The modified Memorial Symptom Assessment Scale Short Form: a modified response format and rational scoring rules

PURPOSE

The Memorial Symptom Assessment Scale Short Form (MSAS-SF) is a widely used symptom assessment instrument. Patients who self-complete the MSAS-SF have difficulty following the two-part response format, resulting in incorrectly completed responses. We describe modifications to the response format to improve useability, and rational scoring rules for incorrectly completed items.

METHODS

The modified MSAS-SF was completed by 311 women in our Peer and Nurse support Trial to Assist women in Gynaecological Oncology; the PeNTAGOn study. Descriptive statistics were used to summarise completion of the modified MSAS-SF, and provide symptom statistics before and after applying the rational scoring rules. Spearman's correlations with the Functional Assessment for Cancer Therapy-General (FACT-G) and Hospital Anxiety and Depression Scale (HADS) were assessed.

RESULTS

Correct completion of the modified MSAS-SF items ranged from 91.5 to 98.7%. The rational scoring rules increased the percentage of useable responses on average 4% across all symptoms. MSAS-SF item statistics were similar with and without the scoring rules. The pattern of correlations with FACT-G and HADS was compatible with prior research.

CONCLUSION

The modified MSAS-SF was useable for self-completion and responses demonstrated validity. The rational scoring rules can minimise loss of data from incorrectly completed responses. Further investigation is recommended.

Non-Hodgkin's lymphoma (NHL) patients at a VA medical center: Comorbidity and treatment

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Background: We hypothesized that measures of comorbidity may help explain the number of treatments administered to patients with non-Hodgkin's lymphoma. Methods: We performed a retrospective, IRB approved protocol, using chart review of all patients diagnosed with non-Hodgkin's lymphoma at the VANJHCS from January 1, 1997 through December 31, 2008. Records were reviewed for demographic, clinical, pathological data, the number of chemotherapy regimens, radiation therapy, and total number of treatments and survival. We tabulated the Charlson Comorbidity Index (CMI), the Kaplan-Feinstein Comorbidity Index (KFI), the Cumulative Illness Rating Scale (CIRS), International Prognostic Index (IPI), and performance status (PS) were tabulated for 100 patients seen at a VA Medical Center. Results: There were 100 patients with median (M) age 62 years (27–89). There were 61 deaths (61%) with M survival(MS) 1068 days(13–3976). The M Stage was 1(0–4), M LDH was 204 IU/L (88–1905), M Hgb 12.3gm/dL (7.3–17.4), M Albumin was 3.8g/dl(1.2–5.4), M Zubrod Performance Status(PS) was 1(0–4) in 50 pts(50%). The M CMI was 6(1–12), M KFI was 3(1–3), M CIRS17 was 1.7(1–3.15). The M total number of systemic therapy regimens received was 1(0–4.5), M radiotherapy was 0(0–1) and the overall M total treatment regimens used was 1 (0–4.5). IPI was a significant predictor in the use of radiation therapy (p<0.054) but did not correlate with the use systemic therapy. The CMI was a predictor of the use of systemic chemotherapy (p<0.007), and the total number of treatments received (p<0.011), but not the KFI or the CIRS 17. The performance status did not predict for the number of treatments. In a Cox regression analysis, the number of treatments did not affect survival. Conclusions: This data provides evidence that one measure of comorbidity, the CMI, may partially explain the number of systemic therapy treatments, and total treatments received by NHL patients. Further work in larger groups of pts is warranted.

No significant financial relationships to disclose.

Comorbidity and survival of hepatocellular carcinoma patients at a VA medical canter

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Background: To determine whether comorbidity indices predict survival in hepatocellular carcinoma (HCC) pts. Methods: In an IRB approved protocol, we reviewed the records of pts with tissue diagnosis of HCC seen at a VA Medical Center between 1/1/1999 to 12/31/2008. Comorbidity was assessed with four comorbidity indices, the Charlson Comorbidity Index (CMI), the Kaplan- Feinstein Index (KFI), the Cumulative Illness Rating Scale (CIRS), and VA Comorbidity Scale (VACS). Demographics, ECOG PS, stage, alpha-fetoprotein (AFP) at diagnosis, hepatitis B (HBV) and C (HCV) status, alcohol use, and iron overload were also reviewed. Cox survival regression analysis was performed. Results: There were 44 pts. All pts were men. The median (M) age at diagnosis was 60.5 years (range 35–86). The overall M survival was 230 days (4–2784). There were Stage I 12 (27%) pts, Stage II 7 (16%) pts, Stage III 14 (32%) pts, and Stage IV 11 (25%) pts. The M ECOG PS was 1.0 (0–4), stage 3 (1–4), CMI 5.75 (1–16), CIRS15 3.0 (1–5), CIRS16 6.0 (1–14), CIRS17 2.0 (0.83–5.0), CIRS18 0 (0–2), CIRS19 0 (0–1), KFI 3.0 (1–3), VACS 6.0 (2–9), and AFP 56.35 (1.1–379567). HBV was positive in 10 pts (23%), HCV 26 (59%) pts, alcohol use 37 (84%) pts, and iron overload 11 (25%) pts. In univariate survival analysis, stage (p<.038), ECOG PS (p<.001), AFP (p<.009), presence of iron overload (p<.006), and CMI (p<.019) were significant in predicting survival. However, age, HBV, HCV, alcohol use, CIRS15, CIRS16, CIRS17, CIRS18, KFI, and VACS were not significant for survival. In multivariate survival analyses that included stage and a comorbidity index, the CMI approaches significance (p<.077). Conclusions: In this sample, the CMI was a predictor for survival in pts with HCC. Further analysis in a larger sample is needed to provide a more definitive conclusion. This was supported by the New Jersey Commission for Cancer Research 09–1133-CCR-EO.

No significant financial relationships to disclose.

Comorbidity and survival in advanced non-small cell lung cancer (NSCLC) veteran patients

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Background: Prognostic value of comorbidity at diagnosis has received increasing attention. We studied whether the Charlson Comorbidity Index (CMI), Cumulative Illness Rating Scale (CIRS), Kaplan Feinstein Index (KFI), and/or VA Comorbidity Scale (VA) independently predicted survival for NSCLC patients Methods: In an IRB approved protocol, the charts of 101 patients with Stage IIIA, IIIB or IV Non small cell lung cancer seen from 2004 through 2006 at a VA medical center were reviewed of whom 94 have already died. Comorbidity scores ECOG performance status (PS), stage, number of treatments, serum LDH, and albumin levels were obtained or coded from medical records. Survival analyses were performed using proportional hazards models. Results: Median (M) patient age was 69 years (range 51–88), the M ECOG PS was 1 (range 0–4); 13 (13%) had stage IIIA, 27 (26%) IIB and 62 (61%) IV. The M number of treatments was 1 (range 0–6). Histologies were adenocarcinoma in 48 (48%) pts, squamous cell in 37 (37%) pts, and other 17 (15%) pts. The M survival was 207 days (range 4–1785 days). The Median (and ranges) were: 4.2 (1.2–12.8) for CMI, 3 (0–6) for CIRS15, 5(0–11) for CIRS16, 1.8 (0–4) for CIRS17, 0(0–1) for CIRS18, 2 (0–3) for KFI, and 4 (0–8) for VA. The M albumin was 3.7 (range 1.9–5.3) and LDH 201 (range 104–1036). In univariate survival analyses, the stage (p<0.001), ECOG PS (p<0.001), albumin (p<0.003), and the CIRS 17 (p <0.052) were predictive of survival; when, however, bisected by median values, the VA scale (p<0.027), ECOG PS (p<0.052) and albumin (p<.0017) were significantly related to survival but age, LDH, CMI, KFI and subscales of the CIRS (CIRS 16, CIRS 17, CIRS18) were not related to survival. In multivariate proportional hazards analyses that included stage and a comorbidity index, the CIRS16 (p<.032) was an independent predictor of survival; the combinations of stage (p<0.008), ECOG PS (p<.004), stage (p<.006) and albumin (p<.002) were independent predictors of survival. Conclusions: In this small sample, current comorbidity indices did not add to determinations of survival of veterans with advanced NSCLC. Further research is needed in a larger sample. Supported in part by the New Jersey Commission for Cancer Research 09–1133-CCR-EO and VA HSRD IIR 02–103.

No significant financial relationships to disclose.

A retrospective analysis of cardiovascular morbidity in metastatic hormone-refractory prostate cancer patients on high doses of the selective COX-2 inhibitor celecoxib

This data were previously presented in February 2007 at the American Society of Clinical Oncology's Prostate Cancer Symposium in Orlando, FL, USA. COX-2 inhibition has shown promise in treating prostate cancer, but concerns exist regarding the risk profile associated with this class of drugs. This study analyzes the cardiovascular and cerebral vascular morbidity associated with high doses of the COX-2 inhibitor, celecoxib, in patients with metastatic hormone-refractory prostate cancer (mHRPC). We retrospectively reviewed 67 patients with mHRPC who were treated at our institution between 1999 and 2005. All charts were reviewed for cardiac risk factors and the clinical course whilst on therapy and post-treatment was analyzed. This study included 34 patients who were on protocols that involved celecoxib 400 mg b.i.d.. Treatment ranged from 21 to 355 days, with a median of 118.5 days. There were three myocardial infarctions (MIs)--two in the study group and one in the control group. One patient had a MI while on treatment, but he had a significant cardiac disease history. There were also two cerebral vascular accidents (CVAs) in each group, although none in any patient who was on-study. Although this is a small study, these findings, in the context of other published data, suggest that some patients with advanced malignancies may still benefit from therapies involving COX-2 inhibitors without clinically significant increase in risk for MI or CVA.

VEGF, PDGF alpha, PDGF beta, and C-Kit expression are not independent survival predictors in stage D2 prostate cancer (PC)

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Background: In PC, overexpression of VEGF, PDGF alpha, PDGF beta, and C-Kit has been reported in over 50% of biopsy samples and may be important predictors of survival. Methods: In an ongoing project, we reviewed the records of 26 patients (pts) with stage D2 PC and stained their archival tissue specimens for VEGF, PDGF alpha, PDGF beta, and C-Kit expression. Immunohistochemistry was performed at US LABS (Irvine CA). All immunostains were evaluated by two pathologists. Immunoreactivity was scored using a semiquantitative system for intensity of staining (0–3+) and % of tumor cells (0–3+). The total score was obtained by averaging the scores between the two readers. All pts had androgen deprivation and were followed at 3 months intervals with physical examination, CBC, chemistry profile and PSA levels. A stepwise Cox model was used with variables: Gleason score, Hemoglobin (Hgb), Alkaline Phosphatase (Alk Phos), PSA, LDH levels, and C-Kit positive or negative staining. Results: Median values were as follows: age 69 years (56–91), Alk Phos 139 U/L(60–1298), PSA 178 ng/ml (1.8–5677), LDH 169 IU/L (100–350), Hgb 12.8 gm/dl (6.8–16.3), Gleason score 8 (5–10), Survival 26 mos (8.3–144.1). The median value for C-Kit staining was 3 on a scale of 0–6. 18 pts were grouped into low staining group (0–4) and 8 pts in a high staining group (4.5–5). The Kappa Coefficient for C-Kit was 0.83, and ranged from 0.78–0.91 for the other 3 stains. In univariate survival analyses, C-Kit staining was a predictor for survival (p=0.037) but not PDGF alfa, PDGF beta, or VEGF. In the stepwise Cox model, independent survival predictors in order of significance were the Gleason score, Hgb, and PSA levels. Conclusions: In this sample, VEGF, PDGF alpha, PDGF beta, and C-Kit overexpression by immunohistochemistry in archival tissue are not independent predictors of survival. The C-Kit, however, has a small association with survival but may have collinearity with known predictors of survival.

No significant financial relationships to disclose.

Comorbidity and survival in cancer patients receiving palliative care

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Background: Comorbidity has received increasing attention in the assessment of patients with early stage cancer, or at diagnosis. We studied whether three indices of comorbidity, the Charlson Comorbidity Index (CMI), the Cumulative Illness Rating Scale (CIRS), and the Kaplan Feinstein Index (KFI) add prognostic information for cancer patients receiving palliative care. Methods: In an IRB approved protocol, 103 patients with advanced cancer were seen at the time they were starting palliative care. They had a Karnofsky Performance Status (KPS) determination, and were followed longitudinally. Comorbidity scores were coded from the medical record. At this time, all patients had died and survival analyses were performed. Results: The median age was 69 years (range 41–87), median Karnofsky Performance Status (KPS) was 70% (range 20–90); primary sites were lung 41 pts (40%), prostate 23pts (22%), colorectal 10 pts (10%), other cancers 29 pts (28%). Median survival was 111 days (range 4–1,145 days). Median CMI was 10 (range 4–14), CIRS15 4 (2–5), CIRS16 9 (4–12), CIRS17 2.3 (1.5–3.33), CIRS18 1 (0–3), KFI 2 (0–3). In univariate survival analyses, when bisected by median values, the KPS, age, CMI, and subscales of the CIRS (CIRS 16, CIRS 17, CIRS18) were significantly related to survival, but not the KFI. In multivariate Cox regression analyses that included KPS (p<0.0001) and age (p<0.003) and a comorbidity index, the CMI (p<0.0001), and certain subscales of the CIRS were independently predictive of survival, specifically the CIRS 15 (p<0.0001), CIRS16 (p<0.0001), CIRS 17 (p<0.0001), and CIRS18 (p<0.0001). The primary site was not an independent survival predictor. Conclusion: In patients with advanced cancer receiving palliative care, measures of comorbidity may contribute to refining estimates of prognosis and ultimately to health care resource utilization. The optimal comorbidity measure remains to be determined. These results will be confirmed in larger populations. Supported in part by the Soros Open Society Institute Project Death in America and VA HSRD IIR 02–103

No significant financial relationships to disclose.

Eukaryotic expression: developments for structural proteomics

The production of sufficient quantities of protein is an essential prelude to a structure determination, but for many viral and human proteins this cannot be achieved using prokaryotic expression systems. Groups in the Structural Proteomics In Europe (SPINE) consortium have developed and implemented high‐throughput (HTP) methodologies for cloning, expression screening and protein production in eukaryotic systems. Studies focused on three systems: yeast (Pichia pastoris and Saccharomyces cerevisiae), baculovirus‐infected insect cells and transient expression in mammalian cells. Suitable vectors for HTP cloning are described and results from their use in expression screening and protein‐production pipelines are reported. Strategies for co‐expression, selenomethionine labelling (in all three eukaryotic systems) and control of glycosylation (for secreted proteins in mammalian cells) are assessed.

Quality of life (QOL) in patients (Pts) with hormone resistant prostate cancer (HRPC) treated with docetaxel (D) and celecoxib (C)

18598

Background: The impact of chemotherapy on QOL for pts with HRPC is not well described. Thirty patients(30) participated in a trial of D and C(Kasimis et al, submitted ASCO 2006). The objectives for this companion study were to study QOL outcomes with the FACT instrument including the Prostate subscale(FP) and utility from the EQ5D. Methods: In a phase II trial, 30 pts with progressive HRPC were treated with D and C for 4 wks in each cycle. Response evaluation was made by RECIST criteria and PSA reduction by >50% for biochemical response every 2 cycles. Patients completed the FACT and EQ5D instruments at the beginning of every cycle. We analyzed the FACT subscales with different statistical approaches, and compared FACT and utility for responders and non responders. Results: All 30 pts accrued were evaluable for toxicity and response. Thirty (30) pts received a minimum of 2 cycles, median (M) 4.5 (range 2–8). The M age was 74 yr (55–94), ECOG PS 1 (0–2). For 19 pts, the baseline mean score for the FACT P was 29, Standard Deviation 10. The Cronbach’s Coefficient was 0.83. The FACT Physical Well Being (PWB) correlated with the EQ5D utility score 0.76 (p < .0003), as did the Functional Well Being (FWB) 0.67 (p < .003) and FACT P 0.62 (p < .006). The FACT PWB, EWB, FP, Treatment Outcome Index, and EQ5D Utility differed significantly between responders and non responders by radiographic parameters, alpha = 0.1. The results for PSA reduction >50% are similar. Conclusions: The FACT Prostate subscale has good psychometric properties, correlates with EQ5D utility measure, and also with responder status by radiography and PSA.

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Substance p-fibronectin-cytokine interactions in myeloproliferative disorders with bone marrow fibrosis

Bone marrow (BM) fibrosis could occur secondarily to several clinical disorders: hematological and nonhematological. Clinical presentation of fibrosis could occur in myeloproliferative diseases, lymphoma, myelodysplastic syndrome and myeloma. The pathophysiology underlying BM fibrosis remains unclear despite intensive study, with a corresponding lack of specific therapy. This review discusses new insights in the role of substance P, cytokines and fibronectin in the development of BM fibrosis. Substance P is a neuropeptide that possesses pleiotropic properties, e.g. neurotransmission and immune/hematopoietic modulation and is linked to BM fibrosis. Cytokines and growth factors, in particular those associated with fibrogenic properties, e.g. TGF-beta, IL-1 and platelet-derived growth factor, are linked to BM fibrosis. Extracellular matrix proteins are increased in patients with BM fibrosis. Fibronectin in the sera of patients with BM fibrosis is complexed to substance P. Fibronectin appears to protect substance P from degradation by endogenous peptidases. This review describes the preliminary findings on the colocalization of substance P and fibronectin in the BM of patients with fibrosis. These data are reviewed in the context of published reports with particular focus on the relevant cytokines. A more detailed understanding of intra- and intercellular mechanisms in BM fibrosis may lead to effective therapy.

Video-assisted thoracoscopic sympathectomy-splanchnicectomy for pancreatic cancer pain

Patients with unresectable pancreatic cancer often suffer severe pain. Various techniques are available for pain control. We present a patient with pancreatic cancer who underwent unilateral video-assisted thoracoscopic sympathectomy-splanchnicectomy and had complete pain relief. This minimally invasive procedure offers promise in carefully selected patients with severe pain from pancreatic cancer and other conditions which are not amenable to conventional interventions.

Mimicry between neurokinin-1 and fibronectin may explain the transport and stability of increased substance P immunoreactivity in patients with bone marrow fibrosis

Bone marrow (BM) fibrosis may occur in myeloproliferative diseases, lymphoma, myelodysplastic syndrome, myeloma, and infectious diseases. In this study, the role of substance P (SP), a peptide with pleiotropic functions, was examined. Some of its functions-angiogenesis, fibroblast proliferation, and stimulation of BM progenitors-are amenable to inducing BM fibrosis. Indeed, a significant increase was found in SP-immunoreactivity (SP-IR) in the sera of patients with BM fibrosis (n = 44) compared with the sera of patients with hematologic disorders and no histologic evidence of fibrosis (n = 46) (140 +/-12 vs 18 +/-3; P <.01). Immunoprecipitation of sera SP indicated that this peptide exists in the form of a complex with other molecule(s). It was, therefore, hypothesized that SP might be complexed with NK-1, its natural receptor, or with a molecule homologous to NK-1. To address this, 3 cDNA libraries were screened that were constructed from pooled BM stroma or mononuclear cells with an NK-1 cDNA probe. A partial clone (clone 1) was retrieved that was 97% homologous to the ED-A region of fibronectin (FN). Furthermore, sequence analyses indicated that clone 1 shared significant homology with exon 5 of NK-1. Immunoprecipitation and Western blot analysis indicated co-migration of SP and FN in 27 of 31 patients with BM fibrosis. Computer-assisted molecular modeling suggested that similar secondary structural features between FN and NK-1 and the relative electrostatic charge might explain a complex formed between FN (negative) and SP (positive). This study suggests that SP may be implicated in the pathophysiology of myelofibrosis, though its role would have to be substantiated in future research. (Blood. 2001;97:3025-3031)

The memorial symptom assessment scale short form (MSAS-SF)

BACKGROUND

The Memorial Symptom Assessment Scale Short Form (MSAS-SF), an abbreviated version of the Memorial Symptom Assessment Scale, measures each of 32 symptoms with respect to distress or frequency alone. A physical symptom subscale (PHYS), psychologic symptom subscale (PSYCH), and global distress index (GDI) can be derived from the Short Form. We validated the MSAS-SF in a population of cancer patients.

METHODS

Two hundred ninety-nine cancer patients examined at the Section of Hematology/Oncology completed the MSAS-SF and the Functional Assessment Cancer Therapy (FACT-G). The Karnofsky performance status (KPS), extent of disease (EOD), and demographic data were assessed. The Cronbach alpha coefficient was used to assess internal reliability. MSAS-SF subscales were assessed against subscales of the FACT-G, the KPS, and EOD to determine criterion validity. Test-retest analysis was performed at 1 day and at 1 week.

RESULTS

The Cronbach alpha coefficients for the MSAS-SF subscales ranged from 0.76 to 0.87. The MSAS-SF subscales showed convergent validity with FACT subscales. Correlation coefficients were -0.74 (P < 0.001) for the PHYS and FACT-G physical well-being subscales, -0.68 (P < 0.001) for the PSYCH and FACT emotional well-being subscales, and -0.70 (P < 0.001) for GDI and FACT summary of quality-of-life subscales. The MSAS-SF subscales demonstrated convergent validity with performance status, inpatient status, and extent of disease. The test-retest correlation coefficients for the MSAS-SF subscales ranged from 0.86 to 0.94 at 1 day and from 0.40 to 0.84 for the 1 week group.

CONCLUSIONS

The MSAS-SF is a valid and easy to use instrument for symptom assessment.

The role of physical proximity in nosocomial diarrhea

To examine physical proximity as a risk factor for the nosocomial acquisition of Clostridium difficile-associated diarrhea (CDAD) and of antibiotic-associated diarrhea (AAD), we assessed a retrospective cohort of 2859 patients admitted to a community hospital from 1 March 1987 through 31 August 1987. Of these patients, 68 had nosocomial CDAD and 54 had nosocomial AAD. In multivariate analysis, physical proximity to a patient with CDAD (relative risk [RR], 1.86; 95% confidence interval [CI], 1.06-3.28), exposure to clindamycin (RR, 4.22; 95% CI, 2.11-8.45), and the number of antibiotics taken (RR, 1.49; 95% CI, 1.23-1.81) were significant. For patients with nosocomial AAD, exposure to a roommate with AAD (RR, 3.94; 95% CI, 1. 27-12.24), a stay in an intensive care unit or cardiac care unit (RR, 1.93; 95% CI, 1.05-3.53), and the number of antibiotics taken (RR, 2.01; 95% CI, 1.67-2.40) were significant risk factors. Physical proximity may be an independent risk factor for acquisition of nosocomial CDAD and AAD.

Validation of the Edmonton Symptom Assessment Scale

BACKGROUND

The Edmonton Symptom Assessment Scale (ESAS) is a nine-item patient-rated symptom visual analogue scale developed for use in assessing the symptoms of patients receiving palliative care. The purpose of this study was to validate the ESAS in a different population of patients.

METHODS

In this prospective study, 240 patients with a diagnosis of cancer completed the ESAS, the Memorial Symptom Assessment Scale (MSAS), and the Functional Assessment Cancer Therapy (FACT) survey, and also had their Karnofsky performance status (KPS) assessed. An additional 42 patients participated in a test-retest study.

RESULTS

The ESAS "distress" score correlated most closely with physical symptom subscales in the FACT and the MSAS and with KPS. The ESAS individual item and summary scores showed good internal consistency and correlated appropriately with corresponding measures from the FACT and MSAS instruments. Individual items between the instruments correlated well. Pain ratings in the ESAS, MSAS, and FACT correlated best with the "worst-pain" item of the Brief Pain Inventory (BPI). Test-retest evaluation showed very good correlation at 2 days and a somewhat smaller but significant correlation at 1 week. A 30-mm visual analogue scale cutoff point did not uniformly distinguish severity of symptoms for different symptoms.

CONCLUSIONS

For this population, the ESAS was a valid instrument; test-retest validity was better at 2 days than at 1 week. The ESAS "distress" score tends to reflect physical well-being. The use of a 30-mm cutoff point on visual analogue scales to identify severe symptoms may not always apply to symptoms other than pain.