Condensed Memorial Symptom Assessment Scale Research Articles

SYMPTOM BURDEN, POSITIVE AFFECT AND RESILIENCY IN OLDER ADULTS EXPERIENCING NORMAL AGING

Abstract Older adults (age≥65) with multimorbid disease burden may be at chronic risk for bothersome symptoms, which can consequently reduce positive affect (e.g., feelings of excitement and enthusiasm). However, we hypothesized that individuals with more resiliency (the ability to “bounce back” from distress) may experience positive affect despite symptom burden. We conducted secondary analysis of baseline self-report survey data (collected between 8/2023-10/2023) from a prospective study of resiliency in older adults residing in nine continuing care retirement communities (CCRCs) across the U.S. Eligible participants lived independently in CCRCs and scored >11/15 on the five-minute Montreal Cognitive Assessment. Surveys assessed symptom burden (Condensed Memorial Symptom Assessment Scale), resiliency (Current Experience Scale), and positive affect (Positive and Negative Affect Schedule-Positive Affect). Bivariate correlations and multiple linear regression evaluated associations of symptom burden and resiliency with positive affect. Participants (M age =81, SD=5.6) were predominantly White (96%) and female (75%). Greater symptom burden correlated with lower positive affect (r=-.295, p<.001) and lower resiliency (r=-2.56, p<.001). In a multiple regression model, lower symptom burden (β = -.136, p=.003) and more resiliency (β=.626, p<.001) were independently associated with greater positive affect. The overall model accounted for 45.4% of variance in positive affect (F(2, 284) =117.198, p<.001). Lower symptom burden and more resiliency contributed to more positive affect among older adults in senior living communities. Because resiliency and positive affect are both potentially modifiable targets for intervention, longitudinal study and psychosocial interventions should explore the effects of increased resiliency on positive affect and general well-being over time.

Analysis of Palliative Care Knowledge and Symptom Burden Among Female Veterans With Serious Illness: A Cross-Sectional Study.

Background: The female Veteran population is rapidly growing, as is their use of Veterans Affairs (VA) medical centers (VAMCs). Additionally, 90% of female Veterans are under 65years old, meaning healthcare providers at VAMCs must be ready to manage the complex serious illnesses that affect female Veterans as they age. These serious illnesses require proper medical management, which can include palliative care. However, little palliative care research includes female Veterans. Aims: The aims of this cross-sectional study were to examine palliative care knowledge and symptom burden among female Veterans' and examine factors associated a symptom burden scale. Methods: Consenting participants completed online questionnaires, including the Palliative Care Knowledge Scale (PaCKS), Condensed Memorial Symptom Assessment Scale (CMSAS), and demographics. Descriptive statistics characterized the sample, bivariate association were carried out with a Chi-square and t test. A generalized linear model explored associations between CMSAS and its subscales with sociodemographic, number of serious illnesses, and facility type (VAMC vs civilian facility). Results: 152 female Veterans completed the survey. PaCKS scores were consistent across our sample. Physical symptoms were rated higher for those receiving care at VAMCs compared to civilian facilities (P = .02) in the bivariate analysis. The factors associated with CMSAS were age, employment status and number of serious illnesses (all P < .05). Conclusions: Palliative care can assist female Veterans with serious illness. More research is needed to further explore variables associated with symptom burden among female Veterans such as age, employment status, and number of serious illnesses.

Characterization of older adults with cancer seeking acute emergency department care: A prospective observational study

IntroductionDisparities in care of older adults in cancer treatment trials and emergency department (ED) use exist. This report provides a baseline description of older adults ≥65 years old who present to the ED with active cancer. Materials and methodsPlanned secondary analysis of the Comprehensive Oncologic Emergencies Research Network observational ED cohort study sponsored by the National Cancer Institute. Of 1564 eligible adults with active cancer, 1075 patients were prospectively enrolled, of which 505 were ≥ 65 years old. We recruited this convenience sample from eighteen participating sites across the United States between February 1, 2016 and January 30, 2017. ResultsCompared to cancer patients younger than 65 years of age, older adults were more likely to be transported to the ED by emergency medical services, have a higher Charlson Comorbidity Index score, and be admitted despite no significant difference in acuity as measured by the Emergency Severity Index. Despite the higher admission rate, no significant difference was noted in hospitalization length of stay, 30-day mortality, ED revisit or hospital admission within 30 days after the index visit. Three of the top five ED diagnoses for older adults were symptom-related (fever of other and unknown origin, abdominal and pelvic pain, and pain in throat and chest). Despite this, older adults were less likely to report symptoms and less likely to receive symptomatic treatment for pain and nausea than the younger comparison group. Both younger and older adults reported a higher symptom burden on the patient reported Condensed Memorial Symptom Assessment Scale than to ED providers. When treating suspected infection, no differences were noted in regard to administration of antibiotics in the ED, admissions, or length of stay ≤2 days for those receiving ED antibiotics. DiscussionWe identified several differences between older (≥65 years old) and younger adults with active cancer seeking emergency care. Older adults frequently presented for symptom-related diagnoses but received fewer symptomatic interventions in the ED suggesting that important opportunities to improve the care of older adults with cancer in the ED exist.

Symptom clusters and quality of life in ambulatory patients with multiple myeloma.

The aim of this study was to investigate symptom clusters and associated clinical factors in ambulatory multiple myeloma patients undergoing medication therapy. We also aimed to determine the correlations between symptom clusters and patient quality of life. A total of 174 multiple myeloma patients hospitalized in the haematology day unit were included in this study. A cross-sectional survey was conducted to examine symptoms and quality of life. Symptoms were assessed by the Chinese version of the Condensed Memorial Symptom Assessment Scale. Quality of life was measured with the Functional Assessment of Cancer Therapy-General. Principal component analysis was used to identify symptom clusters. Independent-samples t tests and chi-square tests were used for comparisons between groups. Spearman's rank correlation analysis was used to identify correlations. We identified three symptom clusters in multiple myeloma patients: psychological; pain, dry mouth, and difficulty sleeping; and fatigue symptom cluster. For each symptom cluster, the patients could be categorized into a severe-symptom group or a mild-symptom group based on the distress of symptoms. The patients in each group exhibited differential demographic and clinical features. Symptom cluster distress was adversely correlated with patients' quality of life. Ambulatory multiple myeloma patients undergoing anticancer medication therapy experience multiple symptoms, which can be categorized into three symptom clusters. For each symptom cluster, level of distress was associated with patients' demographic and clinical characteristics. The presence and level of distress of these symptom clusters have adverse impacts on patients' quality of life.

Implementing the Condensed Memorial Symptom Assessment Scale on an Inpatient Oncology Unit.

Symptom distress places a burden on patients and their families, but it is often not captured in nursing documentation. Using a symptom management tool, such as the Condensed Memorial Symptom Assessment Scale (CMSAS), can assist in this capture and link patients to resources. The purpose of this quality improvement (QI) project was to implement the CMSAS and capture symptom burden to create a streamlined method of documentation. A QI pilot was conducted on an inpatient oncology unit implementing the CMSAS. Then, surveys were provided to the patients to complete at admission and discharge. The most distressing symptoms patients reported were added into the electronic health record nursing care plan that automatically uploaded interventions based on ONS Guidelines™. Patient (N = 73) symptom distress was quickly tracked, and there were no statistically significant changes in patient distress from admission to discharge, except for two symptoms.

Symptom Classes in Decompensated Liver Disease

Patients with decompensated liver disease have been categorized by disease severity. This analysis sought to classify patients with end-stage liver disease based on symptoms rather than disease state and to identify distinct severity classes of physical and psychological symptoms. Patients with a model for end-stage liver disease-sodium score of 15 or higher were recruited from liver clinics in 2 health care organizations. They completed the Condensed Memorial Symptom Assessment Scale, Revised Ways of Coping Checklist, Patient Health Questionnaire, Life Orientation Test-Revised, and the Short-Form Health Survey. Cross-sectional data were analyzed using latent class mixture modeling. The sample (N= 191; age, 56.6 ± 11.1 y; 33.5% ETOH; 28.3% nonalcoholic fatty liver disease; 13.1% autoimmune/primary biliary cholangitis/primary sclerosing cholangitis) was predominantly male (64.2%), Child-Turcotte-Pugh class C (49.5%), with an average model for end-stage liver disease-sodium score of 18.7 ± 4.9. Three distinct classes of symptoms were identified, as follows: mild (26.7%), moderate (41.4%), or severe (31.9%) symptoms. Symptom classes were independent of disease severity and demographic characteristics, except age. All Condensed Memorial Symptom Assessment Scale symptoms and Patient Health Questionnaire scores were significantly different across the 3 classes (P &lt; .05). The symptom classes also differed significantly in physical and mental quality of life, optimism, and avoidance coping behaviors (all P &lt; .001). Patient-reported symptom severity occurred independent of disease severity, contrary to common assumptions. Focusing on the moderate and severe symptom classes as well as patient history of end-stage liver disease complications may enhance providers' ability to improve symptom management for this population.

Symptom Frequency and Distress Underestimated in Decompensated Cirrhosis.

Studies assessing multiple symptoms and the distress of these symptoms in decompensated cirrhosis are lacking. The aims of this study were to assess symptom prevalence and distress among patients with decompensated cirrhosis and to describe medical management of the most prevalent symptoms. Patients were recruited from hepatology clinics within two health-care systems. Eligibility criteria included a model for end-stage liver disease (MELD-Na) score ≥15. Patients completed the Condensed Memorial Symptom Assessment Scale and Patient Health Questionnaire. Comparative statistics were used to analyze the cross-sectional survey data. Of the sample (n = 146), most patients were Child-Turcotte-Pugh (CTP) class B (49.7%) and C (46.2%). Mean age was 56.5years, 65.1% were male, and 88.4% were white. Average MELD-Na score was 19.1 ± 4.5. The most prevalent symptoms were lack of energy and feeling drowsy while the most distressing were lack of energy and difficulty sleeping. Only 24 patients (16.4%) were treated for their difficulty sleeping with sleep medication. Importantly, those prescribed sleep medications had similar distress (3.9 ± 1.2 vs. 3.5 ± 1.2, p = 0.229) compared with patients not prescribed sleep medications. Opioids were prescribed to 57 (39.0%) patients; antidepressants to 34 (23.3%). Forty patients (27.4%) who reported moderate or greater depression were not prescribed an antidepressant. The study highlights the multiple symptoms and distress experienced by patients with decompensated cirrhosis, and the need for improved medical management by health-care providers through enhanced awareness and attention to these complex symptoms. Future research should focus on improvements in symptom management.

Symptom Classes in End-Stage Liver Disease: A First Scientific Step (RP505)

•Describe the differences among the three distinct classes of symptoms in patients with end-stage liver disease.•Describe the three distinct classes of symptoms in context of patent characteristics and disease severity. To date, patients with end-stage liver disease (ESLD) have been categorized by disease severity. This is the first step to identify symptom classes in patients with ESLD based on symptom grouping and not based on disease state. To identify distinct classes of physical and psychological symptoms among patients with ESLD without liver cancer. Adult patients with a MELD-Na score ≥15 were recruited from hepatology clinics of two healthcare organizations as part of a longitudinal study (1R01NR016017, NINR). At baseline patients completed the 14-item Condensed Memorial Symptom Assessment Scale (CMSAS) and 10-item Patient Health Questionnaire (PHQ-9). Using these data, latent class mixture modeling, ANOVA, and chi-square testing were used to address the objective. The sample (n=154, age 56.4±11.1 years) was predominantly male (65.6%), Caucasian (88.4%), CTP class B (55.8%) and C (38.6%) with an average MELD-Na score of 17.0±4.2 and a mix of etiologies (34.4% ETOH, 24.7% NASH, 26.6% viral). Three distinct classes of symptoms were identified: 25.8% of patients had mild, 39.5% had moderate, and 34.7% had more severe symptoms. All 14 CMSAS symptoms were significantly different across 3 classes (all p-values <0.05) but the classes did not differ by PHQ-9 score (p=0.769). The greatest differentiators among the 3 classes were lack of energy (eta2=0.48), worrying (eta2=0.40), and feeling sad (eta2=0.39). There was no difference across the symptom classes in gender, etiology, MELD-Na or CTP score. Patients in the mild class were slightly older compared with patients in the severe class (60.2±11.4 years vs. 54.7±11 years, p=0.048). Symptom severity occurred independent of disease severity, contrary to common assumptions.

The Correlation of Symptom Clusters and Functional Performance in Adult Acute Leukemia Patients Under Chemotherapy.

Adult acute leukemia (AL) patients who receive chemotherapy usually experience multiple symptoms during the treatment course. The symptom clusters (SCs) as well as subsets of concurrent symptoms in AL patients have not yet been demonstrated. To investigate the SCs of adult AL patients who were receiving chemotherapy and to determine their correlations with functional performance. A total of 132 hospitalized adult AL patients were included in this study. A cross-sectional survey aimed to examine symptoms and functional performance was conducted. The patients' symptoms were assessed using the Chinese version of the Condensed Memorial Symptom Assessment Scale, and functional performance was evaluated through activities of daily living and quality of life. We identified 4 SCs in adult AL patients: psychological SC, pain-fatigue-sleep SC, dry mouth-constipation SC, and nutrition-impaired SC. The psychological SC was the most common and most distressing SC. The different SCs were each differentially correlated with patient characteristics. The distress of the psychological SC, pain-fatigue-sleep SC, and nutrition-impaired SC was adversely correlated with functional performance. Adult AL patients undergoing chemotherapy experience multiple symptoms that can be further categorized into 4 SCs. The distress from some SCs is negatively associated with patients' functional performance. Symptom burden remains a major problem for adult AL patients undergoing chemotherapy. Identifying SCs of AL patients should be the basis for accurate and cost-effective interventions. Personalized SC management may improve the functional performance and healthcare quality of adult AL patients.

The Usefulness and Prognostic Value of Memorial Symptom Assessment Short Form and Condensed Memorial Symptom Assessment Scale in Assessment of Lung Cancer Patients

The Usefulness and Prognostic Value of Memorial Symptom Assessment Short Form and Condensed Memorial Symptom Assessment Scale in Assessment of Lung Cancer Patients

The usefulness and prognostic value of Memorial Symptom Assessment-Short Form and Condensed Memorial Symptom Assessment Scale in assessment of lung cancer patients.

Lung cancer is associated with high level of symptoms and patient-reported symptoms have been rarely used as a prognostic score to predict patients survival. Frequency and burden of symptoms in lung cancer patients were evaluated before the diagnosis with the Memorial Symptom Assessment-Short Form (MSAS-SF) and Condensed Memorial Symptom Assessment Scale (CMSAS) questionnaires. Performance status, stage of disease, serum albumin, and C-reactive protein (CRP) levels were recorded. Patients were staged according to 8th TNM classification. A survival analysis was applied. The mean age of 116 patients (adenocarcinoma 51, squamous cell 43, non-small cell 5, small cell 17) was 65.2 ± 10.1 (28-87) years. The most common seen physical and psychological symptoms were cough (86.3%), lack of energy (74.3%), dyspnea (70.1%), and feeling sad (61.5%), feeling nervous (61.5%), and worrying (53.8%). Total and subscores of MSAS and CMSAS are significantly higher in M1 disease than M0 disease. All MSAS-SF and CMSAS scores, but not MSAS-PSYCH and CMSAS-PSYCH, positively correlated with age, high serum CRP, white blood cells/neutrophils counts, and TNM stage, and negatively correlated with albumin levels, performance status, and overall survival (OS). Median survival was 77, 195, 370, and 579days for the four prognostic interquartile groups according to CMSAS-SUM score (p < 0.0001). MSAS-SF and CMSAS questionnaires can be useful tool for discriminating metastatic from non-metastatic disease in treatment-naïve patients with lung cancer. Since both questionnaires well correlated with OS and important prognostic factors, they can use to plan palliative care and to help for predicting survival of lung cancer patients.

Respiratory Failure, Noninvasive Ventilation, and Symptom Burden: An Observational Study

BackgroundNoninvasive ventilation (NIV) is commonly used to manage acute respiratory failure due to decompensated cardiorespiratory disease. We describe symptom burden in this population. MeasuresFifty consecutive, consenting, English-speaking, cognitively intact patients, admitted to wards other than the intensive care unit in a tertiary teaching hospital and treated with NIV for hypercapnic respiratory failure, were recruited. The 14-item Condensed Memorial Symptom Assessment Scale was used to assess physical and psychological symptoms within 36 hours of commencing NIV. Breathlessness (using Borg score), pain location and intensity using a numerical rating scale, and four symptoms potentially prevalent in patients undergoing NIV (cough, sputum, gastric bloating, and dry eyes) were also assessed. OutcomesPatients reported a median of 10 symptoms (IQR 9–13). A median of five symptoms (IQR 3–7) were rated as severe. Breathlessness was the most prevalent and most distressing symptom, with participants reporting a mean maximum Borg score of 7.55 over the 24 hours before admission. Dry mouth, lack of energy, cough, sputum, difficulty sleeping, and psychological symptoms were prevalent. Pain, when reported, was of moderate intensity and contributed to distress. Conclusions/Lessons learnedThis study describes the patient-reported symptoms occurring during an episode of acute respiratory failure. Understanding the symptom profile of patients in this setting may allow clinicians to target symptom relief while simultaneously managing respiratory failure, enhancing care.

Pain-related distress among patients referred to a community-based palliative care program.

Numerous studies have characterized the pain reported by patients with advanced illness in terms of descriptors such as severity, but few have measured pain-related distress. Distress may be important in the clinical approach to pain. To evaluate pain-related distress among adult patients with advanced illness and pain following enrollment in an urban, specialist-level, community-based palliative care program. In a retrospective cross-sectional analysis, data were extracted from the electronic health records of all patients who were able to complete the pain item from the Condensed Memorial Symptom Assessment Scale at the start of care. Bivariate and multivariate analyses evaluated the associations between distress and both sociodemographics and disease-related information. The 506 patients completing the pain item had a mean (SD) age of 70.7 years (13.8); 64.2% were women, 32.1% were Hispanic, 32.6% were white, and 27.7% were black. Of the 503 patients who indicated some level of distress on a 0-4 scale, 221 (43.7%) had high distress, defined as a score ≥3 ("quite a bit" or "very much"). Cancer diagnosis and poor performance status (unable to care for self) were predictors of high pain-related distress (both p &lt; 0.05).Significance of resultsAmong patients with advanced illness who reported pain at the start of care by a specialist palliative care program, high pain-related distress was common, particularly among those with cancer or poor physical function. Further studies are needed to explore the extent to which pain-related distress should inform the assessment and management of pain.

At-Home Transcranial Direct Current Stimulation (tDCS) With Telehealth Support for Symptom Control in Chronically-Ill Patients With Multiple Symptoms.

Transcranial direct current stimulation (tDCS) delivered in multiple sessions can reduce symptom burden, but access of chronically ill patients to tDCS studies is constrained by the burden of office-based tDCS administration. Expanded access to this therapy can be accomplished through the development of interventions that allow at-home tDCS applications.Objective: We describe the development and initial feasibility assessment of a novel intervention for the chronically ill that combines at-home tDCS with telehealth support.Methods: In the developmental phase, the tDCS procedure was adjusted for easy application by patients or their informal caregivers at home, and a tDCS protocol with specific elements for enhanced safety and remote adherence monitoring was created. Lay language instructional materials were written and revised based on expert feedback. The materials were loaded onto a tablet allowing for secure video-conferencing. The telehealth tablet was paired with an at-home tDCS device that allowed for remote dose control via electronic codes dispensed to patients prior to each session. tDCS was delivered in two phases: once daily on 10 consecutive days, followed by an as needed regimen for 20 days. Initial feasibility of this tDCS-telehealth system was evaluated in four patients with advanced chronic illness and multiple symptoms. Change in symptom burden and patient satisfaction were assessed with the Condensed Memorial Symptom Assessment Scale (CMSAS) and a tDCS user survey.Results: The telehealth-tDCS protocol includes one home visit and has seven patient-tailored elements and six elements enhancing safety monitoring. Replicable electrode placement at home without 10–20 EEG measurement is achieved via a headband that holds electrodes in a pre-determined position. There were no difficulties with patients’ training, protocol adherence, or tolerability. A total of 60 tDCS sessions were applied. No session required discontinuation, and there were no adverse events. Data collection was feasible and there were no missing data. Satisfaction with the tDCS-telehealth procedure was high and the patients were comfortable using the system.Conclusion: At-home tDCS with telehealth support appears to be a feasible approach for the management of symptom burden in patients with chronic illness. Further studies to evaluate and optimize the protocol effectiveness for symptom-control outcomes are warranted.

Symptom Distress Among Diverse Patients Referred for Community-Based Palliative Care: Sociodemographic and Medical Correlates

ContextCommunity-based palliative care programs are appearing in the U.S. Many of these programs, particularly those in large cities, serve highly diverse populations. Information about the sources of variation in the conditions that drive illness burden, like symptom distress, may be useful in program planning. ObjectivesTo characterize variation in symptom distress among highly diverse patients referred for palliative care in an urban setting. MethodsThis is a retrospective cross-sectional survey of data obtained from patients at the time of enrollment in a community-based palliative care program. Symptom distress was measured using the Condensed Memorial Symptom Assessment Scale. Severe distress was defined as reporting either “quite a bit”/“very much” or “frequently”/“almost constantly” for one or more symptoms. Multivariate analysis evaluated the associations between symptom distress and sources of patient variability. ResultsPatients (n = 1532) were aged 72.2 years on average; 60.0% were women, 56.4% were African-American or Hispanic, and 30.8% were non-English speaking. Most had cancer or congestive heart failure (68.6%); 90.2% had a Karnofsky Performance Status score of 40–70. The most prevalent symptoms were fatigue (71.8%), pain (47.3%), and sadness (41.6%); the most distressing symptoms were fatigue (58.5%), worrying (54.8%), and weight loss (52.1%). In multivariate analyses, Caucasian race, non-Asian language, low Karnofsky Performance Status scores, and cancer diagnosis predicted severe symptom distress. ConclusionIn a diverse urban population receiving community-based palliative care, symptoms were highly prevalent and distressing, and both sociodemographic and medical factors predicted severe distress. Program planning should consider the needs of subpopulations at risk for high symptom burden.

A High-Touch Model of Community-Based Specialist Palliative Care: Latent Class Analysis Identifies Distinct Patient Subgroups

ContextCommunity-based palliative care may support seriously ill homebound patients. Programs vary widely, and few studies have described the heterogeneity of the populations served or service delivery models. ObjectivesTo evaluate a diverse population served by an interdisciplinary model of community-based specialist palliative care and the variation in service delivery over time and identify subgroups with distinct illness burden profiles. MethodsA retrospective cohort study evaluated longitudinal electronic health record data from 894 patients served during 2010–2013. Illness burden was defined by measures of performance status (Karnofsky Performance Status scale), symptom distress (Condensed Memorial Symptom Assessment Scale), palliative care needs (Palliative Outcome Scale), and quality of life (Spitzer Quality of Life Index). Service utilization included the frequency of visits received and calls made or received by patients. Latent class analysis identified patient subgroups with distinct illness burden profiles, and mixed-effects modeling was used to evaluate associations between patient characteristics and service utilization. ResultsThe mean age was 72.3 years (SD = 14.0); 56.2% were women; 67.5% were English speaking; and 22.2% were Spanish speaking. Most had congestive heart failure (36.4%) or cancer (30.4%); 98.0% had a Karnofsky Performance Status score of 40–70. Four patient subgroups were identified: very low illness burden (26.2%); low burden (39.5%); moderate burden (13.5%); and high burden (20.8%). The subgroups differed in both baseline characteristics and palliative care service utilization over time. ConclusionThe population served by a community-based specialist palliative care program manages patients with different levels of illness burden, which are associated with patient characteristics and service utilization.

Symptom Clustering Among Patients Visiting a Supportive Oncology Clinic (FR435-D)

Objectives Describe a supportive oncology clinic and its patient population. Identify symptoms that compose psychological, treatment-related, and gastrointestinal clusters within a supportive oncology population. Original Research Background: Multiple symptoms are common and often severe in patients with cancer. Identification of symptoms that cluster may serve to elucidate the pathophysiology of the disease and aid in symptom management. Research Objectives: Our aim was to define symptom clusters occurring among cancer outpatients receiving chemotherapy. Methods: November 2011 through May 2014 completed the Condensed Memorial Symptom Assessment Scale plus a sexual dysfunction structured assessment. Data were collected prospectively from 323 consecutive initial visits. Patients rated from 0-4 how

Symptom clustering among patients visiting a supportive oncology clinic.

188 Background: Multiple symptoms are common and often severe in patients with cancer. Identification of symptoms which cluster may serve to elucidate the pathophysiology of the disease and aid in symptom management. Our aim was to define symptom clusters occurring among cancer outpatients receiving chemotherapy. Methods: New and returning patients referred to a supportive oncology clinic (SOC) from our health system’s oncologists from November 2011 through May 2014 completed the Condensed Memorial Symptom Assessment Scale plus a sexual dysfunction structured assessment. Data were collected prospectively from 323 consecutive initial visits. Patients rated from 0-4 how bothersome 15 cancer symptoms were; symptoms were then graded as present (1+) or absent (0). Hierarchical cluster analysis with average linkage was used to identify symptom clusters. The absolute value of the correlation between symptoms was used as the measure of similarity between pairs of symptoms. A correlation of ≥0.6 was used to define the final clusters. A symptom cluster was defined as two or more symptoms that predictably occur together. Results: Three clusters were identified: 1. Psychological (worrying, feeling sad, feeling nervous); 2. Treatment-related (lack of energy, feeling drowsy, difficulty concentrating, dry mouth, constipation); 3. Gastrointestinal (weight loss, lack of appetite, nausea). Pain, difficulty sleeping, shortness of breath, and loss of interest did not cluster with any symptom. Gastrointestinal symptoms are important within the clusters. The prevalence of worrying, feeling sad, and feeling nervous did not cluster with lack of energy or difficulty in sleeping, nor pain with worrying or feeling sad. Conclusions: Three symptom clusters were identified as showing high absolute correlation: a psychological cluster, treatment-related cluster, and gastrointestinal cluster. Identifying symptom clusters may promote our understanding of the pathophysiology of cancer, help prioritize effective pharmacotherapies, and identify drugs likely to help more than one symptom.

Reduced symptom burden after visiting an outpatient supportive oncology clinic.

204 Background: Outpatient palliative care in supportive oncology clinics (SOC) is growing and has shown promise in controlling symptoms. We sought toinvestigate the impact on symptom burden of a SOC in a National Cancer Institute-designated Comprehensive Cancer Center. Methods: New and returning SOC patients referred from our health system’s oncologists from November 2011 through May 2014 completed the Condensed Memorial Symptom Assessment Scale plus a sexual dysfunction structured assessment. Visits include a structured symptom assessment and personalized treatment plan from the clinic’s part-time physician and/or nurse practitioner. Patients rated from 0-4 how bothersome 15 cancer symptoms were. Descriptive statistics were calculated. We used the Wilcoxon signed rank test to compare symptom scores at patients’ first and second visits. Results: 135 patients had multiple SOC visits. Mean age was 54.7 (SD 12.5) years. 55.3% were female. The most common cancers were breast, lung, and head and neck (18.1% each). Median time between visits was 29 days (mean: 52.8, range: 2-446). The most bothersome symptoms at baseline were pain (mean 3.1, SD 1.3), lack of energy (2.4, SD 1.3), and difficulty sleeping (2.1, SD 1.6). Least bothersome were dyspnea (0.8, SD 1.1), sexual problems (0.9, SD 1.4), and nausea (1.0, SD 1.3). Energy, pain, drowsiness, constipation, sleep, worrying, sadness, and nervousness were significantly improved at follow-up with reductions between 0.2 (drowsiness) and 0.5 (pain) points (all p&lt;0.05). Weight loss trended toward improved (p=0.053). Conclusions: 8 of 15 symptoms significantly improved after the first visit to a small-scale SOC. These reductions may underestimate the SOC’s effect if disease was progressing or overestimate differences if disease was shrinking, but such data were unavailable. Larger multi-site trials with well-defined interventions and control groups are needed.

Disparities in hospitalized cancer patients receiving palliative care consultation.

7 Background: Racial and ethnic disparities in healthcare have been well documented among minority groups with respect to access to care, receipt of care, and quality of care. As a result, minority populations are diagnosed with late stage cancer and have inferior outcomes likely leading to increased suffering. Little is known, however, about disparities in access to and outcomes of patients receiving specialty palliative care (PC). Methods: We used data from the Palliative Care for Cancer Patients (PC4C) study, a multisite observational study of the effect of inpatient PC on patient health outcomes and health services use among advanced cancer patients. We limited our sample to patients that received PC from established, interdisciplinary consult teams. We used univariate analyses and multiple regression analyses to compare differences in outcomes among minority (black and Hispanic) and non-minority patients receiving PC. Results: 583 (19%) patients received a PC consult. Of those, 166 (28%) were minorities and 418 (72%) non-minorities. Mean days to a palliative care consult was 4.4 vs. 3.2 in non-minorities and minorities, respectively (p=0.65). At baseline, minority patients reported a higher burden of symptoms as measured by the condensed memorial symptom assessment scale (CMSAS). Similarly, they were less likely to have talked about their wishes with their doctor (p=0.04); less likely to have completed a living will (p&lt;0.001), or have a proxy (p&lt;0.001); had no difference in pain but were less likely to be taking pain medications (p&lt;0.001) or report relief from pain medicines (p=0.05). After PC consult all CMSAS symptoms improved for minority patients (except worry; p=0.03). Additionally, after PC consult there were no longer any significant differences among minorities with respect to discussing their wishes (p=0.27), DNR completion (p=0.72), proxy assignment (p=0.22) and taking pain medications (p=0.22) when compared to non-minorities. Conclusions: PC is associated with improvements in symptom control and discussions of care goals among minority patients who have worse baseline health assessments. Future efforts need to focus on increasing the availability and use of specialty PC for this at-risk population.