The purpose of this study was to compare patient and proxy (physician and nurse) assessments of symptoms in advanced cancer patients. The sample consisted of 49 patients with advanced cancer admitted to an acute palliative care unit. Three independent assessments were completed for each patient on two occasions within 11 days of admission. On each occasion, symptoms were rated independently by the patient and two proxies (treating physician and nurse), using the Edmonton Symptom Assessment System (ESAS). The ESAS is a nine-item visual analogue scale (VAS) for assessing pain, activity, nausea, depression, anxiety, drowsiness, appetite, well-being and shortness of breath. Symptom ratings were compared using a repeated-measures ANOVA procedure and correlations. Average physician ratings were generally lower than average patient ratings for both occasions. Average nurse ratings agreed more closely with patient ratings, with a trend towards lower ratings on occasion 1 and higher ratings on occasion 2. There was a significant rater (person rating the effects) effect (P < 0.01) for three of the nine symptoms: physicians rated drowsiness, shortness of breath and pain significantly lower than patients. For drowsiness and shortness of breath, these differences were clinically relevant, representing a difference of more than 12 mm on a 100-mm VAS. The accuracy of assessments amongst those rating the symptoms did not improve over time. Proxy assessments of symptom intensity, particularly by physicians, were significantly lower than patient assessments for three of the nine symptoms. Further research regarding the reliability of patient and proxy assessments is needed to assess and manage symptoms in advanced cancer effectively.
Foley K. The treatment of cancer pain. N Engl J Med1985; 313: 84–95.
2.
Bruera E. Research in symptoms other than pain. In: Doyle D, Hanks G, MacDonald N eds. Oxford textbook of palliative medicine. Oxford: Oxford Medical Publications, 1993: 87–92.
3.
Bruera E, Fox R, Chadwick S, Brenneis C, MacDonald N. Changing patterns in the treatment of pain and other symptoms in advanced cancer patients. J Pain Symptom Manage1987; 2: 139–144.
4.
Vainio A, Auvinen A. Prevalence of symptoms among patients with advanced cancer: an international collaborative study. J Pain Symptom Manage1986; 12: 3–10.
5.
Beeney LJ, Butow PN, Dunn SM. ‘Normal’ adjustment to cancer: characteristics and assessment. In: Portenoy RK, Bruera E eds. Topics in palliative care, Volume 1. New York: Oxford University Press, 1997: 213–244.
6.
Breitbart W, Bruera E, Chochinov H, Lynch M. Neuropsychiatric syndromes and psychological symptoms in patients with advanced cancer. J Pain Symptom Manage1995; 10: 131–141.
7.
Chochinov HM. Psychiatric care of the cancer patient. Med North Am1994; 17: 671–674.
8.
Chochinov HM, Wilson KG, Enns M, Landers S. Prevalence of depression in the terminally ill: Effects of diagnostic criteria and symptom threshold judgments. Am J Psychiatry1994; 151: 537–540.
9.
Derogatis LR, Morrow GR, Fetting J et al. The prevalence of psychiatric disorders among cancer patients. J Am Med Assoc1983; 249: 751–757.
10.
Lynch ME. The assessment and prevalence of affective disorders in advanced cancer. J Palliat Care1995; 11(1): 10–18.
11.
US Public Health Service Agency for Health Care Policy and Research. US Public Health Service, 1994.
12.
Bruera E. Patient assessment in palliative cancer care. Cancer Treat Rev1996; 22(Suppl. A): 3–12.
13.
Bruera E, MacDonald S. Audit methods: the Edmonton Symptom Assessment System. In: Higginson I ed. Clinical audit in palliative care. Oxford: Radcliffe Medical Press, 1993: 61–77.
14.
Higginson I. Audit methods: a community schedule. In: Higginson I ed. Clinical audit in palliative care. Oxford: Radcliffe Medical Press, 1993: 34–47.
15.
Higginson I. Audit methods: Validation and inpatient use. In: Higginson I ed. Clinical audit in palliative care. Oxford: Radcliffe Medical Press, 1993: 48–54.
16.
McCorkle R, Young K. Development of a symptom distress scale. Cancer Nurs1978; 1: 373–378.
17.
Samurel N, Leddy SK, Greco K et al. Development and testing of the symptom experience scale. J Pain Symptom Manage1996; 12: 221–228.
18.
Sutherland HJ, Lockwood GA, Cunningham AJ. A simple, rapid method for assessing psychological distress in cancer patients: Evidence of validity for linear analog scales. J Psychosoc Oncol1989; 7: 31–43.
19.
Dudgeon D, Raubertas RF, Rosenthal SN. The short-form McGill Pain Questionnaire in chronic cancer pain. J Pain Symptom Manage1993; 8: 191–195.
20.
Grossman SA, Sheidler VR, McGuire DB, Geer C, Santor D, Piantadosi S. A comparison of the Hopkins Pain Rating Instrument with standard visual analogue and verbal descriptor scales in patients with cancer pain. J Pain Symptom Manage1992; 7: 196–203.
21.
Yates JW, Chalmer B, McKegney FP. Evaluation of patients with advanced cancer using the Karnofsky performance status. Cancer1980; 45: 2220–2224.
22.
Bruera E, Watanabe S. New developments in the assessment of pain in cancer patients. Support Care Cancer1994; 2: 312–318.
23.
Portenoy RK. Cancer pain: general design issues. In: Max MB, Portenoy RK, Laska EM eds. Advances in pain research and therapy, Volume 18. The design of analgesic clinical trials. New York: Raven Press, 1991: 233–266.
24.
Bruera E, Fainsinger RL, Miller MJ, Kuehn N. The assessment of pain intensity in patients with cognitive failure: a preliminary report. J Pain Symptom Manage1992; 7: 267–270.
25.
Brunelli C, Costantini M, Di Giulio P et al. Quality-of-life evaluation: when do terminal cancer patients and health-care providers agree?J Pain Symptom Manage1998; 15: 151–158.
26.
Cleeland CS, Gonin R, Hatfield AK et al. Pain and its treatment in outpatients with metastatic cancer. N Engl J Med1994; 330: 592–596.
27.
Higginson IJ. Can professionals improve their assessments? [commentary]. J Pain Symptom Manage1998; 15: 149–150.
28.
Nekolaichuk CL, Bruera E, Maguire TO. An examination of the reliability of the Edmonton Symptom Assessment System (ESAS) in a palliative care setting [abstract]. J Palliat Care1998; 14(3): 125–126.
29.
Sprangers MAG, Aaronson NK. The role of health care providers and significant others in evaluating the quality of life of patients with chronic disease: a review. J Clin Epidemiol1992; 45: 743–760.
30.
Peteet J, Tay V, Cohen G, MacIntyre J. Pain characteristics and treatment in an outpatient cancer population. Cancer1986; 57: 1259–1265.
31.
Grossman SA, Sheidler VR, Swedeen K, Mucenski J, Piantadosi S. Correlation of patient and caregiver ratings of cancer pain. J Pain Symptom Manage1991; 6: 53–57.
32.
Slevin ML, Plant H, Lynch D, Drinkwater J, Gregory WM. Who should measure quality of life, the doctor or the patient?Br J Cancer1988; 57: 109–112.
33.
Sneeuw KCA, Aaronson NK, Sprangers MAG, Delmar SB, Wever LDV, Schornagel JH. Value of caregiver ratings in evaluating the quality of life of patients with cancer. J Clin Oncol1997; 15: 1206–1217.
34.
Bruera E, Kuehn N, Miller MJ, Selmser P, MacMillan K. The Edmonton Symptom Assessment System (ESAS): a simple method for the assessment of palliative care patients. J Palliat Care1991; 7(2): 6–9.
35.
Higginson IJ, McCarthy M. Validity of the support team assessment schedule: do staffs' ratings reflect those made by patients or their families?Palliat Med1993; 7: 219–228.
36.
Huskisson EC. Visual analogue scales. In: Melzack R ed. Pain measurement and assessment. New York: Raven Press, 1983: 33–37.
37.
Price DD, McGrath PA, Rafii A, Buckingham B. The validation of visual analogue scales as ratio scale measures for chronic and experimental pain. Pain1983; 17: 45–56.
38.
Ahles TA, Ruckdeschel JC, Blanchard EB. Cancer-related pain: II. Assessment with visual analogue scales. J Psychosom Res1984; 28: 121–124.
39.
Law M, McIntosh J, Morrison L, Baptiste S. A comparison of two pain measurement scales: their clinical value. Can J Rehab1987; 1: 55–58.
40.
Wilkie D, Lovejoy N, Dodd M, Tesler M. Cancer pain intensity measurement: Concurrent validity of three tools: finger dynamometer, pain intensity number scale, visual analogue scale. Hospice J1990; 6: 1–13.
41.
Bruera E, Carraro S, Roca E, Cedaro L, Chacon R. Association between malnutrition and caloric intake, emesis, psychological depression, glucose taste, and tumor mass. Cancer Treat Rep1984; 68: 873–876.
42.
Bruera E, Brenneis C, Michaud M et al. Association between asthenia and nutritional status, lean body mass, anemia, psychological status, and tumor mass in patients with advanced breast cancer. J Pain Symptom Manage1989; 4: 59–63.
43.
Hurny C, Bernhard J, Coates A et al. Responsiveness of a single-item indicator versus a multi-item scale: assessment of emotional well-being in an international adjuvant breast cancer trial. Medical Care1996; 34: 234–248.
44.
Selby PJ, Chapman JAW, Etazadi-Amoli J, Dalley D, Boyd NF. The development of a method for assessing the quality of life of cancer patients. Br J Cancer1984; 50: 13–22.
45.
Boyd NF, Selby PJ, Sutherland HJ, Hogg S. Measurement of the clinical status of patients with breast cancer: evidence for the validity of self assessment with linear analogue scales. J Clin Epidemiol1988; 41: 243–250.
46.
Sutherland HJ, Lockwood GA, Cunningham AJ. A simple, rapid method for assessing psychological distress in cancer patients: evidence of validity for linear analog scales. J Psychosoc Oncol1989; 7: 31–43.
47.
Stevens J. Applied multivariate statistics for the social sciences, 3rd edn.Mahwah, NJ: Lawrence Erlbaum, 1996.
48.
Bruera E, Sloan P, Mount B, Scott J, Suarez-Almazor M. A randomized, double-blind, double-dummy, crossover trial comparing the safety and efficacy of oral sustained-release hydromorphone with immediate-release hydromorphone in patients with cancer pain. J Clin Oncol1996; 14: 1713–1717.
49.
Bruera E, Fainsinger R, Spachynski K, Babul N, Harsanyi Z, Darke AC. Clinical efficacy and safety of a novel controlled-release morphine suppository and subcutaneous morphine in cancer pain: a randomized evaluation. J Clin Oncol1995; 13: 1520–1527.
50.
Cohen J. Statistical power analysis for the behavioral sciences, 2nd edn.Hillsdale, NJ: Lawrence Erlbaum, 1988.
51.
World Health Organization Expert Committee. Cancer pain relief and palliative care. Technical Report Series No. 804. Geneva: World Health Organization, 1990.
52.
Pereira J, Hanson J, Bruera E. The frequency and clinical course of cognitive impairment in patients with terminal cancer. Cancer1997; 79: 835–842.
53.
Bruera E, Schoeller T, Wenk R et al. A prospective multicenter assessment of the Edmonton Staging System for cancer pain. J Pain Symptom Manage1995; 10: 348–355.
54.
Zenz M. Morphine myths: sedation, tolerance, addiction. Postgrad Med J1991; 67(Suppl. 5): S100–S102.
55.
Cleeland CS. The impact of pain on the patient with cancer. Cancer1984; 54: 2635–2641.
56.
Foley KM. Pain assessment and cancer pain syndromes. In: Doyle D, MacDonald N eds. Oxford textbook of palliative medicine. Oxford: Oxford Medical Publications, 1993: 148–165.
