Disease and treatment characteristics do not predict symptom occurrence profiles in oncology outpatients receiving chemotherapy

Neurodegenerative disease pathways are perturbed in patients with cancer who self-report cognitive changes and anxiety: A pathway impact analysis

BACKGROUND

Cancer-related cognitive impairment (CRCI) and anxiety co-occur in patients with cancer. Little is known about mechanisms for the co-occurrence of these two symptoms. The purposes of this secondary analysis were to evaluate for perturbed pathways associated with the co-occurrence of self-reported CRCI and anxiety in patients with low versus high levels of these two symptoms and to identify potential mechanisms for the co-occurrence of CRCI and anxiety using biological processes common across any perturbed neurodegenerative disease pathways.

METHODS

Patients completed the Attentional Function Index and the Spielberger State-Trait Anxiety Inventory six times over two cycles of chemotherapy. Based on findings from a previous latent profile analysis, patients were grouped into none versus both high levels of these symptoms. Gene expression was quantified, and pathway impact analyses were performed. Signaling pathways for evaluation were defined with the Kyoto Encyclopedia of Genes and Genomes database.

RESULTS

A total of 451 patients had data available for analysis. Approximately 85.0% of patients were in the none class and 15.0% were in the both high class. Pathway impact analyses identified five perturbed pathways related to neurodegenerative diseases (i.e., amyotrophic lateral sclerosis, Huntington disease, Parkinson disease, prion disease, and pathways of neurodegeneration-multiple diseases). Apoptosis, mitochondrial dysfunction, oxidative stress, and endoplasmic reticulum stress were common biological processes across these pathways.

CONCLUSIONS

This study is the first to describe perturbations in neurodegenerative disease pathways associated with CRCI and anxiety in patients receiving chemotherapy. These findings provide new insights into potential targets for the development of mechanistically based interventions.

Stability and consistency of symptom clusters in younger versus older patients receiving chemotherapy

BACKGROUND

By 2035, the number of newly diagnosed cancer cases will double and over 50% will be in older adults. Given this rapidly growing demographic, a need exists to understand how age influences oncology patients' symptom burden. The study purposes were to evaluate for differences in the occurrence, severity, and distress of 38 symptoms in younger (< 60 years) versus older (≥ 60 years) oncology patients undergoing chemotherapy and to evaluate for differences in the stability and consistency of symptom clusters across the two age groups.

METHODS

A total of 1329 patients were dichotomized into the younger and older groups. Patients completed demographic and clinical questionnaires prior to the initiation of their second or third cycle of chemotherapy. A modified version of Memorial Symptom Assessment Scale was used to evaluate the occurrence, severity, and distress of 38 common symptoms associated with cancer and its treatment. Differences between the two age groups in demographic and clinical characteristics and ratings of occurrence, severity, and distress for the 38 symptoms were evaluated using parametric and nonparametric tests. Exploratory factor analyses were done within each age group to identify symptom clusters using symptom occurrence rates.

RESULTS

Compared to the younger group (14.8 (± 7.0)), older adults reported a lower mean number of symptoms (12.9 (± 7.2)). Older patients experienced lower occurrence rates for almost 50% of the symptoms. Regarding symptom clusters, an eight-factor solution was selected for both age groups. Across the two age groups, the eight symptom clusters (i.e., physical and cognitive fatigue, respiratory, psychological, hormonal, chemotherapy-related toxicity, weight gain, gastrointestinal, epithelial) were stable. However, symptoms within the physical and cognitive, chemotherapy-related toxicity, and gastrointestinal clusters were not consistent across the age groups.

CONCLUSIONS

To be able to provide tailored and effective symptom management interventions to older oncology patients, routine assessments of the core symptoms unique to the symptom clusters identified for this group warrants consideration. The underlying mechanism(s) for these inconsistencies in symptom burden is an important focus for future studies.

Identification of subgroups of patients with gastrointestinal cancers based on symptom severity and frequency: A latent profile and latent class analysis

PURPOSE

Identify subgroups of patients with gastrointestinal cancer with different frequency and severity of symptoms and assess differences in demographics, clinical characteristics, and degree of interference with daily life.

METHODS

This was a cross-sectional study. A total of 202 patients with gastrointestinal cancers completed the Chinese version of the MD Anderson Symptom Inventory for Gastrointestinal Cancer Module by convenience sampling. Subgroups of patients were identified using latent profile analysis and latent class analysis. Chi-squared, Mann-Whitney-U, and Kruskal-Wallis tests assessed differences among subgroups.

RESULTS

In terms of symptom severity, low (70.3%), Moderate (13.4%), and high (16.3%) classes were identified. Compared with the other two classes, the Moderate group had a higher proportion of patients with a history of tobacco and alcohol, esophageal cancer, and gastric cancer (P < 0.05). In terms of symptom frequency, all -high (57.9%), high physical symptoms (9.9%), and all-low (32.2%) classes were identified. All-high groups had a younger age and a higher proportion of patients with cancer stage IV (P < 0.05). The high group had the most interference with daily life in both perspectives (P < 0.001), and psycho-emotional symptoms were frequent and severe.

CONCLUSIONS

The two perspectives of symptom severity and frequency can play a complementary role in identifying high-risk groups. Clinical practitioners should strengthen psychological interventions in young and advanced cancer patients and provide pharmaceutical and non-pharmaceutical interventions for dysphagia symptoms in esophageal and gastric cancer patients with a history of tobacco and alcohol.

Worse Depression Profiles Are Associated With Higher Symptom Burden and Poorer Quality of Life in Patients With Gynecologic Cancer

BACKGROUND

Depression is a pervasive symptom in patients with gynecological cancer undergoing chemotherapy.

OBJECTIVES

Purposes were to identify subgroups of patients with distinct depression profiles and evaluate for differences in demographic and clinical characteristics, severity of common symptoms, and quality of life (QOL) outcomes among these subgroups.

METHODS

Patients with gynecological cancer (n = 231) completed the Center for Epidemiologic Studies-Depression Scale 6 times over 2 cycles of chemotherapy. All of the other measures were completed prior to the second or third cycle of chemotherapy. Latent profile analysis was done to identify the distinct depression profiles. Differences were evaluated using parametric and nonparametric tests.

RESULTS

Three distinct profiles were identified: low (60.1%), high (35.1%), and very high (4.8%). Compared with low class, the other 2 classes had lower functional status and were more likely to self-report a diagnosis of depression. Patients in the 2 worse profiles reported a higher comorbidity burden, higher levels of trait and state anxiety, sleep disturbance, and fatigue, as well as lower levels of cognitive function and poorer QOL. State and trait anxiety, evening fatigue, and sleep disturbance scores exhibit a "dose-response effect" (ie, as the depression profile worsened, the severity of these symptoms increased).

CONCLUSIONS

Almost 40% of our sample experienced high or very high levels of depression across 2 cycles of chemotherapy.

IMPLICATIONS FOR PRACTICE

Clinicians can use the identified risk factors to identify high patients risk and provide tailored psychological interventions aimed to decrease symptom burden and prevent decrements in QOL.

Differential Characteristics of Fatigue-Pain-Sleep Disturbance-Depression Symptom Cluster and Influencing Factors of Patients With Advanced Cancer During Treatment: A Latent Class Analysis

BACKGROUND

Patients with advanced cancer may experience symptom clusters during treatment (eg, fatigue, pain, sleep disturbance, depression). Understanding the characteristics and factors associated with symptom cluster classes among this patient population is essential for effective symptom management.

OBJECTIVE

The aims of this study were to identify symptom cluster (fatigue-pain-sleep disturbance-depression) classes and explore influencing factors in patients with advanced cancer during the treatment.

METHODS

A cross-sectional survey was conducted in an oncology department of a tertiary hospital in China from September 2020 to March 2021. Cancer patients (stage III/IV) 18 years or older completed the questionnaires on pain, fatigue, sleep disturbance, depression, physical activity, and exercise self-efficacy. Latent class analysis and multinomial logistic regression were used.

RESULTS

Three hundred sixty-five patients who were male (65.2%) and younger than 60 years (59.5%) completed questionnaires. Three symptom cluster classes were identified: class 1 ("low symptom burden" class), class 2 ("fatigue-insomnia" class), and class 3 ("high symptom burden" class), with a percentage of 54.5%, 38.6%, and 6.8%, respectively. The quality-of-life score, introversion/extroversion, economic burden, Karnofsky Performance Status, albumin level, and exercise self-efficacy were significantly different among the 3 classes (P < .05).

CONCLUSION

Patients with advanced cancer were classified into 3 distinct classes, with class 1 having the best function. Results from this study reveal that Karnofsky Performance Status, albumin level, and exercise self-efficacy were significant factors for the latent classes of symptom cluster.

IMPLICATIONS FOR PRACTICE

Exercise self-efficacy is important for personalized interventions and improving symptom management efficiency.

Symptom Clusters in Patients With Advanced Cancer: A Prospective Longitudinal Cohort Study to Examine Their Stability and Prognostic Significance

This study's purpose was to assess symptom cluster (SC) stability during disease progression and determine their strength of association with survival in patients with advanced cancer . Consecutively eligible patients with advanced cancer not receiving cancer-specific treatment and referred to a Tertiary Palliative Care Clinic were enrolled in a prospective cohort study. At first consultation (D0) and in subsequent consultations at day 15 (D15) and day 30 (D30), patients rated 9 symptoms through the Edmonton Symptom Assessment System scale (0-10) and 10 others using a Likert scale (1-5). Principal components factor analysis with varimax rotation was used to determine SCs at each consultation. Of 318 patients with advanced cancer, 301 met eligibility criteria with a median age of 69 years (range 37-94). Three SCs were identified: neuro-psycho-metabolic (NPM), gastrointestinal, and sleep impairment, with some variations in their constitution over time. Exploratory factor analysis accounted for 40% of variance of observed variables in all SCs. Shorter median survival was observed continuously for NPM cluster (D0 23 vs. 58 days, P < .001; D15 41 vs. 104 days, P=.004; D30 46 vs. 114 days, P = .002), although the presence of 2 or more SCs on D0 and D15 also had prognostic significance (D0: 21 vs. 45 days, P = .005; D30: 50 vs. 96 days, P = .040). In a multivariable model, NPM cluster (D0 hazard ratio estimate: HR 1.64; 95%CI, 1.17-2.31; P = .005; D15 HR: 2.51; 95%CI, 1.25-5.05; P = .009; D30 HR: 3.9; 95%CI, 1.54-9.86; P = .004) and hospitalization (D0 HR: 2.27; 95%CI, 1.47-3.51; P < .001; D15 HR: 2.43; 95%CI, 1.18-5.01; P = .016; D30 HR: 3.41; 95%CI, 1.35-8.62; P = .009) were independently and significantly associated with worse survival. Three clinically relevant SCs were identified, and their constitution had small variations, maintaining a stable set of nuclear symptoms through disease progression. Presence of the NPM cluster and hospitalization maintained their prognostic value over time.

Adverse Childhood Experiences and Higher Levels of Stress Are Associated With the Co-occurrence of Cancer-Related Cognitive Impairment and Anxiety

OBJECTIVES

We sought to identify subgroups of patients with distinct joint cancer-related cognitive impairment (CRCI) AND anxiety profiles and evaluate for differences in demographic and clinical characteristics, as well as levels of global stress, cancer-specific stress, cumulative life stress, and resilience.

DATA SOURCES

Patients (n = 1332) completed the Attentional Function Index and the Spielberger State Anxiety Inventory six times over two cycles of chemotherapy. Global, cancer-specific, and cumulative life stress and resilience were evaluated using Perceived Stress Scale, Impact of Event Scale-Revised, Life Stressor Checklist-Revised, and Connor-Davidson Resilience Scale, respectively. Latent profile analysis was used to identify subgroups of patients with distinct joint CRCI AND anxiety profiles. Differences were evaluated using parametric and nonparametric tests.

RESULTS

Three classes were identified (ie, No CRCI and Low Anxiety [57.3%], Moderate CRCI and Moderate Anxiety [34.5%], and High CRCI and High Anxiety [8.2%]). All of the stress measures showed a dose-response effect (ie, as the CRCI AND anxiety profile worsened, scores for all three types of stress increased). The two highest symptom classes reported higher occurrence rates for six specific stressors (eg, emotional abuse, physical abuse, sexual harassment).

CONCLUSIONS

Findings suggest that higher levels of co-occurring CRCI AND anxiety are associated with some common risk factors, as well as higher levels of stress and lower levels of resilience. Increased knowledge of modifiable risk factors and sources of stress associated with the co-occurrence of these two symptoms will assist clinicians to identify high-risk patients and implement individualized interventions.

Oncology Outpatients With Worse Anxiety and Sleep Disturbance Profiles Are at Increased Risk for a Higher Symptom Burden and Poorer Quality of Life

BACKGROUND

Anxiety and sleep disturbance are frequent symptoms during chemotherapy.

OBJECTIVES

Purposes were to identify subgroups of oncology outpatients with distinct joint anxiety and sleep disturbance profiles, as well as evaluate for differences in demographic and clinical characteristics, sleep disturbance characteristics, severity of common symptoms, and quality-of-life outcomes among these subgroups.

METHODS

Oncology outpatients (n = 1331) completed self-report measures of anxiety and sleep disturbance 6 times over 2 chemotherapy cycles. Latent profile analysis was done to identify subgroups of patients with distinct joint anxiety and sleep disturbance profiles.

RESULTS

Three profiles were identified (ie, no anxiety and low sleep disturbance (59.7%), moderate anxiety and high sleep disturbance (32.5%), high anxiety and very high sleep disturbance (7.8%)). Compared with the no anxiety and low sleep disturbance class, the other 2 classes were younger; less likely to be married; had a lower annual household income; and had childcare responsibilities. Patients in the 2 worse profiles had problems with both sleep initiation and maintenance. These patients reported higher levels of depressive symptoms, trait and state anxiety, and evening fatigue, as well as lower levels of morning and evening energy, cognitive function, and poorer quality of life.

CONCLUSIONS

More than 40% of patients had moderate or high levels of anxiety and high or very high levels of sleep disturbance. Modifiable risk factors associated with these profiles may be used to develop targeted interventions for 1 or both symptoms.

IMPLICATIONS FOR PRACTICE

Clinicians need to assess for the co-occurrence of anxiety and sleep disturbance.

Higher Lifetime Stress and Symptom Burden Contribute to the Occurrence of Shortness of Breath

OBJECTIVES

Among four classes of patients with distinct shortness of breath profiles, evaluate for differences in levels of global, cancer-specific, and cumulative life stress, as well as resilience; evaluate for differences in the occurrence rates for various stressful life events, and evaluate for differences in the severity of common co-occurring symptoms.

DATA SOURCES

Outpatients (N = 1338) completed questionnaires six times over two cycles of chemotherapy. The occurrence of shortness of breath was assessed using the Memorial Symptom Assessment Scale. Latent class analysis was used to identify subgroups of patients with distinct shortness of breath profiles. Differences among the classes were evaluated using parametric and nonparametric tests.

CONCLUSION

Shortness of breath classes were labeled based on their distinct occurrence trajectories: None (70.5%), Decreasing (8.2%), Increasing (7.8%), and High (13.5%). Compared to None class, Decreasing and High classes had higher global and cancer-specific stress scores. The High class reported higher occurrence rates for several adverse childhood experiences. Compared to None class, Decreasing and High classes had higher depression, anxiety, and morning fatigue scores and lower morning energy and cognitive function scores.

IMPLICATIONS FOR NURSING PRACTICE

Given the additive or synergistic relationships between stress, co-occurring symptoms, and shortness of breath, multimodal interventions that include stress management, exercise training, and/or symptom management may decrease shortness of breath in oncology patients.

Longitudinal patient-reported outcomes in patients receiving chimeric antigen receptor T-cell therapy

Chimeric antigen receptor T-cell therapy (CAR-T) has transformed the treatment for relapsed/refractory hematologic malignancies; however, data on patient-reported outcomes in CAR-T are limited. We conducted a longitudinal study of adults with hematologic malignancies receiving CAR-T. We assessed quality of life (QOL; functional assessment of cancer therapy-general), psychological distress (hospital anxiety and depression scale, patient health questionnaire-9, posttraumatic stress disorder [PTSD] checklist), and physical symptoms (Edmonton symptom assessment scale-revised) at baseline, 1 week, 1, 3, and 6 months after CAR-T. We used linear mixed models to identify factors associated with QOL trajectory. We enrolled 103 of 142 eligible patients (3 did not receive CAR-T). QOL (B = 1.96; P < .001) and depression (B = -0.32; P = .001) worsened by 1 week and improved by 6 months after CAR-T. At 6 months, 18%, 22%, and 22% reported clinically significant depression, anxiety, and PTSD symptoms, respectively. At 1 week, 52% reported severe physical symptoms, declining to 28% at 6 months after CAR-T. In unadjusted linear mixed models, worse Eastern Cooperative Oncology Group performance status (B = 1.24; P = .042), receipt of tocilizumab (B = 1.54; P = .042), and receipt of corticosteroids for cytokine release syndrome and/or neurotoxicity (B = 2.05; P = .006) were associated with higher QOL trajectory. After CAR-T, QOL declined, and depression increased early, followed by improvements in QOL, psychological distress, and physical symptoms by 6 months after infusion. A significant minority of patients reported substantial psychological distress and physical symptoms longitudinally.

Identification of distinct symptom profiles in patients with gynecologic cancers using a pre-specified symptom cluster

PURPOSE

Pain, fatigue, sleep disturbance, and depression are four of the most common symptoms in patients with gynecologic cancer. The purposes were to identify subgroups of patients with distinct co-occurring pain, fatigue, sleep disturbance, and depression profiles (i.e., pre-specified symptom cluster) in a sample of patients with gynecologic cancer receiving chemotherapy and assess for differences in demographic and clinical characteristics, as well as the severity of other common symptoms and QOL outcomes among these subgroups.

METHODS

Patients completed symptom questionnaires prior to their second or third cycle of chemotherapy. Latent profile analysis was used to identify subgroups of patients using the pre-specified symptom cluster. Parametric and nonparametric tests were used to evaluate for differences between the subgroups.

RESULTS

In the sample of 233 patients, two distinct latent classes were identified (i.e., low (64.8%) and high (35.2%)) indicating lower and higher levels of symptom burden. Patients in high class were younger, had child care responsibilities, were unemployed, and had a lower annual income. In addition, these women had a higher body mass index, a higher comorbidity burden, and a lower functional status. Patients in the high class reported higher levels of anxiety, as well as lower levels of energy and cognitive function and poorer quality of life scores.

CONCLUSIONS

This study identified a number of modifiable and non-modifiable risk factors associated with membership in the high class. Clinicians can use this information to refer patients to dieticians and physical therapists for tailored interventions.

An Evaluation of the Multifactorial Model of Cancer-Related Cognitive Impairment

BACKGROUND

Up to 45% of patients report cancer-related cognitive impairment (CRCI). A variety of characteristics are associated with the occurrence and/or severity of CRCI. However, an important gap in knowledge of risk factors for CRCI is the relative contribution of each factor. The multifactorial model of cancer-related cognitive impairment (MMCRCI) is a conceptual model of CRCI that can be used to evaluate the strength of relationships between various factors and CRCI.

OBJECTIVES

The purpose of this study was to use structural regression methods to evaluate the MMCRCI using data from a large sample of outpatients receiving chemotherapy ( n = 1,343). Specifically, the relationships between self-reported CRCI and four MMCRCI concepts (i.e., social determinants of health, patient-specific factors, treatment factors, and co-occurring symptoms) were examined. The goals were to determine how well the four concepts predicted CRCI and determine the relative contribution of each concept to deficits in perceived cognitive function.

METHODS

This study is part of a larger, longitudinal study that evaluated the symptom experience of oncology outpatients receiving chemotherapy. Adult patients were diagnosed with breast, gastrointestinal, gynecological, or lung cancer; had received chemotherapy within the preceding 4 weeks; were scheduled to receive at least two additional cycles of chemotherapy; were able to read, write, and understand English; and gave written informed consent. Self-reported CRCI was assessed using the attentional function index. Available study data were used to define the latent variables.

RESULTS

On average, patients were 57 years of age, college educated, and with a mean Karnofsky Performance Status score of 80. Of the four concepts evaluated, whereas co-occurring symptoms explained the largest amount of variance in CRCI, treatment factors explained the smallest amount of variance. A simultaneous structural regression model that estimated the joint effect of the four exogenous latent variables on the CRCI latent variable was not significant.

DISCUSSION

These findings suggest that testing individual components of the MMCRCI may provide useful information on the relationships among various risk factors, as well as refinements of the model. In terms of risk factors for CRCI, co-occurring symptoms may be more significant than treatment factors, patient-specific factors, and/or social determinants of health in patients receiving chemotherapy.

Distinct Profiles of Morning and Evening Fatigue Co-Occurrence in Patients During Chemotherapy

BACKGROUND

Morning and evening fatigue are distinct and distressing symptoms experienced during chemotherapy that demonstrate a large amount of interindividual variability.

OBJECTIVES

The objectives of this study were to identify subgroups of patients with distinct morning and evening fatigue co-occurrence profiles and evaluate for differences among these subgroups in demographic, clinical, and symptom characteristics and quality of life.

METHODS

Oncology patients ( n = 1,334) completed the Lee Fatigue Scale to self-report morning and evening fatigue, six times over two cycles of chemotherapy. Latent profile analysis was used to identify subgroups of patients with distinct morning and evening physical fatigue profiles.

RESULTS

Four distinct morning and evening fatigue profiles were identified (i.e., Both Low, Low Morning + Moderate Evening, Both Moderate, and Both High). Compared to the Both Low profile, the Both High profile was significantly younger, less likely to be married or partnered, more likely to live alone, had a higher comorbidity burden, and lower functional status. The Both High profile had higher levels of anxiety, depressive symptoms, sleep disturbance, and pain and lower levels of quality of life.

DISCUSSION

The variability in the morning and evening severity scores among the four profiles supports the hypothesis that morning and evening fatigue are distinct but related symptoms. Clinically meaningful levels of both morning and evening fatigue were reported by 50.4% of our sample, which suggests that the co-occurrence of these two symptoms is relatively common. Patients in Both Moderate and Both High profiles experienced an extremely high symptom burden that warrants ongoing assessments and aggressive symptom management interventions.

Distinct Worst Pain Profiles in Oncology Outpatients Undergoing Chemotherapy

BACKGROUND

While pain is a significant problem for oncology patients, little is known about interindividual variability in pain characteristics.

OBJECTIVE

The aims of this study were to identify subgroups of patients with distinct worst pain severity profiles and evaluate for differences among these subgroups in demographic, clinical, and pain characteristics and stress and symptom scores.

METHODS

Patients (n = 934) completed questionnaires 6 times over 2 chemotherapy cycles. Worst pain intensity was assessed using a 0- to 10-point numeric rating scale. Brief Pain Inventory was used to assess various pain characteristics. Latent profile analysis was used to identify subgroups of patients with distinct pain profiles.

RESULTS

Three worst pain profiles were identified (low [17.5%], moderate [39.9%], severe [42.6%]). Compared with the other 2 classes, severe class was more likely to be single and unemployed and had a lower annual household income, a higher body mass index, a higher level of comorbidity, and a poorer functional status. Severe class was more likely to have both cancer and noncancer pain, a higher number of pain locations, higher frequency and duration of pain, worse pain quality scores, and higher pain interference scores. Compared with the other 2 classes, severe class reported lower satisfaction with pain management and higher global, disease-specific, and cumulative life stress, as well as higher anxiety, depression, fatigue, sleep disturbance, and cognitive dysfunction scores.

CONCLUSIONS

Unrelieved pain is a significant problem for more than 80% of outpatients.

IMPLICATIONS FOR PRACTICE

Clinicians need to perform comprehensive pain assessments; prescribe pharmacologic and nonpharmacologic interventions; and initiate referrals for pain management and psychological services.

Distinct Shortness of Breath Profiles in Oncology Outpatients Undergoing Chemotherapy

CONTEXT

Shortness of breath is a distressing symptom that occurs in 10% to 70% of oncology patients. Despite this broad range in its occurrence, little is known about inter-individual variability in shortness of breath and associated risk factors among patients receiving chemotherapy.

OBJECTIVES

Identify subgroups of patients with distinct shortness of breath profiles; evaluate for differences among these subgroups in demographic and clinical characteristics; evaluate for differences among symptom dimensions of shortness of breath, and evaluate for differences in quality of life outcomes.

METHODS

Outpatients (n=1338) completed questionnaires six times over two chemotherapy cycles. Occurrence of shortness of breath was assessed using the Memorial Symptom Assessment Scale. Latent class analysis was used to identify subgroups of patients with distinct shortness of breath profiles.

RESULTS

Four distinct shortness of breath profiles were identified (None [70.5%], Decreasing [8.2%], Increasing [7.8%], High [13.5%]). Risk factors for membership in High class included: history of smoking, self-reported diagnosis of lung disease, having lung cancer, and receipt of a higher number of cancer treatments. Compared to the None class, High class reported poorer physical, psychological, and social functioning.

CONCLUSIONS

Almost 14% of patients with heterogeneous types of cancer receiving chemotherapy had persistently high occurrence rates of shortness of breath for almost two months. In addition, compared to the Decreasing and Increasing classes, the High class' episodes of shortness of breath were more frequent and more severe. Clinicians need to assess all oncology patients for shortness of breath and provide targeted interventions.

Distinct Dysphagia Profiles in Patients With Oral Cancer After Surgery

OBJECTIVES

To determine distinct profiles based on symptom severity in patients undergoing surgery for oral cancer and examine whether these profiles differ by participant characteristics.

SAMPLE & SETTING

300 patients who underwent surgery for oral cancer at two outpatient clinics between June and December 2021.

METHODS & VARIABLES

Symptoms were assessed using the MD Anderson Symptom Inventory-Head and Neck Cancer Module. Sociodemographic and clinical characteristics were collected. Latent profile analysis was performed.

RESULTS

Five distinct dysphagia profiles were identified, which qualitatively differed regarding co-occurrence patterns of dysphagia, mucus-related symptoms, speech disturbances, and psychoneurologic symptoms. Significant differences were reported in interference to function, number of co-occurring symptoms, time since diagnosis and treatment completion, use of symptom management medications, oral cancer stage and site, and treatment completed.

IMPLICATIONS FOR NURSING

Identifying distinct dysphagia profiles can improve patient outcomes and help in planning specific nursing interventions to influence nutritional and functional status in oral cancer survivors. Dysphagia and dry mouth can persist beyond one year post-treatment, so follow-up dysphagia assessments are needed.

Associations of Symptom Clusters and Health Outcomes in Adult Survivors of Childhood Cancer: A Report From the St Jude Lifetime Cohort Study

PURPOSE

To identify symptom clusters among adult survivors of childhood cancers and test associations with health-related quality of life (HRQOL) and physical and neurocognitive performance.

METHODS

This cross-sectional study included 3,085 survivors (mean age at evaluation 31.9 ± 8.3 years; mean years from diagnosis 28.1 ± 9.1) participating in the St Jude Lifetime Cohort Study. Survivors self-reported the presence of 37 symptoms capturing 10 domains (cardiac, pulmonary, sensory, motor/movement, nausea, pain, fatigue, memory, anxiety, and depression). The Short Form-36's Physical/Mental Component Summaries assessed HRQOL; the Physical Performance Test evaluated physical performance; and neurocognitive batteries tested attention, processing/psychomotor speed, memory, and executive function. Latent class analysis identified subgroups of survivors experiencing different patterns of symptom burden (ie, symptom clusters). Multivariable regression models identified risk of cluster membership and tested associations with health outcomes.

RESULTS

Four symptom clusters were identified including cluster 1 (prevalence 52.4%; low physical, somatization, and psychologic domains), cluster 2 (16.1%; low physical, moderate somatic, and high psychologic domains), cluster 3 (17.6%; high physical, moderate somatic, and low psychologic domains), and cluster 4 (13.9%; high in all three domains). Compared with cluster 1, survivors in cluster 4 were more likely to have less than high school education (odds ratio [OR], 7.71; 95% CI, 4.46 to 13.31), no insurance (OR, 1.49; 95% CI, 1.04 to 2.13), and exposure to corticosteroids (OR, 1.76; 95% CI, 1.02 to 3.03); survivors in cluster 3 were more likely to have received platinum agents (OR, 2.22; 95% CI, 1.34 to 3.68) and brain radiation ≥ 30 Gy (OR, 3.99; 95% CI, 2.33 to 6.86). Survivors in cluster 4 reported the poorest Physical Component Summary/Mental Component Summary scores (31.0/26.7) and physical and neurocognitive performance versus survivors in the other clusters (P < .001).

CONCLUSION

Nearly 50% of survivors had moderate to high multisymptom burden, which was associated with sociodemographic, treatment factors, HRQOL, and functional outcomes.

Predictors of Unrelieved Symptoms in All of Us Research Program Participants With Chronic Conditions

CONTEXT

Over half of American adults are diagnosed with a chronic condition, with an increasing prevalence being diagnosed with multiple chronic conditions. These adults are at higher risk for having unrelieved, co-occurring symptoms, known as symptom clusters.

OBJECTIVES

To identify symptom phenotypes of patients diagnosed with four common chronic conditions, specifically, cancer, chronic obstructive pulmonary disease, heart failure, and/or type 2 diabetes mellitus, and to understand factors that predict membership in symptomatic phenotypes.

METHODS

We conducted a retrospective, cross-sectional analysis using participant responses (N=14,127) to All of Us Research Program, a National Institutes of Health biomedical database, survey questions. We performed hierarchical clustering to generate symptom phenotypes of fatigue, emotional distress, and pain and used multinomial regression to determine if demographic, healthcare access and utilization, and health-related variables predict symptom phenotype.

RESULTS

Four phenotypes, one asymptomatic or mildly symptomatic and three highly symptomatic (characterized by severe symptoms, severe pain, and severe emotional distress), were identified. The percentage of participants belonging to the severe symptoms phenotype increased with the number of chronic conditions. Most notably, foregoing or delaying medical care and rating mental health as poor or fair increased the odds of belonging to a highly symptomatic phenotype.

CONCLUSION

We found meaningful relationships between demographic, healthcare access and utilization, and health-related factors and symptom phenotypes. With the increasing trends of American adults with one or more chronic conditions and a demand to individualize care in the precision health era, it is critical to understand the factors that lead to unrelieved symptoms.

Symptom Classes in Decompensated Liver Disease

BACKGROUND & AIMS

Patients with decompensated liver disease have been categorized by disease severity. This analysis sought to classify patients with end-stage liver disease based on symptoms rather than disease state and to identify distinct severity classes of physical and psychological symptoms.

METHODS

Patients with a model for end-stage liver disease-sodium score of 15 or higher were recruited from liver clinics in 2 health care organizations. They completed the Condensed Memorial Symptom Assessment Scale, Revised Ways of Coping Checklist, Patient Health Questionnaire, Life Orientation Test-Revised, and the Short-Form Health Survey. Cross-sectional data were analyzed using latent class mixture modeling.

RESULTS

The sample (N = 191; age, 56.6 ± 11.1 y; 33.5% ETOH; 28.3% nonalcoholic fatty liver disease; 13.1% autoimmune/primary biliary cholangitis/primary sclerosing cholangitis) was predominantly male (64.2%), Child-Turcotte-Pugh class C (49.5%), with an average model for end-stage liver disease-sodium score of 18.7 ± 4.9. Three distinct classes of symptoms were identified, as follows: mild (26.7%), moderate (41.4%), or severe (31.9%) symptoms. Symptom classes were independent of disease severity and demographic characteristics, except age. All Condensed Memorial Symptom Assessment Scale symptoms and Patient Health Questionnaire scores were significantly different across the 3 classes (P < .05). The symptom classes also differed significantly in physical and mental quality of life, optimism, and avoidance coping behaviors (all P < .001).

CONCLUSIONS

Patient-reported symptom severity occurred independent of disease severity, contrary to common assumptions. Focusing on the moderate and severe symptom classes as well as patient history of end-stage liver disease complications may enhance providers' ability to improve symptom management for this population.

Distinct sleep disturbance and cognitive dysfunction profiles in oncology outpatients receiving chemotherapy

PURPOSE

Sleep disturbance and cancer-related cognitive impairment (CRCI) are two of the most common symptoms reported by patients undergoing chemotherapy. Less is known about how these symptoms co-occur and their associated risk factors. Study purposes were to identify subgroups of patients with distinct sleep disturbance and CRCI profiles and evaluate for differences among the subgroups in demographic and clinical characteristics, symptom severity scores, and QOL outcomes.

METHODS

A total of 1,333 oncology outpatients receiving chemotherapy completed self-report questionnaires on sleep disturbance and cognitive dysfunction six times over two cycles of chemotherapy. Latent profile analysis was used to identify distinct sleep disturbance AND cognitive dysfunction profiles. Parametric and non-parametric tests were used to evaluate for differences among the classes.

RESULTS

Two distinct profiles were identified (i.e., Low = low levels of both sleep disturbance and cognitive dysfunction (53.5%); High = high levels of both sleep disturbance and cognitive dysfunction (45.5%)). Patients in the High class were younger, more likely to be female, had a lower functional status and a higher level of comorbidity. In addition, these patients had a higher symptom burden and a lower quality of life.

CONCLUSION

Almost half of the patients undergoing chemotherapy experienced clinically meaningful levels of both symptoms. Of note, sleep disturbance is frequently overlooked by both clinicians and patients. Clinicians need to recommend cognitive rehabilitation and physical activity programs to decrease patients' symptom burden.

Identification of Distinct Symptom Profiles in Cancer Patients Using a Pre-Specified Symptom Cluster

CONTEXT

Pain, fatigue, sleep disturbance, and depression often co-occur in oncology patients and negatively impact quality of life (QOL).

OBJECTIVES

Study purposes were to identify subgroups of patients with distinct symptom profiles based on their experiences with a pre-specified symptom cluster (i.e., pain, fatigue, depression, sleep disturbance) and to identify demographic, clinical, and symptom characteristics and QOL outcomes associated with each distinct profile.

METHODS

Patients with breast, lung, gastrointestinal, and gynecologic cancers (n = 1340) were recruited from outpatient clinics during their first or second cycle of chemotherapy. They completed valid and reliable measures of pain, fatigue, sleep disturbance. depression, and QOL prior to their next dose of chemotherapy. Latent class profile analysis was used to identify the patient subgroups. Differences among the profiles were evaluated using parametric and non-parametric tests.

RESULTS

Three distinct profiles were identified (i.e., Low (44.0%), Moderate (45.1%), High (10.8%). Compared to Low class, Moderate and High classes were younger and more likely to be female. Compared to the other two classes, High class was less likely to be married/partnered and employed, more likely to have a lower income and childcare responsibilities, had lower functional status, a higher body mass index, and exercised less. For both QOL scales, differences in subscale and total scores followed the same pattern (Low>Moderate>High).

CONCLUSIONS

Over 55% of patients undergoing chemotherapy had a moderate to high symptom burden associated with these four common co-occurring symptoms. Multimodal interventions are needed to decrease symptom burden and improve QOL outcomes in these patients.

Higher stress and symptom severity are associated with worse depressive symptom profiles in patients receiving chemotherapy

PURPOSE

In a sample of oncology patients, identify subgroups of patients with distinct depressive symptom profiles and evaluate for differences in demographic and clinical characteristics, levels of stress and resilience, and the severity of common co-occurring symptoms.

METHODS

Patients (n = 1327) had a diagnosis of breast, gastrointestinal, gynecological, or lung cancer; had received chemotherapy within the preceding four weeks; and were scheduled to receive at least two additional cycles of chemotherapy. Demographic and clinical characteristics, stress, resilience, and co-occurring symptoms were evaluated at enrollment. Depressive symptoms were evaluated using the Center for Epidemiological Studies-Depression (CES-D) scale a total of six times over two cycles of chemotherapy. Latent profile analysis (LPA) was used to identify subgroups of patients (i.e., latent classes) with distinct depressive symptom profiles using the six CES-D scores.

RESULTS

Based on the findings from the LPA, 47.3% of the patients were classified as "None"; 33.6% as "Subsyndromal"; 13.8% as "Moderate"; and 5.3% as "High". Compared to None class, patients in the Subsyndromal, Moderate, and High classes had a lower functional status, a higher comorbidity burden, and a self-reported diagnosis of depression or back pain. Those patients with higher levels of depressive symptoms reported higher levels of stress, lower levels of resilience, and increased severity of co-occurring symptoms.

CONCLUSIONS

Inter-individual variability in depressive symptoms was associated with demographic and clinical characteristics, multiple types of stress and levels of resilience, as well as with the increased severity of multiple co-occurring symptoms. The risk factors associated with worse depressive symptom profiles can assist clinicians to identify high risk patients and initiate more timely supportive care interventions.

Symptom clusters in patients receiving chemotherapy: A systematic review

BACKGROUND AND PURPOSE

Since 2001, symptom cluster research has grown considerably. However, because multiple methodological considerations remain, ongoing synthesis of the literature is needed to identify gaps in this area of symptom science. This systematic review evaluated the progress in symptom clusters research in adults receiving primary or adjuvant chemotherapy since 2016.

METHODS

Eligible studies were published in English between 1 January 2017 and 17 May 2021; evaluated for and identified symptom clusters 'de novo;' and included only adults being treated with primary or adjuvant chemotherapy. Studies were excluded if patients had advanced cancer or were receiving palliative chemotherapy; symptoms were measured after treatment; symptom clusters were pre-specified or a patient-centred analytic approach was used. For each study, symptom instrument(s); statistical methods and symptom dimension(s) used to create the clusters; whether symptoms were allowed to load on more than one factor; method used to assess for stability of symptom clusters and associations with secondary outcomes and biomarkers were extracted.

RESULTS

Twenty-three studies were included. Memorial Symptom Assessment Scale was the most common instrument and exploratory factor analysis was the most common statistical method used to identify symptom clusters. Psychological, gastrointestinal, and nutritional clusters were the most commonly identified clusters. Only the psychological cluster remained relatively stable over time. Only five studies evaluated for secondary outcomes.

DISCUSSION

While symptom cluster research has evolved, clear criteria to evaluate the stability of symptom clusters and standardised nomenclature for naming clusters are needed. Additional research is needed to evaluate the biological mechanism(s) for symptom clusters.

PROSPERO REGISTRATION NUMBER

CRD42021240216.

Distinct psycho-oncological support inclinations and needs in patients with cancer: A large sample latent class analysis approach

BACKGROUND

In patients with cancer, the routine recording of distress symptoms has been widely established in recent years. Psycho-oncological support has proven to reduce distress and increase quality of life. Despite high levels of distress as well as physical and emotional challenges in patients with cancer, a significant proportion forgoes psycho-oncological services.

METHODS

A cross-sectional retrospective evaluation was carried out. Latent class analysis was used to examine the relationship between distress, physical and emotional challenges, and desire for psycho-oncological services in 2191 patients with cancer.

RESULTS

Latent class analysis revealed four homogeneous subgroups: a) patients with high distress, high physical and low emotional challenges and no desire for psycho-oncology, b) patients with high distress, low physical and high emotional challenges and no desire for psycho-oncology, c) patients with high distress, high physical and emotional challenges and a desire for psycho-oncology, d) patients with low distress, low physical and emotional challenges and no desire for psycho-oncology.

CONCLUSION

The identification of these subgroups of patients with cancer is useful for health care providers in order to focus their efforts in patients with cancer. It might contribute to a more tailored treatment offer for specific subgroups whose needs have so far been insufficiently met.

Psychological Distress, Coping Strategies, and Quality of Life in Breast Cancer Patients Under Neoadjuvant Therapy: Protocol of a Systematic Review

Introduction

Women with breast cancer eligible for neoadjuvant therapy (NAT) present a disorder of biopsychosocial variables and alteration of their quality of life. They cope with this changing by adopting psychological adjustment strategies, either passive or active. This systematic review aims to investigate the psychological distress, coping strategies, and quality of life in breast cancer patients under neoadjuvant therapy.

Methods

Cochrane Library, PubMed, ScienceDirect, Scopus, Web of Science, and Wiley Online library represent the databases that were searched to identify relevant published articles until September 27, 2021. Full-text published articles, written in English and assessing the main outcomes (namely: psychological distress, coping strategies, and quality of life) in women with breast cancer under NAT will be included. Also, we will integrate papers dealing with the related bio psychosocial variables to the main variables. The paper selection, data extraction, and quality assessment of selected studies will be performed independently by two researchers, and disagreements will be resolved through discussions. We will bring together the results of all of the included studies to draw conclusions based on the body of evidence. The narrative approach will be adopted to analyze the results and conclusions extracted and we would perform quantitative groupings if we have similar data.

Ethics and dissemination

Ethical approval is not required as the proposed systematic review will not use primary data. The results of this review will be disseminated through publication in a peer-reviewed journal and conference presentation(s). PROSPERO registration number: CRD42021230300.

Determination of Cutpoints for Symptom Burden in Oncology Patients Receiving Chemotherapy

CONTEXT

Cutpoints can be used as a threshold for screening symptom(s) that warrant intervention(s) and for monitoring patients' responses to these interventions.

OBJECTIVES

In a sample of oncology patients undergoing chemotherapy, study purposes were to determine the optimal cutpoints for low, moderate, and high symptom burden and determine if these cutpoints distinguished among the symptom groups in any demographic, clinical, and stress characteristics, as well as QOL outcomes.

METHODS

Total of 1329 patients completed a modified version of the Memorial Symptom Assessment Scale (38 symptoms). Using the methodology of Serlin and colleagues, cutpoints were created using symptom occurrence rates and cancer-specific quality of life (QOL) scores. Cutpoints were validated using measures of stress and resilience and a generic measure of QOL (i.e., Medical Outcomes Study Short Form 12 (SF-12)).

RESULTS

Of the 25 possible cutpoints evaluated, the optimal cutpoint, with the largest between category F statistic, was CP8,15 (Low = 0-8, Moderate = 9-15, High = 16-38 symptoms). Percentage of patients in the Low, Moderate, and High cutpoint groups were 25.3%, 36.3%, and 38.4%, respectively. Significant differences were found among the symptom burden groups in global, cancer-specific, and cumulative life stress (i.e., Low < Moderate < High) and resilience and SF-12 (i.e., Low > Moderate > High) scores.

CONCLUSION

Our findings provide evidence for clinically meaningful cutpoints that can be used to guide symptom assessment and management. These cutpoints may be used to establish alert thresholds for electronic monitoring of symptoms in oncology patients.

Worst Pain Severity Profiles of Oncology Patients Are Associated With Significant Stress and Multiple Co-Occurring Symptoms

Little is known about the associations between pain, stress, and co-occurring symptoms in oncology patients. Purpose was to identify subgroups of patients with distinct worst pain profiles and evaluate for differences among the subgroups in demographic and clinical characteristics, as well as stress and symptom scores. Oncology outpatients (n = 1305) completed questionnaires prior to their second or third chemotherapy cycle. Worst pain intensity was assessed 6 times over 2 chemotherapy cycles using a 0 to 10 numeric rating scale. The 371 patients (28.4%) who had ≤1 occurrence of pain over the 6 assessments were classified as the None class. For the remaining 934 patients whose data were entered into the latent profile analysis, 3 distinct worst pain profiles were identified (ie Mild [12.5%], Moderate [28.6%], Severe [30.5%]). Compared to None class, Severe class had fewer years of education and a lower annual income; were less likely to be employed and married; less likely to exercise on a regular basis, had a higher comorbidity burden, and a worse functional status. Compared to None class, Severe class reported higher levels of general, disease-specific, and cumulative life stress and lower levels of resilience, as well as higher levels of depressive symptoms, anxiety, fatigue, sleep disturbance, and cognitive dysfunction. This study is the first to identify distinct worst pain profiles in a large sample of oncology patients receiving chemotherapy and associated risk factors. PERSPECTIVE: Unrelieved pain remains a significant problem for oncology patients receiving chemotherapy. High levels of stress and co-occurring symptoms contribute to a more severe pain profile in these patients.

Exploring interpersonal theory of suicide typologies in patients with cancer: A latent profile analysis

The current study examined patterns of endorsement of Interpersonal Theory of Suicide constructs in a group of patients with cancer (N = 133) via Latent Profile Analysis. Four profiles were identified: (1) Interpersonally Distressed (n = 7; 5.2%), (2) Burdened (n = 11; 8.3%), (3) Fearless About Death (n = 40; 30.1%), (4) Non-Distressed (n = 75; 56.4%). Profiles with higher levels of thwarted belongingness, perceived burdensomeness, and hopelessness were associated with greater suicide ideation. Results also suggest there may be characteristics of patients with cancer that require unique consideration about the potential meaning and relevance of such constructs.

Anxiety profiles are associated with stress, resilience and symptom severity in outpatients receiving chemotherapy

PURPOSE

The purposes of this study, in a sample of oncology patients (n = 1326) receiving chemotherapy, were to identify subgroups of patients with distinct anxiety profiles and evaluate for differences in demographic and clinical characteristics, stress and resilience measures, and severity of co-occurring symptoms (i.e., depression, sleep disturbance, attentional function, fatigue, pain).

METHODS

Patients completed self-report questionnaires a total of six times over two cycles of chemotherapy. Severity of state anxiety was evaluated using the Spielberger State Anxiety Inventory and resilience was assessed using the Connor-Davidson Resilience Scale. Symptoms were assessed using the Center for Epidemiologic Studies Depression Scale, General Sleep Disturbance Scale, Lee Fatigue Scale, Attentional Function Index and Brief Pain Inventory.

RESULTS

Based on the findings from the latent profile analysis that utilized the six assessments of state anxiety, 47.7% of the patients were classified as "Low," 28.3% as "Moderate," 19.5% as "High," and 4.5.% as "Very High." Anxiety levels remained relatively stable across the six timepoints. Compared to the Low class, membership in the Moderate, High, and Very High classes was associated with a number of characteristics (e.g., younger age, female gender, lower functional status, more comorbidities). Those patients with higher levels of anxiety reported higher levels of stress, lower levels of resilience, and increased severity of co-occurring symptoms.

CONCLUSION

Our findings suggest that a substantial number of oncology patients may warrant referral to psychological services. Clinicians need to perform systematic assessments of anxiety, stress, and common symptoms and initiate appropriate interventions to enhance resilience and coping.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

IMPLICATIONS FOR CANCER SURVIVORS

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

Subgroups of patients undergoing chemotherapy with distinct cognitive fatigue and evening physical fatigue profiles

PURPOSE

The purpose was to model cognitive fatigue and evening physical fatigue together to determine subgroups of patients with distinct cognitive fatigue AND evening physical fatigue profiles. Once these profiles were identified, differences among the subgroups in demographic and clinical characteristics, co-occurring symptoms, and quality of life outcomes were evaluated.

METHODS

Oncology patients (n = 1332) completed self-report measures of cognitive fatigue and evening physical fatigue, six times over two cycles of chemotherapy. Latent profile analysis, which combined the two symptom scores, was done to identify subgroups of patients with distinct cognitive fatigue AND evening physical fatigue profiles.

RESULTS

Three distinct profiles (i.e., Low [20.5%], Moderate [39.6%], and High [39.6%]) were identified. Compared to the Low class, patients in the High class were younger, female, and more likely to live alone and had a higher comorbidity burden and a lower functional status. In addition, these patients had a higher symptom burden and a poorer quality of life.

CONCLUSION

Based on clinically meaningful cutoff scores, 80% of the patients in this study had moderate to high levels of both cognitive fatigue and evening physical fatigue. In addition, these patients experienced high levels of other common symptoms (e.g., anxiety, depression, sleep disturbance, and pain). These co-occurring symptoms and other modifiable characteristics associated with membership in the Moderate and High classes may be potential targets for individualized symptom management interventions.

A cross-sectional study of breast pain in a diverse population of breast cancer patients

BACKGROUND

Breast cancer is the most common cancer in women, and postoperative breast pain has been reported to be anywhere from 25% to 60%. However, there is sparse data regarding racial/ethnic differences in breast pain among breast cancer patients.

METHODS

We performed a cross-sectional anonymous survey of breast cancer patients from the Hawaii Cancer Consortium over a 6-week period between 2019 and 2020. The 237 breast cancer participants were ages 29 to 98, 74% Asian, and mainly from outpatient oncology clinics. We evaluated the prevalence of breast pain in a diverse group of breast cancer patients and characterized the pain using a modified short-form McGill pain questionnaire (sfMPQ).

RESULTS

Eighty-fourrespondents(35.4%) reported breast pain. On univariable analysis, we found significant racial/ethnic differences in the amount of breast pain, where Chinese and Japanese participants reported significantly less pain compared to White participants on a 10-point pain scale. We found differences in breast pain according to age and endocrine therapy use as well as survey location, however, no differences were seen according to chemotherapy, radiation, or breast surgery. Based on the sfMPQ, the most common descriptors of breast pain were sensory (throbbing, shooting, and stabbing) compared to affective (tiring-exhausting, sickening, fearful, and punishing-cruel) characteristics. Although they were described as mild and intermittent, in women with breast pain, 33.4% reported the breast pain affected their sleep, 16.7% their work, and 15.4% their sexual activity.

CONCLUSIONS

Breast pain is a significant problem in our breast cancer community. This survey assessment has informed our understanding of breast pain in our diverse population. In turn, we are developing culturally appropriate pain management strategies to treat this challenging symptom common in breast cancer survivors.

Cancer pain and lower functional status predict poor trajectories of symptom and fatigue distress in patients with lung cancer

OBJECTIVE

To identify distinct subgroups of patients newly diagnosed with lung cancer (LC) over time and to explore the predictors of distinct trajectories of symptom and fatigue distress in LC patients.

METHODS

A total of 120 patients newly diagnosed with LC were recruited in this longitudinal prospective study. Our survey investigated patients' symptoms in 6 months. Latent growth curve analysis (LGCA) was conducted to identify patients with distinct trajectories of symptom and fatigue distress. The characteristics of the patients among groups were compared for statistical differences by the chi-square test or ANOVA.

RESULTS

The results of LGCA revealed that the linear three-trajectory model had the best model fit for symptom and fatigue distress. Patients' symptom and fatigue distress improved with time, except for patients with increasing trajectories. Patients' trajectories of symptom and fatigue distress were affected by pain, lower functional status, total symptom score and depression. Moreover, patients with increasing trajectories of symptom and fatigue distress experienced more pain, physiological symptoms and depression from 1 to 6 months.

CONCLUSIONS

Pain and functional status were the major factors that deteriorated the recovery of trajectory in symptom distress and fatigue distress among patients with increasing trajectories.

Distinct profiles of multiple co-occurring symptoms in patients with gastrointestinal cancers receiving chemotherapy

PURPOSE

Identify subgroups of gastrointestinal (GI) cancer patients with distinct multiple co-occurring symptom profiles and evaluate for differences among these subgroups in demographic and clinical characteristics and quality of life (QOL) outcomes.

METHODS

Patients with GI cancers (n = 399) completed the Memorial Symptom Assessment Scale (MSAS) that was used to assess for multiple co-occurring symptoms. Latent class analysis (LCA) was used to identify subgroups of patients with distinct symptom profiles using symptom occurrence ratings. Differences in demographic and clinical characteristics and QOL outcomes among the subgroups were evaluated using parametric and nonparametric tests.

RESULTS

All Low (36.6%), Moderate (49.4%), and All High (14.0%) classes were identified. Compared to the All Low class, patients in the other two classes were significantly younger and were more likely to report depression and back pain. Compared to the other two classes, patients in the All High class had fewer years of education and a higher number of comorbidities. Significant differences were found among the three classes for comorbidity burden and total number of MSAS symptoms (i.e., All Low < Moderate < All High), as well as for performance status (i.e., All Low > Moderate > All High). A higher symptom burden was associated with poorer QOL outcomes.

CONCLUSIONS

The first study to identify subgroups of patients with GI cancers based on distinct symptom profiles. LCA allowed for the identification of risk factors associated with a higher symptom burden. Clinicians can use this information to identify high-risk patients and develop personalized symptom management interventions.

Trajectories of Depressed Mood and Anxiety During Chemotherapy for Breast Cancer

BACKGROUND

Women are at risk of mood disturbance during treatment for breast cancer.

OBJECTIVE

The aims of this study were to identify classes of women experiencing similar trajectories of depressed mood and anxiety while receiving chemotherapy for breast cancer and to determine associated antecedents and outcomes. The specific aims were to (1) determine the distinct trajectory classes associated with severity of depressed mood and anxiety reported by women undergoing cycles 2 and 3 of chemotherapy for breast cancer, (2) determine if class membership is associated with various antecedent variables, and (3) determine if class membership is associated with days of missed work and hours spent lying down.

METHODS

In a secondary analysis, classes were identified using Latent Growth Mixture Modeling. Antecedents and outcomes related to class membership were explored.

RESULTS

Participants (n = 166; mean age, 53 [SD, 10.8] years) were mostly white (91.46%); half had early-stage disease. Two trajectories of depressed mood and anxiety were identified. Receipt of doxorubicin was associated with the higher severity class for depressed mood (P < .01) and anxiety (P = .04). No college education (P = .03) or spending more hours lying down (P = .03) was associated with the higher severity class for anxiety.

CONCLUSIONS

Distinct trajectories of mood disturbance are distinguished by baseline severity. Further study is needed to determine if biologic or genomic factors are associated with class membership.

IMPLICATIONS FOR PRACTICE

Identification of women at risk of mood disturbance may allow clinicians to intensify symptom management. Mood disturbance early in the treatment trajectory warrants management to improve outcomes.

Distinct Subgroups of Patients With Lung Cancer Receiving Chemotherapy: A Latent Transition Analysis

Objectives

To identify subgroups of patients with lung cancer receiving chemotherapy based on the severity dimension of symptom experience, and to examine changes in membership between these subgroups over time.

Methods

Patients who were scheduled to receive chemotherapy completed the Chinese version of the MD Anderson Symptom Inventory and the revised lung cancer module with a total of 19 symptom items. Data were collected at three time points: two weeks before chemotherapy (T1), after chemotherapy cycle 1 (T2), and after chemotherapy cycle 3 or above (T3). The latent profile analysis and latent transition analysis were used to identify underlying subgroups and describe changes in subgroup membership over time.

Results

From the total sample (N = 195), 160 patients completed the symptom assessment at T1, T2, and T3. Two distinct latent symptom profiles of patients could be identified at T1, T2, and T3, which were classified as "Mild" and "Moderate-Severe" profiles. From T1 to T2 and T3, members in the Mild profile were more likely to move to the Moderate-Severe profile. Chemotherapy protocols, prior surgery treatment, and level of education can predict the transitions.

Conclusion

Results provide a better understanding of the patient's different symptom experiences and characteristics. These could help clinicians to anticipate symptom patterns and develop interventions in lung cancer patients who were scheduled to receive chemotherapy for the first time.

Distinct diarrhea profiles during outpatient chemotherapy

PURPOSE

Chemotherapy-induced diarrhea (CID) is a common symptom that occurs in 50 to 80% of patients. Given that the majority of the data on the occurrence and severity of CID is based on physician-rated toxicity criteria, this study's purposes were to identify subgroups of patients with distinct CID profiles and determine how these subgroups differ in terms of demographic and clinical characteristics; severity, frequency, and distress of CID; the co-occurrence of common GI symptoms; and QOL.

METHODS

Patients (n = 1133) completed the Memorial Symptom Assessment Scale six times over two cycles of chemotherapy. Latent profile analysis was used to identify subgroups of patients with distinct diarrhea profiles. Differences among these subgroups were evaluated using parametric and nonparametric statistics.

RESULTS

Four distinct diarrhea profiles were identified: none (58.3%), decreasing (22.0%), increasing (5.2%), and high (14.5%). Compared with the none class, patients in the high class had a lower functional status, a worse comorbidity profile, were more likely to have gastrointestinal cancer, and were more likely to receive chemotherapy on a 14-day cycle. No differences were found among the classes in the percentages of patients who received chemotherapy with a targeted therapy.

CONCLUSION

Given that CID occurred in over 40% of the patients, clinicians should assess for this symptom and other common GI symptoms and initiate appropriate pharmacologic and dietary interventions.

Gender Differences in the Use of Engagement and Disengagement Coping Strategies in Patients With Cancer Receiving Chemotherapy

OBJECTIVES

To evaluate the relationship between gender and coping strategies in patients with cancer undergoing chemotherapy in outpatient settings.

SAMPLE & SETTING

Women (N = 277) and men (N = 293) were recruited from two comprehensive cancer centers, one Veterans Affairs hospital, and four community-based oncology programs.

METHODS & VARIABLES

Coping data were obtained from patients with gastrointestinal (n = 412) or lung (n = 158) cancer through the Brief COPE scale.

RESULTS

In terms of engagement coping strategies, women reported higher scores for positive reframing, religion, and using instrumental support. Men reported higher scores for humor. In terms of disengagement coping strategies, women reported higher scores for denial, venting, and self-distraction. Men reported higher scores for substance use.

IMPLICATIONS FOR NURSING

Gender-based stereotypes of emotional expectations may affect how patients express themselves and the ways in which support is offered. Clinicians should be aware of their own preconceived notions about sex and gender and reflect on how these may influence the psychosocial care they provide.

Factors associated with sleep quality during chemotherapy: An integrative review

Aim

To identify the most important factors associated with sleep pattern changes in patients with cancer during chemotherapy treatment.

Design

An integrative review of the literature was performed between December 2017-August 2018.

Methods

Two independent reviewers searching the National Library of Medicine (PubMed/MEDLINE), Cumulative Index of Nursing and Allied Health Literature (CINAHL) and Latin American and Caribbean Literature in Health Sciences (LILACS), Scopus and Scielo. The process followed the recommendations of the PRISMA tool. A total of 16 articles were selected for the final study sample, including 11 cohort studies and 5 cross-sectional studies.

Results

The predisposing factors for the most prevalent sleep disturbances were precipitants related to the disease and the treatment, such as fatigue, pain, depression, anxiety and distress. Predisposing factors related to lifestyle and demographic characteristics have a significant correlation with sleep disturbances.

Co-occurrence of decrements in physical and cognitive function is common in older oncology patients receiving chemotherapy

PURPOSE

Older adults receiving cancer chemotherapy are at increased risk for decrements in physical (PF) and cognitive (CF) function.

OBJECTIVES

Study identified subgroups of patients with distinct PF and CF profiles; risk factors associated with subgroup membership; and impact of subgroup membership on quality of life (QOL).

METHODS

In 366 older oncology patients, PF and CF were assessed using the Physical Component Summary (PCS) of the SF-12 and Attentional Function Index, respectively. Latent profile analysis was used to identify subgroups of older patients with distinct PF/CF profiles.

RESULTS

Three distinct PF/CF profiles were identified (i.e., Very Low PF + Moderate CF (15.6%); Low PF + Low CF (39.3%), Normal PF + Normal CF (45.1%)). Compared to the both Normal class, patients in the other two classes had a lower functional status, a worse comorbidity profile, and were less likely to exercise on a regular basis. Compared to the Both Normal class, patients in the Both Low class were less likely to be married/partnered, more likely to live alone, less likely to be employed, and more likely to report depression and back pain. Compared to the other two classes, patients in the Both Low class had a lower annual household income and were receiving chemotherapy with a worse toxicity profile.

CONCLUSION

First study to use a person-centered analytic approach to identify subgroups of older adults with distinct PF/CF profiles. Fifty-five percent of the older adults had statistically significant and clinically meaningful decrements in both PF AND CF that had negative effects on all aspects of QOL.

Symptom Experience, Management, and Outcomes According to Race and Social Determinants Including Genomics, Epigenomics, and Metabolomics (SEMOARS + GEM): an Explanatory Model for Breast Cancer Treatment Disparity

Even after controlling for stage, comorbidity, age, and insurance status, black women with breast cancer (BC) in the USA have the lowest 5-year survival as compared with all other races for stage-matched disease. One potential cause of this survival difference is the disparity in cancer treatment, evident in many population clinical trials. Specifically, during BC chemotherapy, black women receive less relative dose intensity with more dose reductions and early chemotherapy cessation compared with white women. Symptom incidence, cancer-related distress, and ineffective communication, including the disparity in patient-centeredness of care surrounding patient symptom reporting and clinician assessment, are important factors contributing to racial disparity in dose reduction and early therapy termination. We present an evidence-based overview and an explanatory model for racial disparity in the symptom experience during BC chemotherapy that may lead to a reduction in dose intensity and a subsequent disparity in outcomes. This explanatory model, the Symptom Experience, Management, Outcomes and Adherence according to Race and Social determinants + Genomics Epigenomics and Metabolomics (SEMOARS + GEM), considers essential factors such as social determinants of health, clinician communication, symptoms and symptom management, genomics, epigenomics, and pharmacologic metabolism as contributory factors.

Identification of subgroups of chemotherapy patients with distinct sleep disturbance profiles and associated co-occurring symptoms

STUDY OBJECTIVES

Purposes of this study were to identify subgroups of patients with distinct sleep disturbance profiles and to evaluate for differences in demographic, clinical, and various sleep characteristics, as well for differences in the severity of co-occurring symptoms among these subgroups.

METHODS

Outpatients with breast, gynecological, gastrointestinal, or lung cancer (n = 1331) completed questionnaires six times over two chemotherapy cycles. Self-reported sleep disturbance was evaluated using the General Sleep Disturbance Scale (GSDS). Latent profile analysis was used to identify distinct subgroups.

RESULTS

Three latent classes with distinct sleep disturbance profiles were identified (Low [25.5%], High [50.8%], Very High [24.0%]) across the six assessments. Approximately 75% of the patients had a mean total GSDS score that was above the clinically meaningful cutoff score of at least 43 across all six assessments. Compared to the Low class, patients in High and Very High classes were significantly younger, had a lower functional status, had higher levels of comorbidity, and were more likely to be female, more likely to have childcare responsibilities, less likely to be employed, and less likely to have gastrointestinal cancer. For all of the GSDS subscale and total scores, significant differences among the latent classes followed the expected pattern (Low < High < Very High). For trait and state anxiety, depressive symptoms, morning and evening fatigue, decrements in attentional function, and decrements in morning and evening energy, significant differences among the latent classes followed the expected pattern (Low < High < Very High).

CONCLUSIONS

Clinicians need to perform in-depth assessments of sleep disturbance and co-occurring symptoms to identify high-risk patients and recommend appropriate interventions.

Reduced symptom burden with the support of an interactive app during neoadjuvant chemotherapy for breast cancer - A randomized controlled trial

Objectives

Neoadjuvant chemotherapy causes distressing symptoms, which have to be managed by patients at home. Assessing and acting upon relevant patient-reported symptoms regularly with the support of mHealth such as apps, has shown to decrease symptom burden and improve health-related quality of life (HRQoL). There is a lack of apps for patients with breast cancer which are tested in rigorous trials and only a few include interactive components for immediate clinical management. The aim of this study was to evaluate whether the use of the interactive app Interaktor improves patients’ levels of symptom burden and HRQoL during neoadjuvant chemotherapy for breast cancer.

Materials and methods

This randomized controlled trial included patients in an intervention group (n = 74) and a control group (n = 75), recruited at two university hospitals in Stockholm, Sweden. The intervention group used Interaktor for symptom reporting, self-care advice and support from health-care professionals during treatment, and the control group received standard care alone. Self-reported symptoms and HRQoL were assessed at two time points to determine differences between the groups.

Results

The intervention group rated statistically significant less symptom prevalence in nausea, vomiting, feeling sad, appetite loss and constipation. Overall symptom distress and physical symptom distress were rated statistically significant lower in the intervention group. Further, emotional functioning was rated statistically significant higher in the intervention group.

Conclusions

By using the Interaktor app in clinical practice, patients get individual support when managing treatment-related symptoms during neoadjuvant chemotherapy for breast cancer, leading to decreased symptom burden and improved emotional functioning.

•

Using the app Interaktor reduced symptom burden in patients with breast cancer.

•

The use of Interaktor enhanced emotional functioning during treatment.

•

Interaktor provided individual support during neoadjuvant chemotherapy.

•

Use of Interaktor allowed breast cancer patients for daily reflection over symptoms.

Neuropsychological Symptoms and Intrusive Thoughts Are Associated With Worse Trajectories of Chemotherapy-Induced Nausea

CONTEXT

Although chemotherapy-induced vomiting is well controlled with evidence-based antiemetic regimens, chemotherapy-induced nausea (CIN) remains a significant clinical problem.

OBJECTIVES

Study purposes, in a sample of outpatients with breast, gastrointestinal, gynecological, or lung cancer who received two cycles of chemotherapy (CTX, n = 1251), were to evaluate for interindividual differences in the severity of CIN and to determine which demographic, clinical, symptom, and stress characteristics are associated with higher initial levels as well as with the trajectories of CIN.

METHODS

Patients were recruited during their first or second cycle of CTX. Patients completed self-report questionnaires a total of six times over two cycles of CTX. Hierarchical linear modeling was used to evaluate for interindividual differences in and characteristics associated with the severity of CIN.

RESULTS

Across the two cycles of CTX, higher levels of sleep disturbance, depression, and morning fatigue, as well as higher levels of intrusive thoughts, were associated with higher initial levels of CIN. In addition, lower functional status scores and shorter cycle lengths were associated with higher initial levels of CIN, and younger age and higher emetogenicity of the CTX regimen were associated with both higher initial levels as well as worse trajectories of CIN severity.

CONCLUSION

These findings suggest that common symptoms associated with cancer and its treatment are associated with increased severity of CIN. Targeted interventions for these symptoms may reduce the burden of unrelieved CIN.

Distinct Stress Profiles Among Oncology Patients Undergoing Chemotherapy

CONTEXT

Cancer and its treatment are inherently stressful and stress impacts important patient outcomes. Patients vary considerably in their response to stress. Understanding this variability requires a patient-centered multidimensional approach.

OBJECTIVES

The objectives of this study were to identify and characterize patient subgroups with distinct multidimensional stress profiles (stress appraisal, exposure, and adaptation) during cancer treatment.

METHODS

Among 957 patients undergoing chemotherapy for breast, gastrointestinal, gynecological, or lung cancer, latent profile analysis was performed to identify patient subgroups using concurrent evaluations of global (Perceived Stress Scale) and cancer-specific (Impact of Events Scale-Revised) stress, lifetime stress exposure (Life Stressor Checklist-Revised), and resilience (Connor-Davidson Resilience Scale-10).

RESULTS

Three latent classes were identified: "Normative" (54.3%; intermediate global stress and resilience, lower cancer-related stress, lowest life stress); "Stressed" (39.9%; highest global and cancer-specific stress scores, lowest resilience, most life stress); and "Resilient" (5.7%; lowest global stress, cancer-specific stress comparable to Normative class, highest resilience, intermediate life stress). Characteristics that distinguished the Stressed from the Normative class included the following: younger age, female gender, lower socioeconomic status, unmarried/partnered, living alone, poorer functional status, and higher comorbidity burden. Compared to Stressed patients, Resilient patients were more likely to be partnered, to not live alone, and had a higher functional status. No demographic or clinical characteristics differentiated Normative from Resilient patients. Exposure to specific life stressors differed significantly among the classes.

CONCLUSION

A subset of patients warrants intensive psychosocial intervention to reduce stress and improve adaptation to cancer. Intervention efforts may be informed by further study of Resilient patients.

Gastrointestinal symptoms are associated with trajectories of chemotherapy-induced nausea

PURPOSE

Between 19 and 58% of oncology patients experience chemotherapy-induced nausea (CIN). In a sample of outpatients with breast, gastrointestinal (GI), gynecological, and lung cancer, the study purposes were to evaluate for inter-individual differences in the severity of CIN over two cycles of chemotherapy (CTX) and to determine which demographic and clinical characteristics and GI symptoms were associated with higher initial levels as well as with the trajectories of CIN severity.

METHODS

Patients completed study questionnaires at six time points over two cycles of CTX. These questionnaires provided information on demographic and clinical characteristics, as well as the occurrence of twelve GI symptoms. Hierarchical linear modeling based on full maximum likelihood estimation was performed.

RESULTS

Of the 1251 patients, 47.2% reported CIN. Across two cycles of CTX, lower functional status scores and higher levels of comorbidity were associated with higher initial levels of CIN. Younger age and emetogenicity of the CTX regimen were associated with higher initial levels as well as worse trajectories of CIN. The occurrence of five GI symptoms (i.e., vomiting, lack of appetite, constipation, feeling bloated, and difficulty swallowing) was associated with higher initial levels of CIN. The occurrence of mouth sores was associated with higher initial levels as well as with worst trajectories of CIN.

CONCLUSIONS

This study is the first to identify distinct demographic, clinical, and GI symptom characteristics associated with CIN severity. These findings suggest that the etiology of CIN is complex and may warrant interventions beyond standard antiemetics.