Quality of life in survivors of a primary bone tumour: a systematic review

How much is a leg worth following radical tumor resection in bone sarcomas? Literature review

Bone sarcomas of the lower extremities are rare malignancies occurring mostly amongst adolescents and young adults. Necessarily, the therapy conducted in sarcoma centers is multimodal and multidisciplinary. In certain cases, in a metastasis free situation with adequate therapy, an overall survival rate of 90% can be achieved. Two principal surgical procedures exit for the local control of the malignancy: 1. Limb salvage with biological with/or endoprosthetic reconstruction; and, 2. amputation with restoration of the function with exoprosthesis or endo-exoprosthesis. Currently, limb salvage procedures are performed in up to 95% of cases. In contrast, amputation is performed when the disease has reached an advanced stage or limb salvage has failed. Both of the surgical options have their risks and possible complications. According to the literature, there should be no significant difference between limb salvage and amputation with respect to long-term overall survival, overall quality of life, psycho-socio-economic outcomes, or patient satisfaction. An important advantage of limb salvage is greater everyday functionality. With the expanded indication of limb salvage and great survival rates, the cases of late complications in patients expecting to maintain their own leg continues to increase. In some cases, it requires multiple interventions, ranging from minor up to the most complex revisions, to maintain the functionality of the extremity. Despite the great costs, personal effort, and the possible complications, limb salvage could be a suitable method to achieve functionally beneficial outcomes and patient satisfaction in bone sarcomas of the lower extremities over the long-term even in cases involving complications.

Long-term adverse outcomes in survivors of childhood bone sarcoma: the British Childhood Cancer Survivor Study

Background:

With improved survival, more bone sarcoma survivors are approaching middle age making it crucial to investigate the late effects of their cancer and its treatment. We investigated the long-term risks of adverse outcomes among 5-year bone sarcoma survivors within the British Childhood Cancer Survivor Study.

Methods:

Cause-specific mortality and risk of subsequent primary neoplasms (SPNs) were investigated for 664 bone sarcoma survivors. Use of health services, health and marital status, alcohol and smoking habits, and educational qualifications were investigated for survivors who completed a questionnaire.

Results:

Survivors were seven times more likely to experience all-cause mortality than expected, and there were substantial differences in risk depending on tumour type. Beyond 25 years follow-up the risk of dying from all-causes was comparable to the general population. This is in contrast to dying before 25 years where the risk was 12.7-fold that expected. Survivors were also four times more likely to develop a SPN than expected, where the excess was restricted to 5–24 years post diagnosis. Increased health-care usage and poor health status were also found. Nonetheless, for some psychosocial outcomes survivors were better off than expected.

Conclusions:

Up to 25 years after 5-year survival, bone sarcoma survivors are at substantial risk of death and SPNs, but this is greatly reduced thereafter. As 95% of all excess deaths before 25 years follow-up were due to recurrences and SPNs, increased monitoring of survivors could prevent mortality. Furthermore, bone and breast SPNs should be a particular concern. Since there are variations in the magnitude of excess risk depending on the specific adverse outcome under investigation and whether the survivors were initially diagnosed with osteosarcoma or Ewing sarcoma, risks need to be assessed in relation to these factors. These findings should provide useful evidence for risk stratification and updating clinical follow-up guidelines.

Translation and preliminary validation of the English version of the DUX questionnaire for lower extremity bone tumor patients (Bt-DUX): a disease-specific measure for quality of life

PURPOSE

To translate the Dutch DUX questionnaire for lower extremity bone tumor patients (Bt-DUX), a disease-specific quality of life (QoL) instrument, into the English (UK) language and preliminary validate the English version in patients who were treated for lower-extremity bone tumors.

METHODS

Adaptation and translation process included forward translation, back-translation, and a review of the back-translation by an expert committee. Internal consistency and validity of the translated questionnaire were examined in a sample of adolescents treated for lower extremity osteosarcoma in the United Kingdom. Assessments included the Bt-DUX, the Toronto Extremity Salvage Score (TESS), the Short Form (SF)-36, and the TNO-AZL Questionnaire for Adult's Quality of Life (TAAQOL).

RESULTS

Seventeen patients (7 ♂ and 10 ♀), median age 19.9 (range: 16-25) years completed the questionnaires. Mean Bt-DUX score was 38.8 (range: 23-78), with Cronbach's α being 0.95 domain-total correlations ranged between 0.84 and 0.93 (P < 0.01). Spearman's correlation coefficients between the Bt-DUX total and domain scores and corresponding TAAQOL and SF-36 scores were overall moderate to good and reaching statistical significance in a most cases.

CONCLUSION

Preliminary evidence suggests that the English Bt-DUX translation is a valid disease-specific instrument for evaluating QoL of adolescents with lower extremity bone cancer.

A prospective study on quality of life and functional outcome in children and adolescents after malignant bone tumor surgery

BACKGROUND

Few longitudinal data are available concerning quality of life (QoL) and functioning of young patients undergoing surgical procedures for malignant bone tumors around the knee joint. Aim of the present study was to evaluate patients' quality of life, functional ability, and physical activity during a 2-year postoperative period.

METHODS

This prospective study included patients who underwent surgery for a malignant bone tumor around the knee joint between 2004 and 2008. Assessments were done at 3, 6, 9, 12, 18, and 24 months after surgery. QoL was measured with the TNO-AZL Children's or Adult's Quality of Life Questionnaires (TACQOL and TAAQOL), the Short Form-36 (SF-36) and Bone tumor (Bt)-DUX; functional ability with the Toronto Extremity Salvage Scale (TESS), the 6-minute walk test (6 MWT) and four functional performance tests; and physical activity with the Baecke questionnaire and the ActiLog® activity monitor. Statistical analysis included linear mixed model analysis.

RESULTS

Forty-four patients (27 males, 17 females, mean age 14.9 (SD 4.8) years) were included, 27 (61%) underwent limb-salvage and 17 (39%) ablative surgery. Twenty patients were lost during the 2 years follow-up as a consequence of oncological complications. Over the first year, survivors showed significant improvement of QoL, functional ability and physical activity, except for the mental dimension of the SF-36 and the activity monitor results. Over the second year, these improvements were less pronounced.

CONCLUSIONS

In the first 2 years after bone tumor surgery, survivors improved significantly with respect to QoL, functional ability, and physical activity levels.

Living with rotationplasty--quality of life in rotationplasty patients from childhood to adulthood

BACKGROUND

Knowledge about the long-term sequelae of rotationplasty, in adults treated surgically in childhood for Osteosarcoma in the lower limb, mainly concerns function and performance; the aim of this study is to explore the experience and the Quality of Life (QoL) of the patients who underwent Rotationplasty from 1986 to 2006 in Italy.

METHODS

Quantitative test: Administration SF-36 questionnaire to 20 subjects aged ≥16 years. Qualitative test: Semi-structured interview recorded in 10 of these subjects.

RESULTS

Greater well-being was found in the Mental Component Summary (MCS) scale of subjects aged over 24 years, with a score mean of 54.2 (±4.8), compared with that of those aged up to 24 years, with a mean score of 48.0 (±6.6), P = 0.04. Relational and emotional difficulty in adolescence, which had been partially overcome in adulthood, was revealed.

CONCLUSIONS

The assessment of QoL by the SF-36 questionnaire was effective, and a correspondence was found between what emerged from the quantitative study and the contents of the interview. Knowing the strengths and weaknesses that were highlighted is indispensable for parents and operators when choosing among the various surgical options and to facilitate coming to terms with the injury and the "scars".

Quality of life, functional ability and physical activity after different surgical interventions for bone cancer of the leg: A systematic review

PURPOSE

To systematically review published studies comparing Quality of Life (QoL), functional ability and/or physical activity between different surgical interventions due to a malignant bone tumour of the leg.

METHODS

A systematic literature search, covering the years 2000-2010 was performed using the PubMed, Embase, Web of science and Cochrane databases. Studies were included if they described and statistically compared QoL, functional ability and/or physical activity of at least two surgical interventions for lower extremity bone cancer. In addition, the methodological quality of the selected studies was evaluated by using a 24-point scale. Where appropriate, a qualitative analysis or meta-analysis was performed.

RESULTS

The search strategy resulted in a list of 246 citations. Based on titles and abstracts 50 full-text articles were selected, of which 13 articles describing 12 studies, were finally included. Overall, the methodological quality of the studies was moderate. Studies were heterogeneous with respect to their categorisation of surgical interventions, average age of patients and average duration of follow-up. Overall, results regarding differences between ablative and limb-sparing surgery varied largely. Meta-analysis was considered to be not appropriate due to clinical heterogeneity, methodological differences and flaws.

CONCLUSION

Twelve studies comparing the outcomes of QoL, functional ability and physical activity between limb-sparing and ablative surgery groups were identified, with an overall moderate methodological quality. Their largely varying outcomes suggest that no general conclusions on the advantage of either limb-sparing or ablative surgery in patients with malignant bone tumours of the lower extremity can be drawn.

Quality of life implications as a consequence of surgery: limb salvage, primary and secondary amputation

Purpose. We investigated self-reported quality of life (QoL), body image and daily competence of patients as a consequence of limb salvage surgery (LSS), primary or secondary amputation, and the views of patients following secondary amputation.

Patients. Patients (n=37) had all been treated for osteosarcoma or Ewing's sarcoma in the lower limb.

Methods. QoL was measured by questionnaire. A separate interview to determine satisfaction with decision-making was conducted with those treated for secondary amputation.

Results. For the total group, QoL was below that expected from population norms. There were no differences in QoL between those undergoing LSS surgery compared with amputation. However, LSS reported better daily competence and were less likely to use a walking aid. For the total group, body image and daily competence were associated with better QoL.

Discussion. All these patients are at risk of compromised QoL following surgery. Our data are in line with previous work suggesting outcomes may be better for LSS compared with amputation. Following secondary amputation, most patients (80%) did not regret initial LSS treatment, but felt that the time gained allowed them to come to terms with subsequent surgery.

Psychosocial and functional outcomes in long-term survivors of osteosarcoma: a comparison of limb-salvage surgery and amputation

BACKGROUND

Traditionally, physicians have believed that limb-salvage surgery has functional and cosmetic advantages over amputation, yet the literature is equivocal. Therefore, we sought to compare the psychosocial and functional outcomes in osteosarcoma survivors after limb-salvage surgery and amputation. We hypothesized there to be neither psychosocial nor functional outcome differences between groups.

PROCEDURE

Participants received treatment of extremity osteosarcoma, had received their cancer diagnosis at least 2 years prior, and were at least 16 years old. A comprehensive set of validated psychosocial and functional measures was used to assess outcome.

RESULTS

Fifty-seven patients participated in this study (33 who underwent limb-salvage surgery and 24 who underwent amputation). Participants had gone 12-24 years since diagnosis and were 16-52 years old at study participation. We used multiple linear regression models to examine differences in quality of life, body image, self-esteem, and social support between the two groups and found no differences. Lower limb function was a significant predictor of quality of life (P < 0.001), whereas surgery type did not impact this relationship. Body image was rated significantly worse by those who underwent late amputation, amputation after failed limb salvage, than by those who did not.

CONCLUSIONS

Participants with more functional lower limbs had better quality of life than did those with less functional lower limbs regardless of whether they underwent amputation or limb-salvage surgery.

Quality of life (QOL) in patients with osteosarcoma

Patients with osteosarcoma undergo extensive treatment using aggressive chemotherapy and surgery and this can have substantial acute and long-term effects on patients. In particular, quality of life (QOL) can be affected. It is important that QOL be examined to see how it is influenced. It is also important to determine who is at highest risk for impaired QOL and develop appropriate interventions. QOL is one of several outcomes that are influenced by the diagnosis and treatment of osteosarcoma. Other outcomes include function, disability, and body image. Currently, gaps exist in our knowledge of QOL in osteosarcoma patients and prospective studies are needed.

Self-reported global function among adult survivors of childhood lower-extremity bone tumors: a report from the Childhood Cancer Survivor Study (CCSS)

INTRODUCTION

Adult survivors of childhood lower-extremity bone tumors may experience physical and psychosocial late effects that impact physical performance, global function and quality of life. The identification of survivors at greatest risk for poor outcomes will inform potential intervention targets.

METHODS

Study participants were selected from the Childhood Cancer Survivor Study (CCSS), a multi-institutional study of childhood cancer survivors. Adult survivors (n = 629) of either childhood onset osteosarcoma or Ewing's sarcoma, with a primary tumor location in the lower-extremity were identified and contacted via mail to complete an additional questionnaire. Participants completed the Reintegration into Normal Living Index (RNL) to evaluate global function (maximum score of 22), daily function (maximum score of 16) and self perception (maximum score of 6).

RESULTS

Survivors reported high levels of global function with an adjusted mean overall RNL index score of 20.6 (SE 0.14), mean daily function score of 15.0 (SD 0.10) and mean self perception score of 5.6 (SE 0.05). While female gender and increasing age were associated with lower RNL scores, the magnitude of difference is of questionable clinical significance. Global function was only moderately correlated with physical performance (r = 0.56) and QOL (r = 0.59).

DISCUSSION

Based upon the RNL index, the vast majority of long-term survivors of childhood lower extremity bone tumors adapt well to their environment.

IMPLICATIONS FOR CANCER SURVIVORS

While some long-term survivors of lower-extremity bone tumors may report measurable limitations in physical performance and quality of life, the majority do not report moderate or severe difficulties with social integration.

Young survivors of malignant bone tumours in the extremities: a comparative study of quality of life, fatigue and mental distress

PURPOSE

The purpose of the study was to compare the quality of life (QoL), fatigue and mental distress in survivors of malignant extremity bone tumours (EBT survivors) with age and gender-matched survivors of Hodgkin's disease (HD survivors) and testicular cancer (TC survivors) as well as normative samples from the general population.

PATIENTS AND METHODS

Five years or more after end of treatment, 75 EBT survivors were mailed a questionnaire containing Short Form-36 (SF-36), the Hospital Anxiety and Depression Scale, the Fatigue Questionnaire and questions about demography. Fifty-eight EBT survivors responded. TC survivors, HD survivors and normative samples (NORMs) had earlier on filled in the same questionnaire. For EBT survivors, gender and age-matched controls were randomly selected among TC survivors, HD survivors and NORMs.

RESULTS

No significant differences in the fatigue or mental distress scores were observed between the survivor groups. The EBT survivors had significantly higher fatigue scores and lower depression scores than NORMs and significantly lower scores on all physical dimensions of QoL than TC survivors, HD survivors and NORMs. In multivariate analysis, a low level of education and lack of employment were significantly associated with caseness of mental distress. Older age at survey, female gender, being an EBT survivor and lack of employment were associated with caseness on the SF-36 Physical Component Summary Scale.

CONCLUSION

At long-term follow-up, EBT survivors did not show impaired mental health or fatigue at the group level, although their post-treatment status was characterised by reduced QoL dimensions on physical function compared to TC survivors, HD survivors and NORMs.

Evaluating physical function in an adolescent bone tumor population

BACKGROUND

Survival rates for patients with bone tumors have increased dramatically over the past few decades. Unfortunately, many patients face functional limitations resulting from disease management, but there is little evidence regarding physical functioning in adolescents with bone tumors. This lack is largely due to the absence of a standardized measure for evaluating adolescent sarcoma physical functioning. This review discusses considerations in searching for a measure of adolescent physical functioning, evaluates measures previously used in assessing functional outcome in young sarcoma patients, reviews self-report measures of pediatric physical functioning, and makes recommendations for future research.

PROCEDURE

Electronic databases were searched for studies published between 1980 and 2004. Studies examining physical functioning in adolescent sarcoma patients and those describing measures of pediatric physical functioning were included.

RESULTS

The study includes measures previously used in the adolescent bone tumor literature (Musculoskeletal Tumor Society, Mankin, Groningen Activity Restriction Scale, Toronto Extremity Salvage Score [TESS]), and three measures of pediatric physical function (Functional Disability Inventory, Pediatric Outcomes Data Collection Instrument [PODCI], Activities Scale for Kids [ASK]). The TESS, PODCI, and ASK each met at least four of the outlined applicability and feasibility components.

CONCLUSION

The search for a measure of physical functioning for adolescent sarcoma patients requires an exploration of many developmental and measurement issues. Based on the sensibility review presented, the TESS, PODCI, and ASK are recommended for further evaluation of content and of the measurement properties of reliability, validity, and responsiveness, prior to their use in evaluating adolescent sarcoma patients.

Surgical options for children with osteosarcoma

Osteosarcoma is the most common solid tumour of childhood. Chemotherapy has substantially improved survival, but surgical resection remains essential for cure. Limb-salvage surgery is now common and can be done for up to 85% of children with osteosarcoma. The main surgical challenge in children is how to reconstruct the limb after removal of the tumour. Knowledge of probable outcomes, risks, and benefits of each surgical option is essential for comparison of reconstruction with amputation, which is still the safest and most suitable option in some children.