In this study, we successfully translated and validated a Chinese version of the MDASI-PeriOp-GYN using rigorous methodology in a sample of patients with three common gynecologic cancers at a cancer center in China. Our results provided support for the reliability and validity of the newly translated MDASI-PeriOp-GYN-C.
To our knowledge, this is the first study reporting reliability and validity data for the perioperative symptom burden in Chinese gynecologic cancer patients. The results of reliability and validity showed that the MDASI-PeriOp-GYN-C is a valid and reliable instrument for measuring symptom severity and related interference with functioning in perioperative Chinese gynecologic cancer patients, even with frequent measurement. Furthermore, the numeric rating scale could be integrated into the hospital information system or other computer systems, or an online questionnaire, so that this self-administered assessment was convenient and timely, and healthcare providers could offer timely intervention which contributed to better outcome ([i]).
The mean age of our participants was 51.95 years, consistent with the results of epidemiological studies on gynecologic cancers in China. The age-specific incidence of cervical cancer increases rapidly from the 35–39 years age group, with the peak incidence in the 45–49 years age group ([ii],[iii]). Ovarian cancer incidence increases after 40 years of age, reaching its peak in the 55–59 years age group ([iv]). Most of our participants (92.9%) had a spouse or domestic partner due to the traditional marriage and family in China.
Significantly, only 9.6% of participants had chronic diseases, including hypertension (n=18), diabetes (n=8), and hepatitis B (n=2), and three had both hypertension and diabetes. The incidence of hypertension and diabetes in Chinese adults was 27.9% and 10.9%, respectively; older adults, males, and urban residents had a higher prevalence ([v]). However, only 36.5% of diabetes patients and 30.5% of hypertension patients had been diagnosed by doctors ([vi],[vii]). Among the study participants, 144 (44.4%) were from rural areas, and 74 (22.8%) patients were diagnosed with endometrial cancer that closely related to hypertension and diabetes, which may be the reason for the small proportion of chronic disease patients among the participants.
The MDASI-PeriOp-GYN-C reliability was assessed via internal consistency and test-retest correlations. Internal consistency reliability was strongly supported with Cronbach's α well above 0.73 for the four scales. Test-retest correlations were assessed with a 2-day interval by completing the questionnaire on the fifth and seventh day postoperatively. The reason for choosing these timepoints was that the original study showed that preoperative symptoms were less severe than postoperative symptoms, and symptoms were relatively stable on the fifth and seventh days after surgery (8).
Criterion validity was evaluated by comparing the responses on the MDASI-PeriOp-GYN-C with those on the Chinese version of the EORTC QLQ-C30 and its EORTC QLQ-OV28 module. The QLQ-C30 is the most widely used HRQL assessment in women with gynecologic cancers ([viii]). The use of QLQ-C30 and its QLQ-OV28 module could be recommended when the outcomes of interest are the core domains of HRQL or symptoms ([ix]), while the MDASI-PeriOp-GYN-C focused on symptoms and interference with functioning. Cancer-related symptoms greatly influence the patients’ quality of life and might cause postoperative complications and delayed rehabilitation. However, the symptom burden may be related to personal circumstances, attitudes, and cultural differences. Our study showed high correlations between the symptom and interference scales of the two questionnaires, with values >0.6.
The results showed that within 7 days after surgery, symptom severity changed dramatically, which was consistent with the original study’s findings (6). Professionals should conduct effective symptom management based on patient-reported outcomes to improve their quality of life and outcomes ([x],[xi]). Further studies are needed of symptom clusters in perioperative patients with different type of gynecologic cancers that affect the patients' quality of life to enable early treatment or prevention.
Within 1 week after surgery, fatigue was the most serious core symptom, followed by poor appetite, which was consistent with the results of previous studies (6,[xii]). There are numerous causes of fatigue, including poor appetite, which might result in inadequate dietary intake, particularly energy and protein intake. Fatigue might also be due to insufficient activity after surgery ([xiii]). Bloating and hot flashes were the most serious gynecologic symptoms. Hot flashes have been associated with hormone level changes after surgery, while bloating is caused by impaired gastrointestinal function. Patients reported that the symptoms interfered with their work and general activity, representing impaired physical function. Because of the deep-rooted traditional concept of patient or family caregivers, many postoperative patients rejected getting out of bed. After discharge, they stayed in bed, with little activity. Due to the above factors, multidisciplinary perioperative care including rehabilitation medicine is required for recovery and rehabilitation ([xiv],[xv]).
This study had limitations. First, all participants were from the Chinese mainland and spoke Mandarin and simplified Chinese. Due to differences in the cultural background and mainstream languages in Hong Kong, Macao, and Taiwan, further study on using the MDASI-PeriOp-GYN-C in these populations is needed. Second, 97.5% of the participants were of Han nationality. Differences in beliefs and living habits between the Han and minority nationalities may lead to differences in expressing perioperative symptoms, which need further studies. Third, this study only included patients with three common gynecological tumors. Therefore, the MDASI-PeriOp-GYN-C should be validated in further studies enrolling patients with other gynecologic cancers and benign tumors.
In conclusion, we showed that the MDASI-PeriOp-GYN-C is a valid and reliable tool for measuring symptoms in Chinese patients undergoing surgery for gynecologic cancers. The tool could be used in clinical practice and clinical trials to instantly gather patients’ health and quality of life data.
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