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

Discussion, Implications, and Conclusions

The findings of this study are important. Health-Related Quality of Life LASA increased by both a statistically significant and clinically significant amount when the TRSC was used in the clinic setting. Additionally, although the study findings show that the number of symptoms identified and managed increased when the TRSC was implemented, symptom scores decreased significantly over time in the TRSC cohort. Although this study did not directly investigate the degree to which HRQOL improved because of better identification and management of patient symptoms, it is likely that this accounts for a considerable proportion of the better outcomes in the TRSC group.

The HRQOL and symptom findings are consistent with earlier studies by 2 of the authors that have shown that symptoms of concern to patients are greatly underdocumented in medical records and in the standard clinic interview. The development of the TRSC, which began in 1984,[1,3–9,27] preceded recent efforts by clinicians and researchers that urge use of checklists and other tools to obtain consistent clinically relevant information about patient perceptions, concerns, and preferences. Moreover, patients who participated in symptom monitoring using the TRSC are satisfied and interact with providers more regarding symptom management.[33,51] As noted, the TRSC includes physical and psychological symptoms. The TRSC correlates with HRQOL measures including the Functional Assessment of Cancer Therapy–General.[33] Use of the TRSC as in this study can be extended to address a number of recent interests including more systematic study of patient-reported outcomes.[53]

This study has some limitations. An RCT might follow this study, but an RCT would require a large number of participating clinics and patients and could be rather costly. A significant limitation is the lack of minority representation due to population demographics at the study site. This study, however, at the least suggests that a working-class, lower-middle-income population can benefit from TRSC use. This is a large population that has been hard pressed by economic change in the United States and in the community used in this study. The TRSC might produce similar results in different populations, but this might require adjustments in how it is used and clinical services are delivered. Two of the authors of this study and others have research completed and underway that has included African Americans, Hispanics in the United States, and patients in Puerto Rico,[48,50,52] as well as completed studies in Asia.[7,8,27]


Unlike many tools purported to be usable in clinics, the TRSC was developed to address a specific clinical need: the underdocumentation of a wide array of symptoms of concern to patients receiving treatment for cancer. Later studies have found that subscales of clinical interest are measured on this instrument and that the instrument has desirable psychometric properties that were not anticipated when this checklist was developed.[1,4–9,27,33] The TRSC is easy to answer and can be completed quickly in clinic settings. The TRSC was developed from the bottom-up to meet patient and clinician needs,[9] and the results of this study and others indicate that this tool works well in clinic settings, patient-centered care, and evidence-based practice.[48,50–52,54,55]

Recent research has suggested that the use of checklists can have a powerful influence on both the quality and safety of healthcare services and patient outcomes. The findings of this study are very consistent with such a "checklist manifesto"[56] and even suggest that, during cancer treatment, improved patient outcomes arise from better symptom management and symptom reduction as a consequence of checklist use by clinicians. A newly calibrated TRSC checklist for children (TRSC-C) is published in 2012 in Cancer Nursing.[57] The TRSC-C uses child-friendly terms for each symptom.

In conclusion, use of the patient-friendly TRSC by patients and clinicians in a cancer clinic improves symptom documentation and management and patient HRQOL. Systematic use of checklists can have significant positive influences on the quality and safety of patient treatments and outcomes, especially if these tools can be easily completed in clinics without burdening patients and clinicians.[1,33,51,52,58]