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Symptom Clustering in Older Taiwanese Children With Cancer

Chao-Hsing Yeh
Yi-Chien Chiang
Lung-Chang Chien
Lin Lin
Chao-Ping Yang
Huo-Li Chuang
ONF 2008, 35(2), 273-281 DOI: 10.1188/08.ONF.273-281

Purpose/Objectives: To derive symptom clusters occurring in a large group of older pediatric patients with cancer in Taiwan and to examine whether each cluster differed based on gender, type of cancer and disease, pain, and functional status.

Design: Descriptive, correlational study.

Setting: Pediatric oncology inpatient unit and outpatient clinics in Taiwan.

Sample: 144 pediatric patients with cancer, aged 10-18 years.

Methods: Subjects completed the Memorial Symptom Assessment Scale 10-18, the Play Performance Scale for Children, and a demographic questionnaire. Medical records provided disease and treatment data. Cluster analysis techniques were used to identify the symptoms that clustered together by demographic characteristics, as well as disease, pain, and functional status.

Main Research Variables: Symptom cluster, pain status, and functional status.

Findings: Five clusters were identified from the statistical analysis. The symptoms that clustered together were somewhat surprising, and some can be explained by cultural differences. Patients with pain reported statistically significant higher distress in all five clusters.

Conclusions: Five symptom clusters are identified in older Taiwanese children with cancer. The way and possible rationale of how these symptoms clustered together is discussed.

Implications for Nursing: This is the first study that used a statistical procedure to derive symptom clusters experienced by pediatric oncology patients. Knowledge from this study can provide a starting point to investigate the stability of symptom clusters with different states of disease, different populations, and over various periods of time.


Aparasu, R., McCoy, R.A., Weber, C., Mair, D., & Parasuraman, T.V. (1999). Opioid-induced emesis among hospitalized nonsurgical patients: Effect on pain and quality of life. <i>Journal of Pain and Symptom Management</i>, 18(4), 280-288.

Aquino, V.M., Harvey, A.R., Garvin, J.H., Godder, K.T., Nieder, M.L., Adams, R.H., et al (2005). A double-blind randomized placebo-controlled study of oral glutamine in the prevention of mucositis in children undergoing hematopoietic stem cell transplantation: A pediatric blood and marrow transplant consortium study. <i>Bone Marrow Transplantation</i>, 36(7), 611-616.

Barsevick, A.M. (2007). The concept of symptom cluster. <i>Seminars in Oncology Nursing</i>, 23(2), 89-98.

Behling, O., & Law, K.S. (2000). <i>Translating questionnaires and other research instruments: Problems and solutions</i>. Thousand Oaks, CA: Sage.

Calinski, T., & Harabasz, J. (1974). A dendrite method for cluster analysis. <i>Communications in Statistics</i>, 3, 1-27.

Chang, P.C., & Yeh, C.H. (2005). Agreement between child self-report and parent proxy-report to evaluate quality of life in children with cancer. <i>Psycho-Oncology</i>, 14(2), 125-134.

Chen, M.L., & Tseng, H.C. (2006). Symptom clusters in cancer patients. <i>Supportive Care in Cancer</i>, 14(8), 825-830.

Cleeland, C.S., Bennett, G.J., Dantzer, R., Dougherty, P.M., Dunn, A.J., Meyers, C.A., et al (2003). Are the symptoms of cancer and cancer treatment due to a shared biologic mechanism? A cytokine-immunologic model of cancer symptoms. <i>Cancer</i>, 97(11), 2919-2925.

Collins, J.J., Byrnes, M.E., Dunkel, I.J., Lapin, J., Nadel, T., Thaler, H.T., et al (2000). The measurement of symptoms in children with cancer. <i>Journal of Pain and Symptom Management</i>, 19(5), 363-377.

Collins, J.J., Devine, T.D., Dick, G.S., Johnson, E.A., Kilham, H.A., Pinkerton, C.R., et al (2002). The measurement of symptoms in young children with cancer: The validation of the Memorial Symptom Assessment Scale in children aged 7-12. <i>Journal of Pain and Symptom Management</i>, 23(1), 10-16.

Dodd, M., Janson, S., Facione, N., Faucett, J., Froelicher, E.S., Humphreys, J., et al (2001). Advancing the science of symptom management. <i>Journal of Advanced Nursing</i>, 33(5), 668-676.

Dodd, M.J., Miaskowski, C., & Lee, K.A. (2004). Occurrence of symptom clusters. <i>Journal of the National Cancer Institute Monographs</i>, 32, 76-78.

Dodd, M.J., Miaskowski, C., & Paul, S.M. (2001). Symptom clusters and their effect on the functional status of patients with cancer. <i>Oncology Nursing Forum</i>, 28(3), 465-470.

Francis, A.J., & Dempster, R.J. (2002). Effect of valerian, Valeriana edulis, on sleep difficulties in children with intellectual deficits: Randomised trial. <i>Phytomedicine</i>, 9(4), 273-279.

Goldman, A., Hewitt, M., Collins, G.S., Childs, M., & Hain, R. (2006). Symptoms in children/young people with progressive malignant disease: United Kingdom Children's Cancer Study Group/Paediatric Oncology Nurses Forum survey [Electronic version]. <i>Pediatrics</i>, 117(6), e1179-e1186. Retrieved July 1, 2007, from http://www.pediatrics.org/cgi/content/full/117/6/e1179 <a target="_blank" href='http://www.pediatrics.org/cgi/content/full/117/6/e1179'>http://www.pedia...

Hedstrom, M., Haglund, K., Skolin, I., & von Essen, L. (2003). Distressing events for children and adolescents with cancer: Child, parent, and nurse perceptions. <i>Journal of Pediatric Oncology Nursing</i>, 20(3), 120-132.

Hockenberry, M. (2004). Symptom management research in children with cancer. <i>Journal of Pediatric Oncology Nursing</i>, 21(3), 132-136.

Hockenberry, M., & Hooke, M.C. (2007). Symptom clusters in children with cancer. <i>Seminars in Oncology Nursing</i>, 23(2), 152-157.

Hockenberry-Eaton, M., & Hinds, P.S. (2000). Fatigue in children and adolescents with cancer: Evolution of a program of study. <i>Seminars in Oncology Nursing</i>, 16(4), 261-272.

Iwasaki, M. (2005). Interventional study on fatigue relief in mothers caring for hospitalized children—Effect of massage incorporating techniques from oriental medicine. <i>Kurume Medical Journal</i>, 52(1-2), 19-27.

Jalmsell, L., Kreicbergs, U., Onelov, E., Steineck, G., & Henter, J.I. (2006). Symptoms affecting children with malignancies during the last month of life: A nationwide follow-up. <i>Pediatrics</i>, 117(4), 1314-1320.

Johnson, R.A., and Wichern, D.W. (1992). Applied multivariate statistical analysis (3rd ed.). Upper Saddle River, NJ: Prentice Hall.

Kim, H.J., McGuire, D.B., Tulman, L., & Barsevick, A.M. (2005). Symptom clusters: Concept analysis and clinical implications for cancer nursing. <i>Cancer Nursing</i>, 28(4), 270-282.

Ladas, E.J., Post-White, J., Hawks, R., & Taromina, K. (2006). Evidence for symptom management in the child with cancer. <i>Journal of Pediatric Hematology/Oncology</i>, 28(9), 601-615.

Lansky, L.L., List, M.A., Lansky, S.B., Cohen, M.E., & Sinks, L.F. (1985). Toward the development of a play performance scale for children (PPSC). <i>Cancer</i>, 56(7, Suppl.), 1837-1840.

Lansky, S.B., List, M.A., Lansky, L.L., Ritter-Sterr, C., & Miller, D.R. (1987). The measurement of performance in childhood cancer patients. <i>Cancer</i>, 60(7), 1651-1656.

Miaskowski, C. (2006). Symptom clusters: Establishing the link between clinical practice and symptom management research. <i>Supportive Care in Cancer</i>, 14(8), 792-794.

Miaskowski, C., & Aouizerat, B.E. (2007). Is there a biological basis for the clustering of symptoms? <i>Seminars in Oncology Nursing</i>, 23(2), 99-105.

Miaskowski, C., Dodd, M., & Lee, K. (2004). Symptom clusters: The new frontier in symptom management research. <i>Journal of the National Cancer Institute Monographs</i>, 32, 17-21.

Moulin, D.E., Iezzi, A., Amireh, R., Sharpe, W.K., Boyd, D., & Merskey, H. (1996). Randomised trial of oral morphine for chronic non-cancer pain. <i>Lancet</i>, 347(8995), 143-147.

Portenoy, R.K., Thaler, H.T., Kornblith, A.B., Lepore, J.M., Friedlander-Klar, H., Kiyasu, E., et al (1994). The Memorial Symptom Assessment Scale: An instrument for the evaluation of symptom prevalence, characteristics, and distress. <i>European Journal of Cancer</i>, 30A(9), 1326-1336.

Reindl, T.K., Geilen, W., Hartmann, R., Wiebelitz, K.R., Kan, G., Wilhelm, I., et al (2006). Acupuncture against chemotherapy-induced nausea and vomiting in pediatric oncology. Interim results of a multicenter crossover study. <i>Supportive Care in Cancer</i>, 14(2), 172-176.

Sarle, W.S. (1983). <i>Cubic clustering criterion</i> [SAS Technical Report A-108]. Cary, NC: SAS Institute.

Theunissen, J.M., Hoogerbrugge, P.M., van Achterberg, T., Prins, J.B., Vernooij-Dassen, M.J., & van den Ende, C.H. (2007). Symptoms in the palliative phase of children with cancer. <i>Pediatric Blood and Cancer</i>, 49(2), 160-165.

Walsh, D., & Rybicki, L. (2006). Symptom clustering in advanced cancer. <i>Supportive Care in Cancer</i>, 14(8), 831-836.

Williams, P.D., Schmideskamp, J., Ridder, E.L., & Williams, A.R. (2006). Symptom monitoring and dependent care during cancer treatment in children: Pilot study. <i>Cancer Nursing</i>, 29(3), 188-197.

Yeh, C.H. (2001). Adaptation in children with cancer: Research with Roy's model. <i>Nursing Science Quarterly</i>, 14(2), 141-148.

Yeh, C.H., & Hung, L.C. (2003). Construct validity of a newly developed quality of life assessment instrument for child and adolescent cancer patients in Taiwan. <i>Psycho-Oncology</i>, 12(4), 345-346.

Zeltzer, L.K., Tsao, J.C.I., Stelling, C., Powers, M., Levy, S., & Waterhouse, M.A. (2002). A phase I study on the feasibility and acceptability of an acupuncture/hypnotherapy intervention for chronic pediatric pain. <i>Journal of Pain and Symptom Management</i>, 24(4), 437-446.