Quality of life as an endpoint in EORTC clinical trials. European Organization for Research and Treatment for Cancer

A Prospective Study on Health-Related Quality of Life and Patient-Reported Outcomes in Adult Brain Tumor Patients Treated with Pencil Beam Scanning Proton Therapy

Proton therapy (PT) is delivered to complex brain tumors to obtain an optimal curative treatment with limited toxicity. Value-based oncological medicine is increasingly important, particularly when long-term survival is to be expected. This study aims to evaluate health-related quality of life (HRQOL) and patient reported outcomes (PROs) in patients treated with PT for brain tumors. Adult patients with brain tumors treated with PT filled out the EORTC-QLQ-C30 and BN20 questionnaires up to three years following PT. Toxicity was scored using the CTCAE v4.03. QoL and PRO were correlated to clinical factors. Three-year overall survival, distant brain control and local control rates were 98%, 97% and 84%, respectively. No ≥G3 acute toxicity was observed. Late PT-related ≥G3 severe toxicity occurred in seven patients (5.7%). Lower global QoL scores after PT were significantly correlated to low Karnofsky performance status (KPS) before PT (p = 0.001), surgical complications before PT (p = 0.04) and progressive disease (p = 0.017). A low QLQ-30 summary score at one year follow-up was correlated to sex (p = 0.015), low KPS before PT (p < 0.001), and central nervous system symptoms before PT (p = 0.018). Reported QLQ-BN20 neurological symptoms were correlated to lower KPS at baseline (p < 0.001) and surgical complications before PT (p = 0.03). PT-related toxicity only influenced reported symptoms directly following PT, but not QoL. Although global QoL temporarily decreased after treatment, it improved again from one year onwards. Global QoL and reported symptoms over time were not correlated with the proton therapy and were more related to preexisting symptoms and progressive disease. This study assists in improving patient support in patients with brain tumors receiving PT.

Impact of open-label versus blinded study design on patient-reported outcomes data in randomized clinical trials of immunotherapy in advanced or metastatic cancer patients: a systematic review

AIM

A systematic literature review of immuno-oncology trials was conducted to assess the potential impact of open-label vs double-blind trial design on patient-reported outcome (PRO) data.

METHODS

A systematic search of indexed literature published from January 2009 to May 2019 was conducted using PubMed/MEDLINE, Cochrane Library, and EMBASE database. All randomized clinical trials (RCTs) of immuno-oncology therapies on advanced cancer patients reporting PRO data were identified. Descriptive analyses were performed to quantify differences at baseline and over time, by the type of study, regarding questionnaire completion rate and PRO scores.

RESULTS

In total, 23 studies were retained (15 open-label, 8 blinded). At baseline, no difference in completion rate was observed between arms irrespective of trial design (absolute mean difference of 2.8% and 2.2% for open label and blinded studies, respectively). No clinically significant difference in baseline PRO scores was observed between arms. Over time, impact on PRO scores could not be identified due to the limited number of studies, heterogeneity of questionnaires and tumor types.

CONCLUSIONS

Trial design had no impact on PRO completion rate or baseline scores. Future research should involve analyses by specific cancer types and ideally compare individual data from two similar RCTs (blinded vs. open-label).

Quality of patient-reported outcome reporting according to the CONSORT statement in randomized controlled trials with glioblastoma patients

Background

Randomized controlled trials (RCTs) represent the best evidence in oncology research. Glioblastoma is the most frequent and deadly primary brain tumor, affecting health-related quality of life. An important end point is patient-reported outcomes (PROs). There are no data regarding how well publications of glioblastoma RCTs report PROs. A specific PRO extension of the Consolidated Standards of Reporting Trials (CONSORT) statement was created to improve the quality of reporting. The aim of this study was to evaluate adherence to the CONSORT-PRO statement in reporting RCTs addressing the treatment of patients with glioblastoma. PRO analysis methodology was explored and criteria associated with higher quality of reporting were investigated.

Methods

From PubMed/MEDLINE and the Cochrane Library databases, all phase 2 and 3 RCTs related to glioblastoma published between 1995 and 2018 were reviewed according to the CONSORT-PRO statements. An overall quality score on a 0 to 100 scale was defined based on these criteria and factors associated with this score were identified.

Results

Forty-four RCTs were identified as relevant according to predefined criteria. The median overall quality score was 26. No difference was observed regarding reporting quality over the years. CONSORT-PRO items concerning data collection and analysis were poorly reported. Thirty-four trials (77%) used longitudinal data. The most frequent statistical method for PROs analysis was the mean change from baseline (63%). Factors associated with improved overall quality score were the presence of a secondary publication dedicated to PROs results, the statement of any targeted dimensions, and when trials reported results using multiple methods.

Conclusion

Despite the importance of measuring PROs in patients with glioblastoma, employment of the CONSORT-PRO statement is poor in RCTs.

Longitudinal analysis of health-related quality of life in cancer clinical trials: methods and interpretation of results

PURPOSE

Health-related quality of life (HRQoL) is assessed by self-administered questionnaires throughout the care process. Classically, two longitudinal statistical approaches were mainly used to study HRQoL: linear mixed models (LMM) or time-to-event models for time to deterioration/time until definitive deterioration (TTD/TUDD). Recently, an alternative strategy based on generalized linear mixed models for categorical data has also been proposed: the longitudinal partial credit model (LPCM). The objective of this article is to evaluate these methods and to propose recommendations to standardize longitudinal analysis of HRQoL data in cancer clinical trials.

METHODS

The three methods are first described and compared through statistical, methodological, and practical arguments, then applied on real HRQoL data from clinical cancer trials or published prospective databases. In total, seven French studies from a collaborating group were selected with longitudinal collection of QLQ-C30. Longitudinal analyses were performed with the three approaches using SAS, Stata and R software.

RESULTS

We observed concordant results between LMM and LPCM. However, discordant results were observed when we considered the TTD/TUDD approach compared to the two previous methods. According to methodological and practical arguments discussed, the approaches seem to provide additional information and complementary interpretations. LMM and LPCM are the most powerful methods on simulated data, while the TTD/TUDD approach gives more clinically understandable results. Finally, for single-item scales, LPCM is more appropriate.

CONCLUSION

These results pledge for the recommendation to use of both the LMM and TTD/TUDD longitudinal methods, except for single-item scales, establishing them as the consensual methods for publications reporting HRQoL.

A systematic review and development of a classification framework for factors associated with missing patient-reported outcome data

BACKGROUND/AIMS

Missing patient-reported outcome data can lead to biased results, to loss of power to detect between-treatment differences, and to research waste. Awareness of factors may help researchers reduce missing patient-reported outcome data through study design and trial processes. The aim was to construct a Classification Framework of factors associated with missing patient-reported outcome data in the context of comparative studies. The first step in this process was informed by a systematic review.

METHODS

Two databases (MEDLINE and CINAHL) were searched from inception to March 2015 for English articles. Inclusion criteria were (a) relevant to patient-reported outcomes, (b) discussed missing data or compliance in prospective medical studies, and (c) examined predictors or causes of missing data, including reasons identified in actual trial datasets and reported on cover sheets. Two reviewers independently screened titles and abstracts. Discrepancies were discussed with the research team prior to finalizing the list of eligible papers. In completing the systematic review, four particular challenges to synthesizing the extracted information were identified. To address these challenges, operational principles were established by consensus to guide the development of the Classification Framework.

RESULTS

A total of 6027 records were screened. In all, 100 papers were eligible and included in the review. Of these, 57% focused on cancer, 23% did not specify disease, and 20% reported for patients with a variety of non-cancer conditions. In total, 40% of the papers offered a descriptive analysis of possible factors associated with missing data, but some papers used other methods. In total, 663 excerpts of text (units), each describing a factor associated with missing patient-reported outcome data, were extracted verbatim. Redundant units were identified and sequestered. Similar units were grouped, and an iterative process of consensus among the investigators was used to reduce these units to a list of factors that met the guiding principles. The list was organized on a framework, using an iterative consensus-based process. The resultant Classification Framework is a summary of the factors associated with missing patient-reported outcome data described in the literature. It consists of 5 components (instrument, participant, centre, staff, and study) and 46 categories, each with one or more sub-categories or examples.

CONCLUSION

A systematic review of the literature revealed 46 unique categories of factors associated with missing patient-reported outcome data, organized into 5 main component groups. The Classification Framework may assist researchers to improve the design of new randomized clinical trials and to implement procedures to reduce missing patient-reported outcome data. Further research using the Classification Framework to inform quantitative analyses of missing patient-reported outcome data in existing clinical trials and to inform qualitative inquiry of research staff is planned.

Inconsistencies in quality of life data collection in clinical trials: a potential source of bias? Interviews with research nurses and trialists

Background

Patient-reported outcomes (PROs), such as health-related quality of life (HRQL) are increasingly used to evaluate treatment effectiveness in clinical trials, are valued by patients, and may inform important decisions in the clinical setting. It is of concern, therefore, that preliminary evidence, gained from group discussions at UK-wide Medical Research Council (MRC) quality of life training days, suggests there are inconsistent standards of HRQL data collection in trials and appropriate training and education is often lacking. Our objective was to investigate these reports, to determine if they represented isolated experiences, or were indicative of a potentially wider problem.

Methods And Findings

We undertook a qualitative study, conducting 26 semi-structured interviews with research nurses, data managers, trial coordinators and research facilitators involved in the collection and entry of HRQL data in clinical trials, across one primary care NHS trust, two secondary care NHS trusts and two clinical trials units in the UK. We used conventional content analysis to analyze and interpret our data. Our study participants reported (1) inconsistent standards in HRQL measurement, both between, and within, trials, which appeared to risk the introduction of bias; (2), difficulties in dealing with HRQL data that raised concern for the well-being of the trial participant, which in some instances led to the delivery of non-protocol driven co-interventions, (3), a frequent lack of HRQL protocol content and appropriate training and education of trial staff, and (4) that HRQL data collection could be associated with emotional and/or ethical burden.

Conclusions

Our findings suggest there are inconsistencies in the standards of HRQL data collection in some trials resulting from a general lack of HRQL-specific protocol content, training and education. These inconsistencies could lead to biased HRQL trial results. Future research should aim to develop HRQL guidelines and training programmes aimed at supporting researchers to carry out high quality data collection.

Patient reported outcomes (PROs) in clinical trials: is 'in-trial' guidance lacking? a systematic review

Background

Patient reported outcomes (PROs) are increasingly assessed in clinical trials, and guidelines are available to inform the design and reporting of such trials. However, researchers involved in PRO data collection report that specific guidance on ‘in-trial’ activity (recruitment, data collection and data inputting) and the management of ‘concerning’ PRO data (i.e., data which raises concern for the well-being of the trial participant) appears to be lacking. The purpose of this review was to determine the extent and nature of published guidelines addressing these areas.

Methods and Findings

Systematic review of 1,362 articles identified 18 eligible papers containing ‘in-trial’ guidelines. Two independent authors undertook a qualitative content analysis of the selected papers. Guidelines presented in each of the articles were coded according to an a priori defined coding frame, which demonstrated reliability (pooled Kappa 0.86–0.97), and validity (<2% residual category coding). The majority of guidelines present were concerned with ‘pre-trial’ activities (72%), for example, outcome measure selection and study design issues, or ‘post-trial’ activities (16%) such as data analysis, reporting and interpretation. ‘In-trial’ guidelines represented 9.2% of all guidance across the papers reviewed, with content primarily focused on compliance, quality control, proxy assessment and reporting of data collection. There were no guidelines surrounding the management of concerning PRO data.

Conclusions

The findings highlight there are minimal in-trial guidelines in publication regarding PRO data collection and management in clinical trials. No guidance appears to exist for researchers involved with the handling of concerning PRO data. Guidelines are needed, which support researchers to manage all PRO data appropriately and which facilitate unbiased data collection.

Evaluating Palliative Care—A Review of the Literature

The purpose of this article was to investigate the outcome measures developed and used in palliative care. The paper involved a literature review of published research. Many of the reviewed papers concluded similarly that there was lack of good quality evidence on which to base conclusions. More high quality evidence is needed to compare the relative merits of the differences in models of palliative care services, so that we can learn from other appropriate systems of care at end of life. It follows that quality of life is the main outcome of palliative care, in which the patient instead of the disease represents the target of the clinical approach. Patients struggling with serious illness have other concerns, including managing pain and other symptoms, coordinating care among multiple providers and settings, ensuring that treatments reflect preferences and balance benefits and harms as well as clinical appropriateness, achieving empathic communication and care, fostering well-being, maintaining function and practically supporting family and caregivers through illness and bereavement.

Problems eliciting cues in SEIQoL-DW: quality of life areas in small-cell lung cancer patients

The Schedule of Individual Quality of Life - Direct Weighting (SEIQoL-DW) is an individualized approach in the measurement of quality of life in which patients can choose, value and weight five areas that they consider important for their quality of life. Although a number of studies have reported on the feasibility of the administration of the instrument, little is known about how patients choose and define these five areas, the so-called 'cues'. This article describes problems in the elicitation of cues experienced in a qualitative, exploratory study among small-cell lung cancer patients (n = 31) in the Netherlands. Cues originate from patient-interviewer interaction which is best described as an area of tension between the patient's answers and the instrument instructions. As a result, the interviewer may inadvertently introduce bias while attempting to elicit cues, ultimately affecting patients' SEIQoL-DW measures. In order to prevent possible unnoticed interviewer bias special attention should be paid to the interviewer behaviour. Methods to record the meaning of cues should be considered. More research is needed in order to investigate differences in nominating cues with and without the use of the prompt list.

Quality of life as an endpoint in Phase I oncology clinical trials of novel chemotherapy drugs

This paper examines the rationale, utility and feasibility of including quality of life as an outcome measure in Phase I trials of new applications of chemotherapy drugs. Typically, Phase I trials in oncology are designed to assess safety and maximal tolerated dose; however, it is argued that when subjectively assessed, self perceived quality of life is as important as physical toxicity. The outcomes of studies that have applied quality-of-life assessment in Phase I trials are reviewed, and recommendations are made for future research based on both methodologic and practical considerations.

Proxy ratings of health related quality of life in patients with hepatocellular carcinoma

The present study prospectively assessed consistency of ratings of health-related quality of life between patients with hepatocellular carcinoma and two types of proxy raters, family caregivers and oncologist care providers. Patients and proxies completed the Functional Assessment of Cancer Therapy-Hepatobiliary (FACT-Hep) at baseline prior to treatment (82 patients plus proxies), at 3-months (32 patients plus proxies), and 6-months follow up (16 patients plus proxies) after diagnosis. Patient and proxy demographic data and patient medical data were also collected. At baseline, significant intra-class correlations (ICC) were found for patient--caregiver ratings of physical, social/family, and functional well-being, additional concerns (symptoms, side effects), and overall health related quality of life (HRQL); for patient--care provider ratings of physical well-being; and for caregiver--care provider ratings of physical and emotional well-being. At 3-months follow-up, the most significant number of ICCs were recorded across all three rater pairs. Significant consistencies were found for overall HRQL, and all subscale scores except for social and family well-being. The fewest significant ICCs were found at the 6-month follow-up, and were for patient--caregiver ratings of physical and functional well-being, and additional concerns; and for caregiver--care provider ratings on overall HRQL. These results suggest that family caregivers are adequate proxies of patient physical and functional well-being and additional concerns throughout the patient's illness, more so than oncologist care providers. Further research is warranted with larger samples.

Individualized quality of life, standardized quality of life, and distress in patients undergoing a phase I trial of the novel therapeutic Reolysin (reovirus)

BACKGROUND

The purpose of this study was to evaluate the individualized and standardized quality of life (QL) and psychological distress of patients participating in a Phase I trial of the novel therapeutic reovirus (Reolysin).

METHODS

16 patients with incurable metastatic cancer were interviewed prior to being accepted into the phase I trial with a semi-structured expectations interview, the Schedule for the Evaluation of Individual Quality of Life--Direct Weighting (SEIQoL-DW), the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30), the Brief Symptom Inventory (BSI), the Beck Depression Inventory (BDI), and the Spiritual Health Inventory (SHI).

RESULTS

Patients were able to complete all measures. They felt hopeful and excited about the trial, with about two thirds hoping for disease regression and one third hoping for a cure. The most commonly spontaneously nominated areas of QL were family relationships, activities and friends, and the overall SEIQoL mean index score was 69. Health was nominated by only 38% of the sample. Scores on the SEIQoL were correlated with global QL on the EORTC QLQ C-30. Scores on the BDI and BSI were lower than reported for similar populations, and on the SHI scores were similar to other samples. Global QL on the EORTC QLQ C-30 and depression scores were associated with time to death in the nine patients who had died at the time of writing.

CONCLUSIONS

Individualized QL is easy to assess in seriously ill cancer patients, provides useful information relative to each individual, and is related to standard QL measures. Repeated assessment of individualized QL of patients in Phase I trials would be a useful addition to the research.

Beyond efficacy and effectiveness: conducting economic analyses during clinical trials

Few studies have examined cost issues in the field of dysphagia. This study presents cost data collected during a clinical trial in speech-language pathology, demonstrating the types of cost analyses that can be conducted and highlighting obstacles and issues facing investigators who seek to conduct economic analyses in this arena. Seventy-nine patients were enrolled in the clinical trial to assess the impact of a swallowing intervention on swallowing and speech function. The patients were at least one year past treatment for head and neck cancer. No significant intervention differences were detected in these outcomes. A companion economic analysis was conducted in 37 of these patients using patient diaries and followup with identified health care providers. Analyses indicated that (1) the intervention did not significantly reduce health care expenditures; (2) indirect costs and costs of hospitalizations are both important factors to consider during a trial; and (3) health care costs of this population are high relative to the rest of the U.S. population. Attrition from the overall study population can pose a serious threat to the viability of an economic study. The article concludes with a discussion of how these issues can be addressed in future studies.

Quality of life as a clinical trial endpoint: determining the appropriate interval for repeated assessments in patients with advanced lung cancer

One of the unresolved design issues for clinical trials with quality of life (QOL) as an endpoint is the frequency of measurement in patients with stage III and IV lung cancer. In a retrospective review of clinical trials, the QOL interval varied widely from 1 to 12 weeks during treatment. During follow-up, the interval was generally 2 to 3 months or not at all. The purpose of this methodological study was to determine an appropriate interval for QOL serial measurement based on prospectively collected data. The 20 patients for this study were part of a phase I/I study using combination chemotherapy in patients with advanced non-small cell lung cancer (NSCLC). They were typical of patients in lung cancer clinical trials, with a median age of 67 (interquartile range: 58, 72) years, the majority were male (13, 65%), and a baseline median Karnofsky performance status was 80 (interquartile range: 70%, 90%). The primary instrument, developed in 1985, was the Lung Cancer Symptom Scale (LCSS) patient form, a 9-item self-report and site-specific QOL measure. The method, outcome, and implication of these findings to research are presented for establishing a method for obtaining an appropriate serial measurement interval for QOL during therapy in clinical trials. Based on the findings of this study, an every 3-week QOL assessment for patients with advanced NSCLC provides data similar to more frequent evaluation (94% of data preserved compared to twice-weekly assessment, 95% confidence interval, 86-98%, p=0.05). Less frequent assessment (every 4 or every 6 weeks) retained less than 85% of the data, which is the recommended minimum adequacy rate. Retaining a high percentage of QOL information may lessen the effect of measurement bias due to patient attrition and may give more validity to QOL studies.

Use of health-related quality of life in prescribing research. Part 2: methodological considerations for the assessment of health-related quality of life in clinical trials

This article aims to address key methodological issues that should be considered when assessing health-related quality of life (HRQoL) in a clinical trial. These include justification for the selection of HRQoL as a primary or secondary outcome and choice of an appropriate instrument to assess HRQoL, which meets basic psychometric properties. In addition we consider ways to minimize bias within the trial through optimization of compliance and timing of assessments.

Quality of life in patients with aggressive non-Hodgkin's lymphoma. Validation of the medical outcomes study short form 20 and the Rotterdam symptom checklist in older patients

In the elderly population, cancer treatment aims to cure and/or maintain Quality of Life (QoL). However, there is little QoL data to provide evidence for QoL benefits for some of the cancer treatments. This pilot study developed valid QoL questionnaires in French, for patients over 65 years with a diagnosis of large cell lymphoma, part of the Lymâge phase II study. They were asked to complete two questionnaires, the Medical Outcomes Study Short Form 20 (MOS SF20; generic) and the Rotterdam symptom checklist (RSCL; cancer-specific). Between June 1995 and April 1997, questionnaires were returned by 63 of 89 patients. This article reports the process undertaken to adapt the English version to a French setting, and provides the results of factor analysis, convergent and discriminant validity and reliability. Our data suggest that QoL questionnaires can be used in elderly patients. These two questionnaires are validated in French and would help us to analyse the QoL of elderly patients with the development of new treatments as done in the Lymâge study.

Practical problems with the collection and interpretation of serial quality of life assessments in patients with malignant glioma

OBJECTIVES

To assess the problems involved with the collection and interpretation of serial collected health related quality of life assessments in patients with malignant glioma.

PATIENTS AND METHODS

One-hundred and fifty nine patients with malignant glioma from three Scottish neurosurgical centres in whom assessments of performance status, neurological impairment, mood, and quality of life had been recorded over a 6-month period were prospectively identified. The amount of missing data and the reasons for missing data were assessed. Characteristics of patients that were fully compliant with serial assessments were then compared with those that were not.

RESULTS

Compliance with serial assessments (both patient and observer reported) was poor, dropping to less than 50% at 6 months. Observer reported measures showed a similar pattern of decline as patient reported measures. The largest single cause of missing data (approximately 70%) was due to administrative failure. Compliant patients were found to have a significantly greater probability of survival compared to non-compliant patients and were also found to be younger and fitter relative to the rest of the study population.

CONCLUSIONS

Studies utilising quality of life outcomes should give early consideration to minimising avoidable sources of missing data and recording the reasons for non-compliance. Quality of life studies basing conclusions on a complete case analysis should be wary of possible bias.

The challenges and achievements involved in implementing Quality of Life research in cancer clinical trials

Over the last decade, Quality of Life (QOL) research has become an important aspect of cancer clinical trials. A dramatically increasing number of published studies, both randomised and non-randomised, report QOL outcomes. There is increasing evidence that QOL results impact on both future research and treatment decisions for clinicians. The rising number of studies with QOL components is mirrored within the European Organization for Research and Treatment of Cancer (EORTC), one of the largest cancer clinical trial organisations in Europe. Clinical trial groups have frequently reported on the difficulties and challenges of implementing QOL research. In the following paper, we therefore examine past experience in EORTC QOL studies, with a focus on the challenges presented and the improved approaches that are being implemented to obtain more meaningful outcomes.

Feasibility and compliance of automated measurement of quality of life in oncology practice

PURPOSE

Systematic quality-of-life (QOL) assessment may have value in oncology practice by increasing awareness of a wide range of issues, possibly increasing detection of psychologic morbidity, social problems, and changes in physical status, and improving care and its outcomes. However, logistic problems are substantial. Automated systems solve many of these problems. We field-tested the feasibility and compliance that can be achieved using a computer touchscreen system in two consecutive studies.

PATIENTS AND METHODS

In study 1, a prospective cohort of 272 patients was offered QOL assessment at each clinic appointment for 6 months. In study 2, all patients (N = 1,291) were offered QOL assessment as part of clinic routine during a 12-week period.

RESULTS

In study 1, 82% of patients agreed to take part, but over time, compliance was poor (median, 40%; mean, 43%) and deteriorated with longer follow-up. In study 2, the overall compliance was greatly increased (median, 100%; mean, 70%), and compliance was retained over multiple visits. In study 1, compliance was better in younger patients, males, and socially advantaged patients, but was not affected by the presence of depression or anxiety, or QOL. In the second study, building on experience in the first study, data collection and storage in the computer system was excellent, achieving 98% of collected data stored in one center. In general, patients were comfortable with the computers and the approach. Data collection on the wards was more difficult and less complete than in clinics, especially for patients undergoing acute admissions.

CONCLUSION

Feasibility with higher compliance was demonstrated in study 2, in which the data collection was integrated into routine care, and can be improved with further technical initiatives and education of staff.

Poor-prognosis high-grade gliomas: evolving an evidence-based standard of care

Patients with high-grade glioma (HGG) can be classified as having a favourable prognosis (younger or with good performance status) or a poor prognosis (older or with poor performance status) with median survival of 12-24 months and 6-9 months, respectively. The standard management for the favourable subgroup is maximum safe resection followed by adjuvant conventionally fractionated radio therapy, with or without chemotherapy. However, most patients with HGG have a poor prognosis and their optimum management has yet to be defined. In the poor-prognosis HGG subgroup, short-course radiotherapy is equivalent to conventional radiotherapy in terms of survival and palliation (level II evidence), but chemotherapy is not recommend ed (level II evidence). The problems with the existing systems of prognosis are discussed and a pragmatic system proposed. Owing to lack of any level I evidence, the need to conduct prospective randomised trials with quality of life and palliative effect as primary endpoints is emphasised. Until such time, maximum safe resection followed by a short course of focal radiotherapy is recommended as the standard of care in poor prognosis HGG.

Exploring the factorial structure of the EORTC QLQ-C30: Racial differences in measuring health-related quality of life in a sample of urban, older adults

OBJECTIVES

To assess the European Organization for Research and Treatment of Cancer's 30-item Quality of Life Questionnaire (QLQ-C30) for use with a multiracial study population of adults.

METHODS

Adults aged 50 and older were randomly selected from patients who made at least one visit to the Henry Ford Health System in Detroit, Michigan in 1998.

RESULTS

African American (n = 255) and White (n = 234) subsamples were separately subjected to exploratory factor analysis; each yielded seven factors with eigenvalues above 1.00, accounting for approximately 65% of the variance, although the factorial structures of the subsamples were different.

DISCUSSION

Participants were not screened for cancer or other illnesses, which may contribute to differences between the known scoring model and these results. Researchers are advised to conduct separate analyses on racial/ethnic groups and to supplement the QLQ-C30 with additional items pertinent to the populations being studied and/or the conceptual/theoretical paradigm being tested.

Assessing the reliability of the EORTC QLQ-C30 in a sample of older African American and Caucasian adults

The purpose of this study was to examine the structure and reliability of the EORTC QLQ-C30. This 30-item instrument has five functional scales (physical, role, cognitive, emotional, and social), three symptom scales (fatigue, pain, and nausea and vomiting) and a global health and quality of life scale. Confirmatory factor analysis and Cronbach's alpha estimates were used to assess the functioning of the EORTC QLQ-C30 in a sample of 489 African American (n = 255) and Caucasian (n = 234) adults aged 50 + years. Seven of the nine EORTC QLQ-C30 scales showed good reliability for both the African Americans and the Caucasians in the sample (Cronbach's alpha > 0.75). In contrast, the cognitive functioning scale had a reliability coefficient of only 0.69 for the African Americans and 0.40 for the Caucasians, and the nausea and vomiting scale had a reliability coefficient of only 0.49 for the African Americans and 0.51 for the Caucasians. In summary, although the overall reliabilities of seven of the scales showed good fit, many of the item-to-scale correlations did not. Researchers planning to use the EORTC QLQ-C30 might first consider conducting separate analyses on the different racial or ethnic subgroups in their study populations to determine whether a common set of factors or scales is available for further analysis.

Second and subsequent lines of chemotherapy for metastatic breast cancer: what did we learn in the last two decades?

Despite almost 30 years of clinical cancer research, the true impact of second and subsequent lines of chemotherapy on the outcome of metastatic breast cancer patients, especially on the duration of survival, is still unknown. In the virtually incurable metastatic setting, issues like quality of life and patients' preferences gain particular relevance. At the turn of the century, in-depth rethinking of the design of clinical trials run in this challenging disease setting appears to be warranted.

Timing of quality of life (QoL) assessments as a source of error in oncological trials

AIM OF THE STUDY

To produce an empirical estimate of the nature and magnitude of the error produced by incorrect timing quality of life (QoL) measurements in patients receiving chemotherapy.

DESIGN

In a multicentre trial, 283 patients were randomized to receive either docetaxel (T) or sequential methotrexate and 5-fluorouracil (MF). The QoL was assessed at baseline and before each treatment using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30). The study design was retrospective. Data were analysed using t-tests.

RESULTS

Erroneous timing affected the QoL findings in both treatment arms. At baseline, there were statistically significant differences in the MF group on the nausea/vomiting scale, with ill-timed assessment showing more symptoms, and in the T group on the physical functioning scale with ill-timed assessments indicating better QoL. The mean scores of correct vs. incorrect timings over the first 14 cycles showed statistically significant differences on several scales. In the MF group, ill-timed assessments indicated significantly worse physical functioning and global QoL, and significantly more of the following symptoms: fatigue, nausea/vomiting, insomnia, appetite loss, and constipation. In the T group, ill-timed assessment showed better physical functioning, less dyspnoea and more insomnia than correctly timed assessments. The reasons for erroneous timing were not always detectable retrospectively. However, in some cases the MF group, being in standard treatment, seemed to have followed a clinical routine not involving the active participation of the study nurse responsible, whereas patients in the experimental T group were more consistently taken care of by the study nurses.

CONCLUSIONS

Incorrect timing of QoL assessments in oncological trials jeopardises both the reliability of the QoL findings within treatment and the validity of QoL outcome comparisons between treatments. This issue should be emphasized in the planning of both the study design and clinical routines.

Longitudinal effects of high-dose chemotherapy and autologous stem cell transplantation on quality of life in the treatment of metastatic breast cancer

This study determined the effects of high-dose chemotherapy (HDCT) with autologous blood stem cell transplantation (ASCT) on quality of life (QL) in women with metastatic breast cancer prior to, and during treatment, and up to 1-year post-ASCT. Thirty-three women diagnosed with metastatic breast cancer participated in a phase 1 clinical trial of a new combination of cyclophosphamide (CTX) and mitoxantrone (MXT), with dose escalation of paclitaxel. Longitudinal QL data were collected using the functional living index-cancer (FLIC) and symptom scales at seven time periods: pre-induction chemotherapy (CT), post-induction CT, post-high dose CT (HDCT), and at 3, 6, 9 and 12 months post-ASCT. FLIC scores indicated that the worst problems for patients were feelings of hardship on themselves and their families, followed by psychological functioning and physical functioning problems. The time around diagnosis of the metastatic disease and following HDCT were the worst times for all levels of quality of life, but anxiety and depression symptoms continued to increase in severity across the entire follow-up period. The symptoms that were most problematic were worry about the future, loss of sexual interest, anxiety about the treatment, general worrying, and joint pain. These data highlight the problems that women with metastatic breast cancer encounter at different stages of the disease and treatment process, and can be used to tailor psychosocial interventions appropriate for treating the relevant issues at different points in time.

How are you feeling? Who wants to know? Patients' and oncologists' preferences for discussing health-related quality-of-life issues

PURPOSE

This study investigated (1) the attitudes of cancer patients toward discussing health-related quality-of-life (HRQL) issues; (2) the association between such attitudes and patients' characteristics; and (3) oncologists' attitudes and self-reported behavior regarding these same issues.

PATIENTS AND METHODS

Two hundred seventy-three patients receiving palliative chemotherapy and ten physicians were asked to complete a series of questionnaires.

RESULTS

Almost all patients wanted to discuss their physical symptoms and physical functioning and were also willing to address their emotional functioning and daily activities. However, 25% of the patients were only willing to discuss these latter two issues at the initiative of their physician. Patients varied most in their willingness to discuss their family and social life, with 20% reporting no interest in discussing these issues at all. Female patients were more reluctant to discuss various HRQL issues than male patients. Older and less well-educated patients were more likely to prefer that their physician initiate discussion of HRQL issues. All physicians considered it to be primarily their task to discuss the physical aspects of their patients' health, whereas four physicians indicated that discussion of psychosocial issues was a task to be shared with other health care providers. All physicians indicated that they generally defer to their patients in initiating discussion of psychosocial issues.

CONCLUSION

Although both patients and oncologists seem willing to discuss a wide range of HRQL issues, communication regarding psychosocial issues may be hampered by competing expectations as to who should take the lead in initiating such discussions.

Quality of life in patients with metastatic breast cancer receiving either docetaxel or sequential methotrexate and 5-fluorouracil. A multicentre randomised phase III trial by the Scandinavian breast group

The purpose of this study was to evaluate the effects of two alternative chemotherapy regimes on the quality of life (QoL) of patients with advanced breast cancer. In a multicentre trial, 283 patients were randomised to receive either docetaxel (T) or sequential methotrexate and 5-fluorouracil (MF). QoL was assessed at baseline and before each treatment using the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ-C30). Initial compliance in the QoL study was 96% and the overall compliance 82%. QoL data were available for 245 patients (T 130 and 115 MF). Both treatment groups showed some improvement in emotional functioning during treatment, with a significant difference favouring the MF group at treatment cycles 5 and 6. In the T group, the scores on the other functional scales remained stable throughout the first six cycles. There were significant differences favouring the MF group on the social functioning scale at treatment cycle 6 and on the Global QoL scale at treatment cycles 5 and 6. On most symptom and single-item scales there were no statistically significant differences between the groups. However, at baseline, the T patients reported more appetite loss, at treatment cycles 2-4, the MF patients reported more nausea/vomiting, and at treatment cycle 6, the T patients reported more symptoms of fatigue, dyspnoea and insomnia. There were no statistically significant differences between the groups in the mean change scores of the functional and symptom scales. Interindividual variance was, however, larger in the T group. Differences in QoL between the two treatment groups were minor. Hence, given the expectancy of comparable QoL outcomes, the choice of treatment should be made on the basis of the expected clinical effect.

Impact of computerized quality of life screening on physician behaviour and patient satisfaction in lung cancer outpatients

The purpose of this paper was to determine if providing patient specific Quality of Life (QL) information to clinic staff before a clinic appointment improved patient care in a lung cancer outpatient clinic. Patients were sequentially assigned to either a usual care control group or the experimental group, which completed a computerized version of the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 questionnaire in order to provide the clinic staff with QL information prior to the clinic appointment. The control group completed the EORTC QLQ-C30 paper version after the clinic appointment. Outcome measures were patient satisfaction, the degree to which issues identified on the QL questionnaire were addressed in the appointment, and a chart audit, which measured charting of QL issues and actions taken by the clincian relating to QL. In the experimental group, more QL issues identified by the patient on the EORTC QLQ-C30 were addressed during the clinic appointment than in the control group. As well, marginally more categories were charted and a trend towards more actions being taken was seen in the experimental group. Patients reported being equally and highly satisfied with the treatment in both groups. The clinical implication is that the computerized administration of the EORTC QLQ-C30 questionnaire and providing staff with a report highlighting patient-specific QL deficits is a simple, time-effective and acceptable means of improving patient-provider communication in a busy outpatient clinic. Large trials studying its effectiveness in different patient populations and regions would further elucidate the nature of this effect and potentially improve the overall quality of care that patients receive.