Factor analysis of the psychosocial items of the EORTC QLQ-C30 in metastatic breast cancer patients participating in a psychosocial intervention study

Minimal important differences of EORTC QLQ-C30 for metastatic breast cancer patients: Results from a randomized clinical trial

Purpose

To establish minimal important differences (MIDs) for the European Organisation for Research and Treatment for Cancer Quality of life Questionnaire core 30 (EORTC QLQ-C30) in patients with metastatic breast cancer.

Methods

The dataset was obtained from the SELECT BC-CONFIRM randomized clinical trial. Anchors obtained from patients (transition items) and clinicians (performance status) were used for anchor-based methods. Anchors obtained through 6 months after starting treatment were used for this analysis. Correlation coefficients of anchor and change in QLQ-C30 and effect size were used to qualify for estimating MIDs. Mean change method and generalized estimating equation were applied to estimate MIDs. Distribution-based methods were used for comparison.

Results

We analyzed a dataset of 154 metastatic breast cancer patients. MIDs were estimated in 8 of 15 scales of QLQ-C30. Estimated MIDs for within-group improvement varied from 7 to 15 and those for deterioration varied from − 7 to − 17. Estimated MIDs for between-group improvement varied from 5 to 11 and those for deterioration varied from − 5 to − 8 across QLQ-C30 scales. Patient-reported anchors were more susceptible to early changes in health status than clinician-reported anchors.

Conclusion

We provided the MIDs of the QLQ-C30 using both patient- and clinicians-reported anchors measured in a randomized trial of Japanese patients with metastatic breast cancer. We recommend patient-reported anchors for anchor-based estimation of MID. Our results can aid patients and clinicians, as well as researchers, in the interpretation of QLQ-C30.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11136-021-03074-y.

Breast cancer

Breast cancer is the most frequent malignancy in women worldwide and is curable in ~70-80% of patients with early-stage, non-metastatic disease. Advanced breast cancer with distant organ metastases is considered incurable with currently available therapies. On the molecular level, breast cancer is a heterogeneous disease; molecular features include activation of human epidermal growth factor receptor 2 (HER2, encoded by ERBB2), activation of hormone receptors (oestrogen receptor and progesterone receptor) and/or BRCA mutations. Treatment strategies differ according to molecular subtype. Management of breast cancer is multidisciplinary; it includes locoregional (surgery and radiation therapy) and systemic therapy approaches. Systemic therapies include endocrine therapy for hormone receptor-positive disease, chemotherapy, anti-HER2 therapy for HER2-positive disease, bone stabilizing agents, poly(ADP-ribose) polymerase inhibitors for BRCA mutation carriers and, quite recently, immunotherapy. Future therapeutic concepts in breast cancer aim at individualization of therapy as well as at treatment de-escalation and escalation based on tumour biology and early therapy response. Next to further treatment innovations, equal worldwide access to therapeutic advances remains the global challenge in breast cancer care for the future.

Symptom clusters and quality of life in breast cancer survivors after cancer treatment in a tertiary hospital in Korea

We investigated the symptom clusters and effects of symptom clusters on the quality of life of Korean breast cancer survivors. We recruited 241 breast cancer survivors and collected cross-sectional data on their symptoms. To determine inter-relationships among symptoms, a principal component analysis with varimax rotation was performed based on the patient's symptoms (fatigue, nausea/vomiting, pain, dyspnoea, insomnia, appetite loss, constipation, anxiety, depression, systemic therapy side effects, breast symptoms and arm symptoms). The first symptom cluster consisted of psychological (anxiety and depression) and general (appetite loss, fatigue, insomnia and dyspnoea) symptoms, whereas the second symptom cluster consisted of physical (arm symptom, breast symptom, pain and systemic therapy side effects) and gastrointestinal (nausea/vomiting and constipation) symptoms. Subgroup cluster analysis showed that breast cancer survivors with higher-scoring symptoms had significantly poorer quality of life in both psychological-general symptom cluster and physical-gastrointestinal symptom cluster subgroups, with subgroup-specific patterns. The symptom clusters differed depending on stage and functional status of breast cancer survivors. Breast cancer survivors may have a specific pattern of symptom clusters. Some symptom clusters may have a negative impact on the quality of life. Identifying symptom clusters of breast cancer survivors may have clinical implications by improving symptom management.

Item response theory and factor analysis as a mean to characterize occurrence of response shift in a longitudinal quality of life study in breast cancer patients

BACKGROUND

The occurrence of response shift (RS) in longitudinal health-related quality of life (HRQoL) studies, reflecting patient adaptation to disease, has already been demonstrated. Several methods have been developed to detect the three different types of response shift (RS), i.e. recalibration RS, 2) reprioritization RS, and 3) reconceptualization RS. We investigated two complementary methods that characterize the occurrence of RS: factor analysis, comprising Principal Component Analysis (PCA) and Multiple Correspondence Analysis (MCA), and a method of Item Response Theory (IRT).

METHODS

Breast cancer patients (n = 381) completed the EORTC QLQ-C30 and EORTC QLQ-BR23 questionnaires at baseline, immediately following surgery, and three and six months after surgery, according to the "then-test/post-test" design. Recalibration was explored using MCA and a model of IRT, called the Linear Logistic Model with Relaxed Assumptions (LLRA) using the then-test method. Principal Component Analysis (PCA) was used to explore reconceptualization and reprioritization.

RESULTS

MCA highlighted the main profiles of recalibration: patients with high HRQoL level report a slightly worse HRQoL level retrospectively and vice versa. The LLRA model indicated a downward or upward recalibration for each dimension. At six months, the recalibration effect was statistically significant for 11/22 dimensions of the QLQ-C30 and BR23 according to the LLRA model (p ≤ 0.001). Regarding the QLQ-C30, PCA indicated a reprioritization of symptom scales and reconceptualization via an increased correlation between functional scales.

CONCLUSIONS

Our findings demonstrate the usefulness of these analyses in characterizing the occurrence of RS. MCA and IRT model had convergent results with then-test method to characterize recalibration component of RS. PCA is an indirect method in investigating the reprioritization and reconceptualization components of RS.

Symptoms, clusters and quality of life prior to surgery for breast cancer

AIMS AND OBJECTIVES

To examine the pretreatment symptoms and symptom clusters that women awaiting breast cancer surgery are experiencing and the impact of these symptoms on their quality of life.

BACKGROUND

Most women diagnosed with breast cancer will have surgery as a first-line treatment. The presence of presurgery symptoms may be significant in contributing to distress and impaired quality of life. While it seems that women with breast cancer may experience the symptoms of fatigue, pain, depression and sleep disturbance as a cluster, this has not yet been confirmed by empirical research in the presurgery time period.

DESIGN

A multiple-point prospective longitudinal cohort panel design is used.

METHODS

Presurgery symptoms and quality of life were assessed using the Hospital Anxiety and Depression Scale, Insomnia Severity Index, Functional Assessment of Cancer Therapy-Fatigue, Brief Pain Inventory and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30(3).

RESULTS

Participants (n = 94, age range 30-92) experienced symptoms prior to surgery, with pain being a more prevalent symptom (35%) than fatigue (32%), sleep disturbances (25·5%) or depression (11%). global quality of life was significantly impacted on by fatigue and showed a moderate correlation with emotional functioning and a weak correlation with physical and social functioning. Hierarchical cluster analysis identified the presence of five clusters with symptoms present in differing intensities in each cluster.

CONCLUSION

In this cohort of women, healthy other than having a diagnosis of breast cancer, symptoms were impacting on quality of life. It is evident that clusters of symptoms are present presurgery that must be assessed and managed.

RELEVANCE TO PRACTICE

Healthcare delivery systems must ensure that early symptoms are addressed effectively in the presurgery period to improve quality of life and reduce adverse outcomes postsurgery.

Comparing higher order models for the EORTC QLQ-C30

PURPOSE

To investigate the statistical fit of alternative higher order models for summarizing the health-related quality of life profile generated by the EORTC QLQ-C30 questionnaire.

METHODS

A 50% random sample was drawn from a dataset of more than 9,000 pre-treatment QLQ-C30 v 3.0 questionnaires completed by cancer patients from 48 countries, differing in primary tumor site and disease stage. Building on a "standard" 14-dimensional QLQ-C30 model, confirmatory factor analysis was used to compare 6 higher order models, including a 1-dimensional (1D) model, a 2D "symptom burden and function" model, two 2D "mental/physical" models, and two models with a "formative" (or "causal") formulation of "symptom burden," and "function."

RESULTS

All of the models considered had at least an "adequate" fit to the data: the less restricted the model, the better the fit. The RMSEA fit indices for the various models ranged from 0.042 to 0.061, CFI's 0.90-0.96, and TLI's from 0.96 to 0.98. All chi-square tests were significant. One of the Physical/Mental models had fit indices superior to the other models considered.

CONCLUSIONS

The Physical/Mental health model had the best fit of the higher order models considered, and enjoys empirical and theoretical support in comparable instruments and applications.

Online support groups for women with metastatic breast cancer: a feasibility pilot study

This study evaluates the feasibility and acceptability of an online peer support group intervention for women with metastatic breast cancer (MBC). Feasibility, participation rates, participant satisfaction, and preliminary outcomes are examined from a 1999 to 2000 study of online peer support groups for women with MBC. Thirty women with MBC were randomly assigned to either an immediate online support condition or a waitlisted control condition. For practical and ethical reasons, the waitlist period was limited to 2 months. Six monthly assessments were collected using standardized measurement instruments. Intervention retention rates (73%), assessment completion rates (range = 100%-86% in retained participants) and support group participation (M = 5.9 days per week) were high compared to other published studies on this population. Reported satisfaction with the intervention was also high. An online support intervention study is feasible using a waitlist control. Despite the feasibility and acceptability of the study procedures, the study design and small sample size precluded definitive conclusions about intervention effectiveness. As such, study procedures should be replicated with a larger more representative sample to examine the effectiveness of the intervention.

Quality of life of patients with oesophageal cancer in Taiwan: validation and application of the Taiwan Chinese (Mandarin) version of the EORTC QLQ-OES18: a brief communication

PURPOSE

The aim of this study was to examine the reliability and validity, and the application of the Taiwan Chinese Version of the EORTC QLQ-OES18.

METHODS

The authors translated the questionnaire according to the guideline of the EORTC. Ninety-five patients with oesophageal cancer in National Taiwan University Hospital were interviewed using the questionnaire and the EORTC QLQ-C30 between October 2002 and September 2007. Answer distribution and psychometric properties of the EORTC QLQ-OES18 were examined.

RESULTS

The mean age of the patients was 60 years (SD 12 years). Most of the patients were in advanced stages of disease, with two-thirds off-treatment. The Cronbach's alpha coefficients were satisfactory (0.77-0.82) or near-satisfactory (pain: 0.67). The item-to-own and item-to-other scale correlations showed satisfactory results. Patients who were on-treatment versus off-treatment had significantly poorer quality of life scores in dysphagia, dry mouth, and taste, and a borderline poorer score in cough. Opposite situations were seen in the scales of reflux and choking.

CONCLUSIONS

The EORTC QLQ-OES18 is a valid instrument to assess quality of life issues in patients with oesophageal cancer in Taiwan.

Pain and quality of life

This paper deals with the impact of pain on quality of life (QOL). Two major factors have contributed to the enhanced importance of QOL in recent years: the increasing frequency of pain and the resources devoted to its treatment, and the growing theoretical insight that pain affects the person as a whole. QOL is defined as the person's evaluation of his or her well-being and functioning in different life domains. It is a subjective, phenomenological, multidimensional, dynamic, evaluative, and yet quantifiable, construct. Commonly used scales for its assessment (eg, WHOQOL, SF-36) are described. Studies show that pain affects most domains of QOL, primarily physical and emotional functioning. The effect depends on the extent, duration, acuteness, intensity, affectivity, and meaning of the pain as well as on the underlying disease and the individual's characteristics. QOL is sensitive also to the treatment of pain and treatment modalities, as shown particularly by studies on cancer pain. Pain reduction is not always attended by the expected improvement in QOL. Pain is not synonymous with poor QOL and constitutes only one important factor determining QOL. The main conclusions are that treatment of pain should be multidisciplinary, considering the impact of pain and the treatment on QOL and targetting also improvement of the affected domains of QOL.

Population-based study of the relationship of treatment and sociodemographics on quality of life for early stage breast cancer

OBJECTIVE

To examine the relationship between cancer stage, surgical treatment and chemotherapy on quality of life (QOL) after breast cancer and determine if sociodemographic characteristics modify the observed relationships.

METHODS

A population-based sample of women with Stages 0-II breast cancer in the United States (N = 1357) completed surveys including the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30), and the Breast Cancer-Specific Quality of Life Questionnaire (QLQ BR-23). Regression models calculated mean QOL scores across primary surgical treatment and chemotherapy. Clinically significant differences in QOL were defined as > or = 10 point difference (out of 100) between groups.

RESULTS

Meaningful differences in QOL by surgical treatment were limited to body image with women receiving mastectomy with reconstruction reporting lower scores than women receiving breast conserving surgery (p < 0.001). Chemotherapy lowered QOL scores overall across four QOL dimensions (p values < 0.001), with a disproportionately greater impact on those with lower levels of education. Younger women reported lower QOL scores for seven of nine QOL dimensions (p values < 0.001).

CONCLUSIONS

Women should be reassured that few QOL differences exist based on surgical treatment, however, clinicians should recognize that the impact of treatment on QOL does vary by a woman's age and educational level.

Multidimensional constructs of the EORTC Quality of Life Questionnaire (QLQ-c30) in Korean cancer patients with heterogeneous diagnoses

PURPOSE

The aim of this study was to evaluate the multidimensional constructs of the EORTC Quality of Life Questionnaire (QLQ-C30) in patients with cancer, employing not only the commonly used multitrait scaling analysis and interscale correlations, but also the factorial and multidimensional scaling (MDS) analyses.

MATERIALS AND METHODS

A total of 334 Korean cancer patients participated in this cross-sectional study. All patients completed the QLQ-C30.

RESULTS

With the multitrait scaling analysis, the cognitive functioning scale did not meet item convergent and divergent validities. With the interscale correlations, the physical and role functioning scales were found to be highly correlated; this was also evident in the factorial analysis. The MDS showed that each item within the social, emotional, global health status/quality of life, and nausea/vomiting scales were clustered close together, but far from those of the other scales.

CONCLUSION

The authors conclude that the four way evaluation of the QLQ-C30 produced results that supported the original hypothesized constructs. However, the physical and role functioning scales were not distinctive, and that of the cognitive functioning was somewhat problematic in the Korean population with cancer.

A feasibility study of psychosocial group intervention for breast cancer patients with first recurrence

GOALS OF WORK

The effects of psychosocial group interventions on improving quality of life (QOL) for patients with recurrent breast cancer are not well known. The objective of this study was to assess the feasibility of a psychosocial group intervention in Japanese women with first recurrence of breast cancer.

PATIENTS AND METHOD

The subjects were consecutively selected from among patients who were diagnosed with a first recurrence of breast cancer. We conducted a 6-week psychosocial group intervention. QOL was assessed using the Profile of Mood States (POMS), the Impact of Event Scale-Revised, the Mental Adjustment to Cancer (MAC) scale, and the European Organization for Research and the Treatment of Cancer (EORTC) Quality of Life Questionnaire-Cancer 30/Breast module 23 (QLQ-C30/Br23) at baseline then immediately and 3 and 6 months after completion of the intervention.

RESULTS

Among 58 eligible patients, written consent was obtained from 28 (48%), and the final evaluation was conducted on 19 subjects. The repeated measured analysis of variance (ANOVA) revealed a significant change in tension-anxiety, depression-dejection, anger-hostility and total mood disturbance on the POMS, helplessness/hopelessness on the MAC scale, and body image and future perspective on the QLQ-C30/Br23. Dunnett's test revealed a significant difference in these scores between baseline and 3 months after the intervention but no difference between baseline and 6 months after the intervention.

CONCLUSION

These results suggested the possibility of a short-term effectiveness of the intervention; however the results were inconclusive because of selected small samples.

Quality of life of breast cancer patients in Taiwan: Validation of the Taiwan Chinese version of the EORTC QLQ-C30 and EORTC QLQ-BR23

The objective of this study was to test the reliability and validity of the Taiwan Chinese version of the EORTC QLQ-C30 (version 3) and EORTC QLQ-BR23. The authors followed the guidelines of translation and pilot testing of the questionnaires. The questionnaires were given to 35 breast cancer patients under active treatment and 54 under follow-up at the National Taiwan University Hospital from November 2000 to October 2001. A retest was conducted one to two weeks after the first interview/form completion for the follow-up group. The intraclass correlation coefficients of the two questionnaires were moderate to high in the follow-up group. The Cronbach's alpha coefficients of most scales of the two questionnaires were > or = 0.70 except that of physical functioning (0.68), cognitive functioning (0.53), and arm symptoms (0.59). Correlations of scales measuring similar dimensions of the EORTC QLQ-C30 and the SF-36 were moderate. Patients in the active treatment group had more serious QOL problems due to disease and treatment. Results of this study showed that the Taiwan Chinese version of the two questionnaires had good test/retest reliability, high internal consistency in most scales, and could show the expected differences between patients in active chemotherapy and follow-up group.

Assessment of quality of life in a multicultural cancer patient population

Quality of life (QOL) is increasingly assessed in cancer patients. In this article, the authors examined the psychometric performance of a commonly used QOL questionnaire, the Quality of Life Questionnaire--Cancer 30 (QLQ-C30; N. K. Aaronson et al., 1993), in multiethnic cancer patients. Content validation studies in patients and clinicians identified possible new items. Multiple-group confirmatory factor analysis supported equivalent structure across ethnic groups (Caucasians and Asian/Pacific Islanders [APIs]). A higher order QOL factor appeared to directly affect functioning scales and symptom count. Exploratory factor analysis examined effects of new items. Ten factors were extracted, 6 consistent with the original instrument and 4 reflecting potentially new aspects of QOL: Positive Social Support, Coping, Existential Well-Being, and Sexuality/Intimacy. The QLQ-C30 appears appropriate for use in API cancer patients. Further work needs to ensure that it includes all important domains.

Multidimensional scaling as a tool for analysing quality of life data

Multidimensional scaling (MDS) is introduced and discussed as a graphical method to complement conventional descriptive and confirmatory methods in the validation and analysis of quality of life (QOL) data. An outline of M DS as a statistical technique is given, and its application in the context of QOL research is described. The use of MDS is then illustrated in an example based on a study of 300 cancer survivors who completed the functional assessment of cancer therapy-general (FACT-G) and the EORTC core quality of life questionnaire (QLQ-C30). The correlational structure of the two widely used QOL instruments is investigated by means of MDS, and differences between the two questionnaires are elaborated. Finally, the merits and drawbacks of MDS are discussed in the specific context of the example and in the general framework of QOL research.

Evaluating the relationship between pain presentation and health-related quality of life in outpatients with metastatic or recurrent neoplastic disease

Because cancer pain can in many cases be intermittent, the presence or absence of pain in ambulatory care patients on any given clinic visit may not be an accurate characterization of the impact of pain on functioning or health-related quality of life (HRQOL). The purpose of this study was to describe the relationship between temporal aspects of pain presentation and HRQOL among 187 stage III/IV cancer patients using the Brief Pain Inventory and the EORTC QLQ-C30. A total of 43% of patients reported pain the previous week, with 22% reporting no pain at the time of assessment. Differences between three pain groups (No Pain, Past Pain, and Current Pain) were significant for global HRQOL and five dimensions of HRQOL. Severity of pain was also associated with each dimension of HRQOL. This study highlights the complex relationship between pain presentation and HRQOL. The findings support the continuing need for detailed pain assessments among cancer patients treated in ambulatory care settings. Specifically, standardized, self-report measures of cancer pain that include 'frequency' as well as severity may be the most accurate approach to capture the impact of pain on HRQOL.