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Operationalizing Symptom Distress in Adults With
Cancer: A Literature Synthesis
Teresa T. Goodell, RN, CNS, PhD, CCRN, CS, and Lillian M. Nail, RN, CNS, PhD, FAAN
Key Points . . .
Purpose/Objectives: To address inconsistencies in the definition and
operationalization of symptom distress by synthesizing the literature on
cancer-related symptom distress in adults.
The concept of symptom distress often is mentioned in the
Data Sources: Electronic nursing, psychology, and medicine data-
cancer literature but is operationalized and defined inconsis-
bases; online meeting abstracts; and various print sources.
Data Synthesis: Eight distinct methods of operationalizing the
concept were identified. Gender, ethnic, developmental, cultural, and
A literature synthesis revealed eight distinct operationaliza-
individual differences in symptom distress have not been identified.
tions of symptom distress in published cancer studies, aside
Relationships among symptom frequency, intensity, and distress are
from equating symtom distress with symptom intensity.
A view of symptom distress as a dimension of the symptom
Conclusions: Lack of clarity and consensus in defining and opera-
experience distinct from symptom intensity and frequency
tionalizing symptom distress hinder meta-analysis, research synthesis,
may be emerging but requires examination and validation.
and research utilization. Symptom distress may be emerging as a
component of the multidimensional symptom experience.
Consistently operationalizing symptom distress in a manner
Implications for Nursing: Defining and operationalizing symptom
congruent with patients' interpretations of symptom distress is
distress consistently will enhance research synthesis and assist clini-
recommended to enhance symptom management research.
cians with more effectively meeting the needs of people with cancer.
Research is needed to identify the meanings of symptom distress to
patients with cancer and to differentiate symptom distress from symp-
tom frequency and intensity.
This literature synthesis was carried out according to the
five-stage process described by Cooper (1998). In this model,
the problem is formulated, data are collected, quality of the
ymptom distress often is used to describe the subjective
data is evaluated, data are analyzed and interpreted, and
experience of people in various states of health and ill-
results are presented. In the first stage, problem formula-
ness. Multiple studies have shown that symptom distress
tion, the nature of the sources to be included and excluded is
is related to quality of life, treatment tolerance, and even sur-
determined. Figure 1 summarizes the criteria used to identify
vival in patients with cancer and other illnesses. The importance
sources to be included in this literature synthesis.
of symptom distress as a multidimensional concept in cancer
To include the many valuable sources in which implicit
has been demonstrated repeatedly and is supported by theory.
models of symptom distress are used, rather than clearly ex-
Yet, despite or perhaps because of its ubiquity, symptom dis-
plicated ones, this review does not exclude articles that have
tress remains largely undefined and undeveloped conceptually
left the concept undefined or failed to articulate implicit con-
(McClement, Woodgate, & Degner, 1997). The significance of
ceptual models of symptom distress. In cases where symptom
symptom distress mandates the development of a uniform and
distress remains undefined, the ways in which authors have
valid definition, conceptualization, and operationalization.
This article summarizes and interprets the literature about
symptom distress in adults with cancer, describes definitions
Teresa T. Goodell, RN, CNS, PhD, CCRN, CS, is an assistant professor
in the School of Nursing, and Lillian M. Nail, RN, CNS, PhD, FAAN,
and conceptualizations of symptom distress, differentiates
the Dr. May Rawlinson Endowed Professor of Nursing, is a senior sci-
symptom distress from related terms, and highlights issues
entist, both at the Oregon Health and Science University in Portland.
raised by the lack of consensus regarding symptom distress.
(Submitted March 2004. Accepted for publication October 5, 2004.)
Gaps in the literature are identified, and future directions in
concept development are suggested.
Digital Object Identifier: 10.1188/05.ONF.E42-E47
theses, journal articles, conference proceedings, and research
Source explicitly refers to symptom distress.
monographs were among the final list of relevant sources. The
Symptom distress is measured, not merely mentioned.
research articles included instrument validation, descriptive
Multiple physical and psychoemotional cancer-related symptoms are
and exploratory, intervention, and evaluation studies.
Method of operationalizing the concept is explicit or can be inferred
Definitions of Symptom Distress
from the text.
Symptom distress is not simply equated with symptom intensity or severity.
Symptom distress has been equated with symptom inten-
Measurement is not restricted to one type of cancer or one setting.
sity, a combination of symptom intensity and frequency,
Figure 1. Criteria for Inclusion of Cancer Symptom Distress
quality of life, and health-related quality of life (McClement
et al., 1997). Tishelman, Degner, and Mueller (2000) noted
that even the word "symptom" rarely is defined. Measure-
ments of symptom distress often have been combined with
operationalized the concept and the conclusions drawn can shed
other measures to evaluate clinical trial end points (Dutcher
light on implicit conceptual models of symptom distress.
et al., 2000; Ingham, Seidman, Yao, Lepore, & Portenoy,
This review is restricted to cancer, although symptom dis-
1996; Robert, Soong, & Wheeler, 1997). One recent review
tress also is relevant in other disease categories. The literature
of symptoms in patients with lung cancer (Cooley, Short, &
search produced a predominance of symptom distress sources
Moriarty, 2002) noted that few researchers have delineated
pertaining to cancer. The nature of symptom distress may dif-
the dimensions of the symptom experience being studied.
fer by disease, especially when an interaction occurs among
Table 1 lists symptom distress operationalizations uncov-
multiple symptoms of varying frequency and intensity. Ex-
ered in this literature review aside from the many sources in
ploring differences and similarities across disease categories
which symptom distress simply was equated with symptom
is important but lies outside the scope of this article.
intensity or severity. These operationalizations will be dis-
cussed in chronologic order.
Search Strategy
Johnson (1973) was one of the first to explore the term
"symptom distress" in her work on pain sensations. She
Articles that included symptom distress in the key words,
conceptualized symptoms as consisting of physiologic
title, or abstract were identified through searches of MED-
(sensory) and reactive (distress) components and tested the
LINE, the Cumulative Index to Nursing and Allied Health
independence of both using a quasi-experimental design. A
Literature, PsycINFO, the Cochrane Databases of System-
standard pain stimulus and repeated measures of single-item,
atic Reviews and Abstracts of Reviews of Effectiveness, and
investigator-designed sensory and distress scales were used
Health and Psychosocial Instruments. An initial search of
these databases, conducted in February 2004, revealed more
than 800 unique articles. Limiting this list to English-language
articles relevant to symptom distress and cancer or neoplasms
Table 1. Operationalizations of Symptom Distress
reduced the number to 323. Limiting the search further to
in Different Studies
exclude articles about children and adolescents eliminated
Operationalization of Symptom Distress
just 39 studies, leaving 284 for the final review.
After the initial electronic database searches, hand searches
Bother is equal to distress and distinct from
Johnson, 1973; Johnson &
were done of the citations in the reference lists of relevant
pain intensity.
Rice, 1974
articles. Electronically searchable meeting abstracts (e.g.,
American Society of Clinical Oncology, Oncology Nursing
Distress is synonymous with discomfort.
McCorkle, 1987; McCorkle
Society, World Congress of Psycho-Oncology) and printed
Distress from treatment and disease are
& Young, 1978
proceedings (e.g., University of California, San Francisco,
similar. Distress is equal to the intensity and
Symptom Management Symposia; Western Institute of
frequency of symptoms.
Nursing Assemblies) also were examined. Book chapters,
Distress is physical or mental upset, anguish,
Rhodes et al., 2000; Rhodes
editorials, and presentations that did not report research were
or suffering. Distress and frequency of oc-
& Watson, 1987
excluded. Because of the significance of symptom clusters
currence are two fundamental symptom
(Dodd, Miaskowski, & Paul, 2001), the predominance of mul-
tiple concurrent symptoms of a physical and psychoemotional
nature in patients with cancer, and the potential for multiple
Distress, intensity, and frequency are three
Portenoy et al., 1994
symptoms to exacerbate one another, the authors focused on
fundamental symptom attributes.
symptom distress from multiple cancer-related symptoms. For
this reason, articles focusing strictly on symptom distress in
Distress is equal to bother and one of four
Lenz et al., 1997
relation to psychoemotional symptoms alone were excluded
symptom attributes (the others are quality,
from the review.
timing, and intensity).
Sources that did not include a measurement of symptom
Distress equals symptom interference with life
Cleeland et al., 2000
distress, used only part of a validated symptom distress
activities or emotional upset.
instrument, or focused on distress from a single symptom
were omitted. Eliminating dissertations and theses in which
Distress is psychological, emotional, social, or
National Comprehensive
the operationalization of symptom distress or the findings
spiritual concern caused by physical symp-
Cancer Network, 2004
related to symptom distress could not be determined from
toms or other sources.
the abstract further reduced the list. Abstracts, dissertations,
to examine the sensory and distress components of pain in
al., 2000; Rhodes & Watson, 1987), the authors of the MSAS
healthy volunteers. In two studies, subjects were asked to
considered distress to be one distinct aspect of the symptom
mark a sensory scale to reflect the physical intensity of the
experience to be examined along with other symptom dimen-
pain stimulus and a separate distress scale to reflect "the
sions, not as a summation of the entire symptom experience.
amount of distress the sensations caused" (Johnson, p. 263) or
Lenz et al. (1997) formulated the Theory of Unpleasant
"how much the sensations bother[ed]" them (Johnson & Rice,
Symptoms. According to this theory, distress is one of four di-
1974, p. 206). Both studies identified variations in sensory and
mensions of a symptom and reflects "the degree to which the
distress ratings among subjects given different preparatory
person is bothered by" the symptom (p. 16). The other three
information prior to the same painful stimulus.
dimensions of a symptom are quality, timing, and intensity.
Johnson's (1973) study is significant because its findings
The original theory (Lenz, Suppe, Gift, Pugh, & Milligan,
supported a two-factor conceptualization of pain and were the
1995) was modified to encompass the coexistence of multiple
first to show empirical evidence that symptom distress is not
symptoms. The authors asserted that multiple symptoms oc-
synonymous with symptom intensity. Subsequent studies of
curring simultaneously were likely to have a multiplicative,
symptom distress in people with cancer used "distress" and
not an additive, effect on the person experiencing them. This
"bother" interchangeably. Although Johnson's initial work was
premise, if borne out in subsequent research, casts doubt on
conducted with healthy volunteers, her findings subsequently
the common practice of measuring symptom distress by sum-
have been applied in many clinical oncology studies.
ming several items on a scale.
In a 1987 issue of Seminars in Oncology Nursing dedicated
In the M.D. Anderson Symptom Inventory (Cleeland et
to symptoms, distress is defined as "pressure that is applied to
al., 2000), symptom distress is operationalized as the mean
produce or restrain action" (Rhodes & Watson, p. 243). This
of six items in which subjects rate how much their symptoms
definition is reflected in more recent symptom management
interfere with relationships, mood, enjoyment of life, and
models in which perception and evaluation of a symptom
physical activity. The first half of the tool asks subjects to rate
precede and direct actions intended to relieve the symptom
the highest recent intensity of 13 symptoms on a scale from
(Dodd, Janson, et al., 2001; Teel, Meek, McNamara, & Wat-
110. In this section, one item asks subjects to rate emotional
son, 1997). Rhodes and Watson defined symptom distress as
distress in terms of the intensity of "being distressed (upset)"
"the degree or amount of physical or mental upset, anguish,
(Cleeland et al.). The dual meaning of distress used in this
or suffering experienced from a specific symptom" (p. 243).
tool, as both synonymous with symptom interference and
More recently, Rhodes, McDaniel, Homan, Johnson, and
emotional upset, illustrates the variation in interpretation of
Madsen (2000) distinguished between the frequency of a
the term in research on symptoms.
symptom's occurrence and the distress caused by it. The
The National Comprehensive Cancer Network (NCCN,
combination of these two dimensions was termed "symptom
2004) developed a distress thermometer consisting of a vertical
experience," and a symptom assessment tool, the Adapted
scale resembling a mercury thermometer on which respondents
Symptom Distress Scale-2, was developed using these defi-
rate their global distress. A companion scale asks respondents
to indicate which of five categories of problems (i.e., practi-
In the same issue of Seminars in Oncology Nursing, Mc-
cal, family, physical, spiritual or religious, and emotional) has
Corkle (1987) defined symptom distress as "the person's
caused the distress. The thermometer and its companion scale
level of distress from a specific symptom being experienced"
are meant to be used as a screening tool for distress in clinical
(p. 248) and was the first to determine that symptom distress
did not need to be differentiated according to whether it re-
NCCN (2004) defined distress as
sulted from the disease itself or from the treatment. Symptom
A multifactorial unpleasant emotional experience of
distress was defined earlier by McCorkle and Young (1978)
a psychological (cognitive, behavioral, emotional),
as "the degree of discomfort from the specific symptom as
social, and/or spiritual nature that may interfere with
reported by the patient" (p. 374). This definition was applied
the ability to cope effectively with cancer, its physical
in the development of the Symptom Distress Scale (SDS), per-
symptoms and its treatment. Distress extends along a
haps the most widely used cancer symptom scale. Distress and
continuum, ranging from common normal feelings of
discomfort, therefore, are treated as synonymous in the SDS.
vulnerability, sadness, and fears to problems that can
Symptom distress is operationalized as the sum of responses
become disabling, such as depression, anxiety, panic,
to symptom intensity and frequency items. Not all symptoms
social isolation, and existential and spiritual crisis (p.
in the SDS are rated in terms of both intensity and frequency,
and none is rated in terms of distress or bother. Because the
SDS item stems are not consistent across symptoms, different
This conceptualization emphasizes the emotional aspects
symptoms contribute conceptually diverse information to the
of distress, and symptoms are seen as one of several possible
global symptom description.
causes of distress, which also include coping with fam-
T h e Memorial Symptom Assessment Scale (MSAS)
ily members, financial problems, and existential issues. The
(Portenoy et al., 1994) measures a set of symptoms in terms
NCCN conceptualization is unique in that distress, not the
of frequency, intensity, and distress (bother). The authors
symptom(s) alone, is the stimulus to action and that the ability
described these attributes as the fundamental properties of
to cope with symptoms is an outcome of distress.
symptoms, although the properties themselves are not explic-
Related Terms
itly defined. Portenoy et al. offered evidence of this assertion
by showing that the three subscales are moderately, but not
highly, intercorrelated. Similar to other researchers (Johnson,
Many terms similar to symptom distress have been used in
1973; Lenz, Pugh, Milligan, Gift, & Suppe, 1997; Rhodes et
describing and measuring symptom experiences. "Symptom
burden" is one of the more common. In the large, hospital-
concept analysis, symptom experience was described broadly
based SUPPORT study (Desbiens, Mueller-Rizner, Connors,
as encompassing symptom intensity, frequency, distress, and
Wenger, & Lynn, 1999), symptom intensity and frequency were
meaning (Armstrong, 2003). These articles suggest that symp-
measured with investigator-designed tools. Symptom burden
tom experience encompasses symptom distress, signifying an
was operationalized as the total number of patients per hospital
emerging view of symptom experience as a broader concept
reporting one or more symptoms of moderate to intense severity
than symptom distress.
present half or more of the time or one or more symptoms of
Relationships Among Symptom
extreme severity, regardless of frequency. Among seven disease
categories, the number of people exceeding these investigator-
Distress, Intensity, and Frequency
defined symptom thresholds was highest in the lung cancer
population (Desbiens & Wu, 2000).
Some symptoms likely are more distressing than others. For
In a hospice study, Kutner, Kassner, and Nowels (2001)
example, pain, nausea, fatigue, and shortness of breath often
modified the MSAS, originally a self-report scale, to allow
are observed in clinical practice as distressing, even if they are
providers to rate patients' symptom burden. In the modifi-
moderate in intensity and frequency. In contrast, other symp-
cation, the distress dimension of the scale was omitted and
toms, such as a change in personal appearance or dry mouth,
providers evaluated symptom intensity and frequency alone.
may not cause distress, even if they are frequent and intense.
These two dimensions, combined with the prevalence of
The values of the patient may influence the relationships
symptoms in the sample population, were termed "symptom
among symptom intensity, frequency, and distress. An ex-
ample from the primary author's clinical practice illustrates
Both of these studies used symptom burden to describe
this assertion. Mr. L, a 70-year-old entrepreneur with stage
population or sample characteristics, not individual symptom
IV esophageal cancer, was considering endoscopic treatment
experiences. Symptom burden may be used to refer to the
for malignant dysphagia. Although his dysphagia was only
collective symptom experiences of a group, but its use in this
grade I on the 0 5 dysphagia scale, he described intense
manner is not universal. In addition, no concept development
distress from the social effects of this symptom, which kept
has occurred with respect to symptom burden.
him from attending important business and social events at
"Bother" is another term closely associated with symptom
the city's top steak houses.
distress. Johnson and Rice (1974) evaluated symptom distress
The importance of Mr. L's business and social engage-
by asking subjects how much a symptom (i.e., pain) bothered
ments, centered around sharing a steak dinner, transformed a
them. Similarly, the MSAS measures distress by asking patients
symptom that was mild in intensity (according to a standard
how much a symptom bothers or distresses them (Portenoy
measure) to one that represented significant distress. For an-
et al., 1994). Nesbitt and Heidrich (2000) used a symptom
other individual, grade I dysphagia (dysphagia for only some
bother scale to study older women's functional health, symptom
solid foods) may not be distressing, but Mr. L was distressed
bother, quality of life, illness appraisal, and sense of coherence.
enough to seek palliative treatment.
The symptom bother scale rates 13 symptoms on a scale of 0
If Mr. L's case is representative, the meaning assigned to a
(not bothered) to 3 (bothered a great deal).
symptom by the individual and not its intensity or frequency
Patients understand the terms used to measure their symptoms
may be a predictor of distress. For Mr. L, symptom distress
from a lay viewpoint. Therefore, vernacular definitions of these
seemed linked to the social significance of the symptom,
terms may be useful in understanding their meaning to research
but for others, distress may be associated with the degree of
subjects and patients. Bother, which is synonymous with irk and
functional impairment, a change in personal appearance, or
pester, is defined by Merriam-Webster, Incorporated (2005), as
interference with usual activities caused by the symptom.
"to annoy, especially by petty provocation." However, distress,
With few exceptions, patients' views of the factors that
which is synonymous with being upset, is defined as "the state
contribute to symptom distress have not been reported. One of
of being in great trouble" (Merriam-Webster, Incorporated).
the few studies that examined this issue (Knobf, 2001) showed
These two definitions suggest that distress and bother may
that the symptom experience is context-bound among women
be qualitatively different. Whether patients distinguish bother
experiencing chemotherapy-induced menopause. Although
from distress and whether that distinction affects the validity of
the quality of menopausal symptom distress described by the
measurements of symptom distress are not known.
study participants was similar to that described by women
Symptom experience has been used to describe symptoms
experiencing natural menopause, the study participants' young
of patients with cancer (Knobf, 2001; Rhodes et al. 2000;
age and the abrupt onset of menopausal symptoms within the
Samarel et al., 1996). Samarel et al. operationalized symptom
context of a breast cancer diagnosis influenced their appraisal
experience as the sum of 24 items querying the intensity, fre-
of symptoms and decision making about symptom relief strat-
quency, and distress of eight symptoms. The Symptom Expe-
egies. These findings are consistent with conceptual models
rience Scale, like Rhodes et al.'s Adapted Symptom Distress
such as the University of California, San Francisco, Symptom
Scale-2, began as a modification of the McCorkle SDS. In the
Management Model (Dodd, Janson, et al., 2001) and the
Symptom Experience Scale, distress, frequency, and intensity
Symptom Interpretation Model (Teel et al., 1997) that take
ratings are summed to produce a symptom experience score.
into account the meaning of symptoms to the individual and
Unlike the SDS, these dimensions are measured separately for
give further support to the possibility that symptom meaning
each symptom in both the Symptom Experience Scale and the
may play a role in the degree of symptom distress reported
Adapted Symptom Distress Scale-2.
by patients.
Knobf (2001) also used symptom experience to describe
Only a few investigators have measured the relationships
the findings of a qualitative study of women experiencing
among symptom intensity, frequency, and distress. In a vali-
premature menopause related to breast cancer treatment. In a
dation study of the MSAS in patients with various cancers
(Portenoy et al., 1994), distress consistently was rated lower
understand and describe the various terms used to capture
than frequency or severity, suggesting that patients may not
the impact of their symptoms would contribute a great deal to
evaluate distress as a function of frequency and intensity. Cor-
symptom measurement and enhance clinicians' understand-
relations of frequency (r = 0.43) and intensity (r = 0.70) with
ing of the experiences of patients who live with multiple
symptom distress supported the conceptualization of distress,
frequency, and intensity as distinct but interrelated dimensions
The meaning of symptom distress may differ by race,
of the symptom experience.
ethnicity, socioeconomic status, education, disease, or other
Further support for conceptualizing symptom frequency,
demographic or clinical variables. The initial search results
intensity, and distress as separate dimensions of the symp-
revealed that most of the literature about symptom distress
tom experience is found in Samarel, Fawcett, and Tulman
in cancer applies to adults, although in recent years, more
(1993), who studied the effect of a support group on symp-
attention has been paid to symptom distress in children with
tom distress in women with breast cancer. Women reported
cancer (Woodgate, Degner, & Yanofsky, 2003). In 2002, a
no change in symptom frequency or intensity as measured
National Institutes of Health consensus panel concluded
by the SDS, but participants reported decreased distress in
that too few established symptom assessment tools for chil-
the qualitative portion of the study. Samarel et al. (1996)
dren, adolescents, older adults, individuals with cognitive
subsequently developed the Symptom Experience Scale,
impairments, and individuals of various ethnic and cultural
evaluating symptoms in terms of distress, intensity, and fre-
groups exist.
quency. Distress, frequency, and intensity ratings pertaining
Tishelman, Taube, and Sachs (1991) provided empirical
to a given symptom consistently loaded together in the final
evidence for the contribution of clinical and demographic
rotated factor matrix, but factor loadings did not achieve
factors to symptom distress by measuring psychological and
unity, which supported the idea that the three separate symp-
clinical characteristics, perceptions of care, and demographic
tom dimensions were independent.
variables of patients with cancer. Combining these sets of
In contrast, Nail (1993), in a longitudinal study of women
explanatory variables produced a regression model that ex-
with gynecologic cancer, found high correlations between
plained more of the variance in symptom distress as measured
severity and upset (r = 0.89 0.97), suggesting that they
by the SDS than any single category.
were not distinct dimensions. This finding appears to con-
tradict those of Portenoy et al. (1994) and Samarel et al.
(1996). Nail's findings may be attributable to the meaning
of the word "upset" (as opposed to distress or bother), the
This literature synthesis highlights the many issues associated
characteristics of the population under study, or the nature
with defining and conceptualizing symptom distress in people
of their symptoms.
with cancer. Inconsistent or assumed definitions, incomplete
descriptions of conceptualization and operationalization, and
insufficient research on the nature of the concept itself inhibit
comparisons across studies and may cause confusion with re-
This literature synthesis has reinforced the relevance of
lated issues, such as quality of life and symptom intensity.
symptom distress and the need for further explication of its
Future research should explore symptom distress from the
definition, contributing factors, and the outcomes associated
patient's perspective. Delineating cultural, disease-related, and
with it. Most of the literature regarding symptom distress is
individual differences in symptom distress may assist clini-
concerned with cancer; nearly half of the references initially
cians and researchers with better meeting the needs of people
retrieved concerned cancer or neoplasms. The number of
living with cancer symptoms. Moreover, it may help clinicians
references to symptom distress in the cancer literature has
and researchers understand the overlap of symptom frequency
increased dramatically since 2000. Of the more than 200
and intensity with symptom distress and identify priorities for
sources reviewed for this article, approximately 30% were
research and individual symptom management.
published after January 1, 2000.
The outcomes associated with symptom distress should be
Despite increasing support for a multidimensional con-
explored more thoroughly. McCorkle et al. (2000) suggested
ceptualization of symptom distress, operational definitions
that symptom distress independently influences survival. Symp-
of symptom distress as a simple function of intensity remain
tom distress may be a powerful tool for outcomes prediction if
common in recent literature. For example, Mercadante et al.
proven to be an indicator of individual differences in disease
(2001) measured the effectiveness of methadone versus mor-
states not accounted for by objective disease severity indicators
phine for pain in palliative care by summing a set of symptom
such as cancer staging.
intensity items to produce a distress score. In another study,
Further concept development would permit comparison
Kuo and Ma (2002) examined symptom distress in a sample of
across studies and facilitate meta-analysis. The ability to de-
73 Taiwanese patients with lung cancer. This study employed
scribe relationships among symptom intensity, frequency, and
a 47-item author-designed tool measuring physical and psy-
distress and the influences on the nature of these relationships
chological symptoms on a scale of 0 (never experienced) to
may advance the science of symptom management and help
3 (severe). Although the quality of these two examples, and
clinicians set priorities for symptom management interventions,
many similar studies, is not in dispute, the use of the phrase
which are crucial for improving the treatment of people with
"symptom intensity" or "symptom severity" may be a clearer
cancer symptoms.
representation of the concept.
Whether patients with cancer equate symptom distress
Author Contact: Teresa T. Goodell, RN, CNS, PhD, CCRN,
with related terms such as discomfort, burden, trouble, upset,
CS, can be reached at goodellt@ohsu.edu, with copy to editor at
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