Randomized controlled trial to assess the effectiveness of a videotape about radiotherapy

In a randomized controlled trial, the additional provision of information on videotape was no more effective than written information alone in reducing pre-treatment worry about radiotherapy. Images of surviving cancer patients, however, may provide further reassurance to patients once therapy is completed.

A body image scale for use with cancer patients

Body image is an important endpoint in quality of life evaluation since cancer treatment may result in major changes to patients' appearance from disfiguring surgery, late effects of radiotherapy or adverse effects of systemic treatment. A need was identified to develop a short body image scale (BIS) for use in clinical trials. A 10-item scale was constructed in collaboration with the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Study Group and tested in a heterogeneous sample of 276 British cancer patients. Following revisions, the scale underwent psychometric testing in 682 patients with breast cancer, using datasets from seven UK treatment trials/clinical studies. The scale showed high reliability (Cronbach's alpha 0.93) and good clinical validity based on response prevalence, discriminant validity (P<0.0001, Mann-Whitney test), sensitivity to change (P<0.001, Wilcoxon signed ranks test) and consistency of scores from different breast cancer treatment centres. Factor analysis resulted in a single factor solution in three out of four analyses, accounting for >50% variance. These results support the clinical validity of the BIS as a brief questionnaire for assessing body image changes in patients with cancer, suitable for use in clinical trials.

A protocol for preventative mastectomy in women with an increased lifetime risk of breast cancer

This paper describes a protocol for women at high risk of breast cancer wishing to undergo preventative mastectomy. The protocol described is a holistic approach to each woman involving the use of a multidisciplinary team. The protocol takes a number of months from initiation to surgery. A time delay is deliberate to allow women to fully address the issues involved with a decision for surgery. Early evidence suggests that this prepares the women emotionally and physically for their surgery.

Clinical follow-up after bilateral risk reducing ('prophylactic') mastectomy: mental health and body image outcomes

BACKGROUND

In Manchester, approximately 120 women at > or = 1:4 lifetime risk of breast cancer have considered preventative surgery since 1992. Women treated within the Manchester protocol receive two genetic counselling sessions, a psychological assessment and a surgical consultation pre-operatively and annual follow-up post-operatively. The vast majority of women have breast reconstruction.

METHODS

Since 1996, mental health and body image have been assessed in women attending annual follow-up using self-report questionnaires: the 28-item General Health Questionnaire (GHQ) and 10-item Body Image Scale (BIS). Women with high scores are assessed by clinical interview together with a proportion who have no significant problems.

RESULTS

Between 1995 and 1999, 76 women completed surgery. Ten were awaiting post-operative review and 60 (91%) attended for follow-up of whom 45 (75%) were interviewed. Questionnaire data were available for 52 (79%) women, mean age 40.8 years (range 27-58). Six women were gene mutation carriers and of these three had had breast cancer. One additional patient was affected but had not been genetically tested. Eight (17%) of 47 women with assessments in the first post-operative year scored in the 'caseness' range on the GHQ: the mean GHQ score was 3.8 (S.D. 6.7), range 0-25. Results were comparable with those for women attending the Family History Clinic for risk assessment. The mean score on the BIS was 5.1 (S.D. 5.5), range 0-25, comparable with scores for women undergoing conservative surgery for breast cancer. Twenty-one percent of women reported no negative change in body image following surgery (i.e. zero questionnaire summary scores) and the majority of changes reported were of minor degree (item scores 0 or 1). The most frequently reported changes were in sexual attractiveness (55%), feeling less physically attractive (53%) and self-consciousness about appearance (53%): a third of women felt less feminine to a minimal degree. These results appeared stable over time. A minority of women had more serious psychological or body image concerns, usually in relation to surgical complications: they received further psychiatric intervention.

CONCLUSIONS

For the majority of women there is no evidence of significant mental health or body image problems in the first 3 years following Bilateral Prophylactic Mastectomy (BPM), but women who have complications warrant additional psychological help. Careful pre-operative preparation and long-term monitoring are advocated in this new field of cancer prevention.

Clinical and quality of life outcomes in the first United Kingdom randomized trial of endobronchial brachytherapy (intraluminal radiotherapy) vs. external beam radiotherapy in the palliative treatment of inoperable non-small cell lung cancer

BACKGROUND AND PURPOSE

A randomized controlled trial was designed to evaluate the clinical and quality of life (QL) outcomes of patients receiving endobronchial brachytherapy (EBT) or external beam radiotherapy (XRT) as a primary palliative treatment in advanced lung cancer.

MATERIALS AND METHODS

Ninety-nine patients presenting de novo with lung cancer were randomized to receive EBT or XRT. Eleven key symptoms or clinical signs were assessed by clinicians and patient ratings using self-assessment questionnaires were obtained at the same time. The primary endpoints were a comparison of EBT and XRT for symptom relief and acute and late side-effects (palliation) and their effect on patients' functional status and patient-rated QL outcomes. A secondary objective was a comparison of clinician assessments with patient self-reported symptoms.

RESULTS

Both treatments produced good levels of symptom relief. They were better for XRT at the expense of more acute morbidity. Late side-effects were similar. The functional status of patients was well maintained and changed similarly with time in both groups. XRT gave a better duration of palliation. Twenty-eight percent of XRT patients required EBT (at a median time of 304 days) whereas 51% of EBT patients subsequently had XRT (at a median of 125 days). There was a significant modest gain in median survival with initial XRT (287 vs. 250 days). When clinician and patient assessments were compared, doctors were found to underestimate the severity of breathlessness, anorexia, tiredness and nausea.

CONCLUSIONS

Fractionated XRT is preferred to EBT as an initial treatment in better performance patients because it provides better overall and more sustained palliation with fewer retreatments and a modest gain in survival time. QL assessment is required in the evaluation of palliative treatments because clinicians frequently underestimate the incidence and severity of key symptoms.

Breast cancer risk perception: what do we know and understand?

Women's perceptions of breast cancer risk are largely inaccurate and are often associated with high levels of anxiety about cancer. There are interesting cultural differences that are not well researched. Genetic risk counselling significantly improves accuracy of women's perceptions of risk, but not necessarily to the correct level. Reasons for this are unclear, but may relate to personal beliefs about susceptibility and to problems or variations in risk communication. Research into the impact of demographic and psychological factors on risk perception has been inconclusive. An understanding of the process of developing a perception of risk would help to inform risk counselling strategies. This is important, because knowledge of risk is needed both for appropriate health care decision making and to reassure women who are not at increased risk.

Gemcitabine plus best supportive care (BSC) vs BSC in inoperable non-small cell lung cancer--a randomized trial with quality of life as the primary outcome. UK NSCLC Gemcitabine Group. Non-Small Cell Lung Cancer

Three hundred patients with symptomatic, locally advanced or metastatic NSCLC not requiring immediate radiotherapy were enrolled into this randomized multicentre trial comparing gemcitabine + BSC vs BSC alone. Patients allocated gemcitabine received 1000 mg/m2 on days 1, 8 and 15 of a 28-day cycle, for a maximum of six cycles. The main aim of this trial was to compare patient assessment of a predefined subset of commonly reported symptoms (SS14) from the EORTC QLQ-C30 and LC13 scales. The primary end-points were defined as (1) the percentage change in mean SS14 score between baseline and 2 months and (2) the proportion of patients with a marked (> or = 25%) improvement in SS14 score between baseline and 2 months sustained for > or =4 weeks. The secondary objectives were to compare treatments with respect to overall survival, and multidimensional QL parameters. The treatment groups were balanced with regard to age, gender, Karnofsky performance status (KPS) and disease stage (40% had metastatic disease). The percentage change in mean SS14 score from baseline to 2 months was a 10% decrease (i.e. improvement) for gemcitabine plus BSC and a 1% increase (i.e. deterioration) for BSC alone (P = 0.113, two-sample t-test). A sustained (> or = 4 weeks) improvement (> or =25%) on SS14 was recorded in a significantly higher proportion of gemcitabine + BSC patients (22%) than in BSC alone patients (9%) (P = 0.0014, Pearson's chi-squared test). The QLQ-C30 and L13 subscales showed greater improvement in the gemcitabine plus BSC arm (in 11 domains) than in the BSC arm (one symptom item). There was greater deterioration in the BSC alone arm (six domains/items) than in the gemcitabine + BSC arm (three QL domains). Tumour response occurred in 19% (95% CI 13-27) of gemcitabine patients. There was no difference in overall survival: median 5.7 months (95% CI 4.6-7.6) for gemcitabine + BSC patients and 5.9 months (95% CI 5.0-7.9) (log-rank, P = 0.84) for BSC patients, and 1 -year survival was 25% for gemcitabine + BSC and 22% for BSC. Overall, 74 (49%) gemcitabine + BSC patients and 119 (79%) BSC patients received palliative radiotherapy. The median time to radiotherapy was 29 weeks for gemcitabine + BSC patients and 3.8 weeks for BSC. Patients treated with gemcitabine + BSC reported better QL and reduced disease-related symptoms compared with those receiving BSC alone. These improvements in patient-assessed QL were significant in magnitude and were sustained.

Treatment of endotracheal or endobronchial obstruction by non-small cell lung cancer: lack of patients in an MRC randomized trial leaves key questions unanswered. Medical Research Council Lung Cancer Working Party

Symptoms of endotracheal or endobronchial obstruction caused by non-small cell lung cancer (NSCLC) may be relieved with external beam radiotherapy (XRT) or endobronchial treatment. The comparative roles of these two methods need to be established. Patients with predominantly intraluminal obstruction of the trachea, a main bronchus or a lobar bronchus by unresectable NSCLC were randomized to XRT versus the clinician's choice of endobronchial treatment with brachytherapy, laser resection or cryotherapy, according to local availability and practice. Clinicians' assessments included symptoms of obstruction, WHO performance status, lung function tests and adverse effects of treatment. Patients completed a Rotterdam Symptom Checklist at all assessments and a daily diary card to record the severity of major symptoms during the first 4 weeks. To show a difference of 15% in the relief of breathlessness rates at 4 months (from 65% to 80%), 400 patients were required. In spite of our many previously successful lung cancer trials, and initial interest from clinicians in 24 UK centres, who estimated they could randomize 200 patients per year into the present trial, only 75 patients were randomized from seven centres over 3.5 years. Intake to the trial was therefore abandoned in November 1996 although an independent Data Monitoring and Ethics Committee had concluded in April 1996 that the scientific case for the trial was still strong; there were no competing trials; there were no design problems; and much had been done to promote the trial. The main reasons given by centres for the slow intake were: lack of referrals of untreated patients; patients being referred specifically for endobronchial treatment; patients having already received XRT; emergency endobronchial relief of obstruction being necessary; and XRT and endobronchial treatment being considered complementary and not as alternatives. The relative advantages and disadvantages of XRT versus endobronchial treatment remain to be determined. The lack of recruitment to this trial raises the issue of innovative techniques not being given the chance of proving their worth compared with traditional treatments.

Depression in patients with lung cancer: prevalence and risk factors derived from quality-of-life data

PURPOSE

To evaluate self-reported depression rates in patients with inoperable lung cancer and to explore demographic, clinical, and quality-of-life (QOL) factors associated with depression and thus identify patients at risk.

PATIENTS AND METHODS

Nine hundred eighty-seven patients from three palliative treatment trials conducted by the Medical Research Council Lung Cancer Working Party formed the study sample. 526 patients (53%) had poor prognosis small-cell lung cancer (SCLC) and 461 patients (47%) had good prognosis non-small-cell lung cancer (NSCLC). Hospital Anxiety and Depression Scale data and QOL items from the Rotterdam Symptom Checklist were analyzed, together with relevant demographic and clinical factors.

RESULTS

Depression was self-rated in 322 patients (33%) before treatment and persisted in more than 50% of patients. SCLC patients had a three-fold greater prevalence of case depression than those with NSCLC (25% v 9%; P <.0001). An increased rate for women was found for good performance status (PS) patients (PS of 0 or 1) but the sex difference reduced for poor PS patients (PS of 3 or 4) because of increased depression rates for men (chi(2) for trend, P <.0001). Multivariate analysis showed that functional impairment was the most important risk factor; depression increased by 41% for each increment on the impairment scale. Pretreatment physical symptom burden, fatigue, and clinician-rated PS were also independent predictors, but cell type was not.

CONCLUSION

Depression is common and persistent in lung cancer patients, especially those with more severe symptoms or functional limitations. Psychologic screening and appropriate intervention is an essential part of palliative care.

Improving survival without reducing quality of life in small-cell lung cancer patients by increasing the dose-intensity of chemotherapy with granulocyte colony-stimulating factor support: results of a British Medical Research Council Multicenter Randomized Trial. Medical Research Council Lung Cancer Working Party

PURPOSE

The treatment of small-cell lung cancer patients with good performance status aims to improve survival. Dose-intensification could be a way to achieve improved survival but can be limited by neutropenia and thrombocytopenia. Preliminary, nonrandomized feasibility studies showed that doxorubicin, cyclophosphamide, and etoposide (ACE) could be given every 2 (instead of the usual 3) weeks with granulocyte colony-stimulating factor (G-CSF) (lenograstim; Chugai-Rh¿one-Poulenc, Tokyo, Japan) support. The present multicenter randomized trial was designed to examine whether such dose-intensification improves survival while maintaining acceptable toxicity levels.

PATIENTS AND METHODS

All patients were randomized to receive six cycles of ACE either every 3 weeks (control [C] group) or every 2 weeks with G-CSF (G group). The standard dose-intensity of ACE was increased by 50% in group G.

RESULTS

Four hundred and three patients (G group: n = 201; C group: n = 202) were randomized. The received dose-intensity was 34% higher in the G group than in the C group. Complete response rates were 40% for the G group and 28% for the C group (P =.02), and overall rates were 78% for the G group and 79% for the C group. Survival was longer in the G group (hazard ratio = 0.80; 95% confidence interval, 0.65 to 0.99; P =.04), survival rates for the G and C groups being 47% and 39% at 12 months and 13% and 8% at 24 months, respectively. Metastasis-free survival, nonhematologic toxicity, and quality of life were similar in the two groups. In the G group, there was less neutropenia but more thrombocytopenia and more frequent blood and platelet transfusions.

CONCLUSION

Increasing the dose-intensity of ACE with G-CSF support improved survival while maintaining acceptable toxicity.

Defining and analysing symptom palliation in cancer clinical trials: a deceptively difficult exercise

The assessment of symptom palliation is an essential component of many treatment comparisons in clinical trials, yet an extensive literature search revealed no consensus as to its precise definition, which could embrace relief of symptoms, time to their onset, duration, degree, as well as symptom control and prevention. In an attempt to assess the importance of these aspects and to compare different methods of analysis, we used one symptom (cough) from a patient self-assessment questionnaire (the Rotterdam Symptom Checklist) in a large (>300 patient) multicentre randomized clinical trial (conducted by the Medical Research Council Lung Cancer Working Party) of palliative chemotherapy in small-cell lung cancer. The regimens compared were a two-drug regimen (2D) and a four-drug regimen (4D). No differences were seen between the regimens in time of onset of palliation or its duration. The degree of palliation was strongly related to the initial severity: 90% of the patients with moderate or severe cough at baseline reported improvement, compared with only 53% of those with mild cough. Analyses using different landmark time points gave conflicting results: the 4D regimen was superior at 1 month and at 3 months, whereas at 2 months the 2D regimen appeared superior. When improvement at any time up to 3 months was considered, the 4D regimen showed a significant benefit (4D 79%, 2D 60%, P = 0.02). These findings emphasize the need for caution in interpreting results, and the importance of working towards a standard definition of symptom palliation. The current lack of specified criteria makes analysis and interpretation of trial results difficult, and comparison across trials impossible. A standard definition of palliation for use in the analysis of clinical trials data is proposed, which takes into account aspects of onset, duration and degree of palliation, and symptom improvement, control and prevention.

Psychological support needs for women at high genetic risk of breast cancer: some preliminary indicators

The number of women in the UK seeking genetic counselling, testing and preventative treatment is rapidly increasing. In Manchester 600-800 women are now referred annually to the Family History Clinic. As yet there is no formal provision for this service within the NHS, but research is underway to evaluate such clinics and to identify the psychosocial sequelae of genetic risk counselling. To date, findings have been based on questionnaire data from which it is difficult to ascertain support needs accurately. We interviewed 158 women 3 months after genetic risk counselling because of a family history of breast cancer. Using standard assessment and diagnostic criteria, 21 (13%) women were diagnosed with an affective disorder. This compared with a prevalence of 26% using the 28 item General Health Questionnaire (GHQ). We did not find a relationship between GHQ distress levels and women's understanding of their risk before genetic counselling, but women with accurate risk knowledge post-counsel had significantly lower GHQ scores than those who continued to over or under-estimate and this finding warrants further investigation. Of women referred for psychological help, few reported risk of breast cancer as their main concern, but themes of loss, unresolved grief and relationship problems were common. The value of the GHQ as a screening instrument is discussed and we suggest a new threshold value based on our analysis. We conclude that risk counselling does not adversely affect the general mental health of attenders but a minority of women may need help with the impact of breast cancer in the family.

False family history of breast cancer in the family cancer clinic

AIMS

Awareness of hereditary breast and ovarian cancer in both the general public and the medical profession is increasing. Individuals who may be at risk on the basis of a family history are requesting risk determination and appropriate management in a variety of settings. Risk determination relies largely on pedigree analysis and epidemiological data.

METHODS

We describe five individuals presenting in the family cancer or genetic counselling clinic where a factitious family or personal history led to erroneous risk estimation. Common factors in these families are a history of benign breast disease, poor communication within families, long survival with early onset or bilateral disease, a lack of detailed knowledge of the illness and treatment in close relatives and inconsistencies in the history in repeated consultations.

Survey of the Administration of quality of life (QL) questionnaires in three multicentre randomised trials in cancer. The Medical Research Council Lung Cancer Working Party the CHART Steering Committee

We surveyed centres collaborating in two trials in lung cancer (LU12, LU13) and one in lung and head and neck cancer (CHART) to find out how QL questionnaires were being administered, with the aim of standardising procedures and improving compliance. Dedicated local trials staff were funded for CHART but not for the other trials. In all three trials, patients completed a Rotterdam Symptom Checklist (RSCL) and a Hospital Anxiety and Depression Scale (HADS) at specified times. 17 of 22 LU12 centres, 9 of 11 LU13 and all 10 CHART centres returned survey forms. In LU12 and LU13, the category of staff responsible for questionnaires varied widely; in CHART, only research staff were involved. This led to more consistency in CHART centres in the administration and collection of questionnaires, and more frequent checking of forms. However, even the CHART administration, although better than in the other two trials, could not be regarded as standardised. All centres were equally affected by logistical problems. These embraced organisational deficits (e.g. unavailability of staff, lack of questionnaires) and patient-related factors (e.g. patient deemed to be too ill, had difficulty reading or left before completing the form). Patient refusals were an uncommon reason for non-compliance and patients were considered to be generally in favour of QL assessment. As a result of these findings, a number of measures have been put in place to increase standardisation of procedures and improve compliance. These include publishing guidelines for protocol writing, providing centres with guidelines for QL administration and information leaflets for patients, together with introducing staff training.

Psychological issues in cancer genetics: current research and future priorities

There has been a rapid expansion of genetics research in the field of cancer since cancer predisposing genes are now known to cause a proportion of common cancers as well as rarer cancer syndromes. As a result, the psychosocial impact of being at high risk of cancer has become a focus of evaluation, and studies are being reported which set out to evaluate both the uptake and psychological outcome of genetic counselling, testing and surveillance. Available data concerning psychological aspects are reviewed, including for example, possible implications of genetic testing, attitudes and uptake of breast screening and accuracy of women's risk estimates. Work is in progress to assess the more controversial areas of prophylactic mastectomy, and chemoprevention. Other research examines the longer term impact of belonging to a Cancer Family, and of interventions offered to high risk families. This is crucial since the uptake of counselling and testing is likely to be much greater in cancer prone families than those with other genetic disorders, yet detection and prevention strategies are still unevaluated for important genetically determined cancers such as breast cancer.

Epstein-Barr virus latent membrane protein does not inhibit differentiation and induces tumorigenicity of human epithelial cells

Latent membrane protein (LMP) is a latent Epstein-Barr virus (EBV) protein expressed in the EBV associated malignancy, nasopharyngeal carcinoma (NPC). Properties ascribed to this protein include inhibition of epithelial cell differentiation and deregulation of epithelial cellular gene expression, and are believed to contribute to the development of NPC. Studies to evaluate the oncogenic potential of LMP in epithelial cells have not been conclusive. We carried out studies to determine the tumorigenic activity of LMP in two human epithelial cell lines, SCC12F and HaCaT; while SCC12F LMP transfectants were non-tumorigenic in severe combined immunodeficient mice, HaCaT LMP transfectants were strongly oncogenic. The tumours produced were well differentiated, keratinising squamous cell carcinomas suggesting that LMP does not inhibit epithelial cell differentiation which conflicts with a previous report by Dawson et al. (1990). To resolve this discrepancy we examined the ability of HaCaT and SCC12F LMP transfectants to differentiate in a suspension culture assay. Both lines were able to differentiate to a similar extent as parental lines and control transfectants. Our results indicate that LMP is strongly oncogenic in human epithelial cells but that inhibition of differentiation is not necessarily a mechanism by which LMP contributes to the pathogenesis of NPC.

Randomized trials with quality of life endpoints: are doctors' ratings of patients' physical symptoms interchangeable with patients' self-ratings?

The assessment of physical symptoms is a key component of quality of life studies in palliative care, but is often hampered by missing data from patient-completed questionnaires. In two large multicentre randomized trials of palliative treatment conducted by the Medical Research Council Lung Cancer Working Party, Involving over 700 patients, patients completed Rotterdam Symptom Checklists and doctors reported on eleven of the same physical symptoms at each assessment, using the same 4-point severity scale. Ratings by doctors and patients were compared with respect to compliance, severity, and outcomes for the respective trials. Doctors provided more data than patients: 66% vs. 52% in the first 6 months in one trial, 58% vs. 61% in the other. Comparisons of over 33,000 symptom assessments showed 78% complete agreement between doctor and patient, 18% disagreement by one, 4% two, and 1% three grades (complete disagreement). There was no change in levels of agreement over time, but increasing disagreement with increasing symptom severity, and a consistent bias towards doctors underestimating severity. Nevertheless, the two methods of data collection resulted in similar between-treatment conclusions. Therefore, in randomized trials the doctors' assessments of key physical symptoms may be sufficient for the between-treatment comparison. However, the fact that doctors underestimate symptom severity 15% of the time has important implications for palliative interventions.

Quality of life assessment in clinical trials--guidelines and a checklist for protocol writers: the U.K. Medical Research Council experience. MRC Cancer Trials Office

Many clinical trials groups now routinely consider including Quality of Life (QoL) assessment in trials. Indeed, several have policies stating that QoL should be considered as a potential endpoint in all new trials and that if it is not to be evaluated the applicants should justify not doing so. However, inclusion of QoL in clinical trials presents a number of difficult organisational issues, and serious problems in compliance have frequently been reported. Thus, in multicentre clinical trials many of the expected QoL questionnaires fail to be successfully completed and returned, although a few groups have claimed high success rates. However, it is well recognised that if questionnaires are missing, there may be bias in the interpretation of trial results, and the estimates of treatment differences and the overall level of QoL may be inaccurate and misleading. Hence it is important to seek methods of improving compliance, at the level of both the participating institution and the patient. We describe a number of methods for addressing these issues, which we suggest should be considered by all those writing clinical trial protocols involving QoL assessment. These are based upon over a decade of experience with assessing QoL in Medical Research Council (MRC) cancer clinical trials. In particular, we provide a checklist for points that should be covered in protocols. Examples are given from a range of current MRC Cancer Trials Office protocols, which it is proposed might act as templates when writing new protocols.

Improving quality of life in patients with non-small cell lung cancer: research experience with gemcitabine

Alongside objective response rate, quality of life of patients is important in the treatment of cancer, particularly in the palliative setting. Quality of life is difficult to define precisely and is correspondingly difficult to assess. However, a number of methods have been devised and self-report questionnaires are now widely used. Patients with metastatic non-small cell lung cancer (NSCLC) have a poor prognosis with few patients surviving longer than 8 or 9 months. Curative treatment is often not possible and few patients receive active treatment. Although some patients will accept toxic treatments in return for increased survival, it is generally hoped that any treatment, curative or palliative, will not adversely affect patients' quality of life. In three studies in which gemcitabine was used as a single agent in metastatic NSCLC, objective response rates of 20% were obtained. Gemcitabine was well tolerated. Symptoms improved in the studies where disease-related symptoms were assessed. The degree of improvement compared well with historical data on the relief offered by standard radiotherapy and combination chemotherapy. These findings have led to the initiation of a randomised trial to compare the relief offered by gemcitabine plus best supportive care with best supportive care, using quality of life assessments as a primary endpoint.

Quality of life assessment in chemotherapy trials for non-small cell lung cancer: are theory and practice significantly different?

The problems inherent in quality of life (QL) research reviewed in this report support the view that theory and practice are significantly different. Quality of life data could be collected in many non-small cell lung cancer patients, yet this happens only for a few. Well-defined and constructed QL instruments are available to measure QL, yet clinicians seem reluctant to turn the emphasis away from traditional end points of response and survival. Quality of life study design guidelines exist, yet instrument selection, timing of assessments, and sample size calculations become more difficult in clinical practice. When assessing palliation, symptoms can be quantified by QL measures and analyzed statistically, but there is no agreement regarding the definition of palliation and the clinical correlates for changes in QL scores are unknown. Quality of life data collection assumes that patients attend per protocol and that personnel are available to implement QL assessments; however, compliance is problematic in palliative patients because centers are often lacking resources to collect good quality and quantity data. Although QL data can be summarized numerically to show treatment differences, these differences may not be clear-cut and numerical scores may be of little value to clinicians in discussing treatment with patients. Despite these practical difficulties, considerable experience and expertise now exist to direct QL trials successfully and to better address the challenges that are emerging. There are huge numbers of patients with non-small cell lung cancer, and there has to be a real commitment from clinicians to ensure that the opportunity is taken to logically implement QL research and thereby improve patient care.

The European Organization for Research and Treatment of Cancer breast cancer-specific quality-of-life questionnaire module: first results from a three-country field study

PURPOSE

To construct a breast cancer-specific quality-of-life questionnaire (QLQ) module to be used in conjunction with the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 and to test its reliability and validity cross-culturally.

PATIENTS AND METHODS

Module construction took place after the EORTC guidelines for module development. The module--the QLQ-BR23--consists of 23 items covering symptoms and side effects related to different treatment modalities, body image, sexuality, and future perspective. This module was tested in 170 Dutch, 168 Spanish, and 158 American cancer patients at two points in time. The timing for the Dutch and Spanish patients was before and during treatment with radiotherapy or chemotherapy. For the American patients, the questionnaire was administered at admission at the breast clinic and 3 months after the first assessment.

RESULTS

Multitrait scaling analysis confirmed the hypothesized structure of four of the five scales. Cronbach's alpha coefficients were, in general, lowest in Spain (range; .46 to .94) and highest in the United States (range; .70 to .91). On the basis of known-groups comparisons, selective scales distinguished clearly between patients differing in disease stage, previous surgery, performance status, and treatment modality, according to expectation. Additionally, selective scales detected change over time as a function of changes in performance status and treatment-induced change.

CONCLUSION

These results lend support to the clinical and cross-cultural validity of the QLQ-BR23 as a supplementary questionnaire for assessing specific quality-of-life issues relevant to patients with breast cancer.

Randomized trial of palliative two-fraction versus more intensive 13-fraction radiotherapy for patients with inoperable non-small cell lung cancer and good performance status. Medical Research Council Lung Cancer Working Party

In patients with non-metastatic but inoperable non-small cell lung cancer that is locally too extensive for radical radiotherapy (RT), but who have good performance status, it is important to determine whether thoracic RT should be the minimum that is required to palliate thoracic symptoms or whether treatment should be more intensive, with the aim of prolonging survival. A total of 509 such patients from 11 centres in the UK between November 1989 and October 1992 were admitted to a trial comparing palliative versus more intensive RT with respect to survival and quality of life. They were allocated at random to receive thoracic RT with either 17 Gy in two fractions (F2) 1 week apart (255 patients) or 39 Gy in 13 fractions (F13) 5 days per week (254 patients). Survival was better in the F13 group, the median survival periods being 7 months in the F2 group compared with 9 months in the F13 group, and the survival rates 31% and 36% at one year and 9% and 12% at 2 years, respectively (hazard ratio = 0.82; 95% CI0.69-0.99). There was a suggestion of a trend towards greater benefit in fitter patients. Metastases appeared earlier in the F2 group. As recorded by patients using the Rotterdam Symptom Checklist, the commonest symptoms on admission were cough, shortness of breath, tiredness, lack of energy, worrying and chest pain. These were more rapidly palliated by the F2 regimen. Psychological distress was generally lower in the F13 group. Three patients (two F13, one F2) exhibited evidence of myelopathy. As recorded by patients using a diary card, 76% of the F2 compared with 81% of the F13 patients had dysphagia associated with their RT. This was transient, lasting for a median of 6.5 days in the F2 group compared with 14 days in the F13 group. In conclusion, the F2 regimen had a more rapid palliative effect. In the F13 group, although treatment-related dysphagia was worse, survival was longer.

Symptoms at presentation for treatment in patients with lung cancer: implications for the evaluation of palliative treatment. The Medical Research Council (MRC) Lung Cancer Working Party

The ten most frequently reported pretreatment symptoms on the Rotterdam Symptom Checklist, which was completed by more than 650 patients entering two MRC Lung Cancer Working Party multicentre randomised trials, included general symptoms (tiredness, lack of appetite) and psychological distress (worry, anxiety) in addition to disease-related chest symptoms (cough, shortness of breath). Although the number and severity of symptoms increased with worsening performance status, the commonest symptoms were found to be virtually the same for patients with small-cell lung cancer (SCLC) and non-small-cell lung cancer (NSCLC), and for different grades of performance status. Women with NSCLC reported more psychological symptoms than males, but this difference was much less evident in patients with SCLC. Thus, in order to assess fully the benefit of palliative treatments in patients with lung cancer, account must be taken of all symptoms at presentation, in addition to the traditionally recognised chest symptoms.

Single fraction prophylactic cranial irradiation for small cell carcinoma of the lung

The effectiveness of a single 8-Gy fraction prophylactic cranial irradiation regime was assessed in 106 patients with small-cell carcinoma of the lung. All patients had limited stage disease and received combination chemotherapy consisting of either cisplatin or carboplatin with ifosfamide, etoposide, and vincristine (VICE). Cranial irradiation was administered 48 h after the first cycle of chemotherapy and was well tolerated. Actual 2-year survival was 35% and cranial relapse occurred in 22% of those patients who achieved complete remission. This compares favourably with a cranial relapse rate of 45% incomplete remitters previously reported with the same chemotherapy regime after a minimum follow-up of 2 years where PCI was not used. Formal psychometric testing was performed retrospectively on a series of 25 long-term survivors of whom 14 were taken from this reported series. Whilst 75% of patients were impaired on at least one test with 68% performing badly in the most complex task, this was not associated with clinically detectable neurological damage and the patients did not complain of memory or concentration difficulties. In conclusion, single fraction PCI, when used with platinum based combination chemotherapy, appears to be equally effective but may be less neurotoxic than the more standard fractionated regimes.

The impact of genetic counselling on risk perception in women with a family history of breast cancer

Women with a family history of breast cancer generally self-refer because they have a feeling that their risk is high. However, they have, in general, only a hazy notion of the population risk of breast cancer and their own risk in relation to this. It is probable that they are helped by genetic counselling and, if at substantial risk, by annual mammography. However, the psychological impact of assigning true risk and the value of mammography need to be evaluated. We have assessed risk perception by questionnaire in 517 new referrals to a family history clinic and 200 women returning to the clinic at least 1 year after counselling. Correct assignment of population lifetime risk of breast cancer was 16% in the uninformed precounsel group and 33% in the post-counsel group, likewise personal risk was correct in 11% and 41% respectively. Post-counsel women were significantly more likely to retain information if they were sent a post-clinic letter or if they assessed their personal risk as too high initially.

Approaches to the analysis of quality of life data: experiences gained from a medical research council lung cancer working party palliative chemotherapy trial

Standardization in the choice of quality of life (QOL) instruments and their application in randomised clinical trials have been advocated and generally accepted. However, there is now an urgent need to address the problems relating to the analysis and presentation of the data thus generated. There are intrinsic difficulties associated with QOL data, namely its multidimensional nature, attrition and missing data, and there is no consensus as to how these problems should be dealt with. This paper therefore considers these problems using interim data from a large Medical Research Council randomised trial in patients with small cell lung cancer and a poor prognosis, in which attrition and compliance are major concerns. Three possible approaches to the analysis of these data, which use different subsets of patients, are examined in detail. The strengths and weaknesses of these three methods are discussed, and examples of their use in the literature are given and compared with other reported approaches. The need for a standard definition of compliance is also emphasised, and a method of presentation suggested. The best current advice is that QOL data should be analysed in a number of different ways, and conclusions reached only when consistency is seen.

Neurological and cognitive impairment in long-term survivors of small cell lung cancer

Despite its effectiveness in reducing the rate of brain metastases, the role of prophylactic cranial irradiation (PCI) in the management of small cell lung cancer (SCLC) remains controversial because of concern about radiation-induced neurological morbidity. In order to evaluate morbidity and its impact on quality of life 64 patients surviving > or = 2 years in remission were recalled for assessment. 52 had received PCI. Most of the patients were well: 95% had performance status < or = 1 and nine out of 37 neurological examinations were abnormal. On neuropsychometric testing, only 19% of patients performed at the level expected for their age and intellectual ability on all four tests used. Fifty-four per cent of patients were impaired on two or more of the tests, suggesting a significant degree of measurable cognitive dysfunction. The number of patients who had not received PCI was insufficient for comparative analysis with the number who had, but among those treated with PCI, patients receiving 8 Gy in 1 fraction appeared less impaired than those receiving higher radiation doses in multiple fractions. The study showed that neuropsychometric testing is acceptable to patients, can be administered by non-psychologists in the clinic and is sensitive to otherwise undetected deficits of cognitive function in this patient population. Prospective evaluation of PCI should include neuropsychometric testing.