Elsevier

Gynecologic Oncology

Volume 132, Issue 3, March 2014, Pages 698-702
Gynecologic Oncology

Predictors of high symptom burden in gynecologic oncology outpatients: Who should be referred to outpatient palliative care?

https://doi.org/10.1016/j.ygyno.2014.01.038Get rights and content

Highlights

  • Overall symptom burden in gynecologic oncology outpatients is high.

  • Predictors of higher symptom burden include: young age, ongoing cancer treatment and history of chronic pain, depression or anxiety.

Abstract

Objective

To characterize symptom prevalence in gynecologic oncology outpatients and identify predictors of high symptom burden.

Methods

We performed a retrospective analysis of a convenience sample of symptom surveys from gynecologic oncology patients at a single cancer center over a 20-month period. The survey was based on the Edmonton Symptom Assessment System (ESAS), and assessed pain, depression, anxiety, fatigue and well-being. Information on demographics, disease, treatment and history of chronic pain, depression or anxiety was abstracted from medical records. Data was analyzed with descriptive and t-test statistics.

Results

We analyzed 305 surveys from unique patients. Symptom prevalence (severity score > 0/10) ranged from 60.1% (pain) to 79.7% (fatigue). Prevalence of moderate to severe symptoms (score  4/10) ranged from 32% (pain) to 47% (fatigue). There were no differences in symptom burden by site or stage of cancer. Patients with no active disease (38%) were less symptomatic. There was a trend toward higher symptom burden in patients younger than 50 years. There was higher symptom burden in patients receiving cancer treatment or with a pre-existing history of pain, anxiety or depression. Patients who expressed an interest in being seen by a symptom management service also had higher symptom burden.

Conclusions

Gynecologic oncology outpatients have a high symptom burden regardless of stage and site of cancer. Patients who are young, on treatment or have a history of chronic pain, depression or anxiety have a higher symptom burden. Consideration should be given to targeting these patients for outpatient palliative care services.

Introduction

Patients with gynecologic malignancies experience a significant burden of physical and emotional symptoms from the time of diagnosis, through treatment, recurrences and at the end of life, as well as during long-term survivorship. The American Society of Clinical Oncology (ASCO) defines palliative care as the “integration into cancer care of therapies that address the multiple issues that cause suffering for patients and their families and impact their quality of life” [1]. Unlike hospice services, which are only available to patients with a projected survival of less than six months, palliative care, including symptom management, can be offered from the time of diagnosis until death, concurrently with disease-directed therapies.

Nonrandomized studies have shown receipt of palliative care services to be associated with reduced pain and symptom distress, improved health-related quality of life, high patient and family satisfaction with care and physician communication, reduction in hospital costs per day and reduction in hospital and ICU lengths of stay [2]. In a landmark study, Temel et al. conducted a randomized controlled trial of integration of outpatient palliative care services into standard oncology care from the time of diagnosis in patients with non-small cell lung cancer, and found improved quality of life, less depression and longer median survival [3]. Recently released recommendations from the Society of Gynecologic Oncology suggest that “for women with advanced or relapsed gynecologic cancer, basic level palliative care should not be delayed, and when appropriate, referral should be provided for specialty palliative medicine” [4]. ASCO has recommended consideration of combined standard oncology care and palliative care “early in the course of illness for any patient with metastatic cancer and/or high symptom burden” [5].

Consistent with ASCO's recommendation that patients with high symptom burden represent an appropriate target population for palliative care integration, one study of outpatient palliative care found that the patients with the highest pre-existing symptom burden experienced the greatest benefit [6]. However, data on symptom burden in oncology outpatients, particularly among gynecologic oncology outpatients, is limited. In a large cohort of oncology outpatients (n = 45,118), of whom 8.8% were gynecologic cancer patients, the most prevalent symptom was fatigue (75%), with 53% of patients reporting pain and 44% reporting depression. Predictors of high symptom burden among oncology outpatients included late stage disease, low income, presence of comorbidities and female gender [7]. In another cohort that did not include gynecologic cancers (n = 3106), one third of patients reported ≥ 3 symptoms in the moderate to severe range. Symptoms were more severe in patients receiving active cancer treatment and the prevalence of symptoms increased with increased disease stage [8]. Studies describing gynecologic cancer patients specifically have small numbers and focus almost exclusively on ovarian cancer patients receiving chemotherapy [9], [10], [11], [12].

We sought to identify symptom prevalence in a large, varied population of gynecologic oncology outpatients and assess demographic and clinical features associated with high symptom burden. In doing so, we hoped to identify patients most likely to benefit from outpatient palliative care offered concurrently with their anti-cancer treatment.

Section snippets

Materials and methods

Over a period of 20 months in 2007–2009, a symptom survey was given to all patients in the gynecologic oncology waiting room at the Helen Diller Family Comprehensive Cancer Center at the University of California San Francisco. The survey was available only in English; it was not translated or made available to non-English speaking or non-literate patients. The survey was based on the Edmonton Symptom Assessment System (ESAS), a survey of symptom severity which has been widely used and validated

Results

550 surveys were collected. 109 were excluded because the patient did not have a documented, biopsy-proven gynecologic malignancy. An additional 136 were excluded for reasons including diagnosis (borderline tumors, gestational trophoblastic disease, vulvar and vaginal cancer), survey less than half filled out, or duplicate surveys from the same patient. 305 surveys from 305 unique patients with gynecologic cancer were included in our analysis. We did not record whether participants were

Discussion

Even in a sample of patients with one-third having no evidence of disease at the time of their visit, we demonstrated a high overall symptom burden in a large group of gynecologic oncology patients regardless of stage or cancer site. In keeping with previous studies not limited to gynecologic cancer patients [7], [17], [18], [19], fatigue was the most prevalent symptom in terms of both overall prevalence and prevalence of moderate to severe intensity. Our findings of overall symptom prevalence

Conflict of interest statement

The authors have no conflicts of interest to report.

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    This paper was presented as an oral presentation at the American Association of Hospice & Palliative Medicine (AAHPM) Annual Assembly, Vancouver, Canada, February 2011.

    1

    Present address: Department of Obstetrics, Gynecology & Reproductive Sciences, Division of Gynecologic Oncology, Magee-Womens Hospital of UPMC, Pittsburgh PA 15213, USA.

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