Total Symptom Distress Score Research Articles

Association of physical and psychological symptom burden with time to death among palliative cancer outpatients

19523 Background: Patients with terminal cancer have a high symptom burden, which tends to increase as death approaches. Previous studies have assessed the association of symptom burden with time to death (TTD) among inpatients or using baseline data for patients enrolled in a trial. Our purpose was to determine the association of symptom burden with TTD in patients who were followed by an outpatient palliative oncology clinic (OPOC). Methods: Cancer patients seen in the OPOC between January 2005 to June 2006 and who subsequently died were identified from the palliative care database. The last outpatient Edmonton Symptom Assessment Scale (ESAS) score completed in clinic was compared among patients in the last 4 months of life. Multiple linear regression was used to determine the association of ESAS total symptom distress score (SDS), physical subscore (PHS), psychological subscore (PSS) and individual symptom scores with demographic parameters, disease characteristics and TTD. Results: In total, 198 patients were identified. All patients had stage IV cancer, the mean age was 63.8 years (SD 12.9) and 55% were male. Median survival time from initial assessment was 6.6 weeks (range 0.3 to 16.7) and mean SDS was 46.0 (SD 18.0). Sites of cancer included gastrointestinal (36%), lung (12%), genitourinary (10%), hematological (8%), gynecological (8%), breast (7%) and others (19%). There was no significant association between symptom burden and gender, age or cancer site. TTD was significantly associated with SDS (p<0.001) and PHS (p<0.001), but not with PSS (p=0.19). Individual symptoms most strongly associated with TTD were fatigue (p=0.001), appetite (p=0.001), drowsiness (p=0.0005) and shortness of breath (p=0.0008). There was no significant association between TTD and depression (p=0.24) or anxiety (p=0.20). Conclusions: In this outpatient palliative cancer population, the association between TTD and symptoms held true only for physical symptoms, particularly constitutional symptoms and shortness of breath which are amenable to therapy. Symptoms in palliative patients should be rigorously assessed and treated, regardless of prognosis and especially at end-of-life. No significant financial relationships to disclose.

Adding Insulin Glargine Versus Rosiglitazone

We sought to assess health-related quality of life (HRQOL) in patients with type 2 diabetes treated with insulin glargine or rosiglitazone as add-on therapy to sulfonylurea plus metformin. HRQOL was evaluated in 217 subjects uncontrolled with sulfonylurea plus metformin, enrolled in a 24-week, multicenter, randomized, open-label, parallel-group trial of add-on insulin glargine versus rosiglitazone. A 40-item, self-administered questionnaire at baseline and at weeks 2, 6, 12, 18, and 24 was given, including the 34-item Diabetes Symptom Checklist-Revised (DSC-R), a 5-item mental health scale from the 36-item Short-Form Health Survey (SF-36), and a single-item health rating from the SF-36. These assessments do not specify route of therapy. Both treatment groups showed similar improvements in glycemic control from baseline to week 24 (change in A1C: -1.66% in the insulin glargine group, -1.51% in the rosiglitazone group, P = 0.1446). Both groups also showed improvement in HRQOL, although subjects treated with insulin glargine experienced significantly greater improvements compared with rosiglitazone in the DSC-R total symptom score (P = 0.005), total symptom distress score (P = 0.03), individual domain scores for mood symptoms (P = 0.007), ophthalmologic symptoms (P = 0.007), ophthalmologic distress (P = 0.013), fatigue distress (P = 0.033), and SF-36 perception of general health (P = 0.047). Although addition of insulin glargine and rosiglitazone achieved comparable improvements in glycemic control, insulin glargine was associated with greater improvements in HRQOL, indicating that other factors (e.g., safety profile and nonglycemic actions) may further enhance HRQOL in patients with type 2 diabetes.

Cross-sectional validity of a modified Edmonton symptom assessment system in dialysis patients: A simple assessment of symptom burden

Subjective symptom assessment should be a fundamental component of health-related quality of life (HRQL) assessment in end-stage renal disease (ESRD). Unfortunately, no symptom checklist has established reliability or validity in ESRD. We report the validation of a modified Edmonton Symptom Assessment System (ESAS) in 507 dialysis patients who concurrently completed the Kidney Dialysis Quality of Life-Short Form (KDQOL-SF) questionnaire. The ESAS demonstrated a mean of 7.5+/-2.5 symptoms. The symptoms reported as most severe were tiredness, well-being, appetite, and pain. The overall symptom distress score was strongly correlated with the KDQOL-SF subscales symptom/problem list (r=-0.69, P<0.01), effects of kidney disease (r=-0.52, P<0.01), and burden of kidney disease (r=-0.50, P<0.01), as well as lower RAND-12 physical health composite (PHC) (r=-0.54, P<0.01) and lower RAND-12 mental health composite (MHC) (r=-0.62, P<0.001). In the multivariate regression analysis, after controlling for potential confounding variables including comorbidity using the modified Charlson Comorbidity Index, the ESAS symptom distress score remained strongly associated with the MHC (slope=-0.82+/-0.07, P<0.01) and PHC (slope=-0.48+/-0.07, P<0.01). The ESAS symptom distress score accounted for 29% of the impairment in PHC and 39% of the impairment in MHC. The intraclass correlation coefficient for the total symptom distress score in a 1-week test-retest was 0.70, P<0.01. Symptom burden is high and adversely affects HRQL in dialysis patients. The modified ESAS is a reliable, valid, simple, and useful method for regular symptom assessment in this patient population.

Diabetes-related symptoms and negative mood in participants of a targeted population-screening program for type 2 diabetes: The Hoorn Screening study

To determine the level of diabetes-related symptom distress and its association with negative mood in subjects participating in a targeted population-screening program, comparing those identified as having type 2 diabetes vs. those who did not. This study was conducted within the framework of a targeted screening project for type 2 diabetes in a general Dutch population (age 50-75 years). The study sample consisted of 246 subjects, pre-selected on the basis of a high-risk profile; 116 of whom were subsequently identified as having type 2 diabetes, and 130 who were non-diabetic subjects. Diabetes-related symptom distress and negative mood was assessed approximately 2 weeks, 6 months, and 12 months after the diagnosis of type 2 diabetes, with the Type 2 Diabetes Symptom Checklist and the Negative well-being sub scale of the Well-being Questionnaire (W-BQ12), respectively. Screening-detected diabetic patients reported significantly greater burden of hyperglycemic (F = 6.0, df = 1, p = 0.015) and of fatigue (F = 5.3, df = 1, p = 0.023) symptoms in the first year following diagnosis type 2 diabetes compared to non-diabetic subjects. These outcomes did not change over time. The total symptom distress (range 0-4) was relatively low for both screening-detected diabetic patients (median at approximately 2 weeks, 6 months, and 12 months; 0.24, 0.24, 0.29) and non-diabetic subjects (0.15, 0.15, 0.18), and not significantly different. No average difference and change over time in negative well-being was found between screening-detected diabetic patients and non-diabetic subjects. Negative well-being was significantly positive related with the total symptom distress score (regression coefficient beta = 2.86, 95% CI 2.15-3.58). The screening-detected diabetic patients were bothered more by symptoms of hyperglycemia and fatigue in the first year following diagnosis type 2 diabetes than non-diabetic subjects. More symptom distress is associated with increased negative mood in both screening-detected diabetic patients and non-diabetic subjects.