Comparison and Literature Review of Occupational Stress in a Palliative Radiotherapy Clinic's Interprofessional Team, the Radiation Therapists, and the Nurses at an Academic Cancer Centre.

PURPOSE: The purpose of this study was to assess the predisposing factors for occupational stress within the Rapid Response Radiotherapy Program (RRRP), radiation therapists (RTs), and registered nurses (RNs) at the Odette Cancer Centre (OCC). MATERIALS AND METHODS: All RRRP team members (n = 15, including radiation oncologists, residents, and students), RTs (n = 130), and ambulatory care nurses (n = 80) at the OCC were asked to complete a demographics form on professional background and three validated surveys designed to evaluate stress. The Maslach Burnout Inventory (MBI) was used to assess burnout in the workplace through assessment of personal accomplishment, emotional exhaustion, and depersonalization; the General Health Questionnaire (GHQ-12) assessed psychological morbidity; and the Professional Quality of Life Scale (ProQOL) assessed compassion satisfaction, compassion fatigue, and burnout. Univariate general linear regression was used to determine significant demographic predictors for occupational stress, and one-way analysis of variance was used to compare stress among the three groups. RESULTS: The overall response rate was 28%: 80% for RRRP, 20% for RTs, and 31% for RNs. Females were more likely to report greater personal accomplishment (P = .0393). Being younger (P = .0041), male (P = .0056), having less professional experience (P = .008), and being in the RRRP (P = .0019) was associated with greater depersonalization. Greater self-reported spirituality was predictive of higher compassion satisfaction (P = .0064); those reporting no or lower spirituality experienced higher levels of burnout (P = .0053). Higher GHQ-12 scores (greater stress) were reported by participants that spend more of their work time with palliative patients, and lower GHQ-12 scores (less stress) was reported in participants that participated in stress-relieving activities. A significant difference between groups was only seen in the MBI scale assessing depersonalization (P = .0077), with the RRRP experiencing greater depersonalization. For burnout subscales, 59.0% (RNs), 40.0% (RRRP), and 58.3% (RTs) reported low levels of personal accomplishment; 50% (RNs), 20% (RRRP), and 25% (RTs) reported high levels of emotional exhaustion; and 86.3% (RNs), 53.3% (RRRP), and 66.7% (RTs) reported low levels of depersonalization. CONCLUSION: Greater psychological stress was seen in respondents that worked primarily with palliative patients. Individuals that identified themselves as being spiritual had higher professional satisfaction with work, whereas a detached response to professional practice was associated with being younger, male, having less work experience, and being a member of the RRRP team. Future initiatives should place emphasis on promoting stress-relieving activities, the necessity for stress management courses, and the overall importance of increasing awareness of the potential signs and causes of occupational stress.

Symptom clusters in patients with advanced cancer: a reanalysis comparing different statistical methods.

CONTEXT: The clinical relevance of symptom cluster research remains questionable if inconsistencies, partially attributable to the varying statistical analyses used, exist. OBJECTIVES: To investigate whether symptom clusters identified were consistent using three different statistical methods and to observe the temporal pattern of clusters. A secondary objective was to compare symptom clustering in responders and nonresponders to radiotherapy over time. METHODS: Reanalysis of an existing data set compiled from 1296 patients with advanced cancer was performed using hierarchical cluster analysis (HCA) and exploratory factor analysis (EFA) to extract symptom clusters at baseline, 1-, 2-, 4-, 8-, and 12-week follow-up time points. Findings were compared with results obtained using principal component analysis (PCA) in our previously published study. The original sample was further divided into two subgroups: responders and nonresponders. The symptom clusters present in each subgroup were examined using PCA, HCA, and EFA at the same time points as mentioned above. RESULTS: The symptom cluster findings of HCA and PCA correlated more frequently with each other than either did with the results of EFA. Complete consensus in all three statistical methods was never reached at any assessment time point in the present study. Increasingly diverging patterns of symptom cluster development over time were observed in the responder vs. nonresponder subgroups. Symptom pairs comprising anxiety and depression or fatigue and drowsiness consistently presented in the same cluster despite the shifting of other symptoms in the cluster over time. CONCLUSION: The presence and composition of symptom clusters identified varied depending on which statistical analysis method was used. A key step in achieving consistency in symptom cluster research involves the utilization of a common analytical method.

Prophylaxis of radiotherapy-induced nausea and vomiting in the palliative treatment of bone metastases.

PURPOSE: To document the incidence and timing of radiotherapy-induced nausea and vomiting (RINV) in the treatment of bone metastases among patients receiving prophylaxis with a 5-HT(3) receptor antagonist. METHODS: Patients receiving single (SF) or multiple fraction (MF) palliative radiotherapy (RT) of moderate or low emetogenic risk for bone metastases were prescribed prophylactic Ondansetron. The frequency and duration of prophylaxis and the use of rescue antiemetics were left to the discretion of the treating physicians. Patients documented episodes of nausea (N) and vomiting (V) in daily diaries before and during RT, and until 10 days following RT completion. Rates of complete prophylaxis (CP) for N&V, respectively (CP = no event and no rescue medication), were calculated for the acute phase (the period from the start of RT to the first day following RT completion inclusive) and the delayed phase (the second to tenth days following RT completion inclusive). RESULTS: Fifty-nine patients were enrolled, and 32 were evaluable. CP rates were as follows: moderate-risk SF group (n = 16), acute phase (CP for N = 56%, CP for V = 69%) and delayed phase (CP for N = 31%, CP for V = 44%); moderate-risk MF group (n = 7), acute phase (CP for N = 71%, CP for V = 57%) and delayed phase (CP for N = 43%, CP for V = 57%); low-risk SF group (n = 8), acute phase (CP for N = 50%, CP for V = 100%) and delayed phase (CP for N = 43%, CP for V = 57%); and low-risk MF group (n = 1), acute phase (CP for N = 100%, CP for V = 100%) and delayed phase (CP for N = 100%, CP for V = 100%). CONCLUSIONS: Despite prophylaxis, RINV was common among patients receiving palliative radiotherapy for bone metastases, especially during the delayed phase.

Do elderly patients with metastatic cancer have worse quality of life scores?

PURPOSE: The purpose of this study is to compare self-reported quality of life (QOL) scores in old and young patients with metastatic cancer using the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C15-PAL questionnaire. MATERIALS AND METHODS: Patients receiving palliative radiotherapy (RT) for bone metastases and brain metastases completed the QLQ-C15-PAL questionnaire prior to treatment. Using multiple linear regression analysis, a parametric test, the QLQ-C15-PAL scores were compared using 65 and 70 years as cutoff ages. RESULTS: A total of 340 patients were referred for palliative RT for bone metastases (n = 190) or brain metastases (n = 150). Physical functioning and appetite were worse in the older group using either 65 or 70 years as the cutoff age. Age-related differences in the QLQ-C15-PAL scores varied as a function of age cutoff used and location of metastatic site irradiated. CONCLUSION: Based on the (EORTC) QLQ-C15-PAL, elderly advanced cancer patients have a different QOL profile. Similar observations have been reported with the (EORTC) QLQ-C30 questionnaire.

Comparing baseline symptom severity and demographics over two time periods in an outpatient palliative radiotherapy clinic.

PURPOSE: The primary objective of this study was to compare the symptom severity in two different patient populations assessed in an outpatient palliative radiotherapy clinic over two time periods spanning 10 years. The secondary objective was to assess any changes in the baseline demographics of these patients. METHODS: Data were collected from 1999 to 2009. Upon initial presentation to the clinic, the Edmonton Symptom Assessment Scale (ESAS) was administered to patients to capture symptom severity. This validated assessment tool asks patients to score their level of pain, tiredness, nausea, depression, anxiety, drowsiness, loss of appetite, well-being, and dyspnea on an 11-point Likert scale. Differences between the two patient groups were assessed using chi-squared analysis and Wilcoxon rank-sum tests. A p value of <0.05 was considered significant. RESULTS: A total of 1,439 patients completed the ESAS from 1999 to 2009. Patients were divided into two time periods 1999-2002 (n = 689) and 2006-2009 (n = 750). Pain, depression, nausea, fatigue, anxiety, drowsiness, and dyspnea were significantly better in 2006-2009 (p < 0.0001). Loss of appetite was not statistically different between the two time periods (p = 0.236). Significantly more patients with genitourinary cancers (p = 0.03) or a referral for a mass (p < 0.0001) were seen in 2006-2009. More patients with breast cancer (p = 0.04) and bone pain (p = 0.0002) were seen in 1999-2002. The median age was significantly higher (70 years vs. 68 years, p = 0.03) for patients seen in 2006-2009. No significant differences were seen in performance status or gender between the two groups. CONCLUSION: There have been statistically significant lower scores in the severity of the majority of symptoms as scored by the latter patient cohort; however, whether this difference in magnitude is clinically significant is debatable. The reason for referral and demographics in patients sent for palliative radiotherapy has changed over a 10-year period. This may be a reflection of the changes in systemic therapies and improvements in supportive care for patients with advanced cancer.

Comparison of pain response and functional interference outcomes between spinal and non-spinal bone metastases treated with palliative radiotherapy.

PURPOSE: The purpose of this study was to compare functional interference and pain response outcomes using the Brief Pain Inventory (BPI) for patients treated with palliative radiotherapy to spine versus non-spine bones and determine if dose fractionation was associated with each group's respective response. MATERIALS AND METHODS: Patients treated for painful bone metastases with palliative radiotherapy during May 2003 to June 2007 were analyzed. The BPI was utilized at baseline and monthly for 6 months post-radiation. Pain response was determined using International Bone Metastases Consensus response definitions. Wilcoxon rank-sum test (for continuous variable), Fisher exact test (for categorical value), and two-way analysis of variance were used for comparisons, and a p value of ≤ 0.05 was considered statistically significant. RESULTS: Three hundred eighty-six patients were analyzed, 62% were treated with a single fraction, 38% with multiple fractions. Pain and functional interference scores significantly improved over time in both spine and non-spine sites. At 3 months, 42% of all patients had a partial response, and 25% had a complete response. Location of bone metastases and radiotherapy dose were not predictive factors for pain response nor functional interference following radiation treatment. CONCLUSION: Spine and non-spine bone metastases exhibited similar pain and functional interference improvements over a period of 6 months post-radiotherapy. There were, however, high attrition rates as expected with palliative studies, with approximately half the patients remaining in this study by 3 months and a fifth by 6 months. A single 8 Gy resulted in equal benefits in terms of both pain response and improvement in function.

Fatigue in advanced cancer patients attending an outpatient palliative radiotherapy clinic as screened by the Edmonton Symptom Assessment System.

INTRODUCTION: Advanced cancer patients present with a variety of physical and psychological symptoms. Fatigue is one such symptom which reduces overall quality of life and is difficult to manage. The purpose of this study was to report the presence, severity, and correlating factors of fatigue in advanced cancer patients attending an outpatient palliative radiotherapy clinic. MATERIALS/METHODS: Patients referred to the Rapid Response Radiotherapy Program between January 1999 and October 2009 completed the Edmonton Symptom Assessment System (ESAS) prior to consultation. Demographic information including age, Karnofsky Performance Status (KPS), gender, and primary cancer sites were collected. Ordinal logistic regression analysis was conducted to determine relationships between demographic information, other ESAS items, and levels of fatigue. Multivariate ordinal logistic regression analysis was used to determine the most significant predictors of fatigue. A p value of <0.05 was considered statistically significant. RESULTS: A total of 1,397 patients completed the ESAS prior to consultation. Median age was 68 years (range, 21-95), median KPS was 60 (range, 10-100), and slightly more males completed the ESAS (53.0%). Common primary cancers were of the lung (35.8%), breast (20.7%), and prostate (17.7%). Only 179 (12.8%) patients reported no fatigue; the majority of patients reported moderate (31.8%) or severe (34.4%) fatigue. A low KPS (p < 0.0001), being female (p = 0.0056), or being referred for bone metastases (p = 0.0185) significantly correlated with higher levels of fatigue. Patients with a genitourinary primary cancer (p = 0.0078) and/or referred for malignant spinal cord compression (p = 0.0004) reported less fatigue. All other ESAS items were significantly related to fatigue. The most significant predictors of fatigue were pain (p < 0.0001, odds ratio (OR) = 1.07), nausea (p = 0.0010, OR = 1.10), depression (p < 0.0001, OR = 1.10), drowsiness (p < 0.0001, OR = 1.33), dyspnea (p = 0.0003, OR = 1.08), and overall well-being (p < 0.0001, OR = 1.19). CONCLUSION: Moderate fatigue was reported in over 66% of our advanced cancer patients prior to radiotherapy. Since radiotherapy inherently causes fatigue, proactive and multidisciplinary management is required for these patients. Similar rates of fatigue severity, in lengthier, fatigue-specific tools, suggest that the ESAS may be a good tool for screening the advanced cancer population.

EORTC QLQ-C15-PAL quality of life scores in patients with advanced cancer referred for palliative radiotherapy.

PURPOSE: Symptom control and improved quality of life (QOL) are primary goals of treatment in palliative oncology. The present study assessed and compared patient demographics, baseline Karnofsky Performance Status (KPS) and QOL using the QLQ-C15-PAL questionnaire prior to palliative radiotherapy (RT) for bone, brain, or lung disease. Few studies have used this questionnaire, an abbreviated version that was developed by the European Organization for Research and Treatment of Cancer specifically for patients with advanced cancer to decrease the burden of completing the longer, more time-consuming QLQ-C30. METHODS: Patients referred to an outpatient palliative RT clinic completed QLQ-C15-PAL questionnaires prior to palliative RT for bone, brain, or lung cancer sites. The associations between baseline QLQ-C15-PAL functional/symptom scales, patient demographics, and clinical variables including KPS were explored. RESULTS: When data from all 369 patients were analyzed, higher KPS scores correlated significantly with better overall QOL and higher physical and emotional functioning. The QLQ-C15-PAL provided more detailed information regarding how symptom burden varied depending on disease site. Patients with bone metastases had worse QLQ-C15-PAL scores for pain, while those with brain and lung disease had worse scores for fatigue. Other health-related QOL scores measured by the QLQ-C15-PAL varied as a function of age and gender. CONCLUSION: As the QLQ-C15-PAL provides detailed and often critical information regarding symptom burden, it may eventually be recognized as a universal core questionnaire to assess QOL in this patient population with advanced cancer while relieving the survey burden.

Symptom clusters in patients with advanced cancer: sub-analysis of patients reporting exclusively non-zero ESAS scores.

BACKGROUND: Advanced cancer patients often experience multiple concurrent symptoms, which can have prognostic effects on patients' quality of life. Including patients who did not experience all of the symptoms measured by an assessment tool may interfere with accurate symptom cluster identification. Varying statistical methods may also contribute to inconsistencies of cluster results. AIMS: To compare symptom clusters in a subgroup of patients reporting exclusively non-zero ESAS scores with those in the total patient sample. To examine whether using different statistical methods results in varied symptom clusters. DESIGN: Principal Component Analysis (PCA), Hierarchical Cluster Analysis (HCA) and Exploratory Factor Analysis (EFA) were performed on the 'non-zero' subgroup and the total patient sample to identify symptom clusters at baseline and weeks 1, 2, 4, 8 and 12 following palliative radiotherapy. SETTING/PARTICIPANTS: A previous single-centre study used Principal Component Analysis to explore symptom clusters in 1296 advanced cancer patients. The present study analyzed this previously reported data set. RESULTS: Notably different symptom clusters were extracted between the two patient groups regardless of the statistical method at baseline, with the exception of a cluster composed of drowsiness, fatigue and dyspnea using Principal Component Analysis and Hierarchical Cluster Analysis. At follow-ups, different statistical methods yielded significantly varied symptom clusters. Only anxiety, depression and well-being consistently occurred in the same cluster across methods and over time. CONCLUSIONS: The composition of symptom clusters varied depending on if patients with non-zero scores were excluded at baseline and on the statistical method employed. Identifying valid clusters may prove useful for bettering symptom diagnosis and management for cancer patients.

Pain Management Needs Assessment: A Survey of Radiation Therapists at a Large Academic Comprehensive Cancer Centre.

OBJECTIVE: To determine the knowledge of pain management among the radiation therapists (RTs) at the Odette Cancer Centre (OCC) to aid in the development of a formalized education strategy. METHODS: A needs assessment survey comprising eight topics pertaining to pain management was distributed to 130 RTs at the OCC. Survey topics were ranked using a 4-point Likert scale based on preference for further education, familiarity with the topic, and relevance to practice. RESULTS: RTs rated topics pertaining to the undertreatment, pathophysiology, assessment, diagnosis, and treatment of pain as the most relevant topics requiring further education. RTs were most unfamiliar with topics concerning opioids and addiction, but did not find a need for further education. They also felt that breakthrough cancer pain was the most significant topic for further education. CONCLUSION: Implementation of an educational intervention for RTs to more effectively and efficiently address pain management for their patient population is needed. Topics of most clinical relevance include: undertreatment of pain, pathophysiology of pain, assessment and diagnosis of acute and chronic pain as well as its treatment.

Patterns of pain and functional improvement in patients with bone metastases after conventional external beam radiotherapy and a telephone validation study.

Patients experiencing lower body pain resulting from bone metastases have greater levels of functional interference than those with upper body pain. The purpose of this study was to assess the levels of interference caused by pain after treatment with conventional radiotherapy using the Brief Pain Inventory (BPI) and to validate this tool for telephone use. After radiotherapy, a total of 159, 129, and 106 patients completed the BPI over the telephone at months 1, 2, and 3, respectively. Cronbach's alpha, confirmatory factor analysis, and discriminant validity tests were performed to assess the validity of the BPI. One-way ANOVA was used to compare BPI scores. There was no statistically significant difference in functional interference among patients after treatment. Internal consistency of the BPI was high. Functional interference may be inherently higher in patients with pain in the lower body. Telephone use of the BPI is reliable and recommended in this population.

Self-reported rates of sleep disturbance in patients with symptomatic bone metastases attending an outpatient radiotherapy clinic.

PURPOSE: To examine the reported rates and predictive factors for sleep disturbance in patients with bone metastases. METHODS: Patients with symptomatic bone metastases treated with palliative radiotherapy (RT) were eligible. At initial consultation, demographic information, baseline Brief Pain Inventory (BPI) questionnaire, and analgesic consumption were recorded. The BPI functional interference sleep item was categorized into none (0), mild (1-3), moderate (4-6), and severe (7-10). Follow-up BPI was collected in person or via telephone post-RT at week 4, 8, and 12. Subgroup analysis for BPI between responders and nonresponders was performed. Ordinal logistic regression analysis was used to search for the relationship between sleep disturbance and other covariates. RESULTS: Four hundred patients were enrolled between May 2003 and June 2007. Two hundred thirty-five males (59%) were accrued. The median age was 68 years old (range, 30-91). Within the study population, primary cancer sites included breast (25%), lung (25%), prostate (24%), bladder (4%), pancreas/gastric (3%), and other primaries (18%). In the BPI functional interference items, the mean baseline score for sleep disturbance was 4.8. When categorized in terms of severity, 99 (25%) patients had moderate sleep disturbance and 144 (36%) patients had severe sleep disturbance, respectively. There was an improvement in sleep scores for both responders and nonresponders at week 4 and 8, but scores worsened for nonresponders at week 12. CONCLUSION: Age, Karnofsky Performance Scale (KPS), pain score, and lung primary were the significant variables associated with sleep disturbance. The scores for sleep disturbance improved significantly post-RT in responders at week 4 and 12.

Edmonton symptom assessment scale as a prognosticative indicator in patients with advanced cancer.

BACKGROUND: Few studies incorporate patient self-assessment scales in prognostic models of survival prediction. The Edmonton Symptom Assessment Scale (ESAS) is commonly used as a symptom screening tool in cancer patients. OBJECTIVE: The goal of this study was to evaluate the prognostic value of the ESAS for survival prediction in the advanced cancer population. MATERIALS AND METHODS: Patients completed the ESAS and demographic information prior to palliative radiotherapy consultation and at follow-up at the Odette Cancer Centre between 1999 and 2009. Generalized estimating equation (GEE) methodology was applied to analyze ESAS trends within the last months of life. One-way analysis of variance (ANOVA) with repeated measurements was used to characterize trends between time periods. RESULTS: ESAS records (2377) from 808 patients (433 male and 375 female) were included in this cohort. Median age was 68 years (range 32-95) with median Karnofsky performance status (KPS) of 60 (range 10-100). Primary cancer sites were of the lung (36%), breast (20%), and prostate (19%). All nine ESAS symptoms significantly deteriorated in the last 4 weeks immediately before death when compared with those scores in the preceding months. At one week prior to death, the worst ESAS symptoms experienced by patients were fatigue, appetite, and well-being with mean scores of 7.4, 6.9, and 6.1, respectively. CONCLUSIONS: All ESAS scores significantly worsened in the last 4 weeks prior to death compared with those in the previous months. Sudden deterioration of the global ESAS symptoms may predict impending death. Future studies on a prognostic model should incorporate both ESAS symptom severity and trends.

Functional Interference due to Pain Following Palliative Radiotherapy for Bone Metastases Among Patients in Their Last Three Months of Life.

BACKGROUND: To compare the self-reported ratings of functional interference caused by pain between patients who did and did not respond to palliative radiotherapy for bone metastases during their last three months of life. METHODS: A prospectively gathered Brief Pain Inventory (BPI) database compiled from patients receiving palliative radiotherapy for painful bone metastases was reviewed. Demographic and clinical data, pain response rates and self-reported ratings of functional interference caused by pain were analyzed for those patients who died within three months of beginning radiotherapy. RESULTS: From 400 patients in the database, 83 died within 3 months of beginning radiotherapy. There were 54 male and 29 female patients. Their median age was 69 years and their median KPS was 70. The three most common primary cancers were lung (40%), gastrointestinal (16%) and breast (14%). For patients with available follow-up information the 1-month overall pain response rate was 78% and the 2-month rate was 83%, which include both complete and partial responses as defined by the International Bone Metastases Consensus. At 1 month, patients responding to treatment reported significantly less interference by pain on their general activity, walking ability, normal work, sleeping, and enjoyment of life than did patients not responding to treatment. CONCLUSIONS: Patients that responded to treatment reported less functional interference due to pain than did patients who did not respond. Despite being very near the end of life, patients responding to palliative radiotherapy for painful bone metastases may benefit from more than pain relief alone.

Quality of Life in Patients Treated with Palliative Radiotherapy for Advanced Lung Cancer and Lung Metastases.

BACKGROUND: The purpose of this study was to investigate quality of life (QOL) in patients receiving palliative radiotherapy (RT) for advanced lung cancer/lung metastases using the EORTC QLQ-LC13 and the EORTC QLQ-C15-PAL questionnaires. METHODS: Patients who received palliative RT for lung metastases or advanced lung cancer between November 2007 and October 2010 completed the EORTC QLQ-LC13 and the QLQ-C15-PAL at baseline prior to RT, 1, 2, 4, 8 and 12 weeks post-treatment. The Wilcoxon Signed Rank test was used to compare QOL scores between baseline and each follow-up period. RESULTS: Thirty-one patients with advanced lung disease were included in this study; 61% of participants were male and 39% were female. The median age was 69 years (range 38 - 85), and median KPS and PPS scores at baseline were both 70 (range 30 - 90). All patients received radiotherapy to the lung. None of the QLQ-LC13 scores significantly improved or deteriorated at any follow-up. Of the QLQ-C15-PAL scales, fatigue, pain, insomnia and physical functioning significantly improved at their respective follow-ups. CONCLUSIONS: This was the first study to use the EORTC QLQ-LC13 in conjunction with the EORTC QLQ-C15-PAL questionnaires. Future studies should continue to incorporate quality of life assessment tools specific to disease characteristics in advanced cancer patients.

Gender Difference in Symptom Presentations Among Patients With Bone Metastases in Gender-Specific and Gender-Neutral Primary Cancers.

BACKGROUND: Studies have assessed gender differences on symptoms commonly experienced by cancer patients at various stages in their disease trajectory using heterogeneous cancer populations with different tumor types. The purpose of our study was to evaluate the effect of gender on symptoms among patients with bone metastases while controlling for gender-specific malignancies. METHODS: A retrospective review of patients receiving palliative radiotherapy for bone metastases was conducted on patients that completed the Brief Pain Inventory (BPI) or Edmonton Symptom Assessment System (ESAS) questionnaires from 1999 - 2004. Baseline and follow-up BPI and ESAS symptom scores were compared between males and females, with and without controlling for gender-specific tumors. RESULTS: A total of 900 patients completed baseline questionnaires: ESAS (n = 508) or BPI (n = 392). The most common tumor types were lung (26%), breast (25%) and prostate (24%). In all ESAS patients, females had significantly greater severity of tiredness, nausea, depression, anxiety and breathlessness. In the subgroup analysis when gender-specific primary cancers were removed (i.e., breast, prostate and gynecological), no significant differences in ESAS symptoms were found between genders. The BPI functional item of walking ability was significantly worse for females in both the overall and subgroup analyses. Females had worse symptoms at follow-up prior to the removal of gender-specific primaries in both ESAS and BPI. CONCLUSIONS: Gender-specific cancers may significantly bias gender studies of cancer-related symptoms when primary tumor type is not taken into account. Gender differences are best assessed in gender-neutral primaries.

Analysis of Pain and Interference Patterns With Brief Pain Inventory in Patients With Bone Metastases: A Confirmatory Study.

BACKGROUND: This study investigates the validity of the psychometric properties of the Brief Pain Inventory (BPI) in patients with bone metastases and determines if patients with lower body pain exhibit higher levels of activity interference than those with upper body pain. METHODS: Three hundred and eighty-six patients treated, between May 2003 and June 2007, for painful bone metastases were included in this analysis, 336 patients with complete data were included in further analyses. Cronbach's Alpha, confirmatory factor analysis (CFA), and discriminant validity tests were performed to analyze the psychometric properties of the BPI. One-way analysis of variance was used to compare mean scores of BPI subscales (pain, activity, and affect) in patients with upper or lower bone metastases. RESULTS: Internal consistency of two- and three-factor BPI analysis was high. In both cases, consistency was further improved when the sleep item was removed. CFA confirmed these results and showed that three-factor analysis was recommended. Patients with lower body metastases reporting moderate to severe pain exhibited greater levels of functional interference. A single fraction radiotherapy dose of 8 Gy was as effective as multi-fraction therapy where the predominant fractionation was 20 Gy in 5 fractions. CONCLUSIONS: Our data confirms the psychometric validation of the BPI and the recommendations to use three-factor analysis in patients with bone metastases. Patients exhibiting lower extremity pain should receive prompt pain interventions and functional aid.

What QLQ-C15-PAL Symptoms Matter Most for Overall Quality of Life in Patients With Advanced Cancer?

BACKGROUND: Few studies have evaluated the QLQ-C15-PAL health-related quality of life (QOL) questionnaire, an abbreviated version of the QLQ-C30 questionnaire that was designed specifically for patients with advanced cancer. The present study assessed whether certain symptoms or functional domains from the QLQ-C15-PAL predicted overall QOL when rated prior to palliative radiation treatment (RT). PATIENTS AND METHODS: Patients attending an outpatient palliative radiotherapy clinic completed QLQ-C15-PAL questionnaires prior to palliative RT for bone, brain or lung disease. Pearson correlations were computed between the QLQ-C15-PAL functional/symptom scores and overall QOL scores. Multiple linear regressions were used to evaluate the relative importance of functional/symptom scales in association with overall QOL. RESULTS: Data from 369 patients were analyzed. The QLQ-C15-PAL domains of physical and emotional functioning, pain, and appetite loss were significant predictors of overall QOL in these patients with advanced cancer. Appetite loss was the only significant independent predictor of overall QOL in the subgroup of patients with advanced lung cancer (n = 29). Both appetite loss and emotional functioning were independently predictive of overall QOL in patients with bone metastases (n = 190). In patients with brain metastases (n = 150), independent predictors of overall QOL included physical and emotional functioning as well as fatigue. CONCLUSION: The QLQ-C15-PAL domains of physical and emotional functioning, pain and appetite loss were significant predictors of overall QOL in this cohort of patients with advanced cancer. Different functional and symptom scales predicted overall QOL in patients with bone metastases, brain metastases or advanced lung cancer.

Poor Accrual in Palliative Research Studies: An Update From the Rapid Response Radiotherapy Program.

BACKGROUND: In June 2003, the Rapid Response Radiotherapy Program (RRRP) implemented changes to recruitment strategies in attempts to increase patient accrual to research studies. Such modifications included the use of a dedicated research assistant to screen for and identify eligible study patients, the introduction of more appropriate inclusion criteria, and the switch towards telephone interviews to minimize patient burden. The purpose of this study is to provide an update on patient accrual in the RRRP. METHODS: All patients seen in the RRRP from January 2002 to December 2009 were recorded in a prospective database. Reasons for referral, eligibility for clinical trials, reasons for non-accrual, and various demographics information were recorded. Descriptive statistics summarized findings. RESULTS: A total of 4726 patient visits were recorded from January 1st, 2002 to December 31st, 2009. Prior to changes, the overall rate of accrual into research studies was 14.9% versus 48.1% after changes were implemented. Patients were not accrued onto studies mainly to due ineligibility according to study protocol. Other reasons such as language barrier (12.1%), physician objection (3.5%), patient declining participation (11.3%) and lack of a research assistant (9.3%) were cited. CONCLUSIONS: Changes in clinical structure and study design can significantly impact accrual patterns in palliative radiotherapy studies. Despite these changes however, the majority of patients are still not enrolled in studies. Therefore additional efforts need to be made to maximize patient accrual and minimize attrition.