Evidence-Based and Person-Centered Symptom Cluster Management in Cancer Care: The Value of Symptom Theory

Management of symptom clusters remains a significant issue for cancer patients during all phases of the care trajectory, not least during rehabilitation and survivorship. Symptom clusters are strongly linked to physical, cognitive, and social functioning and affect people’s perceptions of health and quality of life,1 which underlines the importance of ensuring effective symptom management to improve patient outcomes and reduce the burden on healthcare services. Consequently, symptom cluster management is identified as a strategic area for researchers in cancer nursing globally. In the dynamic field of cancer care, the role of evidence-based nursing (EBN) in symptom cluster management is evolving. The idea behind working in an evidence-based way is to ensure that nursing interventions are based on robust scientific evidence and do not only rely on nonreflective experiential knowledge and practices.2,3 With EBN, nursing practice has shifted toward decisions based on high-quality evidence, and this paradigm shift has been driven by advances in nursing research, multidiscipline research, and technological innovations.4 As the cornerstone of modern nursing practice, EBN has significantly advanced the management of symptom clusters, thereby enhancing the quality of life for several populations of cancer survivors. For example, systematic reviews evaluating physical activity and exercise as an intervention to reduce fatigue and improve functional capacity show positive results.5 However, the conclusions that can be drawn regarding clinical usefulness are often limited due to relatively healthy participants from socioeconomically strong groups and evaluation of individual symptoms instead of symptom clusters and research designs such as traditional randomized controlled trials that do not take into account individual variations and temporal aspects of symptom experience. We therefore argue for including also groups of vulnerable patients who experience complex symptom clusters in symptom management research such as patients with lung, head and neck, and colorectal cancers. In addition, the research needs to apply complex intervention designs including multicomponent interventions to reflect the individual complexity of symptom clusters and repeated measurement designs that reflect the temporal context of both symptom experience and symptom management processes. While arguing for the development of multicomponent interventions and the use of robust research designs to evaluate their effect on symptom clusters, it must be acknowledged that how to manage symptom clusters represents a major gap in symptom science.6 Hence, it will take time before we have results that can inform a change in clinical practice and thereby improve patient outcomes. Meanwhile, we argue for the use of theory as a framework for clinical practice. Even if you first think that a theory is there to structure research, a middle-range theory such as the Theory of Unpleasant Symptoms (TOUS) can serve as a heuristic tool for clinical practice.7 By providing an organizing scheme that encourages cancer nurses to think about the interplay between the many aspects of the symptom experience, the TOUS can guide both the assessment of symptoms and the evaluation of symptom management interventions. The relational structure of TOUS indicates that symptoms arise from interrelated physiological, psychological, and situational factors, leading to changes in functional, cognitive, and physical performance. Moreover, the TOUS is applicable at the individual level and highlights the symptoms occur in clusters. By repeated use, the TOUS can serve as a valuable tool for cancer nurses to assess changes in symptom clusters over time and thereby enable adaptation and timely changes of interventions. When patients navigate the grueling journey of cancer, the role of cancer nurses in symptom management becomes not only crucial but indispensable. Cancer nurses offer a unique blend of holistic expertise and compassionate support, making them ideally positioned to monitor, assess, and manage symptom clusters through their close and continuous contact with patients. The use of middle-range theories for symptom management such as the TOUS provides a useful tool for cancer nurses in their endeavor to achieve evidence-based and yet person-centered symptom cluster management for all patients with cancer. Cecilia Olsson, PhD, RN, OCNMaria Larsson, PhD, RN, OCNDepartment of Health Sciences, Karlstad University, Karlstad, Sweden (Drs Olsson and Larsson); and Department of Bachelor in Nursing, Lovisenberg Diaconal University College, Oslo, Norway (Dr Olsson).