Prevalence of Physical Problems Detected by the Distress Thermometer and Problem List in Patients with Breast Cancer

Abstract

Background

Patients with breast cancer have high rates of physical symptoms that negatively impact their quality of life. The relationship between women's perceptions of these physical symptoms and patient demographic and breast cancer characteristics is less well known. This study describes breast cancer patients' physical symptoms and their relationship with patient characteristics.

Methods

Patients (n=125) with breast cancer (Stage 0-IV) completed questionnaires in a dedicated academic medical center breast cancer clinic. Patients reported demographics (age, race/ethnicity, marital status, employment status) and disease characteristics (surgery type, receipt of chemotherapy or anti-hormonal therapy). Patients reported whether they were bothered by any of 22 Physical Problem List (PPL) variables from the Distress Thermometer and Problem List (DT&PL).

Results

The median number of physical problems endorsed by patients was 3.0 (M=3.43, SD=3.42). Approximately one-fourth endorsed no physical symptoms while three-fourths reported at least one problem, and three-fifths endorsed 2 or more problems. Fatigue (40.0%), sleep (34.7%), skin dry/itchy (22.9%), pain (19.5%), and feeling swollen (19.5%) were most commonly reported. Age, race/ethnicity, marital status, employment status, and receipt of chemotherapy were associated with certain physical problems. Problems with breathing, eating, memory/concentration, nausea, and total number of endorsed PPL variables were associated with distress.

Conclusion

The breast cancer population demonstrates heavy physical symptom burden with multiple physical problems that are related to overall functioning. Special attention should be given to the physical symptom burden of younger, non-white, unmarried, and unemployed patients. Future research should investigate the PPL of the DT&PL with other measures of symptom burden.

Introduction

Women with breast cancer have elevated rates of physical and psychological symptoms and their treatment needs remain unmet despite national guidelines.¹ The physical and cognitive effects of breast cancer treatment (e.g., surgery, radiation, chemotherapy, and anti-hormonal therapies) are pervasive and enduring. This physical symptom burden contributes to poor quality of life.^2,3 As such, the NCCN recommends screening for distress at pre-specified time-points however distressing physical symptoms may be present at any time.⁴ Treatment burden and physical toxicity is known to vary by breast cancer treatment,⁵ and physical side effects may also vary by patient characteristics.⁶ Understanding patient and clinical correlates of physical symptom burden is critical for effective palliative care among women treated for breast cancer.

The Distress Thermometer and Problem List (DT&PL) represents an efficient means of capturing distressing physical problems among women across the breast cancer trajectory. This brief measure is endorsed by the National Comprehensive Cancer Network (NCCN) for the identification of psychological distress and to triage symptoms in patients with cancer⁷ and is the most broadly accepted and implemented measure of distress internationally given its convenience and proven acceptability in busy oncology clinics.⁸ The Physical Problem List (PPL) variables that accompany the DT&PL have not been adequately explored for their associations with breast cancer treatments and patient characteristics. The problem list is meant to be a convenient measure to identify pertinent issues that may or may not be associated with the distress level on the D&PL. It provides readily accessible information about physical symptomatology. Few studies have tried to determine which physical items are most salient and related to other breast cancer factors,^9,10 but evidence exists that patient characteristics, such as a history of childhood adversity, affect women's report of physical symptom distress during breast cancer treatment.¹¹ In order for care to be truly comprehensive, care must adequately address physical symptom burdens, with the first step towards this goal being effective symptom assessment. The efficacy of use of the DT&PL as a physical symptom assessment, as well as an assessment of groups of patients who are more likely to endorse physical symptom on the DT&PL, should therefore be sought.

Given this need, this study will evaluate self-reported physical symptom burden among women receiving care at an outpatient breast cancer clinic using the PPL of the DT&PL and examine whether physical bother differs systematically by patient demographic or medical characteristics. Results will identify groups of women vulnerable to elevated physical symptom distress who may benefit from targeted symptom management interventions, as well as provide information about the feasibility and utility of implementing the DT&PL for capturing patient physical symptom distress in an outpatient clinic.

Methods and Materials

The Mount Sinai Hospital Institutional Review Board (IRB) approved this study in July 2014. According to the policy activities that constitute research at the Mount Sinai Hospital, this work met criteria for activities exempt from ethics and full IRB review. Surveys were collected from participants from August 2014 to April 2015.

Participants

Women with Stage 0-IV breast cancer within five years of diagnosis participated in this survey. Inclusion criteria consisted of a confirmed tissue diagnosis of breast cancer within the previous 5 years, as indicated by the patient. Recruitment occurred over six months in a dedicated breast cancer clinic. New and established patients were recruited to participate in the survey.

Procedure

Participants were asked to participate by either a clinic receptionist or an infusion suite nurse. They were told that the survey was anonymous as part of a research initiative and that it would not be part of their ongoing care. Available psychological services were listed in the survey and patients were asked to bring up any concerns with clinic staff. A board-certified psychiatrist oversaw the study and was available for consultation. Participants completed surveys while waiting in the clinic office space prior to their appointments or during chemotherapy infusion.

Measures

Patient demographic and medical characteristics

Patients reported demographic information including age, race/ethnicity, and marital and employment status, as well as medical information including whether they had received surgical treatment, chemotherapy, and anti-hormone therapy.

Physical problems

Patients endorsed whether a physical symptom had been a problem for them over the past week using the PPL on the DT&PL. The DT&PL has been used widely by cancer institutions to meet the Commission on Cancer distress-screening mandate for accreditation in 2015.^{12 12,13} A list of several Problem List categories (e.g., Practical, Family, Emotional, Spiritual/religious, and Physical) appear alongside the Distress Thermometer and are potentially modifiable depending on clinic needs. The PPL contains 22 separate items (see Table 2 for items) to which patients endorse whether or not a particular physical symptom has been a problem for them in the past week.

Table 2.

Number and Percentage of Patients Endorsing Physical Problem List Variables.

	N	%
Fatigue	46	40.0
Sleep	41	34.7
Skin dry/itchy	27	22.9
Pain	23	19.5
Feeling Swollen	23	19.5
Memory/Concentration	22	18.6
Tingling in hands/feet	22	18.6
Eating	21	17.8
Appearance	20	16.9
Constipation	20	16.9
Nose Dry	16	13.6
Breathing	15	12.7
Getting Around	14	11.9
Nausea	13	11.0
Indigestion	12	10.2
Diarrhea	11	9.3
Sexual	10	8.5
Bathing	10	8.5
Mouth Sores	6	5.1
Change in urination	3	2.5
Fevers	1	0.8
Substance Abuse	0	0

Distress

Patients were evaluated for distress using the DT&PL that was filled out at the same time as the PPL. Distress scores were evaluated for their associations with individual PPL variables and with the total number of endorsed PPL variables by patient.

Statistical Analysis

The primary outcome of this study was the prevalence of 22 PPL variables. Associations with demographics (age, race/ethnicity, marital and employment status) and disease characteristics (surgery type, receipt of chemotherapy or antihormonal therapy) were examined if at least 10% of patients endorsed that particular physical symptom (to ensure adequate power). Independent t-tests were used to assess the bivariate associations between patient age and endorsement of physical problems. Chi-square tests were used to assess the bivariate associations between categorical patient characteristics and endorsement of physical problems. For significant chi-square tests with race/ethnicity and surgery type, follow-up pairwise comparisons were conducted to compare proportions of physical problem endorsement among variable levels. Keppel's modified Bonferroni correction was used to control for Type I error at the .05 level across follow-up comparisons.¹⁴ Statistical procedures were performed using the SPSS version 24 software (SPSS, Chicago, IL 2013) and statistical tests were two-tailed with a 5% significance level.

Results

One hundred twenty-five out of 170 women with a confirmed breast cancer diagnosis within the last 5 years participated in the study (73.5% overall response rate). Their characteristics are listed in Table 1. They had an average age of 55.4 years (SD 13.2), ranging from 26 to 84 years. Approximately half of the women endorsed white race/ethnicity (51.2%) and were married (49.2%), and most were employed (64.1%). The majority of women had undergone either mastectomy or lumpectomy, and roughly half reported having taken anti-hormonal medication (52.1%) and received chemotherapy (55.6%).

Table 1. Demographic Information (n=125).

	M	SD
Age	55.4	13.2
	n	%
Race/Ethnicity
Black	26	21.1
White	63	51.2
Latino	22	17.8
Asian	7	5.9
Other	5	4.2
Married (Yes)	61	49.2
Working (Yes)	64	64.1
Surgery
Mastectomy	61	48.8
Lumpectomy	53	42.4
None	11	8.8
Chemotherapy (Yes)	69	55.6
Antihormones (Yes)	62	52.1

The median number of PPL variables endorsed by patients was 3.0 (M=3.43, SD=3.42) with a range from 0 to 14 (see Table 2). Approximately one-fourth endorsed no physical symptoms while three-fourths reported at least one problem, and three-fifths endorsed 2 or more problems. The five most commonly reported physical problems were fatigue (40.0%), sleep (34.7%), skin dry/itchy (22.9%), pain (19.5%), and feeling swollen (19.5%). Problems with changes in urination, fevers, and substance abuse were not common (all <2.5%).

Results of bivariate comparison tests examining the associations between patient characteristics and endorsement of physical problems are listed in Table 3​​​. Patients reporting problems of feeling swollen (p=.028), appearance (p=.001), and constipation (p=.013) were younger on average than those not reporting these problems. Race and ethnicity were associated with endorsing problems with skin dry/itchy (p=.009), pain (p=.046), tingling in hands/feet (p=.003), eating (p=.001), constipation (p=.044), and breathing (p=.040). Follow-up planned comparisons were conducted using Keppel's modified Bonferroni correction (α_pc=.040) for each significant symptom.

Table 3. Associations of Demographic Factors with Physical Problem List Variables.

	Fatigue			Sleep			Skin dry/itchy			Pain
	Yes	No		Yes	No		Yes	No		Yes	No
	M(SD)	M(SD)	t	M(SD)	M(SD)	t	M(SD)	M(SD)	t	M(SD)	M(SD)	t
Age	55.4 (13.9)	55.4 (15.8)	0.228	51.3 (14.0)	56.6 (12.7)	1.954†	51.65 (17.0)	56.64 (11.9)	1.405	56.9 (15.8)	54.3 (12.9)	0.706
	n	n	χ2	n	n	χ2	n	n	χ2	n	n	χ2
Race/Ethnicity			1.744			6.650			13.632**			9.705*
Black	12	12		10	12		4	22		5	14
White	22	30		14	36		8	55		6	42
Latino	8	12		9	9		10	12		8	10
Asian	1	4		4	2		2	4		2	3
Other	1	2		3	2		3	2		2	2
Married			6.526*			0.008			0.987			3.428†
Yes	16	37		21	32		11	50		8	41
No	29	24		19	30		16	47		15	31
Employed			6.253*			2.621			4.530*			2.036
Yes	19	37		17	38		10	56		7	45
No	17	10		12	12		10	19		6	16
Surgery			1.936			2.394			0.984			2.093
Mastectomy	20	29		16	32		11	50		8	36
Lumpectomy	15	22		18	18		11	33		11	24
None	9	6		6	8		4	11		4	9
Chemotherapy			4.424*			1.076			0.056			0.118
Yes	30	29		23	30		15	54		11	39
No	14	32		16	32		11	44		11	33
Antihormones			1.845			0.025			0.417			0
Yes	19	33		21	29		15	47		12	36
No	24	24		19	28		11	46		11	33

^†p<.10,

^*p<.05,

^**p<.01,

^***p<.001

Table 3. Associations of Demographic Factors with Physical Problem List Variables (cont’d).

	Feeling Swollen			Memory/Concentration			Tingling in hands/feet			Eating
	Yes	No		Yes	No		Yes	No		Yes	No
	M(SD)	M(SD)	T	M(SD)	M(SD)	t	M(SD)	M(SD)	t	M(SD)	M(SD)	t
Age	49.9 (13.6)	56.7 (12.8)	2.228*	52.1 (15.4)	55.5 (12.8)	1.024	56.3 (16.2)	55.4 (12.6)	-0.320	53.9 (15.1)	55.9 (12.9)	0.662
	n	n	χ2	n	n	χ2	n	n	χ2	n	n	χ2
Race/Ethnicity			7.208			4.992			11.143**			20.653***
Black	4	21		5	15		7	19		9	17
White	9	54		7	41		7	56		4	59
Latino	7	15		7	12		8	14		3	19
Asian	3	4		2	3		0	7		4	3
Other	0	5		1	2		0	5		0	5
Married			1.239			1.173			5.142*			0.406
Yes	9	52		9	40		6	55		9	52
No	14	48		13	34		16	47		12	51
Employed			0.208			1.854			0.447			2.188
Yes	9	57		8	43		8	58		8	58
No	5	24		7	17		5	24		7	22
Surgery			0.421			1.045			1.249			3.239
Mastectomy	12	49		8	36		13	48		7	54
Lumpectomy	9	34		10	26		6	30		10	34
None	2	13		8	36		2	13		4	11
Chemotherapy			0.357			0.272			3.162†			0.401
Yes	14	54		10	40		16	53		13	56
No	9	46		11	34		6	49		8	47
Antihormones			0.181			0.367			0.001			0.003
Yes	13	49		10	37		11	51		10	52
No	10	46		12	33		10	47		9	48

^†p<.10,

^*p<.05,

^**p<.01,

^***p<.001

Table 3. Associations of Demographic Factors with Physical Problem List Variables (cont’d).

	Appearance			Constipation			Nose Dry			Breathing
	Yes	No		Yes	No		Yes	No		Yes	No
	M(SD)	M(SD)	T	M(SD)	M(SD)	t	M(SD)	M(SD)		M(SD)	M(SD)	t
Age	51.0 (11.9)	56.9 (12.6)	3.516**	48.9 (13.8)	48.9 (13.8)	2.525*	51.0 (11.9)	56.3 (13.3)		53.7 (17.9)	55.8 (12.6)	1.730
	n	n	χ2	n	n	χ2	n	n		n	n	χ2
Race/Ethnicity			4.342			9.794*			1.855			9.846*
Black	5	16		5	21		5	21		5	21
White	9	38		4	59		7	56		3	60
Latino	2	15		7	15		3	19		6	16
Asian	3	3		2	5		1	6		1	6
Other	1	2		1	4		0	5		0	5
Married			2.712†			1.114			0.005			0.577
Yes	14	37		12	49		8	53		6	55
No	6	38		8	55		8	55		9	54
Employed			0.045			1.586			0.200			6.123*
Yes	12	38		9	57		7	59		3	63
No	5	18		7	22		4	25		6	23
Surgery			0.180			1.129			4.045			2.272
Mastectomy	10	35		8	53		5	56		5	56
Lumpectomy	7	27		9	35		9	35		7	37
None	2	10		3	12		1	14		3	12
Chemotherapy			0.760			2.958†			0.350			0.557
Yes	12	39		14	55		10	59		7	62
No	7	36		5	50		6	49		8	47
Antihormones			0.384			0.304			3.101†			0.162
Yes	9	37		11	51		11	51		8	54
No	11	33		8	49		4	53		6	51

^†p<.10,

^*p<.05,

^**p<.01,

^***p<.001

Table 3. Associations of Demographic Factors with Physical Problem List Variables (cont’d).

	Getting Around			Nausea			Indigestion
	Yes	No		Yes	No		Yes	No
	M(SD)	M(SD)	T	M(SD)	M(SD)	t	M(SD)	M(SD)	t
Age	59.5 (16.8)	55.1 (12.7)	-1.119	50.4 (15.3)	56.2 (12.9)	0.662	50.6 (17.9)	56.1 (12.7)	3.634
	n	n	χ2	n	n	χ2	n	n	χ2
Race/Ethnicity			5.446			5.975			6.874
Black	5	21		4	22		2	24
White	4	59		3	60		3	60
Latino	4	18		3	19		5	17
Asian	0	7		2	5		1	6
Other	1	4		1	4		1	4
Married			2.685			0.126			0.003
Yes	4	57		7	54		6	55
No	10	53		6	57		6	57
Employed			5.961*			4.211*			2.524
Yes	2	64		3	63		3	63
No	5	24		5	24		4	25
Surgery			1.522			1.757			1.067
Mastectomy	5	56		5	56		4	57
Lumpectomy	7	37		5	39		5	39
None	2	13		3	12		2	13
Chemotherapy			0.204			4.938*			0.006
Yes	8	61		11	58		6	63
No	5	50		2	53		5	50
Antihormones			3.520†			0.215			0.024
Yes	4	58		5	57		6	56
No	10	47		6	51		6	51

^†p<.10,

^*p<.05,

^**p<.01,

^***p<.001

For problems with skin dry/itchy, women endorsing Latina or Other race/ethnicity were more likely to report problems with this symptom relative to Black and White women. Latina women were 3 times more likely to report a problem with skin dry/itchy than Black women (.455/.154, χ²(1, n=48)=5.215, p=.022) and 3.6 times more likely than White women (.455/.127, χ²(1, n=85)=10.481, p=.001). Women endorsing Other race/ethnicity were 3.9 times more likely to report a problem with skin dry/itchy than Black women (.600/.154, χ²(1, n=31)=4.775, p=.029) and 4.7 times more likely than White women (.600/.127, χ²(1, n=68)=7.644, p=.006). There were no other differences between race/ethnicity groups for skin dry/itchy (ps>.170).

For problems with pain, Latina women were 3.6 times more likely to report problems with this symptom relative to White women (.444/.125, χ²(1, n=66)=7.993, p=.005). There were no other differences between race/ethnicity groups for pain (ps>.046). For tingling in hands/feet, Latina women were 3.3 times more likely to report problems with this symptom relative to White women (.364/.111, χ²(1, n=85)=7.155, p=.007). There were no other differences between race/ethnicity groups for tingling hands/feet (ps>.061).

For problems with eating, several significant paired comparisons were revealed. Black women were 5.5 times more likely to report problems with eating than White women (.346/.063, χ²(1, n=89)=11.789, p=.001). Asian women were 9.1 times more likely to report problems with eating than White women (.571/.063, χ²(1, n=70)=16.057, p<.001), 4.2 times more likely than Latino women (.571/.136, χ²(1, n=29)=5.489, p=.019), and significantly more likely than women of Other race/ethnicity (.571/0, χ²(1, n=12)=4.286, p=.038). There were no other differences between race/ethnicity groups for eating (ps>.094).

For problems with constipation, Latina women were 5 times more likely to report problems with this symptom relative to White women (.318/.063, χ²(1, n=85)=9.388, p=.002). There were no other differences between race/ethnicity groups for constipation (ps>.046). For breathing, Black women were 4 times more likely to report problems with this symptom relative to White women (.192/.048, χ²(1, n=89)=4.710, p=.030), and Latina women were 5.7 times more likely to report problems with this symptom relative to White women (.273/.048, χ²(1, n=85)=8.728, p=.003). There were no other differences between race/ethnicity groups for breathing (ps>.185).

Marital status was associated with reporting problems of fatigue (p=.011) and tingling in hands/feet (p=.023). Women not currently married were 1.81 times more likely to report fatigue (.547/.302) and 2.6 times more likely to report tingling in hands/feet (.254/.098). Employment status was associated with reporting problems of fatigue (p=.012), skin dry/itchy (p=.033), breathing (p=.040), getting around (p=.015), and nausea (p=.026). Women not currently employed were 1.9 times more likely to report fatigue (.630/.339), 2.3 times more likely to report skin dry/itchy (.345/.152), 4.6 times more likely to report problems breathing (.207/.045), 5.7 times more likely to report problems getting around (.172/.030), and 3.8 times more likely to report nausea (.172/.045).

Chemotherapy history was associated with reporting fatigue (p=.035) and nausea (p=.026). Women who reported receiving chemotherapy were 1.7 times more likely to report fatigue (.508/.304) and 4.4 times more likely to report nausea (.159/.036). Surgery and receipt of antihormones were unrelated to reporting physical problems examined.

The average distress score (DT&PL) was 3.95 (SD 2.57). Distress was associated with problems with breathing (p=.05), eating (p=.016), memory/concentration (p=.038), and nausea (p=.005) (Table 4). Number of physical problems was associated with distress (p=.012).

Table 4.

Comparison of Distress for Patients with Breast Cancer who do or do not the Endorse Problems with the Most Common Physical Problems on the Distress Thermometer and Problem List.

		Distress
		Mean (SD)	t
Fatigue	Yes	4.28 (2.5)	0.970
	No	3.74 (2.6)
Sleep	Yes	4.38 (2.5)	1.467
	No	3.54 (2.5)
Skin Dry/Itchy	Yes	4.57 (2.3)	-1.331
	No	3.74 (2.7)
Pain	Yes	3.55 (2.6)	1.634
	No	4.63 (2.3)
Feeling Swollen	Yes	4.43 (2.5)	-0.936
	No	3.83 (2.6)
Memory/concentration	Yes	4.72 (1.8)	2.252*
	No	3.51 (2.6)
Tingling in hand/feet	Yes	4.45 (2.8)	-0.990
	No	3.81 (2.6)
Eating	Yes	5.21 (2.5)	-2.442*
	No	3.63 (2.5)
Appearance	Yes	3.67 (1.5)	0.184
	No	3.8 (2.7)
Constipation	Yes	4.25 (3.1)	-0.524
	No	3.68 (2.5)
Nose Dry	Yes	3.79 (2.0)	0.236
	No	3.96 (2.4)
Breathing	Yes	6.00 (1.9)	-3.267**
	No	3.77 (2.6)
Getting Around	Yes	5.08 (1.8)	-1.716
	No	3.78 (2.7)
Nausea	Yes	6.00 (2.4)	-2.902**
	No	3.67 (2.5)
Indigestion	Yes	5.40 (2.3)	-2.117
	No	3.77 (2.6)

^*p<.05,

^**p<.01,

^***p<.001

Discussion

Over 75% of patients with breast cancer reported at least one physical problem, and over half of patients reported two or more physical problems. Patients who reported physical problems were younger, non-white, unmarried, and/or unemployed. The reasons for these associations are not all together clear. Many of the most common physical problems (e.g., fatigue, sleep disturbance, pain) are associated with psychological symptoms⁶ and overall global functioning in these patients.¹⁵ This descriptive study draws attention to the significant physical symptom burden in women with breast cancer, which may be obtained using the DT&PL.

The prevalences of physical problems were similar to those found among studies of women with breast cancer in other nations. Fatigue was most common in a group of German breast cancer patients¹⁶ and Korean breast cancer patients.¹⁷ Both groups found that problems with sleep, tingling in hands/feet, pain, and pruritus were all reported in more than 20% of women. Correlates of physical symptom burden are also comparable to studies of other breast cancer cohorts^5,18 and other cancer types.¹⁹ Our findings are also consistent with data that suggests that Latino women express greater symptom burden relative to black/women.²⁰ This is likely due to poor symptom control in this group but interpretation of the scale may be another possibility for the discrepancy. In previous studies, Latino women have shown ‘extreme response tendency’ but it is not clear that would translate to a dichotomous measure.²¹ Younger women have been shown to report heavier symptom burden in other cancer scenarios.²² Women who are unmarried and unemployed may be more likely to lack social and economic support and suffer from physical symptoms.

Results show that the PPL of the DT&PL detects poorly controlled physical symptom burden among women with breast cancer and may be useful in determining groups of women who may particularly benefit from enhanced palliative symptom management. Of note, the total number of endorsed PPL on the DT&PL was associated with distress. This tool may be used to identify physical symptom burden. Palliation of those PPL variables should help to lower distress levels. Poorly controlled physical symptom burden may reflect a problem with communication about symptoms in the clinic when not using a scale such as the DT&PL. In conducting the study, there was no noted disruption in clinic flow as a result of implementing the PPL, and anecdotal evidence from clinic staff indicated that women were eager to complete the form. As such, given that the DT&PL is the most commonly used measure to assess distress in oncology clinics internationally, the accompanying PPL may be helpful in triaging physical symptom complaints. Our results inform the adaptation of an abbreviated Problem List of the 15 items reported in 10% or more of women, which may help to address concerns about finding a balance between scale length and comprehensiveness of items. Clinics that treat those populations of patients with characteristics that were highlighted in this study (e.g., ethnically diverse, unemployed, or younger patients) may want to scrutinize some of the associated physical problems more closely, and use endorsement of physical symptom burdens on the DT&PL as the start to a conversation regarding treatment options that may improve patient-centered care.

Study Limitations

A primary weakness of this study is a lack of another validated measure of physical symptom burden, as opposed to measures such as the Edmonton Symptom Assessment System (ESAS)²³ or the Functional Assessment of Cancer Therapy-Breast Cancer (FACT-B),²⁴ which have been validated as patient-reported outcome measures.²⁵ Also, stage and length of time with breast cancer and whether they were currently undergoing treatment was not captured and may have provided more information on the timing of when symptoms arise. Only descriptive statistics were used for this exploratory study but our understanding of PPL associations would have benefited from a multivariate analysis.

Despite its limitations, the prevalences of physical symptoms reported through the PPL were comparable to those documented among other studies using more comprehensive measures.²⁶ Given that the PPL is a brief, easily completed accompaniment to the Distress Thermometer, the most widely implemented distress screening tool in oncology clinics, this measure may be most easily implemented into clinics to regularly assess and improve management of symptom burdens among women with breast cancer. Future research should examine the development of women's physical symptom burden over time through longitudinal study. Furthermore, given the known interrelationship between physical symptoms on psychological symptoms, future work may wish to examine how prevalent physical problems among women with breast cancer related to their psychological health and global functioning.

Clinical Implications

In summary, this study provides preliminary evidence for an association between physical symptom burden and patient demographics using the DT&PL in women with breast cancer. The vast majority of women reported two or more physical symptoms that were problematic, and thus not adequately controlled. Patients who were younger and non-white or Latina reported greater symptom burden while married women had less problems with fatigue and numbness/tingling. Unemployed women and those who had received chemotherapy also had greater symptom burden. The DT&PL, widely implemented as a distress-screening instrument, may also be helpful in delineating problematic physical symptomatology in patients with breast cancer. Future research should focus on groups (younger, non-White, unemployed, and not married) with significant associations for these physical symptoms. The development of targeted, effective symptom management strategies for breast cancer patients at highest risk for adverse outcomes from physical problems associated with the disease and treatment will be critical to sustaining the quality of life among this vulnerable population of patients.