VANCOUVER, B.C. – Gynecologic cancer symptoms may be more severe in younger women; in women with histories of anxiety, depression, and chronic pain; and in women on active treatment, according to survey results from the University of California, San Francisco.
The findings suggest that outpatient palliative care might best be targeted to women in those categories, said lead investigator Dr. Carolyn Casey, an ob.gyn. with the UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco.
She cautioned against overinterpretation, however. The comparisons are unadjusted and simply correlations at this point. "They don’t speak to the ‘whys’ at all," she said.
The findings are important because outpatient palliative care is a newer field and not routinely offered in all cancer centers. Data are limited on who is most likely to benefit.
The handful of previous symptom studies in outpatient gynecologic cancer patients had fewer than 75 patients, and most women had ovarian cancer and were on chemotherapy.
Dr. Casey and her colleagues wanted a broader sample, so they gave Edmonton Symptom Assessment Scale (ESAS) surveys to 305 women in the gynecologic oncology waiting room over a 19-month period, asking them about symptoms during the previous week. The response rate to the survey is unknown at this point.
About 53% of respondents were between 50 and 70 years old, with 18% older and 29% younger; 46% had ovarian cancer, 37% endometrial cancer, and 17% cervical cancer.
The women were split fairly evenly between early- and late-stage disease and between being on and off treatment. Over a third had no evidence of cancer at the time of the survey. About 17% had histories of anxiety or depression, and 11% had chronic pain histories.
The survey asked women to rate pain, fatigue, anxiety, depression, and well-being on a 10-point scale, with 10 being worst. Severity scores of 4 or higher were considered clinically significant.
Thirty-two percent of the women reported clinically significant pain; 32%, depression; 45%, anxiety; and 47%, fatigue.
"We thought that was pretty high, especially in a population where over a third had no evidence of disease. It highlights a high symptom burden in this population that deserves attention," Dr. Casey said.
The findings also illustrate "the potential benefit of incorporating standardized symptom burden evaluations into clinic visits, and targeting patients found to have higher symptom burdens for referrals to, or at least discussion of, the option of concurrent outpatient palliative care," she said.
Simply asking women whether they’d like outpatient help with their symptoms, a question included in the survey, proved to be an excellent screening method for appropriate referral.
Positive responses "really did highlight a group that had a much higher symptom burden across the board. It turns out that just asking a patient if they are interested in that referral does pretty much as good a job as any other categorization," Dr. Casey said.
She and her colleagues compared women aged less than 50 years to women over 70 and found a trend toward greater symptom burden in younger patients, although it reached statistical significance only for pain; 44% of women under 50 reported pain at or above level 4 severity, while that level of pain was reported by only 17% of women over 70 (P = .001).
No difference in symptom burden was found by cancer stage and no statistically significant difference by type of cancer, although there was a trend toward less pain and fatigue in endometrial cancer and less anxiety in cervical cancer.
"Not surprisingly, patients with no evidence of disease at the time of their visit had a lower symptom burden across the board," Dr. Casey said. Similarly, those under treatment had a greater burden of anxiety and fatigue and worse well-being.
A chronic pain history correlated with increased pain, fatigue, and depression. Patients with a history of depression or anxiety had greater anxiety and fatigue and a worse sense of well-being.
For instance, 66% of women with anxiety or depression histories reported fatigue; the prevalence was 45% among women without those histories (P = .016). About 60% with chronic pain histories reported depression; depression was reported by 30% of those without that history (P = .002).
Without the comparisons being adjusted, it’s possible younger patients were simply more likely to be on treatment at the time of the survey, or treated more aggressively. Perhaps older women were less likely to report symptoms.
"We just don’t know," Dr. Casey said.
Dr. Casey said she had no relevant financial disclosures.