Online Exclusive Article

Symptom Clusters in Chinese Patients With Primary Liver Cancer

Yixin Wang

Margaret O'Connor

Yan Xu

Xiaohong Liu

liver neoplasms, quality of life, liver transplantation
ONF 2012, 39(6), E468-E479. DOI: 10.1188/12.ONF.E468-E479

Purpose/Objectives: To derive symptom clusters and their clinical meanings in Chinese patients with primary liver cancer (PLC), to examine the factors related to the identified symptom clusters, and to validate the impact of the identified symptom clusters on patients' quality of life (QOL).

Design: Cross-sectional.

Setting: Inpatient departments at a medical center for hepatobiliary disease in China.

Sample: 277 patients with PLC, aged 18-77 years.

Methods: Data were collected from a number of measures, including demographic and disease characteristics, the MD Anderson Symptom Inventory, six additional symptom items specific to PLC, and the Functional Assessment of Cancer Therapy-Hepatobiliary questionnaire. Factor analysis was used to derive symptom clusters, independent-samples t test or one-way analysis of variance was performed to identify the factors related to each symptom cluster, and multivariate regression models were applied to examine the predictive impact of the identified symptom clusters on PLC.

Main Research Variables: Demographic and medical variables, symptom clusters, and QOL.

Findings: Three symptom clusters were identified: gastrointestinal sickness, neuropsychological, and liver dysfunction. Patients who received liver protection treatment, received more than one kind of treatment, and had poorer physical performance, worse liver function, and more advanced cancer scored higher in severity across all three symptom clusters. All of the symptom clusters explained 48% of the QOL variance, and the liver dysfunction symptom cluster (adjusted R2 = 0.425) showed a superior influence.

Conclusions: The liver dysfunction symptom cluster may be unique to Chinese patients with PLC. Patients with certain demographic and disease characteristics could be at risk for experiencing severe symptom clusters. In addition, a differential impact of the symptom clusters on QOL was noted in these patients.

Implications for Nursing: The factors related to severity should be considered when managing symptom clusters. Because the predictive impacts of the three individual symptom clusters on QOL were varied and ordered in magnitude, healthcare providers should first alleviate the primary symptom cluster. This approach could be cost-effective and improve QOL.

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    References

    American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author.
    Aprile, G., Ramoni, M., Keefe, D., & Sonis, S. (2008). Application of distance matrices to define associations between acute toxicities in colorectal cancer patients receiving chemotherapy. Cancer, 112, 284-292.
    Barsevick, A. M., Whitmer, K., Nail, L. M., Beck, S. L., & Dudley, W. N. (2006). Symptom cluster research: Conceptual, design, measurement, and analysis issues. Journal of Pain and Symptom Management, 31, 85-95.
    Bianchi, G., Loguercio, C., Sgarbi, D., Abbiati, R., Brunetti, N., De Simone, T., … Marchesini, G. (2003). Reduced quality of life of patients with hepatocellular carcinoma. Digestive and Liver Disease, 35, 46-54.
    Cleeland, C. S., Mendoza, T. R., Wang, X. S., Chou, C., Harle, M. T., Morrissey, M., & Engstrom, M. C. (2000). Assessing symptom distress in cancer patients: The MD Anderson Symptom Inventory. Cancer, 89, 1634-1646.
    Cui, L. L. (1989). Nursing care of the patient with hepatitis B with psychological depression. Chinese Journal of Nursing, 24, 413.
    Curley, A. S. (1998). Liver cancer (M. D. Anderson solid tumor oncology series). New York, NY: Springer.
    Dodd, M. J., Cho, M. H., Cooper, B. A., & Miaskowski, C. (2010). The effect of symptom clusters on functional status and quality of life in women with breast cancer. European Journal of Oncology Nursing, 14, 101-110.
    Dodd, M. J., Miaskowski, C., & Paul, S. M. (2001). Symptom clusters and their effect on the functional status of patients with cancer. Oncology Nursing Forum, 28, 465-470.
    Fan, G., Filipczak, L., & Chow, E. (2007). Symptom clusters in cancer patients: A review of the literature. Current Oncology, 14(5), 173-179.
    Francoeur, R. B. (2005). The relationship of cancer symptom clusters to depressive affect in the initial phase of palliative radiation. Journal of Pain and Symptom Management, 29, 130-155.
    Fu, O. S., Crew, K. D., Jacobson, J. S., Greenlee, H., Yu, G., Campbell, J., … Hershman, D. L. (2009). Ethnicity and persistent symptom burden in breast cancer survivors. Journal of Cancer Survivorship, 3, 241-250.
    Gilbertson-White, S., Aouizerat, B. E., & Miaskowski, C. (2011). Methodologic issues in the measurement of cytokines to elucidate the biological basis for cancer symptoms. Biological Research for Nursing, 13, 15-24.
    Heffernan, N., Cella, D., Webster, K., Odom, L., Martone, M., Passik, S., … Blumgart, L. (2002). Measuring health-related quality of life in patients with hepatobiliary cancers: The Functional Assessment of Cancer Therapy-Hepatobiliary questionnaire. Journal of Clinical Oncology, 20, 2229-2239.
    Huang, T. W., & Lin, C. C. (2009). The mediating effects of depression on sleep disturbance and fatigue symptom clusters in patients with hepatocellular carcinoma. Cancer Nursing, 32, 398-403.
    Jemal, A., Center, M. M., DeSantis, C., & Ward, E. M. (2010). Global patterns of cancer incidence and mortality rates and trends. Cancer Epidemiology, Biomarkers and Prevention, 19, 1893-1907.
    Kim, H. J., Barsevick, A. M., & Tulman, L. (2009). Predictors of the intensity of symptoms in a cluster in patients with breast cancer. Journal of Nursing Scholarship, 41, 158-165.
    Kim, H. J., McGuire, D. B., Tulman, L., & Barsevick, A. M. (2005). Symptom clusters: Concept analysis and clinical implications for cancer nursing. Cancer Nursing, 28, 270-282.
    Kim, J. E., Dodd, M. J., Aouizerat, B. E., Jahan, T., & Miaskowski, C. (2009). A review of the prevalence and impact of multiple symptoms in oncology patients. Journal of Pain and Symptom Management, 37, 715-736.
    Lai, Y. H., Shun, S. C., Hsiao, Y. L., Chiou, J. F., Wei, L. L., Tsai, J. T., … Kao, C. Y. (2007). Fatigue experiences in hepatocellular carcinoma patients during six weeks of stereotactic radiotherapy. Oncologist, 12, 221-230.
    Miaskowski, C., Dodd, M., & Lee, K. (2004). Symptom clusters: The new frontier in symptom management research. Journal of the National Cancer Institute. Monographs, 32, 17-21.
    Ministry of Health of the People's Republic of China. (2011). China's health statistics yearbook 2011. Beijing, China: Peking Union Medical College Press.
    Pud, D., Ben Ami, S., Cooper, B. A., Aouizerat, B. E., Cohen, D., Radiano, R., … Miaskowski, C. (2008). The symptom experience of oncology outpatients has a different impact on quality-of-life outcomes. Journal of Pain and Symptom Management, 35, 162-170. doi:10.1016/j.jpainsymman.2007.03.010
    Pugh, R. N., Murray-Lyon, I. M., Dawson, J. L., Pietroni, M. C., & Williams, R. (1973). Transection of the oesophagus for bleeding oesophageal varices. British Journal of Surgery, 60, 646-649.
    Ryu, E., Kim, K., Cho, M. S., Kwon, I. G., Kim, H. S., & Fu, M. R. (2010). Symptom clusters and quality of life in Korean patients with hepatocellular carcinoma. Cancer Nursing, 33, 3-10.
    Science Daily. (2007). Why liver cancer is more prevalent in males than in females. Retrieved from http://www.sciencedaily.com/releases/2007/07/070705153012.htm
    Sherman, M. (2004). Pathogenesis and screening for hepatocellular carcinoma. Clinics in Liver Disease, 8, 419-443.
    Shun, S. C., Lai, Y. H., Jing, T. T., Jeng, C., Lee, F. Y., Hu, L. S., & Cheng, S. Y. (2005). Fatigue patterns and correlates in male liver cancer patients receiving transcatheter hepatic arterial chemoembolization. Supportive Care in Cancer, 13, 311-317.
    Skaug, K., Eide, G. E., & Gulsvik, A. (2007). Prevalence and predictors of symptoms in the terminal stage of lung cancer: A community study. Chest, 131, 389-394.
    Sorensen, J. B., Klee, M., Palshof, T., & Hansen, H. H. (1993). Performance status assessment in cancer patients: An inter-observer variability study. British Journal of Cancer, 67, 773-775.
    Steel, J. L., Geller, D. A., Gamblin, T. C., Olek, M. C., & Carr, B. I. (2007). Depression, immunity, and survival in patients with hepatobiliary carcinoma. Journal of Clinical Oncology, 25, 2397-2405.
    Steel, J. L., Kim, K. H., Dew, M. A., Unruh, M. L., Antoni, M. H., Olek, M. C., … Gamblin, T. C. (2010). Cancer-related symptom clusters, eosinophils, and survival in hepatobiliary cancer: An exploratory study. Journal of Pain and Symptom Management, 39, 859-871.
    Sun, V., Ferrell, B., Juarez, G., Wagman, L. D., Yen, Y., & Chung, V. (2008). Symptom concerns and quality of life in hepatobiliary cancers [Online exclusive]. Oncology Nursing Forum, 35, E45-E52. doi:10.1188/08.ONF.E45-E52
    Talcott, J. A., Manola, J., Clark, J. A., Kaplan, I., Beard, C. J., Mitchell, S. P., … D'Amico, A. V. (2003). Time course and predictors of symptoms after primary prostate cancer therapy. Journal of Clinical Oncology, 21, 3979-3986. doi:10.1200/JCO.2003.01.199
    Tsai, J. S., Wu, C. H., Chiu, T. Y., & Chen, C. Y. (2010). Significance of symptom clustering in palliative care of advanced cancer patients. Journal of Pain and Symptom Management, 39, 655-662. doi:10.1016/j.jpainsymman.2009.09.005
    Tsay, S. L., Chen, H. L., Chen, S. C., Lin, H. R., & Lin, K. C. (2008). Effects of reflexotherapy on acute postoperative pain and anxiety among patients with digestive cancer. Cancer Nursing, 31, 109-115. doi:10.1097/01.NCC.0000305694.74754.7b
    Wang, X. S., Wang, Y., Guo, H., Mendoza, T. R., Hao, X. S., & Cleeland, C. S. (2004). Chinese version of the M. D. Anderson Symptom Inventory: Validation and application of symptom measurement in cancer patients. Cancer, 101, 1890-1901.
    Wang, Y., Shen, J., & Xu, Y. (2011). Symptoms and quality of life of advanced cancer patients at home: A cross-sectional study in Shanghai, China. Supportive Care in Cancer, 19, 789-797. doi:10.1007/s00520-010-0884-z
    Wong, W. S., & Fielding, R. (2008). Eating ability predicts subsequent quality of life in Chinese patients with breast, liver, lung, or naso-pharyngeal carcinoma: A longitudinal analysis. Acta Oncologica, 47, 71-80. doi:10.1080/02841860701441814
    Xiao, C. H. (2010). The state of science in the study of cancer symptom clusters. European Journal of Oncology Nursing, 14, 417-434.
    Yount, S., Cella, D., Webster, K., Heffernan, N., Chang, C., Odom, L., & van Gool, R. (2002). Assessment of patient-reported clinical outcome in pancreatic and other hepatobiliary cancers: The FACT-Hepatobiliary Symptom Index. Journal of Pain and Symptom Management, 24, 32-44. doi:10.1016/S0885-3924(02)00422-0
    Zheng, Y., Wang, J. J., Zou, J. J., Wu, C. X., Bao, P. P., & Lu, W. (2007). Quality of life and its influential factors of cancer patients in Shanghai. Chinese Journal of Cancer, 26, 613-619.
    Zhu, A. X. (2003). Hepatocellular carcinoma: Are we making progress? Cancer Investigation, 21, 418-428. doi:10.1081/CNV-120018233
    Zhu, Z. C., Lang, Q. B., Chen, Z., Li, D. T., & Ling, C. Q. (2008). Evaluation of Chinese version of the Functional Assessment of Cancer Therapy-Hepatobiliary questionnaire. Journal of Chinese Integrative Medicine, 6, 341-345. doi:10.3736/jcim20080403