Patient-reported symptoms before adjuvant locoregional radiotherapy for breast cancer: triple-negative histology impacts the symptom burden

BACKGROUND

Multimodal breast cancer treatment may cause side effects reflected in patient-reported outcomes and/or symptom scores at the time of treatment planning for adjuvant radiotherapy. In our department, all patients have been assessed with the Edmonton Symptom Assessment System (ESAS; a questionnaire addressing 11 major symptoms and wellbeing on a numeric scale of 0-10) at the time of treatment planning since 2016. In this study, we analyzed ESAS symptom severity before locoregional radiotherapy.

PATIENTS AND METHODS

Retrospective review of 132 patients treated between 2016 and 2021 (all comers in breast-conserving or post-mastectomy settings, different radiotherapy fractionations) was performed. All ESAS items and the ESAS point sum were analyzed to identify subgroups with higher symptom burden and thus need for additional care measures.

RESULTS

The biggest patient-reported issues were fatigue, pain, and sleep problems. Patients with triple negative breast cancer reported a higher symptom burden (mean 30 versus 20, p = 0.038). Patients assigned to adjuvant endocrine therapy had the lowest point sum (mean 18), followed by those on Her-2-targeting agents without chemotherapy (mean 19), those on chemotherapy with or without other drugs (mean 26), and those without systemic therapy (mean 41), p = 0.007. Those with pathologic complete response after neoadjuvant treatment had significantly lower anxiety scores (mean 0.7 versus 1.8, p = 0.03) and a trend towards lower depression scores, p = 0.09.

CONCLUSION

Different surgical strategies, age, and body mass index did not impact on ESAS scores, while the type of adjuvant systemic therapy did. The effect of previous neoadjuvant treatment and unfavorable tumor biology (triple negative) emerged as important factors associated with symptom burden, albeit in different domains. ESAS data may facilitate identification of patients who should be considered for additional supportive measures to alleviate specific symptoms.

A comparison of the prevalence of dry mouth and other symptoms using two different versions of the Edmonton Symptom Assessment System on an inpatient palliative care unit

BACKGROUND

Symptom assessment is key to effective symptom management and palliative care for patients with advanced cancer. Symptom prevalence and severity estimates vary widely, possibly dependent on the assessment tool used. Are symptoms specifically asked about or must the patients add them as additional symptoms? This study compared the prevalence and severity of patient-reported symptoms in two different versions of a multi-symptom assessment tool. In one version, three symptoms dry mouth, constipation, sleep problems were among those systematically assessed, while in the other, these symptoms had to be added as an "Other problem".

METHODS

This retrospective cross-sectional study included adult patients with advanced cancer at an inpatient palliative care unit. Data were collected from two versions of the Edmonton Symptom Assessment System (ESAS): modified (ESAS-m) listed 11 symptoms and revised (ESAS-r) listed 9 and allowed patients to add one "Other problem". Seven similar symptoms were listed in both versions.

RESULTS

In 2013, 184 patients completed ESAS-m, and in 2017, 156 completed ESAS-r. Prevalence and severity of symptoms listed in both versions did not differ. In ESAS-m, 83% reported dry mouth, 73% constipation, and 71% sleep problems, but on ESAS-r, these symptoms were reported by only 3%, 15% and < 1%, respectively. Although ESAS-r severity scores for these three symptoms were higher than on ESAS-m, differences did not reach statistical significance.

CONCLUSION

We identified significant differences in patient symptom reporting based on whether symptoms like dry mouth, obstipation and sleep problems were specifically assessed or had to be added by patients as an "Other problem".

Pilot study evaluating feasibility and utility of pharmacist-driven oral antineoplastic agent monitoring program

INTRODUCTION

Oncologists are increasingly prescribing oral antineoplastic agents which have benefits and challenges impacting patient outcomes. Practice guidelines recommend monitoring symptoms and adherence without outlining any specific tools or methods for monitoring. Pharmacists are successful in monitoring patients on therapy and improving outcomes. We aimed to assess the feasibility and utility of a pharmacist-delivered and medical record-integrated adherence and symptom monitoring program for patients on oral antineoplastic agents.

METHODS

This single-center, prospective, interventional study designed and implemented an adherence and monitoring program. A pharmacist contacted patients twice between clinic visits for three months. During telephone encounters, patients were verbally screened for medication adherence and assessed for new or changing symptoms using the Edmonton Symptom Assessment System as a signal of possible adverse events. We measured feasibility via patient enrollment, completed proportion of scheduled contacts, and pharmacist time. Utility was assessed through patient adherence, satisfaction surveys, healthcare resource utilization, and pharmacist interventions (i.e., patient education, adherence assistance, and symptom management).

RESULTS

Fifty-one patients participated. Ninety-one percent of scheduled patient contacts were completed. Edmonton Symptom Assessment System was administered by pharmacy personnel 102 times. Patient-reported adherence was 100%. Overall satisfaction was 85% and 100%, for patients and physicians, respectively. Fifty-one (98%) pharmacist recommendations were accepted. There were 14 total utilizations of healthcare resources-5.2 per 1000 patient days.

CONCLUSIONS

This study suggests a pharmacist monitoring program for patients taking oral antineoplastic agents is feasible and provides utility. Further research is needed to evaluate whether this program improves safety, adherence, and outcomes in patients using oral antineoplastic agents.

Association of Functional Status and Symptom Severity Among Patients Who Received Palliative Care Consultations

Background: The relationship between functional status and the severity of different symptoms in patients with serious illnesses has not been explored in detail. Methods: We retrospectively evaluated registry data of hospitalized patients who received inpatient palliative care consults at the Mount Sinai Health System between January 01, 2020, and December 31, 2022. The registry was approved by the local institutional review board. During the initial consult, palliative care clinicians administered the Australia-modified Karnofsky Performance Status (KPS) and the Edmonton Symptom Assessment System (ESAS). We extracted these measures and other variables of interest from electronic health records and billing data, and assessed the association of functional status and symptom severity for different symptoms using ordinal logistic regression models. Results: The study included 9800 patients who received a palliative care consult. When modeling the association of functional status and the severity of different symptoms, two distinct groups of symptoms emerged: Nausea, physical discomfort, anxiety, depression, and constipation were more prevalent and severe among patients with higher functional status. Conversely, drowsiness, inactivity, dyspnea, anorexia, and agitation were more prevalent and severe among patients with lower functional status. These findings remained statistically significant after adjusting for possible confounders. Conclusion: Among patients who received inpatient palliative care consults, lower functional status was associated with a higher symptom burden. Furthermore, symptom profiles differed between patients with reduced functional status and those with preserved functional status.

A comparison of acute patient-reported outcomes in breast cancer patients with and without regional nodal irradiation using the ESAS and PRFS tool

BACKGROUND AND PURPOSE

Regional nodal irradiation (RNI) is commonly administered in patients with breast cancer with node-positive disease to prevent cancer recurrence. The purpose of this study is to identify whether RNI is associated with greater acute symptom burden from baseline to 1 to 3 months post completion of radiotherapy (RT) when compared to localized RT.

MATERIALS AND METHODS

Patient and treatment characteristics were collected prospectively for breast cancer patients with and without RNI from February 2018 to September 2020. The Edmonton Symptom Assessment System (ESAS) and Patient-Reported Functional Status (PRFS) tool were completed by patients at baseline, weekly during RT, and at a 1- to 3-month follow-up visit. The Wilcoxon rank-sum or Fisher exact tests were used to compare variables between patients with or without RNI.

RESULTS

A total of 781 patients were included in the analysis. Baseline symptom reporting was similar between cohorts, with the exception of PRFS scores (p = 0.0023), which were worse in patients receiving RNI. Across all time points, differences in outcomes between cohorts were minimal, except for lack of appetite (p = 0.03) and PRFS scores (p = 0.049), which were significantly aggravated in patients treated with RNI.

CONCLUSION

There is insufficient evidence to suggest that RNI is associated with greater symptom burden as assessed with the ESAS. Further research should be conducted over a longer time period to determine the impact of late effects of RNI on patient-reported symptoms.

Province-Wide Analysis of Patient-Reported Outcomes for Stage IV Non-Small Cell Lung Cancer

BACKGROUND

In Ontario, Canada, patient-reported outcome (PRO) evaluation through the Edmonton Symptom Assessment System (ESAS) has been integrated into clinical workflow since 2007. As stage IV non-small cell lung cancer (NSCLC) is associated with substantial disease and treatment-related morbidity, this province-wide study investigated moderate to severe symptom burden in this population.

MATERIALS AND METHODS

ESAS collected from patients with stage IV NSCLC diagnosed between 2007 and 2018 linked to the Ontario provincial health care system database were studied. ESAS acquired within 12 months following diagnosis were analyzed and the proportion reporting moderate to severe scores (ESAS ≥4) in each domain was calculated. Predictors of moderate to severe scores were identified using multivariable Poisson regression models with robust error variance.

RESULTS

Of 22,799 patients, 13,289 (58.3%) completed ESAS (84,373 assessments) in the year following diagnosis. Patients with older age, with high comorbidity, and not receiving active cancer therapy had lower ESAS completion. The majority (94.4%) reported at least one moderate to severe symptom. The most prevalent were tiredness (84.1%), low well-being (80.7%), low appetite (71.7%), and shortness of breath (67.8%). Most symptoms peaked at diagnosis and, while declining, remained high in the following year. On multivariable analyses, comorbidity, low income, nonimmigrants, and urban residency were associated with moderate to severe symptoms. Moderate to severe scores in all ESAS domains aside from anxiety were associated with radiotherapy within 2 weeks prior, whereas drowsiness, low appetite and well-being, nausea, and tiredness were associated with systemic therapy within 2 weeks prior.

CONCLUSION

This province-wide PRO analysis showed moderate to severe symptoms were prevalent and persistent among patients with metastatic NSCLC, underscoring the need to address supportive measures in this population especially around treatments.

IMPLICATIONS FOR PRACTICE

In this largest study of lung cancer patient-reported outcomes (PROs), stage IV non-small cell lung cancer patients had worse moderate-to-severe symptoms than other metastatic malignancies such as breast or gastrointestinal cancers when assessed with similar methodology. Prevalence of moderate-to-severe symptoms peaked early and remained high during the first year of follow-up. Symptom burden was associated with recent radiation and systemic treatments. Early and sustained PRO collection is important to detect actionable symptom progression, especially around treatments. Vulnerable patients (e.g., older, high comorbidity) who face barriers in attending in-person clinic visits had lower PRO completion. Virtual PRO collection may improve completion.

Dyspnea on Exercise Is Associated with Overall Symptom Burden in Patients with Chronic Respiratory Insufficiency

Background: Patients with chronic respiratory insufficiency suffer from many symptoms together with dyspnea.

Objective: We evaluated the association of dyspnea on exercise with other symptoms in patients with chronic respiratory insufficiency due to chronic obstructive pulmonary disease or interstitial lung disease.

Design: This retrospective study included 101 patients in Tampere University Hospital, Finland. Dyspnea on exercise was assessed with modified Medical Research Council (mMRC) dyspnea questionnaire, and other symptoms were assessed with Edmonton Symptom Assessment System (ESAS) and Depression Scale (DEPS). The study was approved by Regional Ethics Committee of Tampere University Hospital, Finland (approval code R15180/December 1, 2015).

Results: Patients with mMRC 4 (most severe dyspnea) compared with those with mMRC 0–3 reported higher symptom scores on ESAS in shortness of breath (median 8.0 [IQR 6.0–9.0] vs. 4.0 [2.0–6.0], p < 0.001), dry mouth (7.0 [4.0–8.0] vs. 3.0 [1.0–6.0], p < 0.001), tiredness (6.0 [3.0–7.0] vs. 3.0 [1.0–5.0], p < 0.001), loss of appetite (3.0 [0.0–6.0] vs. 1.0 [0.0–3.0], p = 0.001), insomnia (3.0 [1.0–7.0] vs. 2.0 [0.0–3.0], p = 0.027), anxiety (3.0 [0.0–5.5] vs. 1.0 [0.0–3.0], p = 0.007), and nausea (0.0 [0.0–2.0] vs. 0.0 [0.0–0.3], p = 0.027). Patients with mMRC 4 were more likely to reach the DEPS threshold for depression than those scoring mMRC 0–3 (42.1% vs. 20.8%, p = 0.028).

Conclusions: Patients with chronic respiratory insufficiency need comprehensive symptom screening with relevant treatment, as they suffer from broad symptom burden worsening with increased dyspnea on exercise.

Artificial neural networks for simultaneously predicting the risk of multiple co-occurring symptoms among patients with cancer

Patients with cancer often exhibit multiple co-occurring symptoms which can impact the type of treatment received, recovery, and long-term health. We aim to simultaneously predict the risk of three symptoms: severe pain, moderate-severe depression, and poor well-being in order to flag patients who may benefit from pre-emptive early symptom management. This was a retrospective population-based cohort study of adults diagnosed with cancer between 2008 and 2015. We developed and tested an Artificial Neural Network (ANN) model to predict the risk of multiple co-occurring symptoms within 6 months after diagnosis. The ANN model derived from a training cohort was assessed on an independent test cohort for model performance based on sensitivity, specificity, accuracy, AUC, and calibration. The mutually exclusive training and test cohorts consisted of 35,606 and 10,498 patients, respectively. The area under the curve for the risk of experiencing severe pain, moderate-severe depression, and poor well-being were 71%, 73%, and 70%, respectively. Patient characteristics at highest risk of simultaneously experiencing these three symptoms included: those with lung cancer, late stage cancer, existing chronic conditions such as osteoarthritis, mood disorder, hypertension, diabetes, and coronary disease. Patients with over a 40% risk of severe pain also had over a 70% risk of depression, and over a 55% risk of poor well-being. Our ANN model was able to simultaneously predict the risk of pain, depression, and lack of well-being. Accurate prediction of future symptom burden can serve as an early indicator tool so that providers can implement timely interventions for symptom management, ultimately improving cancer care and quality of life.

Pre-screening of patient-reported symptoms using the Edmonton Symptom Assessment System in outpatient palliative cancer care

OBJECTIVES

Although early palliative care is associated with a better quality of life and improved outcomes in end-of-life cancer care, the criteria of palliative care referral are still elusive.

METHODS

We collected patient-reported symptoms using the Edmonton Symptom Assessment System (ESAS) at the baseline, first and second follow-up visits. A total of 71 patients were evaluable, with a median age of 65 years, male (62%) and Eastern Cooperative Oncology Group (ECOG) performance status distribution of 1/2/3 (28%/39%/33%) respectively.

RESULTS

Twenty (28%) patients had moderate/severe symptom burden with the mean ESAS ≥ 5. Interestingly, most of the patients with moderate/severe symptom burdens (ESAS ≥ 5) had globally elevated symptom expression. While the mean ESAS score was maintained in patients with mild symptom burden (ESAS < 5; 2.7 at the baseline; 3.4 at the first follow-up; 3.0 at the second follow-up; p = .117), there was significant symptom improvement in patients with moderate/severe symptom burden (ESAS ≥ 5; 6.5 at the baseline; 4.5 at the first follow-up; 3.6 at the second follow-up; p < .001).

CONCLUSIONS

In conclusion, advanced cancer patients with ESAS ≥ 5 may benefit from outpatient palliative cancer care. Pre-screening of patient-reported symptoms using ESAS can be useful for identifying unmet palliative care needs in advanced cancer patients.

Patient-reported symptoms following diagnosis in esophagus cancer patients treated with palliative intent

The majority of patients with esophagus cancer have advanced-stage disease without curative options. For these patients, treatment is focused on improving symptoms and quality of life. Despite this, little work has been done to quantify symptom burden for incurable patients. We describe symptoms using the Edmonton Symptom Assessment System (ESAS) among esophagus cancer patients treated for incurable disease. This retrospective cohort study linked administrative datasets to prospectively collected ESAS data of non-curatively treated adult esophagus cancer patients diagnosed between January 1, 2009 and September 30, 2016. ESAS measures nine common cancer-related symptoms: anxiety, depression, drowsiness, lack of appetite, nausea, pain, shortness of breath, tiredness, and impaired well-being. Frequency of severe symptoms (score ≥ 7/10) was described by month for the 6 months from diagnosis for all patients and by treatment type (chemotherapy alone, radiotherapy alone, both chemotherapy and radiotherapy, and best supportive care). A sensitivity analysis limited to patients who survived at least 6 months was performed to assess robustness of the results to proximity to death and resulting variation in follow-up time. Among 2,989 esophagus cancer patients diagnosed during the study period and meeting inclusion criteria, 2,103 reported at least one ESAS assessment in the 6 months following diagnosis and comprised the final cohort. Patients reported a median of three (IQR 2-7) ESAS assessments in the study period. Median survival was 7.6 (IQR 4.1-13.7) months. Severe lack of appetite (53.1%), tiredness (51.1%), and impaired well-being (42.7%) were the most commonly reported symptoms. Severe symptoms persisted throughout the 6 months after the diagnosis. Subgroup analysis by treatment showed no worsening of symptoms over time in those treated by either chemotherapy alone, or both chemotherapy and radiation. Results followed a similar pattern on sensitivity analysis. Patients diagnosed with incurable esophagus cancer experience considerable symptom burden in the first 6 months after diagnosis and the frequency of severe symptoms remains high throughout this period. Patients with this disease require early palliative care and psychosocial support upon diagnosis and support throughout the course of their cancer journey.

Psychological distress associated with active surveillance in patients younger than 70 with a small renal mass

PURPOSE

To compare the psychological distress throughout several predefined disease time points in patients younger than 70 with small renal masses (SRMs) treated with either active surveillance (AS) or ablative/surgical therapy.

METHODS

Using the Edmonton Symptom Assessment System - revised (ESAS-r) questionnaire, we focused on psychological distress symptoms in all consecutive patients with an SRM between 2014 and 2017. We further evaluated the psychological distress sub-score (PDSS) of ESAS-r, consisting of the sum scores of anxiety, depression, and well-being. PDSS of patients treated with AS or ablation/surgery were compared at 4 distinct time points (before and after diagnosis, after a biopsy is performed, and at last follow-up). Multivariable linear regression models were performed to assess factors associated with worse PDSS (1-point score increase).

RESULTS

We examined 477 patients, of whom 217 and 260 were treated with AS and surgery/ablation, respectively. Similar ESAS-r and PDSS scores were shown at all predefined disease time points except following an SRM biopsy and at last, follow-up, where AS-treated patients with a biopsy-proven malignancy had significantly worse PDSS (11.4 vs. 6.1, P = 0.035), and (13.2 vs. 5.4, P = 0.004), respectively. At last follow-up, multivariable linear models demonstrated that a biopsy-proven malignancy (B = 2.630, 95% CI 0.024-5.236, P = 0.048) and AS strategy (B = 6.499, 95% CI 2.340-10.658, P = 0.002) were associated with worse PDSS in all patients, and in those who underwent a biopsy, respectively.

CONCLUSIONS

Offering standardized psychological supportive care may be required for patients younger than 70 years on AS for SRM, especially for those with a biopsy-proven tumor.

Patient-Reported Symptom Severity Among 22,650 Cancer Outpatients in the Last Six Months of Life

CONTEXT

Understanding the magnitude and risk factors for symptom burden of patients with cancer at the end of life is critical to guiding effective patient- and system-level interventions.

OBJECTIVES

We aimed to estimate the prevalence of severe patient-reported symptoms among cancer outpatients during the six months before death and to identify patient groups at a higher risk for reporting severe symptoms.

METHODS

This was a retrospective cohort study of cancer decedents at regional cancer centers from 2010 to 2016. Patient-reported Edmonton Symptom Assessment System (ESAS) scores from the last six months of life were linked to administrative databases. The proportion of patients reporting severe symptom scores (≥7) for anxiety, depression, drowsiness, lack of appetite, nausea, pain, shortness of breath, tiredness, and overall well-being during the six months before death was described. Multivariable modified Poisson regression analyses were used to identify risk factors for reporting severe symptom scores.

RESULTS

Of 39,084 cancer decedents, 22,650 had one or more symptom assessments recorded in the last six months of life, resulting in 92,757 ESAS assessments. Severe scores were highest for tiredness (56%), lack of appetite (46%), and impaired well-being (45%). The proportion of patients reporting severe symptom scores was stable before progressively increasing at three months before death. Elderly, women, patients with high comorbidity, immigrants, and living in urban areas or with high material deprivation were at increased risk of reporting severe scores.

CONCLUSIONS

Despite an integrated symptom screening program, rates of severe patient-reported symptom scores before death were high for outpatients with cancer. Patient subgroups at increased risk of severe symptom burden may benefit from targeted interventions. Ongoing review of routinely collected symptom data may be used to assess the supportive care needs and guide targeted interventions at the health-system level.

Gender-based psychological and physical distress differences in patients diagnosed with non-metastatic renal cell carcinoma

OBJECTIVES

To analyze gender-based differences in distress symptoms in patients with non-metastatic renal cell carcinoma (RCC) at different stages of disease.

METHODS

The Edmonton Symptom Assessment System-revised (ESAS-r) questionnaire includes a physical (PHSDSS) and a psychological distress sub-score (PDSS). The ESAS-r was used to measure psychological and physical distress symptoms in localized RCC patients in a major cancer referral center between 2014 and 2017 at four predefined time points: (a) diagnosis, (b) biopsy, (c) surgery, and (d) last follow-up. Results were gender stratified, and multivariable linear regression models were used to determine associations with increased sub-scores.

RESULTS

Overall, 495 patients were included with 37.2% females. No significant gender differences were seen in mean age, relevant clinical parameters, and treatment. PDSS was significantly higher in females after diagnosis (8.5 vs. 5.1, p = 0.018), biopsy (8.9 vs. 4.1, p = 0.003), and surgery (6.5 vs. 4.4, p = 0.007), while being similar at the last follow-up. The multivariable model demonstrated a statistically significant association of female gender with higher PDSS after diagnosis (B = 3.755, 95% CI 0.761-6.750), biopsy (B = 6.076, 95% CI 2.701-9.451), and surgery (B = 1.974, 95% CI 0.406-3.542). PHSDSS was significantly higher in females after biopsy (10.0 vs. 5.7, p = 0.028) and surgery (8.6 vs. 6.1, p = 0.022). In the multivariable model, female gender conferred a higher PHSDSS only after surgery (B = 2.384, 95% CI 0.208-4.560).

CONCLUSIONS

Gender-associated psychological distress differences exist in non-metastatic RCC patients throughout treatment, while dissipating at last follow-up. Emphasis should be placed on screening for distress symptoms and providing psychological support continuously, particularly for female patients.

Outpatient acupuncture effects on patient self-reported symptoms in oncology care: a retrospective analysis

Background: Increased access to complementary therapies such as acupuncture at academic medical centers has created new opportunities for management of cancer and cancer treatment related symptoms.

Methods: Patients presenting for acupuncture treatment during calendar year 2016 at an outpatient integrative medicine clinic in a comprehensive cancer center were asked to complete a modified Edmonton Symptom Assessment Scale (ESAS; 16 symptoms, score 0-10, 10 worst possible) before and after each visit. ESAS subscales analyzed included global (GDS; score 0-90), physical (PHS, 0-60) and psychological distress (PSS, 0-20). ESAS symptom score change pre/post acupuncture treatment & from baseline visit to first follow up were evaluated by paired t-test.

Results: Of 375 participants [mean age 55.6, 68.3% female, 73.9% white, most common cancer diagnosis of breast (32.8%) and thoracic/head & neck (25.9%)], 73.3% had at least one follow up acupuncture treatment [mean 4.6 (SD 5.1) treatments]. Highest/worst symptoms at baseline were poor sleep (3.92), fatigue (3.43), well-being (3.31), and pain (3.29). Statistically significant reduction/improvement (pre/post) was observed for all ESAS symptoms and subscales for the initial acupuncture treatment (p <0.001). Hot flashes had the highest mean reduction (-1.93), followed by fatigue (-1.72), numbness/tingling (-1.70), and nausea (-1.67). Clinically significant reductions were also observed for ESAS subscales of GDS (-12.2), PHS (-8.5), and PSS (-2.6). For symptom change from initial acupuncture treatment to first follow up (pre/pre), statistically and clinically significant improvement was observed for spiritual pain (-1.10; p<0.001) and ESAS subscale of GDS (-6.09; p=0.048). Clinical response rates (reduction ≥1) on follow up were highest for symptoms of spiritual pain (58.9%), dry mouth (57.8%) and nausea (57.3%).

Conclusions: Outpatient acupuncture was associated with immediate & longitudinal significant improvement across a range of symptoms commonly experienced by individuals during cancer care. Further research is needed to better understand frequency of treatments needed in clinical practice to help maintain benefit.

Group Yoga Effects on Cancer Patient and Caregiver Symptom Distress: Assessment of Self-reported Symptoms at a Comprehensive Cancer Center

Background. Complementary and integrative health approaches such as yoga provide support for psychosocial health. We explored the effects of group-based yoga classes offered through an integrative medicine center at a comprehensive cancer center. Methods. Patients and caregivers had access to two yoga group classes: a lower intensity (YLow) or higher intensity (YHigh) class. Participants completed the Edmonton Symptom Assessment System (ESAS; scale 0-10, 10 most severe) immediately before and after the class. ESAS subscales analyzed included global (GDS; score 0-90), physical (PHS; 0-60), and psychological distress (PSS; 0-20). Data were analyzed examining pre-yoga and post-yoga symptom scores using paired t-tests and between types of classes using ANOVAs. Results. From July 18, 2016, to August 8, 2017, 282 unique participants (205 patients, 77 caregivers; 85% female; ages 20-79 years) attended one or more yoga groups (mean 2.3). For all participants, we observed clinically significant reduction/improvement in GDS, PHS, and PSS scores and in symptoms (ESAS decrease ≥1; means) of anxiety, fatigue, well-being, depression, appetite, drowsiness, and sleep. Clinically significant improvement for both patients and caregivers was observed for anxiety, depression, fatigue, well-being, and all ESAS subscales. Comparing yoga groups, YLow contributed to greater improvement in sleep versus YHigh (−1.33 vs −0.50, P = .054). Improvement in fatigue for YLow was the greatest mean change (YLow −2.12). Conclusion. A single yoga group class resulted in clinically meaningful improvement of multiple self-reported symptoms. Further research is needed to better understand how yoga class content, intensity, and duration can affect outcomes.

Baseline Edmonton Symptom Assessment System and survival in metastatic renal cell carcinoma

Background

Baseline symptom burden as measured using the Edmonton Symptom Assessment System (esas), a patient-reported, validated, and reliable tool measuring symptom severity in 9 separate domains, might yield prognostic information in patients receiving treatment for metastatic renal cell carcinoma (mrcc) and might add to the existing prognostic models.

Methods

In this retrospective single-centre cohort study, we included patients receiving first-line sunitinib therapy for mrcc between 2008 and 2012. Baseline variables included information relevant to the pre-existing prognostic models and pre-treatment esas summation scores (added together across all 9 domains), with higher scores representing greater symptom burden. We used Kaplan-Meier curves and Cox regression modelling to determine if symptom burden can provide prognostic information with respect to overall survival.

Results

We identified 68 patients receiving first-line therapy for mrcc. Most had intermediate- or poor-risk disease based on both the Memorial Sloan Kettering Cancer Center (mskcc) and the International Metastatic Renal Cell Carcinoma Database Consortium (imdc) models. The median baseline esas summation score was 16 (range: 6-57). In univariable analysis, the hazard ratio for overall survival was 1.270 (p = 0.0047) per 10-unit increase in summation esas. In multivariable analysis, the hazard ratio was 1.208 (p = 0.0362) when controlling for mskcc risk group and 1.240 (p = 0.019) when controlling for imdc risk group.

Conclusions

Baseline symptom burden as measured by esas score appears to provide prognostic information for survival in patients with mrcc. Those results should encourage the investigation of patient-reported symptom scales as potential prognostic indicators for patients with advanced cancer.

Couples' symptom burden in oncology care: perception of self and the other

BACKGROUND

The literature suggests that psychological distress and quality of life are interdependent in couples coping with cancer. The current study seeks to extend these findings to physical symptom burden, examining differences in symptom self-rating and perception of partner symptoms.

METHODS

Couples were approached while waiting for an integrative oncology service. Fifty patients and their partners completed the Edmonton Symptom Assessment Scale (ESAS-FS; twelve symptoms, scores 0-10, 10 worst possible) and a Global Health measure (PROMIS10). Patient and partner each also completed the ESAS-FS as it related to their perception of the other's symptoms. ESAS distress subscales analyzed included Global (GDS), Psychosocial (PSS), and Physical (PHS). Analyses included paired t tests to examine all measures.

RESULTS

Fifty-eight percent of patients were female with most common cancer diagnoses of breast (22%), gastrointestinal (16%), and thoracic/H&N (16%). For ESAS-FS self-ratings, patients had significantly higher physical distress than partners, with a no significant difference in psychosocial distress. For PROMIS10 self-ratings, patients reported significantly lower global health and physical health, (p's < 0.001); no differences were found for mental health between patients and caregivers. Patient rating of partner physical distress (PHS, p = 0.01) was significantly higher than partner self-rating, with no significant difference observed in ratings for psychosocial distress. Partner rating of patient psychosocial distress (PSS, p < 0.001) and physical distress (PHS, p = 0.001) was significantly higher than that of patient self-rating.

CONCLUSIONS

Our findings suggest that both patients and partners perceive physical distress of the other higher than self; however, patients may be more sensitive to psychosocial distress in their partners.

The impact of automated screening with Edmonton Symptom Assessment System (ESAS) on health-related quality of life, supportive care needs, and patient satisfaction with care in 268 ambulatory cancer patients

PURPOSE

We aimed to assess the impact of implementing Edmonton Symptom Assessment System (ESAS) screening on health-related quality of life (HRQoL) and patient satisfaction with care (PSC) in ambulatory oncology patients. ESAS is now a standard of care in Ontario cancer centers, with the goal of improving symptom management in cancer patients, yet few studies examine impact of ESAS on patient outcomes.

METHODS

We compared ambulatory oncology patients who were not screened prior to ESAS site implementation (2011-2012), to a similar group who were screened using ESAS after site implementation (2012-2013), to examine between-group differences in patient HRQoL, PSC outcomes, and supportive care needs (Supportive Care Service Survey). Both no-ESAS (n = 160) and ESAS (n = 108) groups completed these measures: the latter completing them, along with ESAS, at baseline and 2 weeks later.

RESULTS

After assessing the impact of implementing ESAS, by matching for potentially confounding variables and conducting univariate analyses, no significant between-group differences were found in HRQoL or PSC. There was significant improvement in symptoms of nausea/vomiting and constipation, after 2 weeks. Lower symptom burden with decreased ESAS scores was significantly correlated with increased HRQoL. There were no between-group differences in knowledge of/access to supportive care.

CONCLUSIONS

Significant correlation between change in ESAS and HRQoL implies ESAS could usefully inform healthcare providers about need to respond to changes in symptom and functioning between visits. This study showed no impact of early-ESAS screening on HRQoL or PSC. Further research should explore how to better utilize ESAS screening, to improve communication, symptom management, and HRQoL.

The Optimal Cutoff Point for Expressing Revised Edmonton Symptom Assessment System Scores as Binary Data Indicating the Presence or Absence of Symptoms

CONTEXT

Terminally ill patients with cancer experience various physical and emotional symptoms that have a negative impact on quality of life and activities of daily living. Recently, revised Edmonton Symptom Assessment System (ESAS-r) scores have been proposed for assessing symptoms in terminally ill patients with cancer.

OBJECTIVE

To determine the optimal cutoff point for expressing ESAS-r scores as binary data, indicating the presence or absence of symptoms.

METHODS

We conducted a retrospective study of patients hospitalized in the palliative care unit of our hospital between September 1, 2014 and May 31, 2015. To determine the optimal cutoff point for expressing ESAS-r scores as binary data, indicating the presence or absence of 6 physical symptoms ("pain," "tiredness," "drowsiness," "nausea," "lack of appetite," and "dyspnea"), the sensitivity and specificity of each measurement were calculated. Cutoff points were estimated using receiver operating characteristic curve analysis.

RESULTS

Data from 157 patients who performed the self-assessment in ESAS-r scores were analyzed. The mean age was 66.5 years. Approximately 60.0% of patients were male. The optimal cutoff point for pain, tiredness, drowsiness, nausea, lack of appetite, and dyspnea was 4, 4, 4, 2, 5, and 4, respectively. The area under the curve for tiredness, nausea, and dyspnea was >0.70, followed in order by pain, lack of appetite, and drowsiness. The area under the curve for drowsiness was 0.55.

CONCLUSION

Our results suggest that physical symptoms other than drowsiness could potentially predict ESAS-r score severity.

The effects of oncology massage on symptom self-report for cancer patients and their caregivers

BACKGROUND

Massage has shown benefit for symptomatic relief in cancer patients and their caregivers. We explored the effects of a single massage session on self-reported symptoms in an outpatient clinic at a comprehensive cancer center.

METHODS

Patients and caregivers receiving oncology massage treatments (30 or 60-min duration) at our Integrative Medicine Center outpatient clinic from September 2012 to January 2015 completed the Edmonton Symptom Assessment Scale (ESAS; 0-10 scale, 10 most severe) pre and post massage. ESAS individual items and subscales of physical distress (PHS), psychological distress (PSS), and global distress (GDS) were analyzed. We used paired t tests with a p value correction (i.e., p < .001) to examine symptoms pre/post massage.

RESULTS

Initial massage visits for 343 patients and 87 caregivers were analyzed. The highest symptom burdens (means) at baseline for patients were sleep 4.22, fatigue 3.57, and pain 2.94; for caregivers, sleep 3.77, well-being 3.01, and pain 2.59. Although patients reported significantly greater global distress and physical symptoms (p < .0001) compared to caregivers at baseline, groups did not differ in regard to psychological symptom burden (p = .66) and individual symptom scores (e.g., pain, sleep, spiritual pain). Massage therapy was associated with statistically (p < .0001) and clinically significant improvements in symptoms of pain, fatigue, anxiety, well-being, and sleep and ESAS subscales for both patients and caregivers. Greater massage duration (30 vs 60 min) did not lead to greater symptom reduction.

CONCLUSIONS

Patients and caregivers reported a moderately high symptom burden. A single massage treatment resulted in acute relief of self-reported symptoms in both groups. Further study is warranted regarding optimal massage dose and frequency.

Integrative Oncology Outpatient Consultations: Long-Term Effects on Patient-Reported Symptoms and Quality of Life

Background: Integrative oncology (IO) seeks to bring non-conventional approaches into conventional oncology care in an evidence-based, coordinated manner. Little is known about the effects of such consultations on patient-reported symptoms.

Methods: We reviewed data from patients referred for an IO outpatient consultation between 2009 and 2013, comparing the cohort of patients with at least one follow-up to the cohort with an initial consultation only. Assessments completed at initial and follow-up encounters included: complementary and alternative medicine (CAM) use questionnaire, Measure Yourself Concerns and Wellbeing (MYCaW), Edmonton Symptom Assessment Scale (ESAS; 10 symptoms, scale 0-10, 10 worst), and post-consultation satisfaction. ESAS individual items and global (GDS; score 0-90), physical (PHS, 0-60) and psychological (PSS, 0-20) distress scales were analyzed.

Results: 642 patients out of 2,474 (26%) new patient IO consultations had at least one follow-up encounter (mean 3.2; SD 1.8). Age, place of residence, and higher satisfaction were predictors of follow-up. Statistically significant improvement in symptoms between initial consult and follow-up were observed for depression, anxiety, well-being, and subscales of GDS and PSS (all p's > 0.01). For those with moderate to severe symptoms at their initial consult (ESAS scores ≥ 4), we observed clinical response rates (improvement) of 49-75% for all ESAS symptoms at follow-up.

Conclusions: Patients presenting for IO follow-up had overall mild to moderate symptoms at baseline and stable symptom burden over time. Greatest improvements were observed for psychosocial symptoms, most pronounced for the subset of patients with moderate to severe symptoms at their initial consultation.

Cancer Care Professionals' Attitudes Toward Systematic Standardized Symptom Assessment and the Edmonton Symptom Assessment System After Large-Scale Population-Based Implementation in Ontario, Canada

CONTEXT

Cancer patients experience a high symptom burden throughout their illness. Despite this, patients' symptoms and needs are often not adequately screened for, assessed, and managed.

OBJECTIVES

This study investigated the attitudes of cancer care professionals toward standardized systematic symptom assessment and the Edmonton Symptom Assessment System (ESAS) and their self-reported use of the instrument in daily practice in a large healthcare jurisdiction where this is routine.

METHODS

A 21-item electronic survey, eliciting both closed and open-ended anonymous responses, was distributed to all 2806 cancer care professionals from four major provider groups: physicians, nurses, radiotherapists, and psychosocial oncology (PSO) staff at the 14 Regional Cancer Centres across Ontario, Canada.

RESULTS

A total of 1065 questionnaires were returned (response rate: 38%); 960 were eligible for analysis. Most respondents (88%) considered symptom management to be within their scope of practice. Sixty-six percent of physicians considered the use of standardized tools to screen for symptoms as "best practice," compared to 81% and 93% of nurses and PSO staff, respectively. Sixty-seven percent of physicians and 85% of nurses found the ESAS to be a useful starting point to assess patients' symptoms. Seventy-nine percent of physicians looked at their patient's ESAS scores at visits either "always" or "often," compared to 29%, 66%, and 89% of radiotherapists, PSO staff, and nurses, respectively. Several areas for improvement of ESAS use and symptom screening were identified.

CONCLUSION

Findings show significant albeit variable uptake across disciplines in the use of the ESAS since program initiation. Several barriers to using the ESAS in daily practice were identified. These need to be addressed.

Using Markov Multistate Models to Examine the Progression of Symptom Severity Among an Ambulatory Population of Cancer Patients: Are Certain Symptoms Better Managed Than Others?

CONTEXT

Patient-reported assessments of symptom severity can assist providers in monitoring and managing symptoms for cancer patients, which is important for offering patients optimal cancer care. Understanding which symptoms deteriorate at a faster rate over time can help identify areas for improving symptom management.

OBJECTIVES

This article aimed to longitudinally examine the transitions in symptom severity over time and determine which symptoms deteriorate most rapidly.

METHODS

This was an Ontario-wide cohort study from 2007 to 2011 of adult outpatients diagnosed with cancer. During every symptom assessment at the cancer center, patients reported their level of severity for each of nine symptoms. A Markov multistate model under an intermittent observation scheme was implemented to examine the progression of symptom severity over time among cancer patients.

RESULTS

This study included 55,883 patients with over 280,000 symptom assessments. The median time between assessments was 29 days, and the majority of patients had at least three assessments. The symptoms deteriorating most rapidly over time were fatigue and well-being, whereas the symptom deteriorating least rapidly over time was nausea.

CONCLUSION

The availability of numerous medications for treating nausea, compared to fatigue and well-being, may be a reasonable explanation for our findings. Alternate management for these symptoms, such as exercise for reducing fatigue, should be investigated to improve patients' quality of life. The use of multistate modeling methods is also unique in the study of symptom progression and provides a more in-depth understanding of the likelihood of symptom deterioration and improvement over time.

Establishing Cutoff Points for Defining Symptom Severity Using the Edmonton Symptom Assessment System-Revised Japanese Version

CONTEXT

Symptom screening is important for appropriate symptom management. It remains uncertain as to which scores on the Edmonton Symptom Assessment System-Revised (ESAS-r) comprise the optimal cutoff points to determine symptom severity for Japanese cancer patients.

OBJECTIVES

To investigate optimal cutoff points for individual ESAS-r items for detecting symptom severity and to evaluate the screening performance of the ESAS-r depression item in Japanese cancer patients.

METHODS

We recruited cancer patients receiving palliative care from five tertiary acute hospitals in Japan. We asked participants to complete the ESAS-r Japanese version, Verbal Rating Symptom Severity Scale, and Quick Inventory of Depressive Symptomatology-Self-Report Japanese version. We calculated sensitivity and specificity for detecting severe and moderate/severe symptoms evaluated by the Verbal Rating Symptom Severity Scale at different cutoff points of the ESAS-r. We also calculated sensitivity and specificity for detecting both the presence of depression and moderate/severe depression evaluated by the Quick Inventory of Depressive Symptomatology-Self-Report at various cutoff points for the depression item of the ESAS-r Japanese version.

RESULTS

A total of 292 participants completed the questionnaire. For most of the ESAS-r symptoms, cutoff points to achieve the best balance between sensitivity and specificity were 5-7 for determining severe intensity and 3-4 for determining moderate/severe intensity. For the ESAS-r depression item, a cutoff point of 2 achieved the best balance between sensitivity and specificity for detecting both the presence of depression and moderate/severe depression.

CONCLUSION

The ESAS-r Japanese version can accurately represent the severity of many symptoms. The cutoff points established for determining the level of symptom severity using ESAS-r provides a guide for symptom management in Japanese cancer patients.

Validation of the Japanese Version of the Edmonton Symptom Assessment System-Revised

CONTEXT

The Edmonton Symptom Assessment System-revised (ESAS-r) is a brief and widely used symptom measurement tool.

OBJECTIVES

To validate the Japanese version of the ESAS-r in Japanese patients with cancer.

METHODS

We assessed the internal consistency, test-retest reliability, concurrent validity, and known-group validity in 292 Japanese adult patients with cancer. They completed Japanese versions of the ESAS-r, M. D. Anderson Symptom Inventory, and European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30.

RESULTS

Cronbach's alpha coefficient of the Japanese version of the ESAS-r was 0.87. The intraclass correlation coefficient in the test-retest examination ranged from 0.82 to 0.91 for each symptom score and was 0.90 for the total score. Pearson correlation coefficients of each ESAS-r symptom score with corresponding M. D. Anderson Symptom Inventory and European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 items ranged from 0.45 to 0.80. The total score of the ESAS-r was significantly higher in patients with an Eastern Cooperative Oncology Group performance status of 2-4 than in those with a performance status of 0 and 1 (P < 0.0001).

CONCLUSION

The Japanese version of the ESAS-r is a reliable and valid tool for measuring symptoms in Japanese adult patients with cancer.

Modified Edmonton Symptom Assessment System including constipation and sleep: validation in outpatients with cancer

CONTEXT

The Edmonton Symptom Assessment System (ESAS) measures the severity of nine symptoms. Constipation and sleep disturbance are common in patients with cancer, but are not currently included in the ESAS.

OBJECTIVES

To validate the numerical rating scale (NRS) versions of ESAS and its revised version (ESAS-r), with the additional symptoms of constipation and sleep (CS), and to assess patient preference for either version.

METHODS

Outpatients with advanced cancer (N = 202) completed three assessments during a single clinic visit: ESAS-CS, and an added time window of "past 24 hours"; ESAS-r-CS, with a time window of "now" and symptom definitions; and the Memorial Symptom Assessment Scale (MSAS). Internal consistency was calculated using Cronbach's alpha. Paired t-tests compared ESAS-CS and ESAS-r-CS scores; these were correlated with MSAS using Spearman correlation coefficients. Test-retest reliability at 24 hours was assessed in 26 patients.

RESULTS

ESAS-CS and ESAS-r-CS total scores correlated well with total MSAS (Spearman's rho 0.62 and 0.64, respectively). Correlation of individual symptoms with MSAS symptoms ranged from 0.54-0.80 for ESAS-CS and 0.52-0.74 for ESAS-r-CS. Although participants preferred the ESAS-r-CS format (42.8% vs. 18.6%) because of greater clarity and understandability, the "past 24 hours" time window (52.8%) was favored over "now" (21.3%). Shortness of breath and nausea correlated better for the "past 24 hours" time window (0.8 and 0.72 vs. 0.74 and 0.64 in ESAS-r-CS, respectively). The 24-hour test-retest of the ESAS-CS demonstrated acceptable reliability (intraclass correlation coefficient = 0.69).

CONCLUSION

The ESAS-CS and ESAS-r-CS NRS versions are valid and reliable for measuring symptoms in this population of outpatients with advanced cancer. Although the ESAS-r-CS was preferred, patients favored the 24-hour time window of the ESAS-CS, which also may best characterize fluctuating symptoms.

Understanding and Addressing the Informational Needs of Radiation Therapists Concerning the Management of Anxiety and Depression in Patients Receiving Radiation Therapy Treatment

PURPOSE

Cancer Care Ontario has mandated that all health care professionals working within oncology centres in Ontario should routinely screen and address symptoms of anxiety and depression in cancer patients. This study aims to assess the informational needs of radiation therapists (RTs) concerning the discussion and management of anxiety and depression symptoms in patients receiving radiation therapy treatment. It will also attempt to determine whether RTs believe that reviewing patients' self-reported symptoms should be included as part of their routine patient assessment.

METHODS

A questionnaire was initially piloted at the host institution to six randomly chosen RTs and then sent via e-mail to all radiation therapists practising in Ontario, Canada (N = 921). The online questionnaire consisted of multiple choice questions and was divided into the following four themes: (1) RT comfort levels surrounding the topics of anxiety and depression; (2) management of anxiety and depression in cancer patients; (3) further education needed/requested in anxiety and depression symptom management; and (4) the Edmonton Symptom Assessment System (ESAS). Data analyses included the calculation of means and two sample two-sided t tests to examine the relationships between various demographics and responses.

RESULTS

RTs feel more comfortable in the discussion of issues surrounding anxiety when compared with depression. The most common positive factor affecting RTs' comfort levels addressing emotional distress is previous experience with patients who have expressed these symptoms; whereas, the most common adverse factor affecting comfort levels is the lack of education regarding emotional distress. Eighty-seven percent of RTs would like further education surrounding anxiety and depression symptom management. Seventy-eight percent of RTs agree that ESAS is an important tool for symptom management; however, only 16% actually use this tool in their clinical practice.

CONCLUSIONS

Although RTs within Ontario feel fairly comfortable addressing anxiety and depression symptoms, they have indicated that further education regarding these topics would be useful. Further research into seamlessly incorporating ESAS into RTs' daily practice should be considered.

Rasch analysis of the Edmonton Symptom Assessment System and research implications

BACKGROUND

Reliable and valid assessment of the disease burden across all forms of cancer is critical to the evaluation of treatment effectiveness and patient progress. The Edmonton Symptom Assessment System (esas) is used for routine evaluation of people attending for cancer care. In the present study, we used Rasch analysis to explore the measurement properties of the esas and to determine the effect of using Rasch-proposed interval-level esas scoring compared with traditional scoring when evaluating the effects of an exercise program for cancer survivors.

METHODS

Polytomous Rasch analysis (Andrich's rating-scale model) was applied to data from 26,645 esas questionnaires completed at the Juravinski Cancer Centre. The fit of the esas to the polytomous Rasch model was investigated, including evaluations of differential item functioning for sex, age, and disease group. The research implication was investigated by comparing the results of an observational research study previously analysed using a traditional approach with the results obtained by Rasch-proposed interval-level esas scoring.

RESULTS

The Rasch reliability index was 0.73, falling short of the desired 0.80-0.90 level. However, the esas was found to fit the Rasch model, including the criteria for uni-dimensional data. The analysis suggests that the current esas scoring system of 0-10 could be collapsed to a 6-point scale. Use of the Rasch-proposed interval-level scoring yielded results that were different from those calculated using summarized ordinal-level esas scores. Differential item functioning was not found for sex, age, or diagnosis groups.

CONCLUSIONS

The esas is a moderately reliable uni-dimensional measure of cancer disease burden and can provide interval-level scaling with Rasch-based scoring. Further, our study indicates that, compared with the traditional scoring metric, Rasch-based scoring could result in substantive changes to conclusions.

Validation of the Edmonton Symptom Assessment System in Korean patients with cancer

CONTEXT

The Edmonton Symptom Assessment System (ESAS) is a brief, widely adopted, multidimensional questionnaire to evaluate patient-reported symptoms.

OBJECTIVES

To develop a Korean version of the ESAS (K-ESAS) and to perform a psychometric analysis in Korean patients with advanced cancer.

METHODS

We tested the K-ESAS in two pilot studies with 15 patients each. We assessed internal consistency, test-retest reliability, and concurrent validity in 163 Korean patients, who completed the K-ESAS along with the Korean versions of the M. D. Anderson Symptom Inventory (K-MDASI) and the Hospital Anxiety and Depression Scale (K-HADS) twice. A total of 38 patients completed the questionnaires again seven days later to assess responsiveness.

RESULTS

The K-ESAS scores had good internal consistency, with a Cronbach's alpha coefficient of 0.88, indicating that no questions had undue influence on the score. Pearson correlation coefficients for K-ESAS symptom scores between baseline and after two to four hours ranged from 0.72 (95% CI 0.64-0.79) to 0.87 (95% CI 0.82-0.90), indicating strong test-retest reliability. For concurrent validity, Pearson correlation coefficients between K-ESAS symptom scores and corresponding K-MDASI symptom scores ranged from 0.70 (95% CI 0.62-0.77) to 0.83 (95% CI 0.77-0.87), indicating good concurrent validity. For the K-HADS, concurrent validity was good for anxiety (r=0.73, 95% CI 0.65-0.79) but moderate for depression (r=0.4, 95% CI 0.26-0.52). For responsiveness, changes in K-ESAS scores after seven days were moderately correlated with changes in K-MDASI scores but weakly correlated with changes in K-HADS scores.

CONCLUSION

The K-ESAS is a valid and reliable tool for measuring multidimensional symptoms in Korean patients with cancer.

Minimal clinically important differences in the Edmonton symptom assessment system in patients with advanced cancer

CONTEXT

Longitudinal symptom monitoring is important in the setting of patients with advanced cancer. Scores over time may naturally fluctuate, although a patient may feel the same.

OBJECTIVES

The purpose of this study was to determine the minimal levels of change required to be clinically relevant (minimal clinically important difference [MCID]) using the Edmonton Symptom Assessment System (ESAS).

METHODS

Between 1999 and 2009, patients completed the ESAS before palliative radiotherapy and at follow-up. MCIDs were calculated using both the anchor- and distribution-based methods for improvement and deterioration; 95% confidence intervals for the differences in mean change scores between adjacent categories also were calculated.

RESULTS

A total of 276 patients completed the ESAS at baseline and during at least one follow-up visit. At the four-week follow-up, decrease of 1.2 and 1.1 units in pain and depression scales, respectively, constituted clinically relevant improvement, whereas increase of at least 1.4, 1.8, 1.1, 1.1, and 1.4 units, respectively, in pain, tiredness, depression, anxiety, and appetite loss items were required for deterioration. At the subsequent follow-ups, these values were similar. Overall, the MCID for improvement tended to be smaller than that for deterioration. The distribution-based method estimates tended to be larger than the 0.3 SD estimates, but closer to the 0.5 SD estimates.

CONCLUSION

MCIDs allow health care professionals to determine the success of treatment in improving the patient's quality of life. MCIDs may prompt health care professionals to intervene with new treatment. Future studies should confirm our findings with a variety of anchors.

The potential role for acupuncture in treating symptoms in patients with lung cancer: an observational longitudinal study

BACKGROUND

Most lung cancer patients experience multiple symptoms related either to the disease or its treatment. The commonly reported symptoms are pain, depression, anxiety, nausea, and poor well-being. The aim of the present study was to evaluate the effect of acupuncture as a potential treatment modality in symptomatic lung cancer patients.

METHODS

This prospective observational study enrolled 33 lung cancer patients from the Peter Brojde Lung Cancer Centre between August 2010 and May 2012. All patients received 45-minute sessions of acupuncture, 1-2 times weekly for a minimum of 4 sessions. Symptom severity was assessed using the Edmonton Symptom Assessment System (esas) before and after completion of acupuncture.

RESULTS

The study cohort included 30 patients with non-small- cell lung cancer and 3 with small-cell lung cancer. Mean age was 62 years (range: 36-88 years); 17 of the patients were women. Most of the patients had advanced-stage cancer (73%) and good performance status (Eastern Cooperative Oncology Group 0-1: 88%). Of these patients, 67% received anticancer treatment (chemotherapy or radiotherapy, or both) with acupuncture. Of the remaining 10 patients, 8 received acupuncture after a complete surgical resection of their tumour, and because of their advanced age, 2 received acupuncture and best supportive care. The median number of acupuncture sessions was 7 (interquartile range: 4-13 sessions). Statistically significant improvements in pain, appetite, nausea, nervousness, and well-being were observed. A clinically important improvement (2 points on the esas) was reported by 61% of patients for pain and by 33% for well-being. A significant positive correlation between improved well-being and the number of acupuncture sessions was observed. This correlation remained significant even after controlling for treatment and narcotic use. Receiver operating characteristic analysis demonstrated that a minimum of 6 acupuncture sessions are required for a 70% chance of a clinically important improvement in well-being.

CONCLUSIONS

The present study is the first to demonstrate that acupuncture may be an effective approach for improving symptoms-in particular, pain and well-being-in lung cancer patients. Acupuncture is a safe and minimally invasive procedure, and it is potentially useful even in patients undergoing anticancer treatment.