Hindawi Journal of Oncology Volume 2022, Article ID 7531545, 10 pages https://doi.org/10.1155/2022/7531545 Research Article Changes in Patient-Reported Health Status in Advanced Cancer Patients from a Symptom Management Clinic: A Longitudinal Study Conducted in China Yening Zhang, Zimeng Li, Ying Pang, Yi He, Shuangzhi He, Zhongge Su, Yuhe Zhou, Yan Wang, Bingmei Wang, Lili Song, Jinjiang Li, Xinkun Han, Chengcheng Zhou, Xiumin Li, and Lili Tang Department of Psycho-Oncology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, China Correspondence should be addressed to Lili Tang; email@example.com Received 26 May 2022; Revised 4 August 2022; Accepted 20 August 2022; Published 16 September 2022 Academic Editor: Yingming Sun Copyright © 2022 Yening Zhang et al. �is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Objectives. �e integration of patient-reported health status has been increasingly emphasised for delivering high-quality care to advanced cancer patients. �is research is designed to track health status changes over time in Chinese advanced cancer patients to explore the risk factors a‡ecting their health status. Methods. Advanced cancer patients were recruited from Peking University Cancer Hospital. An electronic patient-reported outcome (ePRO) system with validated measurements was used to collect the data. ANOVA, the chi-square test, the nonparametric Kruskal–Wallis H test, and generalized estimating equation (GEE) analysis were used for the data analysis. Results. One hundred and three patients completed a baseline survey (T = 0) and two follow-up surveys (T1 = 14 days, T2 = 28 days). Chi-square test results indicate a signiœcant decrease in the percentage of patients reporting moderate or severe dižculty experienced by patients in terms of mobility, pain/discomfort, and anxiety/depression. However, there is a signiœcant increase in the percentage of patients reporting moderate or severe dižculty in self-care and usual activities. Scores on the visual analogue scale in the EQ-5D-5L instrument (EQ-VAS) are associated with patients’ income, and the degree of moderate or severe anxiety/depression is found to be associated with employment status. �e GEE results show that pain, loss of appetite, poor walking status e‡ected by symptoms, depression, and anxiety has worsened the health status. Conclusions. �e health status of Chinese advanced cancer patients under ePRO follow-up in China signiœcantly improves in the physical and psychological dimensions, accompanied by a decrease in usual activities and self-care. Routine screening and rational supportive care are recommended in oncology for cancer care. Based on the rational application of ePRO, longitudinal studies exploring the potential mechanisms of health status changing would provide more beneœcial guidance for improving the quality of life in patients with advanced cancer. to manage in this population [5, 6]. Quality of life (QoL) or 1. Background health status improvement is the primary objective of high- Cancer patients experience subjective distress induced by quality care for advanced cancer patients. Studies on cancer- various symptoms related to both the disease itself and related mechanisms, patient-reported outcome (PRO) treatment-related adverse events [1, 2]. �ough the œve-year monitoring, and multidisciplinary interventions for im- survival rate for cancer in China has increased from 30.9% proving QoL in this population have been reported in recorded in 2003 to 40.5% in 2015 , it is still lower than the various research publications. Recurrent or persistent in- rates in developed countries . Available data indicate that ¬ammation is a common factor in the pathogenesis of approximately 60% of cancer will progress to the advanced neoplasia , and QoL is associated with systemic in- stages; symptom burden would be complicated and dižcult ¬ammation in patients with advanced cancer (based on PRO 2 Journal of Oncology with anticancer treatments. Second, the extant research does measurements) . Some supportive interventions have been proven to improve QoL by modulating inﬂammatory not include longitudinal studies and none of the studies monitor changes in the health status of advanced cancer mediators [9, 10]. PRO monitoring of subjective symptoms in advanced cancer patients will provide a detailed map of patients. )erefore, the objectives of this study are as follows: health status changes and is recommended in the clinical (1) to track changes in health status over time in Chinese practice guidelines on palliative care of the National advanced cancer patients registered on multiple ePRO QoL Comprehensive Cancer Network (NCCN) . PRO that assessment platforms, (2) to examine discrepancies in the includes health status is also viewed as a crucial indicator of EQ-5D-5L results in patients with diﬀerent demographic treatment eﬀectiveness in clinical trials and is an essential and medical condition, and (3) to explore risk factors that inﬂuence the changing of health status in advanced cancer criterion for drug approval, as required by the U.S Food and Drug Administration (FDA) from 2006 . However, both patients. physical and psychosocial symptoms can adversely aﬀect QoL and daily functions . Research shows that im- 2. Materials and Methods provement in the QoL of patients is of great signiﬁcance for their anticancer treatments, long-term rehabilitation, and )is longitudinal study was conducted at Peking University survival. Kypriotakis et al. indicated that advanced cancer Cancer Hospital. Patients who visited the symptom man- patients’ longitudinal experience of QoL is a signiﬁcant agement clinic at Peking University Cancer Hospital be- prognostic factor for survival . tween June 1st to December 31st, 2019 were recruited as Describing the changing trends in the health status, participants in the study on their initial visit. )e inclusion exploring the mechanisms behind ﬂuctuating symptoms, criteria were as follows: (1) aged≥ 18 years old; (2) diagnosis and designing eﬃcient interventions for advanced cancer of an advanced cancer (UICC TNM classiﬁcation stage III patients would be particularly beneﬁcial for improving QoL without curative treatment chance and stage IV), including of this population. )ere have been several longitudinal lung cancer, gastric cancer, oesophageal cancer, liver cancer, studies focused on cancer patients. Van Dijk-Lokkart et al. colorectal cancer, and breast cancer; (3) able to sign in- reported that cancer-related fatigue can improve after formed consent; and (4) could understand the items. Pa- treatment in children diagnosed with cancer, which is tients were excluded if they had a history of severe mental a favourable prognosis for a subsequent increase in physical disorders or major communication diﬃculties. )e study was activity . For cancer patients undergoing pelvic/ab- approved by the Institutional Research Board (IRB) of Peking dominal radiotherapy, eﬀectively managing nausea resulted University Cancer Hospital (approval number 2019YJZ07). in improved sleep . Findings from a follow-up study indicated that QoL became worse for head and neck cancer (HNC) patients after cancer treatment . Another study 2.1. Measures. EQ-5D-5L. )e EQ-5D-5L instrument reports that the QoL of early-stage patients with non-small comprises a short descriptive system questionnaire and cell lung cancer deteriorated six weeks after video-assisted a visual analogue scale (EQ-VAS) . Each respondent is thoracoscopic lung resection and had improved by asked to choose a digital number that best describes their 12 months after the surgery . A few of these studies focus health status for the day on each of the ﬁve dimensions, and speciﬁcally on changes in QoL in advanced cancer patients. the response for each health status dimension is assigned )e study by Contogni et al. focuses on changes in QoL in a ﬁve-digit code. )e EQ-5D-5L health status results are then advanced cancer patients on parenteral nutrition (HPN) converted into a single index value for China . )e EQ . Deteriorating nutrition status would negatively inﬂu- VAS records the self-rated overall health status of the re- ence QoL in advanced colorectal cancer . Based on spondent. )e EQ-5D-5L instrument is used to assess the a longitudinal study, Rojas-Concha suggests that the QoL of participants’ health status on the day of evaluation. )e advanced cancer patients in Chile could beneﬁt from pal- EQ-5D is a preference-based measure of health status and liative care . Research on the longitudinal health status of QoL used worldwide in clinical trials, population studies and patients with advanced cancer is of particularly crucial real-world clinical settings. It was developed from the EQ- clinical signiﬁcance, especially for those who no longer have 5D-3L , the EQ-5D-3L was introduced in the 1990s , the opportunity for eﬀective anticancer treatments. comprises ﬁve dimensions: mobility (MO), self-care (SC), We conducted this study based on a hypothesis drawn usual activities (UA), pain/discomfort (PD), and anxiety/ from research studies by Bash et al., which has indicated that depression (AD) and has three levels in each dimension: no PRO symptom monitoring is beneﬁcial for the QoL and problems, some problems, and extreme problems. Although eventual survival of advanced cancer patients [22, 23]. widely used in the clinical trials, the EQ-5D-3L instrument Hence, we are conducting a pilot study to assess whether also has several limitations; for example, it is not sensitive to signiﬁcant improvements in QoL can be tracked in Chinese mild health changes and it suﬀers from ceiling eﬀects . advanced cancer patients using PRO monitoring. )ere are To solve the issues, a new ﬁve-level EQ-5D (EQ-5D-5L) still a few knowledge gaps in the literature on this area of instrument was developed by the EuroQol Group. It remains research in China. First, previous national studies are either the original dimension and expands the number of levels of on a single cancer type or have cancer survivors as partic- severity in each dimension from three to ﬁve: no problems, ipants and hence cannot be generalized to advanced cancer slight problems, moderate problems, severe problems, and patients whose cancers are unlikely to be cured or controlled unable to/extreme problems; thus deﬁning 3,125(55) distinct Journal of Oncology 3 T1 (Day 14) and T2 (Day 28), on which the patients received health statuses. )e EQ VAS records the self-rated health status valuation of the respondent on a vertical visual an- a reminder message from the ePRO system to complete the follow-up assessment via mobile phone. If the participant alogue scale, with the end points labelled ‘)e best health you can imagine’ (100 score) and ‘)e worst health you can had moderate-to-severe physical and psychological symp- imagine’ (0 score). )e measurement results of the EQ- toms, both the patients and the doctors were immediately 5D-5L instrument can be used to generate health utility sent alerts: reminding the patients to visit the clinic promptly values using value sets. It is generally suggested that diﬀerent and informing the doctors to make timely adjustments to the value sets reﬂect the health preferences of people in diﬀerent patient’s medication. countries. Currently, many countries, including China, have developed EQ-5D-5L value sets based on the health pref- 2.3. Statistical Analysis. )e EQ-5D-5L results were cal- erences of their respective populations [25, 28, 29]. We used culated following the user guide by the EuroQol Research the EQ-5D-5L tariﬀ suggested by Liu in this study . Foundation . )e frequencies and proportions of the )e Chinese version of the MD Anderson Symptom EQ-5D-5L dimensions and levels are presented using de- Inventory (MDASI-C). It is a widely used multisymptom scriptive analysis. Moderate-to-severe diﬃculty was de- inventory with 19 items (13 items for symptom severity and ﬁned as a dimension-level score of ≥3. )e overall health six items for life interference) rated on a 0–10 scale on which status was measured using the EQ VAS, employing mean 0 = nothing and 10 = most severe. MDASI-C is used to assess and standard deviation. )e EQ-5D-5L index was calcu- the symptom severity and the degree of life interference over lated using the Chinese value set and presented as the mean the past 24 hours. As proposed by Cleenland et al., mod- and standard deviation values. To explore discrepancies in erate-to-severe symptoms were deﬁned as scores of ≥5 on the EQ-5D-5L results recorded over time against de- the MDASI . )e MDASI-C has passed reliability and mography and medical data, chi-square tests were used, validity tests and can be used to measure the severity of along with one-way ANOVA (if the homogeneity of var- multiple symptoms and their impact on function . iance assumption was satisﬁed) and the nonparametric )e Hospital Anxiety and Depression Scale (HADS). It Kruskal–Wallis H test (if homogeneity of variance as- has 14 items, with a 0–3 score range for each item. It is used sumption was not satisﬁed). Generalized estimated equa- to measure the anxiety and depression symptoms of patients tion (GEE) analysis was applied to repeated measures of over the past two weeks and is a relatively complete as- EQ-5D-5L and to explore the risk factors for changes in sessment with good reliability and validity . health status. All demographic information, medical data, )e case report form (CRF). It captures the following: (1) and MDASI-C and HADS data were included in the GEE demographic and social economic information, such as age, model. )e statistical analyses were all conducted using sex, occupation, education, marital status, and medical SPSS 25.0 (IBM Corporation). payments; (2) disease data, such as information on disease diagnosis, staging, treatment, and medication; (3) )e Charlson Comorbidity Index (CCI)  is used to evaluate 3. Results complications that have a signiﬁcant impact on the survival 3.1. Demography, Medical Data, and Other Descriptive Results and prognosis of cancer patients. at Baseline. One hundred-and-sixty-one advanced cancer )e Eastern Cooperative Oncology Group Performance patients were recruited as participants and completed in- Status (ECOG-PS) scale. It is a widely used tool for mea- formed consent, with 156 participants completing the survey suring the current functional status of cancer patients on ﬁve at baseline, 126 participants completing the ﬁrst two surveys levels : 0 = normal with no limitations; 1 = not my and 103 participants completing all three surveys (ﬂowchart normal self, but able to be up and about with fairly normal shown in Figure 1). )e mean age of our sample was activities; 2 = not feeling up to most things, but in bed or 56.22± 10.898, with most of these individuals being middle- chair less than half the day; 3 = able to do little activity and aged and elderly (age≥ 45) (n � 125, 55.7%), living with spend most of the day in bed or chair; and 4 = pretty much a spouse (n � 147, 94.2%), and having their medical costs bedridden, rarely out of bed. covered by a government-pay scheme or a medical insurance policy (n � 129, 82.7%). Half the patients with cancer have 2.2. Data Collection. All data were collected on Day 0 (T0), a progress duration of less than half a year. )e results of the Day 14 (T1), and Day 28 (T2) after initial recruitment via an one-way ANOVA and nonparametric Kruskal–Wallis H test electrical PRO (ePRO) system developed by the researchers, indicate that discrepancies in the EQ-5D-5L dimension with participants completing the baseline assessment under responses correspond to speciﬁc demographic characteris- the guidance of research assistants. Several assessments and tics. )ere was a signiﬁcant discrepancy in the EQ-5D-5L training sessions were held for research assistants, and their VAS mean scores of patients with diﬀerent incomes: patients competence (especially evaluation consistency) was evalu- with an income of 15,000 Yuan per month and higher re- ated before commencing the study. )e symptom man- ported poorer health status (measured via VAS scores) than agement clinic of Peking University Cancer Hospital those with lower incomes. Furthermore, there was a signif- requires patients to make a follow-up visit every 14 days. icant discrepancy in the Dimension 5 (anxiety/depression) )us, we designed the follow-up time points of the study as responses of patients with diﬀerent employment statuses: 4 Journal of Oncology 4. Discussion Outpatients contacted (N=205) 4.1.MainFindings. )e EQ-5D-5L has been used extensively Declined to participate to explore health status among diﬀerent populations. We (N=44) found that health status scores among advanced cancer patients (VAS score: 58.35, index value: 0.614) were sig- Completed informed consent (N=161) niﬁcantly lower than the norm scores of the Chinese pop- ulation (VAS score: 85.4, index value: 0.932)  and those Declined to complete the screening (N=5) of cancer survivors in general (VAS score: 70.35, index value: 0.841) . Su et al. report that lung cancer patients have the Completed T0 screening (N=156) lowest health-related QoL compared to other cancer patients Declined to complete the . However, in our study sample, we found no discrep- screening (N=30) ancies between advanced cancer patients with diﬀerent di- Completed T1 screening agnoses. Several recent studies have shown that the health (N=126) status is increasingly viewed as a predictor of survival . Declined to complete the )is was conﬁrmed by Kypriotakis et al. with respect to screening (N=23) advanced cancer patients; they concluded that longitudinal experience of health status is a signiﬁcant prognostic factor Completed T2 screening (N=103) for survival and holds important implications for medical decision-making concerning advanced cancer patients . Figure 1: Study ﬂowchart. If health status monitoring is indeed beneﬁcial for survival, it would be more adoptable—from the perspective of health unemployed patients reported higher levels of anxiety/de- economics—than expensive anticancer treatments. Dis- crepancies in health status were found among patients with pression than those employed (Table 1). )e top ﬁve symptoms reported as moderate-to-severe by diﬀerent demographics and medical data. Patients with monthly incomes of 15,000 Yuan per month and higher advanced cancer patients are as follows: fatigue (61.5%), insomnia (60.9%), pain (58.3%), distress (53.2%), and loss of appetite reported poorer health statuses, as reﬂected by their EQ- 5D-5L VAS scores, than those with lower incomes. )is (46.8%). 57.1% of the participants reported experiencing signif- icant mood distress via the HADS (score of≥ 15). ﬁnding is similar to one of the ﬁndings in the research by Tribius, who reports that locally advanced HNC patients with a high socioeconomic status reported worse QoL than 3.2. Health Status Measured via EQ-5D-5L at Baseline and similar patients with a low economic status . Further- Trends at 3ree Time Points. Signiﬁcant discrepancy was more, a larger proportion of unemployed patients reported found via the chi-square test between the three time moderate problems on the anxiety/depression dimension points, T0 vs. T2 and T1 vs. T2. Responses with moderate than patients who were employed. By contrast, Morrison and severe diﬃculty changed signiﬁcantly in the following reports that lung cancer patients are more likely to report dimensions: decreased in mobility (three time points, emotional problems upon diagnosis if they are employed 2 2 2 χ = 84.541; T1 vs.T2, χ = 60.438; T0 vs.T2, χ = 55.060; . Discrepancies may also occur because the compared p< 0.001), pain/discomfort (three time points, samples are diﬀerent, which indicates that the nature of the 2 2 2 χ = 136.303; T1 vs.T2, χ = 88.542; T0 vs.T2, χ = 99.651; emotional challenges experienced by advanced cancer pa- p< 0.001); and anxiety/depression (three time points, tients is diﬀerent from those experienced by other 2 2 2 χ = 91.625; T1 vs.T2, χ = 60.027; T0 vs.T2, χ = 64.254; populations. p< 0.001) dimensions; but increased in self-care (three Symptoms, function and mood can signiﬁcantly inﬂu- 2 2 time points, χ = 50.202; T1 vs.T2, χ = 33.052; T0 vs.T2, ence the health status among advanced cancer patients. In χ = 29.277; p< 0.001), and usual activities (three time our study, pain, poor walking status eﬀected by symptoms, 2 2 points, χ = 78.562; T1 vs.T2, χ = 53.007; T0 vs.T2, and anxiety/depression are risk factors that signiﬁcantly χ = 48.228; p< 0.001) dimensions (Table 2). )e mean inﬂuence the health status of advanced cancer patients. Pain scores of the EQ-5D-5L index and the VAS values at the is a factor inﬂuencing poor health status, which calls for three time points improved slightly but not signiﬁcantly more attention to pain management for advanced cancer (Table 2). patients, as indicated by the high prevalence of pain in our sample (58.3%). Walking status eﬀected by symptoms has also been conﬁrmed as another factor for low health status 3.3.RiskFactorsforHealthStatusfromtheLongitudinalStudy. by Laird et al., who reported that, among advanced cancer )e results from the GEE model show that ECOG-PS scores patients, performance status is strongly associated with (OR = 0.910, p< 0.001), pain (OR = 0.984, p � 0.005), poor deteriorating QoL parameters . Dunn et al. indicated that walking status eﬀected by symptoms (OR = 0.972, advanced melanoma patients have more signiﬁcantly de- p< 0.001), and anxiety/depression (OR = 0.991, p< 0.001) creased emotional function than patients with a localised were risk factors, which were strongly associated with form of the disease. A high proportion of patients in our changes in the health status of patients with advanced sample reported signiﬁcant psychological distress, which is cancer (Table 3). Journal of Oncology 5 Table 1: Demographic information, medical data, and distribution of EQ-5D-5L dimension responses (% of responses with moderate problems—i.e., Level 3—and above) as a function of various demographic characteristics. Usual Pain/ Anxiety/ Demographic N (%)/M± SD Mobility Self-care EQ-5D-5L index activities discomfort Depression VAS M (SD) characteristics (N � 156) N (%) N (%) M (SD) N (%) N (%) N (%) Age (years) 56.22± 10.898 ≤44 23 (14.7) 6 (26.1) 3 (13.0) 6 (26.1) 9 (39.1) 10 (43.5) 0.67 (0.33) 61.78 (24.34) 45–59 64 (41.0) 20 (31.3) 6 (9.4) 17 (26.6) 43 (67.2) 26 (40.6) 0.59 (0.31) 56.58 (23.36) ≥60 61 (39.1) 20 (32.8) 9 (14.8) 20 (32.8) 35 (57.4) 17 (27.9) 0.63 (0.31) 59.10 (21.00) Missing 8 (5.1) P value 0.355 0.616 0.818 0.060 0.072 0.606 0.610 Sex Male 86 (55.1) 23 (26.7) 8 (9.3) 21 (24.4) 51 (59.3) 28 (32.6) 0.65 (0.29) 60.26 (20.45) Female 69 (44.2) 26 (36.2) 12 (17.4) 24 (34.8) 41 (59.4) 29 (42.0) 0.58 (0.35) 55.48 (23.91) Missing 1 (0.6) P value 0.529 0.815 0.193 0.527 0.148 0.378 0.263 Marital status Without partner (single, separated, divorced, or widowed) 8 (5.1) 44 (29.9) 19 (12.9) 42 (28.6) 88 (59.9) 55 (37.4) 0.61 (0.32) 57.98 (22.41) With spouse 147 (94.2) 4 (50.0) 1 (12.5) 3 (37.5) 4 (50.0) 2 (25.0) 0.61 (0.37) 60.88 (16.39) Missing 1 (0.6) P value 0.233 0.972 0.589 0.581 0.480 0.737 0.742 Education level Junior, middle school, and lower 49 (31.4) 12 (24.5) 6 (12.2) 11 (22.4) 31 (63.3) 17 (34.7) 0.63 (0.30) 57.57 (23.08) High middle school and special secondary school 45 (28.8) 15 (33.3) 7 (15.6) 17 (37.8) 26 (57.8) 18 (40.0) 0.59 (0.35) 56.16 (23.91) Junior college and above 61 (39.1) 21 (34.4) 7 (11.5) 17 (27.9) 35 (57.4) 22 (36.1) 0.63 (0.31) 60.03 (20.01) Missing 1 (0.6) P value 0.494 0.815 0.256 0.797 0.859 0.794 0.659 Average family income <5,000 Yuan/month 42 (26.9) 13 (31.0) 5 (11.9) 14 (33.3) 26 (61.9) 19 (45.2) 0.60 (0.30) 58.67 (20.31) 5,000–10,000 Yuan/month 50 (32.1) 13 (26.0) 7 (14.0) 12 (24.0) 29 (58.0) 15 (30.0) 0.65 (0.33) 60.36 (22.10) 10,000–15,000 Yuan/month 40 (25.6) 14 (35.0) 4 (10.0) 11 (27.5) 22 (55.0) 11 (27.5) 0.63 (0.30) 61.55 (21.66) 15000 Yuan/month and above 23 (14.7) 8 (34.8) 4 (17.4) 8 (34.8) 15 (65.2) 12 (52.2) 0.53 (0.37) 46.35 (23.56) Missing 1 (0.6) P value 0.794 0.850 0.706 0.852 0.108 0.516 p � 0.044 Medical cost coverage Government-pay/Medical insurance 129 (82.7) 40 (31.0) 15 (11.6) 38 (29.5) 74 (57.4) 45 (34.9) 0.63 (0.31) 59.17 (22.74) Self-pay 26 (16.7) 8 (30.8) 5 (19.2) 7 (26.9) 18 (69.2) 12 (46.2) 0.55 (0.34) 52.96 (18.17) Missing 1 (0.6) P value 0.981 0.293 0.796 0.263 0.278 0.161 0.159 Employment status Retired 54 (34.6) 17 (34.5) 9 (16.7) 19 (35.2) 33 (61.1) 19 (35.2) 0.60 (0.34) 59.46 (22.39) Employed 71 (45.5) 22 (31.0) 5 (7.0) 16 (22.5) 38 (53.5) 20 (28.2) 0.66 (0.28) 60.20 (22.49) Without work 28 (17.9) 9 (32.1) 5 (17.9) 8 (28.6) 20 (71.4) 17 (60.7) 0.52 (0.36) 50.11 (20.03) Missing 3 (91.9) P value 0.994 0.172 0.299 0.253 p � 0.010 0.138 0.107 Cancer site 6 Journal of Oncology Table 1: Continued. Usual Pain/ Anxiety/ Demographic N (%)/M± SD Mobility Self-care EQ-5D-5L index activities discomfort Depression VAS M (SD) characteristics (N � 156) N (%) N (%) M (SD) N (%) N (%) N (%) Breast 18 (11.5) 7 (38.9) 5 (27.8) 8 (44.4) 9 (50.0) 9 (50.0) 0.51 (0.44) 55.28 (28.44) Gastric 21 (13.5) 2 (10.0) 1 (5.0) 1 (5.0) 7 (35.0) 5 (25.0) 0.78 (0.19) 59.05 (19.15) Oesophageal 10 (6.4) 4 (36.4) 1 (9.1) 4 (36.4) 8 (72.7) 5 (45.5) 0.58 (0.31) 62.45 (19.86) Liver 12 (7.7） 4 (33.3) 0 (0) 2 (16.7) 9 (75.0) 3 (33.3) 0.67 (0.23) 64.75 (19.86) Lung 49 (31.4) 17 (34.7) 8 (16.3) 17 (34.7) 34 (69.4) 18 (36.7) 0.58 (0.30) 56.37 (23.14) Colorectal 47 (30.1) 15 (32.6) 5 (10.9) 13 (28.3) 26 (56.5) 16 (34.8) 0.62 (0.33) 58.70 (20.55) P value 0.114 0.214 0.305 0.491 0.155 0.127 0.834 Duration of cancer progression (days) <Half years 66 (42.3) 20 (30.3) 11 (16.7) 20 (30.3) 39 (59.1) 27 (40.9) 0.59 (0.35) 56.23 (21.86) Half to less than one year 35 (22.4) 14 (40.0) 3 (8.6) 11 (31.4) 23 (65.7) 14 (40.0) 0.59 (0.31) 60.97 (18.80) Longer than one year 40 (25.6) 12 (30.0) 6 (15.0) 12 (30.0) 24 (60.0) 12 (30.0) 0.62 (0.29) 55.15 (25.27) Missing 15 (9.6) P value 0.384 0.335 0.781 0.807 0.353 0.840 0.404 Oncology therapies No 63 (40.4) 21 (33.3) 9 (14.3) 17 (27.0) 44 (69.8) 22 (34.9) 0.60 (0.32) 58.83 (20.86) Yes 91 (58.3) 27 (29.7) 11 (12.1) 28 (30.8) 48 (52.7) 34 (37.4) 0.62 (0.32) 57.74 (23.14) Missing 2 (1.3) P value 0.394 0.303 0.893 0.106 0.839 0.566 0.981 NS: Not signiﬁcant. p< 0.05 duration of cancer progression (days): it is the duration between the time when ﬁlling out the questionnaires and the time of diagnosis of cancer progression. One-way ANOVA was applied if the homogeneity of variance assumption was satisﬁed, and the non-parametric Kruskal–Wallis H test was utilised if the homogeneity of variance assumption was not satisﬁed. Journal of Oncology 7 Table 2: Distribution of EQ-5D-5L dimension responses at three time points (T0, T1, and T2) and chi-square test results reporting the percentage of patients with moderate and severe problems across three time points. 2 2 2 T0 N (%)/M T1 N (%)/M T2 N (%)/M Chi-square (T0, T1, T2) (χ , P)/ Chi-square (T1, T2) (χ , P)/ Chi-square (T0, T2) (χ , P)/ Dimensions (SD) (SD) (SD) One-way ANOVA One-way ANOVA One-way ANOVA Mobility No problems and slight 74 (71.8) 69 (67.0) 77 (74.8) problems (level≤ 2) ∗∗ 2 2 2 ∗∗ ∗∗ χ � 84.541 p< 0.001 χ � 60.438 p< 0.001 χ � 55.060 p< 0.001 Moderate, severe problems, and 29 (28.2) 34 (33.0) 26 (25.2) unable to do (level≥ 3) Self-care No problems and slight 92 (89.3) 88 (85.4) 85 (82.5) problems (level≤ 2) 2 2 2 ∗∗ ∗∗ ∗∗ χ � 50.202 p< 0.001 χ � 33.052 p< 0.001 χ � 29.277 p< 0.001 Moderate, severe problems, and 11 (10.7) 15 (14.6) 18 (17.5) unable to do (level≥ 3) Usual activities No problems and slight 82 (79.6) 77 (74.8) 76 (73.8) problems (level≤ 2) 2 2 2 ∗∗ ∗∗ ∗∗ χ � 78.562 p< 0.001 χ � 53.007 p< 0.001 χ � 48.228 p< 0.001 Moderate, severe problems, and 21 (20.4) 26 (25.2) 27 (26.2) unable to do (level≥ 3) Pain/Discomfort No problems and slight 46 (44.7) 55 (53.4) 63 (61.2) problems (level≤ 2) 2 2 2 ∗∗ ∗∗ ∗∗ χ �136.303 p< 0.001 χ � 88.542 p< 0.001 χ � 99.651 p< 0.001 Moderate, severe problems, and 57 (55.3) 48 (46.6) 40 (38.8) unable to do (level≥ 3) Anxiety/Depression No problems and slight 68 (66.0) 72 (69.9) 74 (71.8) problems (level≤ 2) 2 ∗∗ 2 ∗∗ 2 ∗∗ χ � 91.625 p< 0.001 χ � 60.027 p< 0.001 χ � 64.254 p< 0.001 Moderate, severe problems, and 35 (34.0) 31 (30.1) 29 (28.2) unable to do (level≥ 3) 0.623 EQ-5D-5L index value 0.614 (0.318) 0.660 (0.323) F � 0.093 p � 0.911 F � 0.155 p � 0.694 F � 0.114 p � 0.736 (0.330) 58.35 61.79 62.28 VAS F � 1.145 p � 0.320 F � 0.027 p � 0.870 F � 1.813 p � 0.180 (22.205) (21.207) (22.832) ∗∗ p< 0.01. Chi-square tests were used for categorical variables, while ANOVA tests were used for continuous variables. 8 Journal of Oncology Table 3: Results from the GEE model. Parameter estimates 95% Wald 95% Wald conﬁdence Hypothesis test conﬁdence interval interval for Exp Parameter B Std. Error Exp (B) (B) Lower Upper Wald chi-square df Sig. Lower Upper (Intercept) 1.127 0.0653 1.000 1.255 298.209 1 0.000 3.088 2.717 3.509 ECOG-PS −0.094 0.0138 −0.121 −0.067 46.754 1 0.000 0.910 0.886 0.935 Pain −0.016 0.0047 −0.025 −0.007 11.630 1 0.001 0.984 0.975 0.993 Walking −0.028 0.0078 −0.044 −0.013 13.185 1 0.000 0.972 0.957 0.987 HADS −0.009 0.0015 −0.012 −0.006 34.462 1 0.000 0.991 0.988 0.994 (Scale) 0.033 Dependent variable: EQ-5D-5L index score model: (Intercept), age range, disease duration range, sex, job, race, marital status, education, income, medical coverage, diagnosis, treatment, ECOG-PS, symptoms and interference (pain, fatigue, nausea, insomnia, distress, shortness of breath, memory, appetite, drowsy, dry mouth, sadness, vomiting, numbness, constipation, general activity, mood, work, relationship, walking, enjoyment), anxiety/depression from HADS, Time (baseline, T1-two week follow-up, T2-four week follow-up). an independent risk factor for deteriorating health status. Inﬂammation is one of the key factors that modulate cancer pain, as proinﬂammatory cytokines and chemokines mod- High-quality supportive care for advanced cancer patients should be a key part of the strategies in the dimensions of ulate neuronal activity. Corticosteroids can relieve pain symptom management, performance status improvement, when administered as anti-inﬂammatory drugs . Both and psychosocial care. physical and psychological symptoms associated with in- In this longitudinal research, health status changes were ﬂammation are independent risk factors for ﬂuctuating captured via sensitive EQ-5D-5L screening, with results health status. Furthermore, inﬂammation negatively impacts indicating that symptom monitoring is of great signiﬁcance cancer prognosis, which is associated with diminished QoL to rational symptom management. Changes in the health . )e results of this research have also inspired us to status were captured at three time points, with signiﬁcant further investigate the ﬂuctuation of inﬂammatory media- tors in relation to changing in health status among patients changes occurring between T0 and T2 and between T1 and T2, but not between T0 and T1. )is indicates that in ad- with advanced cancer. vanced cancer patients, signiﬁcant health changes may occur approximately one month. In this study, all participants 4.2. Limitations. )e limitations of this study are as fol- utilised the ePRO auto-symptom management system. lows: the sample size is small and the study was conducted Symptom alerts, triggered by a score of≥7 (severe symptom at a single centre. A multicenter study with a more rep- burden) on each symptom scale in the MDASI, would resentative sample is recommended for future research. appear in patients’ ePRO terminals, prompting these pa- )is longitudinal study was designed primarily to in- tients to counsel with research coordinators and receive vestigate changes in health status among advanced cancer symptom management knowledge, if they so choose. In our patients; hence, a comparison group was not concluded. study, pain, anxiety and depression can improve with timely However, we compared our results against those of the adjustments of symptoms management informed by the normal Chinese population and cancer survivors. )e ePRO system. )is is supported by the ﬁndings of Basch ﬁndings of this study indicate that advanced cancer pa- et al., who concluded that advanced cancer patients receiving tients could beneﬁt from routine health status monitoring. symptom monitoring are admitted to the emergency room )erefore, we recommend that a random clinical trial less often, remain on chemotherapy longer and have a longer designed speciﬁcally to investigate the beneﬁts of the quality-adjusted survival rate than those who do not receive ePRO system to the health status of advanced cancer symptom monitoring . Furthermore, overall improve- patients be conducted. ment in the survival rate has been conﬁrmed via a clinical trial: 31.2 months among the PRO group vs. 26.0 months 4.3. Clinical Implications. For advanced cancer patients, among the usual care group . It is necessary to explore curative care is not the dominant medical strategy. However, whether the beneﬁts would be derived from ePRO system this population would beneﬁt more from supportive care implementation in terms of the health status and survival in that focuses on how to improve the patient’s health status. It Chinese advanced cancer patients. is necessary to monitor the health status of advanced cancer Many studies have proved that common symptoms with patients using a validated ePRO platform and to develop a high prevalence among cancer patients are modulated by individualised supportive care protocols. Pain management, inﬂammation, patients with high C-reactive protein (CRP) improving mobility, and psychosocial care for anxiety and levels are at greater odds of experiencing fatigue , and depression should be incorporated into supportive care signiﬁcantly high levels of vegetative depression are strongly protocols. linked to elevated levels of interleukin-6 (IL-6) . Journal of Oncology 9  D. H. Henry, H. N. Viswanathan, E. P. Elkin, S. Traina, 5. Conclusion S. Wade, and D. Cella, “Symptoms and treatment burden Monitoring the health status of advanced cancer patients associated with cancer treatment: results from a cross- and developing individualised supportive care protocols are sectional national survey in the U.S,” Supportive Care in Cancer, vol. 16, no. 7, pp. 791–801, 2008. imperative for positive outcomes. )e EQ-5D-5L is a useful  C. S. Cleeland, F. Zhao, V. T. Chang et al., “)e symptom tool for recording patients’ health status via dimension burden of cancer: Evidence for a core set of cancer-related and responses, index scores and the VAS, as well as for capturing treatment-related symptoms from the Eastern Cooperative changes in the health status over time under reasonable Oncology Group Symptom Outcomes and Practice Patterns symptom management or supportive care. )e risk factors study,” Cancer, vol. 119, no. 24, pp. 4333–4340, 2013. for deteriorating health status can serve as useful references  D. Schottenfeld and J. Beebe-Dimmer, “Chronic in- for health status management in advanced cancer patients, ﬂammation: a common and important factor in the patho- especially for symptom management. genesis of neoplasia,” CA: A Cancer Journal for Clinicians, vol. 56, no. 2, pp. 69–83, 2006. Data Availability  B. J. Laird, M. Fallon, M. J. Hjermstad et al., “Quality of life in patients with advanced cancer: Diﬀerential association with All data supporting the ﬁndings of this study and all sup- performance status and systemic inﬂammatory response,” plementary materials are available from the corresponding Journal of Clinical Oncology, vol. 34, no. 23, pp. 2769–2775, author upon reasonable request.  M. Fillon, “Changes in inﬂammation and insulin pathways mediate the association between resistance training and breast Consent cancer survival,” CA: A Cancer Journal for Clinicians, vol. 68, no. 3, pp. 175–177, 2018. Written informed consent was obtained from all  B. Oh, P. N. Butow, B. A. Mullan et al., “Eﬀect of medical participants. Qigong on cognitive function, quality of life, and a biomarker of inﬂammation in cancer patients: a randomized controlled Conflicts of Interest trial,” Supportive Care in Cancer, vol. 20, no. 6, pp. 1235–1242, )e authors of this study declare that they have no conﬂicts  NCCN, 3e NCCN Palliative Care Clinical Practice Guidelines of interest. in Oncology (Version 1.2022), NCCN, Fort Washington, 2022.  BMC, “Guidance for industry: patient-reported outcome Authors’ Contributions measures: use in medical product development to support labeling claims: draft guidance,” Health Qual Life Outcomes, Yening Zhang and Zimeng Li contributed equally to this vol. 4, no. 1, p. 79, 2006. article. All authors provided consent to publish this paper.  M. Al Qadire, O. Shamieh, S. Abdullah, and F. Albadainah, “Symptom Clusters’ content, Stability and Correlation with the quality of life in a Heterogeneous group of cancer patients: Acknowledgments a Large-scale longitudinal study,” Clinical Nursing Research, vol. 29, no. 8, pp. 561–570, 2020. )e study was funded by the Beijing Municipal Health and  G. Kypriotakis, D. J. Vidrine, L. E. Francis, and J. H. Rose, Scientiﬁc and Technological Achievements and Appropriate “)e longitudinal relationship between quality of life and Technology Promotion Projects in China (2018-TG-48, Lili survival in advanced stage cancer,” Psycho-Oncology, vol. 25, Tang, PI). no. 2, pp. 225–231, 2016.  E. M. Van Dijk-Lokkart, L. M. H. Steur, K. I. Braam et al., References “Longitudinal development of cancer-related fatigue and physical activity in childhood cancer patients,” Pediatric Blood  C. M. Reilly, D. W. Bruner, S. A. Mitchell et al., “A literature and Cancer, vol. 66, no. 12, Article ID e27949, 2019. synthesis of symptom prevalence and severity in persons  K. Blom and A. Efverman, “Sleep during pelvic-abdominal receiving active cancer treatment,” Supportive Care in Cancer, radiotherapy for cancer: a longitudinal study with special vol. 21, no. 6, pp. 1525–1550, 2013. attention to sleep in relation to nausea and quality of life,”  R. Dantzer, M. W. Meagher, and C. S. Cleeland, “Translational Cancer Nursing, vol. 44, no. 4, pp. 333–344, 2021. approaches to treatment-induced symptoms in cancer pa-  D. Kumar, A. Bashir, D. Dewan, and R. Sharma, “Quality of tients,” Nature Reviews Clinical Oncology, vol. 9, no. 7, life of head and neck cancer patients before and after cancer- pp. 414–426, 2012. directed treatment - a longitudinal study,” Journal of Cancer  H. Zeng, W. Chen, R. Zheng et al., “Changing cancer survival Research and 3erapeutics, vol. 16, no. 3, pp. 500–507, 2020. in China during 2003-15: a pooled analysis of 17 population-  C. Pompili, Z. Rogers, K. Absolom et al., “Quality of life after based cancer registries,” Lancet Global Health, vol. 6, no. 5, VATS lung resection and SABR for early-stagenon-small cell pp. e555–567, 2018. lung cancer: a longitudinal study,” Lung Cancer, vol. 162,  C. Allemani, T. Matsuda, V. Di Carlo et al., “Global sur- pp. 71–78, 2021. veillance of trends in cancer survival 2000-14 (CONCORD-3):  P. Cotogni, L. De Carli, R. Passera et al., “Longitudinal study analysis of individual records for 37 513 025 patients di- agnosed with one of 18 cancers from 322 population-based of quality of life in advanced cancer patients on home par- enteral nutrition,” Cancer Medicine, vol. 6, no. 7, pp. 1799– registries in 71 countries,” Lancet, vol. 391, no. 10125, pp. 1023–1075, 2018. 1806, 2017. 10 Journal of Oncology  J. R. L. Lieﬀers, Comorbidity, Body Composition and the  J. A. Sloan, X. Zhao, and P. J. Novotny, “Relationship between Progression of Advanced Colorectal Cancer [dissertation], deﬁcits in overall QoL and non-small-cell lung cancer sur- vival,” Journal of Clinical Oncology, vol. 30, no. 13, ProQuest Dissertations Publishing, MI, USA, 2010.  L. Rojas-Concha, M. B. Hansen, M. A. Petersen, and pp. 1498–1504, 2012.  S. Tribius, M. S. Meyer, C. Pﬂug et al., “Socioeconomic status M. Groenvold, “Symptoms of advanced cancer in palliative and quality of life in patients with locally advanced head and medicine: a longitudinal study,” BMJ Supportive & Palliative neck cancer,” Strahlentherapie und Onkologie, vol. 194, no. 8, Care, Article ID 002999, 2021. pp. 737–749, 2018.  E. Basch, A. M. Deal, M. G. Kris et al., “Symptom monitoring  E. J. Morrison, P. J. Novotny, J. A. Sloan et al., “Emotional with patient-reported outcomes during routine cancer problems, quality of life, and symptom burden in patients treatment: a randomized controlled trial,” Journal of Clinical with lung cancer,” Clinical Lung Cancer, vol. 18, no. 5, Oncology, vol. 34, no. 6, pp. 557–565, 2016. pp. 497–503, 2017 Sep.  E. Basch, A. M. Deal, A. C. Dueck et al., “Overall survival  C. M. Alfano, I. Imayama, M. L. Neuhouser et al., “Fatigue, results of a trial assessing patient-reported outcomes for inﬂammation, and ω-3 and ω-6 fatty acid intake among breast symptom monitoring during routine cancer treatment,” cancer survivors,” Journal of Clinical Oncology, vol. 30, no. 12, JAMA, vol. 318, no. 2, pp. 197-198, 2017. pp. 1280–1287, 2012.  M. Herdman, C. Gudex, A. Lloyd et al., “Development and  S. K. Lutgendorf, A. Z. Weinrib, F. Penedo et al., “Interleukin- preliminary testing of the new ﬁve-level version of EQ-5D 6, cortisol, and depressive symptoms in ovarian cancer pa- (EQ-5D-5L),” Quality of Life Research, vol. 20, no. 10, tients,” Journal of Clinical Oncology, vol. 26, no. 29, pp. 1727–1736, 2011. pp. 4820–4827, 2008.  N. Luo, G. Liu, M. Li, H. Guan, X. Jin, and K Rand-Hen-  O. Paulsen, P. Klepstad, J. H. Rosland et al., “Eﬃcacy of driksen, “Estimating an EQ-5D-5L value set for China,” Value methylprednisolone on pain, fatigue, and appetite loss in in Health, vol. 20, no. 4, pp. 662–669, 2017. patients with advanced cancer using opioids: a randomized,  P. Dolan, “Modeling valuations for EuroQol health states,” placebo-controlled, double-blind trial,” Journal of Clinical Medical Care, vol. 35, no. 11, pp. 1095–1108, 1997. Oncology, vol. 32, no. 29, pp. 3221–3228, 2014.  G. H. ZhouTand L. G. MaA, “ComparisonbetweentheEQ-5D-  M. Liu, A. Kalbasi, and G. L. Beatty, “Functio Laesa: cancer 5land the EQ-5D-3l for general population in China,” Chinese inﬂammation and )erapeutic resistance,” Journal of On- Health Econ, vol. 35, no. 3, pp. 17–20, 2016. cology Practice, vol. 13, no. 3, pp. 173–180, 2017.  T. Shiroiwa, S. Ikeda, T. Fukuda et al., “Comparison of value set based on DCE and/or TTO data: Scoring for EQ-5D-5L health states in Japan,” Value in Health, vol. 19, no. 5, pp. 648–654, 2016.  N. J. Devlin, K. K. Shah, Y. Feng, B. Mulhern, and B. Van Hout, “Valuing health-related quality of life: an EQ- 5D-5L value set for England,” Health Economics, vol. 27, no. 1, pp. 7–22, 2018.  L. Liu, S. Li, M. Wang, and G. Chen, “Comparison of EQ- 5D-5L health state utilities using four country-speciﬁc tariﬀs on a breast cancer patient sample in mainland China,” Patient Preference and Adherence, vol. 11, pp. 1049–1056, 2017.  X. S. Wang, Y. Wang, H. Guo, T. R. Mendoza, X. S. Hao, and C. S. Cleeland, “Chinese version of the M. D. Anderson Symptom Inventory: validation and application of symptom measurement in cancer patients,” Cancer, vol. 101, no. 8, pp. 1890–1901, 2004.  A. S. Zigmond and R. P. Snaith, “)e Hospital anxiety and depression scale,” Acta Psychiatrica Scandinavica, vol. 67, no. 6, pp. 361–370, 1983.  M. E. Charlson, P. Pompei, K. L. Ales, and C. MacKenzie, “A new method of classifying prognostic comorbidity in longi- tudinal studies: development and validation,” Journal of Chronic Diseases, vol. 40, no. 5, pp. 373–383, 1987.  M. M. Oken, R. H. Creech, D. C. Tormey et al., “Toxicity and response criteria of the Eastern Cooperative oncology group,” American Journal of Clinical Oncology, vol. 5, no. 6, pp. 649–656, 1982.  Eq, “EQ-5D-5L user guide,” 2019, https://euroqol.org/ publications/user-guides.  Z. Yang, J. Busschbach, G. Liu, and N. Luo, “EQ-5D-5L norms for the urban Chinese population in China,” Health and Quality of Life Outcomes, vol. 16, no. 1, pp. 210–219, 2018.  D. Zhao, M. Su, N. Yao et al., “Health-related quality of life among cancer survivors in rural China,” Quality of Life Re- search, vol. 28, no. 3, pp. 695–702, 2019.
Journal of Oncology
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Published: Sep 16, 2022