Exploring Symptom Clusters in Individuals Undergoing Surgery for Pancreatic Cancer
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Exploring Symptom Clusters in Individuals
Undergoing Surgery for Pancreatic Cancer
Sherry A. Burrell, PhD, RN, ACNS-BC, CNE
Assistant Clinical Professor
School of Nursing – Camden
Rutgers, The State University of New Jersey
Rutgers, The State University of New Jersey
School of Nursing-Camden
Disclosures
• Author Information:
– Sherry A. Burrell: School of Nursing-Camden, Rutgers, The State University
of New Jersey; Suzanne Smeltzer: College of Nursing, Villanova University;
Theresa P. Yeo, Benjamin E. Leiby, Harish Lavu, Eugene P. Kennedy ,
and Charles J. Yeo: Thomas Jefferson University and Thomas Jefferson
University Hospital.
• Conflicts of Interest: No conflicts of interest to declare
• Funding: American Cancer Society (DSCN # 11-195-01)
• Learning Objectives:
– Describe the five symptoms that were among the most prevalent and severe
over time in patients with Stage II PC undergoing surgery.
– Discuss the four core symptom cluster sub-groupings that were
present over time in patients with Stage II PC undergoing surgery.
– Describe two pre-operative factors that influenced the severity of symptom
clusters in patients with Stage II PC undergoing surgery.School of Nursing-Camden
Background and Significance
• Pancreatic Cancer (PC)
– It is predicted that PC will be the second leading cause of
cancer-related death by 2020
– Surgical resection offers the only possibility of a cure for PC
• Symptom Clusters (SCs)
− Two or more symptoms occurring simultaneously, which may or
may not share the same etiology, and that are more strongly
related to each other than symptoms outside the cluster.
− Review of the Literature (N=70)
− SCs found to be associated with poor clinical outcomes
− Only 6% of researchers examined SCs in PC patients (n=4)
(American Cancer Society, 2015; Dodd et al., 2004a; Kim et al., 2005; Pancreatic Cancer Action Network, 2013)School of Nursing-Camden
Study Aims
The purposes of this study were to:
1) describe self-reported symptom profiles;
2) identify the presence of and changes in
symptom clusters; and
3) describe the physiological, psychological, and
situational factors that influence the symptom
cluster experience
… before and at three, six, and nine months after
potentially curative surgery alone or in combination
with adjuvant therapy for stage II PC.School of Nursing-Camden
Research Design & Methods
This study was conducted as a primary nested, descriptive,
longitudinal study within a ongoing single center, prospective,
randomized, double-blind, clinical trial (Parent Study).
Overview of Methods:
Patients were recruited using convenience sampling techniques.
A sub-sample of patients were derived from the Parent Study
Inclusion Criteria: Adults (18 years-old or older) who were able to
read and write in the English language and had stage IIa or IIb PC.
Exclusion Criteria: Patients with periampullary cancer; stage I, III,
and IV PC; and patients that did not return at least one pre-operative
and one post-operative questionnaire.School of Nursing-Camden
Theoretical Framework
THE THEORY OF UNPLEASANT SYMPTOMS (TOUS)
(Lenz et al., 1997, 2008)School of Nursing-Camden Sample Size and Characteristics
School of Nursing-Camden
Symptom Profiles
• Concurrent Symptoms
– Mean number of symptoms were 9.62 at pre-operatively
8.75 at 3 months, 8.66 at 6 months, and 8.98 at 9 months
post-operatively.
• Symptom Prevalence
– Relatively high prevalence for all symptoms
– The five most prevalent symptoms tended to include:
Fatigue, anxiety, trouble sleeping, poor appetite, and weight loss
• Symptom Severity
– Relatively mild to moderate severity for all symptoms
– The five most severe symptoms tended to include:
Fatigue, anxiety, trouble sleeping, poor appetite, and weight lossSchool of Nursing-Camden Pre-Operative Baseline Symptom Clusters EXPLORATORY FACTOR ANALYSIS CONFIRMATORY FACTOR ANALYSIS N=143; Χ261=62.7; p=0.42 N=55; *p
School of Nursing-Camden
Final Pre-Operative Symptom Clusters
Factor 1: Factor 2: Factor 3: Factor 4: Factor 5:
Pain – Mood Symptom Digestive Fatigue - Nutritional Jaundice Symptom
Gastrointestinal Cluster Problems Problems Symptom Cluster
Symptom Cluster Symptom Cluster Cluster
Nausea* Depression Loss of Bowel Dry Mouth Nausea
Control
Trouble Digesting Anxiety Trouble Digesting Change in Taste Jaundice
Food Food*
Abdominal Pain / Fatigue
Cramping
Back Pain Weight Loss
Poor Appetite
Constipation
* Highest loading value for symptoms that loaded on one than one factor (symptom cluster)School of Nursing-Camden
3 Month Post-Operative Symptom Clusters
EXPLORATORY FACTOR ANALYSIS CONFIRMATORY FACTOR ANALYSIS
N=109; Χ262=74.2; p=0.14 *N=55; *pSchool of Nursing-Camden
Final 3 Month Post-Operative
Symptom Clusters
Factor 1: Factor 2: Factor 3: Factor 4:
Mood – Pain – Anorexia Insomnia – Digestive Gastrointestinal Nutritional Problems
– Fatigue Problems Sickness Symptom Cluster
Symptom Cluster Symptom Cluster Symptom Cluster
Anxiety Loss of Diarrhea ~ Itching*
Bowel Control
Depression Trouble Itching ~ Dry Mouth
Digesting Food
Back Pain Trouble Sleeping Nausea ~ Change in Taste
Nausea* Weight Loss
Fatigue
Abdominal Pain /
Cramping
Poor Appetite
* Highest loading value for symptoms that loaded on one than one factor (symptom cluster)
~ CFA factor loading not significant (p=0.010)School of Nursing-Camden 6 Month Post-Operative Symptom Clusters EXPLORATORY FACTOR ANALYSIS CONFIRMATORY FACTOR ANALYSIS N=92; Χ262=66.7; p=0.32 N=55; * p
School of Nursing-Camden
Final 6 Month Post-Operative
Symptom Clusters
Factor 1: Factor 2: Factor 3: Factor 4:
Mood – Pain- Digestive - Bowel Fatigue - Anorexia - Pain - Itching Symptom
Insomnia - Problems Symptom Nutritional Problems Cluster
Gastrointestinal Cluster Symptom Cluster
Symptom Cluster
Depression Loss of Poor Appetite Itching
Bowel Control
Anxiety Trouble Change in Taste Back Pain*
Digesting Food
Trouble Sleeping Diarrhea Dry Mouth Abdominal Pain /
Cramping
Back Pain ~ Fatigue
Constipation Weight loss
* Highest loading value for symptoms that loaded on one than one factor (symptom cluster)
~ CFA factor loading not significant (p=0.010)School of Nursing-Camden 9 Month Post-Operative Symptom Clusters EXPLORATORY FACTOR ANALYSIS CONFIRMATORY FACTOR ANALYSIS N=89; Χ262=69.9; p=0.23 N=55; * p
School of Nursing-Camden
Final 9 Month Post-Operative
Symptom Clusters
Factor 1: Factor 2: Factor 3:
Mood –Pain – Insomnia – Digestive – Weight Loss – Fatigue – Pain – Nutritional
Nausea Symptom Cluster Bowel Problems Problems
Symptom Cluster Symptom Cluster
Anxiety Loss of Change in Taste
Bowel Control
Depression Trouble Fatigue
Digesting Food
Trouble Sleeping Diarrhea Dry Mouth
Back Pain* Weight Loss Constipation*
Abdominal Pain Constipation Back Pain
/ Cramping
Nausea
* Highest loading value for symptoms that loaded on one than one factor (symptom cluster)School of Nursing-Camden Core Symptom Clusters Over Time • Sub-Grouping A – Anxiety and Depression • Sub-Grouping B – Trouble Digesting Food and Loss of Bowel Control • Sub-Grouping C – Dry Mouth, Change in Taste, Fatigue, and Weight loss • Sub-Grouping D – Nausea, Back Pain, and Abdominal Pain / Cramping
School of Nursing-Camden Influencing Factors
School of Nursing-Camden
Study Limitations
• Sample - Related
– Convenience Sampling / One Cancer Center
– Lack of Sample Diversity
– Sample Size
• Parent Study - Related
– Symptom Assessment Measure / Tool
– Limited Data Available Related To:
• Adjuvant Treatment
• Symptom Management StrategiesSchool of Nursing-Camden
Nursing Implications
• Nursing Practice • Nursing Theory
– Bring awareness of SCs as – Advance the development
related to PC to healthcare of key concepts and
professionals. propositions of the TOUS.
– Help inform anticipatory – Connect findings to the
guidance of patients and their larger body of SC knowledge
families. related cancer types.
– Help inform symptom
management and assessments
• Nursing Education
for PC patients and survivors. – Theoretical and evidence-
based knowledge to help
• Nursing Research inform the education of
– Help inform future symptom nursing professionals.
cluster studies in surgical PC
populations.School of Nursing-Camden
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