The elusive concept of the symptom cluster

Trajectory, interactions, and predictors of higher symptom burden during induction therapy for multiple myeloma

BACKGROUND

Patients with multiple myeloma (MM) experience disabling symptoms that are difficult to manage and may persist after induction therapy. Monitoring disease-related and induction therapy-induced symptoms and identifying patients at greater risk for high symptom burden are unmet clinical needs. The objective of this study was to examine the trajectories of symptom severity over time and identify predictors of high symptom burden during MM induction therapy.

METHODOLOGY

Eligible patients with MM rated their symptoms by completing the MD Anderson Symptom Inventory MM module repeatedly during 16 weeks of induction therapy. Group-based trajectory modeling identified patient groups with persistently high-severity (versus low-severity) symptom trajectories over time. Quality of life (QOL) and affective and physical functioning status were assessed. Predictors of high symptom burden were examined by regression analysis.

RESULTS

Sixty-four MM patients participated. Most patients (89%) received bortezomib-based therapy. The five most-severe symptom trajectory groups were pain (59%), muscle weakness (46%), numbness (42%), disturbed sleep (41%), and fatigue (31%). Patients in the high-severity trajectory group for the five most-severe symptoms (31% of the sample) were more likely to have high-severity cognitive and affective symptoms. Patients in the high-severity trajectory groups for fatigue, muscle weakness, disturbed sleep, and bone aches were more likely to have high pain scores (all p < 0.05). Significant increases over time were observed in scores for pain (estimate: 0.026), numbness (0.051), muscle weakness (0.020), physical items (0.028), and affective items (0.014) (all p < 0.05). A higher baseline composite score of the five most-severe symptoms predicted worse QOL (- 6.24), and poor affective (0.80) and physical (1.10) statuses (all p < 0.01). Female sex predicted higher risk for being in the high-severity trajectory group for muscle weakness.

CONCLUSION

Almost one-third of MM patients suffer from up to 5 moderate to severe symptoms persistently, including pain, muscle weakness, numbness, disturbed sleep, and fatigue. Importantly, these results identify a group of symptoms that should be monitored and managed as part of routine patient care during MM induction therapy and suggest that pre-therapy pain management is necessary for better symptom control.

Patient-Reported Outcomes Measurement Information System Pediatric Symptom Profiles of Children With Cancer in China: A Latent Profile Analysis

BACKGROUND

Unpleasant symptoms are common in children with cancer. However, research identifying subgroups of children with cancer who experience similar levels of self-reported symptoms in China is limited.

OBJECTIVES

This study aimed to classify the symptom profiles of children with cancer and detect the possible predictors of the profiles and their effect on children's quality of life (QoL).

METHODS

A total of 272 children aged 8 to 17 years completed the Chinese version of the Pediatric Patient-Reported Outcomes Measurement Information System short form measures, the Pediatric QOL Inventory general core and cancer modules. Latent profile analysis was used to identify symptom profiles, and ordinal logistic regression and analysis of variance were used to examine predictors of symptom profile membership and profile differences on QoL.

RESULTS

The best fit was a 3-profile model: low, moderate, and severe symptom distress. Children who had been inpatients in the past 7 days and were currently under treatment are more likely to have severe symptoms. Participants in the low symptom distress profile reported significantly greater QoL than those in the other profiles.

CONCLUSIONS

Children with cancer are heterogeneous in their experience of symptoms. Children's characteristics, such as inpatient history and treatment status, are predictors of profiles; different symptom profiles are associated with QoL.

IMPLICATIONS FOR PRACTICE

This study identified distinct groups of patients who predictably experience higher symptoms and their predictors, which could help to place children within a profile and perhaps allow nurses to provide targeted supportive care to match children's specific symptom profile.

Effects of Symptom Burden on Quality of Life in Patients with Lung Cancer

Lung cancer patients suffer from numerous symptoms that impact their quality of life. This study aims to identify the symptom burden on quality of life in lung cancer patients. This survey used a structured questionnaire to collect data from 8 March 2021 to 12 May 2021. Patient demographic information was collected. The data on symptom burden and quality of life (QOL) of patients were obtained from the QLQ-C30 and the QLQ-LC13. The stepwise multiple regression analysis was used to estimate lung cancer-related symptom burden in relation to quality of life. The study included 159 patients with lung cancer who completed the questionnaire. The mean age of the patients was 63.12 ± 11.4 years, and 64.8% of them were female. The Global Quality of Life score of the QLQ-C30 was 67.87 ± 22.24, and the top five lung cancer-related symptoms were insomnia, dyspnea, and fatigue from the QLQ-C30, and coughing and dyspnea from the QLQ-LC13. The multiple regression analysis showed that appetite loss was the most frequently associated factor for global QOL (β = -0.32; adjusted R2: 27%) and cognitive function (β = -0.15; adjusted R2: 11%), while fatigue was associated with role function (β = -0.35; adjusted R2: 43%), emotional function (β = -0.26; adjusted R2: 9%), and social function (β = -0.26; adjusted R2: 27%). Dyspnea was associated with physical function (β = -0.45; adjusted R2: 42%). Appetite loss, fatigue, and dyspnea were the main reasons causing symptom burdens on quality of life for lung cancer patients. Decreasing these symptoms can improve the quality of life and survival for patients with lung cancer.

Exploring symptom clusters in mild cognitive impairment and dementia with the NIH Toolbox

OBJECTIVE

Symptom clustering research provides a unique opportunity for understanding complex medical conditions. The objective of this study was to apply a variable-centered analytic approach to understand how symptoms may cluster together, within and across domains of functioning in mild cognitive impairment (MCI) and dementia, to better understand these conditions and potential etiological, prevention, and intervention considerations.

METHOD

Cognitive, motor, sensory, emotional, and social measures from the NIH Toolbox were analyzed using exploratory factor analysis (EFA) from a dataset of 165 individuals with a research diagnosis of either amnestic MCI or dementia of the Alzheimer's type.

RESULTS

The six-factor EFA solution described here primarily replicated the intended structure of the NIH Toolbox with a few deviations, notably sensory and motor scores loading onto factors with measures of cognition, emotional, and social health. These findings suggest the presence of cross-domain symptom clusters in these populations. In particular, negative affect, stress, loneliness, and pain formed one unique symptom cluster that bridged the NIH Toolbox domains of physical, social, and emotional health. Olfaction and dexterity formed a second unique cluster with measures of executive functioning, working memory, episodic memory, and processing speed. A third novel cluster was detected for mobility, strength, and vision, which was considered to reflect a physical functioning factor. Somewhat unexpectedly, the hearing test included did not load strongly onto any factor.

CONCLUSION

This research presents a preliminary effort to detect symptom clusters in amnestic MCI and dementia using an existing dataset of outcome measures from the NIH Toolbox.

A multiphase study protocol of identifying, and predicting cancer-related symptom clusters: applying a mixed-method design and machine learning algorithms

Objectives

In recent years, there has been increasing attention on the cluster approach to symptom management. Two significant challenges in the symptom cluster (SC) approach are identifying and predicting these clusters. This multiphase protocol aims to identify SCs in patients with advanced cancer as the primary objective, with the secondary objective of developing machine learning algorithms to predict SCs identified in the first phase.

Methods

The 2-MIXIP study consists of two main phases. The first phase involves identifying SCs, and the second phase focuses on developing predictive algorithms for the identified SCs. The identification of SCs involves a parallel mixed-method design (quantitative and qualitative). Quantitative and qualitative methods are conducted simultaneously and given equal importance. The data are collected and analyzed independently before being integrated. The quantitative part is conducted using a descriptive-analytical method. The qualitative analysis is conducted using a content analysis approach. Then, the identified SCs from both parts are integrated to determine the final clusters and use them in the second phase. In the second phase, we employ a tree-based machine learning method to create predictive algorithms for SCs using key demographic and clinical patient characteristics.

Conclusion

The findings of the 2-MIXIP study can help manage cancer patients' symptoms more effectively and enhance clinical decision-making by using SCs prediction. Furthermore, the results of this study can provide guidance for clinical trials aimed at managing symptoms.

Symptom and problem clusters in German specialist palliative home care - a factor analysis of non-oncological and oncological patients' symptom burden

BACKGROUND

Specialist palliative home care (SPHC) aims to maintain and improve patients' quality of life in the community setting. Symptom burden may differ between oncological and non-oncological patients. However, little is known about diagnosis-related differences of SPHC patients. This study aims to describe the prevalence of physical symptom burden and psychosocial problems of adult patients in SPHC, and to evaluate diagnosis-related symptom clusters.

METHODS

Secondary analysis of data from a prospective, cross-sectional, multi-centre study on complexity of patients, registered at the German Register for Clinical Studies (DRKS trial registration number: DRKS00020517, 12/10/2020). Descriptive statistics on physical symptom burden and psychosocial problems at the beginning of care episodes. Exploratory and confirmatory factor analyses to identify symptom and problem clusters.

RESULTS

Seven hundred seventy-eight episodes from nine SPHC teams were included, average age was 75 years, mean duration of episode 18.6 days (SD 19.4). 212/778 (27.2%) had a non-oncological diagnosis. Main burden in non-oncological episodes was due to poor mobility (194/211; 91.9%) with significant diagnosis-related differences (χ² = 8.145, df = 1, p = .004; oncological: 472/562; 84.0%), and due to weakness (522/565; 92.4%) in oncological episodes. Two symptom clusters (psychosocial and physical) for non-oncological and three clusters (psychosocial, physical and communicational/practical) for oncological groups were identified. More patients in the non-oncological group compared to the oncological group showed at least one symptom cluster (83/212; 39.2% vs. 172/566; 30.4%).

CONCLUSION

Patients with non-oncological diseases had shorter episode durations and were more affected by symptom clusters, whereas patients with oncological diseases showed an additional communicational/practical cluster. Our findings indicate the high relevance of care planning as an important part of SPHC to facilitate anticipatory symptom control in both groups.

Cognitive Impairment, Physical Impairment, and Psychological Symptoms in Intensive Care Unit Survivors

BACKGROUND

Post-intensive care syndrome (PICS) affects 25% to 50% of adults who survive an intensive care unit (ICU) stay. Although the compounding of PICS impairments (cognitive, physical, and psychological) could intensify the syndrome, research on relationships among impairments is limited, particularly in patients with delirium.

OBJECTIVES

To examine associations among PICS impairments and examine delirium status and its relationship to PICS impairments at ICU discharge and 1 month later.

METHODS

A descriptive, correlational study of adults who survived an ICU stay. Participants completed measures for depression, anxiety, posttraumatic stress, physical function, functional status, and cognition at ICU discharge and 1 month later. Relationships among PICS impairments were examined with Spearman correlations; differences in impairments by delirium status were assessed with t tests.

RESULTS

Of 50 enrolled participants, 46 were screened for PICS impairment at ICU discharge and 35 were screened 1 month later. Cognitive impairment was the most common impairment at both time points. A positive correlation was found between cognition and functional status at ICU discharge (ρ = 0.50, P = .001) and 1 month later (ρ = 0.54, P = .001). Cognition and physical functioning were positively correlated 1 month after discharge (ρ = 0.46, P = .006). The group with delirium had significantly lower functional status scores than the group without delirium at ICU discharge (P = .04).

CONCLUSIONS

The findings suggest a moderate correlation between cognitive and physical impairments. This relationship should be explored further; ICU survivors with undiagnosed cognitive impairment may have delayed physical recovery and greater risk for injury.

Psychoneurological symptoms and inflammatory markers in patients with glioma in China: a network analysis

PURPOSE

Anxiety, depression, sleep disorder, fatigue, and pain develop as common psychoneurological symptoms in patients with glioma, and their occurrence and development are potentially related to inflammatory factors. However, this theory has not been proven within the context of glioma. This study aimed to estimate interconnections among psychoneurological symptoms and inflammatory biomarkers by a network analysis.

PATIENTS AND METHODS

We selected 203 patients with stage I-IV glioma from a tertiary hospital in China using convenient sampling method. Patients completed the self-made questionnaires, Hamilton Anxiety Scale-14 (HAMA-14), Hamilton Depression Scale-24 (HAMD-24), Pittsburgh Sleep Quality Index (PSQI), Multidimensional Fatigue Inventory-20 (MFI-20), and pain Numerical Rating Scale (NRS). The plasma inflammatory cytokines were examined. Partial correlation network analysis was performed to illustrate interactions of symptoms and inflammatory biomarkers.

RESULTS

Among the 203 included patients, all psychoneurological symptoms, except for depression and pain, exhibited significant connections with each other. Depression, anxiety, fatigue, interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNF-α) with higher strength centrality indices were identified as the most central node within the symptom-biomarker network.

CONCLUSIONS

Depression, anxiety, fatigue, IL-6, and TNF-α play a significant role in the symptom-biomarker network in patients with glioma. Medical staff should strengthen the dynamic evaluation of the involved symptoms and inflammatory cytokines and take effective measures to alleviate the burden of symptoms and improve the quality of life of patients.

Factors That Influence Sleep Disturbance and the Mediating Effects of Depression on Sleep Disturbance in Patients With Rheumatoid Arthritis

Little is known about the nature of relationships between sleep disturbance and influencing factors in rheumatoid arthritis. The purpose of this study was to identify factors that influence sleep disturbance and to evaluate mediating effects of depression on sleep disturbance. A nonexperimental, descriptive, correlational study design was adopted. One hundred patients with rheumatoid arthritis were recruited. Inflammatory status and levels of pain, fatigue, functional disability, depression, and sleep disturbance were measured. The factors that directly influenced sleep disturbance were gender, rheumatoid arthritis duration, serum C-reactive protein level, fatigue, and depression. Depression was found to have mediating effects on the relationships between sleep disturbance and arthritis symptoms. Pain, fatigue, and depression were found to have significant direct or indirect impacts on sleep disturbance. Our findings may improve understanding of sleep disturbance and aid the development of effective nursing management strategies for patients with rheumatoid arthritis suffering from sleep disturbance.

Symptom phenotypes in pulmonary arterial hypertension: The PAH "symptome"

Women with pulmonary arterial hypertension (PAH) experience multiple symptoms, including dyspnea, fatigue, and sleep disturbance, that impair their health-related quality of life (HRQOL). However, we know little about phenotypic subgroups of patients with PAH with similar, concurrent, multiple symptoms. The objectives of this study were to define the "symptome" by symptom cluster phenotypes and compare characteristics such as biomarkers, cardiac structure and function (echocardiography), functional capacity (6-min walk distance), and HRQOL between the groups. This cross-sectional study included 60 women with PAH. Subjects completed an assessment battery: Pulmonary Arterial Hypertension Symptom Scale, Pittsburgh Sleep Quality Index, Multidimensional Dyspnea Profile, Patient-Reported Outcomes Measurement Information System (PROMIS®) Physical Function, PROMIS® Sleep-Related Impairment, and the emPHasis-10. Subjects also underwent transthoracic echocardiography, phlebotomy, 6-min walk distance, and actigraphy. The three symptoms of dyspnea, fatigue, and sleep disturbance were used to define the symptom clusters. Other PAH symptoms, plasma and serum biomarkers, cardiac structure and function (echocardiography), exercise capacity (6-min walk distance), sleep (actigraphy), and HRQOL were compared across phenotypes. The mean age was 50 ± 18 years, 51% were non-Hispanic white, 32% were non-Hispanic Black and 40% had idiopathic PAH. Cluster analysis identified Mild (n = 28, 47%), Moderate (n = 20, 33%), and Severe Symptom Cluster Phenotypes (n = 12, 20%). There were no differences for age, race, or PAH etiology between the phenotypes. WHO functional class (p < 0.001), norepinephrine levels (p = 0.029), right atrial pressure (p = 0.001), physical function (p < 0.001), sleep onset latency (p = 0.040), and HRQOL (p < 0.001) all differed significantly across phenotypes. We identified three distinctive symptom cluster phenotypes (Mild, Moderate, and Severe) for women with PAH that also differed by PAH-related symptoms, physical function, right atrial pressure, norepinephrine levels, and HRQOL. These phenotypes could suggest targeted interventions to improve symptoms and HRQOL in those most severely affected.

Varying severities of symptoms underline the relevance of personalized follow-up care in breast cancer survivors: latent class cluster analyses in a cross-sectional cohort

PURPOSE

Insights into the severity of co-existing symptoms can help in identifying breast cancer survivors in need of symptom management. We aimed to identify subgroups of breast cancer survivors based on patterns of symptom severity, and characteristics associated with these subgroups.

METHODS

We selected surgically treated stage I-III breast cancer survivors 1-5 years post-diagnosis from the Netherlands Cancer Registry (N = 876). We assessed experienced severity of fatigue, nausea, pain, dyspnea, insomnia, appetite, constipation, diarrhea, and emotional and cognitive symptoms through the EORTC-QLQ-C30 Quality of Life Questionnaire on a scale of 0-100. We determined subgroups of survivors using latent class cluster analyses (LCA) based on severity of co-existing symptoms and compared their mean severity to the age-matched female reference population to interpret clinical relevance. We assessed subgroup characteristics by multinomial logistic regression analyses.

RESULTS

From 404 respondents (46%), three subgroups of survivors with distinct symptom severity were identified: low severity (n = 116, 28.7%), intermediate severity (n = 224, 55.4%), and high severity (n = 59, 14.6%). The low subgroup reported lower symptom severity than the general population; the intermediate subgroup reported a similar symptom severity, although scores for fatigue, insomnia, and cognitive symptoms were worse (small-medium clinical relevance). The high subgroup had worse symptom severity (medium-large clinical relevance). Compared to the intermediate subgroup, one (RRR: 2.75; CI: 1.22-6.19; p = 0.015) or more (RRR: 9.19; CI: 3.70-22.8; p =  < 0.001) comorbidities were significantly associated with the high subgroup. We found no associated treatment characteristics.

CONCLUSION

We identified distinct subgroups of breast cancer survivors based on symptom severity, underlining the relevance of further exploring personalized follow-up strategies.

Past mercury exposure and current symptoms of nervous system dysfunction in adults of a First Nation community (Canada)

BACKGROUND

The watershed in Asubpeeschoseewagong Netum Anishinabek (Grassy Narrows First Nation) territory has been contaminated by mercury (Hg) since 1962, resulting in very high Hg concentrations in fish, central to the community's culture, traditions, economy and diet. Biomarkers of Hg exposure (umbilical cord blood and hair/blood samples), monitored between 1970 and 1997, decreased over time. A recent Grassy Narrows Community Health Assessment (GN-CHA) survey included current symptoms of nervous system dysfunction. The present study aimed to cluster self-reported symptoms and examine their associations with past Hg exposure.

METHODS

The GN-CHA included 391 adults. Symptom clustering used a two-step segmentation approach. Umbilical cord Hg and/or yearly measurements of equivalent hair Hg were available for 242 participants. Structural Equation Models (SEM) displayed the associations between Hg exposure and clusters, with Hg exposure modelled as a latent variable or in separate variables (prenatal, childhood and having had hair Hg ≥ 5 μg/g at least once over the sampling period). Longitudinal Mixed Effects Models (LMEM) served to examine past hair Hg with respect to clusters.

RESULTS

A total of 37 symptoms bonded into 6 clusters, representing Extrapyramidal impairment, Sensory impairment, Cranial nerve disturbances, Gross motor impairment, Neuro-cognitive deficits and Affect/Mood disorders. Median Hg concentrations were 5 μg/L (1-78.5) and 1.1 μg/g (0.2-16) for umbilical cord and childhood hair, respectively. More than one-third (36.6%) had hair Hg ≥ 5 μg/g at least once. In SEM, latent Hg was directly associated with Extrapyramidal and Sensory impairment, Cranial nerve disturbances and Affect/Mood disorders. Direct associations were observed for prenatal exposure with Affect/Mood disorders, for childhood exposure with Extrapyramidal impairment and Cranial nerve disturbances, and for hair Hg ≥ 5 μg/g with Extrapyramidal and Sensory impairment. For all clusters, a further association between past Hg exposure and symptom clusters was mediated by diagnosed nervous system disorders. LMEM showed higher past hair Hg among those with higher scores for all clusters, except Affect/Mood disorders.

CONCLUSION

Our findings provide evidence that in this First Nation community, past Hg exposure from fish consumption was associated with later-life clusters of coexisting symptoms of nervous system dysfunction.

Characterization of Symptoms and Symptom Clusters for Type 2 Diabetes Using a Large Nationwide Electronic Health Record Database

OBJECTIVE

A variety of symptoms may be associated with type 2 diabetes and its complications. Symptoms in chronic diseases may be described in terms of prevalence, severity, and trajectory and often co-occur in groups, known as symptom clusters, which may be representative of a common etiology. The purpose of this study was to characterize type 2 diabetes-related symptoms using a large nationwide electronic health record (EHR) database.

METHODS

We acquired the Cerner Health Facts, a nationwide EHR database. The type 2 diabetes cohort (n = 1,136,301 patients) was identified using a rule-based phenotype method. A multistep procedure was then used to identify type 2 diabetes-related symptoms based on International Classification of Diseases, 9th and 10th revisions, diagnosis codes. Type 2 diabetes-related symptoms and co-occurring symptom clusters, including their temporal patterns, were characterized based the longitudinal EHR data.

RESULTS

Patients had a mean age of 61.4 years, 51.2% were female, and 70.0% were White. Among 1,136,301 patients, there were 8,008,276 occurrences of 59 symptoms. The most frequently reported symptoms included pain, heartburn, shortness of breath, fatigue, and swelling, which occurred in 21-60% of the patients. We also observed over-represented type 2 diabetes symptoms, including difficulty speaking, feeling confused, trouble remembering, weakness, and drowsiness/sleepiness. Some of these are rare and difficult to detect by traditional patient-reported outcomes studies.

CONCLUSION

To the best of our knowledge, this is the first study to use a nationwide EHR database to characterize type 2 diabetes-related symptoms and their temporal patterns. Fifty-nine symptoms, including both over-represented and rare diabetes-related symptoms, were identified.

Light Therapy for Cancer-Related Fatigue in (Non-)Hodgkin Lymphoma Survivors: Results of a Randomized Controlled Trial

Simple Summary

Cancer-related fatigue (CRF) is one of the most frequently reported symptoms with prevalence rates of 25 to 60 percent in (non-)Hodgkin lymphoma survivors. Several (pilot) studies showed promising effects of light therapy to reduce CRF. The aim of the current study is to evaluate the short- and long-term efficacy of light therapy on CRF and associated symptoms in chronically fatigued (non-)Hodgkin lymphoma survivors. Eighty-three survivors were exposed to bright white light (intervention) and another 83 survivors were exposed to dim white light (comparison). Results showed that all participants, irrespective of light condition, reported reduced levels of fatigue after the completion of light therapy. Similar results were found for depression, sleep quality, and some aspects of quality of life. No effect was found on circadian rhythms or objectively assessed sleep. Therefore, it is important to further investigate which aspects of intervention are associated with the improvements observed after light therapy.

Abstract

Purpose: To evaluate the short- and long-term effects of light therapy on fatigue (primary outcome) and sleep quality, depression, anxiety, quality of life, and circadian rhythms (secondary outcomes) in survivors of (non-)Hodgkin lymphoma presenting with chronic cancer-related fatigue. Methods: We randomly assigned 166 survivors (mean survival 13 years) to a bright white light intervention (BWL) or dim white light comparison (DWL) group. Measurements were completed at baseline (T0), post-intervention (T1), at three (T2), and nine (T3) months follow-up. A mixed-effect modeling approach was used to compare linear and non-linear effects of time between groups. Results: There were no significant differences between BWL and DWL in the reduction in fatigue over time. Both BWL and DWL significantly (p < 0.001) improved fatigue levels during the intervention followed by a slight reduction in this effect during follow-up (ES_T0-T1 = −0.71; ES_T1-T3 = 0.15). Similar results were found for depression, sleep quality, and some aspects of quality of life. Light therapy had no effect on circadian rhythms. Conclusions: BWL was not superior in reducing fatigue compared to DWL in HL and DLBCL survivors. Remarkably, the total sample showed clinically relevant and persistent improvements on fatigue not commonly seen in longitudinal observational studies in these survivors.

A Person-Centered Approach to Symptom Assessment and Management for Children and Adolescents Receiving Cancer Treatment

OBJECTIVES

Discuss the clinical assessment and management of symptoms for children and adolescents receiving treatment for cancer with attention to a person-centered approach to care.

DATA SOURCES

Review of currently published literature and guidelines pertaining to symptom assessment and management for children and adolescents receiving treatment for cancer.

CONCLUSION

Symptoms such as pain, nausea, and fatigue are commonly reported by children and adolescents receiving cancer treatment and are associated with greater symptom burden. Symptom assessment should be tailored to the child or adolescent and include the child's or adolescent's preference for reporting symptoms and attention to the symptoms that are of greatest priority. Evidence-based guidelines for the management of symptoms, including pain and nausea, are available to guide symptom management interventions and should be tailored to provide person-centered care.

IMPLICATIONS FOR NURSING PRACTICE

Nurses can lead efforts through clinical practice and research initiatives to advance person-centered symptom care for children and adolescents with cancer on a global level. Priorities for future work to advance person-centered symptom assessment and management include (1) identification of best practices for symptom assessment, (2) attention to social determinants of health and their subsequent influence on symptom outcomes, (3) compilation of evidence for management of less commonly reported symptoms, and (4) implementation of published clinical guidelines for symptom management in practice settings.

Characteristics of Cancer Symptom Clusters Reported through a Patient-Centered Symptom Cluster Assessment

In the scope of symptom cluster research, few investigators have obtained patients' perceptions of their symptom clusters, even though this information is central to designing effective interventions. In this cross-sectional study, 38 adults with cancer completed measures of demographics, health outcomes (functional status, well-being, quality of life) and a symptom cluster assessment that captured symptom occurrence, severity, distress, clustering, a priority cluster, causal attributions, duration, directional relationships, and cluster interference with daily life. Participants described 72 distinct symptom clusters. Symptoms were most frequently attributed to the cancer diagnosis. Participants' priority symptom cluster typically included two symptoms of continuous duration and one intermittent symptom. Temporal order and direction of symptom relationships varied, with 75 different relationships described among symptom pairs. Greater symptom cluster burden and interference were related to poorer health outcomes. This patient-centered view of symptom clusters revealed substantial variability in symptom cluster characteristics with important implications for symptom management.

Changes in Fatigue, Psychological Distress, and Quality of Life After Chemotherapy in Women with Breast Cancer: A Prospective Study

BACKGROUND

Chemotherapy leads to various symptoms and psychological distress, which contribute to a significant decrease in the quality of life of the patients.

OBJECTIVES

The aim of this study was to identify changes and interrelationships in the fatigue-depression-anxiety symptom cluster and quality of life during the cancer care trajectory in women with breast cancer.

METHODS

Fifty women participated in the study and completed questionnaires at 3 different times: prechemotherapy, postchemotherapy, and 6 months after the completion of chemotherapy. The assessment tools were the Functional Assessment of Cancer Therapy-Fatigue Scale, Hospital Anxiety and Depression Scale, and Functional Assessment of Cancer Therapy-Breast Cancer version 4 Scale. Data were analyzed using descriptive and repeated-measures analysis of variance statistics.

RESULTS

A significant increase in fatigue (F = 41.95, P < .001) and psychological distress (F = 26.55, P < .001) from prechemotherapy to postchemotherapy was noted. Improvement was observed 6 months after the completion of chemotherapy. A positive or negative change in fatigue was associated with the same in psychological distress. Quality of life (F = 65.22, P < .001) also showed similar change patterns as observed with fatigue and psychological distress. Fatigue had a greater impact on quality of life at postchemotherapy, but psychological distress had a greater impact at prechemotherapy and at the 6-month follow-up.

CONCLUSION

These results suggest that chemotherapy is highly associated with the fatigue-depression-anxiety symptom cluster and quality of life in women with breast cancer.

IMPLICATIONS FOR PRACTICE

Nursing intervention is needed to relieve the intensity of the fatigue-depression-anxiety symptom cluster and thus improve the quality of life of patients undergoing chemotherapy from before treatment to follow-up.

Validating a Patient-Reported Outcomes-Derived Algorithm for Classifying Symptom Complexity Levels Among Patients With Cancer

BACKGROUND

The patient-reported outcomes (PROs) symptom complexity algorithm, derived from self-reported symptom scores using the Edmonton Symptom Assessment System and concerns indicated on the Canadian Problem Checklist, has not been validated extensively.

METHODS

This is a retrospective chart review study using data from the Alberta Cancer Registry and electronic medical records from Alberta Health Services. The sample includes patients with cancer who visited a cancer facility in Alberta, Canada, from February 2016 through November 2017 (n=1,466).

RESULTS

The effect size (d=1.2) indicates that the magnitude of difference in health status between the severe- and low-complexity groups is large. The symptom complexity algorithm effectively classified subgroups of patients with cancer with distinct health status. Using Karnofsky performance status, the algorithm shows a sensitivity of 70.3%, specificity of 84.1%, positive predictive value of 79.1%, negative predictive value of 76.7%, and accuracy of 77.7%. An area under the receiver operating characteristic of 0.824 was found for the complexity algorithm, which is generally regarded as good, This same finding was also regarded as superior to the alternative algorithm generated by 2-step cluster analysis (area under the curve, 0.721).

CONCLUSIONS

The validity of the PRO-derived symptom complexity algorithm is established in this study. The algorithm demonstrated satisfactory accuracy against a clinician-driven complexity assessment and a strong correlation with the known group analysis. Furthermore, the algorithm showed a higher screening capacity compared with the algorithm generated from 2-step cluster analysis, reinforcing the importance of contextualization when classifying patients' symptoms, rather than purely relying on statistical outcomes. The algorithm carries importance in clinical settings, acting as a symptom complexity flag, helping healthcare teams identify which patients may need more timely, targeted, and individualized patient symptom management.

Health-related quality of life and symptom burden of epithelioid hemangioendothelioma patients: a global patient-driven Facebook study in a very rare malignancy

Purpose: Epithelioid hemangioendothelioma (EHE) is an ultra-rare vascular sarcoma with unique clinical features. EHE is characterized by an unpredictable, often protracted, clinical course and highly variable clinical presentation. Due to difficulty recruiting ultra-rare cancer patients, health-related quality of life (HRQoL) of EHE patients has not yet been studied. The aim of this study was to assess EHE symptom burden and its impact on HRQoL and psychological distress.Methods: The study was initiated after EHE patients' foundations approached our research group to study HRQoL. Patients were recruited from the international EHE Facebook group from May through October 2018. Data were collected using the online PROFILES registry. Latent class cluster analysis was performed to identify groups based on frequently reported symptoms. Differences in HRQoL (EORTC-QLQ-C30) and psychological distress (Hospital Anxiety and Depression Scale) between symptom-based clusters were examined.Results: Among 115 EHE patients from 20 countries, three clusters were identified, with low-, intermediate- and high-symptom burden, respectively. Highly symptomatic patients (33%) had clinically relevantly lower scores on HRQoL compared to the other two groups (p < 0.001). These patients suffered mostly from pain, insomnia and fatigue. Symptom burden significantly correlated with reduced daily functioning and high levels of psychological distress. Only for highly symptomatic patients, HRQoL and symptom levels were worse compared to healthy individuals.Conclusion: For the first time, we studied HRQoL in a large international cohort of ultra-rare cancer patients with distinct clinical characteristics, enabled by collaboration with patients and use of social media. We showed a considerable number of EHE patients were highly symptomatic, with a significant impact on HRQoL and psychological distress.

Pragmatic cluster randomized trial to evaluate effectiveness and implementation of enhanced EHR-facilitated cancer symptom control (E2C2)

Background

The prevalence of inadequate symptom control among cancer patients is quite high despite the availability of definitive care guidelines and accurate and efficient assessment tools.

Methods

We will conduct a hybrid type 2 stepped wedge pragmatic cluster randomized clinical trial to evaluate a guideline-informed enhanced, electronic health record (EHR)-facilitated cancer symptom control (E2C2) care model. Teams of clinicians at five hospitals that care for patients with various cancers will be randomly assigned in steps to the E2C2 intervention. The E2C2 intervention will have two levels of care: level 1 will offer low-touch, automated self-management support for patients reporting moderate sleep disturbance, pain, anxiety, depression, and energy deficit symptoms or limitations in physical function (or both). Level 2 will offer nurse-managed collaborative care for patients reporting more intense (severe) symptoms or functional limitations (or both). By surveying and interviewing clinical staff, we will also evaluate whether the use of a multifaceted, evidence-based implementation strategy to support adoption and use of the E2C2 technologies improves patient and clinical outcomes. Finally, we will conduct a mixed methods evaluation to identify disparities in the adoption and implementation of the E2C2 intervention among elderly and rural-dwelling patients with cancer.

Discussion

The E2C2 intervention offers a pragmatic, scalable approach to delivering guideline-based symptom and function management for cancer patients. Since discrete EHR-imbedded algorithms drive defining aspects of the intervention, the approach can be efficiently disseminated and updated by specifying and modifying these centralized EHR algorithms.

Trial registration

ClinicalTrials.gov, NCT03892967. Registered on 25 March 2019.

Symptoms in Children Receiving Treatment for Cancer-Part II: Pain, Sadness, and Symptom Clusters

Children and adolescents receiving treatment for cancer experience multiple symptoms as a consequence of their disease and its treatment that interfere with the child's quality of life. Understanding of symptom assessment in children with cancer is foundational to the work of the Children's Oncology Group Nursing Discipline, whose research aims are to address knowledge gaps including understanding illness-related distress. This article is the second of a two-part summary of current evidence addressing the assessment of symptoms frequently reported by children and adolescents receiving treatment for cancer. Studies reporting assessment of pain, sadness, and symptom clusters published between January 2008 and May 2018 were included. Forty-three publications addressed pain. Pain was highly prevalent and distressing, varied in its trajectory across a cycle of chemotherapy and across multiple cycles of treatment, and correlated with biomarkers associated with the pain response. Consequences of pain were poorer functional status and emotional health. Twenty publications addressed sadness. Sadness was the most prevalent psychosocial symptom. Its prevalence decreased over the course of treatment and over a cycle of chemotherapy. Persistent sadness was of greater severity and distress. Eight publications addressed symptom clusters. These studies identified both groups of co-occurring symptoms and groups of patients with common symptom profiles. This two-article series provides evidence for the distressing nature of symptoms among children receiving cancer treatment. Efforts to support clinicians in routine symptom assessment are needed. Additional research directed at alleviating symptoms and building resilience among the child experiencing symptoms is needed.

Individualized sleep promotion in acute care hospitals: Identifying factors that affect patient sleep

BACKGROUND/AIM

One major challenge of inpatient sleep promotion is that there is no "one-size-fits-all" intervention as patients' sleep may be bothered by different factors. A tool evaluating factors that disturb patient sleep is greatly needed as a foundation for generating a personalized action plan to address the patient's specific need for sleep. Unfortunately such tools are currently unavailable in clinical practice. In this study we developed and psychometrically evaluated a brief assessment tool for sleep disruptors important for hospitalized patients, the Factors Affecting Inpatient Sleep (FAIS) scale.

METHODS

The FAIS items were developed by literature review and validated by content validity testing. A survey collected from 105 hospitalized patients was used to select the most significant sleep disruptors. Psychometric evaluation using survey data included item analysis, principal components analysis, and internal consistency reliability.

RESULTS

The final FAIS scale included 14 items in three subscales explaining 56.4% of the total variance: 1) emotional or physical impairment due to illness or hospitalization; 2) sleep disturbance due to discomfort or care plan schedule; 3) sleep interruption due to hospital environment or medical care. The Cronbach's alpha coefficient for the FAIS scale was 0.87, and the reliability of the subscales ranged from 0.72 to 0.81.

CONCLUSION

The FAIS is a brief tool assessing sleep disruptors important for patients, and is empirically grounded, judged to have content validity, and has demonstrated psychometric adequacy. The FAIS scale can be used to guide the development of an individualized patient-centered sleep promotion plan.

The Theory of Unpleasant Symptoms in Pediatric Oncology Nursing: A Conceptual and Empirical Fit?

Symptom management knowledge is a priority for pediatric oncology nursing research. Theories and models can frame the studies of symptoms experienced during childhood cancer. This article describes and analyzes the middle-range theory, theory of unpleasant symptoms (TOUS), for its conceptual and empirical fit with pediatric oncology nursing based on its current use in adult oncology research and its limited use to date in pediatric oncology. Searches in PubMed and CINAHL databases using the keywords theory of unpleasant symptoms and cancer and covering the time period 2000 to 2017 yielded 103 abstracts for review. Twenty published reports met eligibility criteria for review; only one included pediatric oncology patients. No study to date has tested all the components of the TOUS in pediatrics. The TOUS component of performance appears to be underaddressed across completed studies that instead include a focus on patient-reported quality of life rather than on perceived behavioral or performance indicators concurrent with the subjective symptom reports. Additionally, the influence of family, essential in pediatric oncology, is absent in the majority of studies guided by the TOUS. The TOUS is a structurally complicated framework that would be a conceptual fit for pediatric oncology if family influence and perceived function were included. Studies across this population and guided by the TOUS are needed, although testing all the theorized linkages in the TOUS would likely require a large sample size of patients and, thereby, multisite approaches given that cancer is a rare disease in childhood.

Consensus in Identification and Stability of Symptom Clusters Using Different Symptom Dimensions in Newly Diagnosed Acute Myeloid Leukemia Patients Undergoing Induction Therapy

CONTEXT

An unresolved issue in symptom cluster (SC) research is that the numbers and types of SCs vary based on the multiple dimensions of the experienced symptoms that are used for SC identification.

OBJECTIVE

This study aimed to identify SCs using the ratings of occurrence, severity, and distress in newly diagnosed acute myeloid leukemia (AML) patients at three stages of their induction therapy (i.e., T1, T2, and T3). Then, we evaluated the consensus among the numbers and types of symptoms in each SC identified by multiple dimensions over time.

METHOD

The Chinese version of the Memorial Symptom Assessment Scale was used to evaluate the occurrence, severity, and distress ratings of 32 symptoms in patients newly diagnosed with AML during their induction therapy. Exploratory factor analysis was used for SCs identification.

RESULTS

Using the three dimensions in the AML patients (n = 126), four SCs were identified at T1 and T3 and three SCs were identified at T2. The number of symptoms in individual SCs varied over time, whereas the specific symptoms in SCs remained similar over time. The severity ratings fit the data better than did the ratings of occurrence and distress.

CONCLUSION

These findings provided insights into the most common SCs in AML patients undergoing induction therapy by multidimensional evaluation and could lay the foundation for future targeted symptom interventions. Further studies are needed to explore the mechanisms of SCs in AML patients undergoing the chemotherapy.

Mexican Americans' diabetes symptom prevalence, burden, and clusters

AIMS

Type 2 diabetes mellitus (T2DM), serious and increasingly prevalent among Mexican Americans, produces symptoms related to high and low glucose levels, medication side effects, and long-term complications. This secondary analysis explored symptom prevalence, differences among symptom burden levels, and how symptoms clustered.

METHODS

Clinical measurements and survey data (demographic, quality of life, and the symptom subscale of the Diabetes Symptom Self-Management Inventory) collected from Mexican American adults with T2DM (n = 71) were analyzed for symptom prevalence, differences across levels of symptom burden, and symptom clusters. Agglomerative hierarchical and k-means clustering analyses were performed on a Gower matrix. Internal validation methods and rank aggregation were used to identify the best clustering method of the two techniques and to identify symptoms that clustered together.

RESULTS

Participants reported mean = 14 symptoms; tiredness and trouble sleeping were most prevalent. People with high symptom burden had significantly lower quality of life and perceptions of worse diabetes severity. Hierarchical clustering produced three symptom clusters: cluster 1 = 9 symptoms (e.g. intense thirstiness, dry mouth); cluster 2 = 9 symptoms (e.g., itching skin, weight gain, noise or light sensitivity); cluster 3 = 13 symptoms (e.g., nervous, headache, trouble concentrating, and memory loss).

CONCLUSION

Mexican Americans with T2DM report several co-occurring symptoms. Quality of life is significantly worse for people with high symptom burden. Three distinct symptom clusters were identified. Studies with larger samples are needed to further diabetes symptom science. Clinicians should assess and address patients' co-occurring symptoms as a potential means of decreasing symptom burden and improving quality of life.

Capturing the complexity of mental disorders in the medically ill: the network approach on behavioral medicine

Since Descartes introduced dualism, body and mind have been seen as separate entities. The latent disease model, the view that symptoms are caused by an underlying disease, was possible within the dualistic paradigm. This paradigm, although successful in some aspects of medicine, is also assumed to underlie psychiatric disorders. As an alternative to the latent disease model, the network approach conceptualizes disorders as complex networks of causally connected symptoms. It offers a new way of understanding psychiatric disorders by directing attention away from the underlying cause and towards the symptoms and their functional interconnectedness, making the distinction between mental and physical symptoms obsolete. This article discusses how the network perspective helps us to overcome some of the problems we have faced when diagnosing and treating psychopathology in the medically ill. Furthermore, we describe how the network perspective can stimulate new research to better understand psychopathology in medically ill patients and how it can help deliver the most suitable treatment to the individual patient.

Symptom Trajectories Are Associated With Co-occurring Symptoms During Chemotherapy for Breast Cancer

CONTEXT

Symptoms are reported to co-occur during treatment for breast cancer. We previously identified three patterns of fatigue and two patterns of disturbed sleep, depressed mood, and anxiety in women undergoing chemotherapy for breast cancer using a Latent Growth Mixture Model.

OBJECTIVES

The purpose of this study was to explore whether membership in symptom classes of fatigue, disturbed sleep, depressed mood, and anxiety is associated with other symptoms at moderate-to-severe levels.

METHODS

Using data from three longitudinal studies, Wilcoxon rank-sum tests and Jonckheere-Terpstra tests for trend were used to distinguish between classes of women on co-occurring symptoms. Summative scores were calculated, including the number of days subjects reported moderate-to-severe levels (4 or higher on a 0-10 scale) of seven symptoms during two cycles of chemotherapy and compared to class membership.

RESULTS

Participants (n = 166) in the higher fatigue severity class reported more days with moderate-to-severe disturbed sleep, depressed mood, anxiety, nausea, and trouble thinking. Women in the higher severity disturbed sleep class reported more days with moderate-to-severe fatigue, depressed mood, anxiety, and trouble thinking. Women in the higher depressed mood severity class reported more days with moderate-to-severe fatigue, disturbed sleep, anxiety, and nausea. Women in the higher anxiety severity class reported more days with moderate-to-severe fatigue, disturbed sleep, and depressed mood.

CONCLUSION

Moderate-to-severe symptoms co-occur during cancer treatment for breast cancer. The dynamic process of multiple symptoms may be altered by future identification of a shared etiology.

The feasibility, acceptability and outcomes of exergaming among individuals with cancer: a systematic review

Background

Individuals with cancer have reduced quality of life, functionality, range of motion, strength, and an increase in pain and fatigue. Exergaming appears to be an effective rehabilitation tool for Parkinson’s disease, multiple sclerosis and post-stroke patients to improve functionality, balance and quality of life; however, the usefulness of exergaming in individuals with cancer is unknown. The aim of this systematic review is to describe exergaming interventions delivered to adults with a current or previous cancer diagnosis and to report the feasibility, acceptability and outcomes of such interventions.

Methods

Studies reporting on exergaming interventions delivered to individuals with a current or previous cancer diagnosis were included. 12 electronic databases were searched. Eight articles (seven interventions) were identified. Data were extracted and assessed for quality by two reviewers.

Results

Three interventions were delivered at hospital, two at home, one at a clinical laboratory, and one did not report. Two interventions were delivered by a physiotherapist, two by an occupational therapist, and one by a nurse, research staff and an exercise physiologist. The Nintendo Wii was used in four of seven studies, whilst the remaining three used the IREX system, BrightArm Duo Rehabilitation System or a custom made exergame. Studies showed that most participants enjoyed the exergaming intervention, and would recommend their use, with some preferring exergaming over standard care interventions. Adherence rates and enjoyment appear greater during exergaming than standard care. Exergaming interventions appear to support improvements balance, function, physical activity levels, strength, fatigue, emotions, cognition and pain.

Conclusion

Exergaming interventions delivered to individuals with cancer show great heterogeneity; differing in duration, frequency and gaming platform. The disease stage and severity of those included, and the outcome measures assessed also vary widely making it difficult to conclude its effectiveness at this time. However, adherence rates and enjoyment appear greater during exergaming compared to standard care, supporting the feasibility and acceptability of this type of intervention delivery for adults with cancer.

Atrial fibrillation symptom profiles associated with healthcare utilization: A latent class regression analysis

BACKGROUND

Symptoms drive healthcare use among adults with atrial fibrillation, but limited data are available regarding which symptoms are most problematic and which patients are most at-risk. The purpose of this study was to: (1) identify clusters of patients with similar symptom profiles, (2) characterize the individuals within each cluster, and (3) determine whether specific symptom profiles are associated with healthcare utilization.

METHODS

We conducted a cross-sectional secondary data analysis of 1,501 adults from the Vanderbilt Atrial Fibrillation Registry. Participants were recruited from Vanderbilt cardiology clinics, emergency department, and in-patient services. Subjects included in our analysis had clinically verified atrial fibrillation and a completed symptom survey. Symptom and healthcare utilization data were collected with the University of Toronto Atrial Fibrillation Severity Scale. Latent class regression analysis was used to identify symptom clusters, with clinical and demographic variables included as covariates. We used Poisson regression to examine the association between latent class membership and healthcare utilization.

RESULTS

Participants were predominantly male (67%) with a mean age of 58.4 years (±11.9). Four latent classes were evident, including an Asymptomatic cluster (N = 487, 38%), Highly Symptomatic cluster (N = 142, 11%), With Activity cluster (N = 326, 25%), and Mild Diffuse cluster (N = 336, 26%). Highly Symptomatic membership was associated with the greatest rate of emergency department visits and hospitalizations (incident rate ratio 2.4, P < 0.001).

CONCLUSIONS

Clinically meaningful atrial fibrillation symptom profiles were identified that were associated with increased rates of emergency department visits and hospitalizations.

Older Age, Early Symptoms and Physical Function are Associated with the Severity of Late Symptom Clusters for Men Undergoing Radiotherapy for Prostate Cancer

AIMS

To identify symptom clusters and predisposing factors associated with long-term symptoms and health-related quality of life after radiotherapy in men with prostate cancer.

MATERIALS AND METHODS

Patient-reported outcomes (PROs) data from the Medical Research Council RT01 radiotherapy with neoadjuvant androgen deprivation therapy trial of 843 patients were used. PROs were collected over 5 years with the University of California, Los Angeles Prostate Cancer Index (UCLA-PCI) and the 36 item Short-Form Health Survey (SF-36). Symptom clusters were explored using hierarchical cluster analysis. The association of treatment dose, baseline patient characteristics and early symptom clusters with the change in severity of PROs over 3 years was investigated with multivariate linear mixed effects models.

RESULTS

Seven symptom clusters of three or more symptoms were identified. The clusters were stable over time. The longitudinal profiles of symptom clusters showed the onset of acute symptoms during treatment for all symptom clusters and significant recovery by 6 months. Some clusters, such as physical health and sexual function, were adversely affected more than others by androgen deprivation therapy, and were less likely to return to pretreatment levels over time. Older age was significantly associated with decreased long-term physical function, physical health and sexual function (P < 0.001). Both baseline and acute symptom clusters were significant antecedents for impaired function and health-related quality of life at 3 years.

CONCLUSIONS

Men with poorer physical function and health before or during treatment were more likely to report poorer PROs at year 3. Early assessment using PROs and lifestyle interventions should be used to identify those with higher needs and provide targeted rehabilitation and symptom management.

Quality of life, problems, and needs of disease-free breast cancer survivors 5 years after diagnosis

PURPOSE

After cancer treatment, it is desirable to maintain or regain a high quality of life (QoL) and the ability to accomplish everyday tasks well. Therefore, we substantiated the scarce knowledge regarding long-term QoL after breast cancer, burdensome problems, and unmet needs for more support.

METHODS

Disease-free breast cancer survivors (n = 190) who had participated in two randomized controlled exercise trials during primary treatment were followed up to 5 years post-diagnosis. QoL-related functions and symptoms (EORTC QLQ-C30/-BR23), health problems, and support needs were assessed. EORTC-QLQ scores were compared with age-matched normative values from the general population in Germany.

RESULTS

QoL-related functions and symptoms in patients during cancer treatment were worse compared to healthy references, but largely improved over time. Yet, cognitive function and sleep were still significantly impaired at 5-year follow-up. Other common long-term problems included sexual issues (45% of survivors), hot flashes (38%), pain (34%), fatigue (24%), and polyneuropathy (21%). Regression analyses indicated fatigue having the strongest impact on global QoL. Support needs were expressed mainly for menopausal disorders (43%), physical performance (39%), sleep problems (38%), arthralgia (37%), cognitive problems (36%), weight problems (32%), and fatigue (31%).

CONCLUSIONS

While QoL in disease-free breast cancer survivors 5 years post-diagnosis was largely comparable to the general population on average, still many survivors suffered from adverse effects. There appears to be a need for ongoing screening and support regarding fatigue, sleep problems, cognitive problems, arthralgia/pain, menopausal/sexual symptoms, physical performance, and weight problems during and several years following breast cancer therapy.

Symptom Clusters in Adults With Chronic Atrial Fibrillation

BACKGROUND

Symptom clusters have not previously been explored among individuals with atrial fibrillation of any type.

OBJECTIVE

The purpose of this study is to determine the number of symptom clusters present among adults with chronic atrial fibrillation and to explore sociodemographic and clinical factors potentially associated with cluster membership.

METHODS

This was a cross-sectional secondary data analysis of 335 Australian community-dwelling adults with chronic (recurrent paroxysmal, persistent, or permanent) atrial fibrillation. We used self-reported symptoms and agglomerative hierarchical cluster analysis to determine the number and content of symptom clusters present.

RESULTS

There were slightly more male (52%) than female participants, with a mean (SD) age of 72 (11.25) years. Three symptom clusters were evident, including a vagal cluster (nausea and diaphoresis), a tired cluster (fatigue/lethargy, weakness, syncope/dizziness, and dyspnea/breathlessness), and a heart cluster (chest pain/discomfort and palpitations/fluttering). We compared patient characteristics among those with all the symptoms in the cluster, those with some of the symptoms in the cluster, and those with none of the symptoms in the cluster. The only statistically significant differences were in age, gender, and the use of antiarrhythmic medications for the heart cluster. Women were more likely to have the heart symptom cluster than men were. Individuals with all of the symptoms in the heart cluster were younger (69.6 vs 73.7 years; P = .029) than those with none of the symptoms in the heart cluster and were more likely to be on antiarrhythmic medications.

CONCLUSION

Three unique atrial fibrillation symptom clusters were identified in this study population.

How Can We Use Symptom Clusters in Nursing Care of Children with Leukemia?

The incidence of childhood cancers has been gradually rising worldwide. The rate of leukemia, which is the most common cancer type in childhood, has been increasing as well. In recent years, multiple chemotherapeutic agents, radiotherapy and bone marrow transplantation have been using in leukemia treatment. Children receiving treatment for leukemia may experience many symptoms due to the disease and its treatment. These concurrent symptoms may have a complex relationship. The aim of this paper is to review and compile current literature data related to symptom clusters used to explain multiple symptoms that occur in a complex structure due to leukemia and its treatment. Symptom clustering is used in oncology nursing to explain the complex relationship among multiple symptoms and to find out the effects that symptoms have on each other and patient outcomes. There are generally two statistical approaches to modeling symptom clusters. One is to establish the symptom clusters by grounding on clinical experiences, while the other is to establish them according to the results of statistical analysis and then clinical experiences. With the latter method, symptom clusters can be established more objectively and more number of symptoms can be assessed. In the literature, there are four instruments available for the measurement of a large number of symptoms in children. It is important to increase use of symptom clusters in nursing care for a better understanding of the relationship among multiple symptoms experienced during leukemia treatment, a more effective symptom management, and a more holistic care.

Association of Inflammatory Cytokines With the Symptom Cluster of Pain, Fatigue, Depression, and Sleep Disturbance in Chinese Patients With Cancer

CONTEXT

Pain, fatigue, depression, and sleep disturbance are common in patients with cancer and usually co-occur as a symptom cluster. However, the mechanism underlying this symptom cluster is unclear.

OBJECTIVES

This study aimed to identify subgroups of cluster symptoms, compare demographic and clinical characteristics between subgroups, and examine the associations between inflammatory cytokines and cluster symptoms.

METHODS

Participants were 170 Chinese inpatients with cancer from two tertiary hospitals. Inflammatory markers including interleukin-6 (IL-6), interleukin-1 receptor antagonist, and tumor necrosis factor alpha were measured. Intergroup differences and associations of inflammatory cytokines with the cluster symptoms were examined with one-way analyses of variance and logistic regression.

RESULTS

Based on cluster analysis, participants were categorized into Subgroup 1 (all low symptoms), Subgroup 2 (low pain and moderate fatigue), or Subgroup 3 (moderate-to-high on all symptoms). The three subgroups differed significantly in Eastern Cooperative Oncology Group (ECOG) performance status, sex, residence, current treatment, education, economic status, and inflammatory cytokines levels (all P < 0.05). Compared with Subgroup 1, Subgroup 3 had a significantly poorer ECOG physical performance status and higher IL-6 levels, were more often treated with combined chemoradiotherapy, and were more likely to be rural residents. IL-6 and ECOG physical performance status were significantly associated with 1.246-fold (95% CI 1.114-1.396) and 31.831-fold (95% CI 6.017-168.385) increased risk of Subgroup 3.

CONCLUSION

Our findings suggest that IL-6 levels are associated with cluster symptoms in cancer patients. Clinicians should identify patients at risk for more severe symptoms and formulate novel target interventions to improve symptom management.

Los grupos de síntomas en personas con cáncer: una revisión integrativa

Objetivo: explorar el estado actual de desarrollo investigativo del área temática de grupos de síntomas en adultos con cáncer. Método: revisión integrativa de producción científica generada entre 2001 y 2016. Se incluyeron 61 artículos por su aporte en la comprensión del área temática. Resultados: el estudio de los grupos de síntomas en personas con cáncer se consolida como un área temática novedosa, pertinente y necesaria para la investigación y práctica de enfermería en oncología, con tendencias y retos que incluyen: (1) El desarrollo de marcos conceptuales que aporten a la fundamentación, atributos y efectos (2) La determinación de métodos y formas de crearlos y clasificarlos (3) La generación de estudios con poblaciones específicas por tipos de cáncer y tratamiento y la consolidación de intervenciones de enfermería. Conclusiones: los pacientes con cáncer experimentan múltiples síntomas de forma simultánea durante las distintas fases de la enfermedad. Es incipiente el estudio de este fenómeno, los retos para la enfermería se centran en la generación de respuestas que alivien la carga de los grupos de síntomas y mejoren la calidad de vida de estos pacientes. Es necesario validar escalas de carga del síntoma y explorar los grupos de síntomas incluyendo variables clínicas ligadas a los tratamientos oncológicos.

Cytokine Gene Polymorphisms Associated With Symptom Clusters in Oncology Patients Undergoing Radiation Therapy

CONTEXT

Most of the reviews on the biological basis for symptom clusters suggest that inflammatory processes are involved in the development and maintenance of the symptom clusters. However, no studies have evaluated for associations between genetic polymorphisms and common symptom clusters (e.g., mood disturbance, sickness behavior).

OBJECTIVES

Examine the associations between cytokine gene polymorphisms and the severity of three distinct symptom clusters (i.e., mood-cognitive, sickness-behavior, treatment-related) in a sample of patients with breast and prostate cancer (n = 157) at the completion of radiation therapy.

METHODS

Symptom severity was assessed using the Memorial Symptom Assessment Scale. Symptom clusters were created using exploratory factor analysis. The associations between cytokine gene polymorphisms and the symptom cluster severity scores were evaluated using regression analyses.

RESULTS

Polymorphisms in C-X-C motif chemokine ligand 8 (CXCL8), interleukin (IL13), and nuclear factor kappa beta 2 (NFKB2) were associated with severity scores for the mood-cognitive symptom cluster. In addition to interferon gamma (IFNG1), the same polymorphism in NFKB2 (i.e., rs1056890) that was associated with the mood-cognitive symptom cluster score was associated with the sickness-behavior symptom cluster. Polymorphisms in interleukin 1 receptor 1 (IL1R1), IL6, and NFKB1 were associated with severity factor scores for the treatment-related symptom cluster.

CONCLUSION

Our findings support the hypotheses that symptoms that cluster together have a common underlying mechanism and the most common symptom clusters in oncology patients are associated polymorphisms in genes involved in a variety of inflammatory processes.

Depressive symptoms and inflammation are independent risk factors of fatigue in breast cancer survivors

BACKGROUND

Psychosocial and inflammatory factors have been associated with fatigue in breast cancer survivors. Nevertheless, the relative contribution and/or interaction of these factors with cancer-related fatigue have not been well documented.

METHOD

This cross-sectional study enrolled 111 stage 0-III breast cancer patients treated with breast surgery followed by whole breast radiotherapy. Fatigue was measured by the total score of the Multidimensional Fatigue Inventory-20. Potential risk factors included inflammatory markers (plasma cytokines and their receptors and C-reactive protein; CRP), depressive symptoms (as assessed by the Inventory of Depressive Symptomatology-Self Reported), sleep (as assessed by the Pittsburgh Sleep Quality Index) and perceived stress (as assessed by the Perceived Stress Scale) as well as age, race, marital status, smoking history, menopause status, endocrine treatment, chemotherapy and cancer stage. Linear regression modeling was employed to examine risk factors of fatigue. Only risk factors with a significance level <0.10 were included in the initial regression model. A post-hoc mediation model using PROCESS SPSS was conducted to examine the association among depressive symptoms, sleep problems, stress, inflammation and fatigue.

RESULTS

At 1 year post-radiotherapy, depressive symptoms (p<0.0001) and inflammatory markers (CRP: p = 0.015; interleukin-1 receptor antagonist: p = 0.014; soluble tumor necrosis factor receptor-2: p = 0.009 in separate models) were independent risk factors of fatigue. Mediation analysis showed that depressive symptoms also mediated the associations of fatigue with sleep and stress.

CONCLUSIONS

Depressive symptoms and inflammation were independent risk factors for cancer-related fatigue at 1 year post-radiotherapy, and thus represent independent treatment targets for this debilitating symptom.

Symptom Clusters and Quality of Life According to the Survivorship Stage in Ovarian Cancer Survivors

This cross-sectional study evaluated a convenience sample comprising 182 ovarian cancer survivors to identify symptom clusters according to the cancer survivorship stage and to determine their effects on quality of life using the European Organization for Research and Treatment of Cancer Quality of Life-C30 and -OV28 questionnaires. Factor and multiple regression analyses were performed to identify symptom clusters according to the cancer survivorship stage and the symptom clusters that affected the quality of life in each cancer survivorship stage, respectively. Participants in the acute, extended, and permanent survival stages accounted for 33%, 36.3%, and 30.7% of subjects, respectively. Overall, the most common symptom cluster was fatigue-diarrhea, and the symptom clusters affecting the quality of life differed according to the cancer survivorship stage. Thus, to improve the quality of life of ovarian cancer survivors, the main symptom clusters of each cancer survivorship stage must be identified, and management strategies for the related symptoms must be designed.

Advancing Symptom Science Through Symptom Cluster Research: Expert Panel Proceedings and Recommendations

An overview of proceedings, findings, and recommendations from the workshop on "Advancing Symptom Science Through Symptom Cluster Research" sponsored by the National Institute of Nursing Research (NINR) and the Office of Rare Diseases Research, National Center for Advancing Translational Sciences, is presented. This workshop engaged an expert panel in an evidenced-based discussion regarding the state of the science of symptom clusters in chronic conditions including cancer and other rare diseases. An interdisciplinary working group from the extramural research community representing nursing, medicine, oncology, psychology, and bioinformatics was convened at the National Institutes of Health. Based on expertise, members were divided into teams to address key areas: defining characteristics of symptom clusters, priority symptom clusters and underlying mechanisms, measurement issues, targeted interventions, and new analytic strategies. For each area, the evidence was synthesized, limitations and gaps identified, and recommendations for future research delineated. The majority of findings in each area were from studies of oncology patients. However, increasing evidence suggests that symptom clusters occur in patients with other chronic conditions (eg, pulmonary, cardiac, and end-stage renal disease). Nonetheless, symptom cluster research is extremely limited and scientists are just beginning to understand how to investigate symptom clusters by developing frameworks and new methods and approaches. With a focus on personalized care, an understanding of individual susceptibility to symptoms and whether a "driving" symptom exists that triggers other symptoms in the cluster is needed. Also, research aimed at identifying the mechanisms that underlie symptom clusters is essential to developing targeted interventions.

A prospective exploration of symptom burden clusters in women with breast cancer during chemotherapy treatment

PURPOSE

The aim was to prospectively map symptom clusters in patients with stage I-IIIa breast cancer during standard chemotherapy treatment in a randomised study.

METHODS

Participants completed the Memorial Symptom Assessment Scale (MSAS) at baseline, day 12 after the first and third cycle of FEC 75 or FEC 100, and day 12 after the last cycle of Taxotere. Cut-off values for symptom scores, a mean value based on each individual reporting a symptom including occurrence, frequency, severity and distress for inclusion in analysis, were determined.

RESULTS

The symptom burden cluster analysis was conducted in two steps and included symptoms with high frequency and high levels of distress. The factor analysis revealed three symptom clusters; physical, gastro (phys/gastro) and emotional, with core symptoms that remained stable over time. The most prevalent symptoms for the total sample during all cycles were as follows: lack of energy (range between 48 and 90%), feeling sad (48-79%), difficulty sleeping (54-78%), difficulty concentrating (53-74%), worrying (54-74%) and pain (29-67%).

CONCLUSION

In summary, we have prospectively established that symptom clusters remain stable over time with a basis of core symptoms. This knowledge will aid in the development of effective core symptom-focused interventions to minimise symptom burden for patients treated with chemotherapy for breast cancer.

Cancer Symptom Cluster Management

OBJECTIVES

To discuss the importance of cancer symptom clusters in clinical practice, review evidence for symptom cluster interventions, and make recommendations for symptom cluster identification, patient education, and management in clinical practice.

DATA SOURCES

Primary research and review articles identified through CINAHL, PubMed, and PsycINFO databases.

CONCLUSION

Several studies have investigated interventions for multi-symptom management or have evaluated the secondary effects of a single-symptom intervention on related symptoms. To date, only five studies have tested an intervention designed to manage a specific cancer symptom cluster. Those studies used nonpharmacologic approaches (psycho-education, cognitive-behavioral strategies, and acupressure) to address the pain, fatigue, and sleep disturbance symptom cluster, or the respiratory distress symptom cluster with some initial evidence of success. Further development and efficacy testing of symptom cluster interventions is needed.

IMPLICATIONS FOR NURSING PRACTICE

Clinical practice can be guided by knowledge of individual and multi-symptom management, and clinical judgment regarding possible etiologies of cancer symptom clusters. Clinicians should be aware of co-occurring symptoms in their patients, educate and involve patients in identifying symptom clusters and aggravating/alleviating factors, and coordinate treatment recommendations using strategies that are likely to be beneficial across symptoms.

Impact of Symptom Clusters on Quality of Life Outcomes in Patients from Japan with Advanced Nonsmall Cell Lung Cancers

OBJECTIVE

Identify symptom clusters based on symptoms experienced by patients with advanced nonsmall cell lung cancers (NSCLCs), and examine the relationship between the symptom clusters and impairment in everyday life and quality of life (QOL).

METHODS

Using the M.D. Anderson Symptom Inventory, 9 symptom items and the QOL Questionnaire (QLQ-C-30) evaluation apparatus from the European Organization for Research and Treatment of Cancer, we evaluated symptom severity, interference in daily life, and QOL. Factor analysis and multiple regression analysis techniques were used.

RESULTS

Sixty patients with advanced NSCLCs seen in pulmonary medicine departments were included in the study. The average age of patients was 64.33 (standard deviation = 11.40). Thirty-six were male and 24 were female. Three symptom clusters were identified as fatigue/anorexia cluster (dry mouth, altered the sense of taste, drowsiness, fatigue/tiredness, and lack of appetite), pain cluster (anxiety, sadness, and pain), numbness cluster (numbness, leg weakness, and distress). The pain cluster had the strongest influence (adjusted R2 = 0.355) on daily life (emotions) while the numbness cluster most strongly affected walking. The fatigue/anorexia cluster explained 22.7% of role function variance. This symptom clustering may be unique among patients with advanced NSCLCs.

CONCLUSIONS

Each of these clusters affected QOL and everyday life with varying degrees of influence. In clinical screening assessments, focusing on symptom clusters could provide tailored management strategies for patients with advanced NSCLCs. These care strategies may improve outcomes specifically for advanced NSCLCs patients.