Background
Global cancer statistics for 2020 show that lung cancer has the highest mortality rate and is the most prevalent and the second most prevalent cancer in men and women, respectively [
1]. In the People’s Republic of China, lung cancer remains the most common cancer type and is the leading cause of cancer-related deaths for both sexes, thereby accounting for 40% of global lung cancer-related deaths [
2]. Surgery is considered the best curative option for operable lung cancer [
3]. With minimally invasive video-assisted thoracoscopic surgery (VATS) for lung cancer, the patients’ length of hospital stay has decreased significantly [
4]. Currently, most clinicians use clinical indicators to determine when to discharge a patient and these indicators do not include the patient's symptoms at discharge [
5,
6]. However, physical healing should be an important determinant of recovery, and the return of mild symptoms is crucial because no clinical intervention is required and there is little impact on daily functioning, which thereby ensures that the patient can return to normal life [
7].
Nonetheless, the patients’ perceptions of the severity or persistence of their symptoms are often overlooked in assessments that are based on clinical indicators. Patients who underwent surgery for lung cancer and were discharged with severe symptoms [
8,
9] did not experience a return to baseline levels with regard to cough, pain, shortness of breath, sleep disturbance, and fatigue for 1–4 months after the surgery [
10,
11,
12]. Moreover, there was a significant association between the reporting of severe symptoms, such as pain, cough, and shortness of breath, and readmission after discharge [
13]. In addition, many patients with cancer require postoperative adjuvant therapy, such as chemotherapy, radiotherapy, targeted therapy, or a combination of these therapies [
14]. Furthermore, persistent postoperative severe symptoms interfere with the functional recovery of patients and have a negative impact on their prognosis and timely return to their scheduled oncologic therapy [
15]. Thus, patient symptom management is one of the most crucial care needs [
9].
However, most of the previous studies on symptoms have focused on preoperative or post-discharge time-points, and little attention has been paid to the symptoms that are present at discharge [
10,
16,
17]. Furthermore, in the context of VATS, the symptoms at discharge for patients after lung cancer surgery are unclear. Therefore, we conducted this study to identify the core symptoms at discharge and their influencing factors in patients who had undergone surgery for lung cancer.
Discussion
The results of our study showed that the core symptoms at discharge were cough, pain, disturbed sleep, shortness of breath, and fatigue. Though the patients were clinically eligible for discharge after undergoing lung cancer surgery, more than half of the participants experienced one or more of the core symptoms at the time of discharge. The severity of these symptoms ranged from moderate to severe. The incidence of these core symptoms was higher in patients with a low annual income or in those who had two chest tubes after surgery.
Our study showed that cough was the most prevalent of all symptoms at discharge, followed by pain, shortness of breath, fatigue, and disturbed sleep. Similarly, a previous study showed a prevalence of 25–50% [
22,
23] of cough in discharged patients. Lung surgery inevitably results in trauma and anatomical alterations, such as lymph node dissection, bronchial sutures, diaphragmatic elevation, unilateral lung volume loss, and residual lobe deformation, all of which induce persistent postoperative cough [
24]. The degree and duration of postoperative cough can affect the post-discharge quality of life of the patient [
25]. Up to 69% of patients with lung cancer experience moderate to severe postoperative pain, and persistent postoperative pain may interfere with postoperative recovery and affect the development of complications [
16]. Our study showed a lower percentage (28.2%) of moderate to severe postoperative pain, which could be related to the high proportion of VATS [
26,
27]. In our study, the incidence of shortness of breath at discharge was 25.8%, which when severe was generally considered a reason for readmission [
13]. Furthermore, fatigue has been reported as one of the most common and severe symptoms at each time point after thoracotomy-based surgery [
28] and has a negative impact on the patient’s ability to receive postoperative cancer treatment as well as the patient’s long-term prognosis [
29]. In this study, the prevalence of moderate to severe sleep disturbances was 26.3%, which has been reported as the most common symptom in surgical patients [
30]. Compared to other reports, the differences between the patient-reported core symptoms and their lower scores in this study may be related to the use of different patient-reported outcome-measurement instruments and the different time points of outcome measurement.
In this study, we found that more than 50% of the participants reported the presence of one or more of the core symptoms whereas more than 25% of the participants reported three or more core symptoms at the time of discharge. Though most of the existing clinical studies have focused only on one symptom, patients rarely present with a single symptom, but instead with multiple symptoms that occur simultaneously [
30] and may or may not be related to each other [
31]. In the study by Trine et al., symptoms in patients who underwent lung cancer surgery often occurred in clusters and showed strong interrelationships [
32], and the occurrence of symptom clusters was closely related to the patient’s quality of life [
33]. Future studies of symptom management should focus on the assessment of the relationship between multiple symptoms, specific interventions, and patient outcomes [
31].
Studies have shown that patients with cancer who have lower annual incomes are more likely to have severe symptoms [
34,
35]. Our analysis showed that the socioeconomic status of patients with lung cancer was one of the factors that are related to symptom severity. This symptom is related to a lack of access to proper care, poor social support, and increased financial stress [
35]. The medical cost of cancer treatment imposes a heavy burden on society and on the patients’ families. Furthermore, patients who experience economic pressure have more severe symptoms and a poorer quality of life [
35]. In addition, the number of chest tubes that are inserted is a factor that contributes to the development of core symptoms. We found that patients with two chest tubes had more severe symptoms. Moreover, previous studies have reported significantly less pain in patients with a single chest tube after surgery [
36,
37]. Thus, special care management strategies should be developed for patients with two or more chest tubes to reduce their burden of symptoms. Some studies [
38,
39] that compared patients with different surgical approaches showed differences in the severity of the symptoms [
40], but these findings differ from the results of our study. A reason for this difference may be that, instead of a single symptom, the mean score of the core symptoms in this study was used as the dependent variable. In addition, data were collected on the day of discharge, rather than during the postoperative period in this study. In an era of widespread use of VATS, a focus on symptoms at discharge and the factors that influence these symptoms will help establish clinically actionable post-discharge patient management strategies.
This study had some limitations. First, the study included only the annual income of the patient and not of their families. Personal incomes are imperfect measures of socioeconomic status as they may not reflect the household’s financial status [
35]. Future studies will need to include more details to analyse the relationship between the household economic income and the patients' burden of symptoms. Second, though the instrument used to assess patient-reported outcomes in this study was the MDASI-LC, which is one of the four international lung cancer-specific instruments that has been verified and validated in regional populations [
41], the validation study for the MDASI-LC was conducted in patients who were undergoing chemo-radiotherapy [
18]. Thus, the MDASI-LC may not constitute the best instrument for assessing patient-reported outcomes in patients who were undergoing surgery. Third, our study was not free of bias. Patients with poor literacy skills did not participate in the study, and this limitation may have affect the generalizability of the conclusions of this study.
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