Background: Physical, emotional, mental, and social functioning are important factors as patients move through the cancer continuum from diagnosis through treatment to surveillance. The Edmonton Symptom Assessment System (ESAS) is a validated patient reported outcomes (PROs) measure of physical and emotional symptoms that has been adapted for the VHA as the Veteran Symptom Assessment Scale (VSAS). Previous evaluations of PROs in the veteran oncology population have identified gaps in assessing symptoms in VHA oncology clinics, high symptom burden in these patients, and correlations between certain high symptom scores and worse overall survival in selected groups.
Purpose: We have incorporated the VSAS as part of the nurse intake procedure at the hematology-oncology clinic at the Durham VA Medical Center (DVAMC) and now report on our operational experience assessing symptoms in this veteran population.
Methods: The VSAS data were obtained from VHA medical records, along with demographic information, including race, ethnicity, gender, age, and marital status. Additional data related to diagnosis, treatment, and stage were abstracted from individual charts. The VSAS symptoms were reported on a numeric scale from 0 to 10, with 0 as asymptomatic and 10 as highly symptomatic. We determined ranges, median values, and significant differences in patient subgroups (with the chi-square test) using the statistical environment, R.
Results: The VSAS data (n = 116,819) from 2,732 unique patients seen in the DVAMC hematology-oncology clinic were obtained from a 1.5-year period (October 25, 2013, to April 15, 2015). The median age of patients was 66 years, with a range of 22 to 100 years. Of the patients, 91% were male (2,484) and 9% were female (248), 54% were white (1,476), 41% were African American, 1% were American Indian/Alaska Native (26), 0.7% were Native Hawaiian or other Pacific Islander (19), 0.2% were Asian (5), 0.4% were unknown (11), 2% declined to answer (65), and 0.1% were not recorded (4). Ninety-eight percent were not Hispanic or Latino (2678), 1% were Hispanic or Latino (31), 0.5% were unknown (13), and 0.4% declined to answer (10). Symptoms measured in the VSAS (with number of responses) included anorexia (3,111), anxiety (10,122), appetite (7,012), constipation (10,117), depression (10,108), diarrhea (9,512), distress (10,097), drowsiness (10,116), nausea (10,113), shortness of breath (7,012), shortness of breath with exertion (3,013), shortness of breath at rest (3,107), tiredness (10,124), vomiting (3,106), and well-being (6,942). The symptom with the highest median score was tiredness (median 5), followed by well-being (median 4). Female gender, age below the median of 66 years, and nonwhite race were significantly associated with higher scores for most symptoms measured (nominal P < .05). Ongoing analyses are focusing on associations of elevated symptom scores with specific cancer diagnoses, metastatic stage, and treatment status.
Implications: Our experience demonstrates that the VSAS can be incorporated as part of routine care in a VHA hematology/oncology clinic. The description of our experience with VSAS may serve as a baseline for the evaluation of changes in symptom scores over the cancer continuum, interventions based on symptom scores in the VHA oncology population, and symptom assessment in other VHA practice settings.
