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The Spanish Version of the Edmonton Symptom Assessment System-Revised (ESAS-r): First Psychometric Analysis Involving Patients With Advanced Cancer

Open AccessPublished:August 27, 2012DOI:https://doi.org/10.1016/j.jpainsymman.2012.01.014

      Abstract

      Context

      The Edmonton Symptom Assessment System (ESAS) is a measure widely used in palliative care for the assessment of symptoms in patients with advanced cancer. The tool has been validated in different languages, including Spanish. A revised version (ESAS-r) was developed by Watanabe et al. in 2010.

      Objectives

      To develop the Spanish version of the ESAS-r and examine its psychometric properties.

      Methods

      Based on the original English version, a group of experts created a Spanish version of the ESAS-r and administered it to a group of advanced cancer patients. Patients completed the ESAS and ESAS-r and were asked for their perceptions of the tool. The psychometric properties of the ESAS-r that were analyzed were equivalence, internal consistency, and discriminant validity.

      Results

      Sixty-six patients from Spain and Guatemala participated in the survey. Patients perceived the ESAS-r to be significantly easier to understand and easier to complete than the ESAS. Significantly, patients preferred the ESAS-r (47%) to the ESAS (15%; P<0.0007). As to reliability, we found good internal consistency (Cronbach's alpha 0.86), and the equivalence of the two versions was between 0.71 and 0.94. The ESAS-r discriminates between inpatients and outpatients (Mann-Whitney U test; P=0.02) and among those with different palliative performance status (Spearman's rho for pain, tiredness, drowsiness, lack of appetite, well-being; P<0.01).

      Conclusion

      The ESAS-r is a valid instrument with adequate psychometric characteristics. This version is preferred by patients with advanced cancer. The Spanish version of the ESAS-r can, therefore, replace the use of the ESAS.

      Key Words

      Introduction

      The Edmonton Symptom Assessment System (ESAS)
      • Bruera E.
      • MacDonald S.
      Audit methods: the Edmonton Symptom Assessment System.
      has been widely
      • Cumming G.
      • Biondo P.
      • Hagen N.
      • Faisinger R.
      • Stiles C.
      Bibliometric review: Edmonton Symptom Assessment Scale (ESAS).
      used in clinical practice, hospital settings, home-based care, and even by telephone to assess the evolution of symptoms.
      • Chow E.
      • Wong R.
      • Connolly R.
      • et al.
      Prospective assessment of symptom palliation for patients attending a rapid response radiotherapy program: feasibility of telephone follow-up.
      The ESAS has been effectively used to measure the prevalence of symptoms,
      • Modonesi C.
      • Scarpi E.
      • Maltoni M.
      • et al.
      Impact of palliative care unit admission on symptom control evaluated by the Edmonton Symptom Assessment System.
      • De Santiago A.
      • Portela M.A.
      • Ramos L.
      • et al.
      A new palliative care consultation team at the oncology department of a university hospital: an assessment of initial efficiency and effectiveness.
      assess the effectiveness of palliative care programs in hospital centers,
      • Bruera E.
      • Kuehn N.
      • Miller M.
      • Selmser P.
      • MacMillan K.
      The Edmonton Symptom Assessment System (ESAS): a simple method for the assessment of palliative care patients.
      • Merino A.
      • Pacheco M.
      • González J.
      • et al.
      Complexity and assessment of symptom control in outpatients unit of palliative care. [in Spanish]. Abstract of the 5th National Congress of the Spanish Society of Palliative Care.
      • Dudgeon D.
      • Harlos M.
      • Clinch J.
      The Edmonton Symptom Assessment Scale (ESAS) as an audit tool.
      and measure health outcomes following interventions. Some regional cancer and palliative care programs (e.g., Ontario
      • Dudgeon D.
      • Knott C.
      • Chapman C.
      • et al.
      Development, implementation, and process evaluation of a regional palliative care quality improvement project.
      ) and cancer centers (e.g., M. D. Anderson Cancer Center, Houston
      • Bruera E.
      • Driver L.
      • Elsayem A.
      The M. D. Anderson symptom control and palliative care handbook.
      ) have included ESAS evaluation in a systematic way. The European Palliative Care Cancer Symptom Study: A Prospective Data Collection

      The European Palliative Care Cancer Symptom Study (EPCCS). A prospective data collection. Available from http://clinicaltrialsfeeds.org/clinical-trials/show/NCT01362816. Accessed July 8, 2011.

      also has adopted the ESAS-r.
      Validation studies of the ESAS were published in 2008
      • Nekolaichuk C.
      • Watanabe S.
      • Beaumont C.
      The Edmonton Symptom Assessment System: a 15-year retrospective review of validation studies (1991-2006).
      and 2009.
      • Richardson L.A.
      • Jones G.W.
      A review of the reliability and validity of the Edmonton Symptom Assessment System.
      More recently, Carvajal et al.
      • Carvajal A.
      • Centeno C.
      • Watson R.
      • Bruera E.
      A comprehensive study of psychometric properties of the Edmonton Symptom Assessment System (ESAS) in Spanish advanced cancer patients.
      carried out a comprehensive study of the psychometric properties of the Spanish ESAS when used with patients with advanced cancer. This version is slightly different than the original English version used by Watanabe et al.
      • Watanabe W.
      • Nekolaichuck C.
      • Beaumont C.
      • et al.
      A multicenter study comparing two numerical versions of the Edmonton Symptom Assessment System in palliative care patients.
      because it includes an additional item to evaluate sleep disturbance. This item was added by the creator of the ESAS and is currently used at the M. D. Anderson Cancer Center.
      • Bruera E.
      • Driver L.
      • Elsayem A.
      The M. D. Anderson symptom control and palliative care handbook.
      After a study that examined difficulties in interpreting and completing the ESAS,
      • Watanabe S.
      • Nekolaichuck C.
      • Beaumont C.
      • Mawani A.
      The Edmonton Symptom Assessment System—what do patients think?.
      and based on the literature, a revised version (ESAS-r) of the ESAS was created.
      • Watanabe W.
      • Nekolaichuck C.
      • Beaumont C.
      • et al.
      A multicenter study comparing two numerical versions of the Edmonton Symptom Assessment System in palliative care patients.
      The changes made in the ESAS-r include clarification of a number of terms, a change in the format, definition of a specific time frame relating to the ESAS, and the reordering of items. Professional assistance and support for the patient are provided when they complete the form initially. This revised version was submitted to an international cohort of patients who were requested to compare it with the original version. Results showed that patients “significantly preferred” the revised version compared with the original ESAS. The study stressed that to validate the ESAS further, a future research priority should be to examine the use of the ESAS-r in languages other than English.
      We have chosen to replicate the study by Watanabe et al.
      • Watanabe W.
      • Nekolaichuck C.
      • Beaumont C.
      • et al.
      A multicenter study comparing two numerical versions of the Edmonton Symptom Assessment System in palliative care patients.
      using the Spanish version, with an international cohort of Spanish-speaking patients. In addition, to obtain the first proof of validity of the new Spanish ESAS-r version, its psychometric properties were evaluated and compared with data from the original version.
      • Carvajal A.
      • Centeno C.
      • Watson R.
      • Bruera E.
      A comprehensive study of psychometric properties of the Edmonton Symptom Assessment System (ESAS) in Spanish advanced cancer patients.

      Methods

      Bilingual professionals experienced in palliative care and in using the ESAS drafted a Spanish version of the ESAS-r based both on the previous Spanish version and on the English revised version. A reverse translation method was used by bilingual translators to translate the ESAS into Spanish.
      • Argimon J.M.
      • Jiménez J.
      Validation of questionnaires.
      The details of this process have been reported elsewhere.
      • Carvajal A.
      • Centeno C.
      • Watson R.
      • Bruera E.
      A comprehensive study of psychometric properties of the Edmonton Symptom Assessment System (ESAS) in Spanish advanced cancer patients.
      A pilot study with advanced cancer patients was undertaken to obtain patient perceptions about the new version of the instrument. The group of experts reviewed the comments made by the patients and created a final Spanish version of the ESAS-r to be tested.
      A group of patients with advanced cancer completed the Spanish ESAS and ESAS-r; the order of the two instruments was not predetermined. All patients were older than 18 years, with normal cognitive function on the Mini-Mental State Examination (MMSE). Patients from oncology departments of tertiary hospitals were included (Spain: University of Navarra Hospital; Guatemala: National Cancer Institute). Patients with advanced cancer receiving palliative radiotherapy or chemotherapy also were eligible. We anticipated collecting data from a minimum of 30 patients in each center, as in the study by Watanabe et al.
      • Watanabe W.
      • Nekolaichuck C.
      • Beaumont C.
      • et al.
      A multicenter study comparing two numerical versions of the Edmonton Symptom Assessment System in palliative care patients.
      Patients also were asked about their perceptions of both forms and how they compared with each other. Data were gathered between December 2010 and February 2011.
      The study was approved by the Ethics Committee on Clinical Research at the University of Navarra Hospital. Written informed consent was obtained from each patient.
      The instruments used in this study were the Spanish version of the ESAS,
      • Carvajal A.
      • Centeno C.
      • Watson R.
      • Bruera E.
      A comprehensive study of psychometric properties of the Edmonton Symptom Assessment System (ESAS) in Spanish advanced cancer patients.
      the Spanish version of the ESAS-r (Fig. 1), the Palliative Performance Scale (PPS),
      • Anderson F.
      • Downing G.M.
      • Hill J.
      • Casorso L.
      • Lerch N.
      Palliative Performance Scale (PPS): a new tool.
      the MMSE,
      • Folstein M.F.
      • Folstein S.
      • McHugh P.R.
      “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician.
      the Edmonton Classification System for Cancer Pain,
      • Fainsinger R.L.
      • Nekolaichuck C.L.
      A “TNM” classification system for cancer pain: the Edmonton Classification System for Cancer Pain (ECS-CP).
      and a questionnaire requesting the patient's perception of the two versions of the ESAS (the original ESAS and the revised ESAS-r). This questionnaire was derived from the study undertaken by Watanabe et al.
      • Watanabe W.
      • Nekolaichuck C.
      • Beaumont C.
      • et al.
      A multicenter study comparing two numerical versions of the Edmonton Symptom Assessment System in palliative care patients.
      It comprises eight questions focused on the patient's familiarity with the ESAS, ease of understanding and completion, and the assessment of differences between the two versions. For quantitative analysis, patient opinion was collected on a five-point Likert scale ranging from 1 (very easy) to 5 (very hard); data were analyzed using the paired sample t-test and binomial test. Qualitative comments also were obtained.
      Figure thumbnail gr1
      Fig. 1Spanish version of the ESAS-r. Original terms of the English version of the ESAS: no pain, worst possible pain, no tiredness, worst possible tiredness, no drowsiness, worst possible drowsiness, no nausea, worst possible nausea, no lack of appetite, worst possible lack of appetite, no shortness of breath, worst possible shortness of breath, no depression, worst possible depression, no anxiety, worst possible anxiety, best sleep, worst possible sleep, best well-being, worst possible well-being, other problem. ESAS-r=Edmonton Symptom Assessment System-revised.
      A researcher administered the MMSE,
      • Folstein M.F.
      • Folstein S.
      • McHugh P.R.
      “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician.
      PPS,
      • Anderson F.
      • Downing G.M.
      • Hill J.
      • Casorso L.
      • Lerch N.
      Palliative Performance Scale (PPS): a new tool.
      and the Edmonton Classification System for Cancer Pain
      • Fainsinger R.L.
      • Nekolaichuck C.L.
      A “TNM” classification system for cancer pain: the Edmonton Classification System for Cancer Pain (ECS-CP).
      and also gathered demographic and clinical data from the patients. The ESAS and ESAS-r were completed consecutively by the patients in the presence of the researcher. The patient also filled out the structured questionnaire about their perception of the two versions of the ESAS.
      The psychometric properties of the ESAS-r that were analyzed were equivalence between the ESAS and ESAS-r by the intraclass correlation coefficient, the internal consistency of the ESAS-r measured by calculating Cronbach's alpha, the correlation between the sum of the specific items within the ESAS-r and the item “well-being” explored by the Spearman correlation, and discriminant validity evaluated by testing the difference of the ESAS-r score among patients with different functional status (measured using the PPS) by the Spearman correlation. Discrimination between inpatients and outpatients was evaluated by the Mann-Whitney U test.

      Results

      A Spanish version of the ESAS-r was created (Fig. 1). This version differs from the English version in that 1) it includes alternative terms for “fatigue” (agotamiento/exhaustion, cansancio/tiredness, or debilidad/weakness) and “anxiety” (nerviosismo/nervousness, intranquilidad/disquiet, or ansiedad/anxiousness) obtained through previous studies,
      • Centeno C.
      • Portela M.A.
      • Carvajal A.
      • et al.
      What is the best term in Spanish to express the concept of cancer-related fatigue?.
      • Noguera A.
      • Centeno C.
      • Carvajal A.
      • et al.
      Spanish “fine tuning” of language to describe depression and anxiety.
      2) it includes alternative terms for “drowsiness” (somnolencia/drowsiness or adormilado/sleepiness) and “well-being” (sentirse perfectamente/feeling perfectly or sensación de bienestar/feeling of well-being), 3) it includes the item “difficulty in sleeping” as did the previous Spanish version, and 4) it was decided that the alternative term for “other problems” should be “dry mouth,” a very prevalent symptom in palliative care,
      • Kirkova J.
      • Davis M.
      • Walsh D.
      • et al.
      Cancer symptom assessment instruments: a systematic review.
      rather than “constipation” because a previous study
      • Noguera N.
      • Centeno C.
      • Librada S.
      • Nabal M.
      Screening for constipation in palliative care patients.
      found that patients with a perception of constipation, based on visual numerical scales, did not have good correlation with symptoms of constipation and vice versa.
      A total of 14 patients with advanced cancer participated in the pilot study, using a format similar to that of the English version of the ESAS-r. It was noted that patients perceived the new version of the ESAS (ESAS-r) as difficult to read, so some changes in the format were made to obtain a clearer design, that is, print size of the items was changed and shading was added (Fig. 1).
      A total of 66 patients with advanced cancer completed the ESAS and ESAS-r. Table 1 describes the demographic and clinical characteristics of the participants. Average scores for the ESAS and ESAS-r are summarized in Table 2.
      Table 1Patient Characteristics (N=66)
      Characteristicsn (%)
      Gender
       Female46 (70)
       Male20 (30)
      Primary cancer diagnosis
       Gastrointestinal24 (36)
       Genitourinary16 (24)
       Lung3 (5)
       Breast12 (18)
       Other cancer11 (17)
      Current cancer treatment
       Chemotherapy34 (51)
       Radiotherapy5 (8)
       Chemo and radiotherapy1 (2)
       Palliative care only26 (39)
      Education level (years)
       Primary (0–8)31 (47)
       Secondary (8–12)20 (30)
       High (>12)15 (23)
      Prognostic factors in pain control as per ECS-CP
       Neuropathic pain15 (23)
       Incident pain19 (29)
       Psychological distress3 (5)
       Addictive behavior0 (0)
       Cognitive status impaired1 (2)
      Previously filled out ESAS
       No52 (79)
       Yes9 (14)
       Unknown5 (7)
      Patient setting
       Outpatient54 (82)
       Inpatient12 (18)
      Age (years), mean (range)54 (18–84)
      MMSE (average), range 0–3028 (23–30)
      PPS (average), range 0–100%78 (40–100)
      ECS-CP=The Edmonton Classification System for Cancer Pain; ESAS=Edmonton Symptom Assessment System; MMSE=Mini-Mental State Examination; PPS=Palliative Performance Scale.
      Table 2ICC for Symptom Rating Using ESAS and ESAS-r Average Symptom Rating
      Symptoms (N=66)Mean (SD)ICC95% CI
      ESASESAS-r
      Insomnia3.8 (3.5)3.8 (3.6)0.940.91–0.96
      Depression2.8 (3.3)2.9 (3.4)0.920.87–0.95
      Drowsiness3.4 (3.2)3.3 (3.1)0.900.85–0.94
      Lack of appetite3.6 (3.4)3.4 (3.7)0.880.81–0.92
      Tiredness3.7 (3.3)3.5 (3.0)0.860.78–0.91
      Pain2.9 (3.0)2.9 (3.1)0.850.77–0.90
      Well-being3.8 (3.1)3.9 (2.8)0.850.77–0.90
      Anxiety2.1 (2.9)2.2 (2.8)0.820.72–0.88
      Nausea1.0 (2.1)1.0 (2.2)0.750.62–0.83
      Shortness of breath1.5 (2.7)1.5 (2.5)0.710.56–0.81
      ICC=intraclass correlation coefficient; ESAS=Edmonton Symptom Assessment System; ESAS-r=Edmonton Symptom Assessment System-revised.
      Overall, the ESAS-r was easier to understand and complete than the ESAS (Table 3). Patients “significantly preferred” the ESAS-r to the ESAS (Table 3), the most frequent reason being that alternative terms provided more explanation of the items (n=14). Patients also thought that the ESAS-r was visually clearer and easier to read with the gray shadow (n=5) and appreciated that the time frame on symptom assessment was included (n=2). In regard to preference for one or the other version, there were no significant differences either in the educational level or previous experience with the ESAS. However, there were significant differences in this preference when the ESAS-r was the first questionnaire filled out; most of these patients preferred the ESAS-r (Table 4).
      Table 3Comparison of the Spanish Versions of the ESAS and ESAS-r in 66 Patients With Advanced Cancer
      QuestionsESASESAS-rNo PreferenceP-value
      How easy was it to understand each form?
      Scale=1 (very easy) to 5 (very hard).
      Mean (SD)
      1.88 (0.95)1.51 (0.92)0.001
      P<0.05.
      How easy was it to fill out each form?
      Scale=1 (very easy) to 5 (very hard).
      Mean (SD)
      1.77 (0.99)1.56 (0.93)0.042
      P<0.05.
      Overall, which form do you prefer? n (%)10 (15)31 (47)25 (38)0.0007
      P<0.05.
      ESAS=Edmonton Symptom Assessment System; ESAS-r=Edmonton Symptom Assessment System-revised.
      a Scale=1 (very easy) to 5 (very hard).
      b P<0.05.
      Table 4Associations Among Preference for ESAS or ESAS-r and Level of Education, Order of Completion, and Whether Patients Previously Completed the Questionnaire
      CharacteristicsESAS Preference (%)ESAS-r Preference (%)Same Preference (%)P-value
      ESAS vs. ESAS-r by Chi-squared analysis.
      Level of education
       Primary (n=31)7 (23)14 (45)10 (32)0.116
       Secondary (n=20)2 (10)6 (30)12 (60)
       High level (n=15)1 (7)11 (73)3 (20)
      First version completed
       ESAS (n=40)9 (23)15 (37)16 (40)0.02
      P<0.05.
       ESAS-r (n=26)1 (4)16 (61)9 (35)
      Previous experience with ESAS
       Yes (n=9)0 (0)7 (78)2 (22)0.098
       No (n=52)9 (17)23 (44)20 (39)
       Does not remember (n=5)1 (20)1 (20)3 (60)
      ESAS=Edmonton Symptom Assessment System; ESAS-r=Edmonton Symptom Assessment System-revised.
      a ESAS vs. ESAS-r by Chi-squared analysis.
      b P<0.05.
      When asked how different their responses were between the ESAS and ESAS-r on a five-point Likert scale, most patients reported that there was “no difference,” 31 participants reported that the difference was “not important” (rating=1), whereas 11 participants said that the difference was “very important” (rating=5).
      Table 5 presents the results of the psychometric properties measured in the Spanish version of the ESAS-r. Internal consistency obtained a coefficient of 0.86 using Cronbach's alpha. The equivalence reliability between the ESAS and ESAS-r obtained a correlation higher than 0.7 in all the symptoms by the intraclass correlation coefficient (Table 2). The correlation of the item “well-being” also was evaluated with the sum of the individual items, and a moderate correlation between the two variables was found (r=0.67).
      Table 5Results of the Psychometric Analysis for the Spanish Versions of the ESAS-r and ESAS (N=66)
      AspectInstrumentStatistical TestESAS-rESAS
      • Carvajal A.
      • Centeno C.
      • Watson R.
      • Bruera E.
      A comprehensive study of psychometric properties of the Edmonton Symptom Assessment System (ESAS) in Spanish advanced cancer patients.
      Reliability
       Internal consistencyESAS-rCronbach's alpha0.860.75
       Correlation sum of individual items and item well-beingESAS-rSpearman's rhor=0.67r=0.73
       EquivalenceESAS and ESAS-rICCFrom r=0.71 (shortness of breath) to r=0.94 (depression)
      Validity
       Discriminant validityESAS-r between outpatients (n=54) and inpatients (n=12)Mann-Whitney U(P=0.02)(P<0.001) (outpatients n=154; inpatients n=57)
      Inpatients with different performance status
      Palliative Performance Scale was used in the ESAS-r survey, and the Karnofsky Performance Status was used in the ESAS survey.
      Spearman's rho
      • Pain, tiredness, drowsiness, lack of appetite, well-being, difficulty breathing (r=−0.38 to −0.49) (P<0.01)
      • Other symptoms: nausea, anxiety, depression, difficulty in sleeping (r=−0.10 to 0.19) (P>0.01)
      • Pain, tiredness, drowsiness, lack of appetite, well-being, depression, difficulty in breathing, anxiety (r=−0.21 to –0.54) (P<0.001)
      • Nausea and difficulty in sleeping (r=0.12–0.18) (P>0.01)
      ESAS-r=Edmonton Symptom Assessment System-revised; ESAS=Edmonton Symptom Assessment System; ICC=intraclass correlation coefficient.
      a Palliative Performance Scale was used in the ESAS-r survey, and the Karnofsky Performance Status was used in the ESAS survey.
      Discriminant validity of the ESAS-r was evaluated by measuring whether the ESAS scores differed depending on the patient's functional status (using the PPS). Negative correlation (r=−0.38 to −0.45) was found for five items (pain, tiredness, drowsiness, lack of appetite, and well-being). Nevertheless, no significant correlation with the PPS was found for the other symptoms (nausea, anxiety, depression, difficulty in sleeping and breathing). Even being a significant value (P<0.001), the low correlation indicates a weak clinical relevance. A significant correlation between the scores of the ESAS-r for inpatients and outpatients also was found (P=0.02).

      Discussion

      A revised Spanish version of the ESAS (ESAS-r) was developed, and it was perceived by patients as both easier to understand and complete than the ESAS. Moreover, the ESAS-r was “significantly preferred” by the patients because of the inclusion of alternative terms that clarified symptoms and also because of the clarity of the format. Watanabe et al.
      • Watanabe W.
      • Nekolaichuck C.
      • Beaumont C.
      • et al.
      A multicenter study comparing two numerical versions of the Edmonton Symptom Assessment System in palliative care patients.
      drew the same conclusions as the present study and highlighted how the definition of certain terms can be helpful in training new staff to administer the tool.
      Both Spanish versions correlated well (eight of 10 items more than 0.82) (Table 2). The correlation was higher than that in the study by Watanabe et al.
      • Watanabe W.
      • Nekolaichuck C.
      • Beaumont C.
      • et al.
      A multicenter study comparing two numerical versions of the Edmonton Symptom Assessment System in palliative care patients.
      This is possibly because the terms used in the Spanish versions of the ESAS and ESAS-r in this study were amended after studies of clarification of terms
      • Centeno C.
      • Portela M.A.
      • Carvajal A.
      • et al.
      What is the best term in Spanish to express the concept of cancer-related fatigue?.
      • Noguera A.
      • Centeno C.
      • Carvajal A.
      • et al.
      Spanish “fine tuning” of language to describe depression and anxiety.
      that could be problematic for patients; subsequently, the terminology used in this study was adequate in the Spanish context. In the study by Watanabe et al.,
      • Watanabe W.
      • Nekolaichuck C.
      • Beaumont C.
      • et al.
      A multicenter study comparing two numerical versions of the Edmonton Symptom Assessment System in palliative care patients.
      the correlation of the items was weaker, especially for the following three symptoms: drowsiness, appetite, and well-being. The authors justified these differences in the correlation, suggesting that the definitions included in the ESAS-r provided greater clarity in the interpretation of the items and that the responses obtained between the two scales were different.
      A comparison of results relating to the psychometric properties of both Spanish versions of the ESAS is shown in Table 5. The internal consistency of the ESAS-r was better than the Spanish ESAS version (0.75).
      • Carvajal A.
      • Centeno C.
      • Watson R.
      • Bruera E.
      A comprehensive study of psychometric properties of the Edmonton Symptom Assessment System (ESAS) in Spanish advanced cancer patients.
      These results suggest that the items are interrelated and they confirm the consistency of the instrument. The results obtained in the English versions of the ESAS also demonstrated good values in different studies: 0.79,
      • Chang V.
      • Hwang S.
      • Feuerman M.
      Validation of the Edmonton Symptom Assessment Scale.
      0.80,
      • Easson A.M.
      • Bezjak A.
      • Ross S.
      • Wright J.G.
      The ability of existing questionnaires to measure symptom change after paracentesis for symptomatic ascites.
      and 0.93.
      • Tierney R.M.
      • Horton S.M.
      • Hannan T.J.
      • Tierney W.N.
      Relationships between symptom relief, quality of life and satisfaction with hospice care.
      Between 0.8 and 0.9, reliability is good. Higher values mean excellent reliability.
      • George D.
      • Mallery P.
      SPSS/PC+ step by step: A simple guide and reference.
      The correlation of the item “feeling of well-being” with the sum of the individual items was moderate (r=0.67). This result is similar to that of a previous study,
      • Carvajal A.
      • Centeno C.
      • Watson R.
      • Bruera E.
      A comprehensive study of psychometric properties of the Edmonton Symptom Assessment System (ESAS) in Spanish advanced cancer patients.
      suggesting that this item can be related to the overall burden of symptoms.
      We investigated whether ESAS scores varied according to the patient's functional status; this was determined by means of the PPS. A significant correlation was found in five items. These results seem consistent with the fact that those patients with higher scores for symptoms on the ESAS have lower worsened functional status. These results are quite similar to those obtained in the study of the previous Spanish version of the ESAS
      • Carvajal A.
      • Centeno C.
      • Watson R.
      • Bruera E.
      A comprehensive study of psychometric properties of the Edmonton Symptom Assessment System (ESAS) in Spanish advanced cancer patients.
      and suggest that ESAS scores might assist clinicians when considering the patient's functional status.
      Patients who had completed the ESAS previously preferred the ESAS-r in contrast with the study by Watanabe et al.,
      • Watanabe W.
      • Nekolaichuck C.
      • Beaumont C.
      • et al.
      A multicenter study comparing two numerical versions of the Edmonton Symptom Assessment System in palliative care patients.
      which did not find significant differences in ESAS-r preference between those who had previously completed the ESAS and those who had not. It could be hypothesized that patients who possess experience in using the ESAS have more information about the instrument, and this could, therefore, help them when comparing both versions. However, further studies with larger samples need to be carried out to support this result.
      The ESAS was relatively easy to understand at different cultural levels. It was found that the level of patient education does not significantly influence preference for either the ESAS or ESAS-r, a finding confirmed by Watanabe et al.
      • Watanabe W.
      • Nekolaichuck C.
      • Beaumont C.
      • et al.
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      However, some patients with basic education required varying degrees of assistance to understand the tool. Understanding of the ESAS and ESAS-r by patients with lower educational levels will require further investigation.
      Some limitations of this study are worthy of mention. Most patients were unfamiliar with completing the ESAS, which may have affected their perception of the measure. Also, it should be noted that the functional status of the sample in this study was high.
      We conclude that the ESAS-r is a valid instrument that improves the psychometric properties of previous versions of the ESAS and that patients find it both easier to understand and complete. The new Spanish version of the ESAS-r can, therefore, replace other previous versions of the instrument.

      Disclosures and Acknowledgments

      No funding was received for this study and the authors declare no conflicts of interest.
      The authors acknowledge the advice of Sharon Watanabe and Cheryl Nekolaichuck, who reviewed the manuscript.

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