Symptom Experience and Symptom Clusters of Thai Women with Breast Cancer Receiving Chemotherapy

Main Article Content

Supaporn Chongkham-ang
Tipaporn Wonghongkul
Sirirat Panuthai
Nitaya Pinyokham
Christine Miaskowski


Women with breast cancer experience multiple co-occurring symptoms and symptom clusters associated with chemotherapy. Understanding these symptom clusters will help to improve the effectiveness of symptom management. The purposes of this study were to explore symptom experience, symptom clusters, and to compare similarities and differences in symptom clusters based on severity and distress. Three hundred and twenty-two Thai women with breast cancer receiving chemotherapy were recruited from eight hospitals in Thailand. The instruments consisted of a Demographic and Clinical Data Form and the Thai-Memorial Symptom Assessment Scale. Data were analyzed using descriptive statistics and factor analysis.
                    The five most common symptoms reported by these women were hair loss, lack of energy, lack of appetite, change in the way food tastes, and nausea. Lack of appetite was the most frequent symptom, and hair loss was the most severe and distressing symptom. Based on the analysis of severity and distress ratings, four symptom clusters were identified that were labeled emotional, gastrointestinal, image, and discomfort. The four symptom clusters based on severity or distress explained 49.49% and 54.51% of the variance in all of the symptoms, respectively. Similarity rates between the symptom clusters created using severity and distress ratings ranged from 33.33% to 100.00%. These findings suggest that symptom clusters are relatively similar regardless of the dimension evaluated. Nurses and other health care providers should assess these symptom clusters and provide appropriate symptom management interventions for these women.

Article Details

How to Cite
Chongkham-ang S, Wonghongkul T, Panuthai S, Pinyokham N, Miaskowski C. Symptom Experience and Symptom Clusters of Thai Women with Breast Cancer Receiving Chemotherapy. PRIJNR [Internet]. 2018 Jan. 1 [cited 2022 Sep. 25];22(1):43-57. Available from:
Original paper


1. Ferlay J, Soerjomataram I, Dikshit R, Eser S, Mathers C, Rebelo M, et al. Cancer incidence and mortality worldwide: Sources, methods and major patterns in GLOBOCAN 2012. Int J Cancer. 2015 136(5):E359-86.

2. National Cancer Institute of Thailand. Cancer in Thailand volume IV 1998-2000. 2006. [cited 2013 Jan 12]. Available from Cancer%20In%20Thailand%20IV/C-II-13.PDF

3. Rose MG, Devita VT, Lawrence TS, Rosenberg SA. editors. Oncology in primary care. Philadelphia: Wolters Kluwer Lippincott Williams & Wilkins; 2013.

4. National Cancer Institute. Clinical practice guideline in breast cancer 2012. [cited 2013 Jan 12]. Available from [in Thai].

5. Bender CM, Ergÿn FS, Rosenzweig MQ, Cohen SM, Sereika SM. Symptom clusters in breast cancer across 3 phases of the disease. Cancer Nurs. 2005 28(3):219-25.

6. Sullivan CW, Leutwyler H, Dunn LB, Cooper BA, Paul SM, Conley YP et al. Differences in symptom clusters identified using symptom occurrence rates versus severity ratings in patients with breast cancer undergoing chemotherapy. Eur J Oncol Nurs. 2017 28:122-32.

7. Albusoul RM. Symptom clusters among women with breast cancer undergoing chemotherapy [dissertation]. [San Francisco]: University of California; 2013. 150 p.

8. Alkathiri AM, Albothi GK. Symptom cluster and severity among women with breast cancer undergoing chemotherapy in Saudi Arabia. J of Med Med Sci. 2015 6(2), 40-6.

9. Kim HJ, Barsevick AM, Tulman L, McDermott PA. Treatmentrelated symptom clusters in breast cancer: a secondary analysis. J Pain Symptom Manage. 2016 36(5): 468-79.

10. Suwisith N, Hanucharurnkul S, Dodd M, Vorapongsathorn T, Pongthavorakamol K, Asavametha N. Symptom clusters and functional status of women with breast cancer. Pacific Rim Int J Nurs Res. 2008 12(3):153-65.

11. Albusoul RM, Berger AM, Gay CL, Janson SL, Lee KA. Symptom clusters change over time in women receiving adjuvant chemotherapy for breast cancer. J Pain Symptom Manage. 2017 53: 880-6.

12. Hsu HT, Lin KC, Wu LM, Juan CH, Hou MF, Hwang SL et al. Symptom cluster trajectories during chemotherapy in breast cancer outpatients. J Pain Symptom Manage. (in press).

13. Phligbua W, Pongthavornkamol K, Knobf TM, Junda T, Viwatwongkasem C, Srimuninnimit V. Symptom clusters and quality of life in women with breast cancer receiving adjuvant chemotherapy. Pacific Rim Int J Nurs Res. 2013 17(3):249-67.

14. Sarenmalm EK, Browall M, Gaston-Johansson F. Symptom burden clusters: a challenge for targeted symptom management. A lonGastrointestinaltudinal study examining symptom burden clusters in breast cancer. J Pain Symptom Manage. 2014 47(4):731-41.

15. Browall M, Brandberg Y, Nasic S, Rydberg P, Bergh J, Rydén A et al. A prospective exploration of symptom burden clusters in women with breast cancer during chemotherapy treatment. Support Care Cancer. 2016 25:1423-9.

16. Humphreys J, Janson S, Donesky D, Dracup K, Lee K, Puntillo K et al. Theory of symptom management. In Smith MJ, Liehr PR, editors. Middle range theory for nursing. 3rd ed. New York: Springer Publishing; 2014. p.141-164.

17. Dodd MJ, Miaskowski C, Paul SM. Symptom clusters and their effect on the functional status of patients with cancer. Oncol Nurs Forum. 2001 28(3):465-70.

18. Kirkova J, Walsh D. Cancer symptom clusters—a dynamic construct. Support Care Cancer. 2007 15(9):1011-3.

19. Oxford dictionary [Internet]. 2016. frequency; [cited 2016 Dec 16]. Available from: https://en.oxforddictionaries. com/definition/frequency

20. Oxford dictionary [Internet]. 2016. Severity; [cited 2016 Dec 16]. Available from: https://en.oxforddictionaries. com/definition/severity

21. Armstrong TS. Symptoms experience: A concept analysis. Oncol Nurs Forum. 2003 30(4):601-12.

22. Hair JF, Black WC, Babin BJ, Anderson RE. Multivariate data analysis: A global perspective. 7th rev. ed. Upper Saddle River NJ: Pearson Prentice Hall; 2010.

23. Pett MA, Lackey NR, Sullivan JJ. Making sense of factor analysis. Thousand Oaks: Sage. 2010.

24. Portenoy RK, Thaler HT, Kornblith AB, Lepore JM, Friedlander-Klar H, Kiyasu E, et al. The memorial symptom assessment scale: An instrument for the evaluation of symptom prevalence, characteristics and distress. Eur J Cancer. 1994 30(9):1326-36.

25. Jordan K, Gralla R, Jahn F, Molassiotis A. International antiemetic guidelines on chemotherapy induced nausea and vomiting (CINV): Content and implementation in daily routine practice. Eur J Pharmacol. 2014 722:197-202.

26. Friedrichs K, Carstensen MH. Successful reduction of alopecia induced by anthracycline and taxane containing adjuvant chemotherapy in breast cancer–clinical evaluation of sensor-controlled scalp cooling. Springerplus. 2014 1;3(1):500.

27. Brunton, LL, Lazo, JS, Parker, KL, editors. Goodman Gastrointestinallman’s the pharmacoloGastrointestinalcal basis of therapeutics. New York: McGraw Hill; 2006.

28. Paus R, Haslam IS, Sharov AA, Botchkarev VA. Pathobiology of chemotherapy-induced hair loss. Lancet Oncol. 2013 14(2):e50-9.

29. Boltong A, Aranda S, Keast R, Wynne R, Francis PA, Chirgwin J, et al. A prospective cohort study of the effects of adjuvant breast cancer chemotherapy on taste function, food liking, appetite and associated nutritional outcomes. PLOSONE [Internet]. 2014 Jul 31 [cite 2014 Nov 5]; 9(7):e103512. Available from: pone.0103512

30. Boltong A, Keast R. The influence of chemotherapy on taste perception and food hedonics: a systematic review. Cancer Treat Rev. 2012 38(2):152-63.

31. Gamper M, Gastrointestinalesinger M, Oberguggenberger A, Kemmler G, Wintner M, Gattringer K, et al. “Taste alterations in breast and gynaecoloGastrointestinalcal cancer patients receiving chemotherapy: Prevalence, course of severity, and quality of life correlates.” Acta Oncol. 2012 51(4): 490-96.

32. Basch E, Prestrud AA, Hesketh PJ, Kris MG, Feyer, PC, Somerfield MR, et al. Antiemetics: American society of clinical oncology clinical practice guideline update. J Clin Oncol. 2011 29(31), 4189-98.

33. Pettersson G, Berterö C, Unosson M, Börjeson S. Symptom prevalence, frequency, severity, and distress during chemotherapy for patients with colorectal cancer. Support Care Cancer. 2014 22(5):1171-9.

34. Byar KL, Berger AM, Bakken SL, Cetak MA. Impact of adjuvant breast cancer chemotherapy on fatigue, other symptoms, and quality of life. Oncol Nurs Forum. 2006 33(1):18-26.

35. Solheim TS, Blum D, Fayers PM, Hjermstad MJ, Stene GB, Strasser F, et al. Weight loss, appetite loss and food intake in cancer patients with cancer cachexia: Three peas in a pod?–analysis from a multicenter cross sectional study. Acta Oncol. 2014 53(4):539-46.

36. Liao MN, Chen SC, Chen SC, Lin YC, Chen MF, Wang CH, et al. Change and predictors of symptom distress in breast cancer patients following the first 4 months after diagnosis. J Formos Med Assoc. 2015 114(3):246-53.

37. Cleeland CS, Bennett GJ, Dantzer R, Dougherty PM, Dunn AJ, Meyers CA, et al. Are the symptoms of cancer and cancer treatment due to a shared bioloGastrointestinalc mechanism?. Cancer. 2003 97(11): 2919-25.

38. Rosenberg SM, Tamimi RM, Gelber S, Ruddy KJ, Kereakoglow S, Borges VF, et al. Body image in recently diagnosed young women with early breast cancer. Psychooncology. 2013 22(8):1849-55.

39. Chen CL, Liao MN, Chen SC, Chan PL, Chen SC. Body image and its predictors in breast cancer patients receiving surgery. Cancer Nurs. 2012 Sep 1;35(5):E10-6.

40. Choi EK, Kim IR, Chang O, Kang D, Nam SJ, Lee JE, et al. Impact of chemotherapy‐induced alopecia distress on body image, psychosocial well‐being, and depression in breast cancer patients. Psychooncology. 2014 Oct 1;23(10):1103-10.

Most read articles by the same author(s)

1 2 3 > >>