Introduction
Patients with advanced cancer experience many
symptoms frequently. Numerous studies in both
inpatient and outpatient settings have documented
the symptom burden of patients with advanced cancer[–] Teunissen et al. detected that the symptom
group including 37 different symptoms were experienced
by 10% of the research sample in a study
where the patients at the last one or two weeks of
the life were included in the 2nd group while the
others were included in the 1st group within the
scope of a systematic review including 46 different
studies on the symptom frequencies of 26.233 cancer
patients.[] However, pain, fatigue, lack of energy,
weakness and loss of appetite were detected
in more than 50% of the patients in the 1st group. It
was observed that the symptom of weight loss was
detected more in the patients in the 2nd group.[] As
the literature shows, patients with advanced cancer
suffer from physical and psychological symptoms
affecting their lives significantly. Among these
symptoms frequently experienced by the patients,
pain, fatigue, nausea and vomiting, depression,
anxiety, loss of appetite and constipation are primary.[–]
In a study where the priority of the symptoms
caused discomfort and distress in the patients with
advanced cancer followed an expert palliative care
team, the pain was, according to the patients, detected
as the most problematic symptom on its
own among the most prioritised five symptoms
prior to the palliative care programme. Fatigue,
loss of physical function, loss of appetite, nausea
and vomiting and pain were included in the first
five symptoms.[] In some cases, fatigue can be
experienced more frequently by the patients with
advanced cancer.[,] Emotional stress is a state
frequently experienced by a great majority of the
patients who are diagnosed with cancer and are in
different periods of treatment.[,] However, it was
found out that pain and fatigue levels of the cancer
patients suffering from considerably uncontrolled
emotional stress were higher.[,]
Symptoms are multi-dimensional, complex and
subjective elements that may lead to changes in
biological, psychological and cognitive functions
of individuals.[,] At the same time, they can be affected by numerous factors. Determination of
these factors and a proper identification of the effects
of these symptoms on the patients are of vital
importance in terms of symptom control. As the
fundamental objective of providing therapy and
patients with advanced cancer is to control symptoms,
symptom levels and the factors affecting
them should be known.[]
In the studies examining the relationship between
sex and symptom, it was determined that
female cancer patients experience the symptoms
of anxiety and depression more than male patients.
[–] However, in the literature, there are studies
reporting that depression and anxiety are symptoms
which do not differ by sexes and are experienced
at similar frequencies[,] Likewise, while
certain studies report that the symptom of nausea
is experienced by female patients more frequently
than male patients,[,] others stated that symptom
experiences of male and female patients are not
different.[]
Relationship between symptom intensity and
age variable among the patients with advanced
cancer has been addressed in the literature. In a
study, better emotional function, less pain and sleep
disorders were detected in aged cancer patients.[]
In another study, it was found out that the patients
with advanced cancer under the age of 60 reported
higher levels of pain and anxiety in comparison to
the patients with advanced cancer above the age of
60. In the same study, a lower level of appetite was
detected among the elderly.[]
As to the relationship between level of education
and symptom experience, Jordhoy MS (2001)
reported in the study on the factors affecting the
life qualities of cancer patients that cancer patients
with lower levels of education suffer from less pain
in comparison to those with higher levels of education.
In the same study, cancer patients with a
moderate level of education report that their general
well-being is poor in comparison to those having
a higher level of education.[] This study also reveals
that married cancer patients has lower social
functions than the single ones. However, the life of
quality was found statistically significant between
married and single patients.[]
Relationship between symptom experience and
performance levels of individuals is of paramount
importance. In the study where qualities of life of
patients with advanced cancer were determined, a
strong relationship was found between good performance
level and quality of life.[] It was determined
in the study that cancer patients with good
performance levels have a better quality of life. In
another study, a significant relationship was detected
between different performance levels of cancer
patients and emotional function, fatigue, pain, loss
of appetite and constipation. In this study, quality
of life scores were found to be good if the performance
was good while reduced quality of life was
detected when the performance was poor. Physical
function, role, social function and general wellbeing
were found to be very low in the patients
with a Karnofsky performance level below 40.
While minimal change was detected between performance
levels of patients and the symptoms of
diarrhoea, sleeplessness and dyspnea, it was determined
that a regular decrease was observed in the
symptom of nausea and vomiting in the patients
with a performance level of 70 and below.[]
These intense symptoms experienced by the
patients with advanced cancer affect the functional
states and qualities of life of individuals in
a negative manner. Thus, symptom management
constitutes the basis of care. The objective of this
research is to determine the symptom distributions
of patients with advanced cancer as well as the factors
affecting them.
Methods
Carried out in descriptive pattern in order to
determine the symptoms experienced by the patients
with advanced cancer and the factors affecting
them, this study was conducted in the palliative
care and medical oncology clinic of a university
hospital found in İzmir between 01.08.2011 and
31.12.2012. 164 patients who are aged 18 and
above, are conscious, have no visual impairment
and hearing problem, have advanced stage metastases,
have Karnofsky Performance Scale levels of
50 and below and accepted to take part in the research
were included in the research sample.
Research data were collected through face-toface
interviews by using the Patient Identification
Form, Edmonton Symptom Assessment System
(ESAS) and Karnofsky Performance. ESAS was
developed by Bruera E, Kuehn N, Miller M et al.
(1991) in order to identify the symptoms of patients
with advanced cancer.[] It includes 9 symptoms
including pain, fatigue, nausea, depression,
anxiety, drowsiness, loss of appetite, well-being,
and dyspnea. There is also an alternative as “other
symptom”. The scale has a visual analogue or
numeric style of design where symptoms can be
scored between 0 and 10. 0 means that the symptom
is not experienced while 10 means that the
symptom is considerably intense. In ESAS calculation,
the total score of the scale differs between 0
and 90. However, if another symptom not included
in the scale is selected, an additional scope needs
to be supplemented. High score obtained from the
scale refers to high symptom level. Validity and reliability
of ESAS for Turkish society was tested by
Usta Yesilbalkan et al. in 2008 and its Cronbach α
level was found to be over 0.70.[] In the research,
the symptom of “constipation” frequently experienced
in palliative care environments was added as
other symptom. ESAS consisted of 10 symptoms
in total and total score ranged between 0 and 100.
Karnofsky Performance Scale was used in order
to determine the performance levels of patients.
While general and functional states of the patients
were evaluated with this scale, the scores obtained
from the scale ranged between 0 and 100. While
100 indicates the best functional competence level,
0 refers to death in which there is no functional
competence.[] Having a score of 50 and below
(50, 40, 30) in Karnofsky Performance Scale was
used as an inclusion criteria for the study.
Statistical analysis and ethics
For the research to be conducted, ethics committee
of the School of Nursing, hospital and patients
were asked for written and oral permission.
Numbers, percentages, Mann-Whitney test and
Spearman correlation were used in the statistical
analysis of the research data. Statistical significance
level was used as p<0.05.
Results
While 47.6 of the participants were female patients,
52.4% of them were male patients. 81.1% of
them were married, 32.9% of them were graduates
of primary school and 28.7% of them were housewives
(Table 1). In terms of the distribution of patients
according to the disease characteristics, most
of the patients (72%) were in the stage IV, 91.5% of
them had metastases and 59.2% of them were receiving
palliative care. 50% of the patients displayed a
performance status requiring a significant amount of
help (Karnofsky performance score of 50) (Table 2).
Table 1: Patients’ demographic characteristics
Table 2: Distribution of factors related to patients’ illness (n=164)
While the patients’ total score of ESAS scale is
45.58±12.41, their average sub-dimension scores
were found out to be 5.56±2.63 pain, 6.89±2.24
fatigue, 3.64±3.18 nausea, 5.09±2.63 depression,
4.18±2.91 anxiety, 4.23±3.17 drowsiness, 5.91±3.13
poor appetite, 5.00±2.72 poor well-being, 2.24±3.08
dyspnea and 2.87±3.07 constipation (Table 3).
Table 3: ESAS total distress score means and subgroup scores
at baseline
Considering the distribution of factors affecting
the symptom levels of patients, significant relationships
were found between the symptoms of
pain and numbness and the performance levels of
patients; (Table 4) the symptom of fatigue and age;
and the symptom of dyspnea and levels of education
of patients (p>0.05).
Table 4: ESAS Total Distress and subgroup symtom scores and performance status
Discussion
In our study, patients with advanced cancer experienced
the symptoms at different levels. While
the most common symptom was fatigue among patients,
it was followed by pain. However, by some
studies in the literature, pain was reported to be the
most common symptom in patients with advanced
cancer.[,] On the other hand, some studies reported
fatigue as the most frequent symptom in parallel
to the results of our research.[,] Literature also
contains studies in which different symptoms have
higher frequencies.[] Chang et al. detected that
cancer patients experienced moderate or severe fatigue.[] This shows that symptom experience of a patient can be affected by many factors and regular
symptom identification is absolutely essential.
In our study, a significant relationship was
found between the performance status of patients
with advanced cancer and the symptoms of pain
and drowsiness. Patients with worse Karnofsky
performance statuses suffer from more pain and
numbness. In the study conducted by Zimmermann
on symptom burden in patients with advanced cancer,
it was detected that the patients with poor performance statuses experienced fatigue and loss of
appetite more frequently along with a deterioration
in general well-being.[] Another study revealed a
significant relationship between performance status
and the symptoms of fatigue, loss of appetite
and dyspnea.[] In the study where the qualities of
life of patients with advanced cancer were determined,
a strong relationship was found between
good performance level and quality of life.[] It
was reported that cancer patients with good performance
levels had better qualities of life. There
are also other studies on the relationship between
the performance level and quality of life in the literature.[,] In cancer patients, the effect of performance
level on the symptom frequency and quality
of life should certainly be known. This is because
of the fact that performance level of a cancer patient
is an indicator that may determine the estimated
life expectancy in addition to being a value
indicating the prognosis. Thus, performance status
should be closely followed along with symptom
frequency and intensity.
In the present study, a positive significant relationship
was found between age and fatigue level.
It was determined that the patients became more
tired as the age increased. Differently, there are
also studies reporting that young patients experience
higher levels of fatigue than the old patients in the literature.[] Distributions of different symptoms
are also found in the literature. In a study,
it was found out that old cancer patients suffered
from loss of appetite while young patients suffered
from much more pain.[] There are studies revealing
that qualities of life of the elderly are poor
in general population.[] The effect of age on the
quality of life between general elderly population
and cancer patients with advanced cancer was explained
by comorbid situations resulting from advanced
cancer.[] However, in some studies, higher
levels of emotional function, role and social function
incompetence among young cancer patients in
comparison to the old patients were discussed. The
present study reports that the diagnosis of advanced
cancer is more traumatic for young patients.[]
These results imply once more that how symptom
experience is affected by many factors should be
investigated thoroughly in larger populations.
In the literature, researches conducted on the
factors affecting symptom experience reported that
female cancer patients experienced anxiety and depression
more than male patients.[–,] It was determined
that sex had an impact on symptom experience.[] However, a significant relationship could
not be found between sex and symptom frequency.
As a conclusion, in the present study where
symptom frequencies of patients with advanced
cancer and the factors affecting them were examined,
it was found out that fatigue and pain were
the most common symptoms and symptom scores
were generally high in these patients. A relationship
was found between low performance level and age.
For an effective symptom control to be carried out
in the care of a patient with advanced cancer, the
results of this study are invaluable for the multidisciplinary
teams. However, it is a crystal-clear fact
for researchers that symptom experience should be
studied more thoroughly in larger populations with
regular symptom follow-up.
Disclosures and acknowledgments
This study were not supported by other organizations
and companies. The authors have no conflicts
of interest to disclose. The authors thank research
team member for their administrative assistance.
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