Therapy-Related Symptom Checklist Use During Treatments at a Cancer Center

Phoebe D. Williams, PhD, RN, FAAN; Kathleen M. Graham, MS, BSN, RN, APNP-BC, AOCN, CNS; Deborah L. Storlie, RN, NC; Therese M. Pedace, BSN, RN; Kurt V. Haeflinger, BS; David D. Williams, MPH; Diane Otte, MS, RN, OCN; Jeff A. Sloan, PhD; Arthur R. Williams, PhD, MA, MPA


Cancer Nurs. 2013;36(3):245-254. 

In This Article

Abstract and Introduction


Background: Cancer treatment efficacy has improved with therapies at high or sustained dosages. However, there is increasing concern about symptom management and patients' quality of life.

Objective: The objective of this study was to assess whether use of a Therapy-Related Symptom Checklist (TRSC) with oncology outpatients increases the number of symptoms documented and managed and whether this improves patients' health-related quality of life (HRQOL).

Methods: This was a sequential cohort trial. Fifty-five oncology outpatients in treatment received standard of care (group 1, G1). Afterward, another 58 patients (group 2, G2) received standard of care at the same clinic; however, these patients additionally answered the TRSC immediately prior to each consultation. The TRSC results were then shared with clinicians. Repeated measures (2–11 visits) were obtained of the number of patient treatment symptoms documented (medical records G1 and TRSC G2), HRQOL, and Karnofsky scores, n = 696 observations (328 G1 and 368 G2). The number of symptoms reported and HRQOL were covariate adjusted using population averaged generalized estimating equations.

Results: G2 patients had a 7.2% higher population averaged covariate-adjusted HRQOL than G1 patients (3.3 more points on HRQOL, P = .012). One hundred sixteen percent more covariate- and non–covariate-adjusted symptoms were documented/managed in G2 than G1 (6.14 symptoms vs 2.84, P < .0001). The HRQOL, TRSC, and Karnofsky scores correlated r > 0.40.

Conclusion: Use of patient-reported TRSC improves symptom documentation/management and patient HRQOL.

Implications for Practice: Study findings were consistent with recent research that has shown that use of checklists can have powerful influences on both quality and safety of healthcare services and patient outcomes.


As the efficacy of cancer treatment has improved, more types of cancers are being treated with chemotherapy and radiotherapy at high or sustained dosages. Consequently, there is increased concern about symptom documentation and management and patients' quality of life.[1–10] Underdocumentation of symptoms during clinic visits had been reported.[9]

Symptom Monitoring, Symptom Management, and Self-care

Considerable information is available about the management of cancer treatment–related symptoms, but often assessment scales measure only a single or small set of symptoms. Symptoms studied have included nausea and vomiting;[11] taste change, loss of appetite, and weight loss;[12] sore mouth/mucositis;[13] fatigue, pain, and depression;[14,15] dyspnea;[16] and paresthesias.[17] A recent review concluded that pain is well studied, but other symptoms need better understanding and assessment.[18] Although several multiple symptom scales have been developed[1,4,5,19,20] and described in reviews,[3] considerably less studies have assessed multiple symptoms while healthcare is actually being delivered.[21,22] Multidisciplinary initiatives are underway to improve collection of patient-reported outcomes within clinical settings.[23–25]

Clinicians must rely on accurate patient-reported symptoms to manage treatment-related toxicities. Complexity of regimens makes it more likely that patients will experience potentially toxic or disturbing adverse effects, requiring prompt and effective self-care. Some cancer patients are successfully using self-care to complement medical and nursing care for symptom control.6–8,10,26–29 Patients who participate in symptom monitoring are more satisfied and interact with providers more regarding symptom management.[28,29] Effective self-care is increasingly regarded as a requisite of symptom management and adherence to treatment. Approaches to symptom management and the delivery of interventions consistent with and supportive of self-care include home care by trained nurses[10] and clinic-based interventions designed to manage specific symptoms, such as fatigue.[26]

Health-related Quality of Life

Health-related quality of life (HRQOL) refers to a multidimensional construct that has physical, mental, social, economic, and spiritual domains.[30–36] Several HRQOL scales specific to cancer have been developed including the HRQOL Linear Analogue Self-assessment (LASA) used in this study.[37,38] The HRQOL-LASA has been found to be robustly related to symptom occurrence, severity, and patient functional status and easy to use in clinics.[37,38] Health-related quality of life has been used as an outcome in chemotherapy, radiation and surgery, breast cancer, neuro-oncology, lung cancer, advanced cancer, and teleoncology.[1,33–38]

Design of Studies

Increasing calls for translational research and study designs that better reflect real-world treatment conditions have led to interest in observational nonexperimental and quasi-experimental research. These include calls by the National Institutes of Health (PA-05-90) and articles by Black[39] and others[40] in the British Medical Journal. Sequential cohort designs have been helpful to study interventions in settings in which the clinical environment itself is changed by the intervention or other circumstances do not permit randomized clinical trial (RCT).[41] Even where systematic multisite trials may be feasible, a single-site observational study can be helpful before proceeding to more costly designs.[40]

Study Hypotheses

Documentation of patient-reported symptoms, management of symptoms, and HRQOL can be improved through use of the Therapy-Related Symptom Checklist (TRSC) in clinic practice. Study hypotheses are as follows:

H1: A treatment cohort using the TRSC at clinic visits will show a statistically significant positive increase in HRQOL-LASA compared with a treatment cohort receiving standard of care.

H2: A treatment cohort using the TRSC during clinic visits will show a statistically significant larger number of symptoms documented and managed compared with a treatment cohort receiving standard of care.

These hypotheses are tested using a sequential cohort design and generalized estimating equations (GEEs).