and severity from the preoperative period to five months after surgery and to evaluate for predictors of the occurrence and trajectories of these symptoms.

METHODS

Patients completed the Memorial Symptom Assessment Scale before and at one and five months after surgery. Changes in the six most common physical symptoms and the most common psychological symptom were evaluated using multilevel growth mixture modeling. Age, gender, comorbidity, and receipt of adjuvant chemotherapy were included as covariates in the conditional models for symptom occurrence and severity.

RESULTS

The total number of symptoms increased significantly from the preoperative to the one month assessment. At five months, the number of symptoms was lower than at one month but significantly higher than at the preoperative assessment. The occurrence of five of the symptoms (i.e., pain, lack of energy, shortness of breath, feeling drowsy, and worrying) increased significantly from before through the first month after surgery and then decreased over time. Cough and difficulty sleeping persisted over the five months of the study. In general, the effect of the four covariates was to increase patients' overall symptom burden.

CONCLUSION

Changes in the occurrence and severity of these seven symptoms were variable. All seven symptoms occurred at relatively high rates and were of moderate severity. Findings can be used to identify patients who are at higher risk for more severe symptoms.

Exploring hope and healing in patients living with advanced non-small cell lung cancer

PURPOSE/OBJECTIVES

To explore the experience and meaning of hope in relation to the healing process of patients living with stage IIIb or IV non-small cell lung cancer.

RESEARCH APPROACH

Interpretative qualitative study design.

SETTING

Peter Brojde Lung Cancer Centre in the Jewish General Hospital in Montreal, Quebec, Canada.

PARTICIPANTS

12 English- and French-speaking patients, aged 36-78 years.

METHODOLOGIC APPROACH

One 60-90-minute semistructured interview per participant was conducted. An inductive approach to data analysis was taken, involving immersion in the data, coding, classifying, and creating linkages.

FINDINGS

Four main themes emerged: (a) the morass of shattered hope, (b) tentative steps toward a new hope paradigm, (c) reframing hope within the context of a life-threatening illness, and (d) strengthening the link between hope and wellness.

CONCLUSIONS

Patients described a process where hope was diminished or lost entirely, regained, and reshaped as they learned to live and grow following their diagnosis.

INTERPRETATION

This study adds to the literature by describing the dynamic nature of hope as well as factors facilitating or hindering the hope process. It demonstrates how finding meaning, a structural component of healing, can be used to envision a new hopeful future. This study suggests hope and healing cannot exist in isolation, and highlights the importance of understanding the fluctuating nature of hope in patients with advanced lung cancer to foster it, therefore promoting healing.

Patient-reported stressful events and coping strategies in post-menopausal women with breast cancer

The objective of this paper was to explore what stressful events post-menopausal women with primary or recurrent breast cancer experience, how bothersome these events were and which coping strategies these women used. Data were collected from 131 patients diagnosed with primary or recurrent breast cancer. The Daily Coping Assessment was used. Thematic analysis was applied to form themes of stressful events. Six types of stressful events were extracted. The most frequently experienced events for women with primary cancer and those with recurrent cancer were 'distressing bodily symptoms'. The most bothersome event among primary cancer was 'everyday concerns' and in the recurrent group, 'distressing psychological reactions'. The most commonly used strategies were 'acceptance', 'distraction' and 'relaxation'. This study shows that women in different parts of the cancer trajectory differ in what they perceive to be stressful events when reporting them in their own words in a diary. The differences have an impact on the subsequent coping strategies they used.

Psychological wellness and health-related stigma: a pilot study of an acceptance-focused cognitive behavioural intervention for people with lung cancer

People with lung cancer experience health-related stigma that is related to poorer psychosocial and quality of life outcomes. The present Phase 1 study applied mixed methods to test the acceptability of an acceptance-focused cognitive behavioural intervention targeting stigma for this patient group. Fourteen lung cancer patients completed a 6-week Psychological Wellness intervention with pre- and post-test outcome measures of psychological and cancer-specific distress, depression, health-related stigma and quality of life. In-depth interviews applying interpretative phenomenological analysis assessed participants' experiences of the intervention. Moderate to large improvements were observed in psychological (ηp (2)  = 0.182) and cancer-specific distress (ηp (2)  = 0.056); depression (ηp (2)  = 0.621); health-related stigma (ηp (2)  = 0.139). In contrast, quality of life declined (ηp (2)  = 0.023). The therapeutic relationship; self-management of distress; and relationship support were highly valued aspects of the intervention. Barriers to intervention included avoidance and practical issues. The lung cancer patients who completed the Psychological Wellness intervention reported improvements in psychological outcomes and decreases in stigma in the face of declining quality of life with patients reporting personal benefit from their own perspectives. A randomised controlled trial is warranted to establish the effectiveness of this approach.

Identification of symptom clusters among patients with heart failure: an international observational study

BACKGROUND

Virtually all patients with heart failure experience multiple symptoms simultaneously, yet clinicians and researchers usually consider symptoms in isolation. Recognizing and responding early to escalating symptoms is essential to preventing hospitalizations in heart failure, yet patients have considerable difficulty recognizing symptoms. Identification of symptom clusters could improve symptom recognition, but cultural differences may be present that must be considered.

OBJECTIVES

To identify and compare symptom clusters in heart failure patients from the United States, Europe and Asia.

DESIGN

Cross-sectional, observational study.

SETTINGS

In- and out-patient settings in three regions of the world: Asia (i.e., China and Taiwan); Europe (i.e., the Netherlands and Sweden); and the United States.

PARTICIPANTS

A total of 720 patients with confirmed heart failure. Propensity scoring using New York Heart Association Classification was used to match participants from each of the three regions.

METHODS

Symptoms were identified using the Minnesota Living with Heart Failure Questionnaire. To identify symptom clusters we used cluster analysis with the hierarchical cluster agglomerative approach. We used the Euclidean distance to measure the similarity of variables. Proximity between groups of variables was measured using Ward's method. The resulting clusters were displayed with dendrograms, which show the proximity of variables to each other on the basis of semi-partial R-squared scores.

RESULTS

There was a core group of symptoms that formed two comparable clusters across the countries. Dyspnea, difficulty in walking or climbing, fatigue/increased need to rest, and fatigue/low energy were grouped into a cluster, which was labeled as a physical capacity symptom cluster. Worrying, feeling depressed, and cognitive problems were grouped into a cluster, which was labeled as an emotional/cognitive symptom cluster. The symptoms of edema and trouble sleeping were variable among the countries and fell into different clusters.

CONCLUSION

Despite the diversity in cultures studied, we found that symptoms clustered similarly among the cultural groups. Identification of similar symptoms clusters among patients with heart failure may improve symptom recognition in both patients and healthcare providers.

An investigation of symptom burden and quality of life in Chinese chemo-naïve advanced lung cancer patients by using the Instrument-Cloud QOL System

OBJECTIVES

This study was designed to assess the disease-related symptom burden and quality of life (QOL) in Chinese chemo-naïve advanced lung cancer patients.

MATERIALS AND METHODS

Chemo-naïve patients with stage III/IV lung cancer were enrolled. 43 centers from 16 provinces of China participated in the study. Functional Assessment of Cancer Therapy-Lung (FACT-L) scale and Cloud QOL System were applied in the study.

RESULTS

376 eligible patients were analyzed. The three most common and severe symptoms were appetite loss (84.3%, scored 2.46), breathing difficulty (79.0%, scored 2.56), and cough (75.5%, scored 2.81). Significant correlation was found between QOL and symptoms. Regression analysis of QOL indicated that almost every symptom item (except shortness of breath) was the negative indicator of QOL. Moreover, pulmonary diseases, pleural metastases and brain metastases had significant negative impact on both symptoms and QOL. Relatively poor performance status affected the QOL only, while cardiovascular diseases merely affected the symptoms. And patients with EGFR mutations had less symptom burden than those with wild-type EGFR.

CONCLUSION

QOL evaluation by using the Cloud QOL System was feasible. Appetite loss, breathing difficulty and cough were the three most common and severe symptoms seen in Chinese chemo-naïve advanced lung cancer patients. Almost all symptoms had negative impact on QOL. And some clinical characteristics could predict the symptoms and QOL.

Validity and reliability of the Swedish version of the Memorial Symptom Assessment Scale (MSAS): an instrument for the evaluation of symptom prevalence, characteristics, and distress

CONTEXT

There are few scales in Swedish that assess symptoms in the dimensions of frequency, severity, and distress.

OBJECTIVES

The purpose of this study was to translate and determine the validity and reliability of the Memorial Symptom Assessment Scale (MSAS) in a Swedish population of postmenopausal women newly diagnosed with primary or recurrent breast cancer.

METHODS

The original 32-item MSAS, a self-report measure for assessing symptom distress and frequency in cancer patients, was translated and administered to 206 patients (primary, n = 150 and recurrent, n = 56).

RESULTS

The MSAS psychological symptom subscale correlated with the emotional and cognitive functioning subscales of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30), and showed the highest correlation with the EORTC QLQ-C30 emotional functioning subscale (r = -0.78; P < 0.01). The psychological symptom subscale also correlated with the Hospital Anxiety and Depression Scale (HADS) within values for anxiety (r = 0.68; P < 0.01) and with the EORTC QLQ-C30 within cognitive functioning values (r = -0.58; P < 0.01). The Global Distress Index (GDI)-MSAS showed satisfactory correlations with the EORTC QLQ-C30 emotional functioning subscale (r = -0.75; P < 0.01), whereas the correlation between the GDI-MSAS and the EORTC QLQ-C30 cognitive functioning subscale was somewhat lower (r = -0.54; P < 0.01). Correlations between the GDI-MSAS and the HADS anxiety subscale were confirmed (r = 0.62; P < 0.01), and a correlation between the MSAS physical symptom items and symptom items in the EORTC-QLQ-C30 was evident (r = 0.60-0.85; P < 0.01). Cronbach's alpha coefficients for the MSAS and MSAS subscales based on symptom scores ranged from 0.80 to 0.89. The internal consistency at different time points was satisfactory, ranging from 0.86 (baseline) to 0.90 (follow-up).

CONCLUSION

The Swedish version of the MSAS presents as a valid and reliable measure for assessing symptom distress, severity, and frequency in Swedish patients diagnosed with primary and recurrent breast cancer.

Qualitative research into the symptom experiences of adult cancer patients after treatments: a systematic review and meta-synthesis

PURPOSE

This review paper aimed to draw together the findings of qualitative research into the symptom experience of adult cancer patients in order to develop a better understanding of symptom experiences following cancer treatment.

METHODS

Systematic review and meta-synthesis techniques were used to identify, appraise and synthesise the relevant literature.

RESULTS

A thematic account of shared symptom experiences reported across papers is presented. Four main themes are discussed: interaction with health services, changing relationships, changing self and coping. In addition the range of symptoms reported across qualitative cancer research is highlighted.

CONCLUSIONS

Unexpected symptoms can have negative effects on patients who need to be better prepared for long-term symptom experiences. In addition, it is important to acknowledge that patients' symptom experiences do not happen in isolation and should be addressed holistically within the context of patients' lives.

The broad spectrum of unbearable suffering in end-of-life cancer studied in dutch primary care

BACKGROUND

Unbearable suffering most frequently is reported in end-of-life cancer patients in primary care. However, research seldom addresses unbearable suffering. The aim of this study was to comprehensively investigate the various aspects of unbearable suffering in end-of-life cancer patients cared for in primary care.

METHODS

Forty four general practitioners recruited end-of-life cancer patients with an estimated life expectancy of half a year or shorter. The inclusion period was three years, follow-up lasted one additional year. Practices were monitored bimonthly to identify new cases. Unbearable aspects in five domains and overall unbearable suffering were quantitatively assessed (5-point scale) through patient interviews every two months with a comprehensive instrument. Scores of 4 (serious) or 5 (hardly can be worse) were defined unbearable. The last interviews before death were analyzed. Sources providing strength to bear suffering were identified through additional open-ended questions.

RESULTS

Seventy six out of 148 patients (51%) requested to participate consented; the attrition rate was 8%, while 8% were alive at the end of follow-up. Sixty four patients were followed up until death; in 60 patients interviews were complete. Overall unbearable suffering occurred in 28%. A mean of 18 unbearable aspects was present in patients with serious (score 4) overall unbearable suffering. Overall, half of the unbearable aspects involved the domain of traditional medical symptoms. The most frequent unbearable aspects were weakness, general discomfort, tiredness, pain, loss of appetite and not sleeping well (25%-57%). The other half of the unbearable aspects involved the domains of function, personhood, environment, and nature and prognosis of disease. The most frequent unbearable aspects were impaired activities, feeling dependent, help needed with housekeeping, not being able to do important things, trouble accepting the situation, being bedridden and loss of control (27%-55%). The combination of love and support was the most frequent source (67%) providing strength to bear suffering.

CONCLUSIONS

Overall unbearable suffering occurred in one in every four end-of-life cancer patients. Half of the unbearable aspects involved medical symptoms, the other half concerned psychological, social and existential dimensions. Physicians need to comprehensively assess suffering and provide psychosocial interventions alongside physical symptom management.

What is special about patients with lung cancer and pulmonary metastases in palliative care? Results from a nationwide survey

BACKGROUND

Patients with advanced lung cancer constitute a special focus in palliative care not only for epidemiological or prognostic reasons, but also because their symptom burden is felt to be widespread and difficult to treat. This study describes disease-specific characteristics and the symptom burden of patients with advanced incurable lung cancer, comparing them with patients suffering from other diseaseentities.

METHODS

A secondary analysis of the nationwide Hospice and Palliative Care Evaluation (HOPE) was performed, by focussing on inpatient hospice and palliative care unit patients and by using descriptive methods.

RESULTS

From 2006 to 2008, 5487 inpatients were registered, 874 of which were diagnosed with lung cancer and 1884 with pulmonary metastases. Symptoms such as weakness, tiredness, or pain were most prevalent in all subgroups. Dyspnea was significantly more prevalent in all patients with different kinds of pulmonary tumor manifestations; confusion was significantly more prevalent in patients with lung cancer. Dyspnea could not be treated as effectively as pain or nausea. Confusion and nursing problems worsened during the observation period. Dyspnea and confusion were associated with increased risk of death during the observational period.

CONCLUSION

The symptom pattern of patients with lung cancer is characterized by dyspnea and confusion--symptoms that are difficult to treat until discharge and that imply a worse prognosis. Therefore, increased research on the pathophysiology and treatment of dyspnea and confusion is required, and efforts in advance care planning and anticipation of dyspnea and confusion as a critical symptom in patients with lung cancer should be reinforced.

The impact of lung cancer on patients and carers

This article aims to provide a brief review of the literature with regard to the impact of lung cancer on patients and their informal carers. Compared to other types of cancer, the distress associated with lung cancer has been found to be the most intense. Rather than focusing on symptoms in isolation recent emphasis regarding the symptom experience has been on symptoms clusters, as understanding these clusters may improve the management of ongoing and unrelieved symptoms. However, the disparities in methodology are significant barriers to producing comparable results, although recent efforts have been made to address these. Whilst research into symptoms has enormous potential for the management of symptom clusters, it needs to move away from the essentially reductionist stance which currently dominates and broaden its scope to one that acknowledges the complexity of the experience of symptom clusters from the perspective of the patient and their informal carer. Poor management of symptoms complicates patient care and potentially contributes to the heavy burden which often falls on family caregivers, especially as the disease progresses. The majority of studies focus on the experiences of primary care providers, most often the partner/spouse. Such studies have shown that spouses of patients with lung cancer exhibit significant distress and lower levels of quality of life than the general population. Research also indicates that significant others go through a transition process due to changes brought about by the diagnosis of lung cancer and struggle to endure and overcome difficulties and distress. Significant others were seen to suffer during this process of transition and experienced altered relationships. Clinicians working with patients suffering from lung cancer and their carers should intervene to enhance their quality of life from diagnosis, during the disease trajectory and during bereavement. Interventions need to be developed to support both patients and carers.

Cancer-related fatigue: epidemiology, pathogenesis, diagnosis, and treatment

BACKGROUND

Many cancer patients suffer from cancer-related fatigue (CRF) both during and after their treatment. CRF can arise at any point in the course of the disease and can be either self-limited or persistent, sometimes for years. It gives rise to a vicious circle of impaired physical performance, avoidance of exertion, inactivity, inadequate physical recovery, helplessness, and depressed mood. Its hallmarks are tiredness, exhaustion, and lack of energy; it can impair performance so severely that the patient is unable to work. It is associated with increased mortality. Cancer patients are hardly ever systematically asked about the symptoms and signs of CRF. The stress and impairments that it produces are often inadequately appreciated, and the opportunities for treatment often neglected.

METHOD

Selective review of the pertinent literature, including published guidelines from Germany and abroad.

RESULTS

The pathogenesis of CRF is complex, involving an interaction of somatic, emotional, cognitive, and psychosocial factors, with a highly variable pattern of clinical expression. Clinical history-taking plays a key role in diagnostic assessment. Depressive disorders must be considered in the differential diagnosis. Many randomized trials and meta-analyses have documented the efficacy of pharmacological and non-pharmacological treatments for CRF.

CONCLUSION

Cancer-related fatigue is a serious problem that impairs patients physically, mentally, and socially. Physicians need to know how to recognize and treat it.

A longitudinal qualitative analysis of the factors that influence patient distress within the lung cancer population

BACKGROUND

The literature consistently shows that lung cancer patients experience both greater number of symptoms and concerns about health and existential issues compared with patients from other cancer populations and that patient distress near diagnosis predicts survival in lung cancer patients. Also evidence suggests that symptom characteristics (e.g. symptom intensity and frequency) influence distress. The relationship between aspects of patients' symptom experiences can be complex and the mechanisms underpinning this association are not fully understood at present.

METHODS

Semi-structured interviews were conducted with 17 lung cancer patients and 15 primary caregivers at four time points: at the beginning of treatment and then subsequently at three, six, and twelve months, providing a total of 44 patient and 32 caregiver interviews. Interpretative Phenomenological Analysis was employed in the data analysis.

FINDINGS

The analysis presented here concentrates on two areas which was reported to influence distress in this population: (1) patients' perception of symptoms and symptom characteristics and their associated distress; and (2) the relationship between patients' causal reasoning and their distress.

CONCLUSION

The complexity of the issues involved in the development of symptom distress needs to be recognised by health care professionals in this poor prognosis group of patients. Better patient preparation about symptoms may alleviate some of the symptom distress in lung cancer patients.

Symptoms experienced by cancer patients during the first year from diagnosis: patient and informal caregiver ratings and agreement

OBJECTIVE

The aim of this study was to explore the symptom experience of patients with cancer, identify changes in symptoms over time, and explore the congruence of symptom reports between patients and their informal caregivers.

METHOD

This was a prospective longitudinal evaluation of symptoms over 1 year from start of treatments (T1) using the Memorial Symptom Assessment Scale. Assessments and follow up took place at 3 months (T2), 6 months (T3) and 12 months (T4). A heterogeneous sample of 100 patients with cancer participated, providing 325 assessments over time. Furthermore, 82 caregivers also participated, providing 238 dyadic patient-caregiver assessments over the same time.

RESULTS

The most commonly occurring, and by far most distressing, symptom was "lack of energy." Common symptoms reported were lack of concentration, difficulties sleeping, shortness of breath, cough, pain, dry mouth, and feeling drowsy. Symptom occurrence and distress improved over time, particularly from T2 to T3 (p < 0.05), but the "chronicity" of some generic symptoms was notable. Caregivers tended to overestimate occurrence and distress compared to patients, particularly in symptoms of psychological nature; κ statistics had a highest coefficient of 0.45, suggesting moderate agreement between patients and caregivers at best.

SIGNIFICANCE OF RESULTS

More attention needs to be paid to the commonly reported symptoms by patients, as they have the potential of impacting on quality of life (QOL). As patient-caregiver reports had moderate agreement, effort should be directed to improving this agreement, as caregivers are often communicating patient symptoms to clinicians.

Dyspnea in lung cancer patients: a systematic review

Dyspnea is a common and distressing symptom experienced by 19%-51% of patients with advanced cancer. Higher incidences are reported in patients approaching end of life. While the prevalence of dyspnea has been reported to be as frequent as pain in people with lung cancer, less attention has been paid to the distress associated with dyspnea. This review of the literature was undertaken to investigate how dyspnea has been assessed and whether breathlessness in people with lung cancer is distressing. Using a predetermined search strategy and inclusion criteria, 31 primary studies were identified and included in this review. Different outcome measures were used to assess the experience of dyspnea, with domains including intensity, distress, quality of life, qualitative sensation, and prevalence. Overall, the studies report a high prevalence of dyspnea in lung cancer patients, with subjects experiencing a moderate level of dyspnea intensity and interference with activities of daily living. Distress associated with breathing appears to be variable, with some studies reporting dyspnea to be the most distressing sensation, and others reporting lower levels of distress. However, taking into account the prevalence, intensity, and distress of dyspnea, the general consensus appears to be that the experience of dyspnea in people with lung cancer is common, with varying degrees of intensity, but involves considerable unpleasantness. Thus, if dyspnea and pain are both distressing sensations for people with lung cancer, this has potential implications for both clinical and academic areas with regards to both management strategies and further research.

Symptom clusters in men and women with heart failure and their impact on cardiac event-free survival

BACKGROUND

Because patients with heart failure (HF) experience multiple symptoms simultaneously, it is necessary to explore symptom clusters rather than individual symptoms to determine their impact on outcomes. Given gender differences in symptom experience, examination of potential gender differences in clusters is reasonable.

OBJECTIVE

The objective of the study was to compare symptom clusters between men and women with HF, differences in patient characteristics among symptom clusters, and the impact of symptom clusters on cardiac event-free survival.

METHODS

A total of 331 patients with HF recruited from HF clinics were included (35% were female and 62% were of New York Heart Association classes III/IV). Cluster analysis was used to identify symptom clusters between men and women based on ratings of distress related to 7 symptoms. Analysis of variance or chi test was used to compare characteristics of patient groups that were divided by the median split of total distress scores of each cluster. Cox proportional hazards regression was used to determine whether total scores of symptom distress in symptom clusters predicted time to first cardiac event.

RESULTS

Two identical symptom clusters were identified in men and women: a physical symptom cluster composed of dyspnea, fatigue/increased need to rest, fatigue/low energy, and sleep disturbances and an emotional/cognitive symptom cluster composed of worrying, feeling depressed, and cognitive problems. Patients with higher distress from the physical symptom cluster were primarily females and of New York Heart Association classes III and IV (P < .05). Patients with higher distress from the emotional/cognitive symptom cluster were younger than those with lower distress (P < .05). The total symptom distress score in the emotional/cognitive cluster, but not the physical cluster, was an independent predictor of cardiac event-free survival (hazard ratio, 1.18; 95% confidence interval, 1.03-1.37).

CONCLUSION

Although distress for individual symptoms may differ between men and women, they both experienced identical symptom clusters. Only the emotional/cognitive cluster predicted a higher risk for a cardiac event. These results suggested that interventions should be developed that consider symptom clusters. Targeting patients who have high distress from emotional/cognitive symptoms may be particularly important as they may be most vulnerable for adverse outcomes.