Understanding and Managing Symptom Clusters: Insights for Oncology Nurses

Amanda Brink, DNP, APRN, FNP-BC, AOCNP

In oncology care, patients often experience a multitude of symptoms due to both their disease process and its treatment, significantly impacting their quality of life and potentially affecting treatment outcomes. Rather than occurring in isolation, some symptoms frequently present as interrelated groups known as symptom clusters.

Some examples of symptom clusters include:

• Pain, fatigue, and sleep disturbance: Pain can disrupt sleep, leading to fatigue, which in turn can exacerbate pain.
• Nausea, vomiting, and appetite loss: Often associated with chemotherapy, this cluster can lead to severe weight loss and nutritional deficiencies.
• Depression, anxiety, and cognitive dysfunction: Emotional and cognitive symptoms frequently co-occur, affecting patients' mental health and their ability to process information and make decisions.

Recent studies presented at the 49th Oncology Nursing Society (ONS) Congress have shed light on the complexities of symptom clusters and the unique challenges faced by different patient populations. One study, presented by Kristine Kwekkeboom, Ph.D., RN, FAAN, demonstrated the feasibility of a nurse-coordinated approach to managing symptom clusters, emphasizing the need for self-management strategies that address multiple symptoms simultaneously. This approach highlighted the high self-management burden on patients and families, urging the development of interventions targeting co-occurring symptoms to ease this burden.¹

Another study presented by Lisa Morse, MS, RN, AGCNS-BC, focused on older patients with cancer, revealing that inconsistent symptom clusters—such as physical and cognitive fatigue, chemotherapy-related toxicities, and gastrointestinal symptoms—may be influenced by aging processes and treatment variations compared to younger patients. The study underscored the importance of routine symptom assessments and tailored interventions for both age groups, noting that older patients often experience a higher symptom burden due to comorbidities and other age-related factors.^2-3

For oncology nurses, understanding these findings is crucial for improving patient care. By recognizing the interrelated nature of symptoms and employing comprehensive assessment and management strategies, nurses can significantly enhance the quality of life for their patients. This article outlines some practical approaches for managing these complex symptom interactions in oncology care.

Pain, Fatigue, and Sleep Disturbance

Treating the symptom cluster of pain, fatigue, and sleep disturbance often requires a multimodal approach, integrating both pharmacological and non-pharmacological strategies.

Certain medications can effectively target multiple symptoms in this cluster. Gabapentin, for instance, can address both pain and sleep disturbances, while amitriptyline and mirtazapine can help with neuropathic pain, improve sleep, and alleviate depression. Beyond medications, non-pharmacological interventions play a crucial role. Cognitive behavioral therapy (CBT) is particularly useful for insomnia and coping with pain, while physical therapy and exercise can reduce fatigue and improve sleep. Relaxation techniques, including meditation, yoga, and mindfulness, can help manage pain and enhance sleep quality.

A systematic review aimed to evaluate the effectiveness of interventions targeting the symptom cluster of pain, fatigue, and sleep disturbances among cancer survivors. The review included 1269 cancer survivors across studies focusing on various cancers and intervention types.⁴

Key findings include:

1. Exercise- or Movement-Based Programs: These programs showed mixed results. Some studies found significant reductions in fatigue and pain, but not sleep disturbances, while others reported overall improvements in the symptom cluster.
2. Behavioral Therapies: Cognitive behavioral strategies, mindfulness-based stress reduction, and hypnosis combined with CBT were effective in reducing the symptom cluster, particularly in managing pain and sleep disturbances.
3. Pharmacologic Therapies: Medications like caffeine infusion and dexamethasone showed limited effectiveness, primarily reducing pain but not significantly impacting fatigue or sleep disturbances.
4. Stimulation-Based Therapies: Cranial electrical stimulation was ineffective, whereas slow-stroke back massage demonstrated effectiveness in reducing the entire symptom cluster.

Nausea, Vomiting, and Appetite Loss

Pharmacologic therapies are crucial in managing the symptom cluster of nausea, vomiting, and poor appetite. Antiemetics play a significant role, with serotonin (5-HT3) receptor antagonists like ondansetron (Zofran), granisetron (Kytril), and palonosetron (Aloxi) being commonly used to prevent and treat chemotherapy-induced nausea and vomiting (CINV). Dopamine antagonists such as metoclopramide (Reglan) and prochlorperazine (Compazine) also effectively reduce nausea and vomiting by blocking dopamine receptors in the brain. Additionally, neurokinin-1 (NK1) receptor antagonists, like aprepitant (Emend), are often used in combination with other antiemetics to prevent both acute and delayed CINV.

Corticosteroids, particularly dexamethasone, are frequently used with other antiemetics to prevent CINV. Appetite stimulants such as dronabinol (Marinol) help stimulate appetite and promote weight gain, while mirtazapine (Remeron), an antidepressant, increases appetite and helps manage nausea.

Benzodiazepines, such as lorazepam (Ativan), are often used as adjunct treatments for nausea and vomiting, particularly when anxiety is a contributing factor. Combination therapies are common and can provide the most effective relief, such as ondansetron, dexamethasone, and aprepitant used together to prevent CINV, or metoclopramide and dexamethasone for managing delayed CINV. Additionally, dronabinol and metoclopramide can be combined to control nausea and stimulate appetite.⁵

Depression, Anxiety, and Cognitive Dysfunction

To effectively treat the symptom cluster of depression, anxiety, and cognitive dysfunction in oncology patients, a combination of pharmacologic and non-pharmacologic therapies is often employed. Antidepressants such as selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs) are commonly prescribed to alleviate symptoms of depression and anxiety. Anxiolytics, including benzodiazepines and certain anticonvulsants, can be effective in managing severe anxiety, while psychostimulants like methylphenidate may help improve cognitive function and combat cancer-related cognitive impairment. Additionally, atypical antipsychotics are sometimes used for their mood-stabilizing and anxiolytic effects.

Non-pharmacologic approaches are also crucial and include CBT,⁶ which helps patients develop coping strategies and reframe negative thoughts, and mindfulness-based stress reduction,⁷ which promotes relaxation and stress management. Regular physical exercise has been shown to enhance mood,⁸ reduce anxiety, and improve cognitive function. Integrating these therapies can offer a comprehensive approach to managing the intertwined symptoms of depression, anxiety, and cognitive dysfunction.

Nursing Considerations

In oncology care, addressing symptom clusters is essential for improving patients' quality of life and treatment outcomes. Understanding the interplay between symptoms such as pain, fatigue, and sleep disturbance; nausea, vomiting, and appetite loss; and depression, anxiety, and cognitive dysfunction allows for more effective and holistic management strategies. The research presented at the 49th ONS Congress highlights the complexities of these symptom clusters and the unique challenges faced by different patient populations.

Oncology nurses advocate for their patients experiencing symptom clusters in the clinical setting. They can promote the integration of both pharmacologic and non-pharmacologic therapies to address these interconnected symptoms.

References

1. Kwekkeboom K, Eo Y, Hawn R, Miller M, Stevens J. Feasibility of a Nurse-Coordinated Intervention to Reduce Self-Management Burden in Patients with Cancer Experiencing Multiple Co-Occurring Symptoms: A Pilot Randomized Trial. Presented at: 49th Annual Oncology Nursing Society Congress; April 24-28, 2024; Washington D.C.
2. Morse L, Cooper B, Paul S, Miaskowski C. Consistency and Stability of Symptom Clusters in Younger Versus Older Patients Receiving Chemotherapy. Presented at: 49th Annual ONS Congress; April 24-28, 2024; Washington D.C.
3. Morse L, Cooper BS, Ritchie CS, et al. Stability and consistency of symptom clusters in younger versus older patients receiving chemotherapy. BMC Geriatrics. 2024;24:164. doi:10.1186/s12877-024-04755-2.
4. Sheikh-Wu SF, Downs CA, Anglade D. Interventions for Managing a Symptom Cluster of Pain, Fatigue, and Sleep Disturbances During Cancer Survivorship: A Systematic Review. Oncol Nurs Forum. 2020;47(4):E107-E119. doi:10.1188/20.ONF.E107-E119
5. Jordan K, Jahn F, Aapro M. Recent developments in the prevention of chemotherapy-induced nausea and vomiting (CINV): a comprehensive review. Ann Oncol. 2015;26(6):1081-1090. doi:10.1093/annonc/mdv138
6. Liu F, Fu SN, Chen YZ, et al. Effects of Cognitive Behavioral Therapy for Depression and Anxiety, Response Rates and Adverse Events in Patients with Locoregional Advanced Nasopharyngeal Carcinoma. Integr Cancer Ther. 2021;20:15347354211006179. doi:10.1177/15347354211006179
7. Reich RR, Lengacher CA, Alinat CB, et al. Mindfulness-Based Stress Reduction in Post-treatment Breast Cancer Patients: Immediate and Sustained Effects Across Multiple Symptom Clusters. J Pain Symptom Manage. 2017;53(1):85-95. doi:10.1016/j.jpainsymman.2016.08.005
8. Craft LL, Vaniterson EH, Helenowski IB, Rademaker AW, Courneya KS. Exercise effects on depressive symptoms in cancer survivors: a systematic review and meta-analysis. Cancer Epidemiol Biomarkers Prev. 2012;21(1):3-19. doi:10.1158/1055-9965.EPI-11-0634