An international update of the EORTC questionnaire for assessing quality of life in breast cancer patients: EORTC QLQ-BR45

BACKGROUND

The European Organization for Research and Treatment of Cancer (EORTC) QLQ-BR23 was one of the first disease-specific questionnaires developed in 1996 to assess quality of life (QoL) in patients with breast cancer (BC). However, since 1996 major changes in BC treatment have occurred, requiring an update of the EORTC BC module. This study presents the results of the phase I-III update of the QLQ-BR23 questionnaire.

PATIENTS AND METHODS

The update of the EORTC QLQ-BR23 module followed standard EORTC guidelines. A systematic literature review revealed 83 potential relevant QoL issues during phases I and II. After shortening the issues list and following interviews with patients and health care providers, 15 relevant issues were transformed into 27 items. The preliminary module was pretested in an international, multicentre phase III study to identify and solve potential problems with wording comprehensibility and acceptability of the items. Descriptive statistics are provided. Analyses were qualitative and quantitative. We provide a psychometric structure of the items.

RESULTS

The phase I and II results indicated the need to supplement the original QLQ-BR23 with additional items related to newer therapeutic options. The phase III study recruited a total of 250 patients (from 12 countries). The final updated phase III module contains a total of 45 items: 23 items from the QLQ-BR23 and 22 new items. The new items contain two multi-item scales: a target symptom scale and a satisfaction scale. The target symptom scale can be divided into three subscales: endocrine therapy, endocrine sexual and skin/mucosa scale.

CONCLUSION

Our work has led to the development of a new EORTC QLQ-BR45 module that provides a more accurate and comprehensive assessment of the impact of new and scalable treatments on patients' QoL. The final version of the EORTC QLQ-BR45 is currently available for use in clinical practice. The final phase IV study is underway to confirm psychometric properties of the module.

International validation of the European Organisation for Research and Treatment of Cancer QLQ-BRECON23 quality-of-life questionnaire for women undergoing breast reconstruction

Background

The aim was to carry out phase 4 international field-testing of the European Organisation for Research and Treatment of Cancer (EORTC) breast reconstruction (BRECON) module. The primary objective was finalization of its scale structure. Secondary objectives were evaluation of its reliability, validity, responsiveness, acceptability and interpretability in patients with breast cancer undergoing mastectomy and reconstruction.

Methods

The EORTC module development guidelines were followed. Patients were recruited from 28 centres in seven countries. A prospective cohort completed the QLQ-BRECON15 before mastectomy and the QLQ-BRECON24 at 4–8 months after reconstruction. The cross-sectional cohort completed the QLQ-BRECON24 at 1–5 years after reconstruction, and repeated this 2–8 weeks later (test–retest reliability). All participants completed debriefing questionnaires.

Results

A total of 438 patients were recruited, 234 in the prospective cohort and 204 in the cross-sectional cohort. A total of 414 reconstructions were immediate, with a comparable number of implants (176) and donor-site flaps (166). Control groups comprised patients who underwent two-stage implant procedures (72, 75 per cent) or delayed reconstruction (24, 25 per cent). Psychometric scale validity was supported by moderate to high item-own scale and item-total correlations (over 0·5). Questionnaire validity was confirmed by good scale-to-sample targeting, and computable scale scores exceeding 50 per cent, except nipple cosmesis (over 40 per cent). In known-group comparisons, QLQ-BRECON24 scales and items differentiated between patient groups defined by clinical criteria, such as type and timing of reconstruction, postmastectomy radiotherapy and surgical complications, with moderate effect sizes. Prospectively, sexuality and surgical side-effects scales showed significant responsiveness over time (P < 0·001). Scale reliability was supported by high Cronbach's α coefficients (over 0·7) and test–retest (intraclass correlation more than 0·8). One item (finding a well fitting bra) was excluded based on high floor/ceiling effects, poor test–retest and weak correlations in factor analysis (below 0·3), thus generating the QLQ-BRECON23 questionnaire.

Conclusion

The QLQ-BRECON23 is an internationally validated tool to be used alongside the EORTC QLQ-C30 (cancer) and QLQ-BR23 (breast cancer) questionnaires for evaluating quality of life and satisfaction after breast reconstruction.

Improved fluorescence and dual color detection with enhanced blue and green variants of the green fluorescent protein

The green fluorescent protein (GFP) from the jellyfish Aequorea victoria is a versatile reporter protein for monitoring gene expression and protein localization in a variety of systems. Applications using GFP reporters have expanded greatly due to the availability of mutants with altered spectral properties, including several blue emission variants, all of which contain the single point mutation Tyr-66 to His in the chromophore region of the protein. However, previously described "BFP" reporters have limited utility, primarily due to relatively dim fluorescence and low expression levels attained in higher eukaryotes with such variants. To improve upon these qualities, we have combined a blue emission mutant of GFP containing four point mutations (Phe-64 to Leu, Ser-65 to Thr, Tyr-66 to His, and Tyr-145 to Phe) with a synthetic gene sequence containing codons preferentially found in highly expressed human proteins. These mutations were chosen to optimize expression of properly folded fluorescent protein in mammalian cells cultured at 37 degreesC and to maximize signal intensity. The combination of improved fluorescence and higher expression levels yield an enhanced blue fluorescent protein that provides greater sensitivity and is suitable for dual color detection with green-emitting fluorophores.

Quantification of gene expression with a secreted alkaline phosphatase reporter system

The cDNA encoding secreted alkaline phosphatase (SEAP) is a useful tool for investigating the function of known or putative enhancer/promoter elements. SEAP has the unusual properties of extreme heat stability and resistance to the phosphatase inhibitor L-homoarginine. Therefore, endogenous alkaline phosphatase activity in transfected cells can be minimized by pretreatment of samples at 65 degrees C and incubation with the inhibitor. With the use of the chemiluminescent substrate CSPD, 10(-13) g of enzyme can be detected in culture medium, and the enzyme activity can be detected as early as 24 h after transfection. The chemiluminescence-based SEAP assay is about 10-fold more sensitive than similar assays using firefly luciferase as the reporter enzyme. The SEAP activity can also be assayed with a fluorescent substrate MUP, which provides sensitivity comparable to luciferase. Since the enzyme is secreted to culture medium, the enzyme assay can be performed on small samples of the culture supernatant. Because preparation of cell lysates is not required, assaying for SEAP activity is faster and more convenient than assaying for intracellular reporters. Furthermore, because the transfected cells are not disturbed by the sampling procedure, the same cultures can be repeatedly sampled for time-course studies or used for further investigations.

An acid phosphatase assay for quantifying the growth of adherent and nonadherent cells

We describe an acid phosphatase assay for determination of cell growth based on quantification of cytosolic acid phosphatase activity. The assay is based on the hydrolysis of the p-nitrophenyl phosphate by intracellular acid phosphatases in viable cells to produce p-nitrophenol. For all cell types examined, absorbance of p-nitrophenol at 405 nm is directly proportional to the cell number in the range of 10(3)-10(5) cells. The assay can quantify as few as 1000 cells per well in 96-well microtiter plates. The acid phosphatase assay was used to count various adherent and nonadherent cells, including human tumors, L6, and HT-2 cells. We also demonstrate the utility of this assay for analysis of growth factor and cytokine bioactivity on mammalian cells in culture. In comparison to [3H]thymidine incorporation, the acid phosphatase assay has similar sensitivity but a wider linear response range. The method also shows higher sensitivity and reproducibility in comparison to cell proliferation assays based on the reduction of tetrazolium salts. Because of the ease of use, sensitivity, and low cost, the acid phosphatase method is especially suited to applications where a large number of samples are assayed.

Human multiple tissue western blots: a new immunological tool for the analysis of tissue-specific protein expression

Human multiple tissue Western (MTW) blots are premade immunoblots prepared using proteins isolated from adult human tissue. The proteins are isolated from whole tissue homogenates under conditions designed to minimize proteolysis and to ensure maximal representation of tissue-specific proteins. Sodium dodecyl sulfate (SDS) solubilized proteins are fractionated by SDS polyacrylamide gel electrophoresis and electroblotted onto polyvinylidene fluoride membranes to generate blots ready for incubation with researcher-supplied antibodies. Each lane of an MTW blot contains an equivalent amount of total protein, allowing for the analysis of tissue-specific expression of a particular protein(s). The utility of MTW blots for Western blot applications was demonstrated by the detection of various cytoskeletal proteins and members of the annexin family of calcium-dependent, membrane-binding proteins. Several of these antigens were detected in separate cycles of antibody incubations using the same MTW blot. This approach is possible using a stripping procedure that allows the researcher to selectively remove both primary and secondary antibodies in a single incubation. The ease of multiple reprobings makes MTW blots both economical and convenient research tools for Western blot analyses of human tissue-specific proteins.

Correction of optical aberrations by neutron irradiation

The refractive index of optical materials can be modified by means of neutron irradiation. By varying the radiation dose over selected areas of a lens according to some given law, the local change in the refractive index can be adjusted to correct for different types of optical aberrations. The particular case of spherical aberration is treated in detail. It is shown that irradiation leads to index modifications of the required order of magnitude and that irradiation times are acceptable. Moreover, the stability of the index modifications, the possibility of bleaching-without curing the index-and the absence of residual radioactivity make an irradiated lens suitable for optical applications. The optician has thus at his disposal a new parameter.