percent) and pain (54 percent) were the most prevalent symptoms. Donnelly and colleagues (1995) prospectively studied the prevalence and severity of these symptoms in 1,000 patients with advanced cancer. Pain, fatigue, and anorexia were consistently found to be among the 10 most prevalent symptoms at all 17 primary cancer sites studied. When pain, anorexia, weakness, anxiety, lack of energy, severe fatigue, early satiety, constipation, and dyspnea were present, a majority of patients rated them as moderate or severe. Similarly, a prospective study of cancer patients in palliative care centers in Europe, Australia, and the United States found that more than half of the patients reported pain and weakness (Vainio and Auvinen, 1996). Weight loss, anorexia, constipation, nausea, and dyspnea were also common.

As part of the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT), McCarthy and colleagues (2000) evaluated more than 1,000 cancer patients during the three days before death and also at one to three months before death, and three to six months before death. As expected, as they progressed toward death, their estimated six-month prognosis decreased significantly and the severity of their disease worsened. Patients’ functional status also declined significantly as they approached death, such that most patients had four or more symptoms within the three days before death. Patients with cancer experienced significantly more pain and confusion as death approached. Severe pain was common; more than one-quarter of patients with cancer experienced significant pain three to six months before death and more than 40 percent were in significant pain during their last three days of life. However, dying patients were only modestly depressed and anxious during their last three days of life.

The distress caused by symptoms for cancer patients at the end of life is shared by patients who are not yet terminal. Very few epidemiological studies have examined the multiple symptoms of cancer patients with less progressed disease. However, the symptoms associated with aggressive treatments such as chemotherapy and radiotherapy have been well documented. For example, multiple studies have found that the majority of patients undergoing chemotherapy or radiotherapy report significant fatigue during the course of treatment (Cleeland et al., 2000; Irvine, et al., 1994; Smets et al., 1996). A few studies have assessed multiple symptoms in samples of cancer patients with different stages of disease. Portenoy and colleagues (1994) administered the Memorial Symptom Assessment Scale to a random sample of inpatients and outpatients with breast, prostate, colon, or ovarian cancer. The most frequently reported symptoms for the sample were lack of energy, worry, feeling sad, and pain. Patients with metastatic disease reported more symptom distress than patients with less advanced disease. In a recent study of more than 500 patients in active treatment, more than 20 percent of patients reported a variety of severe symptoms, including



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