Supportive Care in Cancer

, Volume 18, Issue 3, pp 335–342 | Cite as

Exploration of symptoms clusters within cancer patients with brain metastases using the Spitzer Quality of Life Index

  • Amanda Hird
  • Jennifer Wong
  • Liying Zhang
  • May Tsao
  • Elizabeth Barnes
  • Cyril Danjoux
  • Edward ChowEmail author
Original Article



Advanced cancer patients can experience many concurrent symptoms. It has been suggested that certain symptoms can cluster together and have a synergistic effect on patient morbidity. The objective of this study was to explore the presence of symptom clusters in patients with brain metastases treated with whole brain radiotherapy (WBRT).

Materials and methods

Patients with brain metastases were asked to rate their symptoms and quality of life (QOL) using the Spitzer Quality of Life Index (SQLI) and a study-designed 17-item symptom questionnaire. Utilizing a principal component analysis, the SQLI and symptoms were analyzed for the presence of symptom clusters. The Cronbach’s alpha statistic was used to estimate the internal consistency and reliability of the derived clusters. Follow-up was carried out at baseline and 1, 2 and 3 months following WBRT.


Between August 2005 to October 2007, 129 patients with brain metastases were enrolled. Analysis of the SQLI items revealed two clusters. Cluster 1 consisted of activity, daily living and health, while cluster 2 consisted of support and outlook. Cronbach’s alpha was 0.69 and 0.40, respectively, for the two clusters, which accounted for 64% of the total variance. Analysis of the 17 additional symptoms revealed three clusters at baseline. These clusters changed slightly over time, but certain symptoms appeared to remain together: (1) trouble concentrating and confusion, (2) memory loss and decreased alertness, (3) nausea and vomiting, (4) numbness and weakness, and (5) dizziness and headache. These clusters persisted despite WBRT.


Symptom clusters exist in patients with brain metastases. Although the clusters varied over time, they did not weaken or disintegrate following WBRT, suggesting the latter one may not significantly improve the QOL and symptom distress in this group.


Brain metastases Radiotherapy Symptom cluster 



We thank Ms. Stacy Lue for the secretarial assistance, staff and research assistance in the accrual, and the Michael and Karyn Goldstein Cancer Research Fund.


  1. 1.
    Dodd MJ, Miaskowski C, Paul SM (2001) Symptom clusters and their effect on the functional status of patients with cancer. Oncol Nurs Forum 28(3):465–470PubMedGoogle Scholar
  2. 2.
    Kim HJ, McGuire DB, Tulman L, Barsevick AM (2005) Symptom clusters: concept analysis and clinical implications for cancer nursing. Cancer Nurs 28(5):270–282PubMedGoogle Scholar
  3. 3.
    Chow E, Davis L, Holden L, Tsao M, Danjoux C (2005) Prospective assessment of patient-rated symptoms following whole brain radiotherapy for brain metastases. J Pain Symptom Manage 30:18–23. doi: 10.1016/j.jpainsymman.2005.02.009 CrossRefPubMedGoogle Scholar
  4. 4.
    Langer CJ, Mehta MP (2005) Current management of brain metastases, with a focus on systemic options. J Clin Oncol 25:6207–6219. doi: 10.1200/JCO.2005.03.145 CrossRefGoogle Scholar
  5. 5.
    Chow E, Fan G, Hadi S, Wong J, Kirou-Mauro A, Filipczak L (2008) Symptom clusters in cancer patients with brain metastases. Clin Oncol 20:76–82. doi: 10.1016/j.clon.2007.09.007 CrossRefGoogle Scholar
  6. 6.
    Tsao MN, Lloyd NS, Wong RK et al (2005) Radiotherapeutic management of brain metastases: a systematic review and meta-analysis. Cancer Treat Rev 31:256–273. doi: 10.1016/j.ctrv.2005.04.007 CrossRefPubMedGoogle Scholar
  7. 7.
    Borgelt B, Gelber R, Kramer S et al (1980) The palliation of brain metastases: final results of the first two studies by the Radiation Therapy Oncology Group. Int J Radiat Oncol Biol Phys 6:1–9PubMedGoogle Scholar
  8. 8.
    Haie-Meder C, Pellae-Cosset B, Laplanche A et al (1993) Results of a randomized clinical trial comparing two radiation schedules in the palliative treatment of brain metastases. Radiother Oncol 26:111–116. doi: 10.1016/0167-8140(93)90091-L CrossRefPubMedGoogle Scholar
  9. 9.
    Murray KJ, Scott C, Greenberg HM et al (1997) A randomized phase III study of accelerated hyperfractionation vs standard in patients with unresected brain metastases: a report of the Radiation Therapy Oncology Group (RTOG) 9104. Int J Radiat Oncol Biol Phys 39:571–574. doi: 10.1016/S0360-3016(97)00341-6 PubMedGoogle Scholar
  10. 10.
    Priestman TJ, Dunn J, Brada M, Rampling R, Baker PG (1996) Final results of the Royal College of Radiologists’ trial comparing two different radiotherapy schedules in the treatment of cerebral metastases. Clin Oncol 8:308–315. doi: 10.1016/S0936-6555(05)80717-4 CrossRefGoogle Scholar
  11. 11.
    Doyle M, Bradley NE, Li K, Sinclair E, Lam K, Chan G, Chow E, Barnes EA, Danjoux C, Tsao MN (2007) Quality of life in patients with brain metastases treated with a palliative course of whole-brain radiotherapy. J Palliat Med 10(2):367–374. doi: 10.1089/jpm.2006.0202 CrossRefPubMedGoogle Scholar
  12. 12.
    Bezjak A, Adam J, Barton R et al (2002) Symptom response after palliative radiotherapy for patients with brain metastases. Eur J Cancer 38:487–496. doi: 10.1016/S0959-8049(01)00150-2 CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag 2009

Authors and Affiliations

  • Amanda Hird
    • 1
  • Jennifer Wong
    • 1
  • Liying Zhang
    • 1
  • May Tsao
    • 1
  • Elizabeth Barnes
    • 1
  • Cyril Danjoux
    • 1
  • Edward Chow
    • 1
    Email author
  1. 1.Rapid Response Radiotherapy Program, Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences CentreUniversity of TorontoTorontoCanada

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