Shirley S. Hwang

Validation of the Edmonton Symptom Assessment Scale

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

The Memorial Symptom Assessment Scale Short Form (MSAS-SF)

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

Symptom and quality of life survey of medical oncology patients at a Veterans Affairs medical center

The current study was conducted to assess symptom prevalence and symptom intensity and their relation to quality of life in medical oncology patients at a Veterans Affairs medical center.

Cancer breakthrough pain characteristics and responses to treatment at a VA medical center.

&NA; The purpose of this study is to analyze cancer breakthrough pain (BP) characteristics and how BP responds to conventional cancer pain management. Seventy‐four cancer pain patients with worst pain severity ≥4 out of 10 completed the Brief Pain Inventory (BPI), Memorial Symptom Assessment Scale‐Short Form, Functional Assessment Cancer Therapy and Breakthrough Pain Questionnaires (BPQ) at an initial interview. Agency for Health Care Policy and Research (AHCPR) cancer pain management guidelines were followed. Pain syndromes and morphine equivalent daily dose (MEDD) orally were determined. One‐week follow‐up assessments were obtained in 66 patients with BPI and BPQ. The BP characteristics were similar at both time points. On day 1, 52 patients (70%) had BP, and the BP was unpredictable in 30 patients (58%). The median time to worst BP severity was 3 min. Patients with BP had significantly higher worst pain (P<0.001). At week 1, the median MEDD doubled from 60 to 120 mg orally, and the number of patients who received adjuvant analgesics doubled from 31.1% (23 patients) on day 1 to 62.2% (41 patients). At week 1, 21 patients (32%) remained without BP, 21 patients (32%) were classified as BP responders and 24 patients (36%) were BP non‐responders. The mean pain relief was similar for all three subgroups, i.e. around 80%. Compared to BP responders, BP non‐responders had significantly higher worst pain (P<0.0001), average pain (P<0.004), and higher BPI interference parameters and shorter time to worst pain severity. The study confirmed the applicability of the BPQ to an US veteran population, and that pain management following the AHCPR guidelines is effective for a group of patients with cancer related BP. Underlying pain syndromes and the BP location may influence the response of BP to treatment. Patients with bone pain located in the spine, back, and pelvis may be at risk for resistant BP.

Multidimensional independent predictors of cancer-related fatigue☆

The purpose of this study was to identify independent predictors of clinically significant fatigue based upon a multidimensional model. A total of 180 cancer patients completed the Brief Fatigue Inventory (BFI), Functional Assessment of Cancer Therapy-Fatigue (FACT-F), Memorial Symptom Assessment Scale Short Form (MSAS-SF), and the Zung Self-Rating Depression Scale (SDS). Additional data included Karnofsky Performance Status (KPS) score, laboratory tests, and demographic information. The BFI usual fatigue severity > or =3/10 was defined as clinically significant fatigue. Possible independent variables were identified from a biopsychosocial model of fatigue. Fishers exact test was used to univariately assess the association of each variable with clinically significant fatigue. Multiple logistic regression analyses were used to identify independent predictors of fatigue within each dimension, and then across dimensions. Fatigue was present in 113 (62%) patients, and 80 (44.4%) patients had usual fatigue > or =3/10. The unidimensional independent predictors were use of analgesics (situation dimension); hemoglobin and serum sodium (biomedical dimension); feeling drowsy, dyspnea, pain and lack of appetite (physical symptom dimension); and feeling sad and feeling irritable (psychological symptom dimension). In a multidimensional model, dyspnea, pain, lack of appetite, feeling drowsy, feeling sad, and feeling irritable predicted fatigue independently with good calibration (Hosmer Lemeshow Chi Square=5.73, P=0.68) and discrimination (area under the receiver operating characteristic curve=0.88). Physical and psychological symptoms predict fatigue independently in the multidimensional model, and superseded laboratory data. These findings support a symptom-oriented approach to assessment of cancer-related fatigue.

Longitudinal Quality of Life in Advanced Cancer Patients: Pilot Study Results from a VA Medical Cancer Center

To document quality-of-life (QOL), symptom distress and Karnofsky Performance Status (KPS) over time, 67 advanced cancer patients completed the Functional Assessment of Cancer Therapy (FACT-G) and Memorial Symptom Assessment Scale - Short Form (MSAS-SF) from the time of determination of no active anti-cancer treatment to death at 3-6 week intervals. The KPS was determined at each time point. Statistical analyses with mixed effects models were performed to examine the association between changes in QOL, symptom distress and KPS at selected time points in the advanced cancer trajectory. Median survival for the population was 115 days, and a median of 5 interviews was completed per patient. Slow steady changes in KPS, MSAS-SF and FACT-G QOL parameters started 6 months prior to death, with accelerated decline in the last 2 to 3 months and dramatic increase in psychological symptoms during the last month. Different domains changed at different rates at different selected time points. The correlation between changes in KPS, FACT-G parameters and MSAS-SF subscales at enrollment and near death suggests that when patients were stable, changes in KPS correlated significantly with changes in sum FACT-G QOL and physical well being, and with changes in the MSAS-SF subscales. However, when patients were near death, changes in KPS did not correlate with any other changes, and only emotional well being reflected changes in physical and psychological symptom distress. The sequence of changes, and how determinants of symptom distress and QOL change over time, may help clinicians assess the prognosis of terminally ill patients and plan appropriate interventions.

Shorter Symptom Assessment Instruments: The Condensed Memorial Symptom Assessment Scale (CMSAS)

Background. Rapid and efficient symptom assessment is an important aspect of palliative care. The objective was to determine whether a smaller number of symptoms from the 32-item Memorial Symptom Assessment Scale Short-Form (MSAS-SF) could convey equivalent quality of life (QOL) information. Methods. Responses from 479 medical oncology patients who completed the MSAS-SF and the Functional Assessment Cancer Therapy (FACT-G) were analyzed. Canonical correlations were performed to assess the relationships of 32 MSAS-SF symptoms to quality of life (FACT-G domains) and clinical variables [age, Karnofsky performance status (KPS), stage of disease, and inpatient status]. The relation of the subscales of the Condensed MSAS (CMSAS) and FACT-G to survival was assessed in a multivariate model. Results. The median age was 67 years (range, 20–89) and median KPS was 80% (range, 20–100). Primary sites were prostate in 141 (29%) patients, lung in 121 (26%) patients, colorectal in 53 (11%) patients, hematologic in 50 (10%) patients, head and neck in 30 (6%) patients and other in 84 (18%) patients. Median survival was 245 days (range, 1–2,215 days). Canonical correlation analyses identified a five-dimensional QOL factor structure. Symptoms important for QOL also correlated significantly with survival and provided the basis for the CMSAS with 14 symptoms and 3 subscales (CMSAS SUM, CMSAS PHYS, and CMSAS PSYCH). In multivariate analyses, the CMSAS PSYCH predicted survival independently of stage, performance status, and QOL. The CMSAS takes 2–4 minutes to complete. Conclusion. The CMSAS contains both QOL and survival information approximately equivalent to the original 32 items.

Prediction of Survival for Advanced Cancer Patients by Recursive Partitioning Analysis: Role of Karnofsky Performance Status, Quality of Life, and Symptom Distress

We performed an exploratory recursive partitioning analysis (RPA) in 429 metastatic cancer patients who had completed a Functional Assessment of Cancer Therapy–General (FACT-G) and a Memorial Symptom Assessment Scale–Short Form (MSAS-SF) to define survival prognostic groups. The Cox model analysis also was performed. Both RPA and Cox models included Karnofsky performance status (KPS), age, FACT-G subscales, and MSAS-SF subscales as survival predictors. Of 429 patients, 348 patients (81.1%) had expired at time of analysis. The median age was 67 years (27–89), with median length of survival of 147 days. The RPA identified four distinct survival groups (p < .0001) with three variables: KPS, physical well-being, and physical symptom distress. The most significant split was KPS of 50%, followed by physical well-being score of 25 and physical symptom distress score of 0.6. The median survival time was 29 days for patients with KPS < 50%; 146 days for patients with KPS ≥ 50% and physical well-being < 25; 292 days for patients with KPS > 50%, physical well-being ≥ 25, and physical symptom distress score > 0.6; and 610 days for patients with KPS ≥ 50%, physical well-being ≥ 25, and physical symptom distress score ≤ 0.6. The Cox model found, in addition to KPS (p < .0001) and physical well-being (p = .08), different predictors: psychological symptom distress (p = .0007), global distress index (p = .02), and age (p < .0001). We concluded that the KPS, quality of life, and symptom distress scores can be combined to define prognostic groups. Such models may be helpful for clinical decision making.

Dynamic Cancer Pain Management Outcomes: The Relationship Between Pain Severity, Pain Relief, Functional Interference, Satisfaction and Global Quality of Life Over Time

To examine the relationship between different cancer pain management outcomes over time, 74 patients with the worst cancer related pain rated as four or greater on an 11-point numeric scale were followed weekly with the Brief Pain Inventory (BPI), and the satisfaction questionnaire and global visual analogue scale quality of life (VASQOL) for 3 weeks. Univariate and multivariate regression analyses were performed at weekly time points. The analyses indicated that pain outcomes can be categorized into separate QOL and satisfaction paths linked by the worst pain severity. In the QOL path, the worst pain severity predicted a pain interference score, which consistently predicted VASQOL. For the satisfaction path, independent predictors were pain relief at Week 1, and worst pain severity and changes in worst pain severity at Week 2. No variables predicted satisfaction at Week 3. The data suggest that satisfaction and quality of life may be independent outcomes of pain management. The timing of assessment may itself be important.

Clinical relevance of fatigue levels in cancer patients at a Veterans Administration Medical Center

The correlation of fatigue levels with functional interference, symptom distress, and quality of life may help determine clinically significant fatigue levels.