Saturday, January 28, 2006
Another e-publication ahead of print from Supportive Care in Cancer...
Our colleagues at the Cleveland Clinic have compared the systematic assessment of patient symptoms to relying on patient reporting of symptoms. They looked at 200 patients referred to their service (the vast majority had cancer; 44% were inpatients). The patients were initially asked two open ended questions about symptoms to see what they volunteered, and then underwent a directed, systematic assessment of 48 symptoms. This is a well done, important, and provocative study.
First off, this gives us a valuable look at symptom burden in a cohort of patients referred to a palliative care service, albeit at a single institution. The top 12 symptoms found, in descending order, were fatigue (73%), dry mouth (67%), pain (64%), anorexia (59%), weight loss (54%), early satiety (49%), insomnia (43%), dyspnea (43%), drowsiness (41%), constipation (39%), cough (39%), and depression (36%). Not surprisingly, the more severe or distressing the patient rated a symptom, the more likely s/he was to report it. However, and this is probably the most important finding of the study, several symptoms were rarely volunteered even if the patient rated them "distressing" when specifically asked about them. This included fatigue (42% volunteered this symptom), anorexia (31%), and early satiety, dry mouth, insomnia, and weight loss (all less than 10%). Likewise, several symptoms which the patients rated as "moderate" or "severe" (even if not "distressing") were rarely volunteered--these included fatigue, dyspnea, early satiety, drowsiness, dry mouth, insomnia, and weight loss.
Does this mean all patients should have directed, systematic, and exhaustive symptom assessments? I don't think so, but you could use these findings to argue with me. Probably very few of us when interviewing patients rely solely upon patient volunteered symptoms, and a good 'review of systems' is integral to every--at least initial--patient assessment. So whether systematic assessment actually offers the patient anything more than routine care is unknown. This assumes of course that routine care is good care, but that's another story. What would need to be demonstrated is that systematic assessment offers patients some benefit--quality of life, symptom improvement, satisfaction with care, etc. There's also the question of burden to the patient of exhaustive interviewing, not to mention the time-cost and practicality of this outside of the research setting. Also, what is one to make of symptoms that patients, when asked, say are distressing or severe, but that previously they didn't bother to offer. Some of these are probably symptoms that patients have resigned themselves to as inevitable, even if they aren't, and these are the ones that we could make an impact on with systematic assessment (or a thorough history taking!). One wonders though, despite being reported as 'distressing,' how many of these symptoms were making a substantial negative impact on the patients' quality of life in this study? Are these research-generated symptom incidentalomas? Nevertheless, clearly it's a good idea to be on the look-out for those under-reported symptoms mentioned above.