title: The added value of assessing the 'most troublesome' symptom among patients with cancer in the palliative phase.
abstract: OBJECTIVE
  In this study among patients with cancer in the palliative phase, we analysed whether assessing the symptom, which is causing the most trouble in the patient's every day life ('most troublesome' symptom) had added value apart from the presence and severity of symptoms, which are most commonly assessed in clinical practice.
  
  
  METHODS
  Patients with cancer (lung, gastro-intestinal, breast cancer) in the palliative phase from two non-academic hospitals were included in the study. Using the Symptom Monitor tool, 10 physical symptoms were assessed with regard to presence and severity. The Symptom Monitor has an extra added item indicating as the 'most troublesome' symptom. This item was monitored to determine whether it had added value apart from the presence of symptoms and 'most severe' symptom. The severity score on the indicated 'most troublesome' symptom was subtracted from the severity score of the 'most severe' symptom. The generated delta score of 0 indicated no added value, whereas a score of one or more indicated that the 'most troublesome' symptom would have been missed if not specifically asked for by the physician, because its severity was lower that the 'most severe' symptom.
  
  
  RESULTS
  One hundred and forty-six patients reported 590 symptoms to be present. In total, 227 symptoms were reported as 'most severe' symptom (n = 138 patients). Among these, fatigue (n = 52) and pain (n = 24) were reported most frequently as 'most severe' symptom. In total, 134 patients indicated a symptom as 'most troublesome'. Fatigue (n = 33; 25%) and pain (n = 22; 16%) were also indicated by most of these patients as the 'most troublesome' symptom. One hundred and fifty-two comparisons could be made between the 'most severe' and the 'most troublesome' symptom. In 102 (67%) of the comparisons assessing the 'most troublesome' symptom had no added value: the score for 'most severe' symptom did not differ from the score for the 'most troublesome' symptom revealing a delta score of 0. In 23 times (15%) of the 152 comparisons made, the delta score was 1 and in 27 (18%) of the comparisons the delta score was 2 or more indicating that assessing the 'most troublesome' symptom substantially had added value.
  
  
  CONCLUSIONS
  In patients in the palliative phase of their disease, extra attention for the 'most troublesome' symptom is needed. In our study, in almost 1/3 of the cases, this symptom would have been missed the physicians attention if not specifically asked for.
  
  
  CONCLUSIONS
  We recommend not only to assess the presence and severity of symptoms, but furthermore to assess the patient's 'most troublesome' symptom in addition.
authors.affiliation: Department of General Practice, Division of Clinical Methods & Public Health, Academic Medical Center-University of Amsterdam, Meibergdreef 15, 1105 AZ, Amsterdam, The Netherlands. marjokehoekstra@hotmail.com
authors.forename: Johanna
authors.initials: J
authors.lastname: Hoekstra
authors.forename: Myrra J F J
authors.initials: MJ
authors.lastname: Vernooij-Dassen
authors.forename: Rien
authors.initials: R
authors.lastname: de Vos
authors.forename: Patrick J E
authors.initials: PJ
authors.lastname: Bindels
mesh_terms: D000203:Activities of Daily Living; D000223:Adaptation, Psychological; D000855:Anorexia / Q000209:etiology*; D001294:Attitude to Health; D003248:Constipation / Q000209:etiology; D003371:Cough / Q000209:etiology; D003967:Diarrhea / Q000209:etiology; D004417:Dyspnea / Q000209:etiology; D005221:Fatigue / Q000209:etiology*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D020380:Needs Assessment; D009369:Neoplasms / Q000150:complications / Q000523:psychology / Q000628:therapy; D009426:Netherlands; D010146:Pain / Q000209:etiology*; D010166:Palliative Care / Q000379:methods; D011788:Quality of Life / Q000523:psychology; D012720:Severity of Illness Index; D012893:Sleep Wake Disorders / Q000209:etiology; D011795:Surveys and Questionnaires