Distribution and determinants of patient satisfaction in oncology with a focus on health-related quality of life

e17578

Background: Cancer patients usually undergo extensive and debilitating treatments, which makes patient satisfaction with care in oncology an important health care assessment measure. We conducted a study to examine patients’ experiences with the care they receive and to investigate the clinical, demographic and quality of life (QoL) factors that can predict satisfaction in a large heterogeneous sample of cancer patients. Methods: A case series of 538 cancer patients treated at Cancer Treatment Centers of America (CTCA) at Midwestern and Southwestern Regional Medical Centers between August 2006-December 2007. A patient satisfaction questionnaire developed in-house by CTCA was used. The questionnaire covered the following dimensions of patient satisfaction: hospital operations and services, physicians and staff, and patient endorsements for themselves and others. QoL was assessed using EORTC QLQ-C30. The available clinical, demographic and QoL factors were evaluated for predictive significance using univariate (t-test or chi-square test) and multivariate logistic regression. Results: The response rate for this study was 24.4%. The mean age of our patient population was 54.1 years (SD = 10.5, range 17–86), with a slight preponderance of females (57.2 %). Breast cancer (n = 124, 23.0 %) and lung cancer (n = 101, 18.8%) were the most frequent cancer types. 481 (89.4%) patients were “very satisfied” with their overall experience with CTCA. Age and several QoL function and symptom scales were predictive of satisfaction upon univariate analysis. However, in the multivariate modeling, only those with a score above the median on the fatigue measure (i.e., worse fatigue) had reduced odds of 0.28 of being “very satisfied” with CTCA (p = 0.03). Conclusions: We found that fatigue was an independent significant predictor of patient satisfaction. This finding argues for special attention and programs for cancer patients who report higher levels of fatigue. Such efforts will help lessen the effect of fatigue on their daily functioning, and may increase their satisfaction with treatment.

No significant financial relationships to disclose.

Vitamin D and prostate cancer risk: a review of the epidemiological literature

Prostate cancer is the most commonly diagnosed cancer in the United States. Prostate cells contain vitamin D receptors as well as enzymes necessary for vitamin D metabolism. Vitamin D metabolites have an antiproliferative and a pro-differentiating effect on prostate cancer cell lines in vitro and in vivo. As a result, there has been an emerging interest in the potential role of vitamin D in the etiology of prostate cancer. This review summarizes all available epidemiological literature on the association between dietary vitamin D, circulating levels of vitamin D and sunlight exposure in relation to prostate cancer risk. To place these studies in context, we also provide some background information on vitamin D, such as its dietary sources, metabolism, optimal levels, hypovitaminosis and relationship with the prostate.

Quality of life: An independent prognostic variable in a general population of cancer patients receiving chemotherapy

19596

Background: It is uncertain whether the current Quality of Life (QL) instruments can facilitate clinical decision-making in oncology. Since the most important outcome in oncology is survival, we investigated QL domains from 2 contrasting QL instruments, EORTC QLQ-C30 and the Quality of Life Index (QLI) to determine if these instruments can partition a heterogeneous population of cancer patients into distinct prognostic groupings. Methods: 1,200 patients consented to participate in Cancer Treatment Center of America's QL program between Mar ‘01 and May ’05. We identified 494 deaths in this group. Most common tumors were breast (n=319), colon (n=159), and lung (n=209). Among 434 patients undergoing definitive treatment 159 had stage 4 and 49 had stage 3 disease, the other patients had failed definitive therapy. The median survival was 39 weeks for newly diagnosed patients and 29.9 weeks for patients with recurrent disease. We used cutpoint analysis using statistical strength of association with QL scores to determine the association between QL score and survival. This information was then used in a recursive partitioning analysis to group our cancer patient population into mutually exclusive prognostic groups. Results: We found several QL domains had a non-linear relationship with survival, which indicates that a relatively small change in QL score could result in a large change in survival. QLI Health/Functioning domain, had the strongest association with survival. Subsequent iterations of the recursive partitioning found that a combination of clinical and QL domain scores partitioned the patient population into distinct groups, whose median survival ranged from 13–100 weeks. Patients with the best prognosis had high QLI health satisfaction scores health and had hormonally dependent tumors. The patients with the poorest survival had intermediate QLI health satisfaction scores, poor appetite, and poor emotional function. Conclusion: This retrospective analysis found specific combination of QL domains and scores that partitioned patients with advanced cancer into distinct prognostic groupings. This analysis indicates that our current instruments have the potential to be developed into tools that could facilitate clinical decision-making.

No significant financial relationships to disclose.

Effect of complementary alternative medical (CAM) therapy on pain and fatigue in pancreatic cancer patients

15142

Background: Pain and fatigue are frequent, difficult to manage, and negatively impact quality of life (QOL) in pancreatic adenocarcinoma patients (PCpts) causing some to seek CAM therapy in place of or in conjunction with conventional analgesics. But the efficacy of CAM on pain and fatigue has not been adequately tested in controlled trials. We employed an alternative strategy by abstracting pain and fatigue scores from the EORTC-QLQ-C30 questionnaire administered to PCpts treated at Midwestern Regional Medical Center, an integrative oncology center offering conventional and CAM treatment. Methods: 50 PCpts treated with chemotherapy and/or radiation clinically appropriate for advanced PC + CAM were evaluated. The CAM group (n=36) had 70%, 11%, and 19% and the nonCAM group (n=14) 71%, 14%, and 15% Stage IV, III, and II tumors respectively. PCpts received narcotic and anti-inflammatory agents consistent with ASCO and NCCN guidelines. CAM treatments included Green Tea Extract; Melatonin; and high-potency multivitamins. Baseline, 3 month(M), and 6M data were analyzed. Results: Median baseline, 3M and 6M pain scores were: 50; 0; 33.3 and 75; 16.6; 83.3 for CAM and nonCAM respectively; not significant (NS) CAM vs nonCAM at any time point by non-parametric tests. Pain control at 3M was improved significantly vs baseline levels for each cohort; p=0.02 (CAM) and 0.03 (nonCAM) by paired 2 tail t tests. The relative numbers of PCpts with manageable pain (≤ 33) were comparable for CAM vs nonCAM at baseline (41% vs 36%) and 3 M (81% vs 90%), but not at 6M (67% vs 22% CAM vs nonCAM respectively, (p<0.05 by ?2 test). Median baseline, 3M and 6M fatigue scores were: 55.5; 33.3; 33.3 and 44.4; 33.3; 66.6 for CAM and nonCAM respectively (NS, CAM vs nonCAM at any time point). By paired 2-tail t tests, 3M (p=0.01) and 6M (p=0.02) values were improved significantly vs baseline in CAM but not nonCAM cohorts. Conclusion: This exploratory study shows that CAM treatment may improve fatigue and extend the period of effective pain control by conventional analgesics in PCpts. Given the negative impact exerted by pain and fatigue on QOL in this difficult to manage malignancy, CAM treatment appears to have efficacy for PCpts.

No significant financial relationships to disclose.

Survival outcomes of advanced pancreatic cancer in an integrative treatment setting: The Cancer Treatment Centers of America experience

15188

Background: In this study, we report the survival outcomes of patients with advanced pancreatic cancer who underwent intra- arterial mitomycin/cisplatin therapy at Cancer Treatment Centers of America (CTCA), a community hospital comprehensive cancer center combining conventional and integrative medical therapies. Methods: At our center, all patients undergo a comprehensive program of nutritional, spiritual, physical, naturopathic, and emotional support while receiving an aggressive conventional treatment protocol. Using data collected by the cancer registry, we identified 114 consecutively treated newly diagnosed cases of invasive pancreatic cancer who underwent definitive treatment between Jan 01 and Dec 05. Results: 26 patients were stage III and 88 were stage IV. The median age was 58 years (range 31 to 81 years). 55 patients were selected for intra-arterial therapy with mitomycin/cisplatin. These patients had a PS of 2 or better and either had no metastatic lesions or a single localized liver metastasis. 16 patients in this cohort received radiotherapy. The 59 other patients underwent a variety of therapies. Intra-arterially treated patients had a median survival of 369 days and a 2-year cumulative survival of 19%. Patients not treated with intra-arterial therapy had a median survival of 249 days and a 2-year survival of 11%. Univariate survival analysis found that patients undergoing intra-arterial therapy had significantly better survival outcomes compared to patients undergoing different therapies (Log rank test P = 0.04). The table compares the survival outcomes of recent phase III investigations on first line therapies for pancreatic cancer with those at CTCA. Conclusion: Currently, the published clinical trial data in advanced pancreatic indicates a one-year survival ranging from less than 10% to 28%. Consequently, the survival outcomes of patients undergoing therapy at our center warrant further investigation.

[Table: see text]

No significant financial relationships to disclose.

Prognostic significance of quality of life index in breast cancer

6135

Background: Quality of Life (QoL) is a multidimensional construct. There is extensive data showing that QoL tools measuring the activities of daily life provide prognostic information in cancer. However, similar information on QoL tools measuring patient satisfaction with their life is sparse. The Ferrans and Powers Quality of Life Index (QLI) is one such instrument. The goal of this study was to evaluate the statistical strength of association between QLI and survival in breast cancer patients undergoing care in a non-clinical trial setting. Methods: We examined a case series of 251 breast cancer patients treated at Cancer Treatment Centers of America between 04/01 and 11/04. QLI defines QoL in terms of satisfaction with the aspects of life that are important to the patient. QLI measures overall QoL and QoL in four major subscales: health and physical, social and economic, psychological and spiritual, and family. All scores range from 0 to 30 with higher scores indicating better QoL. Study patients were dichotomized into 2 groups based on median scores for all QoL subscales. Kaplan Meier method was used to calculate survival. Log-Rank test was used to study the equality of survival distributions. Results: Of 251 patients, 74 were newly diagnosed and 177 had prior treatment history. The median age was 48 years (range 25 - 74 years). 45 patients had stage I disease, 105 stage II, 38 stage III, and 32 stage IV. The table describes the median survival for all QLI subscales. Health and physical functioning subscale and QLI subtotal subscale were significantly associated with survival. Conclusions: This study shows that baseline levels of patient satisfaction with their QoL provide useful prognostic information in breast cancer. While these findings need to be evaluated further to ascertain which subscales of QoL have a role in predicting patients’ prognosis, they have important implications for patient stratification in clinical trials and may aid decision-making in clinical practice.

[Table: see text]

No significant financial relationships to disclose.

A prospective survey evaluating the use of soy products in breast cancer

10562

Background: Many studies have evaluated the potential role of soy in the prevention of breast cancer. A number of components in soy appear to have anticancer properties, including isoflavones, genistein and daidzein. The use of soy by women with breast cancer is now being questioned because of the estrogen-like effects of isoflavones and possible interactions with tamoxifen. Clinicians providing nutrition counseling to these women are concerned because the availability of soy foods has increased dramatically in the past few years. The goal of this study was to quantify the intake of isoflavones in women with breast cancer to determine if their intake is of clinical significance. Methods: We evaluated a consecutive case series of 100 women with breast cancer treated at Cancer Treatment Centers of America between 09/03 and 02/04. After obtaining informed consent, each patient was asked to complete a soy food frequency questionnaire (FFQ) that was scored by Fred Hutchinson Cancer Research Center, the institute that developed and validated FFQ. Results: Mean age was 50.5 years (std. dev. = 9.4; range 31–70) and mean BMI was 27.3kg/m2 (std. dev. = 6.75; range 17–59). Table 1 shows detailed characteristics of our patients. Genistein and Daidzein consumption was limited to 65 patients with a mean intake of 81.5 mg/week (std. dev. = 153; range 0.02–682) and 52.9 mg/week (std. dev. = 98.8; range 0.02–482) respectively. Soy foods with highest reported consumption were soy sauce (37%), soy milk (23%), soy bars (18%), roasted soy nuts (13%) and tofu (13%). Conclusions: Our study suggests that the isoflavone intake of breast cancer patients at our hospital was quite variable. Thirty-five patients reported no soy intake. The mean daily intake translates into 11.6 mg genistein and 7.4 mg daidzein, which is equivalent of less than ¼ cup of tofu per day. This amount is slightly higher than what has been previously reported in non-Asian American women.

[Table: see text]

No significant financial relationships to disclose.

Quality-of-life index: Implications for prognosis in colorectal cancer

16032

Background: Quality of Life (QoL) assessment is important to evaluate the impact of disease and treatment in patients with advanced cancer. Recently, it has been hypothesized that patient satisfaction with their QoL may have a prognostic role in cancer, however, there is little evidence in the literature to support this view. The Ferrans and Powers Quality of Life Index (QLI) is one such instrument. QLI defines QoL as a person’s sense of well-being that stems from satisfaction or dissatisfaction with the areas of life that are important to him/her. The purpose of this study was to determine whether baseline QLI would predict length of survival in patients with colorectal cancer undergoing care in a non-clinical trial setting. Methods: We examined a case series of 177 colorectal cancer patients treated at Cancer Treatment Centers of America between 04/01 and 11/04. QLI measures global QoL and QoL in four major subscales: health and physical, social and economic, psychological and spiritual, and family. All scores range from 0 to 30 with higher scores indicating better QoL. QLI subscales were dichotomized at the median to split the patient population into 2 distinct groups. Kaplan Meier method with Log Rank test was used to calculate survival. Results: Of 177 patients, 46 were newly diagnosed and 131 had prior treatment history. The median age was 53 years (range 25– 85 years). 8 patients had stage I disease, 16 stage II, 51 stage III, and 77 stage IV. Table 1 describes the median survival for all QLI subscales. Conclusions: Baseline levels of patient satisfaction with their health and physical functioning provided useful prognostic information in colorectal cancer. Interestingly, the other subscales that evaluate various existential and economic issues did not provide statistically significant differences in survival. These findings need to be evaluated further to ascertain which subscales of QLI have a role in predicting patients’ prognosis.

[Table: see text]

No significant financial relationships to disclose.

A prospective study evaluating the relationship between fatigue and patient satisfaction in advanced cancer

16025

Background: Fatigue is the most common and disabling symptoms experienced by cancer patients. No study has prospectively quantified the relationship between fatigue and patient satisfaction (PS) in advanced cancer. We therefore assessed this relationship before the start of chemotherapy and at 3 and 6 months after treatment at our integrative cancer treatment center. Methods: 294 cancer patients treated at Cancer Treatment Centers of America between 04/01 and 11/04. Of 954 patients at baseline, only 294 were available for follow-up at 6 months. Fatigue was measured using the EORTC QLQ-C30 3-item fatigue subscale. Scores ranged from 0–100, higher scores indicating more fatigue. PS was measured using Ferrans & Powers Quality of Life Index (QLI). Scores ranged from 0–30, higher scores indicating better QoL. The mean fatigue scores were compared using ANOVA across the 3 time periods at baseline, 3 and 6 months. The relationship between fatigue and QLI was evaluated using multiple linear regression at all 3 time points. Results: Of 294 patients, 106 were males and 188 females. 91 had breast ca, 52 colorectal, 43 lung, 25 pancreas, 13 prostate, and 70 had other cancers. 112 were newly diagnosed and 182 had received prior treatment elsewhere. The mean fatigue scores at baseline, 3 and 6 months were 43.6, 37.3, and 41.8 respectively; the scores at baseline and 3 months were significantly different (p = .009). At baseline, after controlling for age, gender, prior treatment history, and tumor stage at diagnosis, every 10 unit increase in fatigue was significantly associated with 1.3 units decrease in QLI health subscale. Similarly at 3 and 6 months after treatment, every 10 unit increase in fatigue was significantly associated with 1.2 and 1.4 units decrease in QLI health subscale. Conclusions: In our study, we found that fatigue is a strong correlate of PS independent of the effects of age, gender, prior treatment history and tumor stage at diagnosis during the first 6 months of treatment. Interestingly, fatigue showed a significant improvement after 3 months of treatment and returned back to baseline levels at 6 months. This finding needs to be investigated further to evaluate the impact of integrative cancer care services on PS.

No significant financial relationships to disclose.

Circadian function in patients with advanced non-small-cell lung cancer

This study aimed to evaluate whether patients with advanced non-small-cell lung cancer experience disrupted rest–activity daily rhythms, poor sleep quality, weakness, and maintain attributes that are linked to circadian function such as fatigue. This report describes the rest–activity patterns of 33 non-small-cell lung cancer patients who participated in a randomised clinical trial evaluating the benefits of melatonin. Data are reported on circadian function, health-related quality of life (QoL), subjective sleep quality, and anxiety/depression levels prior to randomisation and treatment. Actigraphy data, an objective measure of circadian function, demonstrated that patients' rest–activity circadian function differs significantly from control subjects. Our patients reported poor sleep quality and high levels of fatigue. Ferrans and Powers QoL Index instrument found a high level of dissatisfaction with health-related QoL. Data from the European Organization for Research and Treatment for Cancer reported poor capacity to fulfil the activities of daily living. Patients studied in the hospital during or near chemotherapy had significantly more abnormal circadian function than those studied in the ambulatory setting. Our data indicate that measurement of circadian sleep/activity dynamics should be accomplished in the outpatient/home setting for a minimum of 4–7 circadian cycles to assure that they are most representative of the patients' true condition. We conclude that the daily sleep/activity patterns of patients with advanced lung cancer are disturbed. These are accompanied by marked disruption of QoL and function. These data argue for investigating how much of this poor functioning and QoL are actually caused by this circadian disruption, and, whether behavioural, light-based, and or pharmacologic strategies to correct the circadian/sleep activity patterns can improve function and QoL.

Prognostic significance of Subjective Global Assessment (SGA) in advanced colorectal cancer

OBJECTIVE

To evaluate the prognostic significance of Subjective Global Assessment (SGA) in advanced colorectal cancer and create statistically distinct prognostic groups of colorectal cancer patients based on clinical and nutritional variables.

DESIGN

A retrospective clinical epidemiologic study.

SETTING

A private tertiary care American Cancer Center.

SUBJECTS

In total, 234 colorectal cancer patients aged 29-82 y treated at Cancer Treatment Centers of America at Midwestern Regional Medical Center between January 1995 and March 2001.

INTERVENTION

SGA Questionnaire. SGA A-well nourished; SGA B-moderately malnourished; and SGA C-severely malnourished. Malnutrition was defined as either SGA B or SGA C.

RESULTS

The prevalence of malnutrition in this patient population, as determined by SGA, was 52% (113/217). The median survival of patients with SGA A was 12.8 months (95% CI; 9.1-16.5), those with SGA B was 8.8 months (95% CI; 6.7-10.9) and those with SGA C was 6 months (95% CI; 3.9-8.1); the difference being statistically significant at P=0.0013. Regression tree analysis identified prior treatment history, lactate dehydrogenase (LDH) and SGA to be important predictors of survival for our patient cohort. Patients with no prior treatment history (newly diagnosed disease), low LDH scores, and SGA A had the best overall survival of 40.4 months (95% CI; 30.45-50.4), whereas patients with prior treatment history (progressive disease), high LDH scores, and SGA B/C had the worst overall survival of 4.5 months (95% CI; 2.22-6.76).

CONCLUSION

The SGA provides useful prognostic information in patients with advanced colorectal cancer.

Vascular dementia, hypertension, and the brain

Ischemic vascular dementia is a clinical syndrome of acquired intellectual impairment with ischemic cerebral injury resulting from occlusion of cerebral blood vessels and loss of cerebral tissue caused by cerebrovascular disease. With increasing life expectancy, the developed countries have experienced a shift towards a progressively older population. As the average age of the population increases, the prevalence of cerebrovascular disease and vascular dementia is likely to increase. The risk of vascular dementia seems to be correlated with the epidemiologic risk factors of stroke, namely hypertension. Hypertension is thought to be directly associated with vascular dementia and preliminary evidence suggests an association between elevated blood pressure and impairments in cognitive functioning. Recent investigations have found significant associations between hypertension and cerebral dilation and left hemisphere atrophy, and an increased incidence of white matter hyperintensities among hypertensives. Treatment and prevention of vascular dementia and cognitive dysfunction in the elderly require attention to cerebrovascular risk factors, particularly hypertension. Vascular dementias are potentially preventable and cases of Alzheimer's disease with vascular components are becoming increasingly recognized.