Pocket Oncology (Pocket Notebook Series), 1st Ed.

QUALITY OF LIFE ASSESSMENTS

Jane L. Meisel and Stacy M. Stabler

Introduction

• HRQoL is a multidimensional concept encompassing the pt’s perception of the positive & negative aspects of their sx

• Includes physical, emotional, social, & cognitive functions, as well as, disease sx & s/e of tx

• HRQoL is an important outcome measure in all CA pts, but even more so in the met population where palliation of sx & optimization of QoL are often the main GOC

• Growing recognition of the importance of studying QoL has been reflected in the past decade by the ↑ number of clinical trials that have incorporated measures of QoL as part of their end points

• Higher scores on QoL measures may be predictive of longer survival (BMC Cancer 2011;11:353)

• A recent RCT showed early palliative care & attention to sx like depression & to be a/w prolonged survival in pts w/met NSCLC (J Clin Oncol 2012;30:1310)

Formal Quality of Life (QoL) Assessments in Malignancy

Can be either:

• Generic (applicable across a range of CA)

• Specific (limited to a disease, site, and/or tx modality)

Generic QoL Assessments

Two main generic assessments in CA pts:

FACT-G (Functional Assessment of Cancer Therapy—General) (JCO 1993;11:570)

• Includes specific subscales on physical, social, emotional, & functional well-being

• Likert scale of 0 (not at all) to 4 (very much), pts respond to statements such as “I am able to enjoy life” or “I am sleeping well”

• Higher scores indicate better QoL

EORTC QLQ-C30 (European Organization for Research and Treatment of Cancer QoL Core Questionnaire 30) (JNCI 1993;85:365)

• No specific subscales

• On a scale of 1 (not at all) to 4 (very much), pts respond to questions such as “Do you have any trouble taking a long walk?”

• Lower scores indicate better QoL

Choosing between the FACT-G & EORTC QLQ-C30 for measuring CA-related QoL:

Figure APP-1 Ann Oncol 2011;22:2179. Reprinted with permission from Oxford University Press.

Other widely used generic HRQoL assessments in CA pts:

HADS (Br J Psychiatry 1991;158:255)

• Designed to detect anxiety & depression independent of somatic sx; initially used in medical outpts & later validated in the CA setting

IES-R (Psychosom Med 1979;41:209)

• widely used self-report measure of traumatic stress

Disease-, Treatment-, and Symptom-Specific QoL Assessments

• Both EORTC & FACT have developed disease-specific modules (ie, for breast CA, the EORTC-BR23 or FACT-B) which tailor questions to specific disease-related sx or tx s/e (ie, hair loss, hot flashes, lymphedema in pts w/breast CA)

• Other FACT scales:

• 26 disease-specific sx indices (some in collaboration w/the NCCN) to assess QoL issues related specifically to sx experienced commonly w/each type of CA; these are more abbreviated than the disease-specific modules

• 10 tx-specific sx indices to assess QoL issues related to types of tx (ie, taxanes, EGFR inhibitors) or issues related to disease and/or tx (ie, enteral feeding, neurotoxicity)

• 17 sx-specific measures (ie, cachexia, anemia/fatigue, diarrhea)

• EORTC has a specific module designed to assess how satisfied a pt is w/the information they have received regarding disease, prognosis, & tx options

Interpreting Clinical Trials: Limitations of QoL Assessments

• Different studies employ diverse methodologies, varying assessment instruments, & include pts w/different sites & stages of disease, making comparisons challenging

• Baseline data are necessary to attribute a decline in the level of functioning to disease or tx-related effects, & such data is often not available; in CA related to the consumption of tobacco or EtOH (lung, head & neck, bladder, etc.) baseline functioning may be already be reduced

Use of QoL Assessments in Clinical Practice

• Incorporating standardized HRQoL assessments in daily clinical oncology practice is feasible & heightens physicians’ awareness of pts’ HRQoL issues & facilitates discussion (JAMA 2003;289:987; Eur J Cancer1998;34:1181)

• A recent prospective study assigned 286 CA pts to an intervention group (completion of EORTC-QLQ-C30 & HADS w/feedback given to physicians), attention-control group (completion of questionnaires, but no feedback); or control group (no HRQoL measurement performed), using FACT-G to assess HRQoL outcome over time (JCO 2004;22:714)

• Pts who completed surveys had significantly better HRQoL than those in the control group; pts in the intervention group enjoyed more frequent discussion of pain, role function, & chronic sx w/MDs

• The need for HRQoL assessments to be rapid, facile, & clinically meaningful has led to the recently developed FACT G-7(Ann Oncol 2012;00:1)

• Rapid version of the FACT-G based on CA pts’ assessment of sx they viewed as most important when undergoing CA-related Rx

• May be useful in settings where completion of entire survey is not feasible