CHICAGO - Nonpain symptoms, particularly fatigue, sleep disturbance, and drowsiness, were the most common moderate to severe symptoms among cancer patients undergoing treatment in a community ambulatory setting, according to new data from the Eastern Cooperative Oncology Group study of Symptom Outcomes and Practice Patterns.
The researchers had hypothesized that pain, fatigue, and emotional distress would surface as the most frequent problems in the sample of 3,123 patients (median age 61 years; 30% male) with solid breast (50%), colorectal (23%), lung (17%), and prostate tumors (10%).
The study also found that outpatients who were more ill and symptomatic at baseline were more likely to report benefiting from supportive oncology care at a 1-month follow-up visit, said Dr. Michael J. Fisch, director of the general medical oncology program at M.D. Anderson Cancer Center in Houston.
"It’s upside down of the way we think about treating cancer," Dr. Fisch said in a focus session on symptom management at the annual Chicago Supportive Oncology Conference. "The better off you are, the more likely you are to benefit from chemotherapy or aggressive therapy. But when it comes to symptom management, the sicker you are, the more likely you are to benefit. First of all, you have more room to improve ... but it probably also has something to do with the fact that the sicker you are, the more dedicated [physicians] are at making that problem better. We are not going to take aim at ... things that are more middle-of-the-road in severity."
The study was conducted at 7 academic and 32 community clinics to highlight the most prevalent and significant physical and psychological symptoms in the course of a visit and a follow-up visit in outpatient medical oncology practice, and to describe the pattern and magnitude of functional change in these symptoms.
"We weren’t just interested in patients who were highly symptomatic or patients who had advanced disease," he said. "We wanted to see how things really are as they flow through [the system]. We knew that solid tumor care dominates what really goes on in terms of the patterns and reflexes of care, so we restricted it to the four most common solid tumors. And we let people come as they were, whether they were there for their first visit, long-term follow-up, or third cycle chemotherapy."
Participants took the M.D. Anderson Symptom Inventory (MDASI), which asks patients to rate the severity of multiple symptoms over the previous 24 hours on a 0-10 scale. The inventory was administered again 1 month later. A 2-point change in numerical rating was used as the criterion for meaningful change in a symptom. Data were analyzed on 3,100 patients.
The most prevalent moderate to severe symptoms were fatigue (34%), disturbed sleep (27%) and drowsiness (22%). Other important symptoms in the moderate to severe range were pain, numbness/tingling, distress, dry mouth, and hair loss (19%), and anorexia/cachexia, depression, and cognitive disturbance (16-17%).
Less prevalent symptoms in the moderate to severe range were dyspnea (15%), constipation (13%), diarrhea (11%), coughing (10%), nausea (8%), rash/pruritis (6%), sore mouth (5%), and vomiting (3%).
"We’re always very interested in nausea and vomiting – it’s a big problem – but just in terms of the prevalence of moderate to severe nausea and vomiting in any given outpatient oncology day, it’s not as prevalent," said Dr. Fisch.
Overall, changes in the top symptoms at 1 month were not impressive. For example, fatigue improved in 20% of patients but worsened in 26% of patients after supportive care, and pain improved in 15% of patients but worsened in 18%.
These results are "a little bit humbling," said Dr. Fisch, "if you are comprehensively assessing people and then following up 4-5 weeks later" and are using patients’ ratings on the [MDASI] to plan care. "Overall, symptom burden remains substantial and difficult to resolve."
The largest improvements were seen in patients whose symptoms were moderate to severe. For example, vomiting improved in 78% of patients and worsened in only 2% of patients who reported moderate to severe problems with this symptom at baseline. Similarly, 52% of patients reported improvements in pain and 10% said their pain got worse.
"I had a sense that we would do better than that [with pain management] – that it might be more like 85%," Dr. Fisch said.
Colorectal cancer patients were the only group whose pain significantly improved. The improvement was significantly better than patients with lung cancer, even after adjustment for other variables. In addition, patients with poor performance status significantly improved their pain, and their improvement was significantly better than those with better performance status.