The European Organization for Research and Treatment of Cancer QLQ-C30: a quality-of-life instrument for use in international clinical trials in oncology

Psychological distress in head and neck cancer patients 7-11 years after curative treatment

Long-term survivors of head and neck cancer may suffer from psychological distress and reduced quality of life because of late side-effects of the treatment. In a follow-up study of patients randomised to two different radiation fractionating regimens, 204 patients filled in a mailed questionnaire 7-11 years after treatment. The questionnaire consisted of the General Health Questionnaire, 20-item version (GHQ-20), and the EORTC Core Quality of Life Questionnaire (EORTC QLQ-C30). There were no differences in psychological distress between patients receiving conventional radiotherapy and those receiving a slightly hypofractionated regimen. A high prevalence of psychological distress was found in both treatment groups (30% of 'cases' according to the GHQ-20), especially in patients with impaired cognitive or social function, or with pain. Clinicians need to be aware of this morbidity, and their ability to detect patients with psychological problems needs to be improved. The GHQ-20 can facilitate the communication process in a clinical setting. With an increased awareness of these problems and by using valid instruments for identification of patients at risk, the clinicians may intervene and help the patients to reduce their psychological distress.

Quality of life of 125 adults surviving 6-18 years after bone marrow transplantation

BACKGROUND

Recent studies examining the medical and psychosocial sequelae of bone marrow transplantation have reported most survivors do relatively well while a smaller group continues to experience less than optimal quality of life (QOL). Many of these studies are limited by small sample sizes, limited scope, and focus on a narrow (1-4 year) window of survival.

METHODS

The descriptive survey examined the QOL, late medical complications, psychological distress, demands of long-term recovery, and health perceptions of 125 adults surviving 6-18 (mean 10) years after marrow transplantation. Seven wide-ranging tests covering 271 items were completed on average in 90 min. Two tests were developed by the authors specifically for assessing QOL in this population.

RESULTS

74% of long-term survivors of bone marrow transplantation reported their current QOL was the same or better than before transplantation, 80% rated their current health status and QOL as good to excellent, and 88% said the benefits of transplantation outweighed the side effects. Ten years or more post-transplantation, long-term survivors continued to experience a moderate incidence of lingering complications and demands, including emotional and sexual dysfunction, fatigue, eye problems, sleep disturbance, general pain and cognitive dysfunction. However, the severity or degree of distress attributed to those complications was, for most survivors, consistently low. Nearly all were back to work or school. Only 5% rated both their QOL and health status as poor. Long-term survivors demonstrated good mood and low psychological distress compared to cancer and population norms, and had the same perceptions as the general population of their current health and expectation of future health. Demands attributed to long-term survival appeared to impose little hardship. The most frequently cited demand of recovery was the perceived lack of social support as time went on.

CONCLUSIONS

Almost all long-term survivors were leading full and meaningful lives. Persistent complications were, on the whole, dismissed as relatively trivial and the overwhelming majority viewed themselves as cured and well.

Using quality of life assessment methods in patients with advanced cancer: a clinical perspective

The incidence of cancer is expected to increase in most European countries by at least 20-30% in the next two decades. This change in incidence, combined with probably small changes in cure rate, will call for an increased effort in palliative oncology. Most patients with advanced malignant diseases have various unpleasant symptoms which are inadequately treated. In assessing patients' symptoms and well being, health-related quality of life (HRQL) should be the primary endpoint. Several HRQL instruments have been found to be valid for use in cancer clinical trials. The EORTC QLQ-C30 is one among several cancer-specific HRQL instruments. The QLQ-C30 is composed of nine multi-item scales and six single item measures. This instrument is developed to be used in conjunction with disease and/or specific modules.

Recent clinical trials of pain control: impact on quality of life

The understanding and treatment of pain is one of the oldest challenges for physicians, scientists and philosophers. Much of our present rationale of pain control is based on the Cartesian idea that pain mostly originates from external or internal noxious stimuli, which are transmitted to and interpreted in the brain. Consequently, removal (blocking) of the stimuli and modification of cerebral awareness have been the prime targets of analgesic interventions. Only recently has the relationship between pain and other physical, psychological and social aspects of illness been considered in the overall management plan. Most of the literature on pain control reveals the physical bias of measurement. Apart from simple but reliable tools such as visual analogue scales and Likert-type verbal scales, more sophisticated measures such as multidimensional pain inventories have also been used when it is necessary to characterise pain more specifically. In clinical studies, it is usual to ask the patient to report on his own pain, although proxy measures such as mobility, performance status and analgesic consumption are also often used. The hospice concept of "total pain", in which the psychological, social, spiritual and other aspects are emphasised, has been influential in our new approach to pain measurement. Particularly when it is chronic and related to advancing disease as in metastatic cancer, pain can interact significantly with many facets of daily living. A holistic model of quality of life in such patients should, therefore, include a multidimensional or modular assessment of these areas. Medical interventions themselves can affect quality of life in both positive and negative ways. Some side-effects may be so common as to be accepted as "normal", e.g. constipation or sedation with opioids: it is only by their careful evaluation, when comparing opioids with essentially similar analgesic potentials, that differential toxicities may be revealed. Simple recording of physical side-effects of drugs is really not sufficient, because analgesics as well as other therapies may be associated with mood changes and broader consequences for quality of life. Only in the past few years has quality of life been seriously addressed in palliation research. For example, standardised quality of life scales are now included almost routinely in oncological studies involving radiotherapy or chemotherapy by the Medical Research Council (MRC) of Great Britain. Trials of the new biphosphonates, which can reduce bone pain in metastatic cancer, have been enhanced by incorporating quality of life measures. Based on the experience from earlier efficacy/safety studies with the new transdermal route of drug delivery for the opioid fentanyl, important areas of life such as sleep and cognitive function have been addressed. Randomised controlled trials of analgesics which include quality of life endpoints are still rare, but should be encouraged as these represent the most rigorous way of evaluating new therapies. The current preoccupation with quality assurance in healthcare is directed, ultimately, to the delivery of a better quality of care, which should also be more cost-effective, for large populations. An important intermediate step towards that ideal is the collection of data on pain and other symptoms, but also validated quality of life parameters on well-defined groups. Only by widening the scope of analgesic studies to include these dimensions can we hope to define appropriate strategies for more rational healthcare.

Quality of life in adult cancer patients treated with bone marrow transplantation--a review of the literature

There is now an increasing interest in measuring quality of life (QOL) in cancer patients. Information on psychosocial issues and the patients' QOL give a more comprehensive evaluation of the treatment outcome than survival and relapse free intervals alone. Bone marrow transplantation (BMT) has become a standard, curative treatment in haematological diseases such as leukaemia and lymphomas. However, serious physical and psychological side effects are experienced by some patients. A review of the literature on QOL in adult BMT patients shows that the development in post-BMT research on psychosocial factors is slowly progressing. Most studies are retrospective with small sample sizes, and only five of 48 studies fulfilled our preset quality criteria. Identification of factors that are predictive for poor post-BMT outcome might provide a basis for targeted support programmes. This underlines the necessity of undertaking prospective studies using reliable and well-validated methods for measuring QOL in this patient group.

Methods and problems in measuring quality of life

The US health-care transition demands increased accountability for medical care. This has contributed to increased interest in documenting valued medical outcomes, including improvements in health-related quality of life and treatment satisfaction. These data can only be obtained validly by asking patients directly about their current health state, perception of well-being, and satisfaction with care. A core set of well-validated instruments have been developed to measure health-related quality of life in patients with cancer. As these are employed with increasing frequency, rigorous quality assurance of data collection is critical. Because of the necessity of quality control, patient-reported data collection can be labor-intensive and prohibitively costly. However, time and cost-saving methods, such as centralized telephone survey methods or on-site direct data entry via interactive computer, can guarantee high-quality data while minimizing costs. Justification of the need for these methods and a brief description are provided.

The Karnofsky Performance Status Scale re-examined: a cross-validation with the EORTC-C30

A cross-validation of the Karnofsky Performance Status (KPS) and quality of life (QOL) as measured by item 30 of the quality of life questionnaire developed by the European Organization for Research and Treatment of Cancer Study Group (EORTC QLQ-C30) was conducted using ordered logit analysis and prospective data from a continuous sample of 139 lung cancer patients. The QOL is found to be a much broader concept than the KPS, since it likely captures not only physical functioning but also functioning in the non-physical dimensions of social, emotional, and possibly cognitive well-being as well as the level of distress in the physical dimensions of pain, breathing and fatigue. These results suggest that the palliative treatment of advanced cancer and the terminally ill should be guided by a broad concept of well-being that goes beyond one based only on physical functioning.

Future directions in clinical research for lung cancer

Even since the Surgeon General's 1964 report, the mortality rate from lung cancer has continued to rise. Although there is evidence that this continued increase in mortality will slow or level in the next decade, lung cancer mortality is a major health problem destined to remain with us for at least the next generation. There have been no established advances in the early detection or prevention of lung cancer in the last 30 years and our therapies have increased the cure rate only from 5 to 13% in this 30-year interval. Biologic advances have outpaced clinical advances in recent times and many of the advances are now ripe for clinical exploitation. There are currently more exciting clinical trials for all phases of lung cancer than at any time and it will be stimulating to witness the results of the clinical trials discussed herein. Hopefully, the results of these studies will lead to a decrease in lung cancer mortality in the next century, much as it increased in the past century.

Quality of life in patients treated for penile cancer. A follow-up study

OBJECTIVES

To study the long-term psychosocial well-being of patients following successful physical treatment for cancer of the penis.

PATIENTS AND METHODS

Thirty patients (median age at follow-up 57 years, range 28-75) were followed up for a median of 80 months after treatment for penile cancer (local excision/laser beam treatment, 5; radiotherapy, 12; partial penectomy, 9; total penectomy, 4). They underwent a semi-structured interview and completed the Impact of Events Scale, General Health Questionnaire and the EORTC QLQ C-30 questionnaire. Global scales for measuring sexual function, subjective well-being and social activity were constructed and found reliable and valid.

RESULTS

There was a strong correlation between the well-being scale and the EORTC scales for overall quality of life and psychological distress. Patients treated with partial or total penectomy had a worse outcome with regard to sexual function than patients treated conservatively, but there was no difference in the other domains of quality of life, indicating that even the more radically treated patients usually adapted adequately. Half of the individuals had mental symptoms at follow-up, and these patients were less satisfied and showed less social activity. Seven men reported that, if asked again, they would choose treatment with lower long-term survival to increase the chance of remaining sexually potent, but the majority gave priority to higher long-term survival.

CONCLUSION

Before treatment of penile cancer, physicians should thoroughly discuss the expected outcome and consequences of the different treatment options with the patient. Psychosocial treatment might be helpful for patients with mental symptoms.

A comparison of two measures of quality of life: their sensitivity and validity for patients with advanced cancer

We compared two measures that have been used by professionals to assess the quality of life and care of patients with advanced cancer. The Support Team Assessment Schedule (STAS) is an instrument for palliative cancer support teams to record and evaluate their care; the Hebrew Rehabilitation Centre for the Aged Quality of Life (HRCA-QL) index was used in the National Hospice Study (USA) to assess patients with advanced cancer. STAS has 17 items, each scaled 0 (best) to 4 (worst), and HRCA-QL has five items scaled 0 (worst) to 2 (best). The STAS and the HRCA-QL were assessed contemporaneously by the members of one support team on 128 consecutive patients referred over 17 months. Seventy-four patients spent more than four weeks in care. Ratings for four out of five HRCA-QL items deteriorated significantly in the four to six weeks before death. HRCA-QL index items correlated with similar STAS items. Correlations were highest at referral, especially in patients seen more than four weeks before death (e.g. symptom control (STAS) with health (HRCA-QL) Spearman's rho = -0.64) and the HRCA-QL total was correlated with STAS subtotal of six items (rho = -0.45). There were few correlations at death. The findings support the validity of both measures for the aspects compared, but indicated that STAS was more sensitive to changes in patients in the last six weeks of life.

Psychometric properties and responsiveness of the EORTC quality of Life Questionnaire (QLQ-C30) in patients with breast, ovarian and lung cancer

The QLQ-C30, a health-related quality of life questionnaire developed for use in patients with cancer, has been previously validated in patients with lung cancer and head and neck cancer. In this study, further validation was carried out for 535 patients, including patients with breast cancer (n = 143) and ovarian cancer (n = 111) for whom there is no previously published validation, as well as patients with lung cancer (n = 160) and a heterogeneous group of other cancers (n = 121). All patients were entered in one of two trials of anti-emetics to prevent chemotherapy-induced emesis. The QLQ-C30 was completed before chemotherapy and on day 8 after chemotherapy. The factor structure in patients with breast and ovarian cancer was similar to that previously described. Interdomain correlations, in the entire group, were strongest for the physical and role function domains and the fatigue, pain and global quality of life domains before and after chemotherapy. In addition, after chemotherapy, social function was also strongly correlated with fatigue and global quality of life. These correlations were not always of equal strength in the breast, ovarian and lung groups, suggesting that there may be differences between these groups. The responsiveness of the QLQ-C30 in the presence of widely metastatic, as compared with locoregional, disease showed changes in the expected directions (i.e., diminished function in physical and social role functions and in global quality of life, with greater fatigue and pain in patients with metastatic disease). Eight days after chemotherapy, decreases were seen in physical, role and social functioning and in global quality of life, and there was greater fatigue, nausea and vomiting compared with before chemotherapy. Patients with breast cancer had better physical, role and social functioning and less fatigue and pain than patients with ovarian cancer. This result is expected, since many of the patients with breast cancer had early stage disease, whereas those with ovarian cancer had advanced stage disease. Mean scores for patients with lung cancer were between the other two groups, in keeping with the mixture of early and advanced stage disease in these patients. There was a strong correlation between ECOG performance status scores and several domains of the QLQ-C30; these were all in the expected directions. The results of this study confirm those in earlier studies on patients with lung cancer, and provide new information on patients with breast and ovarian cancer. In addition, the QLQ-C30 is responsive to the effects of chemotherapy and of metastatic disease.

Quality of life after palliative radiotherapy in patients with hormone-resistant prostate cancer: single institution experience

OBJECTIVE

To review the development, methodology and difficulties of evaluating the quality of life (QoL) in patients with hormone-resistant prostate cancer, and to analyse the subjective effect of palliative radiotherapy among these patients.

PATIENTS AND METHODS

Since 1986, a self-administered QoL questionnaire has been developed for patients with hormone-resistant prostate cancer. The study group included 137 such patients, with a median age of 70 years (range 48-87), who received either 89Sr (31) or external beam radiotherapy (106) because of painful bone metastases. Quality of life was assessed in all patients before treatment and, if possible, 3 months afterwards.

RESULTS

The questionnaire had acceptable psychometric properties (validity, reliability). In these patients with very advanced disease, palliative radiotherapy proved less effective than reports in the literature might suggest.

CONCLUSIONS

In patients with hormone-resistant prostate cancer, quality of life assessment is both possible and desirable for the evaluation of palliative treatment. The patients' perception of physical function represents an independent prognostic factor of overall survival together with alkaline phosphatase and performance status. Valid and reliable QoL questionnaires are now available, though further research is required to establish the most effective way of using them. At 3 months palliative radiotherapy was effective in only 25% of the patients investigated, two-thirds of whom had > or = 20 hot spots on bone scan. Palliative radiotherapy should probably be offered during an earlier phase of the disease.

Quality of life and the patient with cancer. Individual and policy implications

This article reviews the developments during the past decade that have led to a better definition and conceptualization of the term "quality of life." There is growing consensus regarding the dimensions of quality of life, along with an expansion of the number of tools appropriate for measuring quality of life in patients with cancer. Quality of life increasingly is being used as an outcome in research, especially clinical trials. However, there remain some areas of controversy, including the application of economic analyses (utility and cost-effectiveness studies) and the potential conflict between the needs of the individual versus society. In the future, we can expect development of a theoretical framework for quality of life research. Clinicians may begin to routinely evaluate quality of life in their patients and use these evaluations as part of the clinical decision making process in individual patients. Ultimately, policy decisions also may incorporate some form of quality of life assessment.

Colorectal cancer screening and quality of life

To evaluate the quality of life of patients following surgery for colorectal cancer, and to compare the quality of life between patients whose cancer was detected as a result of faecal occult blood screening with that of patients whose cancer presented symptomatically, an analysis was conducted within the context of the randomized controlled trial of colorectal cancer screening, University Hospital, Nottingham, UK. A total of 418 survivors of the trial's test and control groups and 33 randomly selected cancer patients completed quality of life questionnaires (Nottingham Health Profile and Health Measurement Questionnaire). The mode of entry to diagnosis and treatment (screening vs. non-screening) appeared to exert no major impact on post-intervention quality of life. The stage of cancer progression was not closely related to outcome life quality. A quality of life coefficient for surviving patients based on the Rosser classification was estimated to lie within the range 0.948-0.981. This figure accords well with the estimates of other studies of interventions in populations of similar age. Overall, there are no grounds for believing that faecal occult blood screening for colorectal cancer per se significantly influences patients' post-intervention quality of life.

Sexuality in patients treated for penile cancer: patients' experience and doctors' judgement

OBJECTIVE

To evaluate sexuality after successful treatment of penile cancer.

PATIENTS AND METHODS

Post-therapy sexuality was evaluated in 30 men (median age 57 years; range 28-75) treated for cancer of the penis 80 months previously (median; range: 11-225 months). Treatment regimes were: local excision/laser beam treatment, 5; definitive radio-therapy, 12; partial penectomy, 9; total penectomy, 4. Patients underwent a semi-structured interview and completed three self-administered questionnaires (psychosocial adjustment to severe illness [PAIS], mental symptoms [GHQ], quality of life [EORTC QLQ C-30]). A global score of overall sexual functioning was constructed consisting of sexual interest, sexual ability, sexual satisfaction, sexual identity, partner relationship and frequency of coitus.

RESULTS

In 10 of 12 patients treated by irradiation the sexual global score was not or only slightly reduced compared with two of nine patients after partial penectomy and one of five patients with local surgery/laser beam treatment. All four patients who had undergone total penectomy recorded a severely reduced sexual global score. Of the six single domains, sexual identity and partner relationship did not change with increasing age, whereas the other scores of sexual life deteriorated as the patient became older. In the patients treated by irradiation doctors evaluated the patients' post-treatment sexuality to be more impaired than that experienced by the patients.

CONCLUSION

Within the limitations due to the small number of patients studied, radiotherapy seems to be the treatment of choice in limited cancer of the penis if preservation of sexuality is a major therapeutic aim. Physicians counselling patients with this rare malignancy need more information about treatment-related problems of sexuality after different therapeutic modalities.

Measurement of quality of life in patients with lung cancer in multicenter trials of new therapies. Psychometric assessment of the Lung Cancer Symptom Scale

BACKGROUND

This study continued the development and psychometric testing of the Lung Cancer Symptom Scale (LCSS), a disease- and site-specific instrument primarily measuring the physical and functional dimensions of quality of life for individuals with lung cancer. The instrument contains two scales, one for patients and a counterpart for health professionals as observers.

METHODS

Feasibility, reliability, construct validity, and criterion-related validity were evaluated with 207 patients with non-small cell lung cancer (NSCLC) from six cancer centers. Within an interview with an observer, patients completed part of a battery of instruments by self-report and were interviewed for the remaining measures. Observers also completed measures after the interview.

RESULTS

Feasibility, reliability, and validity were well supported for this lung cancer population. Feasibility was demonstrated by patient and staff compliance in completion at all six cancer centers. Internal consistency was good, with coefficient alphas of 0.82 for the patient scale and 0.75 for the observer scale. Construct validity was supported by 1. contrasted groups approach: regression lines (with 95% confidence bands) were obtained between the Karnofsky performance scale (KPS) and each of the two LCSS scales; 2. as a refinement, relationship testing: significant correlations between the LCSS and KPS for each item (except hemoptysis for the patient scale); and 3. multitrait-multimethod approach: good reliability (alphas ranging from 0.75 to 0.93), good convergent validity for the two LCSS scales (r = 0.77), and a good discriminant validity pattern from the Brief Symptom Inventory (BSI). Criterion-related validity with relevant gold standard measures (American Thoracic Society Questionnaire [ATS] and McGill Pain questionnaire, KPS, Profiles of Mood States [POMS], and Sickness Impact Profile [SIP]) was supported with significant correlations (0.40-0.67 for the LCSS patient scale; 0.54-0.65 for the LCSS observer scale).

CONCLUSIONS

These psychometric properties demonstrate that the LCSS patient and observer scales are feasible, reliable, and valid quality of life measures that are ready for research and clinical use with lung cancer populations.

Quality of life of cancer patients with different prognoses

This study examines differences and similarities in the quality of life of 253 cancer patients with good, medium and poor prognoses. Our main hypothesis was that patients with a good prognosis will experience a higher quality of life than patients with a medium or poor prognosis. A multivariate analysis of covariance of eight quality of life scales was performed with prognosis as a factor and with age, sex, and the duration of the illness as covariates. Significant main effects of prognosis were found for the general QOL-scale and for physical aspects of quality of life. There were, however, only marginal and non-significant effects of prognosis groups on social and psychological functioning. A final multivariate analysis confirms earlier findings that performance status shows a weak but significant relationship with the psychological functioning. Thus, the physical condition of the patient at the time of measurement seems to have some influence on the psychological functioning, whereas the severity of the disease as indicated by the classification into prognosis groups does not. These results question the general attitude that seriously ill cancer patients have reduced social and psychological well-being. An alternative interpretation is that the scales used to measure psychological aspects of quality of life are inadequately sensitive.

Quality of life in patients treated for head and neck cancer: a follow-up study 7 to 11 years after radiotherapy

PURPOSE

To compare health-related quality of life factors in 845 head and neck cancer patients randomized to receive either conventional radiotherapy (2 Gy, 5 days-a-week) or a hypofractionated regimen (2.35 Gy, 4 days-a-week), a follow-up study was carried out 7 to 11 years after treatment in the surviving patients, representing 30% of the original patient number.

METHODS AND MATERIALS

The cancer-specific EORTC Core Quality of Life Questionnaire (30 item version; the EORTC QLQ-C30) and a 19 item head and neck cancer-specific questionnaire were mailed to the 245 surviving patients of the trial. The EORTC QLQ-C30 is comprised of six multi-item function scales, three symptom scales, and six single items which assess both symptoms and economic consequences of the disease. Two hundred and four patients (83%) completed the questionnaire. The two groups of patients (N = 103 and N = 101) treated by different fractionating schedules, were comparable with regard to sociodemographic variables, tumor site, treatment variables (including different types of surgical treatment), and secondary primary cancers. Patients in the conventional group had more advanced disease and a higher recurrence rate compared to patients in the hypofractionated group.

RESULTS

Unexpectedly, patients in the hypofractionated group, reported similar or better quality of life compared to patients in the conventional fractionated group. Patients in both groups described a high level of symptoms, like dryness in the mouth and mucus production. Clinical and sociodemographic variables did not explain variance in social function, emotional function or fatigue, except for the type of surgery performed, which significantly influenced the patients' emotional function.

CONCLUSION

Long-term survivors of head and neck cancer reported a high level of disease and treatment related symptoms. Emotional function was significantly influenced by the type of surgical procedure. Strategies for future trials in head and neck cancer should continue to attempt to stress conservative surgical approaches and coordinated adjuvant therapy to maximize local regional control and quality of life. Functional and emotional outcome are important parameters which should prospectively be evaluated in future clinical trials in head and neck cancer.

The Memorial Symptom Assessment Scale: an instrument for the evaluation of symptom prevalence, characteristics and distress

The Memorial Symptom Assessment Scale (MSAS) is a new patient-rated instrument that was developed to provide multidimensional information about a diverse group of common symptoms. This study evaluated the reliability and validity of the MSAS in the cancer population. Randomly selected inpatients and outpatients (n = 246) with prostate, colon, breast or ovarian cancer were assessed using the MSAS and a battery of measures that independently evaluate phenomena related to quality of life. Symptom prevalence in the 218 evaluable patients ranged from 73.9% for lack of energy to 10.6% for difficulty swallowing. Based on a content analysis, three symptoms were deleted and two were added; the revised scale evaluates 32 physical and psychological symptoms. A factor analysis of variance yielded two factors that distinguished three major symptom groups and several subgroups. The major groups comprised psychological symptoms (PSYCH), high prevalence physical symptoms (PHYS H), and low prevalence physical symptoms (PHYS L). Internal consistency was high in the PHYS H and PSYCH groups (Cronback alpha coefficients of 0.88 and 0.83, respectively), and moderate in the PHYS L group (alpha = 0.58). Although the severity, frequency and distress dimensions were highly intercorrelated, canonical correlations and other analyses demonstrated that multidimensional assessment (frequency and distress) augments information about the impact of symptoms. High correlations with clinical status and quality of life measures support the validity of the MSAS and indicate the utility of several subscale scores, including PSYCH, PHYS, and a brief Global Distress Index. The MSAS is a reliable and valid instrument for the assessment of symptom prevalence, characteristics and distress. It provides a method for comprehensive symptom assessment that may be useful when information about symptoms is desirable, such as clinical trials that incorporate quality of life measures or studies of symptom epidemiology.

Quality of life assessment in palliative care

Palliative care aims to improve the quality of life of patients through attention to physical, psychological, social and spiritual distress. Assessment of quality of life, expressed as a global score, is difficult because patients are too ill for long interviews, but relatives and professionals are poor proxy respondents for patients. Quality of life assessment tools must be multidimensional, considering both physical and psychosocial issues, must be quick and easy to administer and score and must be sufficiently sensitive to detect changes with time. Quality of life assessment has audit and routine clinical uses; it is an essential consideration in any research involving the patient with advanced cancer. The different types of questionnaire assessment tool are discussed in detail.

Development of a European Organization for Research and Treatment of Cancer (EORTC) questionnaire module to be used in quality of life assessments in head and neck cancer patients. EORTC Quality of Life Study Group

A head and neck cancer specific questionnaire module designed to be used in quality of life assessments before, during, and after radiotherapy and surgery, with or without combinations with chemotherapy has been developed in accordance with guidelines given by the EORTC Quality of Life Study Group. Relevant issues were generated by means of literature search, and interviews with specialists and patients. Pre-testing of a preliminary questionnaire module was performed in patients from Norway, Sweden, Denmark, United Kingdom and French-speaking Belgium. The resulting head and neck cancer module, the EORTC QLQ-H&N37, includes 37 items concerning disease and treatment related symptoms, social function and sexuality. By using a combination of the general EORTC QLQ-C30 and the EORTC QLQ-H&N37, health-related quality of life measurements may be compared between studies in different cancer populations, and still be sensitive to changes in the target population.

The EORTC QLQ-LC13: a modular supplement to the EORTC Core Quality of Life Questionnaire (QLQ-C30) for use in lung cancer clinical trials. EORTC Study Group on Quality of Life

The EORTC Study Group on Quality of Life has developed a modular system for assessing the quality of life of cancer patients in clinical trials composed of two basic elements: (1) a core quality of life questionnaire, the EORTC QLQ-C30, covering general aspects of health-related quality of life, and (2) additional disease- or treatment-specific questionnaire modules. Two international field studies were carried out to evaluate the practicality, reliability and validity of the core questionnaire, supplemented by a 13-item lung cancer-specific questionnaire module, the EORTC QLQ-LC13. In this paper, the results of an evaluation of the QLQ-LC13 are reported. The lung cancer questionnaire module comprises both multi-item and single-item measures of lung cancer-associated symptoms (i.e. coughing, haemoptysis, dyspnoea and pain) and side-effects from conventional chemo- and radiotherapy (i.e. hair loss, neuropathy, sore mouth and dysphagia). It was administered to patients with non-resectable lung cancer recruited from 17 countries. In total, 883 and 735 patients, respectively, completed the questionnaire prior to and once during treatment. The symptom measures discriminated clearly between patients differing in performance status. All item scores changed significantly in the expected direction (i.e. lung cancer symptoms decreased and treatment toxicities increased) during treatment. With one exception (problems with a sore mouth), the change of toxicity measures over time was related specifically to either chemo- or radiotherapy. However, the single item on neuropathy did not measure adequately the full range of symptoms. The hypothesised scale structure of the questionnaire was partially supported by the data. The multi-item dyspnoea scale met the minimal standards for reliability (Cronbach alpha coefficient > 0.70), while the pain items did not form a scale with reliability estimates acceptable for group comparisons. In conclusion, the results form international field testing lend support to the EORTC QLQ-LC13 as a clinically valid and useful tool for assessing disease- and treatment-specific symptoms in lung cancer patients participating in clinical trials, when combined with the EORTC core quality of life questionnaire. In a few areas, however, the questionnaire module could benefit from further refinements. In addition, its performance over a longer period of time still needs to be investigated.

Developing and evaluating cross-cultural instruments from minimum requirements to optimal models

In the age of increased international collaboration in medical research, the necessity of having at hand cross-culturally applicable instruments for the assessment of health-related quality of life (HRQL) in clinical trials has been voiced. Several important theoretical bases leading to cultural bias in HRQL measurement include differences in definitions of HRQL across national and cultural contexts, levels of observation relied upon to indicate HRQL states, and the significance or weight placed upon the various HRQL states or dimensions measured. Despite a growing literature on the development and evaluation of existing HRQL measures in other cultures, comprehensive sets of procedures or requirements for the international part of development and evaluation are lacking. This paper reviews major approaches to developing international HRQL measures, and discusses various methods and criteria that have been recommended for evaluating measurement equivalence in comparisons of research across national and cultural contexts. A summary of recent trends and advances in international HRQL assessment is presented.

Critical review of the international assessments of health-related quality of life

This paper reviews the international adaptation and use of generic health quality of life measures over the last several years, including the Nottingham Health Profile (NHP) the Sickness Impact Profile (SIP), the Medical Outcomes Short-Form 36 (MOS SF-36), the EuroQol, and Dartmouth COOP Charts. International work with disease or condition specific HRQL measures is exemplified with the European Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ), and the Spitzer Quality of Life (QL) Index. Progress towards cross national measurement equivalence in HRQL measures reported in the literature has been uneven. Results show that the development of language-adapted versions of HRQL measures to date have mostly concerned translation issues, within the context of independently conducted studies. Substantially less focus has been placed on psychometric equivalence across language versions necessary for coordinated international studies, such as multi-national clinical trials. However, this picture is rapidly changing with recent projects underway to develop and refine new or existing HRQL measures. Overall, the lack of prominent differences found between countries in ranking of health states in major HRQL measures supports the feasibility of developing internationally applicable HRQL instruments. Recommendations are made for additional data needed to better ascertain the degree of measurement equivalence developed in the various versions of each instrument reviewed.

A validation study of the domains of the core EORTC quality of life questionnaire

A cohort study was conducted to investigate the construct validity of the domains of the EORTC QLQ-C30 (European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire). Ninety-six patients undergoing chemotherapy at the Kingston Regional Cancer Centre, Kingston, Canada were given the EORTC QLQ-C30 and two out of four comparison scales; the Sickness Impact Profile, the McGill Pain Questionnaire, the General Health Questionnaire and the Cancer Rehabilitation Evaluation System, to complete during their clinic visits. Using the multitrait-multimethod matrix to examine relationships, the Spearman ranked correlation coefficients of similar and dissimilar domains between the EORTC QLQ-C30 and the comparison scales were compared. The EORTC QLQ-C30 domains of pain and physical and role functioning performed well in that they converged and diverged appropriately with the other instruments. The domain of psychological functioning had strong associations with domains thought to be dissimilar (social interaction and fatigue). Social interaction and financial impact diverged across dissimilar domains. This lack of specificity may relate to question wording. The symptom domain had strong associations with other domains across the comparison scales. This study shows that the domains of the EORTC QLQ-C30 have substantial construct validity in the multidimensional assessment of the quality of life of cancer patients and identifies where further work is required.

The European Organization for Research and Treatment of Cancer. Approach to quality of life assessment: guidelines for developing questionnaire modules. EORTC Study Group on Quality of Life

The EORTC Study Group on Quality of Life (the Study Group) has adopted a modular approach to quality of life (QOL) assessment in cancer clinical trials. A 'core' instrument-the QLQ-C30-has been designed to cover a range of QOL issues relevant to a broad spectrum of cancer patients. It is intended that this QLQ-C30 be supplemented by more specific subscales ('modules') to assess aspects of QOL of particular importance to specific subgroups of patients. Since individual members of the Study Group were to be involved in module development, guidelines were required to standardize the module development process in order to ensure uniformly high quality across modules. These guidelines are presented in this paper. The term 'module' is defined, the composition of modules is outlined, and the criteria used to develop modules are specified. The module development process, consisting of four phases (generation of relevant QOL issues, operationalization of the QOL issues into a set of items, pretesting the module questionnaire, and large-scale field-testing) is described in detail. Further, issues related to cross-cultural instrument development, and the need for monitoring the module development process from within the Study Group are discussed. Finally, experiences with developing two site-specific modules (i.e., for head and neck, and breast cancer), are presented and the extent to which the guidelines meet practical requirements is discussed. The guidelines appear to provide a practical tool for module construction, that can facilitate the development of a comprehensive system for assessing the QOL of cancer patients internationally.

The impact of generalized malignant melanoma on quality of life evaluated by the EORTC questionnaire technique

Eighty-nine patients with generalized malignant melanoma, 63% men and median age 53 years, were included in a longitudinal quality of life (QOL) study before the start of chemotherapy. QOL was assessed by the EORTC core questionnaire technique (QLQ-C36), a study-specific melanoma (MM) module and the Hospital Anxiety and Depression (HAD) scale. The questionnaires displayed good psychometric qualities and were able to document the florid symptomatology of disseminated melanoma. They were well accepted by the patients. Before treatment the patients reported a relatively low symptom burden, good physical and social functioning, moderate psychological distress and a high overall QOL rating during the past week. Fatigue and pain were the most frequent symptoms reported. The QOL measurement differentiated between subgroups of patients differing in performance status and the tumour burden. We conclude that the EORTC questionnaire technique is feasible and clinically relevant in generalized malignant melanoma patients.

[The characteristics of cytomegalovirus esophagitis in AIDS patients]

The main objective of this study was to investigate whether patients with chronic myeloid leukemia (CML) in treatment with long-term therapy imatinib have a different health-related quality-of-life (HRQOL) profile compared with the general population. In total, 448 CML patients were enrolled, and the SF-36 Health Survey was used to compare generic HRQOL profiles. Symptoms were also assessed. HRQOL comparisons were adjusted for key possible confounders. The median age of patients was 57 years and the median time of imatinib treatment was 5 years (range 3-9 years). The largest HRQOL differences were found in younger patients. In particular, patients aged between 18 and 39 years had marked impairments in role limitations because of physical and emotional problems, respectively: −22.6 (P < .001), −22.3 (P < .001). Patients with CML age 60 or older had a HRQOL profile very similar to that reported by the general population. Women had a worse profile than men when each were compared with their peers in the general population. Fatigue was the most frequently reported symptom. The HRQOL of CML patients is comparable with that of population norms in many areas, however, younger and female patients seem to report the major limitations.

Magnifying endoscopic observation of the gastric mucosa, particularly in patients with atrophic gastritis

The gastric mucosal surface was observed using the magnifying fibergastroscope (FGS-ML), and the fine gastric mucosal patterns, which were even smaller than one unit of gastric area, were examined at a magnification of about 30. For simplicification, we classified these patterns by magnifying endoscopy in the following ways; FP, FIP, FSP, SP and MP, modifying Yoshii's classification under the dissecting microscope. The FIP, which was found to have round and long elliptical gastric pits, is a new addition to our endoscopic classification. The relationship between the FIP and the intermediate zone was evaluated by superficial and histological studies of surgical and biopsy specimens. The width of the band of FIP seems to be related to the severity of atrophic gastritis. Also, the transformation of FP to FIP was assessed by comparing specimens taken from the resected and residual parts of the stomach, respectively. Moreover, it appears that severe gastritis occurs in the gastric mucosa which shows a FIP. Therefore, we consider that the FIP indicates the position of the atrophic border.

Efectos del tipo de tratamiento y grupo de riesgo en la calidad de vida y la información en pacientes con cáncer de próstataEfectos del tipo de tratamiento y grupo de riesgo en la calidad de vida y la información en pacientes con cáncer de próstata

Objetivo: Comprobar las diferencias en la calidad de vida y la información de los pacientes con cáncer de próstata según el tratamiento y grupo de riesgo, y valorar su asociación con las variables sociodemográficas y clínicas. Metodo: entre 2015-2016, 176 hombres con cáncer de próstata seleccionados aleatoriamente, que habían recibido tratamientos locales, hormonales o combinados fueron evaluados mediante entrevista y los cuestionarios EORTC QLQ-C30, EORTC QLQ-PR25 y EORTC QLQ-INFO25. Resultados: La calidad de vida estaba más deteriorada en las escalas física, de rol, social y sexual en el grupo de riesgo avanzado y los tratados con hormonoterapia. La prostatectomía era la que producía más problemas urinarios, y los tratamientos combinados mayor sintomatología hormonal. Los tratados con radioterapia consideraban la información más útil y se sentían más informados sobre la enfermedad, pruebas médicas y tratamientos que los que recibían tratamiento hormonal y estaban más satisfechos que los intervenidos con prostatectomía. Los mayores o con estudios básicos recibieron menos información y la consideraron menos útil. Conclusiones: La calidad de vida es satisfactoria y la sintomatología baja. Los hombres en riesgo avanzado y/o los que reciben hormonoterapia presentan mayor déficit en la calidad de vida. La información es deficitaria, sobre todo en los hombres con problemas urinarios y con peor calidad de vida. Hay poca o ninguna información en las áreas “otros servicios”, “lugares de cuidado” y “pautas de autocuidado”. Es necesario evaluar y tratar a los hombres más vulnerables. Además de formar en información al personal sanitario.