An emotional functioning item bank of 24 items for computerized adaptive testing (CAT) was established

Quality of working life can protect against cognitive and emotional vulnerability in women living with metastatic breast cancer: a cross-sectional study

PURPOSE

Research focusing on the cognitive and emotional health of women with metastatic breast cancer (MBC) is limited. The focal aim of the current study was to explore how quality of working life was related to global health, perceived cognitive function, anxiety and depression. To this end, women's experience of employers after MBC diagnosis and its relationship to quality of working life was also explored.

METHODS

Women living with MBC (N = 88) completed online questionnaires assessing their global health status, perceived cognitive and emotional vulnerability and their experience of employers following diagnosis. Women working at the time of the study also reported on their quality of working life.

RESULTS

Women's experience of employers after MBC diagnosis was positively related to their quality of working life. Importantly, greater quality of working life met with better perceived cognitive function and global health, as well as lower levels of depression in working women.

CONCLUSIONS

Our study is the first to establish the role of quality of working life in protecting against levels of cognitive vulnerability and emotional vulnerability to depression in women with MBC. We also highlight the importance of having a positive experience with employers. Our findings suggest that educational programmes can be provided to employers to enhance their understanding and awareness of the needs of women with MBC.

IMPLICATIONS FOR CANCER SURVIVORS

Women with MBC may benefit from employers accessing educational (or support) programmes that can increase their awareness of the treatment-related sequelae and needs of women with MBC in the workplace.

Self-efficacy of advanced cancer patients for participation in treatment-related decision-making in six European countries: the ACTION study

PURPOSE

Many patients prefer an active role in making decisions about their care and treatment, but participating in such decision-making is challenging. The aim of this study was to explore whether patient-reported outcomes (quality of life and patient satisfaction), patients' coping strategies, and sociodemographic and clinical characteristics were associated with self-efficacy for participation in decision-making among patients with advanced cancer.

METHODS

We used baseline data from the ACTION trial of patients with advanced colorectal or lung cancer from six European countries, including scores on the decision-making participation self-efficacy (DEPS) scale, EORTC QLQ-C15-PAL questionnaire, and the EORTC IN-PATSAT32 questionnaire. Multivariable linear regression analyses were used to examine associations with self-efficacy scores.

RESULTS

The sample included 660 patients with a mean age of 66 years (SD 10). Patients had a mean score of 73 (SD 24) for self-efficacy. Problem-focused coping (B 1.41 (95% CI 0.77 to 2.06)), better quality of life (B 2.34 (95% CI 0.89 to 3.80)), and more patient satisfaction (B 7.59 (95% CI 5.61 to 9.56)) were associated with a higher level of self-efficacy. Patients in the Netherlands had a higher level of self-efficacy than patients in Belgium ((B 7.85 (95% CI 2.28 to 13.42)), whereas Italian patients had a lower level ((B -7.50 (95% CI -13.04 to -1.96)) than those in Belgium.

CONCLUSION

Coping style, quality of life, and patient satisfaction with care were associated with self-efficacy for participation in decision-making among patients with advanced cancer. These factors are important to consider for healthcare professionals when supporting patients in decision-making processes.

Patient-reported outcome measures for emotional functioning in cancer patients: Content comparison of the EORTC CAT Core, FACT-G, HADS, SF-36, PRO-CTCAE, and PROMIS instruments

BACKGROUND

Cancer and its treatment can have substantial impact on patients' emotional functioning. Several patient-reported outcome measures (PROMs) assessing emotional functioning are available, but differences in content limit the comparability of results. To better understand conceptual (dis)similarities, we conducted a content comparison of commonly used PROMs.

METHODS

We included emotional functioning items, scales, and item banks from the EORTC CAT Core, EORTC QLQ-C30, FACT-G, Hospital anxiety and depression scale (HADS), SF-36, PRO-CTCAE, and PROMIS (item banks for anxiety, depression, and anger). Item content was linked to the International Classification of Functioning, Disability, and Health (ICF) and a hierarchical framework established for PROMIS. Single items could be coded with more than one ICF category but were solely assigned to one facet within the PROMIS framework.

RESULTS

The measures comprise 132 unique items covering the ICF components 'Body functions' (136/153 codings, 88.9%) and 'Activities and participation' (15/153, 9.8%). Most ICF codings (112/153, 73.2%) referred to the third-level category 'b1528 Emotional functions, other specified'. According to the PROMIS framework 48.5% of the items assessed depression (64/132 items), followed by anxiety (41/132, 31.1%) and anger (26/132, 19.7%). The EORTC measures covered depression, anxiety, and anger in a single measure, while the PROMIS inventory provides separate item banks for these concepts. The FACT-G, SF-36, PRO-CTCAE and HADS covered depression and anxiety, but not anger.

CONCLUSION

Our results provide an in-depth conceptual understanding of selected PROMs and important qualitative information going beyond psychometric evidence. Such information supports the identification of PROMs for which scores can be meaningfully linked with quantitative methods.

Is the EORTC QLQ-C30 emotional functioning scale appropriate as an initial screening measure to identify brain tumour patients who may possibly have a mood disorder?

Background

Screening glioma patients regularly for possible mood disorders may facilitate early identification and referral of patients at risk. This study evaluated if the EORTC QLQ‐C30 Emotional Functioning (EF) scale could be used as an initial screening measure to identify patients possibly having a mood disorder.

Methods

EORTC QLQ‐C30 EF and Hospital Anxiety and Depression Scale (HADS) scores were collected as part of a study assessing the impact of timing of patient‐reported outcome assessments on actual health‐related quality of life outcomes (N = 99). Spearman correlations and Mann‐Whitney U tests were used to determine the association between the EF and HADS (sub)scales. Receiver Operating Characteristic analyses were performed to determine optimal cut‐off EF scores to identify patients possibly having a mood disorder (i.e. HADS subscale score ≥8 points).

Results

EF and HADS (sub)scales correlated moderately (HADS‐A: r = −0.65; HADS‐D: r = −0.52). Significant EF score differences were found between patients with HADS ≥8 versus <8 points (HADS‐A: mean difference (MD) = 32 and HADS‐D: MD = 23). The EF scale had excellent (HADS‐A; AUC = 0.88) and borderline excellent (HADS‐D; AUC = 0.78) distinguishing capabilities. A statistically optimal (EF score <80) and a most inclusive (sensitivity of 100%, corresponding to an EF score <97) EF cut‐off score correctly identified 88.0% and 96.0% of patients with a possible mood disorder, respectively.

Conclusion

EORTC QLQ‐C30 EF scale seems to be an appropriate screening measure to identify glioma patients possibly having a mood disorder in need of further assessment.

Effectiveness of a nurse-delivered (FOCUS+) and a web-based (iFOCUS) psychoeducational intervention for people with advanced cancer and their family caregivers (DIAdIC): study protocol for an international randomized controlled trial

Background

Worldwide, millions of people with advanced cancer and their family caregivers are experiencing physical and psychological distress. Psychosocial support and education can reduce distress and prevent avoidable healthcare resource use. To date, we lack knowledge from large-scale studies on which interventions generate positive outcomes for people with cancer and their informal caregivers’ quality of life. This protocol describes the DIAdIC study that will evaluate the effectiveness of two psychosocial and educational interventions aimed at improving patient-family caregiver dyads’ emotional functioning and self-efficacy.

Methods

We will conduct an international multicenter three-arm randomized controlled trial in Belgium, Denmark, Ireland, Italy, The Netherlands, and the United Kingdom. In each country, 156 dyads (936 in total) of people with advanced cancer and their family caregiver will be randomized to one of the study arms: 1) a nurse-led face-to-face intervention (FOCUS+), 2) a web-based intervention (iFOCUS) or 3) a control group (care as usual). The two interventions offer tailored psychoeducational support for patient-family caregiver dyads. The nurse-led face-to-face intervention consists of two home visits and one online video session and the web-based intervention is completed independently by the patient-family caregiver dyad in four online sessions. The interventions are based on the FOCUS intervention, developed in the USA, that addresses five core components: family involvement, optimistic outlook, coping effectiveness, uncertainty reduction, and symptom management. The FOCUS intervention will be adapted to the European context. The primary outcomes are emotional functioning and self-efficacy of the patient and the family caregiver, respectively. The secondary outcomes are quality of life, benefits of illness, coping, dyadic communication, and ways of giving support of the patient and family caregiver.

Discussion

DIAdIC aims to develop cost-effective interventions that integrate principles of early palliative care into standard care. The cross-country setup in six European countries allows for comparison of effectiveness of the interventions in different healthcare systems across Europe. By focusing on empowerment of the person with cancer and their family caregiver, the results of this RCT can contribute to the search for cost-effective novel interventions that can relieve constraints on professional healthcare.

Trial registration

Registration on ClinicalTrials.gov on 12/11/2020, identifier NCT04626349.

Date and version identifier

20211209_DIAdIC_Protocol_Article.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-021-00895-z.

Brazilian Validation of the European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Group (QLG) Computerised Adaptive Tests (CAT) Core

Background: This study aimed to validate the Brazilian version of EORTC CAT Core and compare the Brazilian results with those from the original European EORTC CAT Core validation study. Methods: After validated translation, 168 cancer patients from Brazil receiving radiation therapy with or without chemotherapy was assessed. Translated EORTC CAT Core and all QLQ-C30 items were administered to patients using CHES (Computer-Based Health Evaluation System) before (T0) and after (T1) treatment initiation. The association between QLQ-C30 and CAT scores and ceiling/floor effects were estimated. Based on estimates of relative validity (cross-sectional, known-group differences and changes over time), relative sample-size requirements for CAT compared to QLQ-C30 were estimated. Results: Correlation coefficients between CAT and QLQ-C30 domains ranged from 0.63 to 0.93; except for dyspnoea, all coefficients were >0.82 (corresponding figures were 0.81–0.93 in the European study). On average across domains, floor/ceiling was reduced by 10% using CAT (9% in the European study) corresponding to a relative reduction of 32% (37% in the European study). Analyses of known-group validity and responsiveness indicated that, on average across domains, the sample-size requirements may be reduced by 17% using CAT rather than QLQ-C30, without loss of power (28% in the European study). The Brazilian sample had less symptom/quality of life impairment than the European sample, which likely explains the lower sample-size reduction using CAT when comparing with the European sample. Conclusions: The results in the Brazilian cohort were generally similar to those from the European sample and confirm the validity and usefulness of the EORTC CAT Core.

Advance care planning in patients with advanced cancer: A 6-country, cluster-randomised clinical trial

BACKGROUND

Advance care planning (ACP) supports individuals to define, discuss, and record goals and preferences for future medical treatment and care. Despite being internationally recommended, randomised clinical trials of ACP in patients with advanced cancer are scarce.

METHODS AND FINDINGS

To test the implementation of ACP in patients with advanced cancer, we conducted a cluster-randomised trial in 23 hospitals across Belgium, Denmark, Italy, Netherlands, Slovenia, and United Kingdom in 2015-2018. Patients with advanced lung (stage III/IV) or colorectal (stage IV) cancer, WHO performance status 0-3, and at least 3 months life expectancy were eligible. The ACTION Respecting Choices ACP intervention as offered to patients in the intervention arm included scripted ACP conversations between patients, family members, and certified facilitators; standardised leaflets; and standardised advance directives. Control patients received care as usual. Main outcome measures were quality of life (operationalised as European Organisation for Research and Treatment of Cancer [EORTC] emotional functioning) and symptoms. Secondary outcomes were coping, patient satisfaction, shared decision-making, patient involvement in decision-making, inclusion of advance directives (ADs) in hospital files, and use of hospital care. In all, 1,117 patients were included (442 intervention; 675 control), and 809 (72%) completed the 12-week questionnaire. Patients' age ranged from 18 to 91 years, with a mean of 66; 39% were female. The mean number of ACP conversations per patient was 1.3. Fidelity was 86%. Sixteen percent of patients found ACP conversations distressing. Mean change in patients' quality of life did not differ between intervention and control groups (T-score -1.8 versus -0.8, p = 0.59), nor did changes in symptoms, coping, patient satisfaction, and shared decision-making. Specialist palliative care (37% versus 27%, p = 0.002) and AD inclusion in hospital files (10% versus 3%, p < 0.001) were more likely in the intervention group. A key limitation of the study is that recruitment rates were lower in intervention than in control hospitals.

CONCLUSIONS

Our results show that quality of life effects were not different between patients who had ACP conversations and those who received usual care. The increased use of specialist palliative care and AD inclusion in hospital files of intervention patients is meaningful and requires further study. Our findings suggest that alternative approaches to support patient-centred end-of-life care in this population are needed.

TRIAL REGISTRATION

ISRCTN registry ISRCTN63110516.

Effect of the Carer Support Needs Assessment Tool intervention (CSNAT-I) in the Danish specialised palliative care setting: a stepped-wedge cluster randomised controlled trial

BACKGROUND

The Carer Support Needs Assessment Tool intervention (CSNAT-I) has been shown to improve end-of-life care support for informal caregivers. This study investigated the impact of the CSNAT-I on caregivers of patients recently enrolled in specialised palliative care (SPC) at home in Denmark.

METHODS

A stepped-wedge cluster randomised controlled trial with nine clusters (ie, SPC teams). Outcome measures were collected using caregiver questionnaires at baseline (T0) and 2-week (T1) and 4-week (T2) follow-up.

RESULTS

A total of 437 caregivers were enrolled (control group, n=255; intervention group, n=182). No intervention effect was found on the primary outcome, caregiver strain at T1 (p=0.1865). However, positive effects were found at T1 and T2 on attention to caregivers' well-being (p<0.0001), quality of information and communication (p<0.0001), amount of information (T1: p=0.0002; T2: p<0.0001), involvement (T1: p=0.0045; T2: p<0.0001), talking about greatest burdens (p<0.0001) and assistance in managing greatest burdens (p<0.0001). The effect sizes of these differences were medium or large and seemed to increase from T1 to T2. At T1, positive effects were found on distress (p=0.0178) and home care responsibility (p=0.0024). No effect was found on the remaining outcomes.

CONCLUSION

Although no effect was found on caregiver strain, the CSNAT-I showed positive effects on caregiver distress, home care responsibility and key outcomes regarding caregivers' experience of the interaction with healthcare professionals.

TRIAL REGISTRATION NUMBER

NCT03466580.

International validation of the EORTC CAT Core: a new adaptive instrument for measuring core quality of life domains in cancer

BACKGROUND

The European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Group (QLG) has developed computerised adaptive tests (CATs) for the 14 functional and symptom domains of the EORTC QLQ-C30 quality of life questionnaire. This is expected to optimise measurement precision, relevance to patients and flexibility. Here, we present the first international validation of the EORTC CAT Core.

METHODS

A heterogeneous sample of 699 cancer patients scheduled for chemotherapy and/or radiotherapy was recruited across seven European countries. The EORTC CAT Core and all QLQ-C30 items were administered to participants before and after initiating treatment. Correlations between CAT and QLQ-C30 scores and floor/ceiling effects were calculated. Using several grouping variables, relative validity (cross-sectional known groups difference), responsiveness (changes over time) and relative sample size requirements of the CAT compared to the QLQ-C30 were estimated.

RESULTS

Correlations of the CAT and QLQ-C30 ranged from 0.81 to 0.93 across domains. The mean relative reduction in floor and ceiling effects using the CAT was 42% (range 3-99%). Analyses of known groups validity and responsiveness indicated that, across domains, mean sample size requirements for the CAT were 72% and 70%, respectively, of those using the QLQ-C30.

CONCLUSIONS

The EORTC CAT Core measures the same domains as the QLQ-C30 with reduced floor/ceiling effects. The CAT generally facilitated the use of smaller samples (about 30% smaller on average) without loss of power compared to the QLQ-C30. Based on this study, the EORTC QLG will release the EORTC CAT Core for general use.

Do patients consider computer-adaptive measures more appropriate than static questionnaires?

Objective

Computer-adaptive tests (CAT) use individualised sets of questions to assess patient-reported health states, whereas static (conventional) questionnaires present the same questions to all patients. CAT has been shown to increase measurement precision and reduce assessment length. In our study, we investigated if patients perceive CAT questions as more appropriate than static questionnaires, a claim that is frequently associated with CAT measures.

Methods

We compared the static European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30) against its corresponding CAT measures focusing on two domains: Physical Functioning (PF) and Emotional Functioning (EF). Cancer patients completed the questionnaires and participated in a cognitive interview to assess how appropriate they perceive the QLQ-C30 and the CAT questions for their current health state.

Results

Forty-four cancer patients (mean age = 54.6; 56.8% female) were assessed. For the PF domain, patients considered the CAT items more appropriate (p = 0.002) than the QLQ-C30 items (56.8% vs. 15.9%; 27.2% indifferent). For the EF domain, patients were in favour of the QLQ-C30 items (p < 0.001), with 54.5% considering the QLQ-C30, and 4.5% considering the CAT items to be more appropriate; 40.9% were indifferent. Most patients (N = 36) commented on the preference for the CAT (PF), mentioning better matching of the questions and the health state (38.6%) and better item wording (15.9%).

Conclusion

For the PF domain the CAT measure better matched the score distribution in the patient sample than the QLQ-C30 PF scale and was consequently considered more appropriate by patients. For the EF domain, the CAT measure did not show better fit than the QLQ-C30 and hence no such preference in terms of appropriateness was observed.

Assessing Emotional Functioning with Increased Power: Relative Validity of a Customized EORTC Short Form in the International ACTION Trial

OBJECTIVES

There is a need to improve the assessment of emotional functioning (EF). In the international Advance Care Planning: an Innovative Palliative Care Intervention to Improve Quality of Life in Cancer Patients - a Multi-Centre Cluster Randomized Clinical Trial (ACTION) trial involving patients with advanced cancer, EF was assessed by a customized 10-item short form (EF10). The EF10 is based on the European Organisation for Research and Treatment of Cancer (EORTC) EF item bank and has the potential for greater precision than the common EORTC Quality of Life Questionnaire Core 30 four-item scale (EF4). We assessed the relative validity (RV) of EF10 compared with EF4.

METHODS

Patients from Belgium, Denmark, Italy, the Netherlands, Slovenia, and the United Kingdom completed EF10 and EF4, and provided data on generic quality of life, coping, self-efficacy, and personal characteristics. Based on clinical and sociodemographic variables and questionnaire responses, 53 "known groups" that were expected to differ were formed, for example, females versus males. The EF10 and EF4 were first independently compared within this known group, for example, the EF10 score of females vs the EF10 score of males. When these differences were significant, the RV was calculated for the comparison of the EF10 with the EF4.

RESULTS

A total of 1028 patients (57% lung, 43% colorectal cancer) participated. Forty-five of the 53 known-groups comparisons were significantly different and were used for calculating the RV. In 41 of 45 (91%) comparisons, the RV was more than 1, meaning that EF10 had a higher RV than EF4. The mean RV of EF10 compared with that of EF4 was 1.41, indicating superior statistical power of EF10 to detect differences in EF.

CONCLUSIONS

Compared with EF4, EF10 shows superior power, allowing a 20% to 34% smaller sample size without reducing power, when used as a primary outcome measure.

Psychometric evaluation of an item bank for computerized adaptive testing of the EORTC QLQ-C30 cognitive functioning dimension in cancer patients

BACKGROUND

The European Organisation of Research and Treatment of Cancer (EORTC) Quality of Life Group is developing computerized adaptive testing (CAT) versions of all EORTC Quality of Life Questionnaire (QLQ-C30) scales with the aim to enhance measurement precision. Here we present the results on the field-testing and psychometric evaluation of the item bank for cognitive functioning (CF).

METHODS

In previous phases (I-III), 44 candidate items were developed measuring CF in cancer patients. In phase IV, these items were psychometrically evaluated in a large sample of international cancer patients. This evaluation included an assessment of dimensionality, fit to the item response theory (IRT) model, differential item functioning (DIF), and measurement properties.

RESULTS

A total of 1030 cancer patients completed the 44 candidate items on CF. Of these, 34 items could be included in a unidimensional IRT model, showing an acceptable fit. Although several items showed DIF, these had a negligible impact on CF estimation. Measurement precision of the item bank was much higher than the two original QLQ-C30 CF items alone, across the whole continuum. Moreover, CAT measurement may on average reduce study sample sizes with about 35-40% compared to the original QLQ-C30 CF scale, without loss of power.

CONCLUSION

A CF item bank for CAT measurement consisting of 34 items was established, applicable to various cancer patients across countries. This CAT measurement system will facilitate precise and efficient assessment of HRQOL of cancer patients, without loss of comparability of results.

Rasch analysis supported the construct validity of self-report measures of activity and participation derived from patient ratings of the ICF low back pain core set

OBJECTIVE

To investigate whether measures of activity limitations and participation restrictions with sound internal construct validity could be derived from patient ratings of the International Classification of Functioning, Disability and Health Low Back Pain Core Set (LBP-CS).

STUDY DESIGN AND SETTING

The LBP-CS Self-Report Checklist (LBP-CS-SRC) was developed to permit patients to self-rate their functioning according to an extended set of activity and participation categories from the LBP-CS. Rasch analysis was used to examine the validity of the LBP-CS-SRC with a sample of 308 adults with chronic low back pain attending two tertiary-referral outpatient services in Brisbane, Australia.

RESULTS

The activity limitations and participation restrictions qualifier scales functioned satisfactorily, and the LBP-CS-SRC person response validity was good. After deletion of six misfitting items, the dimensionality results supported using the instrument as distinct measures of activity limitations (17 items) and participation restrictions (10 items). The activity and participation measures both had good person separation reliability, and no component items exhibited meaningful differential item functioning.

CONCLUSION

The results demonstrate that measures of activity and participation with sound internal construct validity can be derived from patient ratings of LBP-CS categories. The LBP-CS-SRC can be used in clinical practice and epidemiologic research to support understanding of patients' perspectives on functioning.

Electronic Quality of Life Assessment Using Computer-Adaptive Testing

Background

Quality of life (QoL) questionnaires are desirable for clinical practice but can be time-consuming to administer and interpret, making their widespread adoption difficult.

Objective

Our aim was to assess the performance of the World Health Organization Quality of Life (WHOQOL)-100 questionnaire as four item banks to facilitate adaptive testing using simulated computer adaptive tests (CATs) for physical, psychological, social, and environmental QoL.

Methods

We used data from the UK WHOQOL-100 questionnaire (N=320) to calibrate item banks using item response theory, which included psychometric assessments of differential item functioning, local dependency, unidimensionality, and reliability. We simulated CATs to assess the number of items administered before prespecified levels of reliability was met.

Results

The item banks (40 items) all displayed good model fit (P>.01) and were unidimensional (fewer than 5% of t tests significant), reliable (Person Separation Index>.70), and free from differential item functioning (no significant analysis of variance interaction) or local dependency (residual correlations < +.20). When matched for reliability, the item banks were between 45% and 75% shorter than paper-based WHOQOL measures. Across the four domains, a high standard of reliability (alpha>.90) could be gained with a median of 9 items.

Conclusions

Using CAT, simulated assessments were as reliable as paper-based forms of the WHOQOL with a fraction of the number of items. These properties suggest that these item banks are suitable for computerized adaptive assessment. These item banks have the potential for international development using existing alternative language versions of the WHOQOL items.