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J Palliat Med. 2011 Nov;14(11):1246-53. doi: 10.1089/jpm.2011.0112. Epub 2011 Oct 17.

Subgroups of advanced cancer patients clustered by their symptom profiles: quality-of-life outcomes.

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Temmy Latner Centre for Palliative Care, Mount Sinai Hospital, Toronto, Ontario, Canada.



Symptom cluster analysis is a new frontier of research in symptom management. This study clustered patients by their symptom profiles to identify subgroups that may be at higher risk for poor quality of life (QOL) and that may, therefore, benefit most from targeted interventions.


Longitudinal study of metastatic cancer patients using the Edmonton Symptom Assessment Scale (ESAS). We generated two-, three-, and four-cluster subgroups and examined the relationship of cluster membership with patient outcomes. To address the problem of missing longitudinal data, we developed a novel outcome variable (QualTime) that measures both QOL and time in study.


Two hundred and twenty-one patients with a mean Palliative Performance Scale (PPS) of 59.1 were enrolled. The three-cluster model was chosen for further analysis. The low-burden subgroup had all low severity symptom scores. The intermediate subgroup separates from the low-burden group on the "debility" profile of fatigue, drowsiness, appetite, and well-being. The high-burden group separates from the intermediate-burden group on pain, depression, and anxiety. At baseline, PPS (p=0.0003) and cluster membership (p<0.0001) contributed significantly to global QOL. In univariate analysis, cluster membership was related to the longitudinal outcome, QualTime. In a multivariate model, the relationship of PPS to QualTime was still significant (p=0.0002), but subgroup membership was no longer significant (p=0.1009).


PPS is a stronger predictor of the longitudinal variable than cluster subgroups; however, cluster subgroups provide a target for clinical interventions that may improve QOL.

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