Changes in symptom intensity among cancer patients receiving outpatient palliative care

Context: Symptom changes are usually reported using summary statistics such as mean and/or median, which may obscure the treatment effect. Objectives: The main objective of this retrospective study was to determine the magnitude of symptom changes as assessed by the Edmonton Symptom Assessment System (ESAS) after outpatient palliative care at the first follow-up visit. Methods: We reviewed 1612 consecutive patients with cancer who were referred to the outpatient Supportive Care Center and who completed the ESAS at the initial and first follow-up visits between January 2003 and December 2010. All patients received interdisciplinary care led by the palliative care specialists following an institutional protocol. Results: The distribution of the magnitude of symptom changes was stratified by baseline intensities. Patterns were similar for different ESAS items. At the follow-up visit (median: 15 days later), 52-74% of patients showed a decrease of one or more points in the ESAS score. However, 48-80% of patients with moderate/severe intensity at baseline complained of symptoms with an ESAS score of four or more after outpatient palliative care. Symptoms with absent/mild intensity worsened, ranging from a mean of -3.04 to 0.12 at the first follow-up visit, whereas symptoms with moderate/severe intensity improved from -0.2 to 3.86 (P < 0.001). Conclusion: A considerable proportion of patients with moderate or severe intensity at baseline still had symptoms with an ESAS score of four or more. Patients with absent/mild intensities at baseline complained of symptom exacerbation at the first follow-up visit. Various strategies are needed to optimize symptom control in advanced cancer.