Symptom clusters in cancer patients
Abstract
Goals of work Cancer patients often experience multiple symptoms, many of which have been reported to correlate with each other. The goals of this study were to understand which cancer-related symptoms cluster together and to test the conceptual meanings of the revealed symptom clusters.Patients and methods Patients with various cancer diagnoses (N=151) were recruited from a medical center in northern Taiwan. The 13-item M.D. Anderson symptom inventory was used to assess patients' symptom severity. Selected symptoms were factored using principal-axis factoring with oblique rotation. The known-group technique was used to validate the conceptual meanings of revealed factors.Main results Patients' symptom severity ratings fit a three-factor solution that explained 55% of the variance. These three factors (symptom clusters) were named sickness symptom cluster, gastrointestinal symptom cluster, and emotional symptom cluster. Patients with pain and with advanced diseases had significantly higher mean scores in the sickness symptom cluster than patients without pain and with earlier-stage diseases. The patients' functional status was negatively correlated with mean scores in the sickness symptom cluster. Patients under chemotherapy demonstrated significantly higher mean scores in the gastrointestinal symptom cluster than patients under other treatments. Patients with anxiety or depression also had significantly higher mean scores in the emotional symptom cluster than patients without anxiety or depression.Conclusions This study identified three underlying symptom clusters and verified their conceptual meaning in cancer patients. Knowing these symptom clusters may help healthcare professionals understand plausible mechanisms for the aggregation of symptoms.
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Fatigue clusters with pain and sleep more commonly than with anxiety and depression.
“fatigue clusters with pain and sleep more commonly than with anxiety and depression.26,27”
From Mindfulness and Psychosocial Symptoms in People with Cancer: Testing Rumination and Experiential Avoidance as Mediators, and Sex as a Moderator. (2025) · cites this paper as [26]
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“Increased levels of these pro-inflammatory cytokines also have been found to be related to changes in measurements of depression and quality of life in patients with cancer who had not yet started treatment (Rich, 2007).”
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“sensus on the predictors of SCs, including age, gender, cancer type, stage of disease, and treatments, thus warranting further investigation.(2,7,10,11,15,16)”
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“The items that grouped together in cluster 3 (fatigue, sleep disturbance, and depression) are partially consistent with the literature about adults with cancer (Chen & Tseng, 2006; Cleeland et al., 2003) and pediatric oncology literature (Hockenberry & Hooke, 2007).”
Consistency of Symptom Clusters in Advanced Cancer
Kirkova, J., Aktaş, A., Walsh, D., Rybicki, L. A., & Davis, M. P. (2010) · American Journal of Hospice and Palliative Medicine® · doi:10.1177/1049909110369869 · Cited by 60 · see citing works
“Another example, similar cancer symptom clusters have been reproduced in different populations using the same tool.(5,8,12,13) These studies can be a basis for demonstration of consistent clusters across different populations.”
Han, C. J., Reding, K. W., Cooper, B. A., Paul, S. M., Conley, Y. P., Hammer, M. J., Wright, F., Cartwright, F., Levine, J. D., & Miaskowski, C. A. (2019) · Journal of Pain and Symptom Management · doi:10.1016/j.jpainsymman.2019.04.035 · Cited by 59 · see citing works
Iskandarsyah, A., de Klerk, C., Suardi, D. R., Soemitro, M. P., Sadarjoen, S. S., & Passchier, J. (2013) · PLoS ONE · doi:10.1371/journal.pone.0056353 · Cited by 58 · see citing works
“These results are in line with previous studies results [44–45].”
ResultFan, G., Hadi, S. C., & Chow, E. (2007) · Supportive Cancer Therapy · doi:10.3816/sct.2007.n.010 · Cited by 57 · see citing works
McNutt, M. D., Liu, S., Manatunga, A., Royster, E. B., Raison, C. L., Woolwine, B. J., Demetrashvili, M. F., Miller, A. H., & Musselman, D. L. (2012) · Neuropsychopharmacology · doi:10.1038/npp.2011.330 · Cited by 56 · see citing works
Kim, E., Jahan, T. M., Aouizerat, B. E., Dodd, M. J., Cooper, B. A., Paul, S. M., West, C. M., Lee, K. A., Swift, P. S., Wara, W. M., et al. (2009) · Cancer Nursing · doi:10.1097/ncc.0b013e3181b046ad · Cited by 56 · see citing works
“This finding suggests that this symptom cluster may occur more frequently in patients who receive chemotherapy (CTX) as noted in previous symptom cluster research.(12) An interesting finding in this study is that women with breast cancer reported higher scores for all 3 of the symptom clusters.”
ResultEffendy, C., Vissers, K. C. P., Tejawinata, S., Vernooij-Dassen, M. J. F. J., & Engels, Y. (2014) · Pain Practice · doi:10.1111/papr.12203 · Cited by 56 · see citing works
Gastrointestinal Symptom Representation in Cancer Symptom Clusters: A Synthesis of the Literature
Cherwin, C. H. (2012) · Oncology nursing forum · doi:10.1188/12.onf.157-165 · Cited by 56 · see citing works
“Although the GI components contained within symptom clusters varied from study to study, the most common was nausea and vomiting (Chen & Tseng, 2006; Lin, Chang, Cleeland, Mendoza, & Wang, 2007; Okuyama et al., 2003; Walsh & Rybicki, 2006; Wang et al., 2006; Wang, Tsai, Chen, Lin, & Lin, 2008).”
Hoang, H. T. X., Molassiotis, A., Chan, C. W., Nguyen, T. H., & Nguyen, V. L. (2019) · Sleep And Breathing · doi:10.1007/s11325-019-01839-x · Cited by 56 · see citing works
Psychoneurological symptom cluster in breast cancer: the role of inflammation and diet
George, M. A., Lustberg, M. B., & Orchard, T. (2020) · Breast Cancer Research and Treatment · doi:10.1007/s10549-020-05808-x · Cited by 56 · see citing works
Carey, M. L., Noble, N., Sanson‐Fisher, R., & Mackenzie, L. (2011) · Psycho-Oncology · doi:10.1002/pon.2057 · Cited by 52 · see citing works
Dodd, M. J., Cho, M. H., Cooper, B. A., Petersen, J., Bank, K. A., Lee, K. A., & Miaskowski, C. A. (2010) · Oncology nursing forum · doi:10.1188/11.onf.33-42 · Cited by 50 · see citing works
“Numerous studies have used the conceptual approach of grouping of symptoms to create symptom clusters (Chen & Tseng, 2006; Chow et al., 2008; Cleeland et al., 2000; Gift, Jablonski, Stommel, & Given, 2004; Gift, Stommel, Jablonski, & Given, 2003; Gleason et al., 2007; Kim et al., 2009; Kim,…”
MethodAtay, S., Conk, Z., & Bahar, Z. (2012) · European Journal of Cancer Care · doi:10.1111/j.1365-2354.2012.01324.x · Cited by 48 · see citing works
Symptom clusters in patients with nasopharyngeal carcinoma during radiotherapy
Xiao, W., Chan, C. W. H., Fan, Y., Leung, D. Y. P., Xia, W., He, Y., & Tang, L. (2017) · European Journal of Oncology Nursing · doi:10.1016/j.ejon.2017.02.004 · Cited by 48 · see citing works
Symptom Clusters and Functional Status of Women with Breast Cancer
Suwisith, N., Hanucharurnkul, S., Dodd, M. J., Vorapongsathorn, T., Pongthavorakamol, K., & Asavametha, N. (2008) · Pacific Rim International Journal of Nursing Research · Cited by 46 · see citing works
Symptoms, clusters and quality of life prior to surgery for breast cancer
Denieffe, S., Cowman, S., & Gooney, M. (2013) · Journal of Clinical Nursing · doi:10.1111/jocn.12430 · Cited by 46 · see citing works
“Samples were often heterogeneous for cancer type with a very small proportion being patients with breast cancer (Chen & Tseng 2006, Chen & Lin 2007).”
The psychometric properties of cancer multisymptom assessment instruments: a clinical review
Aktaş, A., Walsh, D., & Kirkova, J. (2015) · Supportive Care in Cancer · doi:10.1007/s00520-015-2732-7 · Cited by 45 · see citing works
Breast Cancer and Symptom Clusters During Radiotherapy
Matthews, E. E., Schmiege, S. J., Cook, P. F., & Sousa, K. H. (2011) · Cancer Nursing · doi:10.1097/ncc.0b013e3182277222 · Cited by 45 · see citing works
“The first approach is to cluster variables in large data sets using exploratory factor analytic models or hierarchical cluster analysis.(8,9) Although the clusters in large data sets may not be clinically predetermined, they can arise from a common pathophysiological pathway.”
MethodPrevalence of Symptoms and Quality of Life Among Jordanian Cancer Patients
Qadire, M. I. A., & Alkhalaileh, M. A. (2014) · Clinical Nursing Research · doi:10.1177/1054773814564212 · Cited by 45 · see citing works
Facing the large variety of life-limiting conditions in children
Hoell, J. I., Weber, H. L., Warfsmann, J., Trocan, L., Gagnon, G., Danneberg, M., Balzer, S., Keller, T., Janßen, G., & Kuhlen, M. (2019) · European Journal of Pediatrics · doi:10.1007/s00431-019-03467-9 · Cited by 44 · see citing works
“By identifying and treating such SC, it is hoped to overcome the shortcoming of treating single symptoms for improving the quality of life [4, 5, 30].”
BackgroundGolan‐Vered, Y., & Pud, D. (2012) · Pain Practice · doi:10.1111/j.1533-2500.2012.00554.x · Cited by 42 · see citing works
Sullivan, C. W., Leutwyler, H. C., Dunn, L. B., Cooper, B. A., Paul, S. M., Conley, Y. P., Levine, J. D., & Miaskowski, C. A. (2017) · European Journal of Oncology Nursing · doi:10.1016/j.ejon.2017.04.001 · Cited by 42 · see citing works
“…were done using samples of patients who were heterogeneous, in terms of their cancer diagnoses and/or cancer treatments (Chen and Lin, 2007; Chen and Tseng, 2006; Karabulut et al., 2010; Molassiotis et al., 2010; Skerman et al., 2012; Yamagishi et al., 2009), research is needed on symptom…”
MethodSymptom clusters and related factors in oesophageal cancer patients 3 months after surgery
Guo, M., Wang, C., Yin, X., Nie, L., & Wang, G. (2019) · Journal of Clinical Nursing · doi:10.1111/jocn.14935 · Cited by 42 · see citing works
Stability of Symptom Clusters in Patients With Gastrointestinal Cancers Receiving Chemotherapy
Han, C. J., Reding, K. W., Cooper, B. A., Paul, S. M., Conley, Y. P., Hammer, M. J., Kober, K. M., Levine, J. D., & Miaskowski, C. A. (2019) · Journal of Pain and Symptom Management · doi:10.1016/j.jpainsymman.2019.07.029 · Cited by 42 · see citing works
Skerman, H. M., Yates, P. M., & Battistutta, D. (2012) · Journal of Pain and Symptom Management · doi:10.1016/j.jpainsymman.2011.07.009 · Cited by 40 · see citing works
Oh, H., Seo, Y., Jeong, H., & Seo, W. (2012) · Journal of Clinical Nursing · doi:10.1111/j.1365-2702.2011.04057.x · Cited by 40 · see citing works
“A similar concept of ‘sickness behaviour’ has also been proposed to explain the common etiologies of symptoms within clusters by Chen and Tseng (2006).”
Zhong, X., Lim, E. A., Hershman, D. L., Moinpour, C. M., Unger, J. M., & Lee, S. M. (2016) · Journal of Oncology Practice · doi:10.1200/jop.2015.006106 · Cited by 40 · see citing works
“Furthermore, if these symptom clusters arise from a common mechanism and are amenable to a common intervention, clinicians can then manage and treat multiple symptoms within the same cluster, which may lead to improvements in quality of life, adherence to treatment, and therapeutic benefit.(9-11) In recent years, symp…”
BackgroundKim, H., McDermott, P. A., & Barsevick, A. M. (2013) · Cancer Nursing · doi:10.1097/ncc.0b013e31828293e0 · Cited by 37 · see citing works
“A psychoneurological symptom cluster (ie, pain, fatigue, sleep disturbance, lack of appetite, and drowsiness) was also found in a heterogeneous sample of oncology patients.(5) An important new line of research is to examine intraindividual change in the symptom cluster experience over time and interindividual variatio…”
BackgroundInsomnia in breast cancer: Independent symptom or symptom cluster?
Gehrman, P., Garland, S. N., Matura, L. A., & Mao, J. J. J. (2016) · Palliative & Supportive Care · doi:10.1017/s1478951516000900 · Cited by 36 · see citing works
Hockenberry, M. J., Taylor, O. A., Pasvogel, A. E., Rodgers, C. C., McCarthy, K., Gundy, P. M., Montgomery, D. W., Ribbeck, P., Scheurer, M. E., & Moore, I. M. (2014) · Oncology nursing forum · doi:10.1188/14.onf.e238-e247 · Cited by 35 · see citing works
“…ve s al l r ig ht s. Oncology Nursing Forum • Vol. 41, No. 4, July 2014 E239 with cancer provided insight into searching for symptom relationships, concurrence, and underlying dimensions (Chen & Tseng, 2006; Dodd, Miaskowski, & Lee, 2004; Kim et al., 2009; Kim, McGuire, Tulman, & Barsevick, 2005).”
Cancer Symptom Clusters: An Exploratory Analysis of Eight Statistical Techniques
Aktaş, A., Walsh, D., & Hu, B. (2014) · Journal of Pain and Symptom Management · doi:10.1016/j.jpainsymman.2014.02.006 · Cited by 34 · see citing works
Symptom Clusters Change Over Time in Patients With Lung Cancer During Perichemotherapy
Li, N., Wu, J., Zhou, J., Wu, C., Dong, L., Fan, W., & Zhang, J. (2020) · Cancer Nursing · doi:10.1097/ncc.0000000000000787 · Cited by 33 · see citing works
Sikorskii, A. E., Given, C. W., You, M., Jeon, S., & Given, B. A. (2009) · Journal of Clinical Epidemiology · doi:10.1016/j.jclinepi.2008.09.007 · Cited by 32 · see citing works
Symptom clusters in patients with cancer in the hospice/palliative care setting
Stapleton, S. J., Holden, J. E., Epstein, J. B., & Wilkie, D. J. (2016) · Supportive Care in Cancer · doi:10.1007/s00520-016-3210-6 · Cited by 32 · see citing works
Ma, J., Xu, H., Liu, S., & Wang, A. (2022) · Cancer Nursing · doi:10.1097/ncc.0000000000001058 · Cited by 29 · see citing works
“It has been widely identified in patients receiving chemotherapy, regardless of the heterogeneous population or specific patients with lung cancer.(37,38) Compared with the study by Wang and Fu,(37) this study had an increased gastrointestinal SC.”
ResultMalignant Ascites Symptom Cluster in Patients Referred for Paracentesis
Husain, A. F., Bezjak, A., & Easson, A. M. (2009) · Annals of Surgical Oncology · doi:10.1245/s10434-009-0774-0 · Cited by 29 · see citing works
Symptom Clusters in Fibromyalgia
Rutledge, D. N., Mouttapa, M., & Wood, P. B. (2009) · Nursing Research · doi:10.1097/nnr.0b013e3181b499d2 · Cited by 28 · see citing works
“These include factor analysis (Chen & Tseng, 2006; Gift et al., 2004), cluster analysis (Bender, Ergyn, Rosenzweig, Cohen, & Sereika, 2005; de Souza et al., 2008; Thieme & Turk, 2006), multiple regression (Gaston-Johansson, Fall-Dickson, Bakos, & Kennedy, 1999), and multistage linear regression…”
MethodThe Nested Structure of Cancer Symptoms
Bellala, G., Ganesan, A., Krishna, R., Saxman, P., Scott, C. D., Silveira, M. J., Given, C. W., & Bhavnani, S. K. (2010) · Methods of Information in Medicine · doi:10.3414/me09-01-0083 · Cited by 27 · see citing works
“In contrast, Chen and Tseng [12] analyzed 151 cancer patients using the MD Anderson Symptom Inventory [19].”
Chen, M., Chen, M., & Yu, C. (2010) · Supportive Care in Cancer · doi:10.1007/s00520-010-1005-8 · Cited by 26 · see citing works
Self-citationSymptom clusters in patients with metastatic cancer: a literature review
Thavarajah, N., Chen, E., Zeng, L., Bedard, G., Giovanni, J. D., Lemke, M., Lauzon, N., Zhou, M., Chu, D., & Chow, E. (2012) · Expert Review of Pharmacoeconomics & Outcomes Research · doi:10.1586/erp.12.41 · Cited by 25 · see citing works
The Future in Psychosocial Oncology: Screening for Emotional Distress – The Sixth Vital Sign
Thomas, B. C., & Bultz, B. D. (2008) · Future Oncology · doi:10.2217/14796694.4.6.779 · Cited by 25 · see citing works
Symptom clusters in outpatients with cancer using different dimensions of the symptom experience
Harris, C., Kober, K. M., Cooper, B. A., Conley, Y. P., Dhruva, A., Hammer, M. J., Paul, S. M., Levine, J. D., & Miaskowski, C. A. (2022) · Supportive Care in Cancer · doi:10.1007/s00520-022-07125-z · Cited by 23 · see citing works
Li, Y., Wang, Q., Liu, C., & Hu, X. (2023) · European Journal of Oncology Nursing · doi:10.1016/j.ejon.2023.102465 · Cited by 24 · see citing works
Pérez, J., Olivier, S., Rampakakis, E., Borod, M., & Shir, Y. (2016) · Pain Research and Management · doi:10.1155/2016/2157950 · Cited by 23 · see citing works
“The lack of significant relief of shortness of breath could be explained by a lack of correlation between shortness of breath and other cancer-related symptoms reported in previous studies [19].”
BackgroundMiaskowski, C. A., Conley, Y. P., Mastick, J., Paul, S. M., Cooper, B. A., Levine, J. D., Knisely, M. R., & Kober, K. M. (2017) · Journal of Pain and Symptom Management · doi:10.1016/j.jpainsymman.2017.05.007 · Cited by 23 · see citing works
Longitudinal changes in clusters of cancer patients over an 18-month period.
Trudel‐Fitzgerald, C., Savard, J., & Ivers, H. (2013) · Health Psychology · doi:10.1037/a0033497 · Cited by 21 · see citing works
- Authors
- Chen, M.-L., & Tseng, H.-C.
- Affiliations
- Chang Gung University (TW)
- Koo Foundation Sun Yat-Sen Cancer Center (TW)
- Corresponding author
- Chen, Mei-Ling
- ORCID
- Chen, Mei-Ling
- Venue
- Supportive Care in Cancer
- Published
- 2006-02-21
- Volume
- 14
- Issue
- 8
- Pages
- 825-830
- ISSN
- 0941-4355 (ISSN-L)
- 1433-7339
- OpenAlex
- W1996624485
- Cited by
- 159
- References
- 29
- Citations by year
- 2025: 6 · 2024: 1 · 2023: 1 · 2022: 5 · 2021: 6 · 2020: 3 · 2019: 6 · 2018: 1 · 2017: 14 · 2016: 9 · 2015: 5 · 2014: 7 · 2013: 12 · 2012: 15
- FWCI
- 6.96
- Type
- journal article
- Language
- en
- Open access
- closed
- Licence
- www.springer.com/tdm (tdm)
- Locations
- Supportive Care in Cancer (publishedVersion)
- PubMed (publishedVersion)
- Funders
- Chang Gung University
- Topics
- Health Sciences › Medicine › Oncology › Cancer survivorship and care
- Health Sciences › Medicine › Anesthesiology and Pain Medicine › Pain Management and Opioid Use
- Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Cancer-related cognitive impairment studies
- Keywords
- cancer symptoms, symptom clusters, symptom severity, gastrointestinal symptoms, emotional symptoms, pain, chemotherapy, anxiety, depression, functional status, disease stage, MD Anderson Symptom Inventory
- MeSH terms
- Activities of Daily Living, Adolescent, Adult, Aged, Factor Analysis, Statistical, Female, Humans, Male, Middle Aged, Neoplasms, Quality of Life, Research Design, Severity of Illness Index, Taiwan, Multivariate Analysis, Cluster Analysis, Karnofsky Performance Status
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