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R E S E A R C H A R T I C L E Open Access
Symptom severity of patients with
advanced cancer in palliative care unit:
longitudinal assessments of symptoms
improvement
Shu-Yu Tai
1,2,3,4
, Chung-Yin Lee
3
, Chien-Yi Wu
3
, Hui-Ya Hsieh
5
, Joh-Jong Huang
3
, Chia-Tsuan Huang
3*†
and Chen-Yu Chien
6,7,8*†
Abstract
Background: This study assessed the symptom severity of patients with advanced cancer in a palliative care unit
and explored the factors associated with symptom improvement.
Methods: This study was conducted in a palliative care unit in Taiwan between October 2004 and December 2009.
Symptom intensity was measured by the “Symptom Reporting Form”, and graded on a scale of 0 to 4 (0 = none,
and 4 = extreme). These measures were assessed on the 1
st
,3
rd
,5
th
, and 7
th
Day in the palliative care unit. The study
data comprised routine clinical records and patients’demographic data. Generalized estimating equation (GEE)
was used to assess the symptom improvement, and investigate the factors associated with the symptom
reporting form scores.
Results: Among the 824 recruited patients with advanced cancer, pain (78.4 %), anorexia (64.4 %) and constipation
(63.5 %)were the most common and severe symptom. After controlling for other factors in the multivariate GEE model,
the day of palliative care administration was a significant factor associated with all of the scales, except Days 7 on the
dyspnoea and oedema scales and Day 5 on the anxiety scale. In addition, patients aged ≥65 years exhibited
significantly lower scores on the pain, sleep disturbance, depression, and anxiety scales than did those aged < 65 years.
Moreover, female patients exhibited higher scores on the vomiting, anorexia, oedema, depression, and anxiety scales
than did male patients. Furthermore, patients with gastrointestinal tract cancer exhibited higher scores on the
constipation, vomiting, anorexia, oedema, depression, and anxiety scales and lower scores on the dyspnoea scale
than did those with lung cancer. Patients with breast cancer exhibited higher scores on the oedema scale and
lower scores on the anxiety scale. Patients with genitourinary cancer exhibited higher scores on the vomiting and
oedema scales and lower scores on the dyspnoea scale. Patients with head, neck, and oral cancer exhibited lower
scores on the oedema scale alone.
Conclusion: The symptom severity declined during the first week in the palliative care unit. In addition, differences in
sex and primary cancer sites may contribute to varying degrees of symptom improvement.
Keywords: Advanced cancer, Palliative care, Symptom severity, Generalised estimating equation
* Correspondence: chtshu@kmu.edu.tw;chenyu@cc.kmu.edu.tw
†
Equal contributors
3
Department of Family Medicine, Kaohsiung Medical University Hospital,
Kaohsiung, Taiwan
6
Department of Otorhinolaryngology, School of Medicine, College of
Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
Full list of author information is available at the end of the article
© 2016 Tai et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Tai et al. BMC Palliative Care (2016) 15:32
DOI 10.1186/s12904-016-0105-8
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Background
Cancer is a leading cause of death worldwide and
accounted for 8.2 million deaths in 2012 [1]. Since
1982, cancer has been the primary cause of death in
Taiwan and accounts for over 30,000 deaths each year
and this figure is increasing [2]. The Hospice Palliative
Care, which originated in England, aims to provide
symptom alleviation and holistic care through physical,
emotional, and spiritual approaches to terminally ill
patients towards the end of their lives. Until 2013, the
hospice care programmes available in Taiwan included
44 hospital-based inpatient hospice care wards (hospice
wards), 64 hospice home-care units (regular home visits
by nurses and other interdisciplinary staff), and 58 hos-
pitals with consultation or a combined care team [3].
Terminally ill patients with cancer suffer from several
physical and psychological symptoms and multiple organ
failures; therefore, one of their main needs is to be com-
fortable and symptom-free at the end stage of their lives
[4]. Consequently, the initial and essential component of
palliative cancer care is to provide advanced-cancer pa-
tients with symptom relief as soon as possible in lieu of
disease treatment [5, 6]. The previous studies may tell us
the symptom patterns [4, 7–10] and the good effect of
the intervention (ex.: the case management model, the
hospital- or day care- based palliative care team…etc.)
in improving symptom control and even quality of life
[11–14] among advanced cancer patients. However,
limited information is available regarding longitudinal
assessments of symptom improvement after admission
to a palliative care unit. Therefore, a clearer under-
standing of symptom improvement and factors associ-
ated with symptom improvement is required to provide
optimal symptom relief for patients with advanced can-
cer. Thus, the Symptom Reporting Form was used in
the present study to assess the symptom severity of pa-
tients with advanced cancer in a palliative care unit.
Methods
Study population
In this prospective study, participants were selected
from amongst consecutive patients with advanced can-
cer who consented and were admitted between October
2004 and December 2009 to the palliative care unit of
Kaohsiung Medical University Hospital, a medical centre
in Southern Taiwan. The inclusion criteria included age
older than 20 years, more than 1-week admission to the
palliative care unit, and adequate level of conscious-
ness to report symptoms in Mandarin or Taiwanese on
admission and in the consecutive symptom assess-
ments. The exclusion criteria included age younger
than 20 years, passing away within one week after ad-
mission to the palliative care unit, and inadequate level
of consciousness to report symptoms. The participants
were receiving care from a multidisciplinary team compris-
ing physicians, nurses, psychologists, social workers, clinical
Buddhist chaplains, and volunteers. The study protocol was
approved by the Kaohsiung Medical University Hospital
Institutional Review Board (KMUH-IRB-20140333). Since
all identifying personal information was not recorded, the
review board waived the requirement for written informed
consent from the patients involved.
Assessment instrument
The assessment tool was a symptom-reporting form
designed by experienced specialists, which assessed the
physical and psychosocial distress by using corresponding
scales (see Additional file 1). The physical and psycho-
social symptoms included pain, constipation, vomiting,
dyspnoea, loss of appetite, sleep disturbance, oedema, un-
comfortable, depression, and anxiety, graded on a scale of
0to4(0=none,1=mild,2=moderate,3=severe,and
4=extreme). The internal consistency of questionnaire,
Coefficients of Cronbach’sαvalue for the baseline
measurement, was 0.715. Besides, 3 experts in the hos-
pice filed were invited to judge and modify the content
of the symptom reporting form and 7 experts to assess
the content validity. The average content validity index
(CVI) [15] was 0.91.
Symptom assessment and data collection
According to patient reports, the symptoms and their
severities were recorded by the physicians on Days 1, 3,
5, and 7 in the palliative care unit and reviewed by the
same staff members. Information regarding psychological
distress, including depression and anxiety, were collected
by medical staff and clinical psychologists. A consensus
regarding the psychological distress rating was obtained
after thorough discussion in team meetings which were
held once per week. The data for this study comprised
routine records, including patients’demographic data
(age, sex, primary site of cancer, and length of time in
care) and the symptom reporting forms collected on Days
1, 3, 5, and 7 in the palliative care unit.
Training of the palliative care unit staff
According to the health insurance guidelines for pallia-
tive care, all the palliative team members, including phy-
sicians, nurses, psychologists, social workers, and clinical
Buddhist chaplains, were required to finish 80 h of pal-
liative care training which included basic, advanced, and
internship courses. In addition, all members were re-
quired to undergo 20 h of palliative training every year
to ensure the quality of care provided.
Statistical analysis
Descriptive statistical data were summarised as frequen-
cies and percentages for categorical variables, medians
Tai et al. BMC Palliative Care (2016) 15:32 Page 2 of 7
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and ranges for age and duration of palliative care re-
ceived, and means (standard deviations, SD) and median
(range) for symptom scores and other continuous vari-
ables. Patient age was categorised into 2 groups for eas-
ier comparisons (< 65 y and ≥65 y). To investigate the
factors associated with the symptom reporting form
scores, a generalised estimating equation (GEE) model
was applied to accommodate the correlated data of re-
peated measurements (on Days 1, 3, 5, and 7) in the
same patient. The symptom reporting score served as a
continuous dependent variable, whereas age, sex, and
type of cancer served as covariates. In addition, multi-
variate GEE models with identity links were used to cal-
culate the adjusted mean differences and standard
errors (SE) of the symptom scores and compare them
with those of an appropriate reference group. A 2-tailed
Pvalue of < .05 indicated statistical significance. All
statistical analyses were performed using the SAS soft-
ware (Version 9.2; SAS Institute Inc., Cary, NC, USA).
Results
The study participants were 824 hospitalised patients
with advanced cancer; 480 (58.3 %) of whom were men.
The median age was 61 years (range: 21–97 y), and the
median duration in care was 20 days (7–118 d). Regard-
ing the primary cancer type, gastrointestinal cancer was
the most common cancer type (32.4 %), followed by
head, neck, and oral cancer (22.4 %) and lung cancer
(18.2 %) (Table 1).
Pain (78.4 %) was the most common symptom, followed
by anorexia (64.4 %) and constipation (63.5 %). Regarding
symptom severity, pain (mean ± SD: 1.63 ± 1.23) was the
most severe symptom, followed by anorexia (1.24 ± 1.24),
constipation (0.92 ± 1.05), dyspnoea (0.82 ± 1.07), and
oedema (0.74 ± 1.10) (Table 2).
As mentioned previously, to investigate factors asso-
ciated with the symptom reporting scores, a GEE model
was applied to accommodate the correlated data of re-
peated measurements (on Days 1, 3, 5, and 7) in the
same patient. After controlling for other factors in the
multivariate GEE model, the day of palliative care ad-
ministration proved a significant factor associated with
all scales (all P≤0.05), except Day 7 on the dyspnoea
(P= .658) and oedema scales (P= .135) and Day 5 on
the anxiety scale (P= .452) (Tables 3 and 4). In addition,
after controlling for other factors in the multivariate
GEE model, patients aged ≥65 years exhibited significantly
lower scores on the pain, sleep disturbance, depression,
and anxiety scales than did those aged < 65 years (all
P≤.001). Moreover, after controlling for other factors in
the multivariate GEE model, the female patients exhib-
ited significantly higher scores on the vomiting (esti-
mate [SD]: 0.32 [0.16] points), anorexia (0.23 [0.06]
points), oedema (0.15 [0.16] points), depression (0.35
[0.11] points), and anxiety (0.77 [0.28] points) scales
than did the male patients (all P≤.05) (Tables 3 and 4).
Patients with gastrointestinal tract cancer exhibited
higher scores on the constipation (0.21 [0.11] points),
vomiting (0.90 [0.16] points), anorexia (0.59 [0.09]
points), oedema (0.59 [0.16] points), depression (0.39
[0.15] points), and anxiety (0.35 [0.14] points) scales
and lower scores on the dyspnoea (−0.36 [0.12] points)
scale than did those with lung cancer. Patients with
breast cancer exhibited higher scores on the oedema
(1.43 [0.64] points) scale and lower scores on the anx-
iety (−0.61 [0.20] points) scale than did those with lung
cancer. Furthermore, patients with genitourinary can-
cer exhibited higher scores on the vomiting (0.79 [0.19]
points) and oedema (0.82 [0.21] points) scales and
lower scores on the dyspnoea (−0.45 [0.15] points)
scale than did those with lung cancer. Patients with
head, neck, and oral cancer exhibited lower scores on
the oedema (−1.02 [0.23] points) scale alone than did
Table 1 Thebaselinedemographiccharacteristicsofall
participants
Total (N= 824)
N%
Age, year
Median (Range) 61 (21–97)
< 65 461 56.0.
≥65 344 41.7
missing 19 2.3
Gender
Female 344 41.7
Male 480 58.3
Primary diagnosis
Lung cancer 150 18.2
Gastrointestinal cancer
a
267 32.4
Breast cancer 55 6.7
Genitourinary cancer
b
108 13.1
Head, neck, and oral cancer 185 22.4
Other cancers
c
59 7.2
Length of time in care
Median (Range) 20 (7–118)
≤14 days 231 28.0
15–30 days 361 43.8
31–60 days 180 21.8
> 60 days 36 4.4
Missing 16
a
Cancers of the gastrointestinal tract from esophagus to the rectum, pancreas,
liver and gallbladder were combined to form this category
b
Cancers of the male and female genitals and the urinary tract were combined
to form this category
c
Cancers that were not included above
Tai et al. BMC Palliative Care (2016) 15:32 Page 3 of 7
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those with lung cancer. In addition, patients with other
cancers exhibited higher scores on the anorexia (0.48
[0.13] points), sleep disturbance (0.58 [0.21] points),
oedema (3.89 [0.54] points), uncomfortable (139.87
[0.19] points), and anxiety (3.08 [0.20] points) scales
than did those with lung cancer (Tables 3 and 4).
Discussion
This study demonstrated that the most severe symptoms of
patients hospitalised for palliative care are pain, anorexia
and constipation. In addition, the integration of hos-
pital palliative care demonstrated favourable improve-
ment in symptom severity. Moreover, differences in sex
and primary cancer sites may contribute to varying
degrees of improvement in symptom severity.
Terminally ill patients with cancer suffer from several
physical and psychological symptoms and multiple
organ failures; therefore, one of their main needs is to
be comfortable and symptom-free at the end stage of
their lives [16]. Thus, palliative cancer care essentially
Table 2 Change in severity of symptoms among 1
st
,3
rd
,5
th
,and 7
th
day after admission (N= 824)
Variable of symptom With
symptom
a
1
st
3
rd
5
th
7
th
Range of severity
(0–4)
N% Mean (SD) Median (range) Mean (SD) Median (range) Mean (SD) Median (range) Mean (SD) Median (range)
Pain 646 78.4 1.63 (1.23) 2 (0–4) 1.05 (0.99) 1 (0–4) 0.84 (0.90) 1 (0–4) 0.61 (0.81) 0 (0–4)
Constipation 463 63.5 0.92 (1.05) 1 (0–4) 0.81 (0.96) 1 (0–4) 0.75 (0.93) 1 (0–4) 0.72 (0.95) 0 (0–4)
Vomiting 313 38.0 0.62 (0.98) 0 (0–4) 0.43 (0.77) 0 (0–4) 0.34 (0.71) 0 (0–4) 0.26 (0.64) 0 (0–4)
Dyspnea 394 47.8 0.82 (1.07) 0 (0–4) 0.64 (0.92) 0 (0–4) 0.62 (0.90) 0 (0–4) 0.78 (1.12) 0 (0–4)
Anorexia 531 64.4 1.24 (1.24) 1 (0–4) 1.04 (1.14) 1 (0–4) 1.00 (1.14) 1 (0–4) 1.03 (1.28) 1 (0–4)
Sleep disturbance 356 43.2 0.67 (0.95) 0 (0–4) 0.50 (0.81) 0 (0–4) 0.46 (0.78) 0 (0–4) 0.35 (0.71) 0 (0–4)
Edema 340 41.3 0.74 (1.10) 0 (0–4) 0.67 (1.01) 0 (0–4) 0.66 (1.02) 0 (0–4) 0.71 (1.08) 0 (0–4)
Uncomfortable 364 44.2 0.67 (1.15) 0 (0–4) 0.60 (1.02) 0 (0–4) 0.57 (0.98) 0 (0–4) 0.55 (1.01) 0 (0–4)
Depression 333 40.4 0.58 (0.87) 0 (0–4) 0.47 (0.77) 0 (0–4) 0.43 (0.71) 0 (0–4) 0.31 (0.60) 0 (0–4)
Anxiety 280 34.0 0.45 (0.76) 0 (0–4) 0.38 (0.68) 0 (0–4) 0.36 (0.62) 0 (0–4) 0.25 (0.53) 0 (0–4)
a
The score at the 1
st
day of admission in this scale was equal to or more than 1
Table 3 Estimates from GEE
b
modles of indicators of pain, constipation, vomiting, dyspnea, and anorexia
Pain Constipation Vomiting Dyspnea Anorexia
Nβ(SE)
a
P-value β(SE)
a
P-value β(SE)
a
P-value β(SE)
a
P-value β(SE)
a
P-value
Age, year
< 65 Reference - Reference - Reference - Reference - Reference -
≥65 −0.23 (0.06) < 0.001 −0.19 (0.08) 0.087 −0.06 (0.12) 0.614 0.07 (0.09) 0.428 0.04 (0.06) 0.475
Gender
Male 480 Reference - Reference - Reference - Reference - Reference -
Female 344 0.01 (0.06) 0.828 0.18 (0.12) 0.129 0.32 (0.16) 0.046 −0.06 (0.09) 0.548 0.23 (0.06) < 0.001
Cancer
Lung cancer 150 Reference - Reference - Reference - Reference - Reference -
Gastrointestinal cancer 267 0.12 (0.08) 0.146 0.21(0.11) 0.044 0.90 (0.16) < 0.001 −0.36 (0.12) 0.002 0.59 (0.09) < 0.001
Breast cancer 55 0.02 (0.13) 0.875 −0.20 (0.19) 0.287 0.41 (0.23) 0.075 0.12 (0.18) 0.507 −0.07 (0.15) 0.638
Genitourinary cancer 108 0.03 (0.10) 0.777 0.10 (0.14) 0.469 0.79 (0.19) <0.001 −0.45 (0.15) 0.002 0.19 (0.12) 0.102
Head, neck, and oral cancer 185 0.15 (0.09) 0.108 0.10(0.13) 0.452 −0.25 (0.22) 0.245 −0.22 (0.13) 0.089 −0.15 (0.13) 0.242
Other cancers 59 −0.02 (0.12) 0.836 0.09 (0.21) 0.684 −0.10 (0.34) 0.773 −0.22(0.15) 0.140 0.48 (0.13) < 0.001
Day of palliative care
1
st
day 822 Reference - Reference - Reference - Reference - Reference -
3
rd
day 824 −0.45 (0.02) < 0.001 −0.20 (0.08) 0.013 −0.35 (0.05) < 0.001 −0.22 (0.03) < 0.001 −0.18 (0.02) < 0.001
5
th
day 823 −0.67 (0.03) < 0.001 −0.22 (0.04) < 0.001 −0.47 (0.08) < 0.001 −0.25 (0.04) < 0.001 −0.23 (0.03) < 0.001
7
th
day 822 −0.98 (0.04) < 0.001 −0.21 (0.06) < 0.001 −1.04 (0.09) < 0.001 −0.02 (0.05) 0.658 −0.18 (0.04) < 0.001
a
Adjusted mean difference compared to referent group.
b
GEE:generalized estimating equation
Tai et al. BMC Palliative Care (2016) 15:32 Page 4 of 7
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aims to provide such patients with symptom relief and
higher quality of life [5, 17]. The findings of the present
study confirmed the efficacy of palliative care based on
the symptom improvement observed during the first
week of the palliative unit inpatient care, except on Day
7 of dyspnoea and oedema assessment and Day 5 of
anxiety assessment. Most previous studies have fo-
cused on the symptoms or symptom cluster screening
in patients with advanced cancer receiving palliative
care [7, 9, 18, 19]. Certain studies have conducted a
longitudinal follow-up to observe the quality of life,
symptom severity, and mood amongst outpatients with
advanced cancer [14, 18]. The present study recruited
824 participants who were all admitted to the palliative
care unit of a medical centre.
In addition, previous studies have focused on the roles
of age and sex differences in symptoms improvement
amongst patients with advanced cancer [9, 20–23]. Con-
sistent with the findings of a previous systematic review
of symptom prevalence [9], we observed a significant as-
sociation between pain improvement and older age.
Moreover, similar associations were observed with sleep
disturbance, depression, and anxiety. These findings sug-
gest that younger patients require particular attention
and active monitoring during symptom management. In
addition considerable sex differences were observed re-
garding certain symptoms: female patients reported less
improvement of vomiting, anorexia, sleep disturbance,
depression, and anxiety after adjustment for age, primary
cancer site, and day of palliative care administration.
These results are consistent with those of a large-scale
study of patients who did not receive anticancer treat-
ments, which revealed marked sex differences in the
prevalence of nausea [9, 23] but is inconsistent with the
results of another similar study [18]. These differences
may be attributable to the different measurement
methods (symptom severity vs frequency), the different
treatment settings (in outpatients vs in a palliative unit
care), and varying analysis methods (adjustment of other
factors or repeated measurements). Therefore, additional
pooled data is required from such settings to determine
the effects of age and sex on symptom improvement in
such a patient population.
Moreover, our results helped identify the crucial as-
pects of symptom improvement for different primary
cancer sites. Regarding pain, no significant differences
were observed between the different types of cancer dur-
ing the first week of admission. Gastrointestinal symp-
toms, including constipation, vomiting, and anorexia,
were the most common and severe problems in patients
with advanced cancer, particularly those with advanced
gastrointestinal cancer; these symptoms may be attribut-
able to refractory ascites or intra-abdominal masses or
may be the side effects of opioid drugs administered to
Table 4 Estimates from GEE
b
modles of indicators of sleep disturbance, edema, uncomfortable, depression and anxiety
Sleep disturbance Edema Uncomfortable Depression Anxiety
Nβ(SE)
a
P-value β(SE)
a
P-value β(SE)
a
P-value β(SE)
a
P-value β(SE)
a
P-value
Age, year
< 65 Reference - Reference - Reference - Reference - Reference -
≥65 −0.39 (0.11) < 0.001 −0.26 (0.15) 0.093 −0.08(0.11) 0.510 −0.52 (0.10) < 0.001 −0.80 (0.12) < 0.001
Gender
Male 480 Reference - Reference - Reference - Reference - Reference -
Female 344 (0.07) 0.664 0.15 (0.16) 0.046 −0.06 (0.09) 0.548 0.35 (0.11) < 0.001 0.77 (0.28) 0.005
Cancer
Lung cancer 150 Reference - Reference - Reference - Reference - Reference -
Gastrointestinal cancer 267 0.37 (0.14) 0.008 0.59 (0.16) < 0.001 0.24 (0.16) 0.126 0.39 (0.15) 0.010 0.35(0.14) 0.012
Breast cancer 55 0.36 (0.37) 0.337 1.43 (0.64) 0.026 0.19 (0.28) 0.502 −0.13 (0.20) 0.527 −0.61 (0.20) 0.002
Genitourinary cancer 108 0.12 (0.19) 0.518 0.82 (0.21) < 0.001 0.16 (0.20) 0.419 0.22 (0.19) 0.252 0.04(0.17) 0.836
Head, neck, and oral cancer 185 −0.03 (0.20) 0.881 −1.02 (0.23) < 0.001 0.07 (0.19) 0.695 0.20(0.16) 0.215 0.34 (0.21) 0.105
Other cancers 59 0.58 (0.21) 0.006 3.89 (0.54) < 0.001 139.87(0.19) <0.001 0.26 (0.19) 0.166 3.08 (0.20) <0.001
Day of palliative care
1 822 Reference - Reference - Reference - Reference - Reference -
3 824 −0.30 (0.04) < 0.001 −0.11 (0.02) < 0.001 −0.12 (0.04) 0.003 −0.20 (0.03) < 0.001 −0.10 (0.02) < 0.001
5 823 −0.41(0.05) < 0.001 −0.10 (0.02) < 0.001 −0.17 (0.05) < 0.001 −0.28 (0.04) < 0.001 −0.02 (0.03) 0.452
7 822 −0.66 (0.07) < 0.001 0.10 (0.07) 0.135 −0.20 (0.06) 0.001 −0.63 (0.06) < 0.001 −1.24 (0.05) < 0.001
a
Adjusted mean difference compared to referent group.
b
GEE generalized estimating equation
Tai et al. BMC Palliative Care (2016) 15:32 Page 5 of 7
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such patients. Dyspnoea is a concerning symptom and is
more challenging to relieve in patients with advanced
lung cancer. It may result from the destruction of lung
tissue because of the growth and spreading of cancer
cells. In addition, improvement of sleep disturbance
was significantly lower amongst patients with advanced
gastrointestinal cancer than amongst those with ad-
vanced lung cancer. Compared with patients with ad-
vanced lung cancer, management of lymphoedema was
more challenging amongst those with advanced gastro-
intestinal, breast, and genitourinary cancer but easier
amongst those with head, neck, and oral cancer. How-
ever, the varying sites of lymphoedema amongst pa-
tients with different types of cancer required further
investigation to facilitate efficient management. Im-
provement of mood states, including depression and
anxiety, was more challenging amongst patients with
advanced gastrointestinal cancer than amongst those with
advanced lung cancer ones. Patients with advanced breast
cancer exhibited greater control of anxiety than did those
with lung cancer; the reasons for this difference may be
complicated because of other underlying physical symp-
toms (eg, dyspnoea).
The conditions of patients with advanced cancer may
rapidly deteriorate during their terminal phase, and
symptoms often worsen rapidly, suddenly, and unexpect-
edly. Thus, rapid and effective management of these
symptoms is essential to ensure adequate improvement
and a high ‘quality of death’. Therefore, the symptom se-
verity assessment of patients with advanced cancer in
palliative care units may provide additional valuable in-
formation regarding this crucial aspect of quality of care.
This was an observational study which evaluated clin-
ical experiences and thus had considerable limitations.
First, the symptom assessment checklist was a relatively
short instrument which assessed only 10 symptoms. Sec-
ond, assessment of the symptom scale scores every 2 days
may be too close. However, this study aimed to explore
the levels of symptom improvement after admission to
the palliative care unit, where the palliative care team
could resolve the symptoms as soon as possible. In
addition, because the cancer progression in such patients
may alter unexpectedly, we used a simple instrument to
closely assess the improvement in symptom severity.
Third, there was no information of the individual co-
morbidity, which may be associated with distressing
symptoms among advanced cancer patients. Fourth, this
study recruited only advanced cancer patients with ad-
equate level of consciousness to report symptoms and
was conducted in one palliative care unit of a medical
center, which may limit the generalization for all ter-
minal patients and all palliative care units. A consistent
symptom assessment tool for the routine quality indica-
tors of the palliative care units is needed in the future.
Conclusion
This study confirmed considerable symptom improve-
ment during the first week of palliative unit inpatient
care, except on Day 7 of dyspnoea and oedema assess-
ment and Day 5 of anxiety assessment. Improvement of
pain, sleep disturbance, depression, and anxiety were sig-
nificantly associated with older age. In addition, female
patients with advanced cancer reported lower symptom
improvement of vomiting, anorexia, sleep disturbance,
depression, and anxiety than did the corresponding male
patients. In addition, patients with different types of ad-
vanced cancer exhibited varying degrees of symptom
improvement.
Additional file
Additional file 1: The Symptom Reporting Form. (DOC 30 kb)
Abbreviations
GEE model: a generalised estimating equation model; Estimate [SD]: estimate
[standard deviation].
Competing interests
The authors declare that they have no competing interests.
Authors’contributions
CTH and CYC conceived of the study. SYT, CYL, CYW and HYH participated in
the data collection and coordination. Data analysis was mainly done by SYT
and CYC. SYT wrote the first draft. All authors (CTH, CYL, HYH, CYW, JJH and
CYC) contributed to the literature search and interpretation of the data. All
authors read and approved the final manuscript.
Acknowledgments
We appreciate the participation of all the advanced cancer patients in this
palliative care unit during the study period and the cooperation of the staff.
Besides, this study was supported by Kaohsiung Medical University Hospital
(KMUH101-1R44 and KMUH103-3R68), Kaohsiung Municipal Hsiao-Kang Hospital
(Kmhk-103-032) and the Ministry of Science and Technology (MOST103-2314-B-
037-004-MY3). None of which had any role in study design, data collection and
analysis, decision to publish, or preparation of the manuscript.
Author details
1
Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical
University, Kaohsiung, Taiwan.
2
Department of Family Medicine, School of
Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung,
Taiwan.
3
Department of Family Medicine, Kaohsiung Medical University
Hospital, Kaohsiung, Taiwan.
4
Department of Family Medicine, Kaohsiung
Municipal Ta-Tung Hospital, Kaohsiung Medical University, Kaohsiung,
Taiwan.
5
Department of Nursing, Kaohsiung Medical University Hospital,
Kaohsiung Medical University, Kaohsiung, Taiwan.
6
Department of
Otorhinolaryngology, School of Medicine, College of Medicine, Kaohsiung
Medical University, Kaohsiung, Taiwan.
7
Departments of Otorhinolaryngology,
Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.
8
Department of
Otolaryngology, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung
Medical University, Kaohsiung, Taiwan.
Received: 28 April 2015 Accepted: 7 March 2016
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