Predictors of high symptom burden in gynecologic oncology outpatients: Who should be referred to outpatient palliative care?☆
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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2021, Journal of Obstetrics and Gynaecology CanadaCitation Excerpt :Interestingly, there were no differences in the intensity of individual symptoms or subscores across patients with ovarian, uterocervical, and vulvovaginal cancers in our study. In a study that evaluated symptom burden and its predictors in outpatient gynaecological oncology patients, a high symptom burden was observed irrespective of the primary site and stage of cancer.26 Moreover, the burden of symptoms continues to be relatively high even in those who have completed treatment for gynaecological cancer, irrespective of the primary site of cancer.27
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2020, International Journal of Nursing StudiesUtilizing the Patient Reported Outcomes Measurement Information System (PROMIS®) to increase referral to ancillary support services for severely symptomatic patients with gynecologic cancer
2019, Gynecologic OncologyCitation Excerpt :The high prevalence of moderate to severe symptomatology in our patient cohort is comparable to other studies assessing HRQL in patients with gynecologic cancer [9–11]. Gynecologic oncology patients experience a high burden of symptoms regardless of their stage or cancer type [12]. Gynecologic cancers have the potential to negatively impact physical, mental/psychological and social functioning and may diminish personal perception of femininity, self-esteem and body image [13].
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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.
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Present address: Department of Obstetrics, Gynecology & Reproductive Sciences, Division of Gynecologic Oncology, Magee-Womens Hospital of UPMC, Pittsburgh PA 15213, USA.