Symptom Management

Symptom Management

PEP Topic 

General symptom management involves approaches aimed at reducing and effectively managing multiple cancer-related symptoms. A combination or variety of approaches may be employed. The effect of managing multiple symptoms in patients with cancer was examined in relation to anxiety.

Effectiveness Not Established

Research Evidence Summaries

de Raaf, P.J., de Klerk, C., Timman, R., Busschbach, J.J., Oldenmenger, W.H., & van der Rijt, C.C. (2013). Systematic monitoring and treatment of physical symptoms to alleviate fatigue in patients with advanced cancer: A randomized controlled trial. Journal of Clinical Oncology, 31, 716–723.

doi: 10.1200/JCO.2012.44.4216

Study Purpose:

To investigate whether nurse monitoring and protocol management of physical symptoms alleviates fatigue

Intervention Characteristics/Basic Study Process:

Patients were randomized to receive either usual care or nurse management patient-tailored treatment using treatment management protocols. In the experimental group, nurse specialists recorded interventions for multiple physical symptoms. During outpatient meetings with the nurse, symptom severity was monitored. When any symptoms were rated ≥ 4 on an 11-point scale, the nurse referred the patient to the oncologist for further assessment and initiation of treatment according to palliative care guidelines, such as medication adjustment, other referrals, or other interventions. Nurses managed as many symptoms independently as possible. Highly specific interventions for pain, nausea, vomiting, constipation, diarrhea, anorexia, dyspnea, cough, and dry mouth were used. No specific interventions aimed at fatigue were identified. Patients met with the nurse at 1, 2–4, 5–7, and 8–10 weeks. Study assessments were done via mail at baseline and one, two, and three months.

Sample Characteristics:

  • The study reported on a sample of 137 patients.
  • Mean patient age was 58 years.
  • The sample was 59% female and 41% male.
  • Multiple solid tumor types were represented, with breast, gastrointestinal, and urogenital being the most common.
  • Seventy-eight percent of patients were married or living with a partner, with more intervention group patients in this group.
  • All patients were Caucasian.
  • Average time since cancer diagnosis was 57 months.
  • Patients were not eligible if they had a level of anxiety or depression requiring referral for psychiatric care or cognitive impairment.


  • Single site
  • Outpatient setting
  • The Netherlands

Study Design:

A randomized controlled trial design was used.

Measurement Instruments/Methods:

  • Numeric rating scale (NRS) to assess symptoms on 0–10 scale
  • Multidimensional Fatigue Inventory (MFI)
  • EORTC Quality of Life Questionnaire (QLC-30)
  • Brief Fatigue Inventory (BFI)
  • Hospital Anxiety and Depression Scale (HADS)


Patients reported that the most troublesome symptoms were pain, dyspnea, and anorexia. Patients had a median of two symptoms with NRS scores of at least 4 at baseline. MFI scores for general fatigue declined significantly over time in the intervention group compared to controls, with effect size ranging from 0.26 to 0.35 (p = 0.01). NRS fatigue scores also demonstrated decline compared to usual care controls (p < 0.001). BFI scores were not reported. Overall symptom burden was reported to decrease over time in the intervention group, while there was no change in controls (maximal effect size = 0.64, p = 0.002). Anxiety decreased in the intervention group compared to controls (maximal effect size = 0.32, p < 0.001).


Findings suggest that comprehensive management and monitoring for symptom control by nurse specialists was effective in reducing anxiety and fatigue in patients with cancer.


  • The study had baseline sample/group differences of import.
  • The study had risk of bias due to no blinding and no appropriate attentional control condition.
  • Unintended interventions or applicable interventions were not described that would influence results.
  • The study used selective outcomes reporting.
  • Measurement/methods were not well described.
  • Participant withdrawals were ≥ 10%.
  • At baseline, fewer control patients were married or partnered, and there was no analysis of significance of baseline differences. This support difference could have influenced results.
  • BFI measures were not reported, causing one to question if findings were not consistent for changes in fatigue.
  • Calculation of “total symptom burden” was not described.
  • Patients who withdrew were more anxious and depressed than those who remained in the study.

Nursing Implications:

Findings suggest that continued symptom management and monitoring with a protocol approach can be effective for reducing symptoms overall, and reducing fatigue and anxiety. There were no specific intervention approaches identified that were used for fatigue, so the suggestion is that reducing other symptoms can have a positive impact on fatigue. There were also no specific interventions identified for anxiety, but anxiety also declined over time. These results suggest that ongoing monitoring and attention to patients alone may positively impact these symptoms.