Longitudinal quality of life assessment of patients with hepatocellular carcinoma after primary transarterial chemoembolization

Multimodal locoregional procedures for cancer pain management: a literature review

Pain is the most common and fearsome symptom in cancer patients, particularly in the advanced stage of disease. In cancer pain management, the first option is represented by analgesic drugs, whereas surgery is rarely used. Prior to considering surgical intervention, less invasive locoregional procedures are available from the wide pain management arsenal. In this review article, comprehensive information about the most commonly used locoregional options available for treating cancer pain focusing on interventional radiology (neurolysis, augmentation techniques, and embolization) and interventional radiotherapy were provided, also highlighting the potential ways to increase the effectiveness of treatments.

The impact of symptom distress on health-related quality of life in liver cancer patients receiving arterial chemoembolization: the mediating role of hope

Background

Trans-hepatic arterial chemoembolization (TACE) is a treatment option for liver cancer patients. It can prolong patients’ survival but can also cause symptom distress. Symptom distress (SDs) can directly impact quality of life (QOL) and may indirectly influence QOL by lessening hope. In this study, we wanted to explore the mediating effect of hope on the relationship between SDs and QOL among patients with liver cancer receiving TACE.

Methods

A cross-sectional study was conducted from December 20, 2017, to August 6, 2018, at a gastroenterology ward of a medical center. The participants were 92 liver cancer patients (69.6% male, mean age 67.8) who were admitted for TACE treatment. Information on SDs, hope, and QOL was collected by questionnaire on discharge day. Hayes’ PROCESS model was used to test the mediating effect of hope on the relationship between SDs and QOL.

Results

The mean score and standard deviation (SD) of SDs, hope, and QOL were 32.08 (SD = 6.22), 27.09 (SD = 3.51), and 55.16 (SD = 17.33), respectively. SDs negatively impacts quality of life. The total effect of SDs on QOL was − 1.41 (95% confidence interval [CI]: − 1.96, − 0.86). The indirect effect via the mediation of hope was − 0.95 (95% CI: − 1.7, − 0.45). Hope partially mediated the effect of SDs on QOL.

Conclusion

SDs after TACE is vital; it directly reduces a patient’s overall QOL and can indirectly hinder it by reducing the patient’s hope. In addition to symptom management, interventions that help patients maintain their hope are key to improving QOL among patients receiving TACE.

Patient-reported outcomes in HCC: A scoping review by the Practice Metrics Committee of the American Association for the Study of Liver Diseases

BACKGROUND AND AIMS

HCC is a leading cause of mortality in patients with advanced liver disease and is associated with significant morbidity. Despite multiple available curative and palliative treatments, there is a lack of systematic evaluation of patient-reported outcomes (PROs) in HCC.

APPROACH AND RESULTS

The American Association for the Study of Liver Diseases Practice Metrics Committee conducted a scoping review of PROs in HCC from 1990 to 2021 to (1) synthesize the evidence on PROs in HCC and (2) provide recommendations on incorporating PROs into clinical practice and quality improvement efforts. A total of 63 studies met inclusion criteria investigating factors associated with PROs, the relationship between PROs and survival, and associations between HCC therapy and PROs. Studies recruited heterogeneous populations, and most were cross-sectional. Poor PROs were associated with worse prognosis after adjusting for clinical factors and with more advanced disease stage, although some studies showed better PROs in patients with HCC compared to those with cirrhosis. Locoregional and systemic therapies were generally associated with a high symptom burden; however, some studies showed lower symptom burden for transarterial radiotherapy and radiation therapy. Qualitative studies identified additional symptoms not routinely assessed with structured questionnaires. Gaps in the literature include lack of integration of PROs into clinical care to guide HCC treatment decisions, unknown impact of HCC on caregivers, and the effect of palliative or supportive care quality of life and health outcomes.

CONCLUSION

Evidence supports assessment of PROs in HCC; however, clinical implementation and the impact of PRO measurement on quality of care and longitudinal outcomes need future investigation.

Psychometric validation of the EORTC QLQ-HCC18 in patients with previously treated unresectable hepatocellular carcinoma

To demonstrate the measurement properties of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Hepatocellular Carcinoma 18-question module (EORTC QLQ-HCC18) within a previously treated, unresectable hepatocellular carcinoma (HCC) clinical trial population that was distinct from the published QLQ-HCC18 validation population. Analyses were conducted using data from BGB-A317-208, an open label, international, clinical trial assessing efficacy and safety of the monoclonal antibody tislelizumab in adult HCC patients. The EORTC Quality of Life Questionnaire Core 30 (EORTC QLQ-C30) and QLQ-HCC18 instruments were assessed at baseline and weeks 3 and 9 follow-up visits. Per US Food and Drug Administration guidance, psychometric validation of the QLQ-HCC18 included reliability (internal consistency and test–retest), construct validity (convergent and discriminant validity and known-groups validity), ability to detect change, and meaningful within-patient change (MWPC). Known-groups validity and MWPC analyses were also stratified on several pre-defined subgroups. A total of 248 patients were included. Only the QLQ-HCC18 fatigue, nutrition, and index domains demonstrated acceptable internal consistency; acceptable test–retest reliability was found for fatigue, body image, nutrition, pain, sexual interest, and index domains. The QLQ-HCC18 fatigue domain achieved the pre-specified criterion defining acceptable convergent and discriminant validity for 13 of 16 correlations, whereas the index domain achieved the pre-specified criterion for 14 of 16 correlations. Clear differentiation of the QLQ-HCC18 change scores between improvement and maintenance anchor groups were observed for body image, fatigue, pain, and index domains, whereas differentiation between deterioration and maintenance anchor groups were observed for fever and fatigue domains. MWPC point estimates defining improvement for the QLQ-HCC18 fatigue and index domains were −7.18 and −4.07, respectively; MWPC point estimates defining deterioration were 5.34 and 3.16, respectively. The EORTC QLQ-HCC18 fatigue and index domains consistently demonstrated robust psychometric properties, supporting the use of these domains as suitable patient-reported endpoints within a previously treated, unresectable HCC patient population.

Health-related quality of life in primary hepatic cancer: a systematic review assessing the methodological properties of instruments and a meta-analysis comparing treatment strategies

PURPOSE

Patient-reported outcomes including health-related quality of life (HRQoL) are important oncological outcome measures. The validation of HRQoL instruments for patients with hepatocellular and cholangiocellular carcinoma is lacking. Furthermore, studies comparing different treatment options in respect to HRQoL are sparse. The objective of the systematic review and meta-analysis was, therefore, to identify all available HRQoL tools regarding primary liver cancer, to assess the methodological quality of these HRQoL instruments and to compare surgical, interventional and medical treatments with regard to HRQoL.

METHODS

A systematic literature search was conducted in MEDLINE, the Cochrane library, PsycINFO, CINAHL and EMBASE. The methodological quality of all identified HRQoL instruments was performed according to the COnsensus-based Standards for the selection of health status Measurements INstruments (COSMIN) standard. Consequently, the quality of reporting of HRQoL data was assessed. Finally, wherever possible HRQoL data were extracted and quantitative analyses were performed.

RESULTS

A total of 124 studies using 29 different HRQoL instruments were identified. After the methodological assessment, only 10 instruments fulfilled the psychometric criteria and could be included in subsequent analyses. However, quality of reporting of HRQoL data was insufficient, precluding meta-analyses for 9 instruments.

CONCLUSION

Using a standardized methodological assessment, specific HRQoL instruments are recommended for use in patients with hepatocellular and cholangiocellular carcinoma. HRQoL data of patients undergoing treatment of primary liver cancers are sparse and reporting falls short of published standards. Meaningful comparison of established treatment options with regard to HRQoL was impossible indicating the need for future research.

Health-Related Quality of Life and Mental Health after Surgical Treatment of Hepatocellular Carcinoma in the Era of Minimal-Invasive Surgery: Resection versus Transplantation

Laparoscopic liver resection (LLR) is an increasingly relevant treatment option for patients with resectable hepatocellular carcinoma (HCC). Orthotopic liver transplantation (OLT) has been considered optimal treatment for HCC in cirrhosis, but is challenged by rising organ scarcity. While health-related quality of life (HRQoL) and mental health are well-documented after OLT, little is known about HRQoL in HCC patients after LLR. We identified all HCC patients who underwent LLR at our hospital between 2014 and 2018. HRQoL and mental health were assessed using the Short Form 36 and the Hospital Anxiety and Depression Scale, respectively. Outcomes were compared to a historic cohort of HCC patients after OLT. Ninety-eight patients received LLR for HCC. Postoperative morbidity was 25% with 17% minor complications. LLR patients showed similar overall HRQoL and mental health to OLT recipients, except for lower General Health (p = 0.029) and higher anxiety scores (p = 0.010). We conclude that LLR can be safely performed in patients with HCC, with or without liver cirrhosis. The postoperative HRQoL and mental health are comparable to that of OLT recipients in most aspects. LLR should thus always be considered an alternative to OLT, especially in times of organ shortage.

Systematic Review of Studies Assessing the Health-Related Quality of Life of Hepatocellular Carcinoma Patients from 2009 to 2018

We reviewed all studies assessing the health-related quality of life (HRQoL) in patients with hepatocellular carcinoma (HCC) between 2009 and 2018 (n = 45). Most studies assessed HRQoL as an outcome, and evaluated or compared the HRQoL of HCC patients depending on the type of treatment or stage of disease. HCC patients had a worse HRQoL than the general population, including in those with early-stage HCC. Patients commonly experienced pain, fatigue, sleep disturbance, distress, and lack of appetite, and these symptoms remained problematic even a few years after treatment. TNM classification of malignant tumors stage, tumor stage, presence of cirrhosis, being Asian, being female, living alone, or being unemployed were associated with a poor HRQoL. While recent studies have included a more diverse patient population, various topics, and different study designs, there were limited studies on supportive interventions. Given the increase in HCC cases and HCC survivors, addressing the HRQoL of HCC patients requires more attention.

Epidemiologic, humanistic and economic burden of hepatocellular carcinoma in the USA: a systematic literature review

AIM

To describe the epidemiologic, humanistic and economic burdens of hepatocellular carcinoma (HCC) in the USA.

MATERIALS & METHODS

Studies describing the epidemiology and economic burden from national cohorts, any economic models, or any humanistic burden studies published 2008-2018 were systematically searched.

RESULTS

HCC incidence was 9.5 per 100,000 person-years in most recent data, but was ∼100-times higher among patients with hepatitis/cirrhosis. Approximately a third of patients were diagnosed with advanced disease. Patients with HCC experienced poor quality of life. Direct costs were substantial and varied based on underlying demographics, disease stage and treatment received. Between 25-77% of patients did not receive surgical, locoregional or systemic treatment.

CONCLUSION

Better treatments are needed to extend survival and improve quality of life for patients with HCC.

Comparison of health-related quality of life after transarterial chemoembolization and transarterial radioembolization in patients with unresectable hepatocellular carcinoma

PURPOSE

The purpose of this study was to compare quality of life (QoL) after two different transarterial therapies [transarterial chemoembolization (TACE) and transarterial radioembolization (TARE)] for patients with unresectable hepatocellular carcinoma (HCC) to assess tumor therapy in palliative situation additional to traditional aims like survival or image response.

MATERIAL AND METHODS

QoL was evaluated with two validated questionnaires (EORTC QLQ-30 and EORTC HCC18) before and 14d after treatment in 94 initial therapies (TACE n = 67; TARE n = 27). QoL changes after treatment were analyzed. Tumor response was evaluated using RECIST/WHO/mRECIST/EASL criteria. A multivariate linear regression was undertaken to identify potential influence factors on change of QoL.

RESULTS

Mean return rate of questionnaires was 71.3% allowing analysis of 67 therapies (TACE n = 46; TARE n = 21). Initial global health status/QoL was significantly higher in TACE (62.5%) compared to TARE with 50.8%. Absolute global health decrease was higher in TACE (- 10.5%) compared to TARE (- 4.8%, p = 0.396). Also relative global health decrease was higher in TACE (- 16.82%) compared to TARE (- 9.37%). Findings for other items were corresponding, as less impairment was found for TARE compared to TACE for physical/social functioning, fatigue and pain. Objective mRECIST response rate was 22.8% in TACE and 21.1% in TARE.

CONCLUSION

Neither TACE nor TARE showed a major decrease in QoL after first treatment. TACE showed a slightly but not significantly higher decrease, so this study is not clearly in favor for one treatment. But with the addition that TARE showed less decrease even in patients with higher tumor burden and lower baseline.

Quality of life in patients undergoing repetitive TACE for the treatment of intermediate stage HCC

PURPOSE

With a limited overall survival (OS) of 20 months in patients diagnosed with intermediate stage hepatocellular carcinoma (HCC), the preservation of quality of life (QoL) during transarterial chemoembolization (TACE) procedures remains a primary goal. The aim of our study was to evaluate the change in QoL amongst patients undergoing repetitive TACE and to identify specific risk factors that may predict change in QoL.

METHODS

QoL was assessed in 82 patients undergoing at least two TACE, before and 14 days after TACE, using validated EORTC QLQ-C30 and EORTC HCC18 questionnaires. Tumour response was assessed using established response criteria. Laboratory and clinical parameters were analysed.

RESULTS

Functional scores decreased due to first TACE treatment (p < 0.01), conversely symptom scores increased significantly (p < 0.01). During repetitive TACE no statistically significant changes were observed. Higher Global Health- and Physical Functioning scores at baseline were identified as independent prognostic factors for greater decrease in QoL. Tumour response did not alter QoL at all. Furthermore higher symptom scales including pain (p = 0.00), nausea and vomiting (p = 0.00) and fever (p < 0.01 for repetitive TACE) at baseline were predictive of a significantly lesser increase of symptom severity, and a greater reduction in pain during a course of TACE. Higher C-reactive protein (CRP) at baseline and female gender were associated with a greater decrease of functional scales and increase of symptom scales.

CONCLUSION

QoL amongst patients receiving repetitive TACE showed neither significant nor clinically relevant changes over time. Pre-treatment assessment of QoL-scores, clinical and laboratory parameters can improve patient selection for TACE whilst optimizing QoL.

Prospective longitudinal quality of life and survival outcomes in patients with advanced infiltrative hepatocellular carcinoma and portal vein thrombosis treated with Yttrium-90 radioembolization

Background

To determine the effect of Yttrium-90 (Y90) radioembolization on health-related quality of life (HRQOL) and its effect on overall survival advanced, unresectable infiltrative hepatocellular carcinoma (HCC) patients with concurrent portal vein thrombosis (PVT).

Methods

Consecutive patients with unresectable infiltrative HCC and PVT were recruited. The Short-Form 36 (SF-36) questionnaire was used to assess HRQOL for consecutive patients treated with glass-based Y90 based on a prospective phase II trial. MR imaging was used to determine tumor progression every 3 months post-treatment. Overall survival (OS) from treatment and time to progression (TTP) was analyzed using Kaplan-Meier estimation and log-rank test.

Results

Thirty patients were treated and followed for 17.4 months; physical and mental component summary scores (PCS & MCS) remained unchanged at one, three, and six months. While no difference was observed in baseline SF-36 scores for patients with prolonged TTP (≥4 months) and OS (≥ 6 months), corresponding 1-month PCS were significantly higher than those with TTP < 4 months and OS < 6 months. At 1 month, patients with normalized Physical Function (PF), Role Physical (RP) and PCS within 2 standard deviations (SD) of US normalized baseline scores had a significantly prolonged median OS (15.7 vs. 3.7 months; p < 0.001) and TTP (12.4 vs. 1.8 mo; p < 0.001) compared those with physical component scores greater than 2SD below normalized US population values.

Conclusion

Y90 radioembolization for HCC demonstrated long-term preservation of HRQOL. Lower baseline HRQOL scores were predictive of poorer OS. Early (1 month post-treatment) significant decreases in PCS were independent predictors of poorer OS and TTP.

Trial registration

ClinicalTrials.gov identifier NCT01556282, registered March 16, 2012.

Incorporating Quality of Life Metrics in Interventional Oncology Practice

Interventional radiologists care for a large number of cancer patients with the breadth of palliative intent minimally invasive procedures that we provide. Understanding our meaningful impact on patients' quality of life is essential toward validating our role in the palliation of cancer patients. As such, it is critically important for interventional radiologists to understand common instruments used for the reporting of patient's quality of life measures. Common instruments used to measure pain and quality of life for cancer patients include the numerical rating scale, visual analog scale, brief pain inventory, the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire, and the Functional Assessment of Cancer Therapy. An ideal quality of life instrument should be a patient reported outcome measure across multiple domains (e.g., physical health, psychological, social), and be both validated and reliable.

The Role of Age in Change in Unmet Supportive Care Needs in Hepatocellular Carcinoma Patients During Transition From Hospital to Home

BACKGROUND

Age might affect the change in care needs in patients with hepatocellular carcinoma after treatment during their transition process from hospital to home. However, there have been no studies that focus on this.

OBJECTIVE

The aim of this study is to examine changes in unmet supportive care needs in young (<65 years old) and elderly (≥65 years old) groups of patients with hepatocellular carcinoma from before discharge to 2 months after discharge.

METHODS

A longitudinal prospective study design was used with recruited participants at a teaching hospital in Taiwan. Data were collected 3 times: within 3 days before discharge and at 1 and 2 months after discharge. A set of questionnaires was used to assess participants' levels of supportive care needs, symptom distress, anxiety, and depression.

RESULTS

A total of 104 patients completed the data collection process. Supportive care needs decreased monthly after discharge, with health system and information being the domain with the highest level of unmet needs in the 2 groups. The young group had a higher level of overall unmet needs before discharge, but they had a lower level of overall needs compared with the elderly group after 2 months of discharge.

CONCLUSIONS

Age could be a significant potential factor to affect change in unmet needs during transition.

IMPLICATIONS FOR PRACTICE

Comprehensive assessment in care needs especially in the health system and information and physical and daily living domains before discharge is recommended to design personalized education programs before discharge.

Value of quality of life analysis in liver cancer: A clinician’s perspective

Health related quality of life (HRQOL) is increasingly recognized as an important clinical parameter and research endpoint in patients with hepatocellular carcinoma (HCC). HRQOL in HCC patients is multifaceted and affected by medical factor which encompasses HCC and its complications, oncological and palliative treatment for HCC, underlying liver disease, as well as the psychological, social or spiritual reaction to the disease. Many patients presented late with advanced disease and limited survival, plagued with multiple symptoms, rendering QOL a very important aspect in their general well being. Various instruments have been developed and validated to measure and report HRQOL in HCC patients, these included general HRQOL instruments, e.g., Short form (SF)-36, SF-12, EuroQoL-5D, World Health Organization Quality of Life Assessment 100 (WHOQOL-100), World Health Organization Quality of Life Assessment abbreviated version; general cancer HRQOL instruments, e.g., the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30, Functional Assessment of Cancer Therapy (FACT)-General, Spitzer Quality of Life Index; and liver-cancer specific HRQOL instruments, e.g., EORTC QLQ-HCC18, FACT-Hepatobiliary (FACT-Hep), FACT-Hep Symptom Index, Trial Outcome Index. Important utilization of HRQOL in HCC patients included description of symptomatology and HRQOL of patients, treatment endpoint in clinical trial, prognostication of survival, benchmarking of palliative care service and health care valuation. In this review, difficulties regarding the use of HRQOL data in research and clinical practice, including choosing a suitable instrument, problems of missing data, data interpretation, analysis and presentation are examined. Potential solutions are also discussed.

Health-Related Quality of Life in Patients with Hepatocellular Carcinoma Treated with Initial Transarterial Chemoembolization

PURPOSE

To investigate the impact of the first transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) on health-related quality of life (HRQoL) and identify predictors for low HRQoL following TACE.

MATERIALS AND METHODS

HRQoL was prospectively evaluated in 79 patients with standardized questionnaires (QlQ-C30 and HCC18) pre- and 2 weeks post-TACE. Treatment response was evaluated using common tumour response criteria. Clinical parameters [e.g. Eastern Cooperative Oncology Group (ECOG) performance status, Model of End Stage Liver Disease (MELD) score], tumour load and pre-TACE HRQoL scores were tested for predicting HRQoL after TACE.

RESULTS

Patients showed a 12.1% decrease in global health score (GHS). Major decreases were observed for physical (-21.4%), role (-23.4%), and social (-21.5%) functioning and increases in symptom severity for fatigue (+30.1%), loss of appetite (+25.3%), pain (+19.4%) after TACE. ECOG performance status >1 was associated with increased nausea/vomiting (p = 0.002) and decreased GHS (p = 0.01). MELD score >10 was associated with increased fatigue (p = 0.021) and abdominal swelling (p < 0.001). Our study showed an increase in symptom severity in patients with no symptoms before TACE for pain (p = 0.005) and abdominal swelling (p < 0.001).

CONCLUSION

The first TACE for treatment of HCC does not result in a major loss of HRQoL in general. For TACE as a palliative therapy maintaining HRQoL is of critical importance and standardized HRQoL assessment can help to detect HRQoL problems.

Quality of Life in Hepatocellular Carcinoma Patients Treated with Transarterial Chemoembolization

Hepatocellular carcinoma (HCC) is one of the most commonly diagnosed cancers worldwide. Majority of patients with HCC are diagnosed in the advanced stages of disease and hence they are only suitable for palliative therapy. TACE (transarterial chemoembolization) is the most commonly used treatment for unresectable HCC. It is however unclear if TACE improves the quality of life (QoL) in patients with HCC. The aim of this review is to evaluate the impact of TACE on QoL of HCC patients.

Preservation of quality of life with doxorubicin drug-eluting bead transarterial chemoembolization for unresectable hepatocellular carcinoma: Longitudinal prospective study

BACKGROUND AND AIM

The study aims to determine the effects of doxorubicin drug-eluting bead transarterial chemoembolization (DEB-TACE) therapies on health-related quality of life (HRQOL) in patients with unresectable hepatocellular carcinoma (HCC).

METHODS

This is a single-center, prospective study assessing HRQOL of consecutive patients with unresectable HCC who underwent DEB-TACE. Longitudinal assessment of HRQOL scores via Short-Form-36 (SF-36) was performed. Baseline HRQOL scores were evaluated for significant change (P < 0.05) pre-therapy, post-therapy, and at 6- and 12-month follow-up. Analysis of overall survival (OS) from HCC diagnosis and OS from first DEB-TACE was performed. Paired t-tests were used to compare HRQOL domain scores.

RESULTS

One hundred eighteen patients (83 male; median age 60 years) were enrolled. Patients had lower baseline scores within all eight HRQOL domains of the SF-36 compared with US age-adjusted healthy norms. No significant changes in all eight domains were observed post-therapy and at 6- or 12-month follow-up compared with baseline (P > 0.05). No significant differences in all eight domains were observed between patients receiving ≥ 4 versus ≤ 3 DEB-TACE (P > 0.05). Both groups were similar for age at HCC diagnosis, gender, ethnicity, HCC etiology, Child-Pugh class and Eastern Cooperative Oncology Group Performance Status (P > 0.05). Patients receiving staged DEB-TACE demonstrated significantly greater median OS from HCC diagnosis (≥ 4 vs ≤ 3 DEB-TACE procedures, 31.9 vs 23.7 months, P = 0.04) and from first DEB-TACE (≥ 4 vs ≤ 3 DEB-TACE, 29.1 vs 20.2 months, P = 0.03).

CONCLUSION

DEB-TACE therapy for HCC demonstrated long-term preservation of HRQOL. In addition, staged DEB-TACE with four or more therapies does not significantly impact long-term HRQOL compared with patients who received three or fewer therapies.

Development and Validation of the Simplified Chinese Version of EORTC QLQ-HCC18 for Patients with Hepatocellular Carcinoma

This study aimed to develop and validate the Simplified Chinese Version of the Quality of Life Questionnaire for Hepatocellular Carcinoma (the QLQ-HCC18). It was developed by the strict translation procedure of EORTC guidelines, and the psychometrics were evaluated on a sample of 114 patients. The internal consistency Cronbach's α were greater than 0.60 for all domains (exception of Jaundice 0.38), and all test-retest reliability coefficients were greater than 0.80. Four out of eight domains had statistically significant changes with effect size standardized response mean (SRM) ranging from 0.31 to 0.73. The Simplified Chinese version of QLQ-HCC18 demonstrates good validity, reliability, and responsiveness.

Pilot randomized trial of selective internal radiation therapy vs. chemoembolization in unresectable hepatocellular carcinoma

BACKGROUND & AIMS

To compare selective internal radiation therapy (SIRT) with transarterial chemoembolization (TACE), the standard-of-care for intermediate-stage unresectable, hepatocellular carcinoma (HCC), as first-line treatment.

METHODS

SIRTACE was an open-label multicenter randomized-controlled pilot study, which prospectively compared primarily safety and health-related quality of life (HRQoL) changes following TACE and SIRT. Patients with unresectable HCC, Child-Pugh ≤B7, ECOG performance status ≤2 and ≤5 liver lesions (≤20 cm total maximum diameter) without extrahepatic spread were randomized to receive either TACE (at 6-weekly intervals until tumour enhancement was not observed on MRI or disease progression) or single-session SIRT (yttrium-90 resin microspheres).

RESULTS

Twenty-eight patients with BCLC stage A (32.1%), B (46.4%) or C (21.4%) received either a mean of 3.4 (median 2) TACE interventions (N = 15) or single SIRT (N = 13). Both treatments were well tolerated. Despite SIRT patients having significantly worse physical functioning at baseline, at week-12, neither treatment had a significantly different impact on HRQoL as measured by Functional Assessment of Cancer Therapy-Hepatobiliary total or its subscales. Both TACE and SIRT were effective for the local control of liver tumours. Best overall response-rate (RECIST 1.0) of target lesions were 13.3% and 30.8%, disease control rates were 73.3% and 76.9% for TACE and SIRT, respectively. Two patients in each group were down-staged for liver transplantation (N = 3) or radiofrequency ablation (N = 1).

CONCLUSIONS

Single-session SIRT appeared to be as safe and had a similar impact on HRQoL as multiple sessions of TACE, suggesting that SIRT might be an alternative option for patients eligible for TACE.

Quality of life and hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is a common and rapidly fatal cancer ranking third among the leading causes of cancer-related deaths. Potentially curative therapies like surgery, transplant and ablation are not an option for most patients as they are often diagnosed when the disease is advanced. Liver directed therapy and oral targeted therapies are used in these patients to prolong life and palliate symptoms of the cancer and associated liver failure. Overall survival remains poor and hence health-related quality of life (HRQoL) is of paramount importance in these patients. As novel therapies are developed to improve outcomes, a comprehensive knowledge of available tools to assess impact on QoL is needed. Hence we reviewed all the studies in HCC patients published within the last 13 years from 2001-2013 which assessed HRQoL as a primary or secondary endpoint. A total of 45 studies and 4 meta-analysis were identified. Commonly used tools were European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30) (15 studies) and the Functional Assessment of Cancer Therapy-Hepatobiliary Questionnaire (FACT-Hep) (14 studies). Of the 45 publications which incorporated HRQoL as end-point only 24 were clinical trials, 17/24 (71%) assessed systemic therapies while 7/24 (29%) assessed liver-directed therapies. Majority of the publications (trials + retrospective reviews) that had HRQoL as an endpoint in HCC patients were studies evaluating liver-directed therapies (23/45 or >50%). We discuss the measures included in the tools, their interpretation, and summarize existing QoL data that will help design future HCC trials.

Transarterial embolization with or without chemotherapy for advanced hepatocellular carcinoma: a systematic review

Transarterial chemoembolization (TACE) and transarterial embolization (TAE) are commonly used as first-line treatment for patients with advanced hepatocellular carcinoma (HCC) and have been shown to improve overall survival (OS). However, there remain concerns regarding whether the benefit of the prolonged survival achieved with TACE is superior to the maximum cytotoxic effect of the associated chemotherapeutics. This systematic review aims to compare the efficiency of TACE and TAE based on randomized controlled trials (RCTs). MEDLINE, EMBASE, the Cochrane library, the Science Citation Index, and the Chinese National Knowledge Infrastructure databases were systematically searched through the end of April 2014. Risk ratios (RRs) and 95 % confidence intervals (CIs) were calculated. Meta-analysis of the RCTs was conducted to estimate the mortality and survival rate between the TACE and TAE groups. The analysis included five RCTs involving 582 patients. For all-cause mortality, TACE did not result in a statistically significant reduced incidence of adverse events than TAE with a pooled RR of 1.21 (95 % CI = 0.74-1.98, P = 0.16). In addition, 6-, 9-, 12-, 24-, and 36-month OS of the TACE group were not significantly higher than that of the TAE group (all P > 0.05). Interestingly, TACE resulted in a significantly higher rate of advanced events. The efficacy of TACE is not superior to TAE in advanced HCC patients. Moreover, TACE was associated with an increased rate of adverse events than TAE. Improved strategies are needed to reduce the risk of post-TACE complications.

Psychometric properties of a brief, clinically relevant measure of pain in patients with hepatocellular carcinoma

PURPOSE

Due to diagnosis at advanced stages, comorbidities, and the impact of treatment, patients with hepatocellular carcinoma (HCC) may experience pain. The purpose of this study was to evaluate the psychometric properties of a brief, clinically relevant measure of pain in HCC.

METHODS

We conducted a secondary data analysis from four longitudinal studies of patients with HCC (total n = 304). All patients completed the FACT-Hepatobiliary (FACT-Hep) questionnaire, and 49 patients completed the Brief Pain Inventory (BPI) Interference scale. We conducted confirmatory factor analysis (CFA), Rasch modeling, and correlational analysis to assess the psychometrics of the three items on the FACT-Hep that assess HCC-relevant pain scale.

RESULTS

Patients had an average age of 63.5 (±12.2) and were mostly male (76 %). The mean three-item pain subscale score was 8.5 ± 3.0. Seventy-four (24.3 %) patients reported no pain (score = 12). Results of a one-factor CFA supported unidimensionality of the items, and all items fit the Rasch model. An item-person map demonstrated that the three items covered all patients with non-extreme scores. Pain scores were significantly associated with baseline general health-related quality of life (FACT-General, r = 0.60, p < 0.001) and pain interference (BPI, r = -0.63, p < 0.001).

CONCLUSIONS

The three FACT-Hep pain items are unidimensional, cover the range of pain experienced by most patients with HCC, and demonstrate convergent validity. This pain subscale is, if future research demonstrates its sensitivity to change, potentially useful for HCC clinical trials.

Increased quality of life among hepatocellular carcinoma patients treated with radioembolization, compared with chemoembolization

BACKGROUND & AIMS

Quality of life (QoL) is an important aspect of any palliative treatment. However, few data are available from studies comparing how embolotherapy affects QoL for patients with hepatocellular carcinoma (HCC). We performed a health-related QoL study in patients with HCC treated by transarterial chemoembolization (TACE) or (90)Y radioembolization.

METHODS

We performed a prospective study of patients undergoing (90)Y radioembolization (n = 29) or TACE (n = 27) for HCC. We assessed patients before treatment and 2 and 4 weeks after treatment using the Functional Assessment of Cancer Therapy-Hepatobiliary (FACT-Hep) survey. We compared differences in health-related QoL between the treatment groups using linear regression repeated-measures analysis.

RESULTS

At baseline, the groups had comparable baseline Child-Pugh class and performance statuses, although patients undergoing TACE had lower tumor burdens (P = .018) and less-advanced disease, based on United Network for Organ Sharing and Barcelona stage (P = .03 and P = .02, respectively), permitting injections at segmental arteries (P < .0001). There were no significant differences between groups in overall FACT-Hep health-related QoL scores (P = .055, effect size [ES], .54), owing to a limited sample size. Despite the more advanced disease of patients who received (90)Y radioembolization, they had a significantly better QoL, based on social well being (P = .019; ES, .65), functional well-being (P = .031; ES, .60), and embolotherapy-specific scores (P = .018; ES, .67). They also had a trend toward better overall QoL (P = .055; ES, .54) and higher Trial Outcome Index (P = .05; ES, .56) and FACT-Hep scores (P = .071; ES, .52).

CONCLUSIONS

In a prospective study, although (90)Y radioembolization was used to treat patients with more advanced disease, those who received this treatment had significant increases in several features of QoL, whereas patients who received TACE had decreases in QoL scores. However, because of the limited sample size, there was no significant difference in overall FACT-Hep health-related QoL scores. The increase was greatest in the embolotherapy-specific score. ClinicalTrials.gov, number NCT00739167.

Safety and feasibility of same-day discharge of patients with unresectable hepatocellular carcinoma treated with doxorubicin drug-eluting bead transcatheter chemoembolization

PURPOSE

The aim of this study was to investigate the safety and feasibility of same-day discharge of patients with unresectable hepatocellular carcinoma (HCC) after doxorubicin drug-eluting bead (DEB) transarterial chemoembolization and to elucidate the factors predisposing to overnight admission.

MATERIALS AND METHODS

Consecutive patients with unresectable HCC who underwent superselective 100-300 μm DEB transarterial chemoembolization were included. The parameters of same-day therapy (group A) were compared with those of patients admitted overnight (group B). A χ2 test and a t test were used to compare categorical and continuous variables accordingly.

RESULTS

Seventy-six patients (mean, 61 y) received 110 DEB transarterial chemoembolization treatments over an 8-month study period. In 84.5% (93/110) of DEB transarterial chemoembolization procedures, the patients were discharged on the same day (group A). The causes of hospitalization included the worsening of comorbidities in 41.1% (7/17), pain control in 29.4% (5/17), and groin and closure device-related complications in 29.4% (5/17) of patients. The mean Charlson comorbidity scores in groups A and B were 6.96 (standard deviation [SD] ± 1.98) and 8.47 (SD ± 2.18) (P = .0005), respectively. All of the patients in group B had Barcelona Clinic Liver Cancer (BCLC) stages C and D HCC (P = .024). There were no Common Terminology Criteria for Adverse Events (CTCAE) grade III or worse adverse events (AEs). There was no mortality or emergency visits within 30 days of discharge.

CONCLUSIONS

Same-day discharge after superselective DEB transarterial chemoembolization for unresectable HCC is safe and feasible. BCLC C or D stage of disease, a higher Charlson comorbidity score, and groin or closure device complications are correlated with a greater likelihood for overnight admission.

[Transarterial chemoembolisation in hepatocellular carcinoma]

Hepatocellular carcinoma is one of the most common cause of cancer related death. The present review gives an overview on the loco-regional therapy performed by transarterial chemoembolization (TACE).TACE combines two different therapeutic approaches. First, application of chemotherapeutic agents into tumor's feeding vessels and second, selectively de-arterialization by different particle embolization applicated during angiography. Different chemoembolization agents and techniques are described. The methode is save and less invasive. Side effects range from the postembolization syndrom with nausea, vomiting, fever and abdominal pain up to hepatic insufficiency, which is very rare.The aim of the therapy is control clinical symptoms, prolonge progression free survival, stabilize quality of life and survival. Further indications are bridging therapy prior liver transplantation and TACE is used as a neoadjuvant therapy.Thus, TACE plays a role in the therapy of HCC and indication should be tailored to the individual patient's condition by an interdisciplinary tumor board.

Quality-of-life assessment after palliative interventions to manage malignant ureteral obstruction

PURPOSE

Malignancies may cause urinary tract obstruction, which is often relieved with placement of a percutaneous nephrostomy tube, an internal double J nephro-ureteric stent (double J), or an internal external nephroureteral stent (NUS). We evaluated the affect of these palliative interventions on quality of life (QoL) using previously validated surveys.

METHODS

Forty-six patients with malignancy related ureteral obstruction received nephrostomy tubes (n = 16), double J stents (n = 15), or NUS (n = 15) as determined by a multidisciplinary team. QoL surveys were administered at 7, 30, and 90 days after the palliative procedure to evaluate symptoms and physical, social, functional, and emotional well-being. Number of related procedures, fluoroscopy time, and complications were documented. Kruskal-Wallis and Friedman's test were used to compare patients at 7, 30, and 90 days. Spearman's rank correlation coefficient was used to assess correlations between clinical outcomes/symptoms and QoL.

RESULTS

Responses to QoL surveys were not significantly different for patients receiving nephrostomies, double J stents, or NUS at 7, 30, or 90 days. At 30 and 90 days there were significantly higher reported urinary symptoms and pain in those receiving double J stents compared with nephrostomies (P = 0.0035 and P = 0.0189, respectively). Significantly greater fluoroscopy time was needed for double J stent-related procedures (P = 0.0054). Nephrostomy tubes were associated with more frequent minor complications requiring additional changes.

CONCLUSION

QoL was not significantly different. However, a greater incidence of pain in those receiving double J stents and more frequent tube changes in those with nephrostomy tubes should be considered when choosing palliative approaches.

Morbidity and mortality following transarterial liver chemoembolization in patients with hepatocellular carcinoma and synthetic hepatic dysfunction

The purpose of this study was to determine the rate and risk factors for the development of irreversible hepatotoxicity after transarterial chemoembolization (TACE) in patients with hepatocellular carcinoma (HCC) and synthetic hepatic dysfunction. Two hundred fifty-one consecutive patients with HCC and hepatic dysfunction who underwent 443 TACE procedures from 2005 to 2010 were retrospectively reviewed. The included patients met one of the following criteria: a pre-TACE bilirubin level ≥ 2 mg/dL, an international normalized ratio (INR) > 1.5, a creatinine level > 1.2 mg/dL, a platelet count ≤ 60,000/mL, a Model for End-Stage Liver Disease (MELD) score > 15, Child-Turcotte-Pugh class B or C, ascites, or portal vein thrombosis. Hepatotoxicity was defined as new or worsening ascites, encephalopathy, or grade 3 or 4 toxicity (bilirubin, aspartate aminotransferase, alanine aminotransferase, creatinine, or INR) according to the National Cancer Institute Common Terminology Criteria for Adverse Events. The rate and risk factors for death or urgent liver transplantation within 6 weeks of TACE and irreversible hepatotoxicity were determined with a generalized estimating equation analysis. Reversible hepatotoxicity developed after 90 procedures (20%) in 78 patients (31%). Irreversible hepatotoxicity developed after 41 procedures (9%) in 37 patients (15%). Six patients (2%) underwent urgent liver transplantation, and 11 (4%) died within 6 weeks of TACE. Patients at increased risk for procedure-related mortality or urgent liver transplantation within 6 weeks of TACE had a baseline serum bilirubin level ≥ 4.0 mg/dL (P = 0.01), an elevated INR (P < 0.001), hypoalbuminemia with an albumin level < 2.0 g/L (P = 0.01), a serum creatinine level > 2.0 mg/dL (P = 0.02), large ascites (P = 0.002), encephalopathy (P = 0.005), or a MELD score ≥ 20 (P < 0.001). In conclusion, TACE can be performed safely in patients with baseline hepatic dysfunction. However, a poor hepatic reserve increases the risk of irreversible hepatotoxicity, which may lead to death or the need for urgent liver transplantation.

Quality of life and survival analysis of patients undergoing transarterial chemoembolization for primary hepatic malignancies: a prospective cohort study

INTRODUCTION

Transarterial chemoembolization (TACE) is indicated for primary hepatic tumours when resection or local ablation are not feasible. Patients undergoing TACE have a better survival than best supportive therapy. However, there is paucity of prospective studies on the quality of life (QOL) after TACE for primary hepatic malignancies, especially in the Western world.

PURPOSE

The primary aim of the present study was to determine if TACE impacts on the QOL of patients affected by primary hepatic tumours, and to assess treatment efficacy in a prospective cohort of patients treated at a tertiary Canadian university medical centre.

METHODS

From September 2005 to December 2010, 48 candidates for TACE underwent at least one TACE session. Data on their QOL, tumour response, serum alpha fetoprotein (AFP) and survival were prospectively collected every 3-4 months.

RESULTS

The overall QOL of patients undergoing TACE did not decline during the first 12 months after treatment. A decline was observed in the physical health domain after the third TACE that coincided with the increasing size of the largest tumour and a rise in the serum AFP levels. Psychological, social and environmental domains remained stable throughout the treatment period. Multivariate analysis revealed that tumour focality, AFP levels and model of end-stage liver disease (MELD) scores were associated with long-term survival (P= 0.001, P= 0.01, P= 0.02, respectively). The overall survival at 12, 36 and 48 months were 72%, 28% and 12%, respectively.

CONCLUSION

TACE is an effective palliative intervention for unresectable and non-ablatable primary liver tumours without affecting the QOL of patients even when repeated interventions are performed.

Quality of life and its associated factors in patients with hepatocellular carcinoma receiving one course of transarterial chemoembolization treatment: a longitudinal study

OBJECTIVE

To (a) explore changes in physical and psychological distress and quality of life (QOL) and (b) identify the significant pre- and postdischarge factors related to changes in physical and mental domains of QOL over a period of 2 months in patients with hepatocellular carcinoma receiving one course of transarterial chemoembolization (TACE) treatment.

METHODS

A longitudinal prospective design was used, with participants recruited from a teaching hospital in Northern Taiwan. Data were collected three times: within 3 days prior to discharge (T0) and at the fourth (T1) and eighth (T2) weeks after discharge. A set of structured questionnaires was used to assess participants' QOL, symptom distress, anxiety, and depression. Changes in QOL and associated factors were examined using generalized estimating equations.

RESULTS

Eighty-nine patients were included in this study. Fatigue was reported to be the most distressful symptom after treatment. Overall QOL improved monthly after discharge. Change in physical QOL 2 months after TACE treatment was associated with age, diagnosis status, level of symptom distress, and depression after discharge. Change in mental QOL was significantly associated with gender, diagnosis status, and anxiety and depression after discharge.

CONCLUSIONS

Health care providers should pay special attention to patients of older age, those who are male, and those who have higher levels of depression and anxiety after discharge. Designing personalized education programs before discharge for patients with newly diagnosed cancer versus those who have recurrent disease is suggested to help patients maintain a better QOL after discharge.

Current concepts in transarterial chemoembolization of hepatocellular carcinoma

Transarterial chemoembolization (TACE) has the potential to improve survival in patients with intermediate stage hepatocellular carcinoma (HCC). Careful selection of patients is mandatory to gain survival benefit and safe quality of life. Basic principles of TACE in HCC include selective treatment via intrahepatic and extrahepatic arteries, proper management of side effects and continuation of treatment guided by imaging. After conventional TACE, based on delivery of cytotoxic drugs emulsified in iodized oil and embolization of various types of particles, has been used for more than 20 years, the new concept of drug-eluting microspheres has been introduced. This technology effectively combines enhanced local drug delivery and ischemic embolization effects. Clinical studies showed intensified local necroses and reduced systemic toxic side effects compared to conventional TACE. Embolization of HCC with sub-100 μm particles penetrating deeply into the tumor vascular bed is another promising new option. Very effective devascularization of HCC nodules has been shown after 40 μm bland embolizations, however, potential risks like passage of particles into hepatic veins and systemic circulation have to be considered. Today the indication for TACE in intermediate stage HCC patients is widely accepted; however, there is no clear methodical standard so far. Further studies are necessary to define how to adapt various available methods to individual HCC and patients characteristics.

Comparison of differences and determinants between presence and absence of sleep disturbance in hepatocellular carcinoma patients

BACKGROUND

Hepatocellular carcinoma patients often experience sleep disturbance after undergoing transcatheter arterial chemoembolization (TACE).

OBJECTIVE

The objectives of this study were to (1) examine and compare symptom distress, depression, and sleep quality in hepatocellular carcinoma patients undergoing TACE with sleep disturbance versus without sleep disturbance and (2) examine the determinants of sleep disturbance in these patients.

METHODS

Hepatocellular carcinoma patients undergoing TACE were recruited. The patients were evaluated 1 week (T1) and 1 month (T2) after receiving TACE in terms of performance status, symptom distress, depression (T1), and sleep disturbance (T2). Logistic regression was used to determine the predictive factors of sleep disturbance.

RESULTS

Patients with sleep disturbance reported significantly higher overall symptom distress and depression and lower sleep quality than patients without sleep disturbance. The 5 leading causes of symptom distress in both groups were fatigue, pain, poor appetite, chest tightness, and fever. Older age, greater symptom distress, and higher levels of depression were significantly associated with sleep disturbance.

CONCLUSIONS

The results of this study show significant associations among symptom distress, depression at baseline, and sleep problems 1 month after undergoing TACE. Clinicians should be aware of the possibility of lasting sleep disturbance in hepatocellular carcinoma patients undergoing TACE.

IMPLICATIONS FOR PRACTICE

In clinical care, symptom management, psychological consultation, and relaxation training may promote sleep quality.

Systematic review: quality of life after treatment for upper gastrointestinal cancer

PURPOSE OF REVIEW

The aim of this systematic review is to scrutinize and summarize the design, conduct and reporting standards of articles recently published describing health-related quality of life (HRQL) outcomes of treatment of upper gastrointestinal cancer.

RECENT FINDINGS

Some 2312 abstracts were published between January and July 2009 and initial elimination of papers reduced this number to 22 articles. Of these, 17 were judged to have robust HRQL methodology, but a further seven were excluded due to a high risk of bias in the study design. Ten articles (four randomized trials) were finally included in the review. Studies in curative treatments for oesophagogastric cancer show that surgery and chemoradiation therapy has a major short-term detrimental effect on HRQL, but recovery occurs within 6 months in long-term survivors but those not achieving a survival benefit report very poor HRQL. In advanced oesophageal cancer, 18 mm self-expandable metal stents and nonstent therapies lead to better short-term HRQL scores than nonexpandable stents and are the recommended standard of care. A small survival advantage and improved HRQL is conferred by adjuvant and palliative gemcitabine chemotherapy in patients with pancreatic cancer.

SUMMARY

This review identified few well-designed studies that also included a robust assessment of HRQL. High-quality trials with reliable HRQL methods are required for outcomes to inform health policy and clinical decision-making.