title: Clinicians' Perspectives on Managing Symptom Clusters in Advanced Cancer: A Semistructured Interview Study.
abstract: BACKGROUND
  Managing symptom clusters or multiple concurrent symptoms in patients with advanced cancer remains a clinical challenge. The optimal processes constituting effective management of symptom clusters remain uncertain.
  
  
  OBJECTIVE
  To describe the attitudes and strategies of clinicians in managing multiple co-occurring symptoms in patients with advanced cancer.
  
  
  METHODS
  Semistructured interviews were conducted with 48 clinicians (palliative care physicians [n = 10], oncologists [n = 6], general practitioners [n = 6], nurses [n = 12], and allied health providers [n = 14]), purposively recruited from two acute hospitals, two palliative care centers, and four community general practices in Sydney, Australia. Transcripts were analyzed using thematic analysis and adapted grounded theory.
  
  
  RESULTS
  Six themes were identified: uncertainty in decision making (inadequacy of scientific evidence, relying on experiential knowledge, and pressure to optimize care); attunement to patient and family (sensitivity to multiple cues, prioritizing individual preferences, addressing psychosocial and physical interactions, and opening Pandora's box); deciphering cause to guide intervention (disaggregating symptoms and interactions, flexibility in assessment, and curtailing investigative intrusiveness); balancing complexities in medical management (trading off side effects, minimizing mismatched goals, and urgency in resolving severe symptoms); fostering hope and empowerment (allaying fear of the unknown, encouraging meaning making, championing patient empowerment, and truth telling); and depending on multidisciplinary expertise (maximizing knowledge exchange, sharing management responsibility, contending with hierarchical tensions, and isolation and discontinuity of care).
  
  
  CONCLUSIONS
  Management of symptom clusters, as both an art and a science, is currently fraught with uncertainty in decision making. Strengthening multidisciplinary collaboration, continuity of care, more pragmatic planning of clinical trials to address more than one symptom, and training in symptom cluster management are required.
authors.affiliation: School of Psychology, The University of Sydney, Sydney, New South Wales, Australia; Psycho-Oncology Co-operative Research Group (PoCoG), The University of Sydney, Sydney, New South Wales, Australia; Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, Sydney, New South Wales, Australia. Electronic address: skye.dong@sydney.edu.au.
authors.forename: Skye T
authors.initials: ST
authors.lastname: Dong
authors.affiliation: School of Psychology, The University of Sydney, Sydney, New South Wales, Australia; Psycho-Oncology Co-operative Research Group (PoCoG), The University of Sydney, Sydney, New South Wales, Australia; Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, Sydney, New South Wales, Australia.
authors.forename: Phyllis N
authors.initials: PN
authors.lastname: Butow
authors.affiliation: Department of Palliative Care, Braeside Hospital, Neringah Hospital and Greenwich Hospital, HammondCare Palliative & Supportive Care Service, Sydney, New South Wales, Australia; South West Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia; Discipline of Palliative and Supportive Services, Flinders University, Adelaide, South Australia, Australia.
authors.forename: Meera
authors.initials: M
authors.lastname: Agar
authors.affiliation: Medical School, The University of Sydney, Sydney, New South Wales, Australia; Department of Palliative Care, Braeside Hospital, Neringah Hospital and Greenwich Hospital, HammondCare Palliative & Supportive Care Service, Sydney, New South Wales, Australia.
authors.forename: Melanie R
authors.initials: MR
authors.lastname: Lovell
authors.affiliation: Medical School, The University of Sydney, Sydney, New South Wales, Australia; Patricia Ritchie Centre for Cancer Care and Research, The Mater Hospital North Sydney, Sydney, New South Wales, Australia.
authors.forename: Frances
authors.initials: F
authors.lastname: Boyle
authors.affiliation: Medical School, The University of Sydney, Sydney, New South Wales, Australia; Department of Oncology, Concord Repatriation Hospital, Sydney, New South Wales, Australia.
authors.forename: Martin
authors.initials: M
authors.lastname: Stockler
authors.affiliation: Department of Palliative Care, Braeside Hospital, Neringah Hospital and Greenwich Hospital, HammondCare Palliative & Supportive Care Service, Sydney, New South Wales, Australia; Patricia Ritchie Centre for Cancer Care and Research, The Mater Hospital North Sydney, Sydney, New South Wales, Australia.
authors.forename: Benjamin C
authors.initials: BC
authors.lastname: Forster
authors.affiliation: Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia; Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, New South Wales, Australia.
authors.forename: Allison
authors.initials: A
authors.lastname: Tong
mesh_terms: D001291:Attitude of Health Personnel; D001315:Australia; D019468:Disease Management; D005260:Female; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D009369:Neoplasms / Q000628:therapy*; D010820:Physicians / Q000523:psychology*; D036301:Qualitative Research; D013577:Syndrome
keywords: Multiple symptoms; advanced cancer; health professionals; qualitative research; symptom clusters; symptom management