Retrospective review of symptoms and palliative care interventions in women with advanced cervical cancer.

2015 ◽  
Vol 33 (29_suppl) ◽  
pp. 104-104
Author(s):  
YuJung Kim ◽  
Mark F. Munsell ◽  
Ji Chan Park ◽  
Larissa Meyer ◽  
Charlotte C. Sun ◽  
...  
Keyword(s):  
Cervical Cancer ◽  
Palliative Care ◽  
Symptom Assessment ◽  
Well Being ◽  
Symptom Distress ◽  
Assessment System ◽  
Clinically Significant ◽  
Time Of Presentation

104 Background: Symptoms reported by women with cervical cancer (CCx) include pain, fatigue, lymphedema, sexual dysfunction, proctitis, cystitis, constipation and diarrhea. The objective of this study was to delineate and measure the symptom distress experienced by patients with advanced CCx at the time of palliative care (PC) referral. Methods: A total of 156 advanced CCx patients were referred to PC from 2010 to 2012. Of these, 88 patients had completed the Edmonton Symptom Assessment System (ESAS) and were included in the analysis. Descriptive statistics were used to summarize the data. Results: At the time of presentation mean age was 45 (25-76), 47% were Caucasian, 18% African American, and 33% Hispanic. Fifty-one percent were married; 64% had no advance directives; 75% had recurrent disease. Clinically significant symptoms (defined as ESAS scores ≥ 4) were pain (81%), anorexia (72%), a poor feeling of well-being (70%), fatigue (69%), and insomnia (54%). The chief complaint was pain in 94% of patients. According to the PC specialists’ assessment, pain (96%), emotional distress (77%), and constipation (50%) were predominant symptoms. Various palliative care interventions including opioids, laxatives, and expressive supportive counseling were provided. The median time from advanced cervical diagnosis to PC consultation was 6.0 months (95% CI 5.0-7.8) and the median survival after first PC visit was 4.8 months (95% CI 3.4-6.2). Clinically significant symptoms including nausea, depression, anxiety, and feeling of well-being showed significant improvements at follow-up visits. Conclusions: More than half of patients with advanced CCx were significantly burdened with pain, anorexia, poor feeling of well-being, fatigue, insomnia, and constipation at the time of PC referral. Clinically significant symptoms showed improvements at follow-up visits. In patients with significant symptom distress, early PC involvement may be important to improve quality of life.

Integrating palliative care services in oncology clinics: An application of the Edmonton Symptom Assessment System (ESAS).

2016 ◽  
Vol 34 (26_suppl) ◽  
pp. 168-168
Author(s):  
Sherri L. Rauenzahn ◽  
Susanne Schmidt ◽  
Jessica Jones ◽  
Ifeoma Aduba ◽  
Laura LaNiel Tenner
Keyword(s):  
Palliative Care ◽  
Symptom Burden ◽  
Symptom Assessment ◽  
Assessment System ◽  
Cancer Center ◽  
Edmonton Symptom Assessment System ◽  
Care Services ◽  
Palliative Care Services

168 Background: Research inpalliative care has shown improvements in overall survival, quality of life, symptom management, care satisfaction and reductions in the cost of care. Therefore, the American Society of Clinical Oncology has recommended early concurrent palliative care in patients with advanced cancer and with high symptom burden. Despite this recommendation, integrating palliative services at our NCI-designated cancer center has been challenging. The aims of this project were to quantitatively describe the symptom burden of patients in ambulatory oncology clinics; facilitate the establishment of an effective referral system by detecting discrepancies between symptom burden and referral practices; and improve the integration of palliative care services by implementing the Edmonton Symptom Assessment System (ESAS) tool into 5 of our oncology clinics. Methods: ESAS forms consist of 10 questions assessing patient symptom burden and quality of life. Total scores range from 0 to 100. This tool was distributed to patients at two breast, two gastrointestinal and the thoracic clinics at each visit. The provider reviewed the forms and decided if a palliative care referral was appropriate based on patient responses. The forms as well as referral decisions were entered into REDCap. Over a 5 month period, 607 patients completed the initial assessment and 430 follow up forms were collected, resulting in a total of 1,037 scores collected. Results: The mean ESAS score for all patient visits was 20.7 (SD = 18.7). Only 3.5% (n = 21) of all patients were initially referred to palliative care and 2.6% (n = 11) of patients were referred on follow up visits. Those with an initial referral had an initial mean score of 39.0 (SD = 19.0) and a mean follow up score of 31.9 (SD = 19.5). Conclusions: This project highlights the low palliative care consultation rate and the under-utilization of services by most oncologists at the cancer center despite using the ESAS tool. However, those who received a referral had lower ESAS scores at follow-up. We propose utilizing a trigger that would capture a preset percentage of patients who indicated scores reflective of high symptom burden and distress.

scholarly journals Prescreening of Patient-reported Symptoms using the Edmonton Symptom Assessment System (ESAS) in Outpatient Palliative Cancer Care

2019 ◽  
Author(s):  
Garden Lee ◽  
Han Sang Kim ◽  
Si Won Lee ◽  
Eun Hwa Kim ◽  
Bori Lee ◽  
...  
Keyword(s):  
Palliative Care ◽  
Cancer Care ◽  
Severe Symptom ◽  
Symptom Burden ◽  
Symptom Assessment ◽  
Assessment System ◽  
Advanced Cancer Patients ◽  
Edmonton Symptom Assessment System ◽  
Patient Reported

Abstract Background: Although early palliative care is associated with a better quality of life and improved outcomes in end-of-life cancer care, the criteria of palliative care referral are still elusive. Methods: We collected patient-reported symptoms using the Edmonton Symptom Assessment System (ESAS) at the baseline, first, and second follow-up visit. The ESAS evaluates ten symptoms: pain, fatigue, nausea, depression, anxiety, drowsiness, dyspnea, sleep disorder, appetite, and wellbeing. A total of 71 patients were evaluable, with a median age of 65 years, male (62%), and the Eastern Cooperative Oncology Group (ECOG) performance status distribution of 1/2/3 (28%/39%/33%), respectively. Results: Twenty (28%) patients had moderate/severe symptom burden with the mean ESAS ≥5. Interestingly, most of the patients with moderate/severe symptom burdens (ESAS ≥5) had globally elevated symptom expression. While the mean ESAS score was maintained in patients with mild symptom burden (ESAS<5; 2.7 at the baseline; 3.4 at the first follow-up; 3.0 at the second follow-up; P =0.117), there was significant symptom improvement in patients with moderate/severe symptom burden (ESAS≥5; 6.5 at the baseline; 4.5 at the first follow-up; 3.6 at the second follow-up; P <0.001). Conclusions: Advanced cancer patients with ESAS ≥5 may benefit from outpatient palliative cancer care. Prescreening of patient-reported symptoms using ESAS can be useful for identifying unmet palliative care needs in advanced cancer patients.

Assessing hope at the end of life: Validation of an experience of hope scale in advanced cancer patients

2004 ◽  
Vol 2 (3) ◽  
pp. 243-253 ◽  
Author(s):  
CHERYL L. NEKOLAICHUK ◽  
EDUARDO BRUERA
Keyword(s):  
Palliative Care ◽  
Cancer Patients ◽  
Advanced Cancer ◽  
Symptom Assessment ◽  
Well Being ◽  
Assessment System ◽  
Validity Evidence ◽  
Advanced Cancer Patients ◽  
Factor I ◽  
Factor Ii

Objective:The purpose of this study was to gather validity evidence for an innovative experience of hope scale, theHope Differential-Short (HDS), and evaluate its clinical utility for assessing hope in advanced cancer patients.Methods:A consecutive sampling approach was used to recruit 96 patients from an inpatient tertiary palliative care unit and three hospice settings. Each participant completed an in-person survey interview, consisting of the following measures: HDS (nine items), Herth Hope Index (HHI), hope visual analog scale (Hope-VAS) and Edmonton Symptom Assessment System (ESAS).Results:Using factor analytic procedures, a two-factor structure for the HDS was identified, consisting ofauthentic spirit(Factor I) andcomfort(Factor II). The HDS factors had good overall internal consistency (α = 0.83), with Factor I (α = 0.83) being higher than Factor II (α = 0.69). The two factors positively correlated with the HHI, Hope-VAS, and one of the ESAS visual analog scales, well-being (range: 0.38 to 0.64) and negatively correlated with depression and anxiety, as measured by the ESAS (range: −0.25 to −0.42).Significance of results:This is the first validation study of the HDS in advanced cancer patients. Its promising psychometric properties and brief patient-oriented nature provide a solid initial foundation for its future use as a clinical assessment measure in oncology and palliative care. Additional studies are warranted to gather further validity evidence for the HDS before its routine use in clinical practice.

scholarly journals A mixed-methods pilot study of ‘LIFEView’ audiovisual technology: Virtual travel to support well-being and quality of life in palliative and end-of-life care patients

2020 ◽  
Vol 34 (7) ◽  
pp. 954-965
Author(s):  
Monisha Kabir ◽  
Jill L Rice ◽  
Shirley H Bush ◽  
Peter G Lawlor ◽  
Colleen Webber ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Palliative Care ◽  
Mixed Methods ◽  
Pilot Study ◽  
Preliminary Data ◽  
Psychological Symptoms ◽  
Well Being ◽  
Assessment System ◽  
Spiritual Well Being

Background: There is evidence that psychosocial and spiritual interventions of short duration, such as reminiscence therapy, provide positive impacts on quality of life and emotional and existential well-being in adults receiving palliative care. Aim: To determine (1) the feasibility of integrating ‘LIFEView’, a video-based software with >1600 videos of world destinations, in palliative care settings, and (2) positive, neutral or harmful effects of using ‘LIFEView’ videos. Design: A mixed-methods pre–post intervention pilot study was conducted to collect feasibility and preliminary data on physical and psychological symptoms, physiological indicators, spiritual well-being and aspects of quality of life. Setting/participants: Adult patients on an inpatient palliative care unit or receiving care from a community palliative care consultation team who were capable of providing consent and completing the outcome measures were eligible participants. Results: Overall, 27/41 (66%) participants took part in the study. Feasibility criteria, including participant acceptability, low participant burden, tool completion rate and retention rate, were fulfilled, though challenges were experienced with recruitment. Modest improvements, though non-significant, were shown on preliminary data collected on physical and psychological symptoms using the Edmonton Symptom Assessment System–revised, spiritual well-being assessed by the 12-item Functional Assessment of Chronic Illness Therapy – Spiritual Well-Being scale and physiological measurements. Qualitative analysis revealed five themes: motivations for using ‘LIFEView’, perceptions of the technology, reminiscence, ‘LIFEView’ as an adaptable technology and ongoing or future use. Conclusion: A future adequately powered study to investigate the impacts of ‘LIFEView’ on patient well-being and quality of life appears to be feasible.

Performance Status and Symptom Scores of Women With Gynecologic Cancer at the End of Life

2013 ◽  
Vol 23 (5) ◽  
pp. 971-978 ◽  
Author(s):  
Lori Spoozak ◽  
Hsien Seow ◽  
Ying Liu ◽  
Jason Wright ◽  
Lisa Barbera
Keyword(s):  
Cervical Cancer ◽  
End Of Life ◽  
Performance Status ◽  
Gynecologic Cancer ◽  
Symptom Burden ◽  
Symptom Assessment ◽  
Well Being ◽  
Assessment System ◽  
Edmonton Symptom Assessment System ◽  
Symptom Scores

ObjectiveThe Palliative Performance Scale (PPS), which measures performance status (100 = best performance to 0 = dead), and the Edmonton Symptom Assessment System (ESAS), which measures severity of 9 symptoms, are routinely collected at ambulatory cancer visits in Ontario. This study describes the trajectory of scores in patients with gynecologic cancer in the last 6 months of life.MethodsAn observational study was conducted between 2007 and 2010. Patients had ovarian/fallopian tube, uterine, and cervical cancer and required 1 or more PPS or ESAS assessment in the 6 months before death. Outcomes were the average PPS and ESAS scores per week before death. Using logistic regression, we analyzed the odds ratio of reporting a moderate to severe score for each symptom.ResultsSeven hundred ninety-five (PPS) and 1299 (ESAS) patients were included. The average PPS score started at 70 and ended at 30, rapidly declining in the last 2 months. For ESAS symptoms, drowsiness, decreased well-being, lack of appetite, and tiredness increased in severity closer to death and were prevalent in more than 70% of patients in the last week of life. Patients with cervical cancer had increased odds of moderate to severe pain (1.74; 95% confidence interval, 1.30–2.32) compared with ovarian cancer.ConclusionsTrajectories of mean performance status had not reached the “end-of-life” phase until 1 week before death. A large proportion of the gynecologic cancer patients reported moderate to severe symptom scores as death approached. Pain was uniquely elevated in the cervical cancer cohort as death approached. Adequately managing the symptom burden appears to be a significant issue in end-of-life gynecologic care.

scholarly journals Quality of Life of Patients with Advanced Cancer in Palliative Therapy and in Palliative Care

Aquichan ◽  
2019 ◽  
Vol 19 (3) ◽  
pp. 1-14
Author(s):  
Leonel dos Santos Silva ◽  
Bruna Eloise Lenhani ◽  
Dabna Hellen Tomim ◽  
Paulo Ricardo Bittencourt Guimarães ◽  
Luciana Puchalski Kalinke
Keyword(s):  
Quality Of Life ◽  
Palliative Care ◽  
Palliative Therapy ◽  
Symptom Assessment ◽  
Assessment System ◽  
Life Questionnaire ◽  
Edmonton Symptom Assessment System ◽  
Quality Of Life Questionnaire ◽  
Chronic Illness Therapy

Objective: To assess the quality of life of patients with advanced cancer in palliative therapy and in palliative care. Materials and Methods: Quantitative, observational, cross-sectional, and analytic study conducted in a teaching hospital in Paraná, Brazil, from January to June 2018, with 126 patients: 107 in palliative therapy; 19 in exclusive palliative care. The questionnaires for data collection were: Quality of Life Questionnaire-Core 15-Palliative, Functional Assessment of Chronic Illness Therapy-Palliative Care 14, and Edmonton Symptom Assessment System. The Spearman non-parametric coefficient test was used for the analysis. Results: The overall quality of life in palliative therapy and in palliative care was, respectively, 71.54/59.65; when correlating the total score of quality of life of the Quality of Life Questionnaire-Core 15-Palliative with the Functional Assessment of Chronic Illness Therapy-Palliative Care 14 (p = 0.001), and the Edmonton Symptom Assessment System (p = 0.001), significant difference of better quality of life was observed in the palliative therapy. Conclusion: Patients in palliative therapy have good overall quality of life, while the palliative care group reports regular quality of life. The symptoms were milder in the palliative therapy and more intense and with greater significance in palliative care; hence, knowing the compromise of quality of life will help professionals in planning interventions with transdisciplinary approach for patients and for their families.

Developing pathways for cancer rehabilitation in tertiary oncology centers: Initial observations at the McGill University Health Centre.

2014 ◽  
Vol 32 (31_suppl) ◽  
pp. 17-17
Author(s):  
Sabrina Cesare ◽  
Irina Uscatescu ◽  
Jonathan di Tomasso ◽  
Lorella Ciutto ◽  
Kevin Yu-Chueh ◽  
...  
Keyword(s):  
Cancer Patients ◽  
Handgrip Strength ◽  
Health Centre ◽  
Symptom Assessment ◽  
Well Being ◽  
Assessment System ◽  
Cancer Rehabilitation ◽  
Targeted Interventions ◽  
Mcgill University ◽  
Clinically Significant

17 Background: No definitive rehabilitation pathways exist for cancer patients. To address this gap, the Cancer Rehabilitation interdisciplinary team at the McGill University Health Centre has developed three program paths (e.g., Restorative, Supportive, and Cachexia) to meet the various specialized and personalized needs of cancer patients. Methods: A consecutive cohort of patients referred to the Cancer Rehabilitation Clinic between January 1st and June 30th, 2014 was considered. We examined the following baseline characteristics: handgrip strength (HGS), the abridged Patient Generated-Subjective Global Assessment (aPG-SGA) and Edmonton Symptom Assessment System (ESAS) self-reported questionnaires. Results: Of the 54 patients evaluated (57.4% male), 20 (mean age: 47.4 yrs), 8 (59.9 yrs) and 26 (64.6 yrs) were assigned to the restorative, supportive and cachexia streams, respectively. The most common cancer diagnoses were gastrointestinal (15%), gynecological (13%), breast (12%) and lung (12%). Table 1 contains baseline aPG-SGA, ESAS and HGS scores. Conclusions: Our preliminary data confirm clinically significant differences in muscle strength across the 3 streams for both males and females, as well as significant differences in nutritional, appetite and well-being scores between the patients in the restorative and cachexia pathways. Our data confirm the need of personalized and targeted interventions to achieve or maintain optimal performance and quality of life in cancer survivors with different disease and treatment characteristics. [Table: see text]

Integration and feasibility of symptom burden assessment and early palliative care into an adolescent and young adult leukemia clinic.

2021 ◽  
Vol 39 (15_suppl) ◽  
pp. 10052-10052
Author(s):  
Amy Yuan Wang ◽  
Karen Sarah Hoehn ◽  
Collin Hanson ◽  
Sarah Monick ◽  
Fay J. Hlubocky ◽  
...  
Keyword(s):  
Palliative Care ◽  
Supportive Care ◽  
Emotional Distress ◽  
Symptom Burden ◽  
Symptom Assessment ◽  
Well Being ◽  
Brief Symptom Inventory ◽  
Early Palliative Care ◽  
Spiritual Well Being

10052 Background: Patients (pts) diagnosed with hematologic malignancies during adolescence & young adulthood (AYA) are a uniquely challenging population who are understood to have robust supportive care needs. Here, we describe their symptom burdens and the feasibility of integrating palliative care into an outpatient, multi-disciplinary AYA leukemia clinic at an academic medical center. Methods: Palliative care was introduced into the AYA clinic in 8/2020 to provide symptom-focused care. Pre-existing clinic services included psychologists, pharmacists, and social workers. All established pts receiving routine follow up were referred by the oncology team to the Supportive Care team, which provided same-day palliative care consultation in the same clinic space with a telehealth option and as needed follow-up. To describe baseline symptom burdens, a random cross-sectional sample of pts completed a multi-domain symptom assessment (SA) using validated self-report instruments including physical (Edmonton Symptom Assessment Scale [ESAS]); emotional (Brief Symptom Inventory-18 [BSI-18]); financial (FACIT-COST); cognitive (Childhood Cancer Survivor Study – Neurocognitive Questionnaire); spiritual (FACIT -Spiritual Well-being Scale); and quality of life (QOL) (FACT-General) measures. All pts have a diagnosis of acute or chronic leukemia and were on active treatment or in survivorship. Results: Over 6 months, 30 pts (median age 29 years at assessment, range 18-45 years) received symptom-focused palliative care over 16 combined clinics with 81 total encounters averaging 5 pts (range 1-8) per clinic. 47% were female. No pts declined palliative care. Pts received on average 2.7 follow up visits (range 1-6), with 50% of encounters resulting in adjustments to medical management. Common issues addressed included pain, muscle cramps, neuropathy, anxiety, insomnia, depression, nausea, and non-pharmacological symptom control remedies. Of 46 pts, 31 (67%) completed the SA (median age 30 years at assessment, range 18-43 years); 48% were female; 84% were on treatment. 100% of pts reported fatigue, and 48% reported > = 1 severe symptom (range 0-7) based on the ESAS with “poor feeling of well-being” as the most common (23%). 45% met criteria for BSI-18 emotional distress, and 45% reported some neurocognitive impairment. Emotional distress (p < 0.01), financial toxicity (p = 0.03), low spiritual well-being (p < 0.01), and presence of pain, nausea, or depression (p < 0.05) were all associated with lower QOL. Conclusions: AYA pts with leukemia undergoing treatment and in survivorship experience high symptom burden with poor QOL. It is feasible to both assess symptom burden and provide early palliative care focused on symptom management in an outpatient, multi-disciplinary clinic setting.

ESAS (Edmonton Symptom Assessment System) as An Effective Outpatient Serial-Longitudinal Symptom Assessment Tool In Patients with Sickle Cell Disease.

Blood ◽  
2010 ◽  
Vol 116 (21) ◽  
pp. 3798-3798
Author(s):  
Gabriel Lopez ◽  
Darla K Liles ◽  
Charles L Knupp
Keyword(s):  
Palliative Care ◽  
Sickle Cell Disease ◽  
Sickle Cell ◽  
Symptom Management ◽  
Assessment Tool ◽  
Symptom Assessment ◽  
Assessment System ◽  
Cell Disease ◽  
Edmonton Symptom Assessment System

Abstract Abstract 3798 Purpose: Our goal is to implement an ongoing symptom assessment strategy using a validated palliative care tool in the outpatient management of adult patients with sickle cell disease at a comprehensive sickle cell center. Methods: Sickle cell disease is a chronic lifetime illness with intermittent acute exacerbations to daily symptoms. The extension of palliative care symptom management strategies to patients with sickle cell disease has been proposed. Symptom assessment tools such as the ESAS (Edmonton Symptom Assessment System), validated in the palliative care population, may have a role in sickle cell disease management. Ten symptoms are assessed, with the average 24 hour symptom score reported on a 0 to 10 numerical scale, 10 being the worst possible. In our study, 75 adult patients with sickle cell disease presenting for their outpatient visit at a comprehensive sickle cell center were enrolled; they were asked to complete the ESAS and a survey regarding their opinion of the ESAS at each clinic visit. Results: Study patients were 100% African American, 56% (42/75) female, ages 19–67, with disease types 71% (53/75) HgbSS, 19% (14/75) HgbSC, and 11% (8/75) HgbS/beta thal. At least 49% (37/75) of patients had one follow up visit after enrollment, for a total of 112 clinic visits. On the initial visit, 92% (65/71) agreed or strongly agreed with the statement “the ESAS is easy to complete”; 97% (71/73) reported instructions as clear; 96% (72/75) reported no words were difficult to understand; 83% (59/71) were satisfied or very satisfied with the ESAS as a way to report symptoms; 93% (68/73) would recommend the ESAS to other patients. 62% (45/73) of patients reported the ESAS helped them remember symptoms they were experiencing; 34% (25/73) were encouraged to discuss medical issues more openly with their health care provider. In a comparison of visit 1 (V1) and 2 (V2) in the 37 patient subset with a single follow up visit, 94% (33/35) on V1 and 94% (33/35) on V2 recommended the ESAS to other patients; 78% (28/36) on V1 and 86% (31/36) on V2 were satisfied or very satisfied with the ESAS. Including all 75 patients on their initial visit, the most intense symptoms (≥ 4 on ESAS scale) recorded were pain 4.6 (± 3.1) and sleep 4.1 (±3). In the 37 patient subset with follow up, V1 pain 4.7 (± 2.7) and V1 sleep 3.5 (± 2.5); V2 pain 4.4 (± 3.2) and V2 sleep 4.3 (± 2.6). Conclusion: The ESAS is an acceptable, brief, easy to understand symptom assessment tool which can be integrated into an outpatient sickle cell clinic as part of a serial-longitudinal symptom management strategy. Future studies should include measuring the impact of symptom-directed interventions on self-reported symptoms. Disclosures: No relevant conflicts of interest to declare.

The variations in symptom clusters related to well-being in palliative care patients during the final weeks of life

2007 ◽  
Vol 25 (18_suppl) ◽  
pp. 19612-19612
Author(s):  
K. L. Olson ◽  
L. Hayduk ◽  
M. Cree ◽  
Y. Tsui ◽  
H. Quan ◽  
...  
Keyword(s):  
Palliative Care ◽  
Goodness Of Fit ◽  
Well Being ◽  
Symptom Clusters ◽  
Assessment System ◽  
Equation Modeling ◽  
Goodness Of Fit Test ◽  
Indicator Variable ◽  
Time Points

19612 Background: The purpose of this study was to determine whether the relationships between symptoms and well-being, as experienced by palliative care patients, changed as patients approached death. Methods: Data were extracted from a database that included Edmonton Symptom Assessment System scores collected from palliative care patients on Day 7 of Weeks 5 (n=123), 2 (n=115), and 1 (n=113) prior to death between 1995 and 2000. The model contained 18 effect parameters. Based on standard sample size requirements for structural equation modeling of 10 cases per indicator variable, the study was adequately powered for all three time points. The majority of patients had advanced cancer and were receiving care in either a tertiary palliative care or hospice setting. All participants had Folstein Mini- Mental Status Examination scores of 22 or higher at the time of original data collection. A causal model, based primarily on clinical discussions, linking pain, anxiety, nausea, shortness of breath, drowsiness, loss of appetite, tiredness, depression, and well-being was proposed. The model was tested against the data from all three time points, using LISREL, version 8.7.2s. Results: The model fit the data for all time points, but was revised slightly based on the modification indices. The final Goodness of Fit Test values were χ2= 4.2 (d.f.=8, p=.84), χ2= 13.3 (d.f.=9, p=.15), and χ2= 5.5 (d.f.=9, p=.79) respectively. With respect to tiredness, depression and well-being, the model explained at least 70% of the variance at Week 5, between 57% and 83% of the variance at Week 2, and 42% to 58% of the variance in Week 1. Nausea was unimportant in all of the models. The two strongest effects, persisting over all three time periods, were those linking anxiety to depression, and drowsiness to tiredness, reflecting strong stability in patient rankings even as health declined and treatment changed. Conclusions: The symptom clusters in this study changed over time, in disagreement with existing research that assumes the relationships between symptoms within symptom clusters remain stable. An improved understanding of alterations in symptom clusters may contribute to improved control of patient comfort, quality of life, and quality of death. No significant financial relationships to disclose.

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