Health-Related Quality of Life in Adults With Hodgkin's Disease: The State of the Science

Reference values for the EORTC QLQ-C30 in patients with advanced stage Hodgkin lymphoma and in Hodgkin lymphoma survivors

OBJECTIVES

To provide reference values for the European Organisation for Treatment and Research of Cancer (EORTC) Quality of Life Questionnaire (QLQ-C30) in advanced-stage Hodgkin lymphoma (HL) patients and 5-year HL survivors. The QLQ-C30 is the most widely used cancer-specific questionnaire to assess Health-Related Quality of Life (HRQoL).

METHODS

The EORTC database was searched to identify HL RCTs in which patients' and survivors' HRQoL was assessed by the QLQ-C30. HRQoL mean scores were calculated and stratified by age and gender. Minimal important differences were used to assess the clinical relevance of the findings. Data from one RCT with HRQoL scores available at baseline (n = 343) and four RCTs with HRQoL scores available at follow-up (n = 1665) were analyzed.

RESULTS

Patients reported worse HRQoL scores than survivors across most functioning scales and symptoms' scales. These scores varied as a function of gender but not age. Survivors' HRQoL reports were comparable to the ones of the general population.

CONCLUSIONS

These values provide an assessment framework for the comparison and interpretation of QLQ-C30 scores in advanced-stage HL. Our findings suggest that although HL patients' HRQoL scores are worse than the general population, HRQoL scores may normalize over long-term survival.

What Do We Know About Psychological Outcomes of Lymphoma in Adults?

Abstract. The goal of this review is to present the results of research on the influence of lymphoma on patients’ emotional status and cognitive functioning. A literature search was conducted to identify articles in English that investigated short- and long-term psychological outcomes of lymphoma and lymphoma treatment. Studies published prior to July 2016 were located by an electronic search using relevant databases such as ScienceDirect and PubMed. The search terms used included both medical subject headings and keywords such as “Hodgkin lymphoma,” “non-Hodgkin lymphoma,” “therapy,” “treatment,” “malignant,” “psychology,” “cognitive function,” “emotion,” “psychological adaptation,” “depression,” and “anxiety.” The retrieved publications were independently evaluated by two reviewers. Articles were selected based on the applicable titles and abstracts. The lists of eligible publications were compared and disagreements were resolved by discussion. Of the 1,418 articles identified in the search, we chose 39 publications, which in our opinion could be interesting or useful for psychologists. Studies show that lymphoma and its treatment lead to severe distress. Thirty-six percent of patients manifest symptoms of anxiety and depression, which are most often associated with the so-called “B-symptoms,” which mark poor prognosis or with side effects of chemotherapy such as nausea or vomiting. Reports also indicate that lymphoma patients may develop mild to severe cognitive decline. Its manifestations may range from benign problems with attention, thinking, and memory to severe cognitive impairment, that is, subcortical dementia. The etiology of intellectual deterioration in lymphoma has not been well described yet, but it may be related to the disease process or to the treatment. Additionally, literature demonstrates that lymphoma may lead to adverse changes in patient’s professional life such as resignation or early retirement.

Seven-year follow-up for energy/vitality outcomes in early stage Hodgkin's disease patients treated with subtotal lymphoid irradiation versus chemotherapy plus radiation: SWOG S9133 and its QOL companion study, S9208

PURPOSE

We describe 7 years of follow-up for the energy/vitality outcome in early-stage Hodgkin's disease patients treated on a randomized clinical trial that compared subtotal lymphoid irradiation (STLI) with combined modality treatment (CMT) (SWOG 9133). Survivorship research questions involved the extent to which symptoms/side effects endured over a follow-up period of 7 years for this early-stage patient group.

METHODS

Two hundred thirty-nine patients participated in the quality of life (QOL) companion study (SWOG 9208) and completed the SF-36 vitality scale, SF-36 health perception item, Cancer Rehabilitation Evaluation System-Short Form (CARES-SF), and symptom distress scale. This paper reports vitality outcome results obtained from randomization, 6 months, and annually for 7 years. To assess changes in vitality over time, we used linear mixed models with patient as a random effect.

RESULTS

Patients receiving CMT had lower observed vitality at 6 months than did the STLI patients (p < .0001). However, beginning at year 1, vitality results did not differ significantly by treatment over the 5-year (p = .13) and 7-year (p = .16) follow-up periods. Vitality only slightly improved over baseline in either group after treatment. The results were similar after accounting for patterns of recurrence and missing data.

CONCLUSIONS

This study demonstrated that patients with early-stage Hodgkin's disease experience a short-term (at 6 months) decrease in vitality with treatment, which is more severe with CMT, but that after the first year, vitality scores were similar between the two treatment groups. Enduring fatigue results for patients receiving these therapies were not observed. Implications for cancer survivors These data provide comprehensive 7-year follow-up vitality information, an important symptom for early-stage lymphoma survivors.

Working toward a good life as a cancer survivor: a longitudinal study on positive health outcomes of a rehabilitation program for young adult cancer survivors

Background:

Research on cancer rehabilitation targeting young adult cancer survivors (YACS) is limited, and little is known about the positive health outcomes of rehabilitation programs tailored specifically for this vulnerable group.

Objective:

The aim of this study was to investigate whether a complex rehabilitation program improved the health-related quality of life (HRQOL) and physical capacities of YACS.

Methods:

A longitudinal prospective study using Norwegian norm-based comparisons was conducted. Twenty YACS (24–35 years old) with different cancer diagnoses participated in a complex rehabilitation program lasting for 6 months, focusing on goal setting, exercise, psychoeducation, individual follow-up, and peer support.

Results:

Health-related quality of life was measured by EORTC QOL C-30 and the scores showed significant increases in overall HRQOL (P < .005–.001) and all functional dimensions (P < .001–.05) and a decrease in fatigue (P < .000–.05) and effect sizes between 0.72 and 1.30. Significant changes occurred within physical fitness (P < .005), lung capacity (P < .05), and left-hand strength (P < .001), but not right-hand strength and body mass index, with effect sizes between −0.04 and 0.48. The values of HRQOL were stable after a 1-year follow-up.

Conclusions:

A complex cancer rehabilitation program especially tailored for YACS seems to build positive health outcomes such as HRQOL and physical capacity in a long-term perspective. The content and structure of the program were feasible with high compliance. The results underline the importance of targeting rehabilitation interventions to YACS in need after cancer treatment, acknowledging rehabilitation as a process that requires adequate time and follow-up.

Implications for practice:

Healthcare providers should be aware of YACS’ symptom burden and monitor HRQOL and physical parameters to ascertain holistic cancer survivorship care.

Need and Use of Healthcare Services in Survivors of Hodgkin Lymphoma

PURPOSE

Hodgkin lymphoma (HL) is the commonest cancer in adolescents and young adults (AYAs), aged 15-29 years. While the survival rate is high, many survivors experience adverse late effects of therapy. Yet, this age group in general makes limited use of health services. This study sought to determine whether the need for health services by HL survivors was mismatched to their health service utilization, as hypothesized a priori.

METHODS

A population-based cohort of survivors (N = 43) younger than 39 years of age was sent a mailed survey for self-assessment of need, as expressed in health-related quality of life (HRQOL), and utilization of health services by validated instruments; the Health Utilities Index and Health and Social Service Utilization Survey, respectively. Survivors who were AYAs at diagnosis were compared to children and older adults.

RESULTS

AYAs had the lowest mean HRQOL score (0.79 on a scale of 0.00-1.00) compared to children (0.86) and older adults (0.94)-clinically meaningful differences. The difference in the single attribute score for cognition reached statistical significance (0.89 vs. 0.99 vs. 1.00, p = 0.02). AYAs also had lower mean overall annual costs for health services (CAN$601) than children (CAN$753) and older adults (CAN$936) did.

CONCLUSIONS

Survivors of HL who were AYAs at diagnosis had a mismatch between high need for and low utilization of health services. Providers of healthcare to this population should be made aware of this discrepancy, and the survivors should be encouraged to seek the health services they need.

Existential challenges experienced by lymphoma survivors: Results from the 2010 LIVESTRONG Survey

We sought to examine the existential challenges that cancer survivors may experience as they strive to make meaning, regain their self-identity, cope with fear of recurrence, and experience feelings of grief and guilt. Lymphoma survivors (n = 429) completed the 2010 LIVE STRONG: survey and provided responses about meaning, cancer worry, security, identity, grief, guilt, and perceived functional impairment due to these concerns. Most survivors (73%-86%) endorsed existential concerns, with 30-39 percent reporting related perceived functional impairment. Concerns were associated with being female, younger, unmarried, and having undergone stem cell transplantation. Lymphoma survivors experience existential challenges that impact their life even years after diagnosis.

Life as a Mentor

The concept of mentorship is personalized in this discussion of Dr. Fawcett’s life as she experienced and thrived as a mentor. The authors describe different types of mentorship and how they were experienced by this leader.

Health-related quality of life after treatment of Hodgkin lymphoma in young adults

PURPOSE/OBJECTIVES

To describe changes in health-related quality of life (HRQOL) and to identify supportive care services used after treatment for Hodgkin lymphoma (HL) in young adults.

DESIGN

A longitudinal, repeated-measures study design was used to test the feasibility of data collection at the conclusion of treatment for HL and at one, three, and six months post-treatment.

SETTING

Participants were identified from two large comprehensive cancer centers in New England.

SAMPLE

40 young adults with newly diagnosed HL were enrolled in the study prior to the completion of chemotherapy or radiation.

METHODS

Data were collected by interviews, standardized questionnaires, and medical record reviews.

MAIN RESEARCH VARIABLES

HRQOL variables defined as symptom distress, functional status, emotional distress, and intimate relationships; use of specific supportive care services; and baseline demographic and disease-related information.

FINDINGS

Results indicate that symptom distress improved at one month post-treatment and remained low at three and six months. Similarly, functional status improved at one month post-treatment. Only 13% of the sample had significant emotional distress at baseline, and this decreased to 8% over time. Patients placed high value on their intimate relationships (i.e., family and friends or sexual partners). A variety of supportive care services were used after treatment, the most common of which were related to economic issues. However, by six months post-treatment, services shifted toward enhancing nutrition and fitness.

CONCLUSIONS

The results from this study suggest that HRQOL in young adults with HL improved one-month post-treatment and that interest in using supportive care services was high.

IMPLICATIONS FOR NURSING

Facilitating the use of supportive care services at the end of cancer treatment appears to be an important part of helping young adults transition to survivorship.

KNOWLEDGE TRANSLATION

Supportive care services appear to be a vital component of the transition to survivorship and often change over time from an emphasis on economic issues to enhancing wellness through nutrition and fitness programs.

Procarbazine and antidepressants: a retrospective review of the risk of serotonin toxicity

BACKGROUND

Procarbazine is an anticancer agent that also inhibits monoamine oxidase, an enzyme responsible for the metabolism of various catecholamines, including serotonin.

METHODS

A retrospective chart review of lymphoma patients who were treated with both procarbazine and an antidepressant, as well as procarbazine alone, was performed to determine if signs and symptoms of serotonin toxicity were present.

RESULTS

A total of 65 patients received procarbazine between 2004 and 2010 and were eligible to be included in the study. Twenty-six of these patients received an antidepressant in combination with procarbazine, with selective serotonin reuptake inhibitors being the most common type of antidepressant. No patients in the study were diagnosed with serotonin toxicity, nor did any meet Hunter's diagnostic criteria for serotonin toxicity. Diarrhea, tremor, and shivering were the symptoms from Sternbach's criteria that were further analyzed, with diarrhea occurring 8.54% of the time, tremor occurring 5.53% of the time, and shivering occurring 2.51% of the time in patients who received an antidepressant with their procarbazine. Despite these symptoms, the diagnosis of serotonin toxicity according to Sternbach's criteria was determined to be unlikely.

CONCLUSIONS

In this small sample of patients treated with procarbazine plus an antidepressant (most typically SSRIs), there were no reports of serotonin toxicity, nor did any patients demonstrate symptoms consistent with serotonin toxicity. The authors urge clinicians to ensure depression is adequately managed in cancer patients who are undergoing procarbazine therapy, starting with typical first-line antidepressant agents.

Persisting fatigue in Hodgkin lymphoma survivors: a systematic review

Hodgkin Lymphoma (HL) survivors are at risk for adverse psychosocial events as a result from cancer diagnosis and treatment. Fatigue is one of the most frequently reported long-term symptoms and is often reported to interfere with daily life. We conducted a systematic review to determine prevalence, severity and predisposing factors of fatigue in HL survivors. A literature search was conducted up to August 2012. Twenty-two articles comparing HL survivors with norm population data met all predefined selection criteria. Prevalence rates, levels of fatigue and clinical relevance of the results were determined. Prevalence of fatigue ranged from 11-76 % in HL survivors compared to 10 % in the general population. Mean fatigue scores were 5-13 % higher compared to the normative population; these findings were clinically relevant in 7 out of 11 studies. Increasing age was associated with higher levels of fatigue in HL survivors. Treatment modality and stage of initial disease were not associated with higher fatigue levels, while comorbidities or other treatment sequelae seemed to impact on the levels of fatigue. HL survivors are at serious risk for developing clinically relevant, long-term fatigue. The impact of patient and treatment characteristics on risk of fatigue is limited. Focus for future research should shift to the role of late-treatment sequelae and psychological distress symptoms.

Association of social network and social support with health-related quality of life and fatigue in long-term survivors of Hodgkin lymphoma

PURPOSE

As the number of survivors of Hodgkin's lymphoma (HL) increases, there has been a growing interest in long-term treatment-related side effects and their impact on the quality of life (QoL). The aim of this study was to assess the association of social network and social support with the QoL and fatigue among long-term HL survivors.

METHODS

A total of 200 HL survivors were included. The generic Short Form-12 (SF-12) questionnaire, the QoL cancer survivor's questionnaire (QOL-CS), and the Multidimensional Fatigue Inventory were used to assess QoL and fatigue. Social network and social support were evaluated with the Social Support Survey.

RESULTS

Social network and all social support measures were favorably associated with two or more SF-12 scales, mainly with physical functioning and the mental health scales. Social network and social support dimensions were also associated with better QOL-CS scores. Affective support, informational support, positive interaction, and emotional support were associated with less fatigue.

CONCLUSIONS

Both social network and social support are associated with better QoL and lower levels of fatigue in HL survivors. This information may be useful to health professionals and community organizations in implementing effective interventions to improve these patients' quality of life.

Psychometric properties of the multidimensional fatigue inventory in Brazilian Hodgkin's lymphoma survivors

CONTEXT

Fatigue is the most common symptom among Hodgkin's lymphoma survivors.

OBJECTIVES

To evaluate the psychometric properties of the Brazilian version of the Multidimensional Fatigue Inventory (MFI).

METHODS

The MFI was translated into Brazilian Portuguese using established forward-backward translation procedures, and the psychometric properties were evaluated in a sample of 200 Hodgkin's lymphoma survivors. The psychometric properties evaluated included internal consistency and construct validity. The MFI was administered along with the informed consent form.

RESULTS

The overall Cronbach's alpha coefficient for the 20 items was 0.84, ranging from 0.59 to 0.81 for each of the five scales. Correlations between items and scales ranged from 0.32 to 0.72. The factor analysis yielded a five-factor solution that explained 65% of the variance. The first factor merged the original "general fatigue" and "physical fatigue" scales, as has been previously reported. The second factor identified the original "mental fatigue" scale and the fifth factor identified the original "reduced activity" scale. Questions from the original "reduced motivation" scale were represented in both factors three and four.

CONCLUSION

The Brazilian version of the MFI showed satisfactory psychometric properties and can be considered a valid research tool for assessing cancer-related fatigue.

Measurement of distress in Chinese inpatients with lymphoma

PURPOSE

The aim of this study was to assess the levels and sources of distress in patients with lymphoma. This study also focused on the influence of factors of the level of distress and the cutoff score using the Distress Thermometer (DT) relative to the Hospital Anxiety and Depression Scale (HADS).

METHOD

DT and HADS were used to estimate the psychological status of 323 eligible lymphoma patients. The DT was evaluated against the HADS for its sensitivity and specificity.

RESULTS

One hundred and ninety-three (59.7%) lymphoma patients experienced overall distress on the HADS, with 137 (42.4%) experiencing anxiety and 114 (35.3%) suffering from depression. There were 199 (61.6%) and 163 (50.5%) patients with distress score ≥ 4 and ≥ 5, respectively. DT was significantly correlated with the HADS-total (T) (r=0.820, p<0.001), HADS-depression (D) (r=0.763, p<0.001), and HADS-anxiety (A) (r=0.738, p<0.001). The consistency of the DT and HADS was favorable (coherence index=0.6030, p<0.01) when the cutoff score was 5 for the DT. Referring to the cutoff of 15 on HADS, 5 on DT yielded optimal specificity (0.869, p<0.001) and sensitivity (0.756, p<0.001). In multiple logistic regression analysis, patients with 'B symptoms' were more likely to have a distress score ≥ 5 [OR=4.512, p<0.05, 95% CI 1.953-10.467].

CONCLUSION

DT is efficacious for screening for anxiety and depression in lymphoma patients.