Complex regional pain syndrome 1--the Swiss cohort study

Economic evaluation of management strategies for complex regional pain syndrome (CRPS)

Background: The economic impact of Complex Regional Pain Syndrome (CRPS) on both patients and the global healthcare system continues to escalate. However, the economic implications associated with management interventions for CRPS have received limited attention. Therefore, our objective is to perform a thorough examination of published economic assessments of the various management strategies utilized for CRPS. Methods: A thorough search spanning four general medical databases and three health economic databases to identify full economic evaluations on CRPS management strategies from January 1994 to June 2023 were conducted. The quality of these studies were evaluated by employing the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement. To enable cross-study comparisons conducted in different countries, we adjusted the costs reported in the selected studies for inflation and converted them into 2023 US dollars. Results: A total of nine economic evaluations, consisting of eight high-quality and one medium-quality, were identified across five nations during a span of 29 years. The findings suggest that the most economically efficient intervention for CRPS are interventional approaches of Spinal Cord Stimulation (SCS) in comparison to conventional management for long periods of time. Furthermore, in situations where there is a limited time period of less than 1 year, rehabilitation therapies, particularly physical therapy, have been demonstrated to be more effective in terms of both cost and clinical outcomes. Conclusion: The interventional management strategies, particularly for severe and persistent CRPS over long periods, may offer the greatest cost efficiency. In conditions with limited timelines, rehabilitation measures, such as rehabilitation therapies, can be cost-effective. However, insufficient data for other common interventions prevents the formation of a definitive conclusion. Similarly, it is crucial to recognize that the results of these interventions might be affected by the selection of comparator and the threshold for willingness to pay.

Cancer survivors and neurotoxic chemotherapy: hearing loss and tinnitus

OBJECTIVES

Little is known about hearing loss and tinnitus associated with neurotoxic chemotherapy. Study evaluated for differences in occurrence rates and effects of hearing loss and tinnitus in survivors who received a platinum alone, a taxane alone or a platinum and taxane containing regimen.

METHODS

Total of 273 survivors with breast, gastrointestinal, gynaecological or lung cancer completed self-report measures of hearing loss and tinnitus and had an audiometric assessment that obtained pure tone air conduction thresholds bilaterally at frequencies of between 0.25 kHz to 16.0 kHz. To adjust for age-related and gender-related changes in hearing, each survivor's audiogram was evaluated using the National Health and Nutrition Examination Survey-modified Occupational Safety and Health Administration standards. Survivor was classified as having hearing loss if at any frequency they scored poorer than the 50th percentile for their age and gender. Survivors were categorised as having tinnitus if they reported that for >10% of their time awake, they were consciously aware of their tinnitus. Differences among the chemotherapy groups were evaluated using parametric and non-parametric tests.

RESULTS

For most of the demographic and clinical characteristics, no differences were found among the three chemotherapy groups. Occurrence rates for audiogram-confirmed hearing loss ranged from 52.3% to 71.4%. Occurrence rates for tinnitus ranged from 37.1% to 40.0%. No differences were found among the three chemotherapy groups in the occurrence rates or effects of hearing loss and tinnitus.

CONCLUSION

These findings suggest that regardless of the chemotherapy regimen common mechanistic pathway(s) may underlie these two neurotoxicities.

Patients with palpitations experience a higher symptom burden prior to breast cancer surgery

PURPOSE

Anxiety, depression, sleep disturbance, fatigue, cognitive dysfunction, and pain are common symptoms reported by patients with breast cancer. Recent evidence suggests that palpitations, a feeling of the heart racing or pounding, may be equally common. Study purpose was to compare the severity and clinically meaningful occurrence rates of common symptoms and quality of life (QOL) outcomes between patients with breast cancer who did and did not report palpitations prior to surgery.

METHODS

Patients (n = 398) were classified as having or not having palpitations using a single item from the Menopausal Symptoms Scale. Valid and reliable measures were used to assess state and trait anxiety, depression, sleep disturbance, fatigue, energy, cognitive function, breast symptoms, and QOL. Between group differences were evaluated using parametric and non-parametric tests.

RESULTS

Patients with palpitations (15.1%) reported significantly higher severity scores for state and trait anxiety, depression, sleep disturbance, and fatigue as well as significant decrements in energy and cognitive function (all p < .05). A higher percentage of these patients had clinically meaningful levels of state anxiety, depression, sleep disturbance and decrements in cognitive function (all p < .05). Except for spiritual well-being, QOL scores were lower in the palpitations group (all p < .001).

CONCLUSION

Findings support the need for routine assessment of palpitations and management of multiple symptoms in women prior to breast cancer surgery.

A Pilot Study of Associations Between the Occurrence of Palpitations and Cytokine Gene Variations in Women Prior to Breast Cancer Surgery

OBJECTIVES

Palpitations are common and have a negative impact on women's quality of life. While evidence suggests that inflammatory mechanisms may play a role in the development of palpitations, no studies have evaluated for this association in patients with breast cancer who report palpitations prior to surgery. The purpose of this pilot study was to evaluate for associations between the occurrence of palpitations and single nucleotide polymorphisms (SNPs) in genes for pro- and anti-inflammatory cytokines, their receptors, and transcriptional regulators.

METHODS

Patients were recruited prior to surgery and completed a self-report questionnaire on the occurrence of palpitations. Genotyping of SNPs in cytokine genes was performed using a custom array. Multiple logistic regression analyses were done to identify associations between the occurrence of palpitations and SNPs in fifteen candidate genes.

RESULTS

Of the 82 SNPs evaluated in the bivariate analyses, eleven SNPs in 6 genes were associated with the occurrence of palpitations. After controlling for functional status, the occurrence of back pain, and self-reported and genomic estimates of race/ethnicity, 3 SNPs in 3 different genes (i.e., interleukin (IL) 1-beta (IL1B) rs1143643, IL10 rs3024505, IL13 rs1295686) were associated with the occurrence of palpitations prior to surgery (all p ≤ .038).

CONCLUSIONS

While these preliminary findings warrant replication, they suggest that inflammatory mechanisms may contribute to the subjective sensation of palpitations in women prior to breast cancer surgery.

Associations among hearing loss, multiple co-occurring symptoms, and quality of life outcomes in cancer survivors

PURPOSE

Evaluate for differences in demographic and clinical characteristics, occurrence of common symptoms, symptom severity scores, and quality of life (QOL) outcomes in survivors with (n = 155) and without (n = 118) audiometrically confirmed hearing loss.

METHODS

Survivors, who were recruited from throughout the San Francisco Bay area, completed the self-report questionnaires to obtain the information of demographic and clinical characteristics; the occurrence and severity of depression, anxiety, fatigue, decrements in energy, sleep disturbance, pain, and cognitive impairment; and the general and cancer-specific QOL outcomes. Parametric and non-parametric tests were used to evaluate for differences between the two survivor groups.

RESULTS

Survivors with audiometrically confirmed hearing loss were older, more likely to be male, were more likely to be unemployed, report a lower annual household income, and had a higher comorbidity burden. Except for the severity of worst pain, no between-group differences were found in the occurrence rates for or severity of any of the symptoms. Survivors with hearing loss reported worse physical function and general health scores.

CONCLUSIONS

While no between-group differences in symptom occurrence rates and severity scores were found, across the total sample, a relatively high percentage of survivors who were over 6 years from their cancer diagnosis reported clinically meaningful levels of depression (25%), anxiety (50%), fatigue (40%), decrements in energy (70%), sleep disturbance (58%), cognitive impairment (57%), and pain (60%).

IMPLICATIONS FOR CANCER SURVIVORS

Clinicians need to perform routine assessments of hearing loss, as well as common co-occurring symptoms and initiate individualized symptom management interventions.

Associations Between Demographic, Clinical, and Symptom Characteristics and Stress in Oncology Patients Receiving Chemotherapy

BACKGROUND

Patients undergoing cancer treatment experience global stress and cancer-specific stress. Both types of stress are associated with a higher symptom burden.

OBJECTIVE

In this cross-sectional study, we used a comprehensive set of demographic, clinical, and symptom characteristics to evaluate their relative contribution to the severity of global and cancer-specific stress.

METHODS

Patients (N = 941) completed study questionnaires before their second or third cycle of chemotherapy.

RESULTS

Consistent with our a priori hypothesis, we found both common and distinct characteristics associated with higher levels of global stress and cancer-specific stress. A significant proportion of our patients had scores on the Impact of Event Scale-Revised suggestive of subsyndromal (29.4%) or probable (13.9%) posttraumatic stress disorder. Four of the 5 stepwise linear regression analyses for the various stress scales explained between 41.6% and 54.5% of the total variance. Compared with various demographic and clinical characteristics, many of the common symptoms associated with cancer and its treatments uniquely explained a higher percentage of the variance in the various stress scales. Symptoms of depression made the largest unique contribution to the percentage of total explained variance across all 5 scales.

CONCLUSION

Clinicians need to assess for global stress, cancer-specific stress, and depression in patients receiving chemotherapy.

IMPLICATIONS FOR PRACTICE

Patients may benefit from integrative interventions (eg, mindfulness-based stress reduction, cognitive behavioral therapy, acupuncture) that simultaneously address stress and symptoms commonly associated with cancer and its treatments.

Similarities in the Neuropathy Phenotype of Cancer Survivors Who Received Different Classes of Chemotherapy Drugs

With the advent of platinum and taxane compounds used as single agents or in combination regimens, survival rates for some of the most common cancers have improved substantially. However, information on differences in the chemotherapy-induced peripheral neuropathy (CIPN) phenotype among single and combination regimens is limited. Study's purposes were to evaluate for differences in demographic and clinical characteristics; subjective and objective measures of CIPN; as well as the severity of common symptoms and quality of life among survivors who received platinum- (n = 95), taxane- (n = 200), or platinum and taxane-containing (n = 131) regimens. Patients completed self-report questionnaires (ie, duration of CIPN, pain intensity, pain qualities, pain interference) and underwent a physical examination that evaluated light touch, pain, and cold sensations and balance. For most of the subjective and objective measures of CIPN, as well as symptom severity and quality of life scores, no differences were found among the 3 chemotherapy groups. In all 3 chemotherapy treatment groups, CIPN was a painful, small fiber, and length dependent neuropathy. These findings support the hypothesis that CIPN induced by different classes of chemotherapy, as single agents or in combination, produce a similar CIPN phenotype which raises the possibility that CIPN induced by diverse chemotherapy protocols has the same underlying mechanism. PERSPECTIVE: In this study, that compared patients who received only platinum, only taxane, or both platinum and taxane containing regimens, no differences were found among the 3 groups in the CIPN phenotype. Findings raise the possibility that CIPN induced by diverse chemotherapy protocols has the same underlying mechanism.

Social support in early-stage breast cancer patients with fatigue

Background

A large number of women with breast cancer suffer from fatigue, and social support is described as having a positive impact on health in stressful life situations. The aim of this study is to evaluate social support in a sample of early-stage breast cancer outpatients with fatigue during treatment, and to evaluate the association between cancer-related fatigue and social support and between social support and demographic and treatment characteristics.

Method

This cross-sectional study includes 160 outpatients with early-stage breast cancer and cancer-related fatigue. The patients were recruited from clinics at a university-based cancer centre in Norway. The research instruments included The Social Provisions Scale (SPS), which measures ‛attachment’, ‛social integration’, ‛reassurance of worth’, and ‛nurturance’, and a fatigue questionnaire (FQ), which measures total, physical and mental fatigue. Data were analysed using descriptive statistics and linear regression analysis.

Results

Median total score for SPS was 59 (min/max = 39/64). Significant associations were found between mental fatigue and the provisions ‛reassurance of worth’ (B = − 0.34, 95% CI = [− 0.60; − 0.08]) and ‛nurturance’ (B = 0.20, 95% CI = [0.08; 0.31]). In addition, an association was found between social support and living with someone (B = 6.09, 95% CI = [4.07; 8.11]). No associations were found between physical fatigue and social support or between social support and treatment variables.

Conclusions

To a large extent, breast cancer patients with fatigue in this study experienced social support from their surroundings. The fact that there were significant associations between mental fatigue and two of the provisions of SPS suggests that social support is more closely related to mental fatigue than to physical fatigue. Findings from this study suggest that living with someone is important for the experience of social support during treatment for breast cancer. Clinicians need to evaluate demographic characteristics in relation to social support in early-stage breast cancer patients with fatigue.

Understanding the Rehabilitation Needs of Korean Patients With Complex Regional Pain Syndrome

OBJECTIVE

To evaluate the current status of pain severity and quality of life (QoL) in patients with complex regional pain syndrome (CRPS), and to assess both their perceived needs and any unmet needs of current rehabilitation services.

METHODS

A single-center questionnaire-based survey was conducted on 47 patients with CRPS who were diagnosed based on Budapest's criteria. It collected demographic and clinical data, and the structured questionnaire included the Brief Pain Inventory (BPI), the Korean version of the World Health Organization Disability Assessment Schedule II (WHODAS-K II), as well as the 5-Level EuroQol-5D (EQ-5D-5L) for measuring the QoL.

RESULTS

The average value of BPI and WHODAS-K II were 7.69%±2.26% and 70.49%±19.22%, respectively. In the evaluation of their perceived needs and unmet needs for rehabilitation, patients had the highest rehabilitation needs in terms of pain (95.74%), followed by bodyaches (80.85%). Regarding their unmet needs, patients had the highest unmet needs in terms of memory impairment (83.33%), followed by weight management (72.00%). According to the regression analysis, only the overall BPI was significantly associated with QoL (p=0.01), and a higher BPI value led to poorer results for QoL.

CONCLUSION

In Korea, patients with CRPS do not receive adequate rehabilitation, and they are not satisfied with current received treatments. A more structured and individualized rehabilitation treatment plan is required to manage every aspect related to chronic pain, and provision should be made for improved care guidelines for future CRPS management.

Signaling pathways and gene co-expression modules associated with cytoskeleton and axon morphology in breast cancer survivors with chronic paclitaxel-induced peripheral neuropathy

Background

The major dose-limiting toxicity of paclitaxel, one of the most commonly used drugs to treat breast cancer, is peripheral neuropathy (paclitaxel-induced peripheral neuropathy). Paclitaxel-induced peripheral neuropathy, which persists into survivorship, has a negative impact on patient’s mood, functional status, and quality of life. Currently, no interventions are available to treat paclitaxel-induced peripheral neuropathy. A critical barrier to the development of efficacious interventions is the lack of understanding of the mechanisms that underlie paclitaxel-induced peripheral neuropathy. While data from preclinical studies suggest that disrupting cytoskeleton- and axon morphology-related processes are a potential mechanism for paclitaxel-induced peripheral neuropathy, clinical evidence is limited. The purpose of this study in breast cancer survivors was to evaluate whether differential gene expression and co-expression patterns in these pathways are associated with paclitaxel-induced peripheral neuropathy.

Methods

Signaling pathways and gene co-expression modules associated with cytoskeleton and axon morphology were identified between survivors who received paclitaxel and did (n = 25) or did not (n = 25) develop paclitaxel-induced peripheral neuropathy.

Results

Pathway impact analysis identified four significantly perturbed cytoskeleton- and axon morphology-related signaling pathways. Weighted gene co-expression network analysis identified three co-expression modules. One module was associated with paclitaxel-induced peripheral neuropathy group membership. Functional analysis found that this module was associated with four signaling pathways and two ontology annotations related to cytoskeleton and axon morphology.

Conclusions

This study, which is the first to apply systems biology approaches using circulating whole blood RNA-seq data in a sample of breast cancer survivors with and without chronic paclitaxel-induced peripheral neuropathy, provides molecular evidence that cytoskeleton- and axon morphology-related mechanisms identified in preclinical models of various types of neuropathic pain including chemotherapy-induced peripheral neuropathy are found in breast cancer survivors and suggests pathways and a module of genes for validation and as potential therapeutic targets.

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.

Differential methylation and expression of genes in the hypoxia-inducible factor 1 signaling pathway are associated with paclitaxel-induced peripheral neuropathy in breast cancer survivors and with preclinical models of chemotherapy-induced neuropathic pain

BACKGROUND

Paclitaxel is an important chemotherapeutic agent for the treatment of breast cancer. Paclitaxel-induced peripheral neuropathy (PIPN) is a major dose-limiting toxicity that can persist into survivorship. While not all survivors develop PIPN, for those who do, it has a substantial negative impact on their functional status and quality of life. No interventions are available to treat PIPN. In our previous studies, we identified that the HIF-1 signaling pathway (H1SP) was perturbed between breast cancer survivors with and without PIPN. Preclinical studies suggest that the H1SP is involved in the development of bortezomib-induced and diabetic peripheral neuropathy, and sciatic nerve injury. The purpose of this study was to identify H1SP genes that have both differential methylation and differential gene expression between breast cancer survivors with and without PIPN.

METHODS

A multi-staged integrated analysis was performed. In peripheral blood, methylation was assayed using microarray and gene expression was assayed using RNA-seq. Candidate genes in the H1SP having both differentially methylation and differential expression were identified between survivors who received paclitaxel and did (n = 25) and did not (n = 25) develop PIPN. Then, candidate genes were evaluated for differential methylation and differential expression in public data sets of preclinical models of PIPN and sciatic nerve injury.

RESULTS

Eight candidate genes were identified as both differential methylation and differential expression in survivors. Of the eight homologs identified, one was found to be differential expression in both PIPN and "normal" mice dorsal root ganglia; three were differential methylation in sciatic nerve injury versus sham rats in both pre-frontal cortex and T-cells; and two were differential methylation in sciatic nerve injury versus sham rats in the pre-frontal cortex.

CONCLUSIONS

This study is the first to evaluate for methylation in cancer survivors with chronic PIPN. The findings provide evidence that the expression of H1SP genes associated with chronic PIPN in cancer survivors may be regulated by epigenetic mechanisms and suggests genes for validation as potential therapeutic targets.

Stability of Symptom Clusters in Patients With Gastrointestinal Cancers Receiving Chemotherapy

CONTEXT

Limited evidence suggests that patients with gastrointestinal (GI) cancers receiving chemotherapy (CTX) experience an average of 13 co-occurring symptoms. An alternative to counting symptoms is to evaluate for symptom clusters.

OBJECTIVES

In a sample of patients with GI cancers receiving CTX (n = 399), we evaluated the occurrence, severity, and distress of 38 symptoms in the week before patients' second or third cycle of CTX (Time 1 [T1]), approximately one week after CTX (Time 2 [T2]), and approximately two weeks after CTX (Time 3 [T3]); evaluated for differences in the number and types of symptom clusters at each of these three assessments using ratings of occurrence, severity, and distress; and evaluated for changes in symptom clusters over time.

METHODS

Modified version of the Memorial Symptom Assessment Scale collected data on 38 common symptoms. Exploratory factor analyses were used to create the symptom clusters.

RESULTS

Five distinct symptom clusters were identified across the three symptom dimensions and the three assessments (i.e., psychological, CTX-related, weight change, GI, and epithelial). Psychological, CTX-related, and weight change clusters were relatively stable across all three symptom dimensions and time. Across all three symptom dimensions, GI cluster was identified only at T1 and epithelial cluster was identified at T2 and T3.

CONCLUSION

The number and types of symptom clusters appear to be relatively stable over time and across the symptom dimensions. Ongoing assessment and management of these clusters is warranted across the entire course of CTX. The underlying mechanism for these clusters warrants investigation.

Associations Between Catecholaminergic and Serotonergic Genes and Persistent Arm Pain Severity Following Breast Cancer Surgery

Persistent arm pain is a common problem after breast cancer surgery. Little is known about genetic factors that contribute to this type of postsurgical pain. Study purpose was to explore associations between persistent arm pain phenotypes and genetic polymorphisms among 15 genes involved in catecholaminergic and serotonergic neurotransmission. Women (n = 398) rated the presence and intensity of arm pain monthly for 6 months after breast cancer surgery. Three distinct latent classes of patients were identified (ie, no arm pain [41.6%], mild arm pain (23.6%), and moderate arm pain (34.8%). Logistic regression analyses were used to evaluate for differences between genotype or haplotype frequencies and the persistent arm pain classes. Compared with the no arm pain class, 3 single nucleotide polymorphisms and 1 haplotype, in 4 genes, were associated with membership in the mild arm pain class: COMT rs4633, HTR2A haplotype B02 (composed of rs1923886 and rs7330636), HTR3A rs1985242, and TH rs2070762. Compared with the no arm pain class, 4 single nucleotide polymorphisms in 3 genes were associated with membership in the moderate arm pain class: COMT rs165656, HTR2A rs2770298 and rs9534511, and HTR3A rs1985242. Findings suggest that variations in catecholaminergic and serotonergic genes play a role in the development of persistent arm pain. PERSPECTIVE: Limited information is available on genetic factors that contribute to persistent arm pain after breast cancer surgery. Genetic polymorphisms in genes involved in catecholaminergic and serotonergic neurotransmission were associated with 2 persistent arm pain phenotypes. Findings may be used to identify patients are higher risk for this common pain condition.

Symptom Clusters in Patients With Gastrointestinal Cancers Using Different Dimensions of the Symptom Experience

CONTEXT

Patients with gastrointestinal (GI) cancers undergoing chemotherapy (CTX) experience multiple cooccurring symptoms.

OBJECTIVES

The aim of this study was to describe the occurrence, severity, and distress of 38 symptoms and to identify symptom clusters based on three symptom dimensions (i.e., occurrence, severity, and distress) in patients with GI cancers receiving CTX (n = 399). We compared whether the numbers and types of symptom clusters differed based on the dimension of the symptom experience used to create the clusters.

METHODS

A modified version of the Memorial Symptom Assessment Scale was used to assess the occurrence, severity, and distress of 38 symptoms before the initiation of the patient's next dose of CTX. Exploratory factor analysis was used to determine the symptom clusters.

RESULTS

These patients experienced 13.0 (±7.1) symptoms before their second or third dose of CTX. For all three symptom dimensions, four symptom clusters were identified, namely psychological distress, CTX-related, GI, and weight change. The number and types of symptom clusters were relatively similar using all three symptom dimensions. However, some variability was found in the specific symptoms within each of the clusters.

CONCLUSION

Our findings suggest that patients with GI cancers experience multiple cooccurring symptoms. Consistent with previous studies of patients with a variety of cancer diagnoses, psychological and GI clusters are common. Clinicians need to assess for and tailor interventions for these symptom clusters.

Stability of Symptom Clusters in Patients With Lung Cancer Receiving Chemotherapy

CONTEXT

Patients with lung cancer who undergo chemotherapy (CTX) experience multiple symptoms. Evaluation of how these symptoms cluster together and how these symptom clusters change over time are salient questions in symptom clusters research.

OBJECTIVES

The purposes of this analysis, in a sample of patients with lung cancer (n = 145) who were receiving CTX, were to 1) evaluate for differences in the number and types of symptom clusters at three time points (i.e., before their next cycle of CTX, the week after CTX, and two weeks after CTX) using ratings of symptom occurrence and severity and 2) evaluate for changes in these symptom clusters over time.

METHODS

At each assessment, a modified version of the Memorial Symptom Assessment Scale was used to assess the occurrence and severity of 38 symptoms. Exploratory factor analyses were used to extract the symptom clusters.

RESULTS

Across the two symptom dimensions (i.e., occurrence and severity) and the three assessments, six distinct symptom clusters were identified; however, only three of these clusters (i.e., lung cancer specific, psychological, nutritional) were relatively stable across both dimensions and across time. Two additional clusters varied by time but not by symptom dimension (i.e., epithelial/gastrointestinal and epithelial). A sickness behavior cluster was identified at each assessment with the exception of the week before CTX using only the severity dimension.

CONCLUSION

Findings provide insights into the most common symptom clusters in patients with lung cancer undergoing CTX. Most common symptoms within each cluster appear to be relatively stable across the two dimensions, as well as across time.

Contribution of Loss of Large Fiber Function to Pain in 2 Samples of Oncology Patients

OBJECTIVES

Numbness associated with neuropathic pain suggests the loss of function in myelinated, large diameter sensory neurons. The purpose of this study was to examine the relationships between pain severity and subjective (ie, severity of numbness) and objective (ie, loss of light touch sensations, vibration thresholds) measures of loss of large fiber function in adult survivors with chemotherapy-induced peripheral neuropathy (CIPN, n=426) and breast cancer patients with persistent postsurgical pain (n=80).

MATERIAL AND METHODS

For both samples, average pain and numbness were evaluated using a 0 to 10 numeric rating scale. Loss of light touch sensations in the hands and feet of patients with CIPN and in the upper arm of patients at 5 and 6 months following breast cancer surgery were assessed using Semmes Weinstein monofilaments. Loss of vibration in the hands and feet of patients with CIPN was assessed using a biothesiometer. Pearson Product Moment correlation coefficients were calculated between average pain and the number or percentage of sites with loss of light touch sensations, mean vibration thresholds, and the severity of numbness.

RESULTS

For both pain conditions, average pain scores were significantly correlated with objective measures of large fiber function (r=0.12 to 0.34; all P<0.05) and numbness (r=0.22 to 0.52; all P<0.008).

DISCUSSION

Our findings, in 2 independent samples of oncology patients, suggest that loss of function of myelinated, large diameter fibers contributes to the severity of neuropathic pain.

Phenotypic Characterization of Paclitaxel-Induced Peripheral Neuropathy in Cancer Survivors

CONTEXT

Although paclitaxel is one of the most commonly used drugs to treat breast, ovarian, and lung cancers, little is known about the impact of paclitaxel-induced peripheral neuropathy (PIPN) on cancer survivors.

OBJECTIVES

The purposes of this study were to evaluate for differences in demographic and clinical characteristics as well as measures of sensation, balance, upper extremity function, perceived stress, symptom burden, and quality of life (QOL) between survivors who received paclitaxel and did (n = 153) and did not (n = 58) develop PIPN.

METHODS

Pain characteristics associated with PIPN are described in detail. Both subjective and objective measures were used to evaluate the impact of PIPN.

RESULTS

Survivors with PIPN were significantly older, had a higher body mass index, and a worse comorbidity profile. The duration of PIPN was almost four years, and pain scores were in the moderate range. Compared with survivors without PIPN, survivors with PIPN had a higher number of upper and lower extremity sites that had lost light touch, cold, and pain sensations. Survivors with PIPN had worse upper extremity function, more problems with balance, a higher symptom burden, and higher levels of perceived stress. In addition, survivors with PIPN had worse QOL scores particularly in the domain of physical functioning.

CONCLUSION

The findings from this large descriptive study are the first to document the impact of PIPN on survivors' symptom burden, functional status, and QOL.

Expression of mitochondrial dysfunction-related genes and pathways in paclitaxel-induced peripheral neuropathy in breast cancer survivors

Background

Paclitaxel is one of the most commonly used drugs to treat breast cancer. Its major dose-limiting toxicity is paclitaxel-induced peripheral neuropathy (PIPN). PIPN persists into survivorship and has a negative impact on patient’s mood, functional status, and quality of life. No interventions are available to treat PIPN. A critical barrier to the development of efficacious interventions is the lack of understanding of the mechanisms that underlie PIPN. Mitochondrial dysfunction has been evaluated in preclinical studies as a hypothesized mechanism for PIPN, but clinical data to support this hypothesis are limited. The purpose of this pilot study was to evaluate for differential gene expression and perturbed pathways between breast cancer survivors with and without PIPN.

Methods

Gene expression in peripheral blood was assayed using RNA-seq. Differentially expressed genes (DEG) and pathways associated with mitochondrial dysfunction were identified between survivors who received paclitaxel and did (n = 25) and did not (n = 25) develop PIPN.

Results

Breast cancer survivors with PIPN were significantly older; more likely to be unemployed; reported lower alcohol use; had a higher body mass index and poorer functional status; and had a higher number of lower extremity sites with loss of light touch, cold, and pain sensations and higher vibration thresholds. No between-group differences were found in the cumulative dose of paclitaxel received or in the percentage of patients who had a dose reduction or delay due to PIPN. Five DEGs and nine perturbed pathways were associated with mitochondrial dysfunction related to oxidative stress, iron homeostasis, mitochondrial fission, apoptosis, and autophagy.

Conclusions

This study is the first to provide molecular evidence that a number of mitochondrial dysfunction mechanisms identified in preclinical models of various types of neuropathic pain including chemotherapy-induced peripheral neuropathy are found in breast cancer survivors with persistent PIPN and suggest genes for validation and as potential therapeutic targets.

Distinct attentional function profiles in older adults receiving cancer chemotherapy

PURPOSE

While attentional function is an extremely important patient outcome for older adults, research on changes in function in this group is extremely limited. The purposes of this study were to: identify subgroups of older patients (i.e., latent growth classes) based on changes in their level of self-reported attentional function; determine which demographic and clinical characteristics were associated with subgroup membership; and determine if these subgroups differed on quality of life (QOL) outcomes.

METHODS

Older oncology outpatients (n = 365) who were assessed for changes in attention and working memory using the Attentional Function Index a total of six times over two cycles of chemotherapy (CTX). QOL was assessed using the Medical Outcomes Study-Short Form 12 and the QOL-Patient Version Scale. Latent profile analysis (LPA) was used to identify subgroups of older adults with distinct attentional function profiles.

RESULTS

Three distinct attentional functional profiles were identified (i.e., low, moderate, and high attentional function). Compared to the high class, older adults in the low and moderate attentional function classes had lower functional status scores, a worse comorbidity profile and were more likely to be diagnosed with depression. In addition, QOL scores followed an expected pattern (low class < moderate class < high attentional function class).

CONCLUSIONS

Three distinct attentional function profiles were identified among a relatively large sample of older adults undergoing CTX. The phenotypic characteristics associated with membership in the low and moderate latent classes can be used by clinicians to identify high risk patients.

Associations Between Perceived Stress and Chemotherapy-Induced Peripheral Neuropathy and Otoxicity in Adult Cancer Survivors

CONTEXT

The most common adverse effects from neurotoxic chemotherapy are chemotherapy-induced neuropathy (CIPN), hearing loss, and tinnitus. Although associations between perceived stress and persistent pain, hearing loss, and tinnitus are documented, no studies have examined these associations in cancer survivors who received neurotoxic chemotherapy.

OBJECTIVES

In this cross-sectional study, we evaluated for associations between perceived stress and the occurrence of CIPN, hearing loss, and tinnitus, in 623 adult cancer survivors who received platinum and/or taxane compounds.

METHODS

Survivors completed self-report measures of hearing loss, tinnitus, and perceived stress (i.e., Impact of Events Scale-Revised [IES-R]). Separate logistic regression analyses were done for each neurotoxicity to evaluate whether each of the IES-R subscale (i.e., intrusion, avoidance, hyperarousal) and total scores made a significant independent contribution to neurotoxicity group membership.

RESULTS

Of the 623 survivors in this study, 68.4% had CIPN, 34.5% reported hearing loss, and 31.0% reported tinnitus. Older age, higher body mass index, poorer functional status, being born prematurely, cancer diagnosis, and higher intrusion (P = 0.013), hyperarousal (P = 0.014), and total (P = 0.047) IES-R scores were associated with CIPN. Older age, being male, poorer functional status, a worse comorbidity profile, and a higher IES-R hyperarousal (P = 0.007) score were associated with hearing loss. Being male, having less education, a worse comorbidity profile, and a higher IES-R hyperarousal (P = 0.029) score were associated with tinnitus.

CONCLUSION

These findings suggest that increased levels of perceived stress are associated with the most common chemotherapy-induced neurotoxicities.

Impact of chemotherapy-induced neurotoxicities on adult cancer survivors' symptom burden and quality of life

PURPOSE

Limited information is available on the impact of chemotherapy (CTX)-induced neurotoxicity on adult survivors' symptom experience and quality of life (QOL). Purposes were to describe occurrence of hearing loss and tinnitus and evaluate for differences in phenotypic characteristics and measures of sensation, balance, perceived stress, symptom burden, and QOL between survivors who received neurotoxic CTX and did (i.e., neurotoxicity group) and did not (i.e., no neurotoxicity group) develop neurotoxicity. Neurotoxicity was defined as the presence of chemotherapy-induced neuropathy (CIN), hearing loss, and tinnitus. Survivors in the no neurotoxicity group had none of these conditions.

METHODS

Survivors (n = 609) completed questionnaires that evaluated hearing loss, tinnitus, stress, symptoms, and QOL. Objective measures of sensation and balance were evaluated.

RESULTS

Of the 609 survivors evaluated, 68.6% did and 31.4% did not have CIN. Of the survivors without CIN, 42.4% reported either hearing loss and/or tinnitus and 48.1% of the survivors with CIN reported some form of ototoxicity. Compared to the no neurotoxicity group (n = 110), survivors in the neurotoxicity group (n = 85) were older, were less likely to be employed, had a higher comorbidity burden, and a higher symptom burden, higher levels of perceived stress, and poorer QOL (all p < .05).

CONCLUSIONS

Findings suggest that CIN, hearing loss, and tinnitus are relatively common conditions in survivors who received neurotoxic CTX.

IMPLICATIONS FOR CANCER SURVIVORS

Survivors need to be evaluated for these neurotoxicities and receive appropriate interventions. Referrals to audiologists and physical therapists are warranted to improve survivors' hearing ability, functional status, and QOL.

Differences in symptom clusters before and twelve months after breast cancer surgery

PURPOSE

Given the inter-relatedness among symptoms, research efforts are focused on an evaluation of symptom clusters. The purposes of this study were to evaluate for differences in the number and types of menopausal-related symptom clusters assessed prior to and at 12-months after surgery using ratings of occurrence and severity and to evaluate for changes in these symptom clusters over time.

METHODS

Prior to and at 12 months after surgery, 392 women with breast cancer completed the Menopausal Symptoms Scale. Exploratory factor analyses were used to identify the symptom clusters.

RESULTS

Of the 392 women evaluated, the mean number of symptoms (out of 46) was 13.2 (±8.5) at enrollment and 10.9 (±8.2) at 12 months after surgery. Using occurrence and severity, three symptom clusters were identified prior to surgery. Five symptom clusters were identified at 12 months following surgery. Two symptom clusters (i.e., pain/discomfort and hormonal) were relatively stable across both dimensions and time points. Two symptom clusters were relatively stable across both dimensions either prior to surgery (i.e., sleep/psychological/cognitive) or at 12 months after surgery (i.e., sleep). The other four clusters (i.e., irritability, psychological/cognitive, cognitive, psychological) were identified at one time point using a single dimension.

CONCLUSIONS

While some menopausal-related symptom clusters were consistent across time and dimensions, the majority of symptoms clustered together differently depending on whether they were evaluated prior to or at 12 months after breast cancer surgery. An increased understanding of how symptom clusters change over time may assist clinicians to focus their symptom assessments and management strategies.

Hearing loss and tinnitus in survivors with chemotherapy-induced neuropathy

PURPOSE

The purpose of this study was to evaluate for differences in demographic, clinical, and pain characteristics, as well as measures of sensation, balance, perceived stress, symptom burden, and quality of life (QOL) among survivors who received neurotoxic chemotherapy (CTX) and who reported only chemotherapy-induced neuropathy (CIN, n = 217), CIN and hearing loss (CIN/HL, n = 69), or CIN, hearing loss, and tinnitus (CIN/HL/TIN, n = 85). We hypothesized that as the number of neurotoxicities increased, survivors would have worse outcomes.

METHODS

Survivors were recruited from throughout the San Francisco Bay area. Survivors completed self-report questionnaires for pain and other symptoms, stress and QOL. Objective measures were assessed at an in person visit.

RESULTS

Compared to survivors with only CIN, survivors with all three neurotoxicities were less likely to be female and less likely to report child care responsibilities. In addition, survivors with all three neurtoxicities had higher worst pain scores, greater loss of protective sensation, and worse timed get up and go scores. These survivors reported higher state anxiety and depression and poorer QOL. For some outcomes (e.g., longer duration of CIN, self-reported balance problems), significantly worse outcomes were found for the survivors with CIN/HL and CIN/HL/TIN compared to those with only CIN.

CONCLUSIONS

Our findings suggest that compared to survivors with only CIN, survivors with CIN/HL/TIN are at increased risk for the most severe symptom burden, significant problems associated with sensory loss and changes in balance, as well as significant decrements in all aspects of QOL.

Association of Personality Profiles with Depressive, Anxiety, and Cancer-related Symptoms in Patients Undergoing Chemotherapy

Background

This study identified latent classes of cancer patients based on Big Five personality dimensions and evaluated for differences in demographic and clinical characteristics, depression, anxiety, and cancer-related symptoms.

Methods

Patients (n=1248) with breast, gastrointestinal, gynecological, or lung cancer completed the Center for Epidemiological Studies-Depression scale, Spielberger State-Trait Anxiety Inventories, NEO-Five Factor Inventory (NEO-FFI), and Memorial Symptom Assessment Scale (MSAS). Latent class profile analysis of NEO-FFI scores was used to identify patient subgroups.

Results

Three latent classes were identified. The "Distressed" class (14.3%) scored highest on neuroticism and lowest on extraversion, agreeableness, and conscientiousness. The "Resilient" class (31.9%) scored lowest on neuroticism and highest on extraversion, agreeableness, and conscientiousness. The "Normative" class (53.8%) was intermediate on all dimensions except openness. Compared to the Resilient class, patients in the Distressed class were younger, less educated, more likely to care for another adult, had more comorbidities, and exercised less. The three classes differed by performance status, marital and employment status, and income, but not by gender, time since diagnosis, or type of prior cancer treatment. The classes differed (Distressed > Normative > Resilient) in depression, anxiety, and cancer symptoms.

Conclusions

Personality is associated with psychological and physical symptoms in cancer patients.

Distinct Physical Function Profiles in Older Adults Receiving Cancer Chemotherapy

CONTEXT

Although physical function is an important patient outcome, little is known about changes in physical function in older adults receiving chemotherapy (CTX).

OBJECTIVES

Identify subgroups of older patients based on changes in their level of physical function; determine which demographic and clinical characteristics were associated with subgroup membership; and determine if these subgroups differed on quality-of-life (QOL) outcomes.

METHODS

Latent profile analysis was used to identify groups of older oncology patients (n = 363) with distinct physical function profiles. Patients were assessed six times over two cycles of CTX using the Physical Component Summary score from the Short Form 12. Differences, among the groups, in demographic and clinical characteristics and QOL outcomes were evaluated using parametric and nonparametric tests.

RESULTS

Three groups of older oncology patients with distinct functional profiles were identified: Well Below (20.4%), Below (43.8%), and Above (35.8%) normative Physical Component Summary scores. Characteristics associated with membership in the Well Below class included the following: lower annual income, a higher level of comorbidity, being diagnosed with depression and back pain, and lack of regular exercise. Compared with the Above class, patients in the other two classes had significantly poorer QOL outcomes.

CONCLUSION

Almost 65% of older oncology patients reported significant decrements in physical function that persisted over two cycles of CTX. Clinicians can assess for those characteristics associated with poorer functional status to identify high-risk patients and initiate appropriate interventions.

Chemotherapy-Induced Neuropathy in Cancer Survivors

CONTEXT

Evidence suggests that chemotherapy-induced neuropathy (CIN) is a significant problem for cancer survivors. However, a detailed phenotypic characterization of CIN in cancer survivors is not available.

OBJECTIVES

To evaluate between-group differences in demographic and clinical characteristics, as well as in measures of sensation, function, and postural control, in a sample of cancer survivors who received a platinum and/or a taxane-based CTX regimen and did (n = 426) and did not (n = 197) develop CIN.

METHODS

Survivors completed self-report questionnaires and underwent objective testing (i.e., light touch, pain sensation, cold sensation, vibration, muscle strength, grip strength, Purdue Pegboard test, Timed Get Up and Go test, Fullerton Advanced Balance test). Parametric and nonparametric statistics were used to compare between-group differences in study outcomes.

RESULTS

Of the 426 survivors with CIN, 4.9% had CIN only in their upper extremities, 27.0% only in their lower extremities, and 68.1% in both their upper and lower extremities. Demographic and clinical characteristics associated with CIN included the following: older age, lower annual income, higher body mass index, a higher level of comorbidity, being born prematurely, receipt of a higher cumulative dose of chemotherapy, and a poorer functional status. Survivors with CIN had worse outcomes for all of the following objective measures: light touch, pain, temperature, vibration, upper and lower extremity function, and balance.

CONCLUSIONS

This study is the first to provide a detailed phenotypic characterization of CIN in cancer survivors who received a platinum and/or a taxane compound. These data can serve as a benchmark for future studies of CIN in cancer survivors.

Differences in Symptom Clusters Identified Using Ratings of Symptom Occurrence vs. Severity in Lung Cancer Patients Receiving Chemotherapy

CONTEXT

An important question in symptom clusters research is whether the number and types of symptom clusters vary based on the specific dimension of the symptom experience used to create the clusters.

OBJECTIVES

Given that lung cancer patients undergoing chemotherapy (CTX) report an average of 14 co-occurring symptoms and studies of symptom clusters in these patients are limited, the purpose of this study, in lung cancer patients undergoing CTX (n = 145), was to identify whether the number and types of symptom clusters differed based on whether symptom occurrence rates or symptom severity ratings were used to create the clusters.

METHODS

A modified version of the Memorial Symptom Assessment Scale was used to assess for the occurrence and severity of 38 symptoms, one week after the administration of CTX. Exploratory factor analysis was used to extract the symptom clusters.

RESULTS

Both the number and types of symptom clusters were relatively similar using symptom occurrence rates or symptom severity ratings. Five symptom clusters were identified using both symptom occurrence rates and severity ratings (i.e., sickness behavior, lung cancer specific, psychological, nutritional, and epithelial). Across these two dimensions, the specific symptoms within each of the symptom clusters were relatively similar.

CONCLUSIONS

Identification of symptom clusters in patients with lung cancer may assist with the development of more targeted symptom management interventions. Future studies are warranted to determine if symptom clusters change over a cycle of CTX in patients with lung cancer.

Painful swelling after a noxious event and the development of complex regional pain syndrome 1: A one-year prospective study

BACKGROUND

The timing of diagnosis of complex regional pain syndrome (CRPS) 1 remains a challenge due to the large heterogeneity of clinical presentations. We describe the distribution and differences in outcomes and clinical manifestations between time points and patient groups with and without CRPS 1 following an initiating event.

METHODS

Prospective cohort study with a consecutive registration of patients presenting with painful swelling of the affected extremity after an initiating event and follow-up visits after 3, 6 and 12 months.

RESULTS

Forty-two patients were enrolled (37 females, mean age 55.1 years). At baseline, 35 participants (83%, females n = 30) fulfilled the diagnostic criteria for CRPS 1. At 3 months, 19 out of the initial 35 CRPS 1 patients (54%) did not meet the diagnostic criteria anymore. Besides our inclusion criteria of a painful swelling, early manifestations indicating a CRPS 1 primarily include an impaired quality of life (SF-35, EQ5-D), more pain (NRS, MPQ) and restricted range of motion.

CONCLUSIONS

CRPS 1 develops within 8 weeks following a noxious event. Although many CRPS 1 patients reach partial remission within the first 3 months, signs and symptoms do not improve significantly at 1 year. In order to identify prognostic risk factors large prospective cohort studies are needed.

SIGNIFICANCE

This prospective cohort study follows patients with complaints most suspected for complex regional pain syndrome (CRPS) 1. CRPS 1 develops within 8 weeks following a noxious event. Although many CRPS 1 patients reach partial remission within the 3 months, symptoms do not improve significantly at 1 year.

Predictors of the multidimensional symptom experience of lung cancer patients receiving chemotherapy

PURPOSE

Few studies have examined interindividual variability in the symptom experience of lung cancer patients. We aimed to identify the most prevalent, severe, and distressing symptoms, and risk factors associated with increased symptom burden.

METHODS

Lung cancer patients (n = 145) reported occurrence, severity, and distress for 38 symptoms on the Memorial Symptom Assessment Scale 1 week after chemotherapy. Using multidimensional subscales, risk factors for higher global distress, physical, and psychological symptoms were evaluated using simultaneous linear regression.

RESULTS

Mean age was 64.0 years and 56.6% were female. Mean Karnofsky Performance Status score was 79.1 (SD 14.6) and mean Self-Administered Comorbidity Questionnaire score was 7.3 (SD 3.9). The most distressing and prevalent symptom was fatigue. Problems with sexual interest/activity had the highest mean severity rating. Patients with lower functional status (p = 0.001) and higher comorbidity (p = 0.02) reported higher global distress. Similarly, lower functional status (p = 0.003) and higher comorbidity (p = 0.04) were associated with a higher physical symptom burden along with lower body mass index (p = 0.02). Higher psychology symptom burden was associated with lower functional status (p = 0.01), younger age (p = 0.02), non-metastatic disease (p = 0.03), higher number of prior treatments (p = 0.04), and income (p = 0.03).

CONCLUSIONS

Fatigue was the most distressing and prevalent symptom among lung cancer patients receiving chemotherapy. Lower functional status was associated with a higher burden of global distress, physical, and psychological symptoms. Younger age and non-metastatic disease were additional risk factors for increased psychological symptoms. Together, these risk factors can help clinicians identify lung cancer patients at increased need for aggressive symptom management.

Distinct Evening Fatigue Profiles in Oncology Outpatients Receiving Chemotherapy

Background

Fatigue is the most common and debilitating symptom experienced by oncology patients during chemotherapy (CTX). Fatigue severity demonstrates a large amount of inter-individual and diurnal variability.

Purpose

Study purposes were to evaluate for subgroups of patients with distinct evening fatigue profiles and evaluate how these subgroups differed on demographic, clinical, and symptom characteristics.

Methods

Outpatients with breast, gastrointestinal, gynecological, or lung cancer (n=1332) completed questionnaires six times over two cycles of CTX. Lee Fatigue Scale (LFS) evaluated evening fatigue severity. Latent profile analysis was used to identify distinct evening fatigue profiles.

Results

Four distinct evening fatigue classes (i.e., Low (14.0%), Moderate (17.2%), High (36.0%), Very High (32.8%)) were identified. Compared to the Low class, patients in the Very High evening fatigue class were: younger, female, had childcare responsibilities, had more years of education, had a lower functional status, had a higher comorbidity burden, and were diagnosed with breast cancer. Patients in the Very High class reported higher levels of depressive symptoms, sleep disturbance, and evening fatigue at enrollment.

Conclusions

Findings provide new insights into modifiable risk factors for higher levels of evening fatigue. Clinicians can use this information to identify higher risk patients and plan appropriate interventions.

Common and Distinct Characteristics Associated With Trajectories of Morning and Evening Energy in Oncology Patients Receiving Chemotherapy

CONTEXT

Although energy conservation strategies are recommended in clinical practice guidelines, little is known about changes in energy levels in oncology patients undergoing cancer treatment.

OBJECTIVES

The objective of this study was to identify variations in the trajectories of morning and evening energy levels and determine which characteristics predicted initial levels and the trajectories of morning and evening energy.

METHODS

Outpatients receiving chemotherapy (CTX) completed demographic and symptom questionnaires six times over two CTX cycles. Energy was assessed using the Lee Fatigue Scale. Hierarchical linear modeling was used to analyze the data.

RESULTS

A large amount of interindividual variability was found in the morning and evening energy trajectories. Patients who lived alone, had childcare responsibilities, had a lower functional status, did not exercise on a regular basis, had lower hemoglobin levels, had lower attentional function, higher trait anxiety, and higher sleep disturbance reported lower morning energy levels at enrollment. Variations in the trajectories of morning energy were associated with a higher body mass index and higher levels of morning energy and higher sleep disturbance scores. For evening energy, patients who were female, white, had lower functional status, and had lower attentional function and higher sleep disturbance reported lower evening energy levels at enrollment. Evening energy levels at enrollment were associated with changes in evening energy over time.

CONCLUSION

Patients undergoing CTX experience decrements in both morning and evening energy. The modifiable characteristics associated with these decrements can be used to design intervention studies to increase energy levels in these patients.

Differences in symptom clusters identified using symptom occurrence rates versus severity ratings in patients with breast cancer undergoing chemotherapy

PURPOSE

One of the unanswered questions in symptom clusters research is whether the number and types of symptom clusters vary based on the dimension of the symptom experience used to create the clusters. Given that patients with breast cancer receiving chemotherapy (CTX), report between 10 and 32 concurrent symptoms and studies of symptom clusters in these patients are limited, the purpose of this study, in breast cancer patients undergoing CTX (n = 515), was to identify whether the number and types of symptom clusters differed based on whether symptom occurrence rates or symptom severity ratings were used to create the clusters.

METHODS

A modified version of the Memorial Symptom Assessment Scale was used to assess for the occurrence and severity of 38 symptoms, one week after the administration of CTX. Exploratory factor analysis was used to extract the symptom clusters.

RESULTS

Both the number and types of symptom clusters were similar using symptom occurrence rates or symptom severity ratings. Five symptom clusters were identified using symptom occurrence rates (i.e., psychological, hormonal, nutritional, gastrointestinal, epithelial). Six symptom clusters (i.e., psychological, hormonal, nutritional, gastrointestinal, epithelial, chemotherapy neuropathy) were identified using symptom severity ratings. Across the two dimensions, the specific symptoms within each of the symptom clusters were similar.

CONCLUSIONS

Identification of symptom clusters in patients with breast cancer may be useful in guiding symptom management interventions. Future studies are warranted to determine if symptom clusters remain stable over a cycle of CTX in patients with breast cancer.

Differences in demographic, clinical, and symptom characteristics and quality of life outcomes among oncology patients with different types of pain

The purposes of this study, in oncology outpatients receiving chemotherapy (n = 926), were to: describe the occurrence of different types of pain (ie, no pain, only noncancer pain [NCP], only cancer pain [CP], or both CP and NCP) and evaluate for differences in demographic, clinical, and symptom characteristics, and quality of life (QOL) among the 4 groups. Patients completed self-report questionnaires on demographic and symptom characteristics and QOL. Patients who had pain were asked to indicate if it was or was not related to their cancer or its treatment. Medical records were reviewed for information on cancer and its treatments. In this study, 72.5% of the patients reported pain. Of the 671 who reported pain, 21.5% reported only NCP, 37.0% only CP, and 41.5% both CP and NCP. Across the 3 pain groups, worst pain scores were in the moderate to severe range. Compared with the no pain group, patients with both CP and NCP were significantly younger, more likely to be female, have a higher level of comorbidity, and a poorer functional status. In addition, these patients reported: higher levels of depression, anxiety, fatigue, and sleep disturbance; lower levels of energy and attentional function; and poorer QOL. Patients with only NCP were significantly older than the other 3 groups. The most common comorbidities in the NCP group were back pain, hypertension, osteoarthritis, and depression. Unrelieved CP and NCP continue to be significant problems. Oncology outpatients need to be assessed for both CP and NCP conditions.

Polymorphisms in Cytokine Genes Are Associated With Higher Levels of Fatigue and Lower Levels of Energy in Women After Breast Cancer Surgery

CONTEXT

Little is known about the phenotypic and molecular characteristics associated with changes over time in fatigue and lack of energy in patients with breast cancer.

OBJECTIVES

The aim of this study was to identify subgroups (i.e., latent classes) of women with distinct fatigue and energy trajectories; evaluate for differences in phenotypic characteristics between the latent classes for fatigue and energy; and evaluate for associations between polymorphisms in genes for pro- and anti-inflammatory cytokines, their receptors, and their transcriptional regulators and latent class membership.

METHODS

Patients were enrolled before and followed for six months after breast cancer surgery. Latent class analyses were done to identify subgroups of patients with distinct fatigue and energy trajectories. Candidate gene analyses were done to identify cytokine genes associated with these two symptoms.

RESULTS

For both fatigue and lack of energy, two distinct latent classes were identified. Phenotypic characteristics associated with the higher fatigue class were younger age, higher education, lower Karnofsky Performance Status score, higher comorbidity, higher number of lymph nodes removed, and receipt of chemotherapy (CTX). Polymorphisms in interleukin (IL) 1β and IL10 were associated with membership in the higher fatigue class. Phenotypic characteristics associated with the lower energy class included: a lower Karnofsky Performance Status score and a higher comorbidity score. A polymorphism in IL1R1 was associated with membership in the lower energy class.

CONCLUSION

Within each latent class, the severity of fatigue and decrements in energy were relatively stable over the first six months after breast cancer surgery. Distinct phenotypic characteristics and genetic polymorphisms were associated with membership in the higher fatigue and lower energy classes.

A Rasch Analysis of Assessments of Morning and Evening Fatigue in Oncology Patients Using the Lee Fatigue Scale

CONTEXT

To accurately investigate diurnal variations in fatigue, a measure needs to be psychometrically sound and demonstrate stable item function in relationship to time of day. Rasch analysis is a modern psychometric approach that can be used to evaluate these characteristics.

OBJECTIVES

To evaluate, using Rasch analysis, the psychometric properties of the Lee Fatigue Scale (LFS) in a sample of oncology patients.

METHODS

The sample comprised 587 patients (mean age 57.3 ± 11.9 years, 80% women) undergoing chemotherapy for breast, gastrointestinal, gynecological, or lung cancer. Patients completed the 13-item LFS within 30 minutes of awakening (i.e., morning fatigue) and before going to bed (i.e., evening fatigue). Rasch analysis was used to assess validity and reliability.

RESULTS

In initial analyses of differential item function, eight of the 13 items functioned differently depending on whether the LFS was completed in the morning or in the evening. Subsequent analyses were conducted separately for the morning and evening fatigue assessments. Nine of the morning fatigue items and 10 of the evening fatigue items demonstrated acceptable goodness-of-fit to the Rasch model. Principal components analyses indicated that both morning and evening assessments demonstrated unidimensionality. Person-separation indices indicated that both morning and evening fatigue scales were able to distinguish four distinct strata of fatigue severity.

CONCLUSION

Excluding four items from the morning fatigue scale and three items from the evening fatigue scale improved the psychometric properties of the LFS for assessing diurnal variations in fatigue severity in oncology patients.

Predictors of initial levels and trajectories of anxiety in women before and for 6 months after breast cancer surgery

BACKGROUND

The diagnosis of breast cancer, in combination with the anticipation of surgery, evokes fear, uncertainty, and anxiety in most women.

OBJECTIVE

Study purposes were to examine in patients who underwent breast cancer surgery how ratings of state anxiety changed from the time of the preoperative assessment to 6 months after surgery and to investigate whether specific demographic, clinical, symptom, and psychosocial adjustment characteristics predicted the preoperative levels of state anxiety and/or characteristics of the trajectories of state anxiety.

INTERVENTIONS/METHODS

Patients (n = 396) were enrolled preoperatively and completed the Spielberger State Anxiety inventory monthly for 6 months. Using hierarchical linear modeling, demographic, clinical, symptom, and psychosocial adjustment characteristics were evaluated as predictors of initial levels and trajectories of state anxiety.

RESULTS

Patients experienced moderate levels of anxiety before surgery. Higher levels of depressive symptoms and uncertainty about the future, as well as lower levels of life satisfaction, less sense of control, and greater difficulty coping, predicted higher preoperative levels of state anxiety. Higher preoperative state anxiety, poorer physical health, decreased sense of control, and more feelings of isolation predicted higher state anxiety scores over time.

CONCLUSIONS

Moderate levels of anxiety persist in women for 6 months after breast cancer surgery.

IMPLICATIONS FOR PRACTICE

Clinicians need to implement systematic assessments of anxiety to identify high-risk women who warrant more targeted interventions. In addition, ongoing follow-up is needed to prevent adverse postoperative outcomes and to support women to return to their preoperative levels of function.

Co-occurrence of anxiety and depressive symptoms following breast cancer surgery and its impact on quality of life

PURPOSE

Little is known about the prevalence of combined anxiety and depressive symptoms (CADS) in breast cancer patients. Purpose was to evaluate for differences in demographic and clinical characteristics and quality of life (QOL) prior to breast cancer surgery among women classified into one of four distinct anxiety and/or depressive symptom groups.

METHODS

A total of 335 patients completed measures of anxiety and depressive symptoms and QOL prior to and for 6 months following breast cancer surgery. Growth Mixture Modelling (GMM) was used to identify subgroups of women with distinct trajectories of anxiety and depressive symptoms. These results were used to create four distinct anxiety and/or depressive symptom groups. Differences in demographic, clinical, and symptom characteristics, among these groups were evaluated using analyses of variance and Chi square analyses.

RESULTS

A total of 44.5% of patients were categorized with CADS. Women with CADS were younger, non-white, had lower performance status, received neoadjuvant or adjuvant chemotherapy, had greater difficulty dealing with their disease and treatment, and reported less support from others to meet their needs. These women had lower physical, psychological, social well-being, and total QOL scores. Higher levels of anxiety with or without subsyndromal depressive symptoms were associated with increased fears of recurrence, hopelessness, uncertainty, loss of control, and a decrease in life satisfaction.

CONCLUSIONS

Findings suggest that CADS occurs in a high percentage of women following breast cancer surgery and results in a poorer QOL. Assessments of anxiety and depressive symptoms are warranted prior to surgery for breast cancer.

Variations in potassium channel genes are associated with distinct trajectories of persistent breast pain after breast cancer surgery

Persistent pain after breast cancer surgery is a common clinical problem. Given the role of potassium channels in modulating neuronal excitability, coupled with recently published genetic associations with preoperative breast pain, we hypothesized that variations in potassium channel genes will be associated with persistent postsurgical breast pain. In this study, associations between 10 potassium channel genes and persistent breast pain were evaluated. Using growth mixture modeling (GMM), 4 distinct latent classes of patients, who were assessed before and monthly for 6 months after breast cancer surgery, were identified previously (ie, No Pain, Mild Pain, Moderate Pain, Severe Pain). Genotyping was done using a custom array. Using logistic regression analyses, significant differences in a number of genotype or haplotype frequencies were found between: Mild Pain vs No Pain and Severe Pain vs No Pain classes. Seven single-nucleotide polymorphisms (SNPs) across 5 genes (ie, potassium voltage-gated channel, subfamily A, member 1 [KCNA1], potassium voltage-gated channel, subfamily D, member 2 [KCND2], potassium inwardly rectifying channel, subfamily J, members 3 and 6 (KCNJ3 and KCNJ6), potassium channel, subfamily K, member 9 [KCNK9]) were associated with membership in the Mild Pain class. In addition, 3 SNPs and 1 haplotype across 4 genes (ie, KCND2, KCNJ3, KCNJ6, KCNK9) were associated with membership in the Severe Pain class. These findings suggest that variations in potassium channel genes are associated with both mild and severe persistent breast pain after breast cancer surgery. Although findings from this study warrant replication, they provide intriguing preliminary information on potential therapeutic targets.

Establishing the characteristics for patients with chronic Complex Regional Pain Syndrome: the value of the CRPS-UK Registry

OBJECTIVE

The long-term prognosis of patients with Complex Regional Pain Syndrome (CRPS) is unknown with no reported prospective studies from the United Kingdom longer than 18 months. The CRPS-UK Network aims to study this by use of a Registry. The aims of this article are, to outline the CRPS-UK Registry, assess the validity of the data and to describe the characteristics of a sample of the UK CRPS population.

METHODS

A web-based CRPS-UK Registry was developed and made accessible to centres experienced in diagnosing and managing patients with CRPS. Pragmatic annual follow-up questions were agreed.

RESULTS

Up until July 2013, the Registry has recruited 240 patients. A blinded, validation study of 20 consecutive patients from two centres (10 each) demonstrated 95.6% completion and 99.4% accuracy of a random sample of the recorded data. These patients had chronic disease (median duration: 29 months); 72.5% were female (2.6:1), with a mean age at symptoms onset of 43 years, and were left-handed more than expected (21.8% versus 10% in the general population). Patients reported a delayed diagnosis, with the median time between symptom onset and diagnosis of 6 months. In all, 30 patients (12.5%) had multiple limb involvement and (83.3%) had a contiguous spread of CRPS.

CONCLUSION

CRPS-UK Registry is a validated method for actively recruiting well-characterised patients with CRPS to provide further information on the long-term outcome.

Subgroups of chemotherapy patients with distinct morning and evening fatigue trajectories

PURPOSE

Purposes of this study were to identify subgroups of patients with distinct trajectories for morning and evening fatigue, evaluate for differences in demographic and clinical characteristics among these subgroups, and compare and contrast the predictors of subgroup membership for morning and evening fatigue.

METHODS

Outpatients with breast, gastrointestinal, gynecological, or lung cancer (n = 582) completed questionnaires, a total of six times over two cycles of chemotherapy (CTX). Morning and evening fatigue severity were evaluated using the Lee Fatigue Scale. Latent profile analysis (LPA) was used to identify distinct subgroups.

RESULTS

Three latent classes were identified for morning fatigue (i.e., low (31.8 %), high (51.4 %), and very high (16.8 %)) and for evening fatigue (i.e., moderate (20.0 %), high (21.8 %), and very high (58.2 %)). Most of the disease and treatment characteristics did not distinguish among the morning and evening fatigue classes. Compared to the low class, patients in the high and very high morning fatigue classes were younger, had a lower functional status, and higher level of comorbidity. Compared to the moderate class, patients in the very high evening fatigue class were younger, more likely to be female, had child care responsibilities, had a lower functional status, and a higher level of comorbidity.

CONCLUSION

LPA allows for the identification of risk factors for more severe fatigue. Since an overlap was not observed across the morning and evening fatigue classes and unique predictors for morning and evening fatigue were identified, these findings suggest that morning and evening fatigue may have distinct underlying mechanisms.

Trajectories of fear of recurrence in women with breast cancer

PURPOSE

Although fear of recurrence (FCR) is common among cancer survivors, it remains unclear what factors predict initial levels (e.g., prior to surgery) or changes in FCR in the post-treatment period. Among women treated for breast cancer, this study evaluated the effects of demographic, clinical, symptom, and psychosocial adjustment characteristics on the initial (preoperative) levels of FCR and trajectories of FCR over 6 months following surgery.

METHODS

Prior to and for 6 months following breast cancer surgery, 396 women were assessed for demographic and clinical (disease and treatment) characteristics, symptoms, psychological adjustment characteristics, and quality of life (QOL). FCR was assessed using a four-item subscale from the QOL instrument. Hierarchical linear modeling was used to examine changes in FCR scores and to identify predictors of inter-individual differences in preoperative FCR levels and trajectories over 6 months.

RESULTS

From before surgery to 6 months post-operatively, women with breast cancer showed a high degree of inter-individual variability in FCR. Preoperatively, women who lived with someone, experienced greater changes in spiritual life, had higher state anxiety, had more difficulty coping, or experienced more distress due to diagnosis or distress to family members reported higher FCR scores. Patients who reported better overall physical health and higher FCR scores at enrollment demonstrated a steeper decrease in FCR scores over time.

CONCLUSIONS

These findings highlight inter-individual heterogeneity in initial levels and changes in FCR over time among women undergoing breast cancer surgery. Further work is needed to identify and provide interventions for women experiencing FCR during and after breast cancer treatment.

Preoperative Breast Pain Predicts Persistent Breast Pain and Disability After Breast Cancer Surgery

CONTEXT

Approximately 30% of the women report pain in the affected breast before breast cancer surgery.

OBJECTIVES

The purpose of this secondary analysis of our prospective study was to determine how women who experienced both preoperative and persistent postsurgical breast pain (n=107) differed from women who did not report preoperative breast pain and did (n=158) or did not (n=122) experience persistent postsurgical breast pain.

METHODS

Differences in demographic and clinical characteristics were evaluated. Linear mixed effects (LME) modeling was used to evaluate for group differences in symptom severity, function, sensation, and quality of life (QOL) over time.

RESULTS

Between-group differences in demographic and clinical characteristics as well as trajectories of shoulder function and QOL were identified. Women with both preoperative and persistent postsurgical breast pain were younger; were more likely to report swelling, strange sensations, hardness, and numbness in the affected breast before surgery; and were more likely to have reconstruction at the time of surgery. Women with both preoperative and persistent postsurgical breast pain had more biopsies in the prior year, more lymph nodes removed, and reported more severe acute postsurgical pain than women without preoperative breast pain. The LME modeling revealed significant group effects for most outcomes evaluated. Over the six months of the study, women with both preoperative and persistent postsurgical pain had persistently poorer shoulder flexion and physical well-being than women without preoperative breast pain.

CONCLUSION

Investigations of the etiology and molecular mechanisms of preoperative breast pain, as well as interventions for this high-risk group, are needed.

Potential risk factors for the onset of complex regional pain syndrome type 1: a systematic literature review

Anaesthetists in the acute and chronic pain teams are often involved in treating Complex Regional Pain Syndromes. Current literature about the risk factors for the onset of Complex Regional Pain Syndrome Type 1 (CRPS 1) remains sparse. This syndrome has a low prevalence, a highly variable presentation, and no gold standard for diagnosis. In the research setting, the pathogenesis of the syndrome continues to be elusive. There is a growing body of literature that addresses efficacy of a wide range of interventions as well as the likely mechanisms that contribute to the onset of CRPS 1. The objective for this systematic search of the literature focuses on determining the potential risk factors for the onset of CRPS 1. Eligible articles were analysed, dated 1996 to April 2014, and potential risk factors for the onset of CRPS 1 were identified from 10 prospective and 6 retrospective studies. Potential risk factors for the onset of CRPS 1 were found to include being female, particularly postmenopausal female, ankle dislocation or intra-articular fracture, immobilisation, and a report of higher than usual levels of pain in the early phases of trauma. It is not possible to draw definite conclusions as this evidence is heterogeneous and of mixed quality, relevance, and weighting strength against bias and has not been confirmed across multiple trials or in homogenous studies.

Polymorphisms in Tumor Necrosis Factor-α Are Associated With Higher Anxiety Levels in Women After Breast Cancer Surgery

INTRODUCTION

Before and after breast cancer surgery, women have reported varying anxiety levels. Recent evidence has suggested that anxiety has a genetic basis and is associated with inflammation. The purposes of the present study were to identify the subgroups of women with distinct anxiety trajectories; to evaluate for differences in the phenotypic characteristics between these subgroups; and to evaluate for associations between polymorphisms in cytokine genes and subgroup membership.

PATIENTS AND METHODS

Patients with breast cancer (n = 398) were recruited before surgery and followed up for 6 months. The patients completed the Spielberger State Anxiety Inventory and provided a blood sample for genomic analyses. Growth mixture modeling was used to identify the subgroups of patients with distinct anxiety trajectories.

RESULTS

Two distinct anxiety subgroups were identified. The women in the higher anxiety subgroup were younger and had a lower functional status score. Two single nucleotide polymorphisms in tumor necrosis factor-α (rs1799964, rs3093662) were associated with the higher anxiety subgroup.

CONCLUSION

The results of the present exploratory study suggest that polymorphisms in cytokine genes could partially explain the interindividual variability in anxiety. The determination of phenotypic and molecular markers associated with greater levels of anxiety can assist clinicians to identify high-risk patients and initiate appropriate interventions.

Persistent breast pain following breast cancer surgery is associated with persistent sensory changes, pain interference, and functional impairments

Interindividual variability exists in persistent breast pain following breast cancer surgery. Recently, we used growth mixture modeling to identify 3 subgroups of women (N = 398) with distinct persistent breast pain trajectories (ie, mild, moderate, severe) over 6 months following surgery. The purposes of this study were to identify demographic and clinical characteristics that differed among the breast pain classes and, using linear mixed effects modeling, to examine how changes over time and in sensitivity in the breast scar area, pain qualities, pain interference, and hand and arm function differed among these classes. Several demographic and clinical characteristics differentiated the breast pain classes. Of note, 60 to 80% of breast scar sites tested were much less sensitive than the unaffected breast. Significant group effects were observed for pain qualities and interference scores, such that, on average, women in the severe pain class reported higher scores than women in the moderate pain class. In addition, women in the moderate pain class reported higher scores than women in the mild pain class. Compared to women in the mild pain class, women in the severe pain class had significantly impaired grip strength, and women in the moderate and severe pain classes had impaired flexion and abduction.

PERSPECTIVE

Subgroups of women with persistent postsurgical breast pain differed primarily with respect to the severity rather than the nature or underlying mechanisms of breast pain. Pervasive sensory loss and the association between persistent breast pain and sustained interference with function suggest the need for long-term clinical follow-up.

Persistent arm pain is distinct from persistent breast pain following breast cancer surgery

Persistent pain following breast cancer surgery is well documented. However, it is not well characterized in terms of the anatomic site affected (ie, breast, arm). In 2 separate growth mixture modeling analyses, we identified subgroups of women (N = 398) with distinct breast pain and arm pain trajectories. The fact that these latent classes differed by anatomic site, types of tissue affected, and neural innervation patterns suggests the need for separate evaluations of these distinct persistent pain conditions. The purposes of this companion study were to identify demographic and clinical characteristics that differed between the 2 arm pain classes and determine if differences existed over time in sensitivity in the upper inner arm and axillary lymph node dissection sites, pain qualities, pain interference, and hand and arm function, as well as to compare findings with persistent breast pain. Higher occurrence rates for depression and lymphedema were found in the moderate arm pain class. Regardless of pain group membership, sensory loss was observed in the upper inner arm and axillary lymph node dissection site. Arm pain was described similarly to neuropathic pain and interfered with daily functioning. Persistent arm pain was associated with sustained impairments in shoulder mobility.

PERSPECTIVE

For persistent breast and arm pain, changes in sensation following breast cancer surgery were notable. Persistent arm pain was associated with sustained interference with daily functioning and upper body mobility impairments. Long-term management of persistent pain following breast cancer surgery is warranted to improve the quality of survivorship for these women.