Quality-of-life assessment in cancer patients

Self assessment of health status and symptoms by cancer patients

A study was carried out to assess the value and feasibility of using a short questionnaire to evaluate overall health status and common symptoms in cancer patients attending an outpatient clinic.

A cancer specific questionnaire (CSQ) was developed to assess the impact of cancer on overall health, appetite, energy, mood and pain. Patient ratings were compared with the doctor rating made at the same time. A pilot study was carried out in 20 patients to identify any practical problems associated with administration of the CSQ. Thirty patients deemed to be clinically stable were asked to complete the CSQ on two separate occasions to assess its reliability. Three hundred patients were recruited to the main study.

In the pilot study, the CSQ was found to be comprehensible and practical to use. Subjects required between two and five minutes to complete the CSQ. No statistically significant difference in any of the categories of the CSQ (chi-squared test, P>0.05) was found in the 30 patients who completed the CSQ on two occasions.

In the main study, the majority (72 per cent) of patients considered their overall health status as fair to good. Appetite was rated as normal in 63 per cent of patients. Only 22 per cent of patients considered their energy status as normal. Fifty-two per cent of the patients rated their mood as normal. Fifty-seven per cent of patients had some degree of pain. There was no statistically significant difference (ehi-squared, P>0.05) between doctor and patient ratings made on the same occasion in any category. Assessments matched closely in cases where there was no impairment in the category assessed. However, when there was some impairment doctor and patient agreement fell to less than 50 per cent.

The data obtained were useful in the identification of problems but did not provide sophisticated qualitative information regarding the nature of the symptoms. The information obtained from the patient could provide a focus for further discussion during the medical consultation.

Life-satisfaction in patients with head and neck cancer

Life-satisfaction is a measure of a patient's perception of the difference between his reality and his needs, or wants. This study reports the results of a longitudinal survey of patients' self-reported life-satisfaction following treatment for head and neck cancer. Life-satisfaction scores improved with time, and were related to pain, speech difficulty, and dysphagia. Lack of adequate family support was also important, although an uncommon problem. Treatment modality did not emerge as a significant determinant of life-satisfaction; speech difficulties were more likely to be due to articulation problems than voicing difficulty.

The psychiatrist's perspective on quality of life and quality of care in oncology: concepts, symptom management, communication issues

The important prevalence of psychosocial problems and psychiatric disturbances that have been reported in oncology, underlines the need for comprehensive psychosocial support for cancer patients and their families. Psychosocial support is designed to preserve, restore or enhance quality of life. Quality of life refers not only to psychosocial distress and adjustment-related problems but also to the management of cancer symptoms and treatment side-effects. Psychosocial interventions designed for this purpose should be divided into five categories: prevention, early detection, restoration, support and palliation. Firstly, preventive interventions are designed to avoid the development of predictable morbidity secondary to treatment and/or disease. Secondly, early detection of patients' needs or problems refers to the assumption that early interventions' could have therapeutic results superior to those of delayed support, both for quality of life and survival. Thirdly, restorative interventions refer to actions used when a cure is likely, the aim being the control or elimination of residual cancer disability. Fourthly, supportive rehabilitation is planned to lessen disability related to chronic disease, characterised by cancer illness remission and progression, and to active treatment. Fifthly, palliation is required when curative treatments are likely to no longer be effective, and when maintaining or improving comfort becomes the main goal. Psychological interventions are often multidisciplinary, with a variety of content. The type of psychological intervention ranges from information and education to more sophisticated support programmes including directive (behavioural or cognitive) therapies, or non-directive (dynamic or supportive) therapies. Social interventions usually include financial, household, equipment, and transport assistance depending on individual and family needs and resources. These interventions may be combined with the prescription of pharmacological (psychotropic, analgesic), physical, speech or occupational therapies, especially in rehabilitation programmes. Health care services devoted to delivery of these interventions are hospital, hospice or home-based and organised very differently depending on already available community resources and local practice.

Common psychiatric disorders in cancer patients. I. Adjustment disorders and depressive disorders

A high prevalence of adjustment and depressive disorders has been reported in oncology. These conditions are highly treatable, therefore the assumption that emotional distress is just a foreseeable and ordinary reaction to cancer had to be reviewed. Clinical presentation, etiology, assessment, and therapy of adjustment and depressive disorders are summarized in order to optimize supportive care.

Assessment of the Impact of Cancer on Work, Recreation, Home Management and Sleep Using a General Health Status Measure

A general health status measure (the UK Sickness Impact Profile) was used to assess health-related quality of life in 212 cancer patients [143 women, mean (SD - standard deviation) age 55.3 (11.7) years] compared to 105 age-sex matched control subjects [71 women, mean (SD) age 54.7 (12.2) years]. The four main areas of impairment in the cancer patient group were work, recreation and pastimes, home management and sleep and rest. The majority of patients were unable to work or working shorter hours due to their disease. A diagnosis of cancer was likewise found to have a major impact on active leisure pursuits and led to reduced participation in social and community activities. Patients had particular problems in carrying out household chores and maintenance or repair work in the house. Many patients had difficulty sleeping at night and tended to sleep during the day or rest for much of the day.

The majority of studies of quality of life in oncology patients concentrate upon alterations in symptoms, such measures would fail to detect impairment in the aspects described above. Greater attention should be directed towards addressing issues such as changes in employment status and the need for help in the home to improve the overall care of cancer patients.

A validation study of the domains of the core EORTC quality of life questionnaire

A cohort study was conducted to investigate the construct validity of the domains of the EORTC QLQ-C30 (European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire). Ninety-six patients undergoing chemotherapy at the Kingston Regional Cancer Centre, Kingston, Canada were given the EORTC QLQ-C30 and two out of four comparison scales; the Sickness Impact Profile, the McGill Pain Questionnaire, the General Health Questionnaire and the Cancer Rehabilitation Evaluation System, to complete during their clinic visits. Using the multitrait-multimethod matrix to examine relationships, the Spearman ranked correlation coefficients of similar and dissimilar domains between the EORTC QLQ-C30 and the comparison scales were compared. The EORTC QLQ-C30 domains of pain and physical and role functioning performed well in that they converged and diverged appropriately with the other instruments. The domain of psychological functioning had strong associations with domains thought to be dissimilar (social interaction and fatigue). Social interaction and financial impact diverged across dissimilar domains. This lack of specificity may relate to question wording. The symptom domain had strong associations with other domains across the comparison scales. This study shows that the domains of the EORTC QLQ-C30 have substantial construct validity in the multidimensional assessment of the quality of life of cancer patients and identifies where further work is required.

Long-term effects of cancer treatment and consequences of cure: cancer survivors enjoy quality of life similar to their neighbours

To assess the long-term effects of cancer treatment and consequences of cure, 102 index cancer cases were compared with 95 neighbourhood controls of similar age and sex and with 78 cardiac controls. The quality of life experienced by these three groups was examined using multiple instruments with proven psychometric properties. All the major quality of life domains (physical, psychological and social) were covered. The findings revealed that the index cases were similar to their neighbours in areas of subjective well-being. However, the index cases exhibited more sexual dysfunction, were more conscientious, determined and emotionally disciplined, and applied the defence mechanisms of displacement and reaction formation more often than the neighbourhood controls. The cardiac controls were older, more anxious, more conventional/less imaginative and used suppression as a defence mechanism to a greater degree than the index cases. In conclusion, young adult cancer survivors enjoy a quality of life similar to their neighbours, whereas coronary bypass survivors adjust less well psychosocially.

Optimization of uncomplicated control for head and neck tumors

Almost 200 patients have been treated for head and neck tumors at two different dose levels. Based on the clinically observed probabilities for tumor control and fatal normal tissue complications at the two dose levels, the dose giving maximum uncomplicated control has retrospectively been calculated and compared with the clinical data. A Poisson statistical model for control and complications has been used including a correlation parameter, delta, to describe the fraction of patients where control and complications are statistically independent. The clinically observed probability of uncomplicated tumor control, P+, is consistent with only a small fraction of the patients treated being statistically independent (delta = 0.2 or 20%). Customarily, 100% of the patients are assumed to be statistically independent with regard to tumor control and normal tissue complications. More precisely, the clinical data are consistent, with almost 20% of the patients being significantly more sensitive to radiation since they gain local tumor control but simultaneously suffer fatal complications. An even larger fraction of the patients (almost 30%) seemed to be more resistant to radiation, showing neither serious treatment complications nor control of the local tumor growth. It is suggested that if these patient groups could be identified by a predictive assay for the radiation sensitivity of their normal tissues and preferably also for their tumors, the uncomplicated tumor control could be increased by about 20%. This figure is based on the actuarial survival of the patients and has been corrected for the inevitable uncertainty in dose delivery. It is also pointed out that about 20% of the patients can never be saved by a predictive assay because of the considerable statistical variance associated with the Poisson process and the eradication of the last clonogenic tumor cell. Finally, note that the possible existence of radiation sensitive and resistant patient groups is consistent with known genetic deficiencies such as ataxia telangiectasia for the sensitive patients and the existence of repair efficient head and neck tumors that are unusually efficient in repairing double strand breaks. If such sensitive and resistant patient groups do exist, it should be sufficient to perform a predictive assay on normal tissues alone avoiding the often impossible task of sampling the most radiation resistant tumor cell line.

Performance status assessment in cancer patients

Performance status assessment, Karnofsky performance status (KPS), and Eastern Cooperative Oncology Group (ECOG) scales were performed in 100 consecutive patients independently by two physicians and by the patients themselves to evaluate the scales' validity and reliability. Findings of Kendall's correlation were highly significant between physicians (0.76 for KPS, 0.75 for ECOG) and between physicians and patients (0.65 for KPS, 0.59 for ECOG). The authors point out that patients' self evaluation could provide a valuable and reliable assessment.

The promise of a new technology: knowledge-based systems in radiation oncology and diagnostic radiology

The revolutionary changes in computer capabilities in the last decade, both in software and hardware, have opened new doorways for the uses of computers in radiation oncology and diagnostic radiology. Knowledge-based systems offer the potential to function as aids, consultants and advisors in the differential diagnosis of disease, staging, selection of therapy and treatment management and delivery for cancer patients. These computer-based systems can also provide for the training and teaching of radiotherapy and diagnostic radiology residents, and act as advisors and teachers to the medical physicists, dosimetrists and technicians. Following a brief history of the development of knowledge-based systems, the general capabilities of computer-based physician workstations in a department of radiation oncology are described.