Symptom Clusters And Quality Of Life Of Ovarian Cancer Patients Receiving Adjuvant Chemotherapy: A Longitudinal Study

Objectives:To investigate the prevalence and intensity of symptoms and explore the changes ofsymptom clusters and quality of life in ovarian cancer patients after surgery receivingadjuvant chemotherapy at different time points. We also describe the characteristics ofsymptom clusters and find out the relationships between symptom clusters and quality oflife. The results information may help healthcare professionals develop optimized therapiesto manage multiple symptoms.Methods:The study was a prospective longitudinal study. A convenient sample of115patients withovarian cancer hospitalized in Gynecology department was selected from five tertiaryhospitals in Shanghai between February2012and February2013. The basic details of thepatients were documented and a survey was carried out with Memorial SymptomAssessment Scale (MSAS) and Functional Assessment of Cancer Therapy-Ovary (FACT-O) to examine frequency and severity of symptoms and quality of life atfour time points.The four time points were: the day before chemotherapy(T1),chemotherapy cycle#1(T2), chemotherapy cycle#3(T3), chemotherapy cycle#6(T4).Data were performed using SPSS version16.0. Descriptive statistics (mean, standarddeviation, percentage) was used to describe patient demographic and clinicalcharacteristics and the frequency and severity of symptoms and the exploratory factoranalysis to determine the components of symptom clusters. Spearman correlation analysiswas used to observe the relationship between symptom clusters and quality of life ofovarian cancer patients at different time points.Results:1. Symptom Occurrence and Symptom Severity in ovarian cancer patients receivingchemotherapy:the number of symptoms ranged from (6.04±3.21) to (11.87±4.45) inovarian cancer patients at the4time points. The number of symptom incidence>20%ranged from13to20; symptom severity score ranged from (1.17±0.63) to (3.28±0.72).(1) Symptom Occurrence:1) the day before chemotherapy (T1): the three highestincidence symptoms were lack of energy (59.64%), worrying (49.55%)and sweats(45.95%)2) chemotherapy cycle#1(T2): the three highest incidence symptoms were lackof energy(75.93%), difficulty sleeping (74.07%) and nausea (72.22%);3) chemotherapycycle#3(T3): the three highest incidence symptoms were hair loss (100.00%), lack of energy (84.16%)and difficulty sleeping (70.34%);4) chemotherapy cycle#6(T4): the threehighest incidence symptoms were hair loss (100%), lack of energy (85.26%), difficultysleeping (67.37%).(2) The symptoms severity:1) the day before chemotherapy (T1):the highest severitysymptoms were sweats (1.94±1.01), lack of energy (1.80±0.86) and lack of appetite(1.79±0.78);2) chemotherapy cycle#1(T2): the highest severity symptoms were lack ofenergy(2.07±1.02), sweats (2.06±1.06)and lack of appetite(2.02±0.97);3) chemotherapycycle#3(T3): the highest severity symptoms were hair loss (2.45±1.01), lack of energy(2.12±0.98) and lack of appetite (1.97±0.89);4) chemotherapy cycle#6(T4): the highestseverity symptoms were hair loss (3.28±0.72), lack of energy (2.24±0.96) and lack ofappetite (2.02±0.88).2. Six symptom clusters were indentified in ovarian cancer patients receiving adjuvantchemotherapy at4time points: pain-related symptom cluster, psychological symptomcluster, perimenopausal symptom cluster, gastrointestinal symptom cluster, body imagesymptom cluster and neurologic symptom cluster.Three symptom clusters were determined at the day before chemotherapy(T1).(1) Pain-related symptom cluster, including4symptoms. The symptoms occurred infrequency from high to low in turn for: pain40.54%, dizziness25.23%and feelingbloated20.72%. the symptoms severity respectively were:(1.69±0.76),(1.36±0.56),and(1.52±0.73).(2) Psychological symptom cluster, including3symptoms. The symptoms occurred infrequency from high to low in turn for: worrying49.55%, feeling sad41.44%and feelingnervous37.84%, the symptoms severity respectively were:(1.76±0.71),(1.70±0.81)and(1.72±0.77).(3) Perimenopausal symptom cluster, including6symptoms. The symptoms occurred infrequency from high to low in turn for: lack of energy59.46%, sweats45.95%, difficultysleeping40.35%, lack of appetite36.85%, dry mouth35.05%and feelingirritable32.43%,the symptoms severity respectively were:(1.80±0.86),(1.94±1.01),(1.58±0.73),(1.79±0.78),(1.44±0.67) and(1.28±0.66).Five symptom clusters were determined at chemotherapy cycle#1(T2).(1) Pain-related symptom cluster, including4symptoms. The symptoms occurred infrequency from high to low in turn for: pain50.93%, dizziness30.48%and feelingbloated25%, the symptoms severity respectively were:(1.84±0.86),(1.76±0.70), (1.41±0.56) and(1.60±0.78).(2) Psychological symptom cluster, including3symptoms. The symptoms occurred infrequency from high to low in turn for: worrying65.74%, feeling sad57.41%and feelingnervous49.07%, the symptoms severity respectively were:(1.81±0.84),(1.72±0.71) and(1.78±0.80).(3) Perimenopausal symptom cluster, including6symptoms.The symptoms occurred infrequency from high to low in turn for: lack of energy75.93%, difficulty sleeping74.07%,lack of appetite57.41%, dry mouth52.78%, sweats50.00%and feeling irritable35.19%,the symptoms severity respectively were:(2.07±1.02),(1.88±1.00),(2.07±1.02),(1.60±0.78),(2.06±1.06) and (1.34±0.78).(4) Gastrointestinal symptom cluster, including2symptoms. The symptoms occurred infrequency from high to low in turn for: nausea72.22%,weight loss35.52%andvomiting54.63%,the symptoms severity respectively were:(1.95±0.90),and (2.00±0.98)(5) Body image symptom cluster, including2symptoms. The symptoms occurred infrequency from high to low in turn for: hair loss67.59%and constipation33.33%, thesymptoms severity respectively were:(1.99±0.96) and(1.61±0.73).Six symptom clusters were determined at chemotherapy cycle#3(T3).(1) Pain-related symptom cluster, including2symptoms. The symptoms occurred infrequency from high to low in turn for: pain60.40%and feeling bloated25.74%, thesymptoms severity respectively were:(1.80±0.91) and (1.54±0.71).(2) Psychological symptom cluster, including3symptoms. The symptoms occurred infrequency from high to low in turn for: worrying55.45%, feeling sad46.53%and feelingnervous43.56%,the symptoms severity respectively were:(1.50±0.66),(1.43±0.48) and(1.56±0.41).(3) Perimenopausal symptom cluster, including6symptoms. The symptoms occurred infrequency from high to low in turn for: lack of energy84.16%, difficulty sleeping70.34%,lack of appetite66.34%,sweats55.45%,dry mouth47.52%and feeling irritable34.65%(,thesymptoms severity respectively were:(2.12±0.98),(1.94±0.87),(1.97±0.89),(1.93±0.99),(1.56±0.71)and1.26±0.61).(4)Gastrointestinal symptom cluster, including4symptoms. The symptoms occurred infrequency from high to low in turn for: nausea64.39%, vomiting51.58%, weight loss26.73%and change in the way food tastes37.72%, the symptoms severity respectively were:(1.76±0.99),(1.97±1.02),(1.74±0.71) and (1.71±0.71). (5)Body image symptom cluster, including3symptoms. The symptoms occurred infrequency from high to low in turn for: hair loss100.00%, constipation40.59%,“I don’tlook like myself”27.72%, the symptoms severity respectively were:(2.45±1.01),(1.78±0.94) and (1.50±0.84).(6)Neurologic symptom cluster, including2symptoms. The symptoms occurred infrequency from high to low in turn for: Numbness/tingling in hands/feet46.53%anddizziness31.69%, the symptoms severity respectively were:(1.23±0.52) and(1.20±0.30).Six symptom clusters were determined at chemotherapy cycle#6(T4).(1)Pain-related symptom cluster, including2symptoms. The symptoms occurred infrequency from high to low in turn for: pain53.63%and feeling bloated28.42%, thesymptoms severity respectively were:(1.72±0.76) and (1.48±0.70).(2)Psychological symptom cluster, including3symptoms. The symptoms occurred infrequency from high to low in turn for: worrying53.68%, feeling sad41.05%and feelingnervous35.79%, the symptoms severity respectively were:(1.51±0.68),(1.37±0.63) and(1.50±0.44).(3)Perimenopausal symptom cluster, including6symptoms. The symptoms occurred infrequency from high to low in turn for: lack of energy85.26%, difficulty sleeping67.37%,,lack of appetite62.11%, dry mouth55.79%, sweats44.21%and feeling irritable42.11%,the symptoms severity respectively were:(2.24±0.96),(1.97±0.89)(2.02±0.88),(1.64±0.69),(1.91±0.90) and (1.28±0.60).(4)Gastrointestinal symptom cluster, including4symptoms. The symptoms occurred infrequency from high to low in turn for: nausea58.95%,vomiting51.49%, weightloss23.16%and change in the way food tastes42.63%, the symptoms severityrespectively were:(1.75±0.98),(1.89±0.67),(1.82±0.73)and (1.58±0.62).(5)Body image symptom cluster, including3symptoms. The symptoms occurred infrequency from high to low in turn for: hair loss100.00%, constipation48.42%,“I don’tlook like myself”28.32%,the symptoms severity respectively were:(3.28±0.72),(1.98±0.75) and(1.52±0.71).(6)Neurologic symptom cluster, including2symptoms. The symptoms occurred infrequency from high to low in turn for: Numbness/tingling in hands/feet52.63%anddizziness34.47%,the symptoms severity respectively were:(1.61±0.51) and (1.18±0.39).3.The mean severity scores of symptom clusters at the four times were：pain-related symptom cluster T1(1.520.17), T2(1.620.22),T3(1.670.18),T4(1.600.17);psychological symptom cluster T1(1.73±0.18), T2(1.77±0.05), T3(1.50±0.07),T4(1.46±0.08); perimenopausal symptom cluster T1(1.64±0.25), T2(1.83±0.30), T3(1.80±0.32), T4(1.84±0.34); gastrointestinal symptom cluster T2(1.90±0.13), T3(1.80±0.12), T4(1.76±0.13), body image symptom cluster T2(1.80±0.27),T3(1.91±0.49),T4(2.26±0.91); neurologic symptom cluster T3(1.22±0.02),T4(1.40±0.30).4. The score of quality of life in different dimensions in ovarian cancer patients receivingpostoperative chemotherapy at4time points: T1the total scores of quality of life(106.566.96), physical wellbeing (18.593.56), social/family wellbeing (21.575.21),emotional wellbeing (17.184.43), functional wellbeing (16.033.42)and additionalconcerns (33.193.86); T2the total scores of quality of life(98.43±6.64), physicalwellbeing (16.89±4.53), social/family wellbeing (21.56±5.22), emotional wellbeing(17.38±4.52), functional wellbeing (12.51±4.72) and additional concerns (30.09±5.29); T3the total scores of quality of life (101.516.11), physicalwellbeing (16.56±4.90),social/family wellbeing (21.53±5.35),emotional wellbeing (18.74±2.90), functionalwellbeing (14.49±3.26) and additional concerns (30.19±5.09); T4the total scores of qualityof life (102.315.43), physical wellbeing (16.62±4.57), social/family wellbeing(21.26±4.05), emotional wellbeing (19.19±2.55), functional wellbeing (15.86±3.19) andadditional concerns (29.38±5.74). All of three time points, functional wellbeing dimensionscore were minimum, followed by emotional wellbeing and additional concernsdimension. Analysis of variance showed that the difference in the total score of quality oflife in patients with ovarian cancer receiving chemotherapy was statistically significant (F=6.40, P=0.000).5.The relationship between severity of symptom clusters and quality of life: pain-relatedsymptom cluster had significantly negative correlation with physical wellbeing(r=－0.21～－0.48, P<0.01); pain-related symptom cluster had significantly negative correlation withadditional concerns(r=－0.30～－0.48, P<0.01); psychological symptom cluster hadsignificantly negative correlation with emotional wellbeing(r=－0.31～－0.52, P<0.01);perimenopausal symptom cluster had significantly negative correlation with physicalwellbeing(r=－0.21～－0.47,P<0.01or P<0.05); perimenopausal symptom clustersignificantly negative correlation with additional concerns(r=－0.16～－0.34, P<0.01orP<0.05); gastrointestinal symptom cluster had significantly negative correlation withphysical wellbeing(r=－0.25～－0.40,P<0.01or P<0.05); body image symptom cluster had a small but significantly negative correlation with additional concerns(r=－0.10～－0.27,P<0.01or P<0.05); neurologic symptom cluster had a small but significantly negativecorrelation with emotional wellbeing(r=－0.21～－0.26, P<0.01or P<0.05); neurologicsymptom cluster had a small but significantly negative correlation with additionalconcerns(r=－0.16～－0.23, P<0.01or P<0.05).Conclusion:(1) Taking into account the number and prevalence and severity of the symptoms whichbrought considerable burden to ovarian cancer patients after surgery, more attention shouldbe paid to clinical symptom assessment and management of ovarian patients.(2) ovarian cancer patients experienced different number of symptom clusters at differenttime points: the day before chemotherapy(T1) was3, chemotherapy cycle#1(T2) was5,chemotherapy cycle#3(T3) was6, chemotherapy cycle#6(T4) was6; symptom clusters:pain-related symptom cluster, psychological symptom cluster, perimenopausal symptomcluster, gastrointestinal symptom cluster, body image symptom cluster and neurologicsymptom cluster.(3)It shuold be taken a different focus for intervention at different time points: the daybefore chemotherapy(T1) was psychological symptom cluster, chemotherapy cycle#1(T2)was gastrointestinal symptom cluster, chemotherapy cycle#3(T3) was neurologicsymptom cluster, chemotherapy cycle#6(T4) was body image symptom cluster.(4) Functional wellingbeing dimension score is the minimum, it is the main factors leadingto decline the quality of life in ovarian patients.(4) The symptom clusters and quality of life are negatively correlated in ovarian cancerpatients at different time points. Management of symptom clusters is recommended as torelieve symptom burden and enhance quality of life in ovarian patients.