Background: Gynecological cancer is the most common cancer after breast cancer in women. In Indonesia, the incidence of gynecological cancer was 2nd among women’s cancers in 2012, and this figure is expected to increase by around 20% by 2020. Dramatic advances in cancer diagnosis and treatment have improved the prognosis; however, multiple concurrent symptoms are experienced by cancer patients undergoing chemotherapy. The research on symptom management has changed from exploring single symptoms to symptom clusters. However, there have been limited symptom cluster studies on patients with gynecological cancer and its impact on their quality of life.
Purpose: to explore the structure of symptom clusters and their impact on the QOL at different time points during chemotherapy treatment among gynecological cancer patients.
Methods: A longitudinal design was used to explore the patterns of symptom clusters across four time periods from pre-chemotherapy (T0), 1-3 weeks after cycle 1 treatment (T1), cycle 2 treatment (T2) to cycle 3 (T3) in Dr. Sardjito General Hospital, Indonesia. The subjects were women diagnosed with gynecological cancer. Inclusion criteria for the subjects were planning to undergo chemotherapy, older than 18 years old, and able to read Bahasa. Exclusion criteria were cancer recurrence, cognitive impairment, central nervous system metastasis, and co-morbidity with other cancers. Three instruments were used including the Demographic and Clinical Characteristics, the Memorial Symptom Assessment Scale (MSAS), and the Short Form-36 (SF-36) questionnaires.
Data Analysis: Descriptive statistics were used to analyze the demographic and clinical characteristics as well as symptom occurrence and severity. Exploratory factor analysis (EFA) was used to identify the structures of symptom clusters at each time point. A panel regression was used to analyze the influence of demographic and clinical characteristics on symptom clusters across time and the influence of the symptom cluster on QOL across time.
Results: Overall, 120 patients with gynecological cancer provided baseline data, and 82 participants retained at T3. Before chemotherapy, the pain-related, nutrition, emotion, and treatment-related symptom clusters were determined as the four symptom clusters. However, after first cycle of chemotherapy, the symptom clusters were floating and changing across time points. The nutrition, fatigue-treatment, emotion, and pain-related symptom clusters presented after first cycle of chemotherapy (T1). After third cycle of chemotherapy (T3), the nutrition, emotion, body-image and pain-treatment symptom clusters presented. Cancer metastasis, types of gynecological cancer, stages, disease comorbidity and the level of education influence symptom clusters across time. Emotion and pain-related symptom clusters influence the QOL index.
Conclusions: Four symptom clusters were identified across time points with slightly different structures. The patterns of symptom clusters changed across time points, which indicated the complexity of symptom clusters and the dynamic relationships among symptoms. Assessing symptom clusters is important to gynecological cancer patients undergoing chemotherapy.

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