title: Modified Edmonton Symptom Assessment System including constipation and sleep: validation in outpatients with cancer.
abstract: BACKGROUND
  The Edmonton Symptom Assessment System (ESAS) measures the severity of nine symptoms. Constipation and sleep disturbance are common in patients with cancer, but are not currently included in the ESAS.
  
  
  OBJECTIVE
  To validate the numerical rating scale (NRS) versions of ESAS and its revised version (ESAS-r), with the additional symptoms of constipation and sleep (CS), and to assess patient preference for either version.
  
  
  METHODS
  Outpatients with advanced cancer (N = 202) completed three assessments during a single clinic visit: ESAS-CS, and an added time window of "past 24 hours"; ESAS-r-CS, with a time window of "now" and symptom definitions; and the Memorial Symptom Assessment Scale (MSAS). Internal consistency was calculated using Cronbach's alpha. Paired t-tests compared ESAS-CS and ESAS-r-CS scores; these were correlated with MSAS using Spearman correlation coefficients. Test-retest reliability at 24 hours was assessed in 26 patients.
  
  
  RESULTS
  ESAS-CS and ESAS-r-CS total scores correlated well with total MSAS (Spearman's rho 0.62 and 0.64, respectively). Correlation of individual symptoms with MSAS symptoms ranged from 0.54-0.80 for ESAS-CS and 0.52-0.74 for ESAS-r-CS. Although participants preferred the ESAS-r-CS format (42.8% vs. 18.6%) because of greater clarity and understandability, the "past 24 hours" time window (52.8%) was favored over "now" (21.3%). Shortness of breath and nausea correlated better for the "past 24 hours" time window (0.8 and 0.72 vs. 0.74 and 0.64 in ESAS-r-CS, respectively). The 24-hour test-retest of the ESAS-CS demonstrated acceptable reliability (intraclass correlation coefficient = 0.69).
  
  
  CONCLUSIONS
  The ESAS-CS and ESAS-r-CS NRS versions are valid and reliable for measuring symptoms in this population of outpatients with advanced cancer. Although the ESAS-r-CS was preferred, patients favored the 24-hour time window of the ESAS-CS, which also may best characterize fluctuating symptoms.
authors.affiliation: Division of Medical Oncology & Haematology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Psychosocial Oncology & Palliative Care, Ontario Cancer Institute, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.
authors.forename: Breffni
authors.initials: B
authors.lastname: Hannon
authors.affiliation: Department of Psychosocial Oncology & Palliative Care, Ontario Cancer Institute, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.
authors.forename: Martin
authors.initials: M
authors.lastname: Dyck
authors.affiliation: Department of Psychosocial Oncology & Palliative Care, Ontario Cancer Institute, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.
authors.forename: Ashley
authors.initials: A
authors.lastname: Pope
authors.affiliation: Department of Psychosocial Oncology & Palliative Care, Ontario Cancer Institute, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.
authors.forename: Nadia
authors.initials: N
authors.lastname: Swami
authors.affiliation: Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Psychosocial Oncology & Palliative Care, Ontario Cancer Institute, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.
authors.forename: Subrata
authors.initials: S
authors.lastname: Banerjee
authors.affiliation: Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Psychosocial Oncology & Palliative Care, Ontario Cancer Institute, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.
authors.forename: Ernie
authors.initials: E
authors.lastname: Mak
authors.affiliation: Division of Medical Oncology & Haematology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Psychosocial Oncology & Palliative Care, Ontario Cancer Institute, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.
authors.forename: John
authors.initials: J
authors.lastname: Bryson
authors.affiliation: Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada; Department of Psychosocial Oncology & Palliative Care, Ontario Cancer Institute, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; Campbell Family Cancer Research Institute, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.
authors.forename: Gary
authors.initials: G
authors.lastname: Rodin
authors.affiliation: Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Psychosocial Oncology & Palliative Care, Ontario Cancer Institute, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.
authors.forename: Julia
authors.initials: J
authors.lastname: Ridley
authors.affiliation: Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada; Department of Psychosocial Oncology & Palliative Care, Ontario Cancer Institute, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.
authors.forename: Chris
authors.initials: C
authors.lastname: Lo
authors.affiliation: Department of Biostatistics, Ontario Cancer Institute, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.
authors.forename: Lisa W
authors.initials: LW
authors.lastname: Le
authors.affiliation: Division of Medical Oncology & Haematology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Psychosocial Oncology & Palliative Care, Ontario Cancer Institute, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; Campbell Family Cancer Research Institute, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada. Electronic address: camilla.zimmermann@uhn.ca.
authors.forename: Camilla
authors.initials: C
authors.lastname: Zimmermann
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000553:Ambulatory Care / Q000379:methods*; D003248:Constipation / Q000175:diagnosis* / Q000209:etiology; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009369:Neoplasms / Q000150:complications / Q000175:diagnosis*; D010166:Palliative Care / Q000379:methods; D011594:Psychometrics / Q000379:methods; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index; D012893:Sleep Wake Disorders / Q000175:diagnosis* / Q000209:etiology; D063189:Symptom Assessment / Q000379:methods*
keywords: Edmonton Symptom Assessment System; cancer; constipation; numerical rating scale; palliative care; sleep; validation