Subgroups of Patients With Cancer With Different Symptom Experiences and Quality-of-Life Outcomes: A Cluster Analysis

Christine Miaskowski

Bruce A. Cooper

Steven M. Paul

Marylin Dodd

Kathryn A. Lee

Bradley E. Aouizerat

Claudia M. West

Maria H. Cho

Alice Bank

ONF 2006, 33(5), E79-E89. DOI: 10.1188/06.ONF.E79-E89

Purpose/Objectives: To identify subgroups of outpatients with cancer based on their experiences with the symptoms of fatigue, sleep disturbance, depression, and pain; to explore whether patients in the subgroups differed on selected demographic, disease, and treatment characteristics; and to determine whether patients in the subgroups differed on two important patient outcomes: functional status and quality of life (QOL).

Design: Descriptive, correlational study.

Setting: Four outpatient oncology practices in northern California.

Sample: 191 outpatients with cancer receiving active treatment.

Methods: Patients completed a demographic questionnaire, Karnofsky Performance Status scale, Lee Fatigue Scale, General Sleep Disturbance Scale, Center for Epidemiological Studies-Depression Scale, Multidimensional Quality-of-Life Scale-Cancer, and a numeric rating scale of worst pain intensity. Medical records were reviewed for disease and treatment information. Cluster analysis was used to identify patient subgroups based on patients' symptom experiences. Differences in demographic, disease, and treatment characteristics as well as in outcomes were evaluated using analysis of variance and chi square analysis.

Main Research Variables: Subgroup membership, fatigue, sleep disturbance, depression, pain, functional status, and QOL.

Findings: Four relatively distinct patient subgroups were identified based on patients' experiences with four highly prevalent and related symptoms.

Conclusions: The subgroup of patients who reported low levels of all four symptoms reported the best functional status and QOL.

Implications for Nursing: The findings from this study need to be replicated before definitive clinical practice recommendations can be made. Until that time, clinicians need to assess patients for the occurrence of multiple symptoms that may place them at increased risk for poorer outcomes.

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    Belfer, I., Wu, T., Kingman, A., Krishnaraju, R.K., Goldman, D., & Max, M.B. (2004). Candidate gene studies of human pain mechanisms: Methods for optimizing choice of polymorphisms and sample size. Anesthesiology, 100, 1562-1572.

    Bruehl, S., Harden, R.N., Galer, B.S., Saltz, S., Backonja, M., & Stanton-Hicks, M. (2002). Complex regional pain syndrome: Are there distinct subtypes and sequential stages of the syndrome? Pain, 95, 119-124.

    Carpenter, J.S., Andrykowski, M.A., Wilson, J., Hall, L.A., Rayens, M.K., Sachs, B., et al. (1998). Psychometrics for two short forms of the Center for Epidemiologic Studies-Depression Scale. Issues in Mental Health Nursing, 19, 481-494.

    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. Cancer, 97, 2919-2925.

    Cleeland, C.S., Mendoza, T.R., Wang, X.S., Chou, C., Harle, M.T., Morrissey, M., et al. (2000). Assessing symptom distress in cancer patients: The M.D. Anderson Symptom Inventory. Cancer, 89, 1634-1646.

    Davis, P.J., Reeves, J.L., Graff-Radford, S.B., Hastie, B.A., & Naliboff, B.D. (2003). Multidimensional subgroups in migraine: Differential treatment outcome to a pain medicine program. Pain Medicine, 4, 215-222.

    Diatchenko, L., Slade, G.D., Nackley, A.G., Bhalang, K., Sigurdsson, A., Belfer, I., et al. (2005). Genetic basis for individual variations in pain perception and the development of a chronic pain condition. Human Molecular Genetics, 14, 135-143.

    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.

    Dorsey, C.M., Lee, K.A., & Scharf, M.B. (2004). Effect of zolpidem on sleep in women with perimenopausal and postmenopausal insomnia: A four-week, randomized, multicenter, double-blind, placebo-controlled study. Clinical Therapeutics, 26, 1578-1586.

    Everitt, B.S., Landau, S., & Leese, M. (2001). Cluster analysis (4th ed.). New York: Oxford University Press.

    Ferrell, B.R., Wisdom, C., & Wenzl, C. (1989). Quality of life as an outcome variable in the management of cancer pain. Cancer, 63(11, Suppl.), 2321-2327.

    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.

    Gay, C.L., Lee, K.A., & Lee, S.Y. (2004). Sleep patterns and fatigue in new mothers and fathers. Biological Research for Nursing, 5, 311-318.

    Gift, A.G., Jablonski, A., Stommel, M., & Given, C.W. (2004). Symptom clusters in elderly patients with lung cancer. Oncology Nursing Forum, 31, 202-212.

    Gift, A.G., Stommel, M., Jablonski, A., & Given, W. (2003). A cluster of symptoms over time in patients with lung cancer. Nursing Research, 52, 393-400.

    Given, B., Given, C., Azzouz, F., & Stommel, M. (2001). Physical functioning of elderly cancer patients prior to diagnosis and following initial treatment. Nursing Research, 50, 222-232.

    Guyatt, G.H., Osoba, D., Wu, A.W., Wyrwich, K.W., & Norman, G.R. (2002). Methods to explain the clinical significance of health status measures. Mayo Clinic Proceedings, 77, 371-383.

    Hann, D., Baker, F., Denniston, M., Gesme, D., Reding, D., Flynn, T., et al. (2002). The influence of social support on depressive symptoms in cancer patients: Age and gender differences. Journal of Psychosomatic Research, 52, 279-283.

    Humphreys, J.C., Lee, K.A., Neylan, T.C., & Marmar, C.R. (1999). Sleep patterns of sheltered battered women. Image: The Journal of Nursing Scholarship, 31, 139-143.

    Jacobsen, P.B., Donovan, K.A., Trask, P.C., Fleishman, S.B., Zabora, J., Baker, F., et al. (2005). Screening for psychologic distress in ambulatory cancer patients. Cancer, 103, 1494-1502.

    Jensen, M.P. (2003). The validity and reliability of pain measures in adults with cancer. Journal of Pain, 4(1), 2-21.

    Karnofsky, D., Abelmann, W.H., Craver, L.V., & Burchenal, J.H. (1948). The use of nitrogen mustard in the palliative treatment of cancer. Cancer, 1, 634-656.

    Kelley, K.W., Bluthe, R.M., Dantzer, R., Zhou, J.H., Shen, W.H., Johnson, R.W., et al. (2003). Cytokine-induced sickness behavior. Brain, Behavior, and Immunity, 17(Suppl. 1), S112-S118.

    Kurtz, M.E., Kurtz, J.C., Stommel, M., Given, C.W., & Given, B. (2002). Predictors of depressive symptomatology of geriatric patients with lung cancer—A longitudinal analysis. Psycho-Oncology, 11, 12-22.

    Landgraf, R., & Wigger, A. (2003). Born to be anxious: Neuroendocrine and genetic correlates of trait anxiety in HAB rats. Stress, 6, 111-119.

    Lee, B.N., Dantzer, R., Langley, K.E., Bennett, G.J., Dougherty, P.M., Dunn, A.J., et al. (2004). A cytokine-based neuroimmunologic mechanism of cancer-related symptoms. Neuroimmunomodulation, 11, 279-292.

    Lee, K., Cho, M., Miaskowski, C., & Dodd, M. (2004). Impaired sleep and rhythms in persons with cancer. Sleep Medicine Reviews, 8, 199-212.

    Lee, K.A. (1992). Self-reported sleep disturbances in employed women. Sleep, 15, 493-498.

    Lee, K.A., Hicks, G., & Nino-Murcia, G. (1991). Validity and reliability of a scale to assess fatigue. Psychiatry Research, 36, 291-298.

    Lee, K.A., Portillo, C.J., & Miramontes, H. (1999). The fatigue experience for women with human immunodeficiency virus. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 28, 193-200.

    Lee, K.A., Portillo, C.J., & Miramontes, H. (2001). The influence of sleep and activity patterns on fatigue in women with HIV/AIDS. Journal of the Association of Nurses in AIDS Care, 12(Suppl.), 19-27.

    McQuitty, L.L. (1966). Similarity analysis of reciprocal pairs for discrete and continuous data. Educational and Psychological Measurement, 27, 21-46.

    Mendoza, T.R., Wang, X.S., Cleeland, C.S., Morrissey, M., Johnson, B.A., Wendt, J.K., et al. (1999). The rapid assessment of fatigue severity in cancer patients: Use of the Brief Fatigue Inventory. Cancer, 85, 1186-1196.

    Miaskowski, C. (2004). Gender differences in pain, fatigue, and depression in patients with cancer. Journal of the National Cancer Institute Monographs, 32, 139-143.

    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.

    Miaskowski, C., & Lee, K.A. (1999). Pain, fatigue, and sleep disturbances in oncology outpatients receiving radiation therapy for bone metastasis: A pilot study. Journal of Pain and Symptom Management, 17, 320-332.

    Milligan, G.W., & Cooper, M.C. (1985). An examination of procedures for determining the number of clusters in a data set. Psychometrika, 50, 159-179.

    Nagel, G.C., Schmidt, S., Strauss, B.M., & Katenkamp, D. (2001). Quality of life in breast cancer patients: A cluster analytic approach. Empirically derived subgroups of the EORTC-QLQ-BR 23—A clinically oriented assessment. Breast Cancer Research and Treatment, 68, 75-87.

    Norman, G.R., Sloan, J.A., & Wyrwich, K.W. (2003). Interpretation of changes in health-related quality of life: The remarkable universality of half a standard deviation. Medical Care, 41, 582-592.

    Osoba, D., Rodrigues, G., Myles, J., Zee, B., & Pater, J. (1998). Interpreting the significance of changes in health-related quality-of-life scores. Journal of Clinical Oncology, 16, 139-144.

    Padilla, G.V., Ferrell, B., Grant, M.M., & Rhiner, M. (1990). Defining the content domain of quality of life for cancer patients with pain. Cancer Nursing, 13, 108-115.

    Payne, J.K., Piper, B.F., Rabinowitz, I., & Zimmerman, M.B. (2006). Biomarkers, fatigue, sleep, and depressive symptoms in women with breast cancer: A pilot study. Oncology Nursing Forum, 33, 775-783.

    Portenoy, R.K., Thaler, H.T., Kornblith, A.B., Lepore, J.M., Friedlander-Klar, H., Coyle, N., et al. (1994). Symptom prevalence, characteristics, and distress in a cancer population. Quality of Life Research, 3, 183-189.

    Potash, M., & Breitbart, W. (2002). Affective disorders in advanced cancer. Hematology/Oncology Clinics of North America, 16, 671-700.

    Serlin, R.C., Mendoza, T.R., Nakamura, Y., Edwards, K.R., & Cleeland, C.S. (1995). When is cancer pain mild, moderate or severe? Grading pain severity by its interference with function. Pain, 61, 277-284.

    Sheehan, T.J., Fifield, J., Reisine, S., & Tennen, H. (1995). The measurement structure of the Center for Epidemiologic Studies Depression Scale. Journal of Personality Assessment, 64, 507-521.

    Simpson, J.S., Carlson, L.E., Beck, C.A., & Patten, S. (2002). Effects of a brief intervention on social support and psychiatric morbidity in breast cancer patients. Psycho-Oncology, 11, 282-294.

    StataCorp. (2003). Cluster analysis reference manual, release 8. College Station, TX: Author.

    Taheri, S. (2004). The genetics of sleep disorders. Minerva Medica, 95, 203-212.

    Trask, P.C., & Griffith, K.A. (2004). The identification of empirically derived cancer patient subgroups using psychosocial variables. Journal of Psychosomatic Research, 57, 287-295.

    Walsh, D., Donnelly, S., & Rybicki, L. (2000). The symptoms of advanced cancer: Relationship to age, gender, and performance status in 1,000 patients. Supportive Care in Cancer, 8, 175-179.

    Watkins, L.R., & Maier, S.F. (1999). Implications of immune-to-brain communication for sickness and pain. Proceedings of the National Academy of Sciences of the United States of America, 96, 7710-7713.