Public Release: 

Symptom burden may increase hospital length of stay, readmission risk in advanced cancer

Greater physical and psychological symptoms associated with higher utilization of health care resources in hospitalized patients with advanced cancer

Massachusetts General Hospital

Hospitalized patients with advanced cancer who report more intense and numerous physical and psychological symptoms appear to be at risk for longer hospital stays and unplanned hospital readmissions. The report from a Massachusetts General Hospital (MGH) research team, published online in the journal Cancer, is one of the first to focus on symptom prevalence and severity among hospitalized patients with cancer and the first to demonstrate a relationship between uncontrolled symptoms and the use of health care services.

"Hospitalized patients with advanced cancer experience an immense burden of physical and psychological symptoms," says Ryan Nipp MD, of the MGH Cancer Center, co-lead and corresponding author of the Cancer paper. "Patients' symptoms represent potentially modifiable risk factors, and prior research has shown that interventions aimed at symptom improvement can enhance patient-reported outcomes. We found novel results regarding the relationship between patients' symptoms and their use of health care services, which highlight the critical need to develop and test interventions addressing the symptoms experienced by hospitalized patients with advanced cancer to improve both the care these patients receive and their utilization of health care services."

The study enrolled 1,036 patients with advanced cancer - defined as those receiving treatment focused on comfort or symptom relief, rather than an attempt to cure their disease - with unplanned admissions to the MGH from September 2104 through May 2016. Upon admission, participants completed several surveys designed to assess the presence of physical symptoms - such as pain, fatigue, drowsiness, nausea, poor appetite and shortness of breath - and symptoms of depression and anxiety.

More than half of the participating patients reported currently experiencing moderate to severe fatigue, pain, drowsiness, lack of appetite or poor overall well-being. More than a quarter reported significant levels of depression or anxiety symptoms. Patients' physical symptoms were significantly associated with longer hospital lengths of stay and increased risk of unplanned readmission within 90 days. Overall psychological distress and depression scores were associated with longer lengths of stay, while patients' anxiety symptoms were associated with higher readmission risk.

"We know that hospitalized patients with advanced cancer often experience a higher symptom burden compared with those treated in the outpatient setting, but until now, most efforts to improve symptom management have focused on ambulatory patients," says Nipp, who is an instructor in Medicine at Harvard Medical School. "There is a critical need to focus on efforts to alleviate suffering among hospitalized patients with advanced cancer. For example, future efforts should determine the efficacy of implementing symptom monitoring and supportive care interventions for such patients in an effort to relieve their symptoms, improve quality of life and enhance the quality of their cancer care."

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Areej El-Jawahri, MD, of the MGH Cancer Center is co-lead author of the Cancer paper, and Jennifer Temel, MD, MGH Cancer Center, is senior author. Additional co-authors are Connor Johnson, MD, Daniel Lage, MD, Risa Wong, MD, Inga Lennes, MD, MPH, MBA, Barbara Cashavelly, RN, David Ryan, MD, and Ephraim Hochberg, MD, MGH Cancer Center; Samantha Moran, Sara D'Arpino, Lara Traeger, PhD, and Joseph Greer, PhD, MGH Department of Psychiatry; William Pirl, MD, MPH, University of Miami, Florida; and Vicki Jackson, MD, MPH, MGH Division of Palliative Care. Support for the study includes National Institutes of Health grant K24 CA181253, MGH Cancer Center Funds, and the Scullen Center for Cancer Data Analysis.

Massachusetts General Hospital, founded in 1811, is the original and largest teaching hospital of Harvard Medical School. The MGH Research Institute conducts the largest hospital-based research program in the nation, with an annual research budget of more than $850 million and major research centers in HIV/AIDS, cardiovascular research, cancer, computational and integrative biology, cutaneous biology, genomic medicine, medical imaging, neurodegenerative disorders, regenerative medicine, reproductive biology, systems biology, photomedicine and transplantation biology. The MGH topped the 2015 Nature Index list of health care organizations publishing in leading scientific journals and earned the prestigious 2015 Foster G. McGaw Prize for Excellence in Community Service. In August 2017 the MGH was once again named to the Honor Roll in the U.S. News & World Report list of "America's Best Hospitals."

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