Province‐Wide Analysis of Patient Reported Outcomes for Stage IV Non‐Small Cell Lung Cancer – The Oncologist


In Ontario, Canada, patient reported outcomes (PRO) evaluation through Edmonton Symptom Assessment System (ESAS) has been integrated into clinical workflow since 2007. As stage IV non-small cell lung cancer (NSCLC) is associated with substantial disease and treatment-related morbidity, this province-wide study investigated moderate-to-severe symptom burden in this population.


ESAS collected from stage IV NSCLC patients diagnosed between 2007-2018 linked to Ontario provincial healthcare system database were studied. ESAS acquired within 12 months following diagnosis were analyzed and the proportion reporting moderate-to-severe scores (ESAS ≥4) in each domain was calculated. Predictors of moderate-to-severe scores were identified using multivariable Poisson regression models with robust error variance.


Of 22,799 patients, 13,289 (58.3%) completed ESAS (84,373 assessments) in the year following diagnosis. Patients with older age, high comorbidity, and not receiving active cancer therapy had lower ESAS completion.

Majority (94.4%) reported at least 1 moderate-to-severe symptoms. Most prevalent were tiredness (84.1%), low wellbeing (80.7%), low appetite (71.7%), and shortness of breath (67.8%). Most symptoms peaked at diagnosis, while declining, remained high in the following year.

On multivariable analyses, comorbidity, low income, non-immigrants, and urban residency were associated with moderate-to-severe symptoms. Moderate-to-severe scores in all ESAS domains aside from anxiety were associated with radiotherapy within 2 weeks prior, while drowsiness, low appetite and wellbeing, nausea, and tiredness were associated with systemic therapy within 2 weeks prior.


This province-wide PRO analysis showed moderate-to-severe symptoms were prevalent and persistent among metastatic NSCLC patients, underscoring the need to address supportive measures in this population especially around treatments.

Implications for Practice

This is the largest patient reported outcome (PRO) results among lung cancer patients worldwide. Our results demonstrated the worse moderate-to-severe symptoms among stage IV non-small cell lung cancer patients compared to other patients with metastatic, other malignancies such as breast, gastric, or esophageal cancers assessed with similar methodology. These patients symptom severity also peaked early, and persistently high during 1 year follow-up. Symptoms burden was also associated with recent radiation and systemic treatments. This emphasized the importance of early and sustained PRO collection to detect actionable symptom progression, especially around treatments. Moreover, PRO completion was lower among patients who were older, had higher comorbidity, and not receiving active cancer treatment; these were arguably more vulnerable patients who faced barrier to attend in-person clinic visit to complete PRO. We suggested PRO collection during virtual clinics improve completion.