Symptom clustering and quality of life in patients with ovarian cancer undergoing chemotherapy


      • Ovarian cancer patients may have a specific symptom cluster.
      • The symptom clusters were differently depending on age, age at disease onset, disease duration, and, recurrence.
      • Recurrence and performance status of ovarian cancer were related with the symptom clusters.
      • Ovarian cancer patients experienced different symptom clusters according to cancer stage.
      • Symptom clusters have a negative effect on quality of life in ovarian cancer patients.



      The symptom clusters in patients with ovarian cancer undergoing chemotherapy have not been well evaluated. We investigated the symptom clusters and effects of symptom clusters on the quality of life of patients with ovarian cancer.


      We recruited 210 ovarian cancer patients being treated with chemotherapy and used a descriptive cross-sectional study design to collect information on their symptoms. To determine inter-relationships among symptoms, a principal component analysis with varimax rotation was performed based on the patient's symptoms (fatigue, pain, sleep disturbance, chemotherapy-induced peripheral neuropathy, anxiety, depression, and sexual dysfunction).


      All patients had experienced at least two domains of concurrent symptoms, and there were two types of symptom clusters. The first symptom cluster consisted of anxiety, depression, fatigue, and sleep disturbance symptoms, while the second symptom cluster consisted of pain and chemotherapy-induced peripheral neuropathy symptoms. Our subgroup cluster analysis showed that ovarian cancer patients with higher-scoring symptoms had significantly poorer quality of life in both symptom cluster 1 and 2 subgroups, with subgroup-specific patterns. The symptom clusters were different depending on age, age at disease onset, disease duration, recurrence, and performance status of patients with ovarian cancer. In addition, ovarian cancer patients experienced different symptom clusters according to cancer stage.


      The current study demonstrated that there is a specific pattern of symptom clusters, and symptom clusters negatively influence the quality of life in patients with ovarian cancer. Identifying symptom clusters of ovarian cancer patients may have clinical implications in improving symptom management.


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        • Ashing-Giwa K.T.
        • Kim J.
        • Tejero J.S.
        Measuring quality of life among cervical cancer survivors: preliminary assessment of instrumentation validity in a cross-cultural study.
        Qual. Life Res. 2008; 17: 147-157
        • Balayssac D.
        • Ferrier J.
        • Descoeur J.
        • Ling B.
        • Pezet D.
        • Eschalier A.
        • et al.
        Chemotherapy-induced peripheral neuropathies: from clinical relevance to preclinical evidence.
        Expert Opin. Drug Saf. 2011; 10: 407-417
        • Barnes N.M.
        • Sharp T.
        A review of central 5-HT receptors and their function.
        Neuropharmacology. 1999; 38: 1083-1152
        • Berek J.S.
        • Novak E.
        Berek & Novak's Gynecology.
        fourteenth ed. Lippincott williams & wilkins, Philadelphia2007
        • Buysse D.J.
        • Reynolds C.F.
        • Monk T.H.
        • Berman S.R.
        • Kupfer D.J.
        The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research.
        Psychiatry Res. 1989; 28: 193-213
        • Byun H.S.
        • Kim G.D.
        • Chung B.Y.
        • Kim K.H.
        Fatigue and quality of life of Korean cancer inpatients.
        Korean J. Hospice Palliat. Care. 2010; 13: 98-108
        • Calhoun E.A.
        • Welshman E.E.
        • Chang C.H.
        • Lurain J.R.
        • Fishman D.A.
        • Hunt T.L.
        • et al.
        Psychometric evaluation of the functional assessment of cancer therapy/gynecologic oncology group-neurotoxicity (Fact/GOG-Ntx) questionnaire for patients receiving systemic chemotherapy.
        Int. J. Gynecol. Cancer. 2003; 13: 741-748
        • Carpenter J.S.
        • Andrykowski M.A.
        Psychometric evaluation of the Pittsburgh sleep quality index.
        J. Psychosomatic Res. 1998; 45: 5-13
        • Cella D.F.
        • Tulsky D.S.
        • Gray G.
        • Sarafian B.
        • Linn E.
        • Bonomi A.
        • et al.
        The Functional Assessment of Cancer Therapy scale: development and validation of the general measure.
        J. Clin. Oncol. 1993; 11: 570-579
        • Chandran V.
        • Bhella S.
        • Schentag C.
        • Gladman D.D.
        Functional assessment of chronic illness therapy-fatigue scale is valid in patients with psoriatic arthritis.
        Ann. Rheumatic Dis. 2007; 66: 936-939
        • Cho J.
        • Kang D.
        • Lee J.Y.
        • Kim K.
        • Kim S.J.
        Impact of dose modification on intravenous bortezomib-induced peripheral neuropathy in multiple myeloma patients.
        Support. Care Cancer. 2014; 22: 2669-2675
        • Clevenger L.
        • Schrepf A.
        • Degeest K.
        • Bender D.
        • Goodheart M.
        • Ahmed A.
        • et al.
        Sleep disturbance, distress, and quality of life in ovarian cancer patients during the first year after diagnosis.
        Cancer. 2013; 119: 3234-3241
        • Dodd M.J.
        • Miaskowski C.
        • Paul S.M.
        Symptom clusters and their effect on the functional status of patients with cancer.
        Oncol. Nurs. Forum. 2001; 28: 465-470
        • Fox S.W.
        • Lyon D.
        • Farace E.
        Symptom clusters in patients with high-grade glioma.
        J. Nurs. Scholarsh. 2007; 39: 61-67
        • Herrmann C.
        International experiences with the Hospital Anxiety and Depression Scale-a review of validation data and clinical results.
        J. Psychosomatic Res. 1997; 42: 17-41
        • Huang H.Q.
        • Brady M.F.
        • Cella D.
        • Fleming G.
        Validation and reduction of FACT/GOG-Ntx subscale for platinum/paclitaxel-induced neurologic symptoms: a gynecologic oncology group study.
        Int. J. Gynecol. Cancer. 2007; 17: 387-393
        • Huang J.
        • Gu L.
        • Zhang L.
        • Lu X.
        • Zhuang W.
        • Yang Y.
        Symptom clusters in ovarian cancer patients with chemotherapy after surgery: a longitudinal survey.
        Cancer Nurs. 2016; 39: 106-116
        • Hwang K.H.
        • Cho H.O.
        • Yoo Y.S.
        Symptom clusters of ovarian cancer patients undergoing chemotherapy, and their emotional status and quality of life.
        Eur. J. Oncol. Nurs. 2016; 21: 215-222
        • Jeong J.H.
        • Nho J.H.
        • Kim G.S.
        • Lee Y.E.
        • Yu S.Y.
        • Lee H.J.
        • et al.
        Characteristics and quality of life in gynecologic cancer patients with chemotherapy-induced peripheral neuropathy.
        Korean J. Women Health Nurs. 2013; 19: 201-210
        • Kalueff A.V.
        • Nutt D.J.
        Role of GABA in anxiety and depression.
        Depress Anxiety. 2007; 24: 495-517
        • Kim H.J.
        • McGuire D.B.
        • Tulman L.
        • Barsevick A.M.
        Symptom clusters: concept analysis and clinical implications for cancer nursing.
        Cancer Nurs. 2005; 28: 270-282
        • Kim H.Y.
        • So H.S.
        • Park K.S.
        • Jeong S.J.
        • Lee J.Y.
        • Ryu S.B.
        Development of the Korean-version of female sexual function index (FSFI).
        Korean J. Androl. 2002; 20: 50-56
        • Kim S.R.
        • So H.Y.
        • Choi E.
        • Kang J.H.
        • Kim H.Y.
        • Chung S.J.
        Influencing effect of non-motor symptom clusters on quality of life in Parkinson's disease.
        J. Neurological Sci. 2014; 347: 310-315
        • Koldjeski D.
        • Kirkpatrick M.K.
        • Swanson M.
        • Everett L.
        • Brown S.
        Ovarian cancer: early symptom patterns.
        Oncol. Nurs. Forum. 2003; 30: 927-933
        • Lee E.H.
        • Chun M.
        • Kang S.
        • Lee H.J.
        Validation of the Functional Assessment of Cancer Therapy-General (FACT-G) scale for measuring the health-related quality of life in Korean women with breast cancer.
        Jpn. J. Clin. Oncol. 2004; 34: 393-399
        • Lopez V.
        • Copp G.
        • Brunton L.
        • Molassiotis A.
        Symptom experience in patients with gynecological cancers: the development of symptom clusters through patient narratives.
        J. Support. Oncol. 2011; 9: 64-71
        • Manir K.S.
        • Bhadra K.
        • Kumar G.
        • Manna A.
        • Patra N.B.
        • Sarkar S.K.
        Fatigue in breast cancer patients on adjuvant treatment: course and prevalence.
        Indian J. Palliat. Care. 2012; 18: 109-116
        • Maughan K.
        • Clarke C.
        The effect of a clinical nurse specialist in gynaecological oncology on quality of life and sexuality.
        J. Clin. Nurs. 2001; 10: 221-229
        • Miaskowski C.
        • Cooper B.A.
        • Paul S.M.
        • Dodd M.
        • Lee K.
        • Aouizerat B.E.
        • et al.
        Subgroups of patients with cancer with different symptom experiences and quality-of-life outcomes: a cluster analysis.
        Oncol. Nurs. Forum. 2006; 33: E79-E89
        • Nho J.H.
        • Park Y.S.
        Descriptive study on sexuality for women with gynecological cancer.
        Korean J. Women Health Nurs. 2012; 18: 17-27
        • Oh S.M.
        • Min K.J.
        • Park D.
        A study on the standardization of the Hospital Anxiety and Depression Scale for Koreans-A comparison of normal, depressed and anxious groups.
        J. Korean Neuropsychiatric Assoc. 1999; 38: 289-296
        • Pud D.
        • Ben Ami S.
        • Cooper B.A.
        • Aouizerat B.E.
        • Cohen D.
        • Radiano R.
        • et al.
        The symptom experience of oncology outpatients has a different impact on quality-of-life outcomes.
        J. Pain Symptom Manag. 2008; 35: 162-170
        • Ries L.A.G.
        • Kosary C.L.
        • Hankey B.F.
        • Miller B.A.
        • Harras A.
        • Edwards B.K.
        SEER Cancer Statistics Review, 1973-1994.
        (NIH Pub. No. 97-2789) National Cancer Institute, Bethesda, MD1997
        • Rosen R.
        • Brown C.
        • Heiman J.
        • Leiblum S.
        • Meston C.
        • Shabsigh R.
        • et al.
        The Female Sexual Function Index (FSFI): a multidimensional self-report instrument for the assessment of female sexual function.
        J. Sex Marital Ther. 2000; 26: 191-208
        • Sankaranarayanan R.
        • Ferlay J.
        Worldwide burden of gynaecological cancer: the size of the problem.
        Best Practice & Res. Clin. Obstetrics Gynaecol. 2006; 20: 207-225
        • Skerman H.M.
        • Yates P.M.
        • Battistutta D.
        Multivariate methods to identify cancer-related symptom clusters.
        Res. Nurs. Health. 2009; 32: 345-360
        • Sohn S.I.
        • Kim D.H.
        • Lee M.Y.
        • Cho Y.W.
        The reliability and validity of the Korean version of the Pittsburgh sleep quality index.
        Sleep Breath. 2012; 16: 803-812
        • Sorensen J.B.
        • Klee M.
        • Palshof T.
        • Hansen H.H.
        Performance status assessment in cancer patients. An inter-observer variability study.
        Br. J. Cancer. 1993; 67: 773-775
        • Sweeney C.W.
        Understanding peripheral neuropathy in patients with cancer: background and patient assessment.
        Clin. J. Oncol. Nurs. 2002; 6: 163-166
        • Webster K.
        • Cella D.
        • Yost K.
        The functional assessment of chronic illness therapy (FACIT) Measurement system: properties, applications, and interpretation.
        Health Qual. Life Outcomes. 2003; 1: 79
        • Wiegel M.
        • Meston C.
        • Rosen R.
        The female sexual function index (FSFI): cross-validation and development of clinical cutoff scores.
        J. Sex Marital Ther. 2005; 31: 1-20
        • Wolf S.
        • Barton D.
        • Kottschade L.
        • Grothey A.
        • Loprinzi C.
        Chemotherapy-induced peripheral neuropathy: prevention and treatment strategies.
        Eur. J. Cancer. 2008; 44: 1507-1515
        • Zigmond A.S.
        • Snaith R.P.
        The hospital anxiety and depression scale.
        Acta Psychiatr. Scand. 1983; 67: 361-370