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

Measuring Quality of Life in Deprescribing Trials: A Scoping Review

BACKGROUND

Quality of life (QoL) is an important outcome to capture in clinical trials evaluating deprescribing interventions.

OBJECTIVE

We aimed to conduct a scoping review to examine how QoL has been measured in deprescribing trials among older people and identify potentially relevant QoL scales, to better inform QoL measurement in future deprescribing trials.

METHODS

We searched MEDLINE, Embase, PsycINFO, the Cochrane Central Register of Controlled Trials, Google Scholar, Epistemonikos, ClinicalTrials.gov, and reference lists of eligible studies (from inception to October 2023). We included randomized and non-randomized comparative studies with a control group that evaluated deprescribing and polypharmacy reduction interventions in people ≥ 65 years of age and measured QoL as an outcome. We also included studies describing the development and validation of QoL scales related to deprescribing, polypharmacy, or medication burden in adults ≥ 18 years of age. Two independent reviewers screened titles and abstracts, then full texts. Two independent reviewers extracted data from 25% of eligible studies in order to verify agreement, then a single reviewer extracted data from the remaining studies, which a second reviewer cross-checked. We critically appraised scales based on the COSMIN checklist.

RESULTS

We retrieved 7290 articles, of which 52 were eligible for inclusion, including 44 deprescribing trials and eight scale development studies. From these studies, we found 21 scales that have been used in the context of deprescribing/polypharmacy (12 generic scales used in clinical trials and nine medication-specific scales). Variations of the generic EQ-5D were the most used scales. The measurement properties of scales for capturing changes in QoL from deprescribing were uncertain. Medication-specific QoL scales have not been employed in deprescribing clinical trials and thus, their performance in this context is also not clear.

CONCLUSIONS

Several existing QoL scales have been applied to the context of deprescribing/polypharmacy clinical trials, and new scales specific to the problem have been proposed. If deprescribing does impact QoL, our findings suggest it is uncertain whether existing QoL scales can practically and reliably capture such a change or whether any scale is best. However, this review compares various aspects of the scales that researchers and clinicians can consider in decisions about measuring QoL in deprescribing trials, and in planning future research.

PROTOCOL REGISTRATION

Open Science Framework: osf.io/aez6w.

The Impact of the Timing of Health-Related Quality of Life Assessments on the Actual Results in Glioma Patients: A Randomized Prospective Study

Background: The aim of this study was to explore the impact of the timing of Health-Related Quality of Life (HRQoL) measurements in clinical care on the obtained HRQoL scores in glioma patients, and the association with feelings of anxiety or depression. Methods: Patients completed the European Organisation for Research and Treatment of Cancer (EORTC)’s Quality of Life Questionnaires (QLQ-C30 and QLQ-BN20), and the Hospital Anxiety and Depression Scale (HADS) twice. All patients completed the first measurement on the day of the Magnetic Resonance Imaging (MRI) scan (t = 0), but the second measurement (t = 1) depended on randomization; Group 1 (n = 49) completed the questionnaires before and Group 2 (n = 51) after the consultation with the physician. Results: median HRQoL scale scores on t0/t1 and change scores were comparable between the two groups. Between 8–58% of patients changed to a clinically relevant extent (i.e., ≥10 points) on the evaluated HRQoL scales in about one-week time, in both directions, with only 3% of patients remaining stable in all scales. Patients with a stable role functioning had a lower HADS anxiety change score. The HADS depression score was not associated with a change in HRQoL. Conclusions: Measuring HRQoL before or after the consultation did not impact HRQoL scores on a group level. However, most patients reported a clinically relevant difference in at least one HRQoL scale between the two time points. These findings highlight the importance of standardized moments of HRQoL assessments, or patient-reported outcomes in general, during treatment and follow-up in clinical trials.

Measuring Quality-Adjusted Life-Years When Health Fluctuates

Recurrent fluctuations in health states can occur as a result of long-term conditions with episodic symptoms or through side effects of cycles of treatment. Fluctuations and associated duration of symptoms can be predictable (eg, side effects of chemotherapy treatment) or unpredictable (eg, relapse in multiple sclerosis). Such recurrent fluctuations in health states can have an important impact on a person's health-related quality of life. When symptoms vary by time of day, day of the week, or during the month, it is challenging to obtain reliable health-related quality of life estimates for use in assessing cost-effectiveness of interventions. The adequacy of the quality of life estimate will be affected by (1) the standard recall period associated with the chosen measure (eg, "health today" EQ-5D, "past 4 weeks" for SF-36/SF-6D) and the way that respondents understand and make judgments about these recall periods, (2) the chosen time points for assessing health-related quality of life in relation to the fluctuations in health, and (3) the assumptions used to interpolate between measurement time points and thus calculate the quality-adjusted life-years. These issues have not received sufficient methodological attention and instead remain poorly accounted for in economic analyses. There is potential for these issues to considerably distort treatment decisions away from the optimal allocation. This article brings together evidence from health economics, psychology, and behavioral economics to explore these challenges in depth; presents the solutions that have been applied to date; and details a methodological research agenda for measuring quality-adjusted life-years in recurrent fluctuating health states.

Are all outcomes in chronic heart failure rated equally? An argument for a patient-centred approach to outcome assessment

Chronic heart failure (CHF) is a multi-dimensional and complex syndrome. Outcome measures are important for determining both the efficacy and quality of care and capturing the patient's perspective in evaluating the outcomes of health care delivery. Capturing the patient's perspective via patient-reported outcomes is increasingly important; however, including objective measures such as mortality would provide more complete account of outcomes important to patients. Currently, no single measure for CHF outcomes captures all dimensions of the quality of care from the patient's perspective. To describe the role of outcome measures in CHF from the perspective of patients, a structured literature review was undertaken. This review discusses the concepts and methodological issues related to measurement of CHF outcomes. Outcome assessment at the level of the patient, provider and health care system were identified as being important. The perspectives of all stakeholders should be considered when developing an outcomes measurement suite to inform CHF health care. This paper recommends that choice of outcome measures should depend on their ability to provide a comprehensive, comparable, meaningful and accurate assessment that are important to patient.

Patient-reported outcome (PRO) assessment in clinical trials: a systematic review of guidance for trial protocol writers

BACKGROUND

Evidence suggests there are inconsistencies in patient-reported outcome (PRO) assessment and reporting in clinical trials, which may limit the use of these data to inform patient care. For trials with a PRO endpoint, routine inclusion of key PRO information in the protocol may help improve trial conduct and the reporting and appraisal of PRO results; however, it is currently unclear exactly what PRO-specific information should be included. The aim of this review was to summarize the current PRO-specific guidance for clinical trial protocol developers.

METHODS AND FINDINGS

We searched the MEDLINE, EMBASE, CINHAL and Cochrane Library databases (inception to February 2013) for PRO-specific guidance regarding trial protocol development. Further guidance documents were identified via Google, Google scholar, requests to members of the UK Clinical Research Collaboration registered clinical trials units and international experts. Two independent investigators undertook title/abstract screening, full text review and data extraction, with a third involved in the event of disagreement. 21,175 citations were screened and 54 met the inclusion criteria. Guidance documents were difficult to access: electronic database searches identified just 8 documents, with the remaining 46 sourced elsewhere (5 from citation tracking, 27 from hand searching, 7 from the grey literature review and 7 from experts). 162 unique PRO-specific protocol recommendations were extracted from included documents. A further 10 PRO recommendations were identified relating to supporting trial documentation. Only 5/162 (3%) recommendations appeared in ≥50% of guidance documents reviewed, indicating a lack of consistency.

CONCLUSIONS

PRO-specific protocol guidelines were difficult to access, lacked consistency and may be challenging to implement in practice. There is a need to develop easily accessible consensus-driven PRO protocol guidance. Guidance should be aimed at ensuring key PRO information is routinely included in appropriate trial protocols, in order to facilitate rigorous collection/reporting of PRO data, to effectively inform patient care.

Assessing quality of life on the day of chemotherapy administration underestimates patients' true symptom burden

Background

In chemotherapy trials quality of life (QOL) is assessed mostly at the days of chemotherapy administration (i.e. event-driven) during treatment and follows fixed time intervals in the aftercare phase (i.e. time-driven). Specific QOL impairments and treatment side-effects are known to be time dependent following different trajectories. Therefore, acute problems are likely to be missed if assessments are done infrequently or at inappropriate time points. Since the planning of supportive care interventions during chemotherapy depends on knowledge about symptom trajectories, such information may be of substantial importance to a clinician.

Methods

Cancer patients receiving chemotherapy at Kufstein County Hospital were assessed using an electronic version of the EORTC QLQ-C30 at the day of chemotherapy administration at the hospital. One and two weeks later assessments were repeated via the internet while patients were at home. Assessments at home and the hospital were conducted using the web-based software CHES. Data were analysed by means of linear mixed models.

Results

A sample of 54 chemotherapy outpatients participated in electronic QOL assessments at the hospital and at home. For 9 out of the 15 QOL domains of the EORTC QLQ-C30 patients reported increased burden one week after chemotherapy administration compared to the day of chemotherapy administration. Most pronounced differences were found for Fatigue, Constipation, and Appetite Loss.

Conclusions

Our results indicate that patients experience most severe QOL impairments in the week following chemotherapy administration. This is a period that is usually not covered by QOL assessments in chemotherapy trials which may result in underestimation of true treatment burden. Our findings suggest to conduct QOL assessments not only event- or time-driven, but to rely on specific hypotheses on symptom and functioning trajectories.

[Temporal changes in quality of life after prostate carcinoma]

INTRODUCTION

Each year more than 60,000 German men are diagnosed with prostate cancer. The incidence nearly doubled in the last 10 years due to intensified use of PSA testing for early detection. To date, either radical prostatectomy or radiotherapy is recommended for treatment of localized prostate cancer. Both strategies have similar survival chances (83-94%), but show different side effects. In view of the good prognosis implications for health-related quality of life (QoL) may play an important role in the therapy decision-making process and should be discussed with patients.

MATERIALS AND METHODS

Prostate cancer patients were asked twice about oncological health care and QoL (EORTC QLQ-C30, Version 2) as part of the OVIS study conducted in Schleswig-Holstein. The first questioning took place 16 months after the initial diagnosis and the second one at month 42. QoL was compared with German reference data. Logistic regression identified predictors for (a) low QoL at baseline (as indicated by global health status/QoL below the group median) and (b) clinically relevant detriments, defined as a difference of ≥10 points, in the chronological sequence.

RESULTS

Prostate cancer patients (n=1,345; median age at diagnosis 66 years) report a mean global QoL score that is higher than that of a healthy German reference sample (difference 6.3). In the temporal course, 56% of patients did not experience a clinically relevant change in QoL (<10 points difference). However, 20% reported a clinically relevant decrease and 24% a clinically relevant increase (≥ 10 points difference) regarding global health status/QoL. Higher age, lower social class, chemotherapy, undesired side effects and long-term complications as well as rehabilitative care predict low QoL at baseline, while progression of the disease and living in an urban surrounding as well as young age at diagnosis predict a decrease of QoL in the chronological sequence.

CONCLUSIONS

Self-reported QoL of prostate cancer patients depends on various personal and medical factors. Physicians should be aware of these factors and include them in the discussion about the appropriate therapy method with their patients. In general, therapists and family members have problems describing the QoL of their patients and relatives. Assessing the QoL and QoL-influencing factors with a short questionnaire seems to be feasible and may be helpful in the therapy decision-making process.

What is the methodological and reporting quality of health related quality of life in chronic heart failure clinical trials?

BACKGROUND

Although the number of clinical trials assessing health related quality of life (HRQoL) in chronic heart failure (CHF) has increased exponentially over the last decade, little is known about the quality of reporting. The purpose of this review was to assess the methodological and reporting rigor of HRQoL in RCTs of pharmacological therapy in CHF.

METHODS

The electronic data bases, Medline and EMBASE were searched from 1990 to 2009 using the key search terms 'heart failure' combined with 'quality of life', 'pharmacological therapy' and 'randomized controlled trials'. A total of 136 articles were identified and evaluated according to the "Minimum Standard Checklist (MSC) for Evaluating HRQoL Outcomes".

RESULTS

According to the MSC criteria, 26 (19.1%) studies were considered 'very limited', 91 (66.9%) were 'limited' and only 19 (14.0%) studies were considered to be of a 'probably robust' in terms of methodological and reporting rigor. In fact, the quality of HRQoL reporting has not improved over time.

CONCLUSION

HRQoL is a critical consideration in CHF management, yet reporting is highly variable. There is a need to develop a standardized method for measuring and reporting HRQoL measures in clinical trials to aid in the interpretation and application of findings.

Effectiveness of a Home Care Nursing Program in the Symptom Management of Patients With Colorectal and Breast Cancer Receiving Oral Chemotherapy: A Randomized, Controlled Trial

Purpose

To assess the effectiveness of a symptom-focused home care program in patients with cancer who were receiving oral chemotherapy in relation to toxicity levels, anxiety, depression, quality of life, and service utilization.

Patients and Methods

A randomized, controlled trial was carried out with 164 patients with a diagnosis of colorectal (n = 110) and breast (n = 54) cancers who were receiving oral capecitabine. Patients were randomly assigned to receive either a home care program by a nurse or standard care for 18 weeks (ie, six cycles of chemotherapy). Toxicity assessments were carried out weekly for the duration of the patients' participation in the trial, and validated self-report tools assessed anxiety, depression, and quality of life.

Results

Significant improvements were observed in the home care group in relation to the symptoms of oral mucositis, diarrhea, constipation, nausea, pain, fatigue (first four cycles), and insomnia (all P < .05). This improvement was most significant during the initial two cycles. Unplanned service utilization, particularly the number of inpatient days (57 v 167 days; P = .02), also was lower in the home care group.

Conclusion

A symptom-focused home care program was able to assist patients to manage their treatment adverse effects more effectively than standard care. It is imperative that patients receiving oral chemotherapy are supported with such programs, particularly during initial treatment cycles, to improve their treatment and symptom experiences.

Art therapy improves experienced quality of life among women undergoing treatment for breast cancer: a randomized controlled study

Women with breast cancer are naturally exposed to strain related to diagnosis and treatment, and this influences their experienced quality of life (QoL). The present paper reports the effect, with regard to QoL aspects, of an art therapy intervention among 41 women undergoing radiotherapy treatment for breast cancer. The women were randomized to an intervention group with individual art therapy sessions for 1 h/week (n = 20), or to a control group (n = 21). The WHOQOL-BREF and EORTC Quality of Life Questionnaire-BR23, were used for QoL assessment, and administrated on three measurement occasions, before the start of radiotherapy and 2 and 6 months later. The results indicate an overall improvement in QoL aspects among women in the intervention group. A significant increase in total health, total QoL, physical health and psychological health was observed in the art therapy group. A significant positive difference within the art therapy group was also seen, concerning future perspectives, body image and systemic therapy side effects. The present study provides strong support for the use of art therapy to improve QoL for women undergoing radiotherapy treatment for breast cancer.

Objective physical activity and self-reported quality of life in patients receiving palliative chemotherapy

There is little objective data on how cancer and its therapy affect physical activity. The main aims of this pilot study were 1) to compare physical activity in patients receiving palliative chemotherapy and healthy controls, and 2) to explore the relationship between patients' activity, quality of life (QoL), and clinical performance status. A miniaturized electronic meter objectively recorded activity for one week in 20 patients with upper gastrointestinal cancer receiving palliative chemotherapy and in 13 age-matched healthy controls. Patients also completed the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30, Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F; fatigue), and Functional Assessment of Anorexia and Cachexia Therapy (FAACT; anorexia/cachexia) quality-of-life questionnaires. The patients' median estimated total energy expenditure was 8% lower (P=0.0003), median time spent upright was approximately two hours/day less (P=0.0002), and median steps taken/day was 43% lower (P=0.002) than that of the control group. Neither estimated energy expenditure nor average steps taken/day correlated significantly with EORTC QLQ-C30 physical functioning, fatigue, or global health status/QoL. There was no correlation with the FAACT "Trial Outcome Index" (TOI), but the FACIT-F TOI and both estimated energy expenditure and the average steps taken/day correlated significantly (r=0.59, P=0.009 and r=0.59, P=0.008). It is concluded that patients receiving palliative chemotherapy were less active than healthy controls; however, the relationship between physical activity and QoL requires further characterization.

The OVIS study: health related quality of life measured by the EORTC QLQ-C30 and -BR23 in German female patients with breast cancer from Schleswig-Holstein

The OVIS study is a population-based study that aims at evaluating medical care in Schleswig-Holstein (Germany). In this paper, the health related quality of life (QoL, EORTC QLQ-C30 and -BR23) of 1,927 women with breast cancer is reported. The global health status/QoL score was comparable to reference data of the age-adjusted German general population, but clinical meaningful differences (> or = 10 points) were found for all functioning scales (with the exception of physical functioning) and for three of the symptom scales/items (fatigue, dyspnoe, insomnia) with OVIS patients showing more deficits. Furthermore, OVIS patients scored higher on the item financial difficulties. Logistic regression analyses revealed that coming from an urban surrounding, having a higher social status and attendance to a regular aftercare predicted a good overall QoL, while factors that were related to perceived complications in the course of the therapy raised the risk for a low QoL rating. It is of interest, that attendance to a rehabilitation and interest in self-help groups independently predicted an increased risk for a low quality of life. Overall, we assume the global QoL is rating slightly too optimistic since major deficits were reported on the specific physical and functional scales/items.

Does a patient’s self-reported health-related quality of life predict survival beyond key biomedical data in advanced colorectal cancer?

The purpose of this study was to determine whether baseline patients' self reported health-related quality of life (HRQOL) parameters could predict survival beyond key biomedical prognostic factors in patients with metastatic colorectal cancer. The analysis was conducted on 299 patients. HRQOL baseline scores were assessed using the European Organisation for Research and Treatment of Cancer, Quality of Life Questionnaire-Core30 (EORTC QLQ-C30). The Cox proportional hazards regression model was used for both univariate and multivariate analyses of survival. In addition, a bootstrap resampling technique was used to assess the stability of the outcomes. The final multivariate Cox regression model retained four variables as independent prognostic factors for survival: white blood cell (WBC) count with a hazard ratio (HR) of 1.961 (95% CI, 1.439-2.672; P<0.001), alkaline phosphatase with HR=1.509 (95% CI, 1.126-2.022; P=0.005), number of sites involved with HR=1.108 (95% CI, 1.024-1.198; P=0.01) and the patient's score on the social functioning scale with HR=0.991 (95% CI, 0.987-0.996; P<0.001) which translates into a 9% decrease in the patient's hazard of death for any 10 point increase. The independent prognostic importance of social functioning and the stability of the final Cox regression model were also confirmed by the additional bootstrap model averaging analysis, based on 1000 bootstrap-generated samples. The results suggest that social functioning, acts as a prognostic measure of survival beyond a number of previously known biomedical parameters.

Assessing the quality of life—reality or impossible dream?

Many now claim that maintaining or improving the quality of life is the essence of healthcare (i.e. care and/or treatment that improves the patients' quality of life). Interest in QL, however, stems from increasing recognition that individuals are an integrated whole rather than a series of disconnected parts or disease states. Though this represents a significant change from the past--when the emphasis lay solely on physical or medical condition--it is not, in itself, meaningful unless reliable and valid ways of evaluating the human aspects of the experience can be identified (i.e. quality of life). As quality of life (QL) is seen as a positive state, a desirable outcome of healthcare interventions, it has gained credence as an appropriate outcome measure and has intuitive appeal. Indeed, it is suggested that, because of its close relationship to mortality, self-perceived QL may be the most important outcome of both acute and, particularly, chronic disease. Lack of consensus about its meaning has, however, resulted in ambiguity and, therefore, difficulties in its measurement reflecting, in turn, the difficulty in identifying the components of this multifaceted concept. This paper explores these issues and questions whether we are, in fact, attempting to measure something that cannot truly be measured.

Quality of life in randomized trials of cytotoxic or hormonal treatment of advanced breast cancer. Is there added value?

BACKGROUND

Since most advanced cancers are still incurable, oncologic clinical research pays considerable attention to palliation, increasingly valuing subjective measures of outcome such as quality of life (QoL). We reviewed randomised clinical trials (RCT) of cytotoxic or hormonal treatments in advanced breast cancer (ABC), published before December 2003, to evaluate the methodological quality of QoL assessment and assess its added value (over classical clinical endpoints (CCE), i.e. survival, response, time to progression, toxicity) in the choice of the best treatment option.

METHODS

RCTs were classified according to treatment characteristics and the CCEs. A descriptive analysis was based on the methodological aspects of QoL assessment and the clinical value of QoL findings was judged by counting the frequency of reporting in the study abstracts and the assessment of QoL combined with CCEs.

RESULTS

We retrieved 33 eligible RCTs (10,791 patients); only 20 reported the number of patients considered in QoL principal analysis and only 69% of randomized patients were included in such analyses. A total of 17 different QoL questionnaires were used, 11 only once. QoL assessment lasted from less than 12 weeks to progression, and timing of questionnaires from 2 to 12 weeks. Compliance rates were 85.7% for baseline forms and 67% for overall assessment, but this information was available for only 18 and 20 trials, respectively. Wide variability emerged in analysis strategies and statistical approaches. QoL findings were reported in 12 study abstracts (37% of patients). Eight studies reported a significant difference in QoL scores but since QoL data often failed to parallel the clinical findings (e.g. better QoL scores were reported in two of 17 trials with better CCEs and in six of 20 with significant differences in toxicity profiles), the QoL added value was difficult to ascertain and, on the whole, only moderate.

CONCLUSION

In ABC trials, QoL assessment added relatively little value to CCEs in helping select the best treatment option, apparently largely because of sub-optimal methodological standards.

Randomized, controlled trial investigating short-term health-related quality of life with doxorubicin and paclitaxel versus doxorubicin and cyclophosphamide as first-line chemotherapy in patients with metastatic breast cancer: European Organization for Research and Treatment of Cancer Breast Cancer Group, Investigational Drug Branch for Breast Cancer and the New Drug Development Group Study

PURPOSE

To compare health-related quality of life (HRQOL) in patients with metastatic breast cancer receiving the combination of doxorubicin and paclitaxel (AT) or doxorubicin and cyclophosphamide (AC) as first-line chemotherapy treatment.

PATIENTS AND METHODS

Eligible patients (n = 275) with anthracycline-naive measurable metastatic breast cancer were randomly assigned to AT (doxorubicin 60 mg/m(2) as an intravenous bolus plus paclitaxel 175 mg/m(2) as a 3-hour infusion) or AC (doxorubicin 60 mg/m(2) plus cyclophosphamide 600 mg/m(2)) every 3 weeks for a maximum of six cycles. Dose escalation of paclitaxel (200 mg/m(2)) and cyclophosphamide (750 mg/m(2)) was planned at cycle 2 to reach equivalent myelosuppression in the two groups. HRQOL was assessed with the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire C30 and the EORTC Breast Module at baseline and the start of cycles 2, 4, and 6, and 3 months after the last cycle.

RESULTS

Seventy-nine percent of the patients (n = 219) completed a baseline measure. However, there were no statistically significant differences in HRQOL between the two treatment groups. In both groups, selected aspects of HRQOL were impaired over time, with increased fatigue, although some clinically significant improvements in emotional functioning were seen, as well as a reduction in pain over time. Overall, global quality of life was maintained in both treatment groups.

CONCLUSION

This information is important when advising women patients of the expected HRQOL consequences of treatment regimens and should help clinicians and their patients make informed treatment decisions.

Health-Related Quality of Life Parameters As Prognostic Factors in a Nonmetastatic Breast Cancer Population: An International Multicenter Study

Purpose

The purpose of this research was to evaluate whether baseline health-related quality of life (HRQOL) parameters are prognostic factors for survival in locally advanced breast cancer patients. Although the literature highlights the important role of HRQOL parameters in predicting survival in advanced metastatic disease, little evidence exists for earlier stages.

Patients and Methods

The overall sample consisted of 448 patients randomly assigned to receive cyclophosphamide, epirubicin, and fluorouracil versus epirubicin, cyclophosphamide, and granulocyte colony-stimulating factor. Patients were enrolled in 12 countries. HRQOL baseline scores were assessed using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30. The Cox proportional hazards regression model was used for both univariate and multivariate analyses of survival. In addition, a bootstrap resampling technique was used to assess the stability of the outcomes. Bootstrap results were then applied for model averaging purposes as a means to account for the observed model selection uncertainty.

Results

The final multivariate model retained inflammatory breast cancer (T4d) as the only factor predicting overall survival (OS) with a hazard ratio of 1.375 (95% CI, 1.027 to 1.840; P = .03). The presence of inflammatory breast cancer lowers the median survival time from 6.6 to 4.2 years (36% reduction). None of the preselected HRQOL variables were prognostic for OS or disease-free survival, in either the univariate or multivariate analysis.

Conclusion

Our findings suggest that baseline HRQOL parameters have no prognostic value in a nonmetastatic breast cancer population.

Research methodology: cancer cachexia syndrome

Cachexia is a syndrome and therefore does not have a specific definition. Patients are characterized by the presence of anorexia, early satiety, weight loss, weakness, anaemia and oedema. These features occur to a variable extent in different patients and may change in severity during the course of a patient's illness. The multifactorial origin of cachexia precludes a uniform pathophysiological definition. Taken together these factors have hindered clinical studies both at a fundamental level and in terms of the introduction of effective therapy. The advent of novel therapeutic targets (e.g., ubiquitin-proteasome pathway) and biological response modifiers has opened possibilities for new clinical trials in cachexia. Regulatory authorities feel it is important not only to demonstrate efficacy in terms of patients' nutritional status (e.g., lean body mass) but also functional status (e.g., performance status). This article reviews current methods to assess the latter. Methods focused on measuring physical activity level (e.g., doubly labelled water technique or physical activity meters) promise objective data which can be readily interpreted in terms of clinically meaningful benefit.

Baseline health-related quality-of-life data as prognostic factors in a phase III multicentre study of women with metastatic breast cancer

The potential value of baseline health-related quality-of-life (HRQOL) and clinical factors in predicting prognosis was examined using data from an international randomised phase III trial which compared doxorubicin and paclitaxel with doxorubicin and cylophosphamide as first line chemotherapy in 275 women with metastatic breast cancer. The European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 and the related breast module (QLQ-BR23) were used to assess baseline HRQOL data. The Cox proportional-hazards regression model was used for both univariate and multivariate analyses of survival. In the univariate analyses, performance status (P<0.001) and number of sites involved (P=0.001) were the most important clinical prognostic factors. The HRQOL variables at baseline most strongly associated with longer survival were better appetite, physical and role functioning, as well as less fatigue (P<0.001). The final multivariate model retained performance status (P<0.001) and appetite loss (P=0.005) as the variables best predicting survival. Substantial loss of appetite was the only independent HRQOL factor predicting poor survival and was strongly correlated (/r/>0.5) with fatigue, role and physical functioning. In addition to known clinical factors, appetite loss appears to be a significant prognostic factor for survival in women with metastatic breast cancer. However, the mechanism underlying this association remains to be precisely defined in future studies.

Misrepresenting random sampling? A systematic review of research papers in the Journal of Advanced Nursing

AIM

This paper discusses the theoretical limitations of the use of random sampling and probability theory in the production of a significance level (or P-value) in nursing research. Potential alternatives, in the form of randomization tests, are proposed.

BACKGROUND

Research papers in nursing, medicine and psychology frequently misrepresent their statistical findings, as the P-values reported assume random sampling. In this systematic review of studies published between January 1995 and June 2002 in the Journal of Advanced Nursing, 89 (68%) studies broke this assumption because they used convenience samples or entire populations. As a result, some of the findings may be questionable.

DISCUSSION

The key ideas of random sampling and probability theory for statistical testing (for generating a P-value) are outlined. The result of a systematic review of research papers published in the Journal of Advanced Nursing is then presented, showing how frequently random sampling appears to have been misrepresented. Useful alternative techniques that might overcome these limitations are then discussed. REVIEW LIMITATIONS: This review is limited in scope because it is applied to one journal, and so the findings cannot be generalized to other nursing journals or to nursing research in general. However, it is possible that other nursing journals are also publishing research articles based on the misrepresentation of random sampling. The review is also limited because in several of the articles the sampling method was not completely clearly stated, and in this circumstance a judgment has been made as to the sampling method employed, based on the indications given by author(s).

CONCLUSION

Quantitative researchers in nursing should be very careful that the statistical techniques they use are appropriate for the design and sampling methods of their studies. If the techniques they employ are not appropriate, they run the risk of misinterpreting findings by using inappropriate, unrepresentative and biased samples.

Prognostic value of quality of life scores for time to progression (TTP) and overall survival time (OS) in advanced breast cancer

The purpose of the study was to investigate whether baseline quality of life (QoL) and changes in QoL scores from baseline are prognostic for time to progression (TTP) and/or overall survival (OS) in patients with advanced breast cancer receiving docetaxel (T) or sequential methotrexate and 5-fluorouracil (MF). QoL was assessed at baseline and before each treatment using the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ-C30). Survival curves and probabilities were estimated using the Kaplan-Meier technique. The Cox proportional hazards regression model was used for both the univariate and multivariate analyses to explore relationships between baseline QoL variables and TTP, as well as OS. In the univariate analysis, more severe pain and fatigue at baseline were predictive for a shorter OS; global QoL, physical functioning and appetite loss had a borderline significance (P=0.0130 for global QoL; P=0.0256 for physical functioning: P=0.0149 for appetite loss). World Health Organization (WHO) performance status was significantly predictive for OS. In the multivariate analysis, more severe pain at baseline was predictive for a shorter OS. In contrast, baseline QoL had no prognostic value for the duration of TTP. QoL change scores from baseline QoL predicted neither OS nor TTP. Our findings suggest that while QoL measurements are important in evaluating patients' QoL, they have no great importance in predicting primary clinical endpoints such as TTP or OS in advanced breast cancer patients.

Postnatal quality of life: a pilot study using the Mother-Generated Index

BACKGROUND

Although postnatal morbidity has been well documented in recent years, postnatal quality of life has not been addressed. A newly derived subjective measurement of postnatal quality of life (the Mother-Generated Index) combines a quantitative and qualitative evaluation.

AIMS

This part of our pilot study aimed to compare the aspects of their lives nominated by women with low and high quality of life (Primary Index) scores, and to examine the respective importance of these areas.

METHODS

The Mother-Generated Index was tested using the Edinburgh Postnatal Depression Scale, Short Form 12, and an established maternal and neonatal physical morbidity index as validators. Four health visitors administered these at 6-8 weeks and 8 months postpartum to 103 women by structured face-to-face interviews between June 2000 and March 2001. Data were entered into Epi-Info, and exported to Microsoft Excel and SPSS for analysis.

RESULTS

A wide variety of quality of life aspects were reported, including emotional, social and financial concerns. Tiredness was prevalent in all groups, but other physical problems were rare at 8 months. Mothers with low quality of life (Primary Index) scores at 6-8 weeks and 8 months commonly reported having less personal time. Low scoring areas, which health professionals might consider in greatest need of attention, were often not the ones mothers deemed most important.

LIMITATIONS

The study involved only 103 participants, and did not assess the degree of support experienced by the mothers.

CONCLUSIONS

The Mother-Generated Index helps mothers to identify the areas of their lives which are of most concern to them. This pilot suggests that mothers with high and low quality of life scores have markedly divergent experiences.