Effectiveness of Different Severity Thresholds for Chemotherapy-Related Symptom Alerts

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In a study reported in JCO Oncology Practice, Shi et al found that use of higher-than-currently-recommended severity thresholds for symptom alerts for patients receiving outpatient chemotherapy would result in failure to identify and treat many patients requiring clinical intervention for symptoms.

Study Details

The study involved data from patients from 38 U.S. sites receiving outpatient chemotherapy in the Eastern Cooperative Oncology Group (ECOG)-American College of Radiology Imaging Network E2Z02 Symptom Outcomes and Practice Patterns study, including 642 with breast cancer, 486 with colorectal cancer, and 340 with lung cancer. Patients rated the severity of their symptoms using the MD Anderson Symptom Inventory at two timepoints 1 month apart. Percentages of patients with pain, dyspnea, fatigue, or distress at threshold scores of ≥ 4 and ≥ 7 on the 0–10 inventory scale were compared; a threshold of ≥ 4 is commonly recommended as the threshold for generating symptom alerts. The percentage of patients with worsened ECOG performance status at second assessment was used to estimate risk for missing clinically important symptom data with use of higher severity thresholds.

Key Points

At first assessment, 60% of patients rated one or more of the four symptoms as ≥ 4 on the severity scale. Among these patients, 27% had worsened performance status 1 month later at second assessment. A higher percentage of patients with one or more symptom(s) rated ≥ 4 had worsened performance status at second assessment vs patients with no symptom rated ≥ 4 (20%, P = .007).

At first assessment, 31% of patients rated one or more of the 4 symptoms as ≥ 7 on the severity scale. Among these patients, 14% had worsened performance status at second assessment.  

If the alert threshold were increased from ≥ 4 to ≥ 7, 49% of patients with worsened performance status would not be identified, since an alert would not be generated at first assessment.

The investigators concluded, “The burden to clinicians from an alert threshold of ≥ 4 (per many current guidelines) would be substantial. However, setting higher alert thresholds may miss a large percentage of patients who need clinical intervention. These results may inform resource planning when implementing electronic symptom screening at an institutional or practice level.”

Qiuling Shi, MD, PhD, of the Department of Symptom Research, The University of Texas MD Anderson Cancer Center, is the corresponding author for the JCO Oncology Practice article.

Disclosure: The study was supported by grants from the National Cancer Institute. For full disclosures of the study authors, visit

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