Supportive Care in Cancer

, Volume 21, Issue 12, pp 3327–3336 | Cite as

Assessing suffering in advanced cancer patients using Pictorial Representation of Illness and Self-Measure (PRISM), preliminary validation of the Spanish version in a Latin American population

  • Alicia KrikorianEmail author
  • Joaquín T. Limonero
  • John J. Vargas
  • Carolina Palacio
Original Article



This study aims to adapt the Pictorial Representation of Illness and Self-Measure (PRISM), a practical, nonverbal method with strong psychometric properties, to Spanish and to explore its criterion validity in advanced cancer and palliative care (PC).


Of the consecutive advanced cancer patients attending a palliative care consultation, 209 were invited to participate. To examine criterion validity, correlations were calculated between the PRISM, the Detection of Emotional Distress scale (DED), the Edmonton Symptom Assessment System (ESAS), the Structured Interview of Symptoms and Concerns (SISC), and the suffering visual analogue scale (VAS).


Ninety-eight patients fulfilled inclusion criteria (mean age, 60 years; SD, 14.25; 57 % female). The most frequent types of cancer were lung, breast, and colorectal. Average time since diagnosis was 30 months (2.5 years). PRISM significantly correlated with the Suffering VAS, the DED, and the SISC. It also showed significant correlations with psychosocial factors such as emotional distress, anxiety, loss of control, and perceived coping and spiritual distress items such as loss of dignity and hopelessness, but not with items examining physical symptoms.


The PRISM is a valid measure of suffering in advanced cancer patients. Its Spanish version fits adequately with current definitions and conceptualizations of suffering and may be used in PC settings. Further analysis of other psychometric properties in Spanish-speaking settings is recommended.


Suffering Assessment Palliative care Validation studies Cancer Measurement 



A. Krikorian thanks Universidad Pontificia Bolivariana for their financial support. All authors thank T. Alvarez, N. Acosta, and the Instituto de Cancerología of Clínica Las Américas for their invaluable help while conducting the study.


  1. 1.
    Cassell EJ (1999) Diagnosing suffering: a perspective. Ann Intern Med 131(7):531–534PubMedCrossRefGoogle Scholar
  2. 2.
    Krikorian A, Limonero JT (2012) An integrated view of suffering in palliative care. J Palliat Care 28(1):41–49PubMedGoogle Scholar
  3. 3.
    WHOQOL (1997) Measuring quality of life. Resource document World Health Organization. Accessed 12 February 2013
  4. 4.
    Hui KK, Hui EK, Johnston MF (2006) The potential of a person-centered approach in caring for patients with cancer: a perspective from the UCLA center for East-West medicine. Integr Cancer Ther 5(1):56–62PubMedCrossRefGoogle Scholar
  5. 5.
    World Health Organization (WHO) (2002) Cancer Control Program: policies and managerial guidelines, 2nd edn. WHO, GenevaGoogle Scholar
  6. 6.
    Morrison RS, Meier DE (2011) The National Palliative Care Research Center and the Center to Advance Palliative Care: a partnership to improve care for persons with serious illness and their families. J Pediatr Hematol Oncol 33(Suppl 2):S126–S131. doi: 10.1097/MPH.0b013e318230dfa0 PubMedCrossRefGoogle Scholar
  7. 7.
    WHO (2013) WHO definition of palliative care. Accessed 13 March 2013
  8. 8.
    Büchi S, Sensky T, Sharpe L, Timberlake N (1998) Graphic representation of illness: a novel method of measuring patients’ perceptions of the impact of illness. Psychother Psychosom 67(4–5):222–225PubMedGoogle Scholar
  9. 9.
    Büchi S, Sensky T (1999) PRISM: Pictorial Representation of Illness and Self Measure. A brief nonverbal measure of illness impact and therapeutic aid in psychosomatic medicine. Psychosomatics 40(4):314–320PubMedCrossRefGoogle Scholar
  10. 10.
    Büchi S, Villiger P, Kauer Y, Klaghofer R, Sensky T, Stoll T (2000) PRISM (Pictorial Representation of Illness and Self Measure): a novel visual method to assess the global burden of illness in patients with systemic lupus erythematosus. Lupus 9(5):368–373PubMedCrossRefGoogle Scholar
  11. 11.
    Büchi S, Buddeberg C, Klaghofer R, Russi EW, Brändli O, Schlösser C et al (2002) Preliminary validation of PRISM (Pictorial Representation of Illness and Self Measure)—a brief method to assess suffering. Psychother Psychosom 71(6):333–341PubMedCrossRefGoogle Scholar
  12. 12.
    Rumpf HJ, Löntz W, Uesseler S (2004) A self-administered version of a brief measure of suffering: first aspects of validity. Psychother Psychosom 73(1):53–56PubMedCrossRefGoogle Scholar
  13. 13.
    Kassardjian CD, Gardner-Nix J, Dupak K, Barbati J, Lam-McCullock J (2008) Validating PRISM (Pictorial Representation of Illness and Self Measure) as a measure of suffering in chronic non-cancer pain patients. J Pain 9(12):1135–1143PubMedCrossRefGoogle Scholar
  14. 14.
    Klis S, Vingerhoets AJ, de Wit M, Zandbelt N, Snoek FJ (2008) Pictorial Representation of Illness and Self Measure Revised II (PRISM-RII): a novel method to assess perceived burden of illness in diabetes patients. Health Qual Life Outcome 6:104CrossRefGoogle Scholar
  15. 15.
    Streffer ML, Büchi S, Mörgeli H, Galli U, Ettlin D (2009) PRISM (Pictorial Representation of Illness and Self-Measure): a novel visual instrument to assess pain and suffering in orofacial pain patients. J Orofac Pain 23(2):140–146PubMedGoogle Scholar
  16. 16.
    Lehmann V, Oerlemans S, van de Poll-Franse LV, Vingerhoets AJ, Mols F (2011) Suffering in long-term cancer survivors: an evaluation of the PRISM-R2 in a population-based cohort. Qual Life Res 20(10):1645–1654PubMedCrossRefGoogle Scholar
  17. 17.
    Wouters EJ, Reimus JL, van Nunen AM, Blokhorst MG, Vingerhoets AJ (2008) Suffering quantified? Feasibility and psychometric characteristics of 2 revised versions of the Pictorial Representation of Illness and Self Measure (PRISM). Behav Med 34(2):65–78PubMedCrossRefGoogle Scholar
  18. 18.
    Sensky T (2010) Suffering. Int J Integr Care 10:66–68Google Scholar
  19. 19.
    Krikorian A, Limonero JT, Corey M (2012) Suffering assessment: a review of available instruments for use in palliative care. J Palliat Med 16(2):130–142. doi: 10.1089/jpm.2012.0370 CrossRefGoogle Scholar
  20. 20.
    Woodruff R (2004) Palliative care: basic principles. In: Bruera E, DeLima L, Wenk R, Farr W (eds) Palliative care in developing countries: principles and practice. IAHPC Press, Texas, pp 1–9Google Scholar
  21. 21.
    El-Jawahri A, Greer JA, Temel JS (2011) Does palliative care improve outcomes for patients with incurable illness? A review of the evidence. J Support Oncol 9(3):87–94PubMedCrossRefGoogle Scholar
  22. 22.
    Brislin RW (1980) Translation and content analysis of oral and written materials. In: Triandis HC, Berry JW (eds) Handbook of cross-cultural psychology, vol 2. Allyn & Bacon, Boston, pp 389–444Google Scholar
  23. 23.
    Maté J, Mateo D, Bayés R, Bernaus M, Casas C, Gonzalez-Barboteo J et al (2009) Elaboración y propuesta de un instrumento para la detección de malestar emocional en enfermos al final de la vida. Psicooncología 6:507–518Google Scholar
  24. 24.
    Limonero JT, Mateo D, Maté-Méndez J, González-Barboteo J, Bayés R, Bernaus M et al (2012) Assessment of the psychometric properties of the Detection of Emotional Distress Scale in cancer patients. Gac Sanit 26(2):145–152PubMedCrossRefGoogle Scholar
  25. 25.
    Bruera E, Kuehn N, Miller MJ, Selmser P, Macmillan K (1991) The Edmonton Symptom Assessment System (ESAS): a simple method for the assessment of palliative care patients. J Palliat Care 7(2):6–9PubMedGoogle Scholar
  26. 26.
    Carvajal A, Centeno C, Watson R, Bruera E (2011) A comprehensive study of psychometric properties of the Edmonton Symptom Assessment System (ESAS) in Spanish advanced cancer patients. Eur J Cancer 47(12):1863–1872PubMedCrossRefGoogle Scholar
  27. 27.
    Nekolaichuk C, Watanabe S, Beaumont C (2008) The Edmonton Symptom Assessment System: a 15-year retrospective review of validation studies (1991–2006). Palliat Med 22(2):111–122PubMedCrossRefGoogle Scholar
  28. 28.
    Richardson LA, Jones GW (2009) A review of the reliability and validity of the Edmonton Symptom Assessment System. Curr Oncol 16(1):53–64Google Scholar
  29. 29.
    Krikorian A, Limonero JT, Maté J (2011) Suffering and distress at the end-of-life. Psychooncology 21(8):799–808CrossRefGoogle Scholar
  30. 30.
    Wilson KG, Graham ID, Viola RA, Chater S, de Faye BJ, Weaver LA et al (2004) Structured interview assessment of symptoms and concerns in palliative care. Can J Psychiatry 49(6):350–358PubMedGoogle Scholar
  31. 31.
    Cohen J (1988) Statistical power analysis for the behavioral sciences, 2nd edn. Psychology Press, New JerseyGoogle Scholar
  32. 32.
    Abraham A, Kutner JS, Beaty B (2006) Suffering at the end of life in the setting of low physical symptom distress. J Palliat Med 9(3):658–665PubMedCrossRefGoogle Scholar
  33. 33.
    SPSS Inc (2009) PASW statistics for windows, version 18.0. SPSS Inc, ChicagoGoogle Scholar
  34. 34.
    Sherman DW, McSherry CB, Parkas V, Ye XY, Calabrese M, Gatto M (2005) Recruitment and retention in a longitudinal palliative care study. Appl Nurs Res 18(3):167–177PubMedCrossRefGoogle Scholar
  35. 35.
    O’Mara AM, St Germain D, Ferrell B, Bornemann T (2009) Challenges to and lessons learned from conducting palliative care research. J Pain Symptom Manage 37(3):387–394. doi: 10.1016/j.jpainsymman.2008.03.014 PubMedCrossRefGoogle Scholar
  36. 36.
    Dirección Seccional de Salud de Antioquia (DSSA) (2012) Registro Poblacional de Cáncer de Antioquia. SSSA: Datos preliminares 2007–2009. Accessed 21 February 2013
  37. 37.
    Rivero J (2000) Reforma y desigualdad educativa en América Latina. Rev Iberoamericana Educa, 23:103–133. Accessed 19 February 2013
  38. 38.
    Echeverría R (2000) Opciones para reducir la pobreza rural en América Latina y el Caribe. Cepal 70:147–160. Accessed 22 January 2013
  39. 39.
    Herrera MC (1993) Historia de la educación en Colombia la republica liberal y la modernización de la educación: 1930–1946. Rev Colombiana Educa 26:97–124Google Scholar
  40. 40.
    Bayés R, Limonero JT (1999) Prioridad en el tratamiento de los síntomas que padecen los enfermos oncológicos en situación terminal. Med Paliat 6:19–21Google Scholar
  41. 41.
    Thompson GN, Chochinov HM, Wilson KG, McPherson CJ, Chary S, O’Shea FM et al (2009) Prognostic acceptance and the well-being of patients receiving palliative care for cancer. J Clin Oncol 27(34):5757–5762PubMedCrossRefGoogle Scholar
  42. 42.
    Lieberman MD, Eisenberger NI, Crockett MJ, Tom SM, Pfeifer JH, Way BM (2007) Putting feelings into words: affect labeling disrupts amygdala activity in response to affective stimuli. Psychol Sci 18(5):421–428PubMedCrossRefGoogle Scholar
  43. 43.
    Wilson KG, Chochinov HM, McPherson CJ, LeMay K, Allard P, Chary S et al (2007) Suffering with advanced cancer. J Clin Oncol 25(13):1691–1697PubMedCrossRefGoogle Scholar
  44. 44.
    Schroepfer TA, Noh H, Kavanaugh M (2009) The myriad strategies for seeking control in the dying process. Gerontologist 49(6):755–766PubMedCrossRefGoogle Scholar
  45. 45.
    Wittmann L, Sensky T, Meder L, Michel B, Stoll T, Büchi S (2009) Suffering and posttraumatic growth in women with systemic lupus erythematosus (SLE): a qualitative/quantitative case study. Psychosomatics 50(4):362–374PubMedCrossRefGoogle Scholar
  46. 46.
    Chochinov HM (2006) Dying, dignity, and new horizons in palliative end-of-life care. CA Cancer J Clin 56(2):84–103PubMedCrossRefGoogle Scholar
  47. 47.
    McGrath P (2002) Creating a language for ‘spiritual pain’ through research: a beginning. Support Care Cancer 10(8):637–646PubMedCrossRefGoogle Scholar
  48. 48.
    Taylor SE, Burklund LJ, Eisenberger NI, Lehman BJ, Hilmert CJ, Lieberman MD (2008) Neural bases of moderation of cortisol stress responses by psychosocial resources. J Pers Soc Psychol 95(1):197–211PubMedCrossRefGoogle Scholar
  49. 49.
    Zigmond AS, Snaith RP (1983) The Hospital Anxiety and Depression Scale. Acta Psychiatrica Scandinava 67:361–370CrossRefGoogle Scholar
  50. 50.
    Al-Shahri MZ, Eldali AM, Al-Zahrani O (2012) Prevalence and severity of suffering among patients with advanced cancer. Support Care Cancer 20(12):3137–3140PubMedCrossRefGoogle Scholar
  51. 51.
    Baines BK, Norlander L (2000) The relationship of pain and suffering in a hospice population. Am J Hosp Palliat Care 17(5):319–326PubMedCrossRefGoogle Scholar
  52. 52.
    Bruera E, Neumann CM (1999) Respective limits of palliative care and oncology in the supportive care of cancer patients. Support Care Cancer 7(5):321–327PubMedCrossRefGoogle Scholar
  53. 53.
    Moreno F, Otero J (2006) Demografía de la lengua española. Instituto Complutense de Estudios Internacionales, Madrid, pp 38. Accessed 5 February 2013

Copyright information

© Springer-Verlag Berlin Heidelberg 2013

Authors and Affiliations

  • Alicia Krikorian
    • 1
    Email author
  • Joaquín T. Limonero
    • 2
  • John J. Vargas
    • 1
    • 3
  • Carolina Palacio
    • 1
    • 3
  1. 1.Pain and Palliative Care Group, School of Health SciencesUniversidad Pontificia BolivarianaMedellínColombia
  2. 2.Research Group on Stress and Health (GIES), Faculty of PsychologyUniversitat Autònoma de BarcelonaBarcelonaSpain
  3. 3.Clínica Las AméricasInstituto de CancerologíaMedellínColombia

Personalised recommendations