Symptom severity and complexity trends in patients undergoing radiation therapy

Symptom severity and complexity trends in patients undergoing radiation therapy | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Symptom severity and complexity trends in patients undergoing radiation therapy Demetra Yannitsos, Siwei Qi, Oluwaseun Davies, Linda Watson, Lisa Barbera This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3273369/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective: Symptom severity has considerable impact on patients’ cancer care journey. This study aims to better understand psychological and physical symptom scores of radiotherapy patients across their radiotherapy care trajectory. Methods: Patients who received radiotherapy at a single tertiary cancer center, who also completed at least one symptom-reporting questionnaire, the Edmonton Symptom Assessment Scale – Revised (ESAS-r) between October 1, 2019 and April 1, 2020 were included in this retrospective analysis. Within the study period, time points included consultation, first and last radiation treatment reviews and first post-treatment follow-up. Symptoms were divided into psychological and physical. Mixed effect models assessed trajectories of psychological and physical scores across appointments. A symptom complexity score was assigned to each ESAS-r encounter. Symptom complexity score association with appointment type and tumor group was modelled using Generalized Estimating Equations (GEE). Results: The study cohort consisted of 1,632 patients who completed 2,519 ESAS-r questionnaires. Patients reported significantly higher psychological symptom scores at consultations than at first review, last review and follow-up. Patients reported significantly higher physical scores at last reviews compared to consultations. Patients at first review had significantly lower odds of having a higher (more severe) symptom complexity score, compared with patients at consultations (OR =0.77, 95% CI=0.64-0.93). Conclusions: Symptoms change over the course of a patient’s care trajectory. Understanding how particular symptoms change over time provides a target for initiatives that improve symptom management. Figures Figure 1 Introduction Oncology patients receiving treatment experience a dynamic range of physical and psychological symptoms [ 1 ]. Understanding symptom trajectory across the continuum of care is crucial for providing optimal care and improving quality of life. Specifically, such data enables providers to highlight populations at risk for increasing symptom severity, generate novel symptom management interventions, and develop targeted quality assurance initiatives. Patient-reported outcomes measures (PROMs) enable systematic collection of each patient’s perspective on their symptoms. Routine collection of PROMs has been shown to identify unmet symptom needs, improve communication, improve treatment adherence, reduce utilization of acute care services, and improve survival [ 2 – 5 ]. Within CancerCare Alberta (CCA), a provincial ambulatory program, PROMs, including the Edmonton Symptom Assessment Scale – Revised (ESAS-r), are routinely incorporated into clinical workflows and are administered to all oncology patients receiving ambulatory care [ 6 ]. Within our institution, PROMs are routinely collected at initial consultation appointments, at the first and last treatment review during radiation therapy, and follow-up appointments post treatment. Previous studies investigating symptom trajectories in oncology patients have used temporal measures in months or weeks, and few studies have investigated a radiation specific cohort of patients across multiple tumour groups. This study describes the trajectory of ESAS-r scores in patients receiving radiation treatment at a large tertiary ambulatory cancer care centre. Methods Study design This retrospective observational study was conducted using several sources of linked electronic healthcare data. The dataset used was part of a larger study that received ethics approval from the Health Research Ethics Board of Alberta’s Cancer Committee (HREBA.CC-20-0022). Data sources and variables The study utilized administrative data from the Alberta Cancer Registry (ACR), clinical data from CCA’s electronic medical record (EMR), and from the Canadian Institute for Health Information (CIHI) Discharge Abstract Database (DAD). Data linkage was achieved through a unique provincial health care number assigned to each patient as part of the ACR’s process at the time. We collected age, sex, tumour group, and rurality index from the ACR database; Charlson Comorbidity Index (CCI) from the DAD database; and appointment types from the EMR. Tumour groups were defined as breast, gastrointestinal (GI), genitourinary (GU), gynecology (gyne), hematology (hem), head and neck (H&N), lung and other. Rurality index for each patient was assigned based on the postal code of their most recent residence, using a seven-level index created by Alberta Health Services (AHS), and assigned to one of three groups for analysis: metro, urban, and rural. The appointment types were defined relative to the radiation treatment journey: consult (pre-treatment), first treatment review, last review and follow-up. The first follow up typically occurred 3–4 months post radiation treatment, however the first radiation treatment follow up was always chosen. A modified version of the CCI was used which excluded cancer as a condition so that this did not contribute to the index score, as all participants in this study had a cancer diagnosis [ 7 , 8 ]. Cohort ascertainment The study cohort was comprised of patients in Alberta who were 18 years of age and older with any cancer diagnosis, who had at least one radiation therapy appointment at the Tom Baker Cancer Centre (TBCC) radiotherapy program between October 1, 2019 and April 1, 2020. To be eligible for inclusion, patients also had to have completed at least one ESAS-r questionnaire within this timeframe at specific time points: radiation consultation, first and last radiation treatment review and first follow up post radiation treatment. Patients whose ESAS-r was not completed within 2 days of the appointment date were excluded. Outcome The ESAS-r is a 9-item PROM which measures prevalent evidence-based symptoms experienced by patients with cancer [ 9 – 11 ]. Patients rate each symptom on a severity scale from 0 to 10, with 10 indicating the highest severity. The 9 ESAS-r symptoms include pain, tiredness, drowsiness, nausea, lack of appetite, shortness of breath, depression, anxiety and wellbeing. In this study, we collapsed the ESAS-r symptoms into two groups and reported them as psychological and physical scores [ 12 ]. Psychological scores were the sum scores of depression and anxiety (ranging from 0 to 20), while physical scores were the sum scores of pain, tiredness, drowsiness, nausea, lack of appetite, and shortness of breath (ranging from 0 to 60). Overall wellbeing was excluded from the analysis as this symptom encompasses an overall measure, including both physical and psychological, and does not specifically fit into either group. This grouping of symptoms has also been utilized in other studies [ 13 ]. The Canadian Problems Checklist ( CPC) is an evidence-based, 54-item self-report checklist designed to identify common concerns that patients with cancer experience. It is used in conjunction with the ESAS-r and tracks emotional, informational, social, practical, spiritual and physical concerns [ 14 ]. The symptom complexity score, derived from ESAS-r and CPC, considers the unique combination of symptoms and concerns the patient has identified [ 15 ]. It rates the self-reported severity of symptoms and the number of concerns indicated at a single visit and assigns a symptom complexity score (low, moderate, or severe) for the encounter ( Appendix A ). Statistical Analyses Demographic data and symptom outcomes were summarized using descriptive statistics. Our primary interest was the association of appointment type and tumor groups with each outcome. We evaluated the association of these variables with ESAS-r physical and psychological scores [ 16 ] using mixed-effects models (MEM). Models incorporated the patient as a random effect and all other variables as fixed effects [ 17 ]. Models included appointment types and tumour group, as well as age, sex, rurality index and CCI. Given the highly skewed distribution of physical and psychological scores (both > 1), we also ran models on log-transformed scores [ 18 ], a widely used method to deal with skewed data; results were generally unaffected, so we report parameter estimates on the basis of original scores. The association of appointment type and tumor group with symptom complexity score was modelled using Generalized Estimating Equations (GEE), with the outcomes as ordinal (low, moderate, and high). We used the GEE approach to consider within-subjects variability and account for the correlated data resulting from repeated measurements across different time points and multiple observations of the same individual [ 19 ]. Data were exported into SPSS Version 25.0 (Chicago, IL, USA) and SAS statistical software Version 9.4 (SAS Institute, Cary, NC) for analysis and statistical significance was set a priori at p < 0.05. Results Study Sample Table 1 presents the baseline demographic information for the full study cohort (N =1,632). The mean age was 63.4 years, and 935 participants (57.3%) were male. The majority (81.5%) of the cohort lived in a metro area. The most common tumour group within this cohort was breast (31.1%), followed by genitourinary (17.4) and lung (13.1%). A small portion of the cohort (13.4%) had a Charlson Comorbidity Index (CCI) score at or above 1. Table 1: Cohort characteristics n % Age Mean (SD) 63.4 (12.7) Sex Female Male 697 935 42.7 57.3 Rurality Index Metro Urban Rural 1,311 82 216 81.5 5.1 13.4 Tumour Group Breast Gastrointestinal Genitourinary Gynecology Hematology Head & Neck Lung Other* 508 176 284 107 69 109 213 166 31.1 10.8 17.4 6.6 4.2 6.7 13.1 10.2 CCI 0 ≥1 1,414 218 86.6 13.4 Other included: CNS, endocrine, melanoma, no melanoma skin, other malignant and sarcoma Descriptive Statistics-Symptom Severity and Complexity Within the six-month study period, 1,632 patients completed 2,519 ESAS-r questionnaires within 2 days of their appointment date. Of the 2,519 questionnaires, 1,001 (39.7%) were collected at consult, and 727 (28.9%), 583 (23.1%) and 208 (8.3%) were collected at first review, last review and follow-up, respectively. The detailed psychological and physical scores and symptom complexity scores are presented at each appointment type (Table 2) and by each tumour group (Table 3). Table 2: Symptom severity and complexity at each appointment Consult (n=1,001) First Review (n=727) Last Review (n=583) Follow-Up (n=208) Symptom severity Psychological * Physical ** M (SD) 3.78 (4.66) 10.7 (10.6) M (SD) 2.96 (4.13) 11.5 (10.1) M (SD) 2.74 (4.00) 11.7 (10.4) M (SD) 3.10 (4.60) 11.2 (11.0) Symptom complexity Low Moderate High n (%) 622 (62.1%) 186 (18.6%) 193 (19.3%) n (%) 475 (65.3%) 156 (21.5%) 96 (13.2%) n (%) 382 (65.5%) 112 (19.2%) 89 (15.3%) n (%) 134 (64.4%) 40 (19.2%) 34 (16.3%) * Psychosocial scores = sum of depression and anxiety ** Physical scores = sum of pain, tiredness, drowsiness, nausea, lack of appetite and shortness of breath Table 3: Symptom severity and complexity by tumour group BR (n=898) GI (n=272) GU (n=383) GYNE (n=175) HEM (n=111) HN (n=155) LNG (n=299) Other (n=226) Symptom severity Psychological * Physical ** M (SD) 3.19 (4.32) 9.47 (9.20) M (SD) 3.27 (4.35) 11.8 (11.6) M (SD) 2.55 (3.69) 9.08 (9.59) M (SD) 3.59 (4.53) 12.1 (10.7) M (SD) 2.64 (3.92) 12.1 (10.1) M (SD) 2.69 (4.04) 15.4 (12.7) M (SD) 4.30 (5.27) 15.3 (11.3) M (SD) 3.68 (4.44) 11.6 (9.76) Symptom complexity Low Moderate High n (%) 618 (68.8%) 166 (18.5%) 114 (12.7%) n (%) 171 (62.9%) 52 (19.1%) 49 (18.0%) n (%) 277 (72.3%) 53 (13.8%) 53 (13.8%) n (%) 106 (60.6%) 41 (23.4%) 28 (16.0%) n (%) 75 (67.6%) 18 (16.2%) 18 (16.2%) n (%) 83 (53.5%) 35 (22.6%) 37 (23.9%) n (%) 147 (49.2%) 75 (25.1%) 77 (25.8%) n (%) 136 (60.2%) 54 (23.9%) 36 (15.9%) * Psychosocial scores = sum of depression and anxiety ** Physical scores = sum of pain, tiredness, drowsiness, nausea, lack of appetite and shortness of breath Factors associated with Psychological Score Appointment timing was significantly associated with psychological score, after adjusting for baseline covariates, ( F =12.7, p <.01). Scores were significantly lower (indicating symptoms were less severe) at first review (β =-.84, 95% CI =-.55 – -1.12, p <0.01) and at last review (β =-.79, 95% CI =-.48 – -1.10, p <0.01) when compared with the scores at consult (Figure 1a). Tumor group was also associated with psychological scores after adjusting for baseline covariates ( F =5.21, p <.01), with scores for patients with lung (β =1.81, 95% CI =1.14 – 2.48, p <0.01) and other types of cancer (β =0.83, 95% CI =.11 – 1.54, p <0.05) being significantly higher (indicating symptoms were more severe) than the scores from patients with breast cancer (Figure 1b). Factors associated with Physical Scores Physical scores were associated with appointment timing ( F =7.81, p <0.01), after controlling for baseline covariates. Physical scores were significantly higher at last review (β =1.78, 95% CI =.96 – 2.59, p <0.01) when compared with the scores at consult (Figure 1c). Physical scores were also associated with tumour group after controlling for baseline covariates ( F =19.3, p <0.01). Using patients with breast cancer as the reference group, patients from six other tumour groups (gastrointestinal, gynecology, head & neck, hematology, lung, and other) reported higher physical scores (Figure 1d). Genitourinary was the only tumour group that did not significantly differ from the breast group. Factors associated with Symptom Complexity Scores We observed a significant association between appointment timing and symptom complexity after correcting for baseline covariates. Patients at first review had significantly lower odds of having a higher (more severe) symptom complexity score, compared with patients at consult (OR =0.77, 95% CI =0.64 – 0.93). Patients at last review and follow-up also had lower odds of having a more severe complexity score, however not at a significant level. We also observed a significant association between tumour group and symptom complexity after correcting for baseline covariates. Compared to patients with breast cancer, patients with gastrointestinal, head & neck, lung and other cancers were significantly more likely to have higher symptom complexity scores (ORs ranged from 1.65 to 2.77). Differences between the patients with breast cancer and genitourinary, gynecology, and hematology cancers were not significant. Details are shown in Table 4. Table 4: GEE results of parameters associated with an odds ratio of having a higher symptom complexity score OR (95% CI) p Age 0.96 (0.99-1.00) 0.211 Sex Male* Female 1 0.65 (0.49-0.86) 0.002 Charlson comorbidity index CCI ≥1* CCI =0 1 0.66 (0.51-0.87) 0.003 Rurality Rural* Metro Urban 1 1.07 (.80-1.42) 1.16 (0.71-1.91) 0.665 0.548 Appointment type Consult* First review Last review Follow-up 1 0.77 (0.64 – 0.93) 0.84 (0.67 – 1.02) 0.81 (0.60 – 1.10) 0.005 0.079 0.171 Tumour Group Breast* Gastrointestinal Genitourinary Gynecology Hematology Head & Neck Lung Other 1 1.65 (1.14 – 2.40) 1.31 (0.86 – 1.99) 1.38 (0.92 – 2.07) 1.47 (0.85 – 2.54) 2.77 (1.80 – 4.26) 2.73 (1.93 – 3.85) 1.70 (1.16 – 2.48) 0.008 0.207 0.125 0.166 0.000 0.000 0.006 * Reference group Discussion This study demonstrates physical and psychological symptom severity and symptom complexity trends experienced by patients during their radiation treatment journey. Overall, we found associations with both physical and psychological symptom scores across appointment timing as well as tumour groups. Psychological symptoms were more severe at initial radiation consultation compared to on-treatment, whereas physical symptoms were more severe at the end of radiation treatment compared to consultation. Symptom severity was high for lung patients in both mean physical and psychological symptom scores. Overall, symptom complexity scores were higher at consultation compared to first review, and for patients with GI, H&N, lung or other cancers, compared to breast. These findings can help to direct timing-specific QI work to help improve patient experience and symptom management. Our results are concordant with previous studies that demonstrated psychological symptoms being most severe at the beginning of the cancer journey [ 20 – 24 ]. One study found that oncology patients’ anxiety scores were elevated 1–2 months post cancer diagnosis, and then decreased until month 6, when scores plateaued [ 20 ]. Results from another study found the proportion of patients with moderate-severe anxiety decreased by 10% within 6 months of diagnosis [ 22 ]. Our results found that psychological symptom scores were less severe at first and last review compared to consultations, indicating consultations are an important source of psychological support. Encouraging patients to access available resources, and educating patients on various support options may further benefit the patient. The most cited barrier to oncology patients accessing supportive services is a lack of awareness of available supports, and a lack of referrals from their physicians [ 25 ]; however, patients are often overwhelmed at consultation, both emotionally and by the volume of information presented. Even when healthcare providers encourage discussions of available supportive care services, many patients cannot retain or remember those details afterwards. An additional education-based appointment scheduled shortly after the patient’s consultation may help to address these issues. Overall, alternative approaches to providing psychological support at consultation require investigation. Further, education may be beneficial to oncologists and nurses. Previous studies have shown positive results when providers engage in psychological support training programs to improve communication skills around patient emotional concerns and wellbeing [ 26 , 27 ]. These skills may be especially important during consultations. Although not statistically significant, there was a slight increase in severity of mean psychological symptom scores from last review to first follow up, perhaps indicating some increase in anxiety regarding treatment success or fear of recurrence. Patients typically receive radiation treatments consistently on weekdays, for a certain number of consecutive weeks, allowing for daily interactions with the healthcare team, which may help patients feel well supported during treatment. It may be helpful for oncologists and nurses to acknowledge with patients that they are prone to higher psychological burden after completion of radiation [ 28 , 29 ], highlighting another opportunity to explore alternative approaches to providing support. Our results show physical symptom scores were significantly higher at the end of radiation compared to consultations, likely due to treatment-related toxicities [ 30 ]. Although increased symptom severity is in part unavoidable due to treatment, earlier interventions and referrals to allied health could play a role in decreasing overall symptom severity. Implementing a tumour-specific PROM weekly during radiotherapy has been found to be a feasible and accepted resource, with the potential to help physicians identify problematic symptoms earlier on in their patients’ treatment trajectory [ 31 – 33 ]. Compared to breast, almost all tumour groups reported significantly higher mean physical symptom scores, with lung and H&N having the most severe. Further, patients with H&N and lung, as well as other and GI cancers, were more likely to have a higher symptom complexity score, compared to patients with breast cancer. Greater symptom burden in patients with H&N and lung cancers has been previously reported in both tumour groups [ 20 , 34 , 35 ] as well as patients with lung cancer [ 20 , 36 , 37 ]. Although patients with lung cancer can present with particularly complex symptom profiles, many do to not engage with supportive resources or services [ 25 , 27 , 38 ]. In a US study of breast, lung, GI and other tumour groups, results indicated that patients with lung cancer were half as likely to access supportive care and palliative care services compared to the other tumour groups [ 25 ]. However, research has shown that patients with lung cancer who do engage in interdisciplinary supportive care and interventions do benefit [ 39 – 41 ]. Our results highlight a need to improve symptom management in patients with lung cancer, in particular to promote uptake of supportive resources. Collecting and monitoring symptom complexity scores can assist clinicians in identifying patients requiring increased clinical support. The symptom complexity score considers all symptoms together and encompasses the overall symptom burden of the patient at their visit. This makes it useful as a clinical flag at a particular visit to alert the team to patients who require more specific care, as any symptom (physical or psychological) would require the same clinical team to address the patient’s concerns initially. Further action could include more detailed assessment to identify appropriate clinical action, as well as providing appropriate referrals. Therefore, the use of symptom complexity scores in routine clinical practice can help clinicians effectively identify, monitor and manage each patient’s needs. Strengths of this study include its longitudinal design, allowing for the identification of the changes of symptoms over the continuum of radiation therapy. There were few limitations to our study. First, not all the patients filled out the PROs at the four timepoints and thus the mixed effects model was selected as it is the appropriate method to manage missing data. This method has the potential for bias, if data are not missing at random as assumed; this is always a risk in observational studies of this type [ 42 ]. ESAS-r is routinely collected at our institution, but completion by the patient is voluntary, which may have over or under-represented certain sub-populations. Further, those who are more ill may be less likely or able to complete ESAS-r compared to those who are well. Also, our dataset includes patients who received radiation therapy, but did not allow us to distinguish between patients receiving radiation alone vs. concurrent chemo-radiation. Treatment modality would be a key factor in symptom severity and complexity for patients. Conclusion Our results highlight significant differences in symptom experiences across appointment types as well as tumour groups. Alternative approaches to managing anxiety and/or depression at consultations may help decrease psychological symptom burden experienced by patients early in their cancer trajectory. Certain tumour groups, notably lung, report both severe physical and psychological symptoms and may require additional supportive care. Cancer care organizations and radiation departments may apply these findings to build patient-centered quality improvement initiatives tailored to specific time points in care. Declarations Funding: Person-centered Radiation Oncology Service Enhancement (PROSE) program. Competing interests: The authors have no relevant financial or non-financial interests to disclose. Author contributions: All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Siwei Qi. The first draft of the manuscript was written by Demetra Yannitsos and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Informed consent: Informed consent was obtained from participants. Availability of data: De-identified data can be shared upon request. Ethics approval: The Institutional Research Information Services Solution (IRISS) Health Research Ethics Board through the University of Calgary provided ethics approval: HREBA.CC-18-0588 Corresponding author: Lisa Barbera, BSc MD MPA FRCPC Professor and Head, Division of Radiation Oncology University of Calgary and Tom Baker Cancer Centre (p) 403-521-3095 [email protected] Disclosures: none. References Reilly CM, Bruner DW, Mitchell SA, Minasian LM, Basch E, Dueck AC, Cella D, Reeve B.B (2013) A literature synthesis of symptom prevalence and severity in persons receiving active cancer treatment. Support Care Cancer 21:1525–1550 doi: 10.1007/s00520-012-1688-0. 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BMC Cancer 3;14:3 Ester M, Culos-Reed SN, Abdul-Razzak A, Daun JT, Duchek D, Francis G, et al (2021) Feasibility of a multimodal exercise, nutrition, and palliative care intervention in advanced lung cancer. BMC Cancer 21(1):1–13. Lehto RH (2017) Psychosocial challenges for patients with advanced lung cancer: Interventions to improve well-being. Lung Cancer Targets Ther 8:79–90 Verkissen MN, Hjermstad MJ, Van Belle S, Kaasa S, Deliens L, Pardon K (2019) Quality of life and symptom intensity over time in people with cancer receiving palliative care: Results from the international European Palliative Care Cancer Symptom study. PLoS ONE 14:e0222988 Additional Declarations No competing interests reported. Supplementary Files APPENDIXA.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3273369","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":227251311,"identity":"d99a7f22-aea7-40f9-9657-bf3bda49cc61","order_by":0,"name":"Demetra Yannitsos","email":"","orcid":"","institution":"University of Calgary","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Demetra","middleName":"","lastName":"Yannitsos","suffix":""},{"id":227251312,"identity":"664d217e-0726-4dd0-83f6-737789d79ccd","order_by":1,"name":"Siwei Qi","email":"","orcid":"","institution":"Albert Health Services","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Siwei","middleName":"","lastName":"Qi","suffix":""},{"id":227251313,"identity":"1ce14934-3b77-4b06-80a8-34b37c107ac7","order_by":2,"name":"Oluwaseun Davies","email":"","orcid":"","institution":"Tom Baker Cancer Centre","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Oluwaseun","middleName":"","lastName":"Davies","suffix":""},{"id":227251314,"identity":"1fde7f7b-3848-40e6-936f-92451559c6c9","order_by":3,"name":"Linda Watson","email":"","orcid":"","institution":"University of Calgary","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Linda","middleName":"","lastName":"Watson","suffix":""},{"id":227251315,"identity":"cff2e0d1-4760-4318-bd86-f55d2ad191b6","order_by":4,"name":"Lisa Barbera","email":"data:image/png;base64,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","orcid":"","institution":"University of Calgary","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Lisa","middleName":"","lastName":"Barbera","suffix":""}],"badges":[],"createdAt":"2023-08-17 21:29:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3273369/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3273369/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":42038319,"identity":"e62a326a-a888-4a67-af61-cade259c8a23","added_by":"auto","created_at":"2023-08-23 19:16:35","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":83376,"visible":true,"origin":"","legend":"\u003cp\u003ePanel chart reporting mean symptom scores. Top panels show psychological scores, bottom panels show physical scores. Note: BR = breast; GI = gastrointestinal; GU = genitourinary; GYNE = gynecology; HEM = hematology; H\u0026amp;N = head and neck; LNG = lung\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-3273369/v1/9725e752701b279e29918d04.png"},{"id":47566553,"identity":"f0e466e7-e85b-443d-ae15-271ef42153b1","added_by":"auto","created_at":"2023-12-04 16:23:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":314594,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3273369/v1/389fcde3-858e-4e4c-aab0-fa5d7cc980ed.pdf"},{"id":42038318,"identity":"5e58f1f4-4c06-44c4-a840-52bb7405ca06","added_by":"auto","created_at":"2023-08-23 19:16:35","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":94635,"visible":true,"origin":"","legend":"","description":"","filename":"APPENDIXA.docx","url":"https://assets-eu.researchsquare.com/files/rs-3273369/v1/390011ae5f047295a8b62078.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Symptom severity and complexity trends in patients undergoing radiation therapy","fulltext":[{"header":"Introduction","content":"\u003cp\u003eOncology patients receiving treatment experience a dynamic range of physical and psychological symptoms [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Understanding symptom trajectory across the continuum of care is crucial for providing optimal care and improving quality of life. Specifically, such data enables providers to highlight populations at risk for increasing symptom severity, generate novel symptom management interventions, and develop targeted quality assurance initiatives.\u003c/p\u003e \u003cp\u003ePatient-reported outcomes measures (PROMs) enable systematic collection of each patient\u0026rsquo;s perspective on their symptoms. Routine collection of PROMs has been shown to identify unmet symptom needs, improve communication, improve treatment adherence, reduce utilization of acute care services, and improve survival [\u003cspan additionalcitationids=\"CR3 CR4\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Within CancerCare Alberta (CCA), a provincial ambulatory program, PROMs, including the Edmonton Symptom Assessment Scale \u0026ndash; Revised (ESAS-r), are routinely incorporated into clinical workflows and are administered to all oncology patients receiving ambulatory care [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Within our institution, PROMs are routinely collected at initial consultation appointments, at the first and last treatment review during radiation therapy, and follow-up appointments post treatment.\u003c/p\u003e \u003cp\u003ePrevious studies investigating symptom trajectories in oncology patients have used temporal measures in months or weeks, and few studies have investigated a radiation specific cohort of patients across multiple tumour groups. This study describes the trajectory of ESAS-r scores in patients receiving radiation treatment at a large tertiary ambulatory cancer care centre.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eStudy design\u003c/p\u003e \u003cp\u003eThis retrospective observational study was conducted using several sources of linked electronic healthcare data. The dataset used was part of a larger study that received ethics approval from the Health Research Ethics Board of Alberta\u0026rsquo;s Cancer Committee (HREBA.CC-20-0022).\u003c/p\u003e \u003cp\u003eData sources and variables\u003c/p\u003e \u003cp\u003eThe study utilized administrative data from the Alberta Cancer Registry (ACR), clinical data from CCA\u0026rsquo;s electronic medical record (EMR), and from the Canadian Institute for Health Information (CIHI) Discharge Abstract Database (DAD). Data linkage was achieved through a unique provincial health care number assigned to each patient as part of the ACR\u0026rsquo;s process at the time.\u003c/p\u003e \u003cp\u003eWe collected age, sex, tumour group, and rurality index from the ACR database; Charlson Comorbidity Index (CCI) from the DAD database; and appointment types from the EMR. Tumour groups were defined as breast, gastrointestinal (GI), genitourinary (GU), gynecology (gyne), hematology (hem), head and neck (H\u0026amp;N), lung and other. Rurality index for each patient was assigned based on the postal code of their most recent residence, using a seven-level index created by Alberta Health Services (AHS), and assigned to one of three groups for analysis: metro, urban, and rural. The appointment types were defined relative to the radiation treatment journey: consult (pre-treatment), first treatment review, last review and follow-up. The first follow up typically occurred 3\u0026ndash;4 months post radiation treatment, however the first radiation treatment follow up was always chosen. A modified version of the CCI was used which excluded cancer as a condition so that this did not contribute to the index score, as all participants in this study had a cancer diagnosis [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCohort ascertainment\u003c/p\u003e \u003cp\u003eThe study cohort was comprised of patients in Alberta who were 18 years of age and older with any cancer diagnosis, who had at least one radiation therapy appointment at the Tom Baker Cancer Centre (TBCC) radiotherapy program between October 1, 2019 and April 1, 2020. To be eligible for inclusion, patients also had to have completed at least one ESAS-r questionnaire within this timeframe at specific time points: radiation consultation, first and last radiation treatment review and first follow up post radiation treatment. Patients whose ESAS-r was not completed within 2 days of the appointment date were excluded.\u003c/p\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003cp\u003e \u003cem\u003eThe ESAS-r\u003c/em\u003e is a 9-item PROM which measures prevalent evidence-based symptoms experienced by patients with cancer [\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Patients rate each symptom on a severity scale from 0 to 10, with 10 indicating the highest severity. The 9 ESAS-r symptoms include pain, tiredness, drowsiness, nausea, lack of appetite, shortness of breath, depression, anxiety and wellbeing.\u003c/p\u003e \u003cp\u003eIn this study, we collapsed the ESAS-r symptoms into two groups and reported them as psychological and physical scores [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Psychological scores were the sum scores of depression and anxiety (ranging from 0 to 20), while physical scores were the sum scores of pain, tiredness, drowsiness, nausea, lack of appetite, and shortness of breath (ranging from 0 to 60). Overall wellbeing was excluded from the analysis as this symptom encompasses an overall measure, including both physical and psychological, and does not specifically fit into either group. This grouping of symptoms has also been utilized in other studies [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cem\u003eThe Canadian Problems Checklist\u003c/em\u003e (\u003cem\u003eCPC)\u003c/em\u003e is an evidence-based, 54-item self-report checklist designed to identify common concerns that patients with cancer experience. It is used in conjunction with the ESAS-r and tracks emotional, informational, social, practical, spiritual and physical concerns [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cem\u003eThe symptom complexity\u003c/em\u003e score, derived from ESAS-r and CPC, considers the unique combination of symptoms and concerns the patient has identified [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. It rates the self-reported severity of symptoms and the number of concerns indicated at a single visit and assigns a symptom complexity score (low, moderate, or severe) for the encounter (\u003cspan refid=\"Sec6\" class=\"InternalRef\"\u003eAppendix A\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eStatistical Analyses\u003c/p\u003e \u003cp\u003eDemographic data and symptom outcomes were summarized using descriptive statistics. Our primary interest was the association of appointment type and tumor groups with each outcome. We evaluated the association of these variables with ESAS-r physical and psychological scores [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] using mixed-effects models (MEM). Models incorporated the patient as a random effect and all other variables as fixed effects [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Models included appointment types and tumour group, as well as age, sex, rurality index and CCI. Given the highly skewed distribution of physical and psychological scores (both \u0026gt;\u0026thinsp;1), we also ran models on log-transformed scores [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], a widely used method to deal with skewed data; results were generally unaffected, so we report parameter estimates on the basis of original scores.\u003c/p\u003e \u003cp\u003eThe association of appointment type and tumor group with symptom complexity score was modelled using Generalized Estimating Equations (GEE), with the outcomes as ordinal (low, moderate, and high). We used the GEE approach to consider within-subjects variability and account for the correlated data resulting from repeated measurements across different time points and multiple observations of the same individual [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eData were exported into SPSS Version 25.0 (Chicago, IL, USA) and SAS statistical software Version 9.4 (SAS Institute, Cary, NC) for analysis and statistical significance was set a priori at \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eStudy Sample\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 1 presents the baseline demographic information for the full study cohort (N =1,632). The mean age was 63.4 years, and 935 participants (57.3%) were male. The majority (81.5%) of the cohort lived in a metro area. The most common tumour group within this cohort was breast (31.1%), followed by\u0026nbsp;genitourinary (17.4) and lung (13.1%).\u0026nbsp;A small portion of the cohort (13.4%) had a Charlson Comorbidity Index (CCI) score at or above 1.\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eTable 1: Cohort characteristics\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"58.1769436997319%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.91152815013405%\" valign=\"top\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.91152815013405%\" valign=\"top\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"58.1769436997319%\" valign=\"top\"\u003e\n \u003cp\u003eAge\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Mean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"41.8230563002681%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e63.4 (12.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"58.1769436997319%\" valign=\"top\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Female\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Male\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.91152815013405%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e697\u003c/p\u003e\n \u003cp\u003e935\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.91152815013405%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e42.7\u003c/p\u003e\n \u003cp\u003e57.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"58.1769436997319%\" valign=\"top\"\u003e\n \u003cp\u003eRurality Index\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Metro\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Urban\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Rural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.91152815013405%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1,311\u003c/p\u003e\n \u003cp\u003e82\u003c/p\u003e\n \u003cp\u003e216\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.91152815013405%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e81.5\u003c/p\u003e\n \u003cp\u003e5.1\u003c/p\u003e\n \u003cp\u003e13.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"58.1769436997319%\" valign=\"top\"\u003e\n \u003cp\u003eTumour Group\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Breast\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Gastrointestinal\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Genitourinary\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Gynecology\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Hematology\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Head \u0026amp; Neck\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Lung\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Other*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.91152815013405%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e508\u003c/p\u003e\n \u003cp\u003e176\u003c/p\u003e\n \u003cp\u003e284\u003c/p\u003e\n \u003cp\u003e107\u003c/p\u003e\n \u003cp\u003e69\u003c/p\u003e\n \u003cp\u003e109\u003c/p\u003e\n \u003cp\u003e213\u003c/p\u003e\n \u003cp\u003e166\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.91152815013405%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e31.1\u003c/p\u003e\n \u003cp\u003e10.8\u003c/p\u003e\n \u003cp\u003e17.4\u003c/p\u003e\n \u003cp\u003e6.6\u003c/p\u003e\n \u003cp\u003e4.2\u003c/p\u003e\n \u003cp\u003e6.7\u003c/p\u003e\n \u003cp\u003e13.1\u003c/p\u003e\n \u003cp\u003e10.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"58.1769436997319%\" valign=\"top\"\u003e\n \u003cp\u003eCCI\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 0 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026ge;1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.91152815013405%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1,414\u003c/p\u003e\n \u003cp\u003e218\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.91152815013405%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e86.6\u003c/p\u003e\n \u003cp\u003e13.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOther\u003c/strong\u003e included: CNS, endocrine, melanoma, no melanoma skin, other malignant and sarcoma\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eDescriptive Statistics-Symptom Severity and Complexity\u003c/p\u003e\n\u003cp\u003eWithin the six-month study period, 1,632 patients completed 2,519 ESAS-r questionnaires within 2 days of their appointment date. \u0026nbsp; Of the 2,519 questionnaires, 1,001 (39.7%) were collected at consult, and 727 (28.9%), 583 (23.1%) and 208 (8.3%) were collected at first review, last review and follow-up, respectively. The detailed psychological and physical scores and symptom complexity scores are presented at each appointment type (Table 2) and by each tumour group (Table 3). \u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"780\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003eTable 2: Symptom severity and complexity at each appointment\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.46153846153846%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003eConsult (n=1,001)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.307692307692307%\" valign=\"top\"\u003e\n \u003cp\u003eFirst Review (n=727)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.923076923076923%\" valign=\"top\"\u003e\n \u003cp\u003eLast Review (n=583)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.53846153846154%\" valign=\"top\"\u003e\n \u003cp\u003eFollow-Up (n=208)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.46153846153846%\" valign=\"top\"\u003e\n \u003cp\u003eSymptom severity\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;Psychological *\u003c/p\u003e\n \u003cp\u003ePhysical **\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003eM (SD)\u003c/p\u003e\n \u003cp\u003e3.78 (4.66)\u003c/p\u003e\n \u003cp\u003e10.7 (10.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.307692307692307%\" valign=\"top\"\u003e\n \u003cp\u003eM (SD)\u003c/p\u003e\n \u003cp\u003e2.96 (4.13)\u003c/p\u003e\n \u003cp\u003e11.5 (10.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.923076923076923%\" valign=\"top\"\u003e\n \u003cp\u003eM (SD)\u003cbr\u003e\u0026nbsp;2.74 (4.00)\u003c/p\u003e\n \u003cp\u003e11.7 (10.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.53846153846154%\" valign=\"top\"\u003e\n \u003cp\u003eM (SD)\u003cbr\u003e\u0026nbsp;3.10 (4.60)\u003cbr\u003e\u0026nbsp;11.2 (11.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"28.46153846153846%\" valign=\"top\"\u003e\n \u003cp\u003eSymptom complexity\u003c/p\u003e\n \u003cp\u003eLow\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eModerate\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003cp\u003e622 (62.1%)\u003c/p\u003e\n \u003cp\u003e186 (18.6%)\u003c/p\u003e\n \u003cp\u003e193 (19.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.307692307692307%\" valign=\"top\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003cp\u003e475 (65.3%)\u003c/p\u003e\n \u003cp\u003e156 (21.5%)\u003c/p\u003e\n \u003cp\u003e96 (13.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.923076923076923%\" valign=\"top\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003cp\u003e382 (65.5%)\u003c/p\u003e\n \u003cp\u003e112 (19.2%)\u003c/p\u003e\n \u003cp\u003e89 (15.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.53846153846154%\" valign=\"top\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003cp\u003e134 (64.4%)\u003c/p\u003e\n \u003cp\u003e40 (19.2%)\u003c/p\u003e\n \u003cp\u003e34 (16.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003e* Psychosocial scores = sum of depression and anxiety\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e** Physical scores = sum of pain, tiredness, drowsiness, nausea, lack of appetite and shortness of breath\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"780\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"9\" valign=\"top\"\u003e\n \u003cp\u003eTable 3: Symptom severity and complexity by tumour group\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.153846153846153%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10%\" valign=\"top\"\u003e\n \u003cp\u003eBR (n=898)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10%\" valign=\"top\"\u003e\n \u003cp\u003eGI (n=272)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10%\" valign=\"top\"\u003e\n \u003cp\u003eGU (n=383)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.538461538461538%\" valign=\"top\"\u003e\n \u003cp\u003eGYNE (n=175)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003eHEM (n=111)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10%\" valign=\"top\"\u003e\n \u003cp\u003eHN (n=155)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003eLNG (n=299)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003eOther (n=226)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.153846153846153%\" valign=\"top\"\u003e\n \u003cp\u003eSymptom severity\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;Psychological *\u003c/p\u003e\n \u003cp\u003ePhysical **\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10%\" valign=\"top\"\u003e\n \u003cp\u003eM (SD)\u003c/p\u003e\n \u003cp\u003e3.19 (4.32)\u003c/p\u003e\n \u003cp\u003e9.47 (9.20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10%\" valign=\"top\"\u003e\n \u003cp\u003eM (SD)\u003c/p\u003e\n \u003cp\u003e3.27 (4.35)\u003c/p\u003e\n \u003cp\u003e11.8 (11.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10%\" valign=\"top\"\u003e\n \u003cp\u003eM (SD)\u003cbr\u003e\u0026nbsp;2.55 (3.69)\u003c/p\u003e\n \u003cp\u003e9.08 (9.59)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.538461538461538%\" valign=\"top\"\u003e\n \u003cp\u003eM (SD)\u003cbr\u003e\u0026nbsp;3.59 (4.53)\u003cbr\u003e\u0026nbsp;12.1 (10.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003eM (SD)\u003c/p\u003e\n \u003cp\u003e2.64 (3.92)\u003c/p\u003e\n \u003cp\u003e12.1 (10.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10%\" valign=\"top\"\u003e\n \u003cp\u003eM (SD)\u003c/p\u003e\n \u003cp\u003e2.69 (4.04)\u003c/p\u003e\n \u003cp\u003e15.4 (12.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003eM (SD)\u003cbr\u003e\u0026nbsp;4.30 (5.27)\u003c/p\u003e\n \u003cp\u003e15.3 (11.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003eM (SD)\u003cbr\u003e\u0026nbsp;3.68 (4.44)\u003cbr\u003e\u0026nbsp;11.6 (9.76)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.153846153846153%\" valign=\"top\"\u003e\n \u003cp\u003eSymptom complexity\u003c/p\u003e\n \u003cp\u003eLow\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eModerate\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10%\" valign=\"top\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003cp\u003e618 (68.8%)\u003c/p\u003e\n \u003cp\u003e166 (18.5%)\u003c/p\u003e\n \u003cp\u003e114 (12.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10%\" valign=\"top\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003cp\u003e171 (62.9%)\u003c/p\u003e\n \u003cp\u003e52 (19.1%)\u003c/p\u003e\n \u003cp\u003e49 (18.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10%\" valign=\"top\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003cp\u003e277 (72.3%)\u003c/p\u003e\n \u003cp\u003e53 (13.8%)\u003c/p\u003e\n \u003cp\u003e53 (13.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.538461538461538%\" valign=\"top\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003cp\u003e106 (60.6%)\u003c/p\u003e\n \u003cp\u003e41 (23.4%)\u003c/p\u003e\n \u003cp\u003e28 (16.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003cp\u003e75 (67.6%)\u003c/p\u003e\n \u003cp\u003e18 (16.2%)\u003c/p\u003e\n \u003cp\u003e18 (16.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10%\" valign=\"top\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003cp\u003e83 (53.5%)\u003c/p\u003e\n \u003cp\u003e35 (22.6%)\u003c/p\u003e\n \u003cp\u003e37 (23.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003cp\u003e147 (49.2%)\u003c/p\u003e\n \u003cp\u003e75 (25.1%)\u003c/p\u003e\n \u003cp\u003e77 (25.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.76923076923077%\" valign=\"top\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003cp\u003e136 (60.2%)\u003c/p\u003e\n \u003cp\u003e54 (23.9%)\u003c/p\u003e\n \u003cp\u003e36 (15.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"9\" valign=\"top\"\u003e\n \u003cp\u003e* Psychosocial scores = sum of depression and anxiety\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e** Physical scores = sum of pain, tiredness, drowsiness, nausea, lack of appetite and shortness of breath\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eFactors associated with Psychological Score\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAppointment timing was significantly associated with psychological score, after adjusting for baseline covariates, (\u003cem\u003eF\u003c/em\u003e =12.7, \u003cem\u003ep\u003c/em\u003e \u0026lt;.01). Scores were significantly lower (indicating symptoms were less severe) at first review (\u0026beta; =-.84, 95% CI =-.55 \u0026ndash; -1.12, \u003cem\u003ep\u0026nbsp;\u003c/em\u003e\u0026lt;0.01) and at last review (\u0026beta; =-.79, 95% CI =-.48 \u0026ndash; -1.10, \u003cem\u003ep\u0026nbsp;\u003c/em\u003e\u0026lt;0.01) when compared with the scores at consult (Figure 1a).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTumor group was also associated with psychological scores after adjusting for baseline covariates (\u003cem\u003eF\u003c/em\u003e =5.21, \u003cem\u003ep\u003c/em\u003e \u0026lt;.01), with scores for patients with lung (\u0026beta; =1.81, 95% CI =1.14 \u0026ndash; 2.48, \u003cem\u003ep\u0026nbsp;\u003c/em\u003e\u0026lt;0.01) and other types of cancer (\u0026beta; =0.83, 95% CI =.11 \u0026ndash; 1.54, \u003cem\u003ep\u0026nbsp;\u003c/em\u003e\u0026lt;0.05) being significantly higher (indicating symptoms were more severe) than the scores from patients with breast cancer (Figure 1b). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFactors associated with Physical Scores\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePhysical scores were associated with appointment timing (\u003cem\u003eF\u003c/em\u003e =7.81, \u003cem\u003ep\u003c/em\u003e \u0026lt;0.01), after controlling for baseline covariates. Physical scores were significantly higher at last review (\u0026beta; =1.78, 95% CI =.96 \u0026ndash; 2.59, \u003cem\u003ep\u003c/em\u003e \u0026lt;0.01) when compared with the scores at consult (Figure 1c).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePhysical scores were also associated with tumour group after controlling for baseline covariates (\u003cem\u003eF\u003c/em\u003e =19.3, \u003cem\u003ep\u003c/em\u003e \u0026lt;0.01). Using patients with breast cancer as the reference group, patients from six other tumour groups (gastrointestinal, gynecology, head \u0026amp; neck, hematology, lung, and other) reported higher physical scores (Figure 1d). Genitourinary was the only tumour group that did not significantly differ from the breast group.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFactors associated with Symptom Complexity Scores\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe observed a significant association between appointment timing and symptom complexity after correcting for baseline covariates. Patients at first review had significantly lower odds of having a higher (more severe) symptom complexity score, compared with patients at consult (OR =0.77, 95% CI =0.64 \u0026ndash; 0.93). Patients at last review and follow-up also had lower odds of having a more severe complexity score, however not at a significant level. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe also observed a significant association between tumour group and symptom complexity after correcting for baseline covariates. Compared to patients with breast cancer, patients with gastrointestinal, head \u0026amp; neck, lung and other cancers were significantly more likely to have higher symptom complexity scores (ORs ranged from 1.65 to 2.77). Differences between the patients with breast cancer and genitourinary, gynecology, and hematology cancers were not significant. Details are shown in Table 4.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"474\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eTable 4: GEE results of parameters associated with an odds ratio of having a higher symptom complexity score\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.08438818565401%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.92827004219409%\" valign=\"top\"\u003e\n \u003cp\u003eOR (95% CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.9873417721519%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.08438818565401%\" valign=\"top\"\u003e\n \u003cp\u003eAge\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.92827004219409%\" valign=\"top\"\u003e\n \u003cp\u003e0.96 (0.99-1.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.9873417721519%\" valign=\"top\"\u003e\n \u003cp\u003e0.211\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.08438818565401%\" valign=\"top\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003cp\u003eMale*\u003c/p\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.92827004219409%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e0.65 (0.49-0.86)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.9873417721519%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e0.002\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.08438818565401%\" valign=\"top\"\u003e\n \u003cp\u003eCharlson comorbidity index\u003c/p\u003e\n \u003cp\u003eCCI \u0026ge;1*\u003c/p\u003e\n \u003cp\u003eCCI =0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.92827004219409%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e0.66 (0.51-0.87)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.9873417721519%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e0.003\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.08438818565401%\" valign=\"top\"\u003e\n \u003cp\u003eRurality\u003c/p\u003e\n \u003cp\u003eRural*\u003c/p\u003e\n \u003cp\u003eMetro\u003c/p\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.92827004219409%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1.07 (.80-1.42)\u003c/p\u003e\n \u003cp\u003e1.16 (0.71-1.91)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.9873417721519%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.665\u003c/p\u003e\n \u003cp\u003e0.548\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.08438818565401%\" valign=\"top\"\u003e\n \u003cp\u003eAppointment type\u003c/p\u003e\n \u003cp\u003eConsult*\u003c/p\u003e\n \u003cp\u003eFirst review\u003c/p\u003e\n \u003cp\u003eLast review\u003c/p\u003e\n \u003cp\u003eFollow-up\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.92827004219409%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e0.77 (0.64 \u0026ndash; 0.93)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e0.84 (0.67 \u0026ndash; 1.02)\u003c/p\u003e\n \u003cp\u003e0.81 (0.60 \u0026ndash; 1.10)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.9873417721519%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e0.005\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e0.079\u003c/p\u003e\n \u003cp\u003e0.171\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.08438818565401%\" valign=\"top\"\u003e\n \u003cp\u003eTumour Group\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eBreast*\u003c/p\u003e\n \u003cp\u003eGastrointestinal\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Genitourinary\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Gynecology\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Hematology\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Head \u0026amp; Neck\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Lung\u003c/p\u003e\n \u003cp\u003eOther \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.92827004219409%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e1.65 (1.14 \u0026ndash; 2.40)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e1.31 (0.86 \u0026ndash; 1.99)\u003c/p\u003e\n \u003cp\u003e1.38 (0.92 \u0026ndash; 2.07)\u003c/p\u003e\n \u003cp\u003e1.47 (0.85 \u0026ndash; 2.54)\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e2.77 (1.80 \u0026ndash; 4.26)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e2.73 (1.93 \u0026ndash; 3.85)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e1.70 (1.16 \u0026ndash; 2.48)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.9873417721519%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e0.008\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e0.207\u003c/p\u003e\n \u003cp\u003e0.125\u003c/p\u003e\n \u003cp\u003e0.166\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e0.000\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e0.000\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e0.006\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e* Reference group\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study demonstrates physical and psychological symptom severity and symptom complexity trends experienced by patients during their radiation treatment journey. Overall, we found associations with both physical and psychological symptom scores across appointment timing as well as tumour groups. Psychological symptoms were more severe at initial radiation consultation compared to on-treatment, whereas physical symptoms were more severe at the end of radiation treatment compared to consultation. Symptom severity was high for lung patients in both mean physical and psychological symptom scores. Overall, symptom complexity scores were higher at consultation compared to first review, and for patients with GI, H\u0026amp;N, lung or other cancers, compared to breast. These findings can help to direct timing-specific QI work to help improve patient experience and symptom management.\u003c/p\u003e \u003cp\u003eOur results are concordant with previous studies that demonstrated psychological symptoms being most severe at the beginning of the cancer journey [\u003cspan additionalcitationids=\"CR21 CR22 CR23\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. One study found that oncology patients\u0026rsquo; anxiety scores were elevated 1\u0026ndash;2 months post cancer diagnosis, and then decreased until month 6, when scores plateaued [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Results from another study found the proportion of patients with moderate-severe anxiety decreased by 10% within 6 months of diagnosis [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Our results found that psychological symptom scores were less severe at first and last review compared to consultations, indicating consultations are an important source of psychological support. Encouraging patients to access available resources, and educating patients on various support options may further benefit the patient. The most cited barrier to oncology patients accessing supportive services is a lack of awareness of available supports, and a lack of referrals from their physicians [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]; however, patients are often overwhelmed at consultation, both emotionally and by the volume of information presented. Even when healthcare providers encourage discussions of available supportive care services, many patients cannot retain or remember those details afterwards. An additional education-based appointment scheduled shortly after the patient\u0026rsquo;s consultation may help to address these issues. Overall, alternative approaches to providing psychological support at consultation require investigation. Further, education may be beneficial to oncologists and nurses. Previous studies have shown positive results when providers engage in psychological support training programs to improve communication skills around patient emotional concerns and wellbeing [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. These skills may be especially important during consultations.\u003c/p\u003e \u003cp\u003eAlthough not statistically significant, there was a slight increase in severity of mean psychological symptom scores from last review to first follow up, perhaps indicating some increase in anxiety regarding treatment success or fear of recurrence. Patients typically receive radiation treatments consistently on weekdays, for a certain number of consecutive weeks, allowing for daily interactions with the healthcare team, which may help patients feel well supported during treatment. It may be helpful for oncologists and nurses to acknowledge with patients that they are prone to higher psychological burden after completion of radiation [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], highlighting another opportunity to explore alternative approaches to providing support.\u003c/p\u003e \u003cp\u003eOur results show physical symptom scores were significantly higher at the end of radiation compared to consultations, likely due to treatment-related toxicities [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Although increased symptom severity is in part unavoidable due to treatment, earlier interventions and referrals to allied health could play a role in decreasing overall symptom severity. Implementing a tumour-specific PROM weekly during radiotherapy has been found to be a feasible and accepted resource, with the potential to help physicians identify problematic symptoms earlier on in their patients\u0026rsquo; treatment trajectory [\u003cspan additionalcitationids=\"CR32\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCompared to breast, almost all tumour groups reported significantly higher mean physical symptom scores, with lung and H\u0026amp;N having the most severe. Further, patients with H\u0026amp;N and lung, as well as other and GI cancers, were more likely to have a higher symptom complexity score, compared to patients with breast cancer. Greater symptom burden in patients with H\u0026amp;N and lung cancers has been previously reported in both tumour groups [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] as well as patients with lung cancer [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Although patients with lung cancer can present with particularly complex symptom profiles, many do to not engage with supportive resources or services [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. In a US study of breast, lung, GI and other tumour groups, results indicated that patients with lung cancer were half as likely to access supportive care and palliative care services compared to the other tumour groups [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. However, research has shown that patients with lung cancer who do engage in interdisciplinary supportive care and interventions do benefit [\u003cspan additionalcitationids=\"CR40\" citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Our results highlight a need to improve symptom management in patients with lung cancer, in particular to promote uptake of supportive resources.\u003c/p\u003e \u003cp\u003eCollecting and monitoring symptom complexity scores can assist clinicians in identifying patients requiring increased clinical support. The symptom complexity score considers all symptoms together and encompasses the overall symptom burden of the patient at their visit. This makes it useful as a clinical flag at a particular visit to alert the team to patients who require more specific care, as any symptom (physical or psychological) would require the same clinical team to address the patient\u0026rsquo;s concerns initially. Further action could include more detailed assessment to identify appropriate clinical action, as well as providing appropriate referrals. Therefore, the use of symptom complexity scores in routine clinical practice can help clinicians effectively identify, monitor and manage each patient\u0026rsquo;s needs.\u003c/p\u003e \u003cp\u003eStrengths of this study include its longitudinal design, allowing for the identification of the changes of symptoms over the continuum of radiation therapy. There were few limitations to our study. First, not all the patients filled out the PROs at the four timepoints and thus the mixed effects model was selected as it is the appropriate method to manage missing data. This method has the potential for bias, if data are not missing at random as assumed; this is always a risk in observational studies of this type [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. ESAS-r is routinely collected at our institution, but completion by the patient is voluntary, which may have over or under-represented certain sub-populations. Further, those who are more ill may be less likely or able to complete ESAS-r compared to those who are well. Also, our dataset includes patients who received radiation therapy, but did not allow us to distinguish between patients receiving radiation alone vs. concurrent chemo-radiation. Treatment modality would be a key factor in symptom severity and complexity for patients.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur results highlight significant differences in symptom experiences across appointment types as well as tumour groups. Alternative approaches to managing anxiety and/or depression at consultations may help decrease psychological symptom burden experienced by patients early in their cancer trajectory. Certain tumour groups, notably lung, report both severe physical and psychological symptoms and may require additional supportive care. Cancer care organizations and radiation departments may apply these findings to build patient-centered quality improvement initiatives tailored to specific time points in care.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eFunding: Person-centered Radiation Oncology Service Enhancement (PROSE) program.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCompeting interests: \u003cem\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthor contributions: All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Siwei Qi. The first draft of the manuscript was written by Demetra Yannitsos and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eInformed consent: Informed consent was obtained from participants.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAvailability of data: De-identified data can be shared upon request.\u003c/p\u003e\n\u003cp\u003eEthics approval: The Institutional Research Information Services Solution (IRISS) Health Research Ethics Board through the University of Calgary provided ethics approval: HREBA.CC-18-0588\u003c/p\u003e\n\u003cp\u003eCorresponding author:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLisa Barbera, BSc MD MPA FRCPC\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eProfessor and Head, Division of Radiation Oncology\u003c/p\u003e\n\u003cp\u003eUniversity of Calgary and Tom Baker Cancer Centre\u003c/p\u003e\n\u003cp\u003e(p) 403-521-3095\u003c/p\u003e\n\u003cp\[email protected]\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDisclosures: none.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eReilly CM, Bruner DW, Mitchell SA, Minasian LM, Basch E, Dueck AC, Cella D, Reeve B.B (2013) A literature synthesis of symptom prevalence and severity in persons receiving active cancer treatment. Support Care Cancer 21:1525\u0026ndash;1550 doi: 10.1007/s00520-012-1688-0. \u003c/li\u003e\n\u003cli\u003eYang LY, Manhas DS, Howard AF, Olson RA (2018) Patient-reported outcome use in oncology: A systematic review of the impact on patient-clinician communication. Support Care Cancer\u003cem\u003e \u003c/em\u003e26:41\u0026ndash;60 \u003c/li\u003e\n\u003cli\u003eBarbera L, Sutradhar R, Seow H, et al (2020) Impact of standardized Edmonton symptom assessment system use on emergency department visits and hospitalization: Results of a population-based retrospective matched cohort analysis. JCO Oncol Pract 16:e958\u0026ndash;e965\u003c/li\u003e\n\u003cli\u003eBarbera L, Sutradhar R, Seow H, et al (2020) The impact of routine Edmonton Symptom Assessment System (ESAS) use on overall survival in cancer patients: Results of a population-based retrospective matched cohort analysis. Cancer Med 9:7107\u0026ndash;7115 \u003c/li\u003e\n\u003cli\u003eBasch E, Deal AM, Dueck AC, et al (2017) Overall survival results of a trial assessing patient-reported outcomes for symptom monitoring during routine cancer treatment. JAMA 318:197\u0026ndash;198\u003c/li\u003e\n\u003cli\u003eCuthbert CA, Watson L, Xu Y, Boyne DJ, Hemmelgarn BR, Cheung WY (2019) Patient-Reported Outcomes in Alberta: Rationale, Scope, and Design of a Database Initiative. Curr Oncol 26:503\u0026ndash;509\u003c/li\u003e\n\u003cli\u003eCharlson ME, Pompei P, Ales KL, MacKenzie CR (1987) A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation. J Chron Dis 40:373-383\u003c/li\u003e\n\u003cli\u003eDeyo RA, Cherkin DC, Ciol MA (1992) Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol 45:613-619\u003c/li\u003e\n\u003cli\u003eWatanabe S, Nekolaichuk C, Beaumont C, Mawani A (2009) The Edmonton symptom assessment system-what do patients think? Support Care Cancer 17(6):675\u0026ndash;683\u003c/li\u003e\n\u003cli\u003eNekolaichuk C, Watanabe S, Beaumont C (2009) The Edmonton Symptom Assessment System: A 15-year retrospective review of validation studies (1991\u0026ndash;2006). Palliat Med 22:111-122\u003c/li\u003e\n\u003cli\u003eRichardson LA, Jones GW (2009) A review of the reliability and validity of the Edmonton Symptom Assessment System. Curr Oncol 16:55\u003c/li\u003e\n\u003cli\u003eSingh N, Batra A, Yang L et al (2021) Patient-Reported Symptom Burden Near the End of Life in Patients With Gynaecologic Cancers. JOGC 43:26\u0026ndash;33 \u003c/li\u003e\n\u003cli\u003eCheung WY, Barmala N, Zarinehbaf S, Rodin G, Le LW, Zimmermann C (2009) The association of physical and psychological symptom burden with time to death among palliative cancer outpatients. J Pain Symptom Manage 37:297-304 doi:10.1016/j.jpainsymman.2008.03.008\u003c/li\u003e\n\u003cli\u003eWatson L, Delure A, Qi S et al (2021) Utilizing Patient Reported Outcome Measures (PROMs) in ambulatory oncology in Alberta: Digital reporting at the micro, meso and macro level. J Patient Rep Outcomes \u003cstrong\u003e5\u003c/strong\u003e:97\u003c/li\u003e\n\u003cli\u003eWatson L, Qi S, DeIure A, Photitai E, Chmielewski L, Smith L (2020) Validating a Patient-Reported Outcomes\u0026ndash;Derived Algorithm for Classifying Symptom Complexity Levels Among Patients With Cancer. J Natl Compr Cancer Netw 18:1518\u0026ndash;1525. doi: 10.6004/jnccn.2020.7586.\u003c/li\u003e\n\u003cli\u003eHui D, Bruera E (2017) The Edmonton Symptom Assessment System 25 years later: past, present and future developments. J Pain Symptom Manage 53: 630\u0026ndash;643\u003c/li\u003e\n\u003cli\u003eSingmann H, Kellen D (2019) An introduction to mixed models for experimental psychology. In D. H. Spieler \u0026amp; E. Schumacher (Eds.), New Methods in Cognitive Psychology pp4-31.\u003c/li\u003e\n\u003cli\u003eFeng C, Wang H, Lu N, et al (2014). Log-transformation and its implications for data analysis. Shanghai Arch Psychiatry 26(2): 105\u0026ndash;109. doi: 10.3969/j.issn.1002-0829.2014.02.009\u003c/li\u003e\n\u003cli\u003eHanley J, Negassa A, Edwards M, Forrester J (2003). Statistical analysis of correlated data using generalized estimating equations: an orientation. Am J Epidemiol 157(4):364-75. doi: 10.1093/aje/kwf215.\u003c/li\u003e\n\u003cli\u003eBubis LD, Davis L, Mahar A, Barbera L, Li Q, Moody L, et al (2018) Symptom Burden in the First Year After Cancer Diagnosis: An Analysis of Patient-Reported Outcomes. J Clin Oncol 36(11):1103\u0026ndash;11\u003c/li\u003e\n\u003cli\u003eBeek FE, Jansen F, Mak L, Lissenberg-Witte BI, Buter J, Vergeer MR, et al (2020) The course of symptoms of anxiety and depression from time of diagnosis up to 2 years follow-up in head and neck cancer patients treated with primary (chemo)radiation. Oral Oncol 102:104576.\u003c/li\u003e\n\u003cli\u003eHallet JI, Davis L, Mahar AL, Law C, Bubis L, Isenberg-Grzeda E, et al (2019) Symptom burden at the end of life for neuroendocrine tumors: A population-based analysis of patient-reported outcomes. J Clin Oncol 37(4):297 \u003c/li\u003e\n\u003cli\u003eWong E, Zhang L, Rowbottom L, Chiu N, Chiu L, McDonald R, et al (2016) Symptoms and quality of life in patients with brain metastases receiving whole-brain radiation therapy. Support Care Cancer 24(11):4747\u0026ndash;59\u003c/li\u003e\n\u003cli\u003eKumar P, Casarett D, Corcoran A, Desai K, Li Q, Chen J, et al (2012) Utilization of supportive and palliative care services among oncology outpatients at one academic cancer center: Determinants of use and barriers to access. J Palliat Med 15(8):923\u0026ndash;30 \u003c/li\u003e\n\u003cli\u003eLaffan AJ, Daniels J, Osborn M (2015) Profiling the Psychological Training and Support Needs of Oncology Staff, and Evaluating the Effectiveness of a Level 2 Psychological Support Training Program Workshop. J Psychosoc Oncol 33(6):686-702\u003c/li\u003e\n\u003cli\u003eBrown RF, Bylund CL, Kline N, De La Cruz A, Solan J, Kelvin J, Gueguen J, Eddington J, Kissane D, Passik S (2009) Identifying and responding to depression in adult cancer patients: evaluating the efficacy of a pilot communication skills training program for oncology nurses. Cancer Nurs 32(3):E1-7.\u003c/li\u003e\n\u003cli\u003eLuigjes-Huizer YL, Tauber NM, Humphris G, et al (2022) What is the prevalence of fear of cancer recurrence in cancer survivors and patients? A systematic review and individual participant data meta-analysis. Psychooncology 31(6):879-892. doi:10.1002/pon.5921\u003c/li\u003e\n\u003cli\u003eKantsiper, M, McDonald EL, Geller G et al (2009) Transitioning to Breast Cancer Survivorship: Perspectives of Patients, Cancer Specialists, and Primary Care Providers. J GEN INTERN MED 24 (Suppl 2):459\u0026ndash;466. https://doi.org/10.1007/s11606-009-1000-2\u003c/li\u003e\n\u003cli\u003eKnobf MT, Sun Y (2005) A Longitudinal Study of Symptoms and Self‐care Activities in Women Treated With Primary Radiotherapy for Breast Cancer. Cancer Nurs 28(3):210 \u003c/li\u003e\n\u003cli\u003eAl-Rashdan A, Grendarova P, Yannitsos D, Quon H, Banerjee R, Barbera L (2022) Feasibility and Acceptability of Implementing Site-Specific Patient-Reported Outcome Measure in Head and Neck Cancer Clinics: A Prospective Institutional Study. Adv Radiat Oncol 7(6):101036\u003c/li\u003e\n\u003cli\u003eVelikova G, Absolom K, Hewison J, et al (2022) Electronic self-reporting of adverse events for patients undergoing cancer treatment: the eRAPID research programme including two RCTs. NIHR Journals Library\u003c/li\u003e\n\u003cli\u003eRocque GB, Pisu M, Jackson BE, et al (2017) Resource use and Medicare costs during lay navigation for geriatric patients with cancer. JAMA Oncol 3:817-825\u003c/li\u003e\n\u003cli\u003eJensen RE, Potosky AL, Moinpour CM, et al (2017) United States population-based estimates of patient-reported outcomes measurement information system symptom and functional status reference values for individuals with cancer. J Clin Oncol 50(35): 1913-1920 \u003c/li\u003e\n\u003cli\u003eRosenthal DI, Mendoza TR, Fuller CD, et al (2014) Patterns of symptom burden during radiotherapy or concurrent chemoradiotherapy for head and neck cancer: A prospective analysis using the University of Texas MD Anderson Cancer Center Symptom Inventory-Head and Neck Module. Cancer 120: 1975-1984\u003c/li\u003e\n\u003cli\u003eHirpara DH, Gupta V, Davis LE, Zhao H, Hallet J, Mahar AL, et al (2020) Severe symptoms persist for Up to one year after diagnosis of stage I-III lung cancer: An analysis of province-wide patient reported outcomes. Lung Cancer 142:80\u0026ndash;9\u003c/li\u003e\n\u003cli\u003eTjong MC, Doherty M, Tan H, Chan WC, Zhao H, Hallet J, et al (2021) Province‐Wide Analysis of Patient‐Reported Outcomes for Stage IV Non‐Small Cell Lung Cancer. Oncologist 26(10):e1800\u0026ndash;11\u003c/li\u003e\n\u003cli\u003eMaguire R, Papadopoulou C, Kotronoulas G, Simpson MF, McPhelim J, Irvine L (2013) A systematic review of supportive care needs of people living with lung cancer. Eur J Oncol Nurs 17(4):449\u0026ndash;64\u003c/li\u003e\n\u003cli\u003eRaz DJ, Sun V, Kim JY, Williams AC, Koczywas M, Cristea M, Reckamp K, Hayter J, Tiep B, Ferrell B (2016) Long-Term Effect of an Interdisciplinary Supportive Care Intervention for Lung Cancer Survivors After Surgical Procedures. Ann Thorac Surg 101(2):495-502\u003c/li\u003e\n\u003cli\u003eSchellekens MP, van den Hurk DG, Prins JB, Molema J, Donders AR, Woertman WH, van der Drift MA, Speckens A (2014) Study protocol of a randomized controlled trial comparing Mindfulness-Based Stress Reduction with treatment as usual in reducing psychological distress in patients with lung cancer and their partners: the MILON study. BMC Cancer 3;14:3\u003c/li\u003e\n\u003cli\u003eEster M, Culos-Reed SN, Abdul-Razzak A, Daun JT, Duchek D, Francis G, et al (2021) Feasibility of a multimodal exercise, nutrition, and palliative care intervention in advanced lung cancer. BMC Cancer 21(1):1\u0026ndash;13.\u003c/li\u003e\n\u003cli\u003eLehto RH (2017) Psychosocial challenges for patients with advanced lung cancer: Interventions to improve well-being. Lung Cancer Targets Ther 8:79\u0026ndash;90\u003c/li\u003e\n\u003cli\u003eVerkissen MN, Hjermstad MJ, Van Belle S, Kaasa S, Deliens L, Pardon K (2019) Quality of life and symptom intensity over time in people with cancer receiving palliative care: Results from the international European Palliative Care Cancer Symptom study. PLoS ONE 14:e0222988 \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-3273369/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3273369/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective:\u003c/strong\u003e Symptom severity has considerable impact on patients’ cancer care journey. This study aims to better understand psychological and physical symptom scores of radiotherapy patients across their radiotherapy care trajectory.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e Patients who received radiotherapy at a single tertiary cancer center, who also completed at least one symptom-reporting questionnaire, the Edmonton Symptom Assessment Scale – Revised (ESAS-r) between October 1, 2019 and April 1, 2020 were included in this retrospective analysis. Within the study period, time points included consultation, first and last radiation treatment reviews and first post-treatment follow-up. Symptoms were divided into psychological and physical. Mixed effect models assessed trajectories of psychological and physical scores across appointments. A symptom complexity score was assigned to each ESAS-r encounter. Symptom complexity score association with appointment type and tumor group was modelled using Generalized Estimating Equations (GEE).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The study cohort consisted of 1,632 patients who completed 2,519 ESAS-r questionnaires. Patients reported significantly higher psychological symptom scores at consultations than at first review, last review and follow-up. Patients reported significantly higher physical scores at last reviews compared to consultations. Patients at first review had significantly lower odds of having a higher (more severe) symptom complexity score, compared with patients at consultations (OR =0.77, 95% CI=0.64-0.93).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e Symptoms change over the course of a patient’s care trajectory. Understanding how particular symptoms change over time provides a target for initiatives that improve symptom management.\u003c/p\u003e","manuscriptTitle":"Symptom severity and complexity trends in patients undergoing radiation therapy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-08-23 19:16:30","doi":"10.21203/rs.3.rs-3273369/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c4b70fe0-0f37-42ac-8c8e-b11b41b32e5b","owner":[],"postedDate":"August 23rd, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2023-12-04T16:15:01+00:00","versionOfRecord":[],"versionCreatedAt":"2023-08-23 19:16:30","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3273369","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3273369","identity":"rs-3273369","version":["v1"]},"buildId":"cBFmMYwuxLRRLfASyISRj","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}