Table 4.
Longitudinal Studies of Symptom Clusters in Homogeneous Samples of Oncology Patients
| Author, Year, Title, Purpose, and Design | Sample Size, Patient Characteristics, Time of Symptom Assessment | Symptom Assessment Instrument(s), Number of Symptoms on Instrument, Statistical Analysis Method, Symptom Dimension(s) Used to Create Symptom Clusters | Number of Symptom Clusters, Number of Symptoms Within Each Cluster, Change in Symptom Clusters Over Time | Strengths and Limitations |
|---|---|---|---|---|
|
Brown et al., 2011 Title: A Symptom Cluster and Sentinel Symptom Experienced by Women With Lung Cancer Purpose(s): Describe the occurrence, severity, and clusters of symptoms experienced by women with NSCLC; describe the relationships of demographic and clinical characteristics, health status factors, and meaning of illness with symptom experience and symptom clusters; and determine if a co-occurring sentinel symptom was associated with the presence of symptom clusters Design: Prospective, longitudinal |
N=196 Mean age: 65.4 (SD=11.4), range: 33–89 Female: 100% Outpatients: 100% Diagnosis: NSCLC: 100% Treatment:
|
Instrument(s): Lung Cancer Symptom Scale: 6 items Symptom Query Questionnaire: self report of symptoms during past 4 weeks obtained during a semi-structured interview Center for Epidemiologic Studies-Depression scale: 20 items Charlson Comorbidity Index: measures the presence of multiple co-morbidities Analysis: Symptoms on the LCSS were coded uniquely and analyzed to determine patterns of co-occurring symptoms Dimension(s): Occurrence |
1 un-named symptom cluster identified: Fatigue, shortness of breath, poor appetite, cough, pain Change in symptom clusters over time: The assessment of symptoms on the previous day revealed a 5-item symptom cluster for 64% of the patients. No predominant symptom cluster was identified for the assessment of the past 4 weeks. |
Strengths: First study to evaluate symptom experience of women with early stage NSCLC who were treated surgically Identified a co-occurring sentinel symptom (i.e., pain) that was the most highly correlated symptom with the presence of the 5-symptom cluster Limitations: Use of SQQ depended on patient’s recall of symptoms over the past 4 weeks which may have contributed to under-reporting Did not address sleep problems, weight loss or decreased concentration reported by 10%–23% of sample Did not use a standard statistical approach to identify symptom clusters Used an instrument with only 6 symptoms to assess symptom clusters |
|
Gift et al., 2003 Title: A Cluster of Symptoms Over Time in Patients With Lung Cancer Purpose(s): Determine whether symptom cluster identified at time of diagnosis remained at 3 and 6 months later; determine whether there was a difference in mean symptom number and mean level of symptom severity over time Design: Prospective, longitudinal |
N=112 Mean age: 72, (SD=4.9), range: 65–83 Female: 48% Outpatients: 100% Diagnosis: Lung cancer: 100% Treatment:
Time of diagnosis At 3 months At 6 months |
Instrument(s): Physical Symptom Experience Tool: 37 items, only 32 items were used in this analysis Analysis: Factor analysis Dimension(s): Occurrence |
1 un-named symptom cluster identified Fatigue, weakness, nausea, vomiting, loss of appetite, weight loss, altered taste Change in symptom clusters over time: Based on an evaluation of Cronbach’s alpha, the symptom cluster met the requisite reliability for a summated rating scale |
Strengths: Symptom cluster identified as an independent predictor of mortality Evaluated mean symptom severity and the number of symptoms at diagnosis Evaluated symptoms in patients ≥ 65 of age Limitations: Secondary analysis Primarily White patients Only patients over 65 were eligible to participate; symptom reporting may be different in a younger age group |
|
Huang et al., 2016 Title: Symptom Clusters in Ovarian Cancer Patients with Chemotherapy After Surgery Purpose(s): To investigate ovarian cancer patients receiving adjuvant CTX throughout treatment; to identify symptom clusters; and to explore changes in symptom clusters over 4 time points. Design: Convenient sample, longitudinal |
N=111 Mean age: 53.7 (SD=10.89), range: 19–78 Female: 100% Outpatients: 100% Diagnosis: Ovarian cancer: 100% Treatment: CTX Time of symptom assessment: Time 1= before surgery Time 2= after first cycle Time 3= after third cycle Time 4= after sixth cycle of CTX |
Instrument(s): MSAS-Chinese: 32 items, only 20 items were used in this analysis Analysis: Exploratory factor analysis Dimension(s): Severity |
Number of symptom clusters a each Time point: T1=3 symptom clusters T2=5 symptom clusters T3=6 symptom clusters T4=6 symptom clusters T1: Pain-related: pain, feeling bloated, dizziness, weight loss Psychological: feeling nervous, feeling sad, anxiety Menopausal: lack of energy, dry mouth, difficulty sleeping, sweats, lack of appetite, feeling irritated T2: Pain-related: pain, feeling bloated, dizziness, weight loss Psychological: feeling nervous, feeling sad, anxiety, feeling irritated Menopausal: lack of energy, dry mouth, difficulty sleeping, sweats, lack of appetite, feeling irritated GI: lack of appetite, nausea, vomiting, weight loss Body image: hair loss, constipation T3: Pain-related: pain, feeling bloated, weight loss Psychological: feeling nervous, feeling sad, anxiety, feeling irritated Menopausal: lack of energy, dry mouth, difficulty sleeping, sweats, lack of appetite, feeling irritated GI: lack of appetite, nausea, vomiting, weight loss, change in the way food tastes Body image: hair loss, constipation, do not look like himself/herself Neurologic: numbness/tingling in hands/feet, dizziness T4: Pain-related: pain, feeling bloated, weight loss Psychological: feeling nervous, feeling sad, anxiety, feeling irritated Menopausal: lack of energy, dry mouth, difficulty sleeping, sweats, lack of appetite, feeling irritated GI: lack of appetite, nausea, vomiting, weight loss, change in the way food tastes Body image: hair loss, constipation, do not look like himself/herself Peripheral Neurologic: numbness/tingling in hands/feet, dizziness Change in symptom clusters over time: Three symptom clusters (i.e., pain-related, psychological, menopausal) remained relatively stable over time |
Strengths: Evaluated symptoms using a multidimensional symptom assessment instrument Evaluated changes in symptom clusters over 4 time points Evaluated symptom clusters in a sample of women not frequently studied in terms of the symptom experience Identified 3 symptom clusters consistent with previous studies (i.e., GI, psychological, menopausal) The majority of the patients received one type of CTX regimen Limitations: Symptom clusters were not evaluated after the completion of CTX Patients with disease recurrence were not evaluated Relatively small sample size |
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Kim et al., 2008 Title: Treatment-Related Symptom Clusters in Breast Cancer: A Secondary Analysis Purpose(s): To identify treatment-related symptom clusters in breast cancer patients across three points in the treatment trajectory and to examine the influence of demographic/clinical variables on symptom clustering Design: Secondary analysis from a randomized clinical trial |
N=282 Mean age: 55.2 (SD=12.1), range: 30–83 Female: 100% Outpatients: 100% Diagnosis: Breast: 100% Treatment:
For CTX patient: Prior to CTX (Time 1), 48 hours after the second cycle of CTX (Time 2), and 48 hours after the third cycle of CTX (Time 3) For RT patients: Prior to RT (Time 1), during the last week of RT (Time 2), and one month after the completion of RT (Time 3) |
Instrument(s): General Fatigue Scale: 1 item Profile of Mood States-Short Form: Depression and Confusion subscales were used 10 items Pittsburgh Sleep Quality Index: 19 items Side Effect Checklist: 16 items Analysis: Common factor analysis with principal axis factoring Dimension(s): Severity |
2 symptom clusters identified: Psycho-neurological: depressed mood, cognitive disturbance, fatigue, insomnia, pain, hot flashes UGI: nausea, vomiting, decreased appetite Change in symptom clusters over time: The psycho-neurological symptom cluster was present at all three time points. The UGI symptom cluster was present at the second and third assessments |
Strengths: Investigated treatment-related symptom clusters and the influence of selected demographic and clinical characteristics at 3 time points across two treatments (i.e., CTX, RT) Limitations: Use of a single item to rate symptom severity The effect of confounding variables on symptom clustering were not controlled for in the analyses Under-representation of minorities and late stage breast cancer patients |
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Phligbua et al., 2013 Title: Symptom Clusters and Quality of Life in Women with Breast Cancer Receiving Adjuvant Chemotherapy Purpose(s): To identify the existence of symptom clusters; to examine the influence of distressing symptoms on QOL in women with breast cancer at before, during, and 1 month after completion of neoadjuvant CTX Design: Prospective, longitudinal |
N=112 Mean age: 49.7 (SD=10.70), range: 19–73 Female: 100% Outpatients: 100% Diagnosis: Breast: 100% Treatment: Adjuvant CTX Time of symptom assessment: T1: before CTX T2: before receiving 2nd cycle T3: 1 month after CTX |
Instrument(s): Modified MSAS: 39 items FACT-B, 4.0: 36 items Analysis: Exploratory factor analysis with principal components (varimax) Dimension(s): Distress |
Time 1: 5 symptom clusters Time 2: 5 symptom clusters Time 3: 5 symptom clusters Time 1 Menopausal: sweats, night sweats, hot flashes, mood swings, feeling irritable, difficulty concentrating Discomfort: dizziness, joint pain, vaginal itching/irritation, constipation Postoperative: coughing, itching, numbness/tingling in hands/feet Fatigue: lack of energy and difficulty sleeping Psychological: feeling sad, worrying Time 2 GI-related fatigue: lack of energy, nausea, lack of appetite, pain, feeling drowsy, dizziness, taste changes Disturbed in mood: feeling irritable, feeling nervous, pain Psychologically-related self-image: “I don’t look like myself”, worrying, difficulty concentrating, hair loss, skin changes Discomfort: constipation, problems with urination, difficulty sleeping, feeling bloated Oral: mouth sore, dry mouth Time 3 GI-related fatigue: lack of energy, feeling drowsy, lack of appetite, taste changes Menopausal: sweats, hot flashes, night sweats, difficulty concentrating, difficulty sleeping, worrying, pain Disturbed in mood: mood swings, feeling irritable, joint pain Discomfort: numbness/tingling in hands/feet, dry mouth Self-image: “ I don’t look like myself”, hair loss, skin changes Change in symptom clusters over time: One symptom cluster (i.e., discomfort) remained relatively stable over time |
Strengths: Evaluated for differences across symptom dimensions and time points Evaluated menopausal symptoms (i.e., sweats, night sweats, hot flashes, mood swings) and its clustering with other symptoms commonly associated with menopause, after receiving CTX Identified a significant increase in menopausal symptoms associated with receiving adjuvant CTX Identified a menopausal cluster, psychologically-related self-image, and a GI-related fatigue symptom clusters that remained stable over CTX cycles Limitations: Symptoms and symptom clusters identified in text were inconsistent with the tables at each of the three time points Relatively small sample size Investigated only women with breast cancer who received adjuvant CTX at one university hospital |
Abbreviations: CTX, chemotherapy; FACT-B, Functional Assessment of Cancer Therapy Cancer-Breast, 4.0; GI, gastrointestinal; LCSS, Lung Cancer Symptom Scale; MSAS, Memorial Symptom Assessment Scale; NSCLC, non-small cell lung cancer; RT, radiation therapy; SQQ, Symptom Query Questionnaire; UGI, upper gastrointestinal.