Assessment of the quality of life of patients with advanced and end-stage cancer or serious infections with a symptom-based or an impact-based instrument

In 1992 a project was started in which home care technology was made available to patients with cancer or serious infections. Primary care providers were trained and supported to administer parenteral drugs and fluids in the home setting. Between 1992 and 1995 we applied the Rotterdam Symptom Checklist (RSCL) and the Sickness Impact Profile (SIP) as questionnaires for quality of life (QoL) assessment in a group of 112 hospitalized patients who were prepared to receive further treatment at home. Scores on the RSCL revealed a high level of symptomatology in both the physical and the psychological dimension. Factor analysis showed a five-factor rather than a two-factor structure. The SIP showed considerable restrictions in daily living, particularly in the physical dimension. Whereas the RSCL and the SIP correlated well in the psychological and physical dimensions in advanced cancer patients, this correlation disappeared in the group of end-stage cancer patients. The data indicate that the health-related QoL of end-stage cancer patients cannot be reliably be assessed with a symptom-based instrument alone; it needs to be supplemented by other instruments, such as the SIP.     

Patients' self reports and caregivers' perception of symptoms in Turkish cancer patients

PurposeThe study's aim was to compare cancer patients' and family caregivers' perceptions of symptom distress in patients receiving chemotherapy in Turkey.MethodThe study used a cross-sectional design. A convenience sample of 80 dyads, composed of cancer patients and their caregivers, completed the Rotterdam Symptom Checklist (RSCL) in an out-patient chemotherapy unit. This scale is a 27-item Likert -type scale assessing both physical and psychological symptoms in cancer patients.ResultsPrimary caregivers' physical symptom scores were moderately correlated with patients' physical symptom scores (r = 0,74; P < 0.01). Levels of patient - caregiver agreement were better for loss of hair (ICC 0.80) and lack of appetite (ICC 0.68) on physical symptoms. Level of agreement was moderate for 16 symptoms of the 27 symptoms of the RSCL.ConclusionThe study illustrates that family caregivers play a vital role in the assessment of cancer symptoms, particularly in Turkey where contact with professional health carers may be limited after discharge, and argues for greater support and better education for carers in relation to all aspects of this caring role. However, family caregivers have greater difficulty in achieving high levels of accuracy on psychological as opposed to physical symptoms.     

音乐放松训练对缓解乳腺癌患者化疗不良反应的效果研究

目的探讨音乐放松训练对缓解乳腺癌术后患者化疗引起焦虑和不良反应的效果。方法采用方便抽样的方法,将符合入选条件的乳腺癌术后患者分为干预组55例,干预组患者在接受常规护理的同时,给予2个化疗周期的音乐放松训练(音乐治疗、渐进性肌肉放松及引导性意象)。以状态焦虑问卷和Rotterdam症状检测量表的评定为主要指标,分别在第2次化疗前、第3次化疗前对干预效果进行评价。对照组55例按照乳腺癌术后化疗的护理常规进行护理。结果干预组患者干预后的Rotterdam症状检测量表得分、焦虑得分的上升趋势显著低于对照组,差异有统计学意义(P0.05)。结论音乐放松训练能减轻患者化疗的不良反应,减轻患者化疗期的焦虑程度,在对乳腺癌术后化疗患者的心理行为干预中具有可操作性。     

Concurrent validity of the modified Edmonton Symptom Assessment System with the Rotterdam Symptom Checklist and the Brief Pain Inventory

As part of a longitudinal prospective study we sought a self-completed instrument of symptom assessment suitable for a population of cancer patients who were receiving palliative therapy. The modified Edmonton Symptom Assessment System (ESAS) is such an instrument, but it required validation for this population. This study represents a validation of the modified ESAS with the Rotterdam Symptom Checklist and the Brief Pain Inventory – two instruments widely used in patients receiving palliative therapy for cancer. We conclude that the modified ESAS is a valid, self-administered instrument to assess symptoms for patients from differing palliative care settings.     

An evaluation of aromatherapy massage in palliative care

The use of complementary therapies, such as massage and aromatherapy massage, is rising in popularity among patients and healthcare professionals. They are increasingly being used to improve the quality of life of patients, but there is little evidence of their efficacy. This study assessed the effects of massage and aromatherapy massage on cancer patients in a palliative care setting. We studied 103 patients, who were randomly allocated to receive massage using a carrier oil (massage) or massage using a carrier oil plus the Roman chamomile essential oil (aromatherapy massage). Outcome measurements included the Rotterdam Symptom Checklist (RSCL), the State-Trait Anxiety Inventory (STAI) and a semi-structured questionnaire, administered 2 weeks postmassage, to explore patients' perceptions of massage. There was a statistically significant reduction in anxiety after each massage on the STAI (P < 0.001), and improved scores on the RSCL: psychological (P < 0.001), quality of life (P < 0.01), severe physical (P < 0.05), and severe psychological (P < 0.05) subscales for the combined aromatherapy and massage group. The aromatherapy group's scores improved on all RSCL subscales at the 1% level of significance or better, except for severely restricted activities. The massage group's scores improved on four RSCL subscales but these improvements did not reach statistical significance. Massage with or without essential oils appears to reduce levels of anxiety. The addition of an essential oil seems to enhance the effect of massage and to improve physical and psychological symptoms, as well as overall quality of life.     

A randomized controlled trial of aromatherapy massage in a hospice setting

Research suggests that patients with cancer, particularly in the palliative care setting, are increasingly using aromatherapy and massage. There is good evidence that these therapies may be helpful for anxiety reduction for short periods, but few studies have looked at the longer term effects. This study was designed to compare the effects of four-week courses of aromatherapy massage and massage alone on physical and psychological symptoms in patients with advanced cancer. Forty-two patients were randomly allocated to receive weekly massages with lavender essential oil and an inert carrier oil (aromatherapy group), an inert carrier oil only (massage group) or no intervention. Outcome measures included a Visual Analogue Scale (VAS) of pain intensity, the Verran and Snyder-Halpern (VSH) sleep scale, the Hospital Anxiety and Depression (HAD) scale and the Rotterdam Symptom Checklist (RSCL). We were unable to demonstrate any significant long-term benefits of aromatherapy or massage in terms of improving pain control, anxiety or quality of life. However, sleep scores improved significantly in both the massage and the combined massage (aromatherapy and massage) groups. There were also statistically significant reductions in depression scores in the massage group. In this study of patients with advanced cancer, the addition of lavender essential oil did not appear to increase the beneficial effects of massage. Our results do suggest, however, that patients with high levels of psychological distress respond best to these therapies.     

The use of the Rotterdam Symptom Checklist in palliative care.

The Rotterdam Symptom Checklist (RSCL), which measures both physical and psychological aspects of quality of life (QOL), was given to all new patients admitted to a palliative care unit who were thought capable of filling out a questionnaire as an outcome measure of symptom control. Assessments were obtained from 52 patients at baseline (week 1). This represented only 53% of the new patients admitted to the unit. Thirty-one patients completed a second questionnaire at week 2, and only 28 patients completed a third (week 3). In these selected patients, the median overall RSCL scores were 57, 52, and 49 at weeks 1, 2, and 3. There was a significant improvement in QOL scores across the three measurements with a significant difference between weeks 1 and 3 (P = 0.05) but not between weeks 1 and 2. Primarily because of the inability of many patients to complete the questionnaire and the high attrition rate, the appropriateness of this tool as a symptom control measure in palliative care patients is questioned.     

Quality of life in patients with ovarian cancer: Current state of research

Ovarian cancer is the most malignant cancer in women, where it is the fifth leading cause of cancer-related death. The disease and its treatment have considerable effects on the quality of life of patients with this cancer. This study reviews existing literature on quality of life in patients with ovarian cancer to demonstrate the importance of the topic, to comment on improvements achieved and to consider their implications for the implementation of optimal treatment. A literature search was carried out through MEDLINE and of published papers on quality of life in patients with ovarian cancer from 1976 to 1994. Twenty papers have been reviewed, of which, 10 were treatment-related assessments of quality of life and the remaining 10 dealt with different topics including psychometric issues in measuring health-related quality of life. Twenty-four instruments were employed to measure quality of life. Of these, the Rotterdam Symptom Checklist (RSCL) and The European Organisation for Research and Treatment of Cancer Core Quality of Life Questionnaire (EORTC QLQ-C30) were found to be the most appropriate. Although meta-analysis of results is impossible, it appears that debulking surgery followed by platinum-based chemotherapy could improve both quality of life and survival. In addition to effective and efficient treatment, psychological counselling, palliative and home care, nutritional support and pain relief are the most important areas for improving quality of life of patients with ovarian cancer. Knowledge and insight into the quality of life of patients with ovarian cancer are still limited, and a large carefully planned international study is required. Use of existing standard measures is preferable and agreement should be reached on a selected single instrument.     

Assessment of fatigue in and care needs of Turkish women with breast cancer

Using Piper's Integrated Fatigue Model, this research project was planned to determine the level of fatigue experienced by Turkish women with breast cancer undergoing adjuvant chemotherapy, to discover the factors affecting fatigue, and to provide a reference by means of which an effective nursing care for such patients could be planned. In assessing the level of fatigue and factors affecting it, a patient information form, the Piper Fatigue Scale, and the Rotterdam Symptom Checklist were used. The reliability tests performed afterwards showed that the scales are appropriate tools for use in Turkish women with breast cancer. Before treatment, psychological symptoms' distress was higher than physical symptoms' distress. However, following treatment, the latter was found to be closer to the former. When pretreatment and posttreatment physical and psychological symptoms were compared, it was noticed that fatigue, nausea, anorexia, vomiting, constipation, depression, and loss of hope for the future were among the symptoms observed to increase the most in the posttreatment period. Different from the other studies, we determined that all of the patients experienced fatigue 7 to 10 days after the chemotherapy cycle and the sensory/affective fatigue scores were high. Breast cancer patients undergoing chemotherapy experienced a moderate level of fatigue, which was influenced by level of income, stage of disease, and symptoms related to chemotherapy, showing compliance with similar studies. Following up patients individually and keeping the treatment-related symptoms under control were noticed to help prevent fatigue.     

Symptom indexes to assess outcomes of treatment for early prostate cancer

BACKGROUND: Patients' perceptions of treatment outcomes are important in the management of early prostate cancer, but few studies have offered reliable and responsive measures to assess the likely side effects of the most common treatments. OBJECTIVE: To develop indexes of urinary, bowel, and sexual function, and related distress. RESEARCH DESIGN: Prospective cohort study of the outcomes of treatment for early prostate cancer, with self-administered questionnaires completed before treatment, and 3 and 12 months afterward. Hypothesized indexes, based on a clinical model of pathophysiological side effects of treatment, were defined and evaluated with respect to reliability and validity. SUBJECTS: Patients (n = 184) undergoing radical prostatectomy or external beam radiotherapy for early prostate cancer. MEASURES: Urinary and bowel items pertained to frequency or intensity of symptoms of dysfunction; parallel items assessed symptom-related distress. Sexual dysfunction items assessed the quality of erections, orgasm, and ejaculation; distress was assessed by 2 items adapted from the MOS Sexual Problems (MOS-SP) scale. HRQoL was assessed by the SF-36 and Profile of Mood States. RESULTS: Symptom and symptom-related distress indexes for urinary incontinence, urinary obstruction/irritation, bowel dysfunction, and sexual dysfunction were defined. Symptom and distress indexes in each domain were highly correlated. Responsiveness was substantial and varied by treatment in ways consistent with clinical experience. The indexes accounted for significant proportions of the variance in HRQoL measures. CONCLUSIONS: These indexes may be used in monitoring outcomes of treatment for early prostate cancer.     

The measurement of symptoms in children with cancer

The purpose of this study was to determine symptom prevalence, characteristics, and distress in children with cancer. The Memorial Symptom Assessment Scale (MSAS) 10-18, a 30-item patient-rated instrument adapted from a previously validated adult version, provided multidimensional information about the symptoms experienced by children with cancer. This instrument was administered to 160 children with cancer aged 10-18 (45 inpatients, 115 outpatients). To confirm the instrument's reliability and validity, additional data about symptoms were collected from both the parents and the medical charts, and retesting was performed on a subgroup of inpatients. Patients could easily complete the scale in a mean of 11 minutes. The analyses supported the reliability and validity of the MSAS 10-18 subscale scores as measures of physical, psychological, and global symptom distress, respectively. Symptom prevalence ranged from 49.7% for lack of energy to 6.3% for problems with urination. The mean (+/- SD) number of symptoms per inpatient was 12.7 +/- 4.9 (range, 4-26), significantly more than the mean 6.5 +/- 5.7 (range, 0-28) symptoms per outpatient. Patients who had recently received chemotherapy had significantly more symptoms than patients who had not received chemotherapy for more than 4 months (11.6 +/- 6.0 vs. 5. 2 +/- 5.1), and those patients with solid tumors had significantly more symptoms than patients with either leukemia, lymphoma, or central nervous system malignancies (9.9 +/- 7.0 vs. 6.8 +/- 5.5 vs. 6.8 +/- 5.0 vs. 8.0 +/- 6.1). The most common symptoms (prevalence > 35%) were lack of energy, pain, drowsiness, nausea, cough, lack of appetite, and psychological symptoms (feeling sad, feeling nervous, worrying, feeling irritable). Of the symptoms with prevalence rates > 35%, those that caused high distress in more than one-third of patients were feeling sad, pain, nausea, lack of appetite, and feeling irritable. Subscale scores demonstrated large variability in symptom distress and could identify subgroups with high distress. The prevalence, characteristics, and distress associated with physical and psychological symptoms could be quantified in older children with cancer. The data confirm a high prevalence of symptoms overall and the existence of subgroups with high distress associated with one or multiple symptoms. Symptom distress is relatively higher among inpatients, children with solid tumors, and children who are undergoing antineoplastic treatment. Systematic symptom assessment may be useful in future epidemiological studies of symptoms and in clinical chemotherapeutic trials. Symptom epidemiology may also provide a focus for future clinical trials related to symptom management in children with cancer.     

The role of informal caregivers during cancer patients’ recovery from chemotherapy

Scand J Caring Sci; 2013; 27; 147–155 The role of informal caregivers during cancer patients’ recovery from chemotherapy Aims: (i) To investigate the availability, perceived importance and roles of informal caregivers in the recovery of patients treated at day oncology centres and (ii) identify differences between patients with and without informal caregivers in the extent to which they experienced symptoms, and the level of bother symptoms caused. Method: Patients from three Australian hospitals (n = 122) were recruited during cycles 1 or 2 of adjuvant chemotherapy. Participants completed a modified version of the Rotterdam Symptom Checklist (RSCL) each day for 5 days after chemotherapy. A telephone interview conducted 10 days post‐treatment explored the availability, importance and roles of caregivers. During the interview, participants also completed the modified RSCL in which they were asked about the extent to which they experienced, and were bothered by, each symptom over the prior 5 days combined. Results: Overall, 71% of participants had an informal caregiver in the 5 days postchemotherapy, commonly a partner. More women (71%) than men (48%) had a caregiver (p < 0.05). Caregivers were perceived to be highly important; they were more important for women than men (U = 213.50, p < 0.01). The most common assistance caregivers provided was meal preparation and emotional support and companionship. On days 6–10 postchemotherapy, the extent to which overall physical symptoms were experienced was higher for patients with a caregiver than without (U = 987.50, p < 0.05); similarly their symptoms caused more bother (U = 966.00, p < 0.01). Conclusions: These findings highlighted the importance of informal caregivers to patients postchemotherapy. It is imperative that patients are informed of the importance of this support so a caregiver can be arranged, if possible. Understanding the needs of patients following chemotherapy would enable health professionals to advise patients, with or without caregivers, how to best prepare for and manage their recovery at home.     

Academic Progress in Palliative Care

This new section of Progress in Palliative Care will feature summaries of recently awarded PhD or MD theses by colleagues from all disciplines. We feel that the prompt publishing of differentiations will help to disseminate the growing knowledge base of the academic foundation of palliative care. Readers are invited to submit their own work, or to alert colleagues who may have recently completed relevant dissertations.

In this study I investigated doctors' attitudes towards dying patients and their effects on anxiety and depression in patients with advanced cancer.

The first phase involved the design of appropriate methodology. A patient interview schedule was developed, comprising standardised instruments (Hospital Anxiety and Depression Scale—HAD—and Rotterdam Symptom Checklist—RSCL), open and semi-structured questions on history of diagnosis (including Breaking Bad News), social support and experience of others with cancer, and a new Doctor-Patient Relationship Questionnaire. This last instrument was piloted among 175 patients with advanced cancer, and aimed to measure both patients' perceptions of their doctors, and their desire for information and involvement in decision-making.

Open questions at the end of the interview also addressed ‘unanswered questions’ and ‘worries’ before a final question on ‘positive outcomes’ of the illness experience. Following each interview, observer ratings were made of patients' ‘Understanding of Diagnosis and Prognosis’.

Doctors' attitudes were measured on the Patient-centredness score and WERD-score (‘Words Emotionally Related to Dying’). These measures arose from and had been previously validated in the context of experiential workshops which pre-dated and ran in parallel with the study.     

Quality of life in palliative care: An analysis of quality-of-life assessment

Abstract

The principal aim of palliative care is to improve patients' quality of life. This is more complicated than it seems. There is no generally accepted way to assess quality of life. Through an extensive literature research multiple instruments were found. Of these, four were chosen to be examined further (Schedule for the Evaluation of Individual Quality of Life – Direct Weighting (SEIQoL-DW), European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire – Core 15 – of Palliative Care (EORTC QLQ-C15-PAL), Rotterdam Symptom Checklist (RSCL), and Palliative Care Outcome Scale (POS)). These were used with patients in a German palliative care ward. Staff and patients were interviewed on their understanding of quality of life and its assessment. The results of literature research, interviews, and application of the instruments were then collated and critically evaluated. It became obvious that a deliberate choice of an instrument has a great impact on practicability and outcome in a clinical setting. The EORTC QLQ-C15-PAL seems particularly useful for (international) studies; it leads to clear and easily comparable results. For routine use in clinical palliative care, however, it seems too impersonal to represent more than a rough idea of patients' actual quality of life. Applying the RSCL, the researcher could gain a basic overview of symptoms and psychological condition of his patients – even though it seems too rigid to allow a deeper insight in quality of life. The POS offers additional insight via an open question and a staff questionnaire. This could provide particularly helpful information for clinical routine – provided patients can cope with its more complex format. The SEIQoL-DW seems to be best suited for use in a clinical situation even though its use can be challenging for both researcher and patient. Assessment requires both parties to interact directly, which seems to have a beneficial impact on relationship and communication. It is the most flexible assessment instrument of those analysed here and therefore seems to be best suited to investigate such a complex matter as quality of life.     

癌症患儿症状体验的现况调查

目的:评估和描述癌症患儿症状的发生率、频率、严重度和困扰度。方法:对125名4岁及以上的癌症患儿使用记忆症状量表进行自我评估或家长代评。结果:其症状发生率从1.6%(吞咽困难)到76.8%(出汗);最常发生(发生率≥40%)的症状包括:出汗、缺乏体力、没有食欲、急躁易怒、疼痛、恶心、感到紧张、体重下降、口干和咳嗽;在发生率<40%的症状中,困扰度较高(≥40%)的症状包括:小便有问题、吞咽困难、呕吐和口腔溃疡。处于治疗期的患儿其症状出现数量(11.35±4.10)多于未开始治疗或休疗的患儿(8.15±4.43),且不同治疗状态患儿的生理症状维度得分和总得分上差异有统计学意义(P<0.01)。结论:癌症患儿症状普遍存在,且极易受各种身心症状的困扰。运用多维的工具进行系统性的症状评估,可获得更多关于症状体验方面的信息,进而有利于医护人员更加有针对性地采取干预措施,以完善护理实践。     

The quality of life and self-efficacy of Turkish breast cancer patients undergoing chemotherapy

Self-efficacy has a positive effect on health behaviors, symptom control, compliance with cancer treatment, and quality of life. This study aims to describe the quality of life and self-efficacy of Turkish breast cancer patients undergoing chemotherapy. The sample consisted of 141 patients. Data was gathered using a Patient Information Form, the Functional Assessment of Cancer Therapy-Breast Cancer (FACT-B), a scale about Strategies Used by Patients to Promote Health and the Rotterdam Symptom Checklist. All quality of life dimensions were negatively affected at a significant level. Following commencement of chemotherapy, there was an increase in the negative effect on physical well-being, emotional well-being and additional concerns subscales and total FACT-B and their self-efficacy was negatively affected to a moderate degree. However, a significant degree of change did not occur in the self-efficacy. During treatment the physical symptoms and psychological distress increased and the activity level was negatively affected. The quality of life and self-efficacy were influenced by personal and medical characteristics, showing consistency with similar studies. Because there are negative effects of cancer and chemotherapy on patients' quality of life and self-efficacy, nurses need to focus on designing psychosocial interventions to improve their self-efficacy and quality of life.     

Impacts of self-care education on adverse events and mental health related quality of life in breast cancer patients under chemotherapy

ObjectiveAs a consequence of its high incidence, breast cancer has become a severe health risk in women. Chemotherapy is one of the main treatments for breast cancer, but causes a decline in life quality of patients. Self-care is a non-medical intervention and has been reported to improve the life quality of colorectal cancer patients. We aim to explore whether self-care is also effective in breast cancer.Materials and methods85 breast cancer patients under chemotherapy participated in this research, among whom 44 patients received the self-care education. The physical and mental conditions of patients before and after chemotherapy were evaluated by Anxiety Inventory, Rotterdam Symptom checklists and QLQ-C30.ResultsThe result showed that the occurrence rates of symptoms were significantly reduced after self-care measures. Anxiety Inventory and Rotterdam Symptom checklists indicated that self-care measures could improve both the physical and mental conditions of patients. The Global Quality of Life (QoL) from QLQ-C30 questionnaire further confirmed the effectiveness of self-care measures in breast cancer patients.ConclusionsBased on the results, self-care measures are effective in improving the physical and mental conditions of breast cancer patients under chemotherapy. Self-care measures play an important role in improving patients’ life quality.     

Measuring symptom occurrence and symptom distress: development of the symptom experience index

AIM: This paper is a report of a study to assess reliability and construct validity of revised and refined version of the Adapted Symptom Distress Scale: the Symptom Experience Index (SEI). BACKGROUND: The development of the SEI, a 41-item Likert Scale assessing 20 symptoms, was based on self-regulation theory and an integrative conceptual analysis of symptom assessment and management. The model emphasizes the difference between the occurrence of a symptom (or multiple symptoms) and the distress (emotional) response to the occurrence of a symptom. It is the distress from symptom occurrence that promotes a person to take action and use known coping strategies to prevent the symptom occurrence or alleviate the distress from the symptom. METHOD: A contrast-group and test-retest approach was used to assess construct validity and reliability with a convenience sample of 158 patients at United States of America in 2003-2004. RESULTS: The SEI demonstrated reasonable internal consistency with a Cronbach's alpha of 0.91 for symptom experience, 0.85 for symptom occurrence and 0.84 for symptom distress. Test-retest reliability was supported by high intra-class correlation coefficients (symptom experience r = 0.93; symptom occurrence r = 0.94; symptom distress, r = 0.92). Construct validity was supported by statistically significant differences between patients and healthy adults. CONCLUSION: The SEI can be used as a baseline and outcome measure to assess the impact of multiple symptoms on patients, and the effectiveness of interventions to manage these symptoms.     

Measuring the symptom experience of seriously ill cancer and noncancer hospitalized patients near the end of life with the memorial symptom assessment scale

The objectives of this study were twofold: (1) to explore and compare the symptom experience of seriously ill hospitalized cancer and noncancer patients near the end of life using the Memorial Symptom Assessment Scale (MSAS) and (2) to determine if the MSAS is a valid and useful measure of symptom distress for patients with noncancer conditions. This was a prospective cohort study of hospitalized patients with end-stage congestive heart disease, chronic pulmonary disease, cirrhosis, or metastatic cancer. Eligible patients were interviewed to ascertain symptom prevalence, severity and distress using the MSAS and levels of fatigue using the Piper Fatigue Scale (PFS). Sixty-six patients with metastatic cancer and 69 patients with end-stage disease were enrolled in the study. There was a significant difference in the prevalence of selected physical symptoms, but not psychological symptoms, between cancer and noncancer patients. There were no significant differences in symptom distress scores, a computed score of frequency, severity and distress, if the symptom was present. In both groups the principal components factor analysis with varimax rotation yielded one factor comprising psychological symptoms and a second factor comprising three subgroups of physical symptoms. Internal consistency was high for the psychological subscale (Cronbach alpha coefficients of 0.85 for the cancer group and 0.77 for the noncancer group) and for the physical subscale groupings, with coefficients ranging between 0.78 to 0.87. The symptom scores were significantly correlated with perceptions of fatigue. These findings show that both seriously ill cancer and noncancer patients experience symptom distress, and that the MSAS seems to be a reliable measure of symptom distress in noncancer patients, as well as with cancer patients.