Symptom Cluster Assessment Tools for Gastric Cancer Care in China: A Comprehensive Review

Introduction

Gastric cancer is a common malignant tumor, and its incidence rate ranks first among malignant tumors of the digestive tract [1], seriously endangering human physical and mental health [2]. According to the data of Global Tumor Epidemiology Survey (GTES), in 2020 there will be more than 1 million new cases of gastric cancer and 769 000 deaths worldwide, making it the fifth most common cancer and the fourth leading cause of cancer deaths in the world [1]. East Asian populations, including those in China, South Korea, and Japan, exhibit the highest global incidence of gastric cancer, at 37.4 per 100 000 individuals [3]. Gastric cancer is often treated with surgery and chemotherapy [4], and patients experience physical and psychological symptoms, and the symptoms mostly appear in the form of “cluster” [5]. In 2001 Dodd [6] used the concept of “symptom cluster” (SC) to explain this phenomenon of simultaneous occurrence of multiple symptoms, and the study of SCs in cancer patients has been progressively developed. Since then, the study of SCs in cancer patients has become a hot topic in the field of cancer symptom management [7,8]. Molassiotis [9] defined SCs as 2 or more concurrently occurring and interrelated symptoms, with the core symptoms within the cluster remaining stable over time and the symptoms in the cluster being independent of each other. Validation of the concept of SCs is difficult because assessing symptom interrelationships presents considerable methodological challenges [10]. In addition, symptoms within a cluster are synergistically reinforcing and can have a more severe impact on functional status and quality of life than a single symptom [11,12]. The current standard of care for patients with gastric cancer is coordinated care by an inter-professional team [13], and valuation of SCs can help to understand patients’ symptoms from a more comprehensive perspective and promote joint management of symptoms [14]. Here, we review the contents, applications, advantages, and disadvantages of the SC assessment tools used for gastric cancer patients in China, and the basic conditions and contents of each assessment tool are compared, in order to provide a reference for the development of specific assessment tools suitable for the SCs of gastric cancer patients in China, and provide a basis for the optimization of symptom management of patients and the clinical decision-making in the following period. Therefore, this article aimed to review current tools for assessment of symptom clusters in the nursing care of patients with gastric cancer in China.

Assessment Tools for SCs in Gastric Cancer Patients – the Universal Assessment Tools

CANCER REHABILITATION EVALUATION SYSTEM-SHORT FORM:

The Cancer Rehabilitation Evaluation System-Short Form (CARES-SF) is a scale developed in 1991 to comprehensively assess the quality of life of cancer patients. The items of the scale included physical, psychosocial, marital relationship, relationship with medical personnel, and sexual relationship, and the items were scored on a 5-point Likert scale [15]. The higher the score of the scale, the more severe the symptoms experienced by the cancer patient in the past month, and the worse the quality of life of the patient. In 2006, Hu Yan translated the scale into Chinese, and the Cronbach’s α coefficients of the Chinese version of the CARES-SF were determined to be in the range of 0.66–0.93, with the overall re-test reliability reaching 0.81 [16]. The CARES-SF has been widely used in clinical practice and research in China and abroad, involving groups including patients with breast cancer, gastric cancer, colorectal cancer, cervical cancer [15–17].

The advantages of CARES-SF are: (1) the internal consistency of the Chinese version of CARES-SF is good, and it has a high degree of stability; (2) the scale can confirm the theoretical structure that the quality of life is multidimensional, and it has good parallel validity; (3) the scale has good sensitivity and discriminative validity, which is not only able to differentiate between differences in the quality of life of patients with the same type of cancer at different stages of disease development and the differences in the quality of life of different cancer patients, but also able to reflect the differences in the quality of life of patients with different types of cancer, and also to reflect the differences in the quality of life of patients with different types of cancer. The scale has good sensitivity and discriminant validity, which can distinguish the differences in the quality of life of similar cancer patients at different stages of disease development and the differences in the quality of life between different types of cancer patients, as well as reflecting longitudinal changes in the quality of life of patients. Its disadvantages are: (1) it takes a long time for patients to complete the CARES-SF, and it requires effort to complete the form; (2) the Chinese version of the scale still lacks a large-scale test in the Chinese cultural context; (3) implementing the CARES system assessment in clinical cancer care requires data analysis of the patient’s scale and customization of the care plan based on the results, which is challenging.

MEMORIAL SYMPTOM ASSESSMENT SCALE:

The Memorial Symptom Assessment Scale (MSAS) was developed by Memorial Sloan-Kettering Cancer Center in 1994 [18]. The scale can be used to assess the incidence, frequency, severity, and distress of common symptoms in patients with malignant tumors and consists of 24 physical and 8 psychological symptoms. The scale is scored on a 5-point Likert scale, with higher scores on the scale indicating that patients experience more severe symptoms. The MSAS scale can also be used to calculate a patient’s overall distress index by summing the prevalence scores for the 4 psychological symptoms with the distress scores for the 6 common physical symptoms. The Cronbach’s α coefficients for the original version of the MSAS scale range from 0.58 to 0.88. Cheng translated the scale into Chinese in 2009 and experimentally determined its Cronbach’s α coefficient to be between 0.79 and 0.87 [19]. The MSAS has been widely used in China for symptom assessment of patients with cancer and some chronic diseases.

The advantages of MSAS are: (1) the items of the scale are simple and easy to understand, and it contains comprehensive symptom dimensions; (2) the structural reliability of the scale is good. Its disadvantages are that the scale has more assessment items and the scoring method is more complicated, which may affect the patients’ compliance in completing the scale.

EDMONTON SYMPTOM ASSESSMENT SCALE:

The Edmonton Symptom Assessment System (ESAS), developed in 1991 by Canadian scholars, is used to assess the presence and severity of 10 common symptoms in patients in the last 24 h [20]. The scale can be used to assess patients’ pain, fatigue, drowsiness, nausea, loss of appetite, dyspnea, depression, anxiety, lack of well-being, and optional symptoms. The scale items are scored on a scale of 0–10 points, with the higher the score, the more severe the symptom, and the Cronbach’s alpha coefficient for this scale is 0.79. In 2009, Watanabe et al added a brief definition of the scale’s 9 core symptoms and changed “loss of appetite” to “lack of appetite” to form a revised version of the ESAS-r, and the revised items were easy to understand and had higher validity [21]. In 2015 Dong translated the scale into a Chinese version and determined the Cronbach’s α coefficient to be 0.72 [22]. Currently, ESAS is mainly used in palliative care organizations in China and abroad for symptom screening and monitoring of patients.

The advantages of ESAS are that the scale is simple and easy to understand, and it is suitable for patients with low literacy levels. The time required to use the scale is short, about 3 minutes, and little effort is needed. Its disadvantages are: (1) the scale is limited and cannot comprehensively assess the overall symptoms of the patient, and is not applicable to patients with severe and complex clinical symptoms; (2) the scale still lacks further reliability testing when used in patients with different diseases; (3) the accuracy of the scale for symptom assessment is poor, and it is not suitable for use in research.

Assessment Tools for SCs in Gastric Cancer Patients – Specificity Assessment Tools

ANDERSON SYMPTOM ASSESSMENT SCALE-GASTROINTESTINAL CANCER-SPECIFIC MODULE:

The M.D. Anderson Symptom Inventory (MDASI), which was compiled by the Anderson Oncology Center at the University of Texas in 2000 and can be used to assess the symptoms of cancer patients, was translated into Chinese in 2004 [23]. The M.D. Anderson Symptom Inventory-Gastrointestinal Cancer (MDASI-GI) consists of 13 core items with 5 specific symptoms of GI cancers, which was improved by the Chinese version of the M.D. Anderson Symptom Inventory (MDASI-GI), which contains 5 specific symptoms: constipation, diarrhea, dysphagia, change in appetite, and feeling full [24]. The Chinese version of the MDASI-GI consists of 2 main categories, the first of which is the total symptom items, which are used to assess the severity of symptoms, including 13 general cancer symptoms and 5 gastric cancer-specific symptoms; the second is the total interference items, which are mainly used to assess the degree of impact of the above 18 symptoms on 6 activities of daily living, and are scored on a 11-point scale. The higher the score of an item, the more severe the symptom of that item/the greater the degree of interference of the symptom on daily life of the subject. Chen et al [25] applied the Chinese version of MDASI-GI to patients with gastrointestinal tumors and measured the Cronbach’s α coefficients of the total number of symptomatic items and the total number of interfering items to reach 0.842 and 0.859, respectively. MDASI-GI is now widely used in symptom assessment of gastrointestinal cancer patients in China and abroad.

The advantages of MDASI and MDASI-GI are: (1) they contain almost all the main symptoms of gastric cancer patients, and are highly versatile and widely applicable; (2) the scales are simple and clear, and the assessment process takes less time, so the patients are more compliant, which makes them suitable for clinical application. The disadvantages are: (1) the severity scores of the total symptoms and total interferences depend on the subjective judgment of the patients without specific conditions, which may lead to bias in the assessment results; (2) there are still differences between Chinese and Western cultures in some of the items, and the definitions of individual items are not precise enough.

EORTC QLQ-STO52 RATING SCALE:

The EORTC QLQ-STO52 rating scale was developed by the European Organization for Research and Treatment of Cancer (EORTC) and consists of 2 scales – QLQ-C30 (Quality of Life Questionnaire-Core 30) and QLQ-STO22 scales. The QLQ-C30 is the core scale, which has been widely used in many countries and regions to measure the quality of life of cancer patients through the development of multidimensional items [26]. The QLQ-STO22 is the gastric cancer-specific module of the scale, which consists of 22 items to assess the symptoms of the disease, toxic adverse effects of treatment, sexual functioning, impact of the disease on the patient’s life, and expectations for the future [27]. The items were scored on a 4-point Likert scale, with the scores listed in ascending order, and the final conclusion is reached by linear transformation of the raw scores. The EORTC QLQ-STO52 is currently the most frequently used scale worldwide to assess the quality of life of patients with gastric cancer.

The advantages of EORTC QLQ-STO52 are: (1) the scale is compatible with the current clinical treatment techniques and can better respond to the symptomatic changes and objective status of gastric cancer patients; (2) the assessment is simple and rapid. Its disadvantages are that it only allows assessment of symptom occurrence and severity, without reflecting other dimensions (eg, stress) and does not measure affective-cognitive symptoms. The scale is scored on an equidistant 4-point scale, which is not as precise as the 5-point Likert scale.

FACT-GA RATING SCALE:

The core module of the Functional Assessment of Cancer Therapy (FACT) consists of 4 modules – physical health, social health, emotional health, and functional health – with a total of 27 items [28]. In addition, the Functional Assessment of Cancer Therapy-Gastric (FACT-Ga) scale contains 19 items as a supplement to the core module. The scale’s items are scored on a 5-point Likert scale, with higher scores indicating a better quality of life for the patient. The scale contains only 1 item on dietary symptoms and 2 items focusing on pain symptoms. The scale is somewhat more focused on patients’ emotional and social problems than the QLQ-STO52. The scale has good reliability and validity, with a Cronbach’s alpha coefficient of 0.93. Zhou [29] translated it into Chinese and validated the FACT-Ga. Currently, the FACT-Ga has been used in clinical studies worldwide to detect significant changes in the quality of life of individual patients.

The advantages of FACT-Ga are it is sufficiently reliable and valid for gastric cancer patients, and is an important complement to quality-of-life measurement tools. Its disadvantages are that it may be more sensitive to deterioration than improvement in quality of life, and there are fewer scientific studies on FACT-Ga-SC in China.

POST-GASTRECTOMY SYNDROME ASSESSMENT SCALE:

The Post-gastrectomy Syndrome Assessment Scale-45 (PGSAS-45) is a multidimensional scale based on the Short-Form Health Survey (SF-8) and Gastrointestinal Symptom Rating Scale (GSRS), which was developed by the Japanese Working Group on Post-gastrectomy Syndrome for assessment of post-gastrectomy syndrome [30]. The PGSAS-45 scale consists of 45 items [31], of which 8 are from the SF-8, 15 are from the GSRS, and 22 were screened by members of the Japanese Working Group on Post-Gastrectomy Syndrome for clinical importance. The PGSAS-45 questionnaire consists of 23 items related to the symptoms of post-gastrectomy syndrome (items 9–33), of which 15 were from the GSRS and 8 were additional selected items. In addition, 12 questionnaire items related to dietary intake and satisfaction with daily life were included. Factor analysis was used to integrate the 23 symptom items into 7 symptom subscales. Nineteen primary outcome indicators were refined through the integration and screening process and categorized into 3 domains: symptoms, life status, and quality of life. The 5-point Likert scale was used to comprehensively assess the physical and psychological status, gastrointestinal symptoms, living conditions, and quality of life of patients who underwent gastrectomy, as well as the significant impacts of “dumping” (also known as rapid gastric emptying) and “discomfort with dietary intake”. The PGSAS-45 may become one of the most important standards in assessment of post-gastrectomy syndromes because it is a subscale of symptoms that significantly affect quality of life after gastrectomy, including “dumping” and “discomfort with dietary intake”.

The advantages of PGSAS-45 are that it was designed for patients after gastrectomy and facilitates provision of individualized guidance and care. Its disadvantages are that the outcome indicators of are highly influenced by various background factors [32], and it is necessary to consider the factors related to each specific patient.

QUALITY OF LIFE INSTRUMENTS FOR STOMACH CANCER PATIENTS:

The Quality of Life Instruments for Cancer Patients-Stomach Cancer (QLICP-ST) was developed by Meng Qiong [33] in 2008 by combining the commonality module with the gastric cancer-specific module on the basis of the Quality of Life Measurement Scale for Cancer Patients system. The QLICP-ST was developed by Meng et al in 2008 by combining the commonality module of the QLICP system with the specificity module of gastric cancer. The scale consists of 32 common items 7 specific item, 11 sub-aspects, and 5 domains, with multiple items comprising sub-aspects, multiple sub-aspects comprising domains, and all domains comprising the total scale, which has a clear structure. The QLICP-ST adopts a 5-point Likert scale, in which the scores of each item are reversed to a negative number and then calculated. The scale has good reliability and validity, with a Cronbach’s α coefficient of 0.91. In 2017, Ding et al [34] revised the specificity panel of the scale using a procedural decision-making model, deleting the symptom items of abdominal discomfort and constipation, and adding 5 items for acid reflux belching, dizziness, fatigue, and postoperative impact on the patient’s diet. However, the revised scale lacked a more systematic reliability test.

Advantages of QLICP-ST: (1) it is clear and hierarchical, and can be used to narrow the scope of changes and realize refined analysis by lowering the level; (2) the scale was developed based on the Chinese cultural background, which is suitable for Chinese patients; (3) the language of the scale is easy to understand. Disadvantages are: (1) the sample size of existing studies is small and geographically limited, and no changes in the quality of life in the field of social functioning have been found; (2) the optimized scale lacks sufficient reliability and validity tests.

GASTRIC CANCER TCM NURSING SYMPTOM ASSESSMENT CATEGORY:

The Gastric Cancer TCM Nursing Symptom Assessment Category were developed by Mei et al [35] in 2013 through the steps of related literature research, expert screening and argumentation, clinical empirical investigation, expert consultation, and reliability testing. The category includes a total of 37 gastric cancer TCM nursing symptom items, with good reliability and Cronbach’s α coefficient of 0.912. The gastric cancer TCM nursing symptom assessment category is now an important tool for quality-of-life measurement in the field of TCM in China.

Advantages of Gastric Cancer TCM Nursing Symptom Assessment Category are: (1) it is a scale with Chinese characteristics, is based on TCM theories, and can better show the macroscopic and holistic nature of the quality of life research; (2) the descriptions of the symptoms are more detailed and graphic, which can reflect the different types of pain, and have the features of TCM syndrome; (3) combining gastric cancer symptoms with nursing assessment reflects the nursing concept and promotes the development of TCM nursing. Disadvantages are: (1) there are fewer scientific studies on the assessment of gastric cancer symptoms in TCM nursing; (2) the quantitative grading of each TCM nursing symptom item is still not perfect.

Comparison and Analysis of SC Assessment Tools for Gastric Cancer Patients

BASIC COMPARISON:

The 9 SC assessment tools for gastric cancer patients were compared according to the development time, content framework, and other aspects, as shown in Table 1. Among the universal gastric cancer patients’ SC assessment tools, the MSAS is a better assessment tool, with relatively well-developed measurement dimensions and relatively high quality of assessment (Table 1).

COMPARISON OF CONTENT:

The content focus of the 9 instruments for assessing SCs in gastric cancer patients varied. Among the specific instruments, the EORTC QLQ-STO52 has a higher proportion of functional and physical concerns, whereas the FACT-Ga emphasizes social and emotional issues to a greater extent, and in contrast to both, the PGSAS-45 contains items that are more specifically tailored to post-gastrectomy patients, such as issues related to dumping syndrome, but further research is needed to validate its use in a broader patient population. Caregivers can carefully select the most appropriate scale with regard to the strengths and weaknesses of the scale, as well as patient-specific characteristics and research, or select multiple scales to complement each other where available.

Future Directions

INADEQUACIES OF EXISTING ASSESSMENT TOOLS:

Existing assessment tools for SCs of gastric cancer patients were mostly developed by foreign scholars and focus on common physical and psychological symptoms, and there is a comparative lack of scales developed for the characteristics of different periods of care, such as the characteristics of perioperative gastric cancer patients. In addition, the use of assessment tools is mostly based on patients’ subjective perceptions and lacks assessment items by health care workers or caregivers, so the results lack objectivity. The quality testing of the Chinese versions of 7 of the foreign-developed assessment tools for SCs of gastric cancer patients needs to be further improved, and there is an urgent need for large-scale assessment in the Chinese cultural context and improvement of specific items. The domestically developed QLICP-ST and gastric cancer TCM nursing symptom assessment categories lack multi-regional and large sample size research validation, modification, improvement, and systematic testing of their revised versions.

IMPLICATIONS FOR FUTURE RESEARCH:

The SC Assessment Tool for Gastric Cancer Patients can assist nursing staff in understanding the care needs of patients affected by physiological, psychological, social, and other aspects, and in identifying the factors that will help the patients’ condition improve, and it is an important auxiliary tool for nursing staff to carry out nursing care. To promote the development of high-quality SC assessment tools for gastric cancer patients suitable for China’s cultural background and to improve the efficacy and quality of nursing care, we present some recommendations for future research. (1) When importing and localizing high-quality SC assessment tools from outside China, we should take into account the objective point of view of patients’ family members and adapt the assessment tools based on the current situation of the domestic gastric cancer patients’ care, so as to improve the local adaptability of the localized version of the assessment tools. (2) There is a need to develop scales for the characteristics of care at different periods of the gastric cancer process, and test their quality, so as to shorten the time needed to choose appropriate assessment tools in clinical work and improve the efficacy of care.

Conclusions

At present, most domestic gastric cancer research assessment tools are foreign translations. To accurately assess SCs, real-time imports/developments of the latest scales are needed, requiring studies to verify applicability, causing delays. Cross-cultural differences exist, limiting foreign scale applicability. Therefore, we encourage scholars to develop/refine local tools by leveraging existing scales’ strengths and weaknesses to create a SC assessment tool for Chinese gastric cancer patients, providing a basis for optimization of symptom management and clinical decision-making in the post-treatment period.