106 Seminars in Oncology Nursing, Vol 23, No 2 (May), 2007: pp 106 –112

OBJECTIVES:

CLINICAL
To review the principles of symptom
cluster assessment, choosing appro-
priate symptom measures, and meth-
ods to identify symptom clusters.

DATA SOURCES:
Review articles, research articles, and
specialty texts.
ASSESSMENT OF
CONCLUSION:
Identification of symptom clusters is
SYMPTOM CLUSTERS
clinically challenging and includes the
use of reliable symptom assessment
tools and clinical judgment. Evidence
to guide assessment of symptom clus-
ters is based on limited clinical re- CHERYL LACASSE AND SUSAN L. BECK
search and expert practice. Additional
research is needed to guide the accu-
rate assessment of symptom clusters
and the patient’s symptom experience.

IMPLICATIONS
PRACTICE:
FOR NURSING
Comprehensive assessment of symp-
tom clusters in individuals with can-
cer will lead to tailored, comprehen-
sive symptom management strategies
that may have a profound impact on
cancer-related quality of life.
KEY WORDS:
Symptom cluster assessment, co-
occurring symptoms, multiple
symptom evaluation, symptom
assessment model
E FFECTIVE symptom management in cancer care can
significantly improve health-related quality of life. Clin-
ical management of symptoms is based on the clinician’s
thorough assessment of symptoms and their understanding of the
multiple dimensions of cancer-related, treatment-related, and
non-cancer–related symptoms. These symptoms often occur in
dyads or clusters of three or more, which present challenges for
assessment and subsequent treatment. The occurrence of multiple
symptoms has long been identified and treated by cancer care
clinicians, yet this clinical phenomenon of a symptom cluster is
just beginning to be systematically described and analyzed in the
health care literature. This article explores the various challenges
to symptom cluster assessment and considers approaches using a
variety of measurement tools and methodologies.
CONCEPTS IN SYMPTOM CLUSTER ASSESSMENT

The clinical assessment of symptom clusters presents several

Cheryl Lacasse, RN, MS, OCN®: Doctoral
candidate, College of Nursing, University of
Utah, Salt Lake City, UT. Susan L. Beck, PhD,
APRN, AOCN®, FAAN: Associate Dean for Ac-
ademic Programs and Professor, College of
Nursing, University of Utah, Salt Lake City,
UT, and Clinical Associate Professor, College
of Nursing, University of Arizona, Tucson, AZ.
Cheryl Lacasse is supported in part by the
following grants: National Cancer Institute
Training Grant (R25 CA093831), American
Cancer Society Doctoral Scholarship in Cancer
Nursing (DSCN-03-200-01-SCN), and John A.
Hartford Building Academic Geriatric Nursing
Capacity Predoctoral Scholarship (04-115).
Address correspondence to Cheryl
Lacasse, RN, MS, OCN®, 9040 E Seneca
St, Tucson, AZ 85715; e-mail: clacasse@
nursing.arizona.edu
© 2007 Elsevier Inc. All rights reserved.
0749-2081/07/2302-$30.00/0
doi:10.1016/j.soncn.2007.01.007
challenges, beginning with a clear understanding of what consti-
tutes a symptom cluster. A symptom cluster includes two or more
acute or chronic symptoms that are related and co-occur with
moderate to severe intensity and distress. These symptoms are
often part of a group of systemic symptoms such as fatigue or
depression and/or symptoms specific to a disease process or treat-
ment.
There may be variability in the extent to which symptoms that
co-occur are related. Some symptom clusters have the same eti-
ology, for example cellular destruction. Others may influence one
another, for example pain may disturb sleep which may result in
fatigue.1 There also may be two symptoms that are moderate or
severe in intensity that may be weakly related to other symptoms;
it is unknown whether this constitutes a symptom cluster.2 In
addition, the concept of symptom groupings specific to cancer
diagnosis has raised the question of the significance of symptoms
being present without interrelationships indicating a symptom
cluster.2 For example, women with breast cancer may have pain
related to surgery and hair loss related to chemotherapy. Another

concept that increases the complexity of symptom
clusters is the occurrence of systemic symptoms
and localized symptoms that may be disease-spe-
cific or treatment-specific, creating a cluster that
is specific for a target population. For example,
men with prostate cancer receiving radiation ther-
apy and hormonal therapy may experience fatigue
and hot flashes (systemic) as well as dysuria and
diarrhea (localized). In addition, cancer disease-
specific symptom clusters may overlap with clus-
ters for specific co-morbidities, which may create
a challenge in the assessment of symptoms that
have multiple and potentially overlapping causes.
Thus, the assessment of symptom clusters must
extend beyond just occurrence and must be con-
sidered within the context of disease, treatment,
and co-morbid conditions.
APPROACHES TO GUIDE SYMPTOM
ASSESSMENT
The assessment of cancer-related symptoms is an
integral part of cancer care throughout the disease
trajectory. Multiple measurement approaches
ranging from simple single-question assessments
to complex multi-symptom measures can be used
to determine symptom presence, intensity, dis-
tress, and interference with life activities. Symp-
toms are subjective in nature and it is commonly
understood that patient self-report is the most
accurate approach to symptom assessment. Self-
report also allows for consideration of the multiple
dimensions of an individual’s symptom percep-
tion.3–5 Clinical assessment, the first step in the
nursing process, is critical to the development and
implementation of comprehensive cancer symp-
tom management.
There are many approaches to symptom evalu-
ation that can be applied to the assessment of
symptom clusters. These models range from sim-
ple screening methods, to multi-symptom assess-
ment tools, to sophisticated use of technology to
record self-report of symptoms that in turn pro-
vides clinicians with valuable information in a
timely manner for efficient treatment. These ap-
proaches are summarized in Table 1 and each is
described below.
Screening for Symptom Clusters
One practical issue in assessing symptom clus-
ters is the consistent use of valid and reliable
CLINICAL ASSESSMENT OF SYMPTOM CLUSTERS 107
measures of multiple symptoms. The first ap-
proach to screening may be a checklist or as-
sessment guide in which patients indicate in a
“yes/no” format whether they are experiencing
a specific symptom. This approach allows for
in-depth assessment in areas that may be prob-
lematic. The second step is to assess intensity
and/or distress using a systematic approach.
The most widely used general scale is the 0 to 10
numeric scale for rating symptoms, where 0
indicates no symptom presence and 10 repre-
sents the worst possible symptom experience.6
Clinicians have adapted this scale from the pain
assessment literature and extended its use to
many cancer-related symptoms such as fatigue,
sleep quality, nausea, and general feeling of
well-being. These methods of assessment of in-
dividual symptoms are useful as a quick bedside,
outpatient, or home care assessment approach
with which many health care professionals and
individuals are familiar. The approach also al-
lows for repeated assessments to evaluate
change over time. However, this method of as-
sessment is best used for screening and assess-
ing for symptom co-occurrence and may be too
simplistic to systematically assess symptom
clusters in depth.
Traditional Clinical Assessment of Individual
Co-occurring Symptoms
Another frequently used method of symptom as-
sessment in general medical-surgical nursing is
the assessment of each symptom complaint by
using the pneumonic PQRST.7 This model evalu-
ates each symptom by describing provoking fac-
tors (P), quality (Q), region or site of symptom
(R), severity or intensity of symptom (S), and
timing of onset or cause, peak, and duration of the
symptom (T). This type of assessment is com-
monly used to explore acute symptoms such as
pain, but may be applied to a wide variety of
symptoms. This method provides a more in-depth
assessment of individual symptoms that may be
co-occurring (and verified by a screening ques-
tion) but does not specifically address the interre-
lationship of symptoms that are often found in a
symptom cluster. The assessment of provoking
factors may elicit information about related symp-
toms: for example, pain may provoke an episode
of nausea.
108 C. LACASSE AND S.L. BECK
Approach
Screening and assessment of
intensity
Traditional symptom
assessment
Multi-symptom assessment
tools
Focused assessment of
identified clusters
Disease or treatment specific
multi-symptom assessment
Sentinel symptoms
Multidisciplinary Model
Electronic assessment
TABLE 1.
Approaches to Symptom Assessment
Description: Features, Use, and Limitations
Features: Ask whether patient is experiencing a symptom. Then rate each
symptom on scale with 0 ⫽ no symptom and 10 ⫽ worst possible symptom
Use: screening for multiple symptoms
Limitations: does not allow for indepth assessment of symptoms.
Features: PQRST Model (provoking factors, quality, region of symptom, severity,
timing of onset, peak, and duration for each symptom
Use: gaining deeper perspective on individual symptoms
Limitations: Focus is on individual symptoms
Features: This method utilizes a comprehensive, reliable symptom assessment tool
to measure symptom presence, intensity, and bother of many diverse symptoms
Use: These tools are helpful in assessing the overall symptom experience and
emerging symptom patterns.
Limitations: These tools are not specific to the assessment of symptom clusters
and may be considered as a global symptom measure which requires complex
scoring. These tools are suitable to use in symptom research but are generally
not practical for frequent clinical use.
Features: Symptom assessment based upon broad clinical knowledge of disease
and treatment
Use: Tailored assessment to known or expected symptoms
Limitations: Other symptoms co-occurring with specific symptoms may be missed
Features: Using specific symptom assessment tools based upon assessment of
specific expected cancer-related or treatment-related symptoms.
Use: Measurement of known or suspected symptom clusters.
Limitations: Only specific symptoms will be assessed and treated.
Features: Assessment focuses on the most problematic symptom or a trigger
symptom that may lead to development of other related symptoms.
Use: The presence of sentinel symptoms may lead to specific treatment for a
defined symptom cluster or a prioritized approach to assessment.
Limitations: Patients may not notice specific times when specific symptoms began
or are exacerbated; confounding symptoms such as those characteristic of
specific co-morbidities may make symptoms hard to assess.
Features: This model includes the collaboration of several disciplines (each
contributing their unique perspective) to determine a specific symptom cluster
Use: Complex patient populations may require a team approach to determine
specific manifestations of cancer and its treatments, co-morbidities, and other
complex life circumstances.
Limitations: The team approach to assessment may lead to multiple varying results
and opinions on symptom cluster.
Features: Individuals log in their assessment into a computer database linked to
their medical record which correlates specific symptoms with each other and the
patient’s unique history
Use: Provides database entry directly into the individual’s medical record which
gives clinicians timely information on which to base treatment
Limitations: Patients may not be comfortable interacting with computers or
personal digital assistants (PDAs) and this might prevent accurate, timely
assessment of symptom clusters.
 CLINICAL ASSESSMENT OF SYMPTOM CLUSTERS 109

TABLE 2.
General Symptom Measurement Scales Used in Cancer Care

Scale Name Description

Edmonton Symptom Type: Self report on nine items

Assessment Scale (ESAS)8-10
Scale: VAS (0 – 100 mm); numeric rating scale may be substituted
Dimensions: frequency, severity, and distress
Time frame: current symptom levels
Population used with: palliative care; medical oncology inpatients/outpatients
Estimated time for completion: approximately 8 minutes

M.D. Anderson Symptom Type: Self report on 15 core items

Inventory (MDASI)11
Scale: VAS (0 – 10)
Dimensions: symptom presence, severity, and interference
Time Frame: within past 24 hours
Population used with: medical oncology outpatients
Estimated time for completion: approximately 8 minutes

Memorial Symptom Type: Self report on 32 items

Assessment Scale-SF Scale: 5-point Likert scale; three subscales: high and low prevalence symptoms and
(MSAS-SF)12-14 psychological symptoms; overall Global Distress Index
Dimensions: symptom presence, frequency, and severity
Time Frame: current symptom levels
Population used with: clinical trials, medical oncology inpatients/outpatients
Estimated time for completion: approximately 10 minutes

Rotterdam Symptom Checklist Type: Self report on 31 items

(RSCL)9,15 Scale: 4-point Likert scale with verbal descriptors
Dimensions: presence and bother
Time frame: current symptom levels
Population used with: clinical trials; medical oncology inpatients/outpatients on
chemotherapy
Estimated time for completion: approximately 8 minutes

Symptom Distress Scale Self report on 13 items

(SDS)16-18 Scale: 5-point Likert scale; VAS (0 – 100mm) in revised versions
Dimensions: frequency, intensity and distress
Time Frame: current symptom levels
Population used with: multiple types of cancers
Estimated time for completion: approximately 3 minutes

Abbreviation: VAS, Visual Analogue Scale.

Multi-symptom Assessment Tools of energy), nausea, depression (feeling sad), lack

Several self-report, multi-symptom assessment
tools are reported in the literature as being useful
for assessing cancer-related symptoms and symp-
tom clusters. These tools include the Edmonton
Symptom Assessment Scale,8 –10 M.D. Anderson
Symptom Inventory,11 Memorial Symptom As-
sessment Scale,12–14 Rotterdam Symptom Check-
list,9,15 and the Symptom Distress Scale,16 –18 and
are summarized in Table 2. Although these tools
assess a wide range of symptoms, the symptoms
most common among all tools include: pain, fa-
tigue (or related descriptors such as tired or lack
of appetite, and dyspnea. These tools have strong
validity and reliability in measuring cancer-re-
lated symptoms and are reported to take no longer
than 10 minutes to complete. The most common
tools include visual analogue, numeric, or verbal
descriptor scales. Limitations of these tools may
be that they require a basic level of competent
cognitive functioning and they are not well-suited
for accurate completion by a proxy such as a
health care provider or significant other.19 Al-
though these tools are useful in assessing multiple
symptoms, they may be difficult to use with indi-
110 C. LACASSE AND S.L. BECK
viduals who have difficulty concentrating, limited
or altered cognition, and/or severe symptoms that
affect their ability to participate in a full symptom
assessment via self-report.
Focused Assessment Based on Commonly
Reported Symptoms
There are several cancer-related symptom clus-
ters that have been identified in the literature in
the past several years. The study of specific symp-
tom clusters has been focused on commonly co-
occurring symptoms in several oncology popula-
tions, and there is increasing evidence to support
a cluster of pain-sleep disturbance-fatigue (plus or
minus depression). This knowledge indicates that
a symptom cluster assessment approach focused
on these four symptoms and how they may relate
is needed.20 In women with breast cancer who
were between adjuvant chemotherapy treatments
and bone marrow transplant or peripheral stem
cell transplant, fatigue, pain, and depression were
found to be correlated with each other and overall
well-being.20 The symptoms of pain, fatigue, and
sleep disturbances in cancer patients receiving
outpatient radiation therapy for bone metasta-
ses21 were related; lower fatigue levels in the
morning, and sleep disturbances were affected by
radiation treatment and functional status. In can-
cer outpatients receiving chemotherapy, pain and
fatigue were strong predictors of change in func-
tional status and fatigue emerged as the dominant
symptom in the cluster.22 Using a mediation
model, sleep disturbance was found to partially
account for the effect of pain on fatigue.1
The measurement of a commonly occurring
symptom cluster might use existing symptom-spe-
cific tools (eg, the Brief Pain Inventory and General
Fatigue Scale) or a subset of items from existing
multi-symptom tools. Most symptom measurement
tools are self-report scales and ask patients to de-
scribe several dimensions of their current symp-
toms, such as the frequency, severity, and distress of
each symptom. Symptom assessment scales range
from the Edmonton Symptom Assessment Scale,8 –10
which has nine items, to the Memorial Symptom
Assessment Scale–Short Form, which lists 32
items.12–14 Yet other scales have been developed to
specifically assess symptoms that are disease- and/or
treatment-related, such as the Prostate Symptom
Self-Report.23
Multi-Symptom Assessment Approaches
Specific to Cancer Diagnosis or Treatment
Symptom clusters may be disease-specific, treat-
ment-specific, or both, and may be best assessed
using multiple disease-specific measures (see arti-
cle by Honea and Brant elsewhere in this issue). A
longitudinal, descriptive study of 19 women with
ovarian cancer found a primary symptom cluster
of bloating, vague abdominal pain, indigestion,
fatigue, painful spots and lumps in the abdomen,
and urinary problems and a secondary cluster of
11 symptoms.24 Symptoms were also examined by
stages of disease development, and results suggest
a dominant symptom cluster of gastrointestinal
symptoms (bloating and indigestion), focused ab-
dominal pain, and fatigue in early stage ovarian
cancer patients. Later stage ovarian cancer symp-
toms were more systemic in nature, including
fluid accumulation in abdomen and chest, diffuse
pain, and gastrointestinal symptoms. This study
suggests that in populations with multiple com-
plex symptoms, such as ovarian cancer patients,
there may be two symptom clusters that co-occur:
the primary cluster consisting of the higher fre-
quency symptoms and the secondary cluster con-
sisting of lower frequency symptoms. In addition,
this study suggests that a focused assessment of
symptoms occurring in ovarian cancer patients
may be influenced by the stage of disease, and the
types of symptoms that occur in ovarian cancer
may be different from the usual lists of common
symptoms included in most symptom distress
scales. Disease-specific tools that include these
specific problems (eg, bloating) are recom-
mended.
Another example emerges from an exploratory
study of breast cancer patients in various stages of
disease and treatment. Investigators found a com-
mon cluster of fatigue (lack of energy and physical
weakness), loss of concentration, and mood dis-
turbance (anxiety, nervousness, depression).25
This cluster was assessed using multiple symp-
tom-related measures ranging from a general
symptom checklist to a focused assessment of
menopausal quality of life. This study illustrates
the assessment of common systemic symptoms
throughout stages of disease using a general symp-
tom measure, as well as a tool focused on co-
morbid symptoms related to menopause.
Assessment in men with prostate cancer may
also require more specific tools that include uri-
nary, bowel, and sexual symptoms. These symp-

toms may cluster because of the effects of radia-
tion therapy. There are several tools that are
specific to this population and are frequently used
in clinical trials that include localized symptoms
related to the disease and/or treatment. For exam-
ple, The Prostate Symptom Self-Report23 is an
11-item symptom questionnaire that assesses the
frequency, severity, and amount of bother of uri-
nary, bowel, and sexual symptoms experienced
during the past month.
Other Assessment Models
Other models of symptom cluster assessment in-
clude the determination of a sentinel symptom. A
sentinel symptom can be described in two ways.
In one approach, the patient is asked an open-
ended question such as “What problems or symp-
toms have been troubling you the most this past
week?” A drill-down assessment then focuses on
symptom distress, intensity, timing of onset and
duration, and the quality or character of this
symptom or group of symptoms. In a second ap-
proach, a sentinel symptom may be more of a
trigger, for example pain which then causes sleep
disturbance or depression. In this case, assess-
ment may ascertain specifically whether pain is
leading to any other problems.
Most standardized methods of symptom assess-
ment are sensitive to the perception of the indi-
vidual symptoms within a specified time frame but
not groups of symptoms. Further, most patients
are not aware of the nuances of chronic symptom
development until symptoms increase in their
level of “bother” and begin to interfere with inde-
pendence and overall quality of life. Typical symp-
tom assessments focus on one symptom at a time.
Assessing co-occurring symptoms may assist cli-
nicians to discover symptom clusters that are not
readily recognized by the patient. For example, a
thorough pain assessment often includes ques-
tions about sleep disturbances, fatigue, physical
functioning, and coping. This type of multi-symp-
tom assessment may increase a patient’s aware-
ness of co-occurring acute and chronic symptoms.
In addition, treatment-related symptoms may
need to be assessed over longer time intervals
such as 4 to 6 weeks to identify cyclic symptom
clusters that coincide with cancer treatments.
Another model of assessment involves a multi-
disciplinary team approach that may enhance the
assessment of multiple dimensions of a symptom
cluster beyond symptom presence, intensity, and
CLINICAL ASSESSMENT OF SYMPTOM CLUSTERS 111
distress. For example, a nurse, physician, and
social worker may work together to assess a com-
plex older adult with multiple co-morbidities (eg,
cancer, arthritis, coronary artery disease, and di-
abetes), symptoms of pain, sleep disturbance and
depression, and decreased physical and cognitive
functioning. This method may enhance the clini-
cian’s understanding of the meaning and context
of an individual’s symptoms and their overall in-
fluence on the cancer experience.
Electronic assessment methods use computer
technology to assess the multiple dimensions of
many symptoms, analyze the symptom assessment
data using statistical methods, and generate clini-
cian-friendly reports based on the patient’s current
symptom experience as compared with previous
symptom assessments. This type of symptom as-
sessment has been evaluated in outpatient clinic
settings and found to be a feasible method of assess-
ing pain and fatigue,26 multiple symptoms,27,28 and
quality of life.27,28 From the patient perspective, this
method of symptom assessment may enhance com-
munication between patients and health care pro-
viders and trigger automatic alerts for multidisci-
plinary team involvement in various aspects of care.
The use of this type of system to evaluate symptoms
requires strong technology resources in the clinical
setting and may prove to enhance the efficiency and
accuracy of symptom assessment and symptom
cluster identification. Algorithms could be devel-
oped that indicate when a specific symptom cluster
exists.
CONCLUSION
Clinical assessment of symptom clusters in cancer
care is a rich area for further development and
exploration. Consistent use of multidimensional
symptom assessment tools is a significant first
step in comprehensive symptom assessment of
presence, frequency, intensity, and distress of in-
dividual symptoms. When deciding the best ap-
proach to assessing symptom clusters in the clin-
ical practice the following issues should be
considered: the characteristics of the clinical set-
ting including patient load; the type and pace of
care delivered; nursing role within the cancer care
team; the clinical skill mix, including the use of
nursing and other health care personnel to deliver
care; and the resources available to patients and
health care providers. Integration of symptom as-
sessment into electronic medical records can pro-
112 C. LACASSE AND S.L. BECK
vide systematic ways to assess the multiple di-
mensions of the symptom experience and create
databases for future knowledge generation.
In addition, further development of self-report
measures of symptom clusters is needed. This
should include consistent scaling, multiple dimen-
sions such as presence, intensity, quality, and dis-
tress within a consistent time frame and clinical
context without placing an excessive measurement
burden on the patient.19 In addition, self-report tools
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