Predictors of Quality of Life in Dyspneic Patients with Advanced Cancer

Uncontrolled dyspnea is frightening for patients and adversely affects quality of life. It is disabling and interferes with daily activities and limits valuable time spent with family and friends.  Dyspnea and related symptoms in advanced cancer are not adequately treated due to limited research and understanding of the total symptom experience. Dyspnea is a complex, distressing symptom in advanced cancer which occurs with other symptoms and smothers QOL.

                The purpose of this study was to identify symptoms which correlate with dyspnea in advanced cancer patients, and how the dyspnea symptom cluster predicted quality of life.  A descriptive, predictive correlational design was used to identify the symptoms that correlated with dyspnea, and predicted QOL. The study included 407 Hospice patients with dyspnea. The most frequently reported symptoms reported with dyspnea were lack of energy (91%), dry mouth (74%), pain (72%), and lack of appetite (64%). Other commonly reported symptoms with dyspnea included drowsiness, cough, and constipation.  Additional symptoms which occurred with dyspnea in more than half of the patients included drowsiness (62%) and cough (57%).  The dependent variable for the regression analysis was quality of life, measured by the Hospice Quality of Life Index.  A subscale of the Memorial Symptom Assessment Scale was used to measure symptom intensity and distress. In addition, age and functional status were added into the regression analysis from the demographic data.

                 Shortness of breath occurred in all of the patients from this subset of hospice patients.  Lack of energy occurred most frequently with shortness of breath, and was the most distressing of all measured symptoms. Pain was the next most distressing symptom which emerged with shortness of breath.  Symptom intensity was reported for all variables.  Sexual problems had the highest reported intensity but were only reported in 15% of patients.  Several symptoms were rated as 2 or greater, corresponding to somewhat severe intensity. The most frequently reported symptoms with somewhat severe intensities for dyspneic patients were lack of energy, dry mouth, pain, and lack of appetite.

                Prediction of QOL from correlates of dyspnea at the univariate and multivariate level were computed. At the univariate level, distress from fatigue, dry mouth, and pain were significantly related to QOL. The relationship was negative, which indicated that as distress from pain, fatigue, and dry mouth increases, QOL declines. Dyspnea and fatigue severity were also significant negative predictors of QOL.

                For the multivariate analysis, all five predictors were entered into the regression analysis simultaneously. The combined dimensions of symptoms accounted for 31% of the variance in QOL scores. Distress from fatigue and dry mouth were significant predictors of QOL (p<.001). Pain distress and dyspnea and fatigue severity were also significant predictors of QOL (p< .05).

                Distressing symptoms associated with dyspnea were the significant predictors of QOL. Fatigue, dry mouth, and pain cluster with dyspnea and are negatively correlated with QOL. Distress from fatigue is a stronger predictor than intensity from fatigue. Higher symptom intensity and distress are linked with lower QOL. In order to improve QOL, interventions should be focused on managing the symptom, and the meaning of the symptom to the patient, which can result in distress. This is best accomplished through multidisciplinary efforts, which can be provided in the hospice setting.