Development of an EORTC questionnaire module to be used in quality of life assessment for patients with oesophageal cancer. The EORTC Quality of Life Study Group

A prospective comparison of quality of life measures for patients with esophageal cancer

Among the most widely used instruments to assess quality of life (QOL) in patients with cancer are the European Organization for Research and Treatment of Cancer core questionnaire (EORTC QLQ-C30) and the Functional Assessment of Chronic Illness Therapy, cancer instrument (FACT-G). This study compared these approaches in patients who had undergone esophagectomy for cancer. The EORTC core questionnaire and esophageal module and the FACT-G and esophageal scale were completed by 57 patients. Missing data, relationships between QOL scales and analyses of patients' preferences were examined. There were 14/2736 (0.5%) missing items from EORTC questionnaires and 45/2565 (1.8%) from FACT instruments (p < 0.01). Relationships between corresponding generic EORTC and FACT scales were average to good (r > 0.57) except for the social function scale (r = 0.01). EORTC symptom scores were moderately correlated with the FACT general scale, but poorly related to the FACT esophageal scale (r < 0.28). EORTC swallowing scores were moderately correlated with all FACT scales. The FACT-E and EORTC QLQ-C30 measure assess similar generic aspects of QOL (except social function). EORTC esophageal symptom scores relate poorly to FACT esophageal scales, except for swallowing. Choice of QOL measure after esophagectomy for cancer depends upon outcomes of interest. Future studies will determine which instruments are appropriate in each context.

Health-related quality of life during neoadjuvant treatment and surgery for localized esophageal carcinoma

BACKGROUND

Esophagectomy has a negative influence on health-related quality of life (HRQL) during the first postoperative year, but it is not known how chemotherapy or chemoradiotherapy treatment before surgery affects HRQL. The current study examined HRQL during preoperative chemotherapy/chemoradiotherapy treatment and compared postoperative recovery of HRQL in patients undergoing combined treatment with patients undergoing surgery alone.

METHODS

One hundred three patients completed standardized HRQL measures before and during neoadjuvant treatment and before and after surgery. Mean HRQL scores were calculated and preoperative scores were used to model postoperative ratings using linear regression.

RESULTS

Deterioration in most aspects of HRQL occurred during preoperative chemotherapy. Patients proceeding to concomitant radiotherapy further deteriorated with specific problems with reflux symptoms and role function (difference between means >15, P < 0.01). After neoadjuvant treatment, but before surgery, HRQL returned to baseline levels. Six weeks after surgery, patients reported marked reductions in physical, role, and social function (difference between means > 30, P < 0.01) and increase in fatigue, nausea and emesis, pain, dyspnea, appetite loss, and coughing (difference between means > 15, P < 0.01). Recovery of HRQL was not hampered by preoperative treatment, and fewer problems with postoperative nausea, emesis, and dysphagia were reported by patients who had undergone neoadjuvant treatment compared with patients who had undergone surgery alone.

CONCLUSIONS

Preoperative chemotherapy or chemoradiotherapy had a negative impact on HRQL that was restored in patients proceeding to surgery. Recovery of HRQL after esophagectomy was not impaired by neoadjuvant treatment. These results supported the use of neoadjuvant treatment before surgery.

Development of a questionnaire module to supplement the EORTC QLQ-C30 to assess quality of life in patients with hepatocellular carcinoma, the EORTC QLQ-HCC18

Measurement of quality of life (QoL) in hepatocellular carcinoma (HCC) requires assessment of factors related to chronic liver disease, as well as issues related to the primary tumour and its treatment. This study describes the development of a questionnaire module in patients from Europe, as well as Taiwan and Hong Kong. The questionnaire was developed according to the European Organisation for Research and Treatment of Cancer (EORTC) QoL Group guidelines. Twenty nine QoL issues were identified from a literature search. Semi-structured interviews with patients (n=32) and health-care professionals (n=10) reduced the issues to 22 items forming a provisional questionnaire. This was tested in 158 patients from three countries. Descriptive statistics and clinical judgement reduced the module to 18 items conceptualised as containing six scales and two single item. This study recommends the EORTC QLQ-HCC18 to accompany the QLQ-C30 to measure QoL in clinical trials in HCC.

Esophageal stents with antireflux valve for tumors of the distal esophagus and gastric cardia: a randomized trial

BACKGROUND

Self-expandable metal stents deployed across the gastroesophageal junction predispose to gastroesophageal reflux. The efficacy of a stent with an antireflux mechanism in preventing gastroesophageal reflux was assessed.

METHODS

Thirty patients with carcinoma of the distal esophagus or of the gastric cardia were randomized to receive either a stent with a windsock-type antireflux valve (FerX-Ella) (n = 15) or a standard open stent (n = 15) of the same design minus the valve. Gastroesophageal reflux was assessed by using standardized questionnaires and by 24-hour pH monitoring 14 days after treatment.

RESULTS

Technical problems occurred during stent placement in 3 patients: migration (n = 2) and a problem with the introducing system (n = 1). Dysphagia improved from a median score of 3 (liquids only) to 1 (eat some solid food) in the antireflux group and from 3 to 0 (solid foods) in the open stent group ( p > 0.20). Reflux symptoms were reported by 3/12 patients (25%) with an antireflux stent and by 2/14 (14%) with an open stent. In 11 patients, 24-hour pH monitoring was obtained, and increased esophageal acid exposure (normal: <4%) was present with both types of stent: median 24-hour reflux time (9 patients) with the antireflux stent was 23% vs. 10% in (2 patients) with the open stent ( p = NS). Major complications occurred in 3 patients (20%) in each group and included bleeding (n = 3), severe pain (n = 2), and aspiration pneumonia (n = 1). The main cause of recurrent dysphagia was stent migration, which occurred in 7 of the 30 patients (23%).

CONCLUSIONS

The FerX-Ella antireflux stent provided relief of dysphagia caused by malignancy of the distal esophagus and gastric cardia. However, the antireflux valve failed to prevent gastroesophageal reflux.

Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia from oesophageal cancer: multicentre randomised trial

BACKGROUND

Both single-dose brachytherapy and self-expanding metal stent placement are commonly used for palliation of oesophageal obstruction due to inoperable cancer, but their relative merits are unknown. We undertook a randomised trial to compare the outcomes of brachytherapy and stent placement in patients with oesophageal cancer.

METHODS

Nine hospitals in the Netherlands participated in our study. Between December, 1999, and June, 2002, 209 patients with dysphagia from inoperable carcinoma of the oesophagus or oesophagogastric junction were randomly assigned to stent placement (n=108) or single-dose (12 Gy) brachytherapy (n=101), and were followed up after treatment. Primary outcome was relief of dysphagia during follow-up, and secondary outcomes were complications, treatment for persistent or recurrent dysphagia, health-related quality of life, and costs. Analysis was by intention to treat.

FINDINGS

Nine patients (six [brachytherapy] vs three [stent placement]) did not receive their allocated treatments. None was lost to follow-up. Dysphagia improved more rapidly after stent placement than after brachytherapy, but long-term relief of dysphagia was better after brachytherapy. Stent placement had more complications than brachytherapy (36 [33%] of 108 vs 21 [21%] of 101; p=0.02), which was mainly due to an increased incidence of late haemorrhage (14 [13%] of 108 vs five [5%] of 101; p=0.05). Groups did not differ for persistent or recurrent dysphagia (p=0.81), or for median survival (p=0.23). Quality-of-life scores were in favour of brachytherapy compared with stent placement. Total medical costs were also much the same for stent placement (8215) and brachytherapy (8135).

INTERPRETATION

Despite slow improvement, single-dose brachytherapy gave better long-term relief of dysphagia than metal stent placement. Since brachytherapy was also associated with fewer complications than stent placement, we recommend it as the primary treatment for palliation of dysphagia from oesophageal cancer.

Quality of life after palliative treatment for oesophageal carcinoma -- a prospective comparison between stent placement and single dose brachytherapy

Metal stent placement and single dose brachytherapy are commonly used treatment modalities for the palliation of inoperable oesophageal carcinoma. We investigated generic and disease-specific health-related quality of life (HRQoL) after these palliative treatments. Patients with dysphagia from inoperable oesophageal carcinoma were randomised to placement of a covered Ultraflex stent (n = 108) or single dose (12 Gy) brachytherapy (n = 101). We obtained longitudinal data on disease-specific (dysphagia score, European Organisation for Research and Treatment of Cancer (EORTC) OES-23, visual analogue pain scale) and generic (EORTC Quality of Life-Core 30 Questionnaire (QLQ-C30), Euroqol (EQ)-5D) HRQoL at monthly home visits by a specially-trained research nurse. We compared HRQoL between the two treatments and analysed changes in HRQoL during follow-up. Dysphagia improved more rapidly after stent placement than after brachytherapy, but long-term relief of dysphagia was better after brachytherapy. For generic HRQoL, there was an overall significant difference in favour of brachytherapy on four out of five functional scales of the EORTC QLQ-C30 (role, emotional, cognitive and social) (P < 0.05). Generic HRQoL deteriorated over time on all functional scales of the EORTC QLQ C-30 and EQ-5D, in particular physical and role functioning (on average -23 and -24 on a 100 points scale during 0.5 years of follow-up). This decline was more pronounced in the stent group. Major improvements were seen on the dysphagia and eating scales of the EORTC OES-23, in contrast to other scales of this disease-specific measure, which remained almost stable during follow-up. Reported levels of chest or abdominal pain remained stable during follow-up in both treatment groups, general pain levels increased to a minor extent. The effects of single dose brachytherapy on HRQoL compared favourably to those of stent placement for the palliation of oesophageal cancer. Future studies on palliative care for oesophageal cancer should at least include generic HRQoL scales, since these were more responsive in measuring patients' functioning and well-being during follow-up than disease-specific HRQoL scales.

Development of a questionnaire to evaluate the information needs of cancer patients: the EORTC questionnaire

Information disclosure is one of the key areas of support that patients may receive. The European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Group has a group working on the development of a questionnaire that evaluates information received by cancer patients at different stages of their disease--EORTC QLQ-INFO30. This instrument is being developed by professionals from most European regions. The questionnaire aims to evaluate the information received by cancer patients on different areas of the disease, diagnosis, treatment and care. Besides, the instrument also assesses qualitative aspects of the information they have received. The present paper presents the first two phases of the module development process that include literature review, interviews with patients and professionals, and formulation of the items. All these steps have been carried out in different countries and have been approved by the EORTC QLG.

Assessment of health state utilities and quality of life in patients with malignant esophageal Dysphagia

OBJECTIVES

Palliation of terminal conditions such as malignant dysphagia must take into account individual preferences for aggressive or nonaggressive care, with a focus on quality of life. Despite this, there are very few data on patients' preferences for palliative therapy. This study is designed to quantitatively determine individual preferences for palliation of malignant dysphagia using health state utilities (HSU).

METHODS

HSU were measured using three methods: time trade-off (TTO), visual analog scale (VAS), and the EQ-5D. Patients with esophageal cancer were asked to rate their own state of health and of three standardized scenarios of local, regional, and metastatic disease.

RESULTS

Fifty patients with esophageal cancer were enrolled. Using the TTO method, the utilities of their own health state were 0.80 (95% CI 0.59-0.99) for localized, 0.54 (0.37-0.70) for regional, and 0.52 (0.32-0.71) for metastatic cancer showing no significant difference in mean utility scores for the three staging groups. VAS and EQ5D gave statistically similar values to TTO. Patients consistently rated their own utility better than the utility of standardized scenarios with similar stage and prognosis. Independent of their staging, patients with high dysphagia scores rated their utility worse than patients with low dysphagia scores.

CONCLUSIONS

These results confirm the perceived poor state of health of patients with esophageal cancer and are substantially lower than previous estimates in operated patients. Cost-effectiveness models must take into account significant differences between patients' assessment of their own state of health, and that of a "societal" perspective of others with a similar disease. All three methods provided similar estimates. Given the ease of use of VAS and EQ-5D, these methods may be preferable to TTO.

Quality of life after esophagectomy

Esophagectomy is associated with high complication rates and consequent mortality. The 5-year survival for esophageal cancer is also discouraging with rates of 6 to 33% after surgery. Nonsurgical series of selected patients have shown similar survival. Therefore, quality of life may be a better assessment of patient outcomes than survival. At present few reports have address quality of life in patients after esophagectomy, particularly in those patients who succumb quickly to recurrent cancer. This article investigates the determinants of quality of life after esophagectomy and reviews the use of quality of life measures in comparative trials. Quality of life measures may become valuable tools in the selection of patients for esophagectomy.

The EORTC Ophthalmic Oncology Quality of Life Questionnaire Module (EORTC QLQ-OPT30). Development and Pre-Testing (Phase I-III)

AIMS

The research objective was to develop a questionnaire module to be used, in addition to the European Organisation into Research and Treatment of Cancer (EORTC) QLQ-C30, for measurement of quality of life (QL) among patients with uveal melanoma treated with methods such as transpupillary thermotherapy, plaque radiotherapy, proton beam radiotherapy, local resection, and enucleation. The present paper describes the development through Phases I-III.

METHODS

Relevant QL issues were generated from literature search and from interviews with ophthalmologists, nurses, and patients with uveal melanoma representing three major treatment options: enucleation, plaque brachytherapy, and proton beam therapy.

RESULTS

The provisional module was pretested in 61 patients from Finland, Sweden, and UK. The EORTC QLQ-OPT30 module consists of 26 items for all patients, and four additional items for patients receiving treatments other than enucleation. It measures ocular irritation, vision impairment, headache, worry about recurrent disease, problems with driving, problems with appearance functional problems due to vision impairment, and problems reading.

CONCLUSIONS

Several treatment modalities are available for uveal melanoma. There is limited knowledge of the impact of these treatments on QL in the long and short term. We hope that the OPT30 module together with the EORTC QLQ-C30 core questionnaire can be a useful tool in research.

Feasibility of quality of life assessment in patients with upper gastrointestinal tract cancer

Quality of life (QOL) is an important outcome after treatment for upper gastrointestinal tract cancer but few studies report good accrual and subsequent attrition is usually high. This study investigated the feasibility of a nurse-led service to obtain longitudinal QOL assessments and explored how clinical and sociodemographic factors influence patients' need for help to complete questionnaires. Fully informed patients were invited into the study. Baseline hospital assessments were scheduled by telephone and thereafter by post unless patients' health indicated the need for a home visit. In all, 128 out of 140 (91%) baseline QOL assessments were performed. Follow-up questionnaire completion was good, with 114 patients (89%) completing all but one of the expected assessments. At baseline, 41 (32%) patients required a lot of help to complete questionnaires. Patients requiring help were more likely to be undergoing palliative treatment than treatment aimed at cure (68 vs 33%; odds ratio 3.48, P<0.01). Patients' with advanced stage cancer of the upper gastrointestinal tract receiving palliative treatment require dedicated staff to ensure good compliance with longitudinal QOL data collection. It is essential to budget for this in clinical trails.

Clinical and psychometric validation of an EORTC questionnaire module, the EORTC QLQ-OES18, to assess quality of life in patients with oesophageal cancer

Quality of life (QOL) assessment requires clinically relevant questionnaires that yield accurate data. This study defined measurement properties and the clinical validity of the European Organisation for Research and Treatment of Cancer (EORTC) questionnaire module to assess QOL in oesophageal cancer. The oesophageal module the QLQ-OES24 and core questionnaire, the Quality of Life-Core 30 questionnaire (QLQ-C30) was administered patients undergoing treatment with curative (n=267) or palliative intent (n=224) and second assessments performed 3 months or 3 weeks later respectively. Psychometric tests examined scales and measurement properties of the module. Questionnaires were well accepted, compliance rates were high and less than 2% of items had missing data. Multi-trait scaling analyses and face validity refined the module to four scales and six single items (QLQ-OES18). Selective scales distinguished between clinically distinct groups of patients and demonstrated treatment-induced changes over time. The EORTC QLQ-OES18 demonstrates good psychometric and clinical validity. It is recommended for use with the core questionnaire, the QLQ-C30, to assess QOL in patients with oesophageal cancer.

Development of an EORTC disease-specific quality of life questionnaire for use in patients with liver metastases from colorectal cancer

Quality of life (QL) is an important outcome measure within clinical trials. This paper describes the development of a QL module for patients with liver metastases from colorectal cancer (CRC) to supplement the European Organization for Research and Treatment of Cancer (EORTC) core QL questionnaire, the EORTC QLQ-C30. Phases 1-3 of the EORTC QL Group guidelines for developing QL modules were followed. The literature search generated 71 QL issues. Semi-structured interviews with eight healthcare professionals and 47 patients from the United Kingdom, France, Germany and Austria reduced the list to 23 issues. Questionnaire items were formulated to be compatible with the EORTC QLQ-C30. The provisional module was further tested in 102 patients resulting in a 21-item module, the QLQ-LMC21 (Liver Metastases Colorectal). A combination of the core questionnaire and the QLQ-LMC21 will provide essential QL information regarding the use of treatments in both the curative and palliative settings.

Quality of life as an outcome measure in surgical oncology

Background

There is a growing interest in assessing the impact of a disease and the effect of a treatment on a patient's life, expressed as health-related quality of life (HRQoL). HRQoL assessment can provide essential outcome information for cancer surgery.

Methods

The core of this review is derived from a literature search of the Medline database.

Results

Three types of HRQoL instrument can be distinguished: generic, disease specific and symptom specific. There are criteria against which HRQoL instruments may be evaluated. The instrument chosen must be reliable, valid and sensitive to change.

Conclusion

HRQoL measurement may be useful in identifying the optimal surgical procedure. It may also be of help in deciding whether surgery in patients with limited life expectancy should still be considered. No HRQoL instrument fits all the recommended conditions or is suitable in all clinical situations. Using the appropriate instrument is essential to arrive at valid and clinically meaningful outcome measures.

Quality of life after esophagectomy for cancer

PURPOSE/OBJECTIVES

To examine symptoms and quality of life (QOL) of esophagectomy patients after curative surgery.

DESIGN

Longitudinal, descriptive pilot study.

SETTING

Comprehensive cancer center in the northeastern United States.

SAMPLE

23 patients were surveyed: 20 men and 3 women. The mean age was 62.3 years.

METHODS

The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30 (version 2.0) and the esophageal-specific module were used. Data collection included three or four time points: before neoadjuvant treatment (if administered), before surgery, and three and six months after surgery.

MAIN RESEARCH VARIABLES

The effects on symptoms and QOL of curative esophagectomy performed by a thoracic surgical oncologist.

FINDINGS

Global QOL declined slightly over time; this change was not statistically significant. A significant inverse relationship was found between symptom intensity and global QOL. The intensity of hoarseness, reflux, and diarrhea increased significantly pre- to postsurgery. The average symptom intensity for the esophageal-specific subset of 24 symptoms increased significantly over time; the greatest intensity was found before surgery.

CONCLUSIONS

Over the six-month observation period, the study found little average change in global QOL or functional status. However, symptoms increased significantly during this time period. Increased symptoms were associated with decreased QOL.

IMPLICATIONS FOR NURSING

Symptom management should focus on symptoms that interfere with patients' QOL. Further research should target the evaluation of specific interventions for symptoms.

Randomized clinical trial comparing self-expanding metallic stents with plastic endoprostheses in the palliation of oesophageal cancer

BACKGROUND

There is little evidence of the clinical and cost effectiveness of self-expanding metallic stents in the palliation of oesophageal cancer. The aims of this randomized trial were to evaluate the immediate and medium-term clinical outcomes following palliative intubation, examine patient quality of life, and evaluate costs and benefits from the perspective of the health service.

METHODS

Fifty patients with inoperable oesophageal cancer were randomly allocated a metallic stent (n = 25) or plastic endoprosthesis (n = 25). Patients were followed up monthly until death.

RESULTS

There was no significant difference in procedure-related complications or mortality rate between the two groups. There was a trend towards significance in favour of metallic stents with respect to quality of life and survival (median survival 62 versus 107 days for plastic prosthesis and metallic stent respectively). The cost of the initial placement of metallic stents was significantly higher than that of plastic endoprostheses ( pound 983 versus pound 296). After 4 weeks, cost differences were no longer significant.

CONCLUSION

Metallic stents may contribute to improved survival and quality of life in patients with oesophageal cancer. Although initially more expensive, this cost difference does not last beyond 4 weeks. A larger trial involving approximately 300 patients would be required to detect a quality of life benefit of the magnitude observed in this trial.

The impact of hemoglobin levels on fatigue and quality of life in cancer patients

BACKGROUND

Although fatigue is a commonly reported symptom in cancer patients its etiology is still poorly understood. The objective of the present study was to investigate the relationship between hemoglobin (Hb) levels and the subjective experience of fatigue and quality of life in cancer patients with mild or no anemia undergoing chemotherapy.

PATIENTS AND METHODS

Sixty-eight cancer patients (25 colorectal, 26 lung and 17 ovarian cancer) presently undergoing chemotherapy participated in the study. Fatigue was measured with the Multidimesional Fatigue Inventory (MFI-20), quality of life with The European Organization for Research and Treatment of Cancer QLQ-C30. In order to provide normative data for fatigue levels, the MFI-20 was also completed by a sex- and age-matched sample of 120 healthy controls.

RESULTS

Compared with healthy subjects, cancer patients experienced significantly higher levels of subjective fatigue. Correlations between Hb values and subscales of the MFI-20 were moderate with a tendency to increase during chemotherapy. Hb values alone, however, do not fully account for the observed fatigue. Other symptoms, especially pain, dyspnea and sleep disturbances, also showed an association with perceived fatigue.

CONCLUSIONS

Despite significant correlations, these results indicate that Hb values only partially explain subjectively experienced fatigue and quality of life in cancer patients. It is suggested therefore that the treatment of fatigue must be multidimensional and involve all areas which contribute to the syndrome.

Impact of surgical treatment on quality of life of patients with gastrointestinal tumors

Quality-of-life assessment is becoming an important concern even of surgeons. The new trend applies specifically to surgical oncology, where particular attention is now being paid to the outcome of surgical treatment. Gastrointestinal cancers are heterogeneous in their presentation and in treatment, but they share common aspects related to the surgical approach. A functional outcome is fundamental in all the operations performed for gastrointestinal cancers and many improvements have been made thanks to the increased rate of conservative approaches and the amelioration of the technology applied to surgery. The measurement of the surgical outcome and the methods to be applied is still undergoing extensive evaluation but the flourishing interest in the issues concerning quality of life all over the surgical community will rapidly lead to a better definition of goals and results.

Vinorelbine and cisplatin in metastatic squamous cell carcinoma of the oesophagus: response, toxicity, quality of life and survival

BACKGROUND

Vinorelbine and cisplatin are active against squamous cell oesophageal carcinoma. The purpose of this phase II study was to evaluate the efficacy and safety of vinorelbine plus cisplatin in previously untreated patients with metastatic squamous cell oesophageal carcinoma and to estimate the progression-free survival, overall survival and quality of life (QoL) of the patient population.

PATIENTS AND METHODS

Seventy-one eligible patients were entered into a study of vinorelbine 25 mg/m2 on days 1 and 8 plus cisplatin 80 mg/m2 on day 1, every 3 weeks. Degree of dysphagia relief was monitored and QoL was measured using the EORTC QLQ-C30.

RESULTS

All eligible patients were assessed for response and 24 achieved a confirmed partial response (33.8%; 95% confidence interval 23-46); the median duration of response was 6.8 months, progression-free survival was 3.6 months and median survival of the whole group was 6.8 months. Toxicity was mainly related to neutropenia (grade 3/4 in 41% of patients). At cycle 2, 43% of the patients reported at least a moderate improvement in global health status/QoL and 25% experienced a large improvement.

CONCLUSIONS

Vinorelbine plus cisplatin represents a well-tolerated active palliative regimen for patients with advanced squamous cell carcinoma of the oesophagus. This combination may offer a better therapeutic index than cisplatin-5-fluorouracil.

Quality of life research within the EORTC-the EORTC QLQ-C30. European Organisation for Research and Treatment of Cancer

In forming its Quality of Life Group, the EORTC created one of the earliest and largest of such groups in Europe. The EORTC QLQ-C30 which this group developed has become the most widely used questionnaire in Europe for cancer patients, and is extensively used around the world. The Quality of Life Group continues to build upon this success, both by refining the QLQ-C30, whilst developing a range of additional modules, and by initiating research projects that explore aspects of quality of life assessment, evaluation and interpretation. We review the progress to date and indicate directions of further research and development.

A randomized trial of thermal ablative therapy versus expandable metal stents in the palliative treatment of patients with esophageal carcinoma

BACKGROUND

Expandable metal stent insertion and thermal tumor ablation (TTA) both improve dysphagia in patients with advanced esophageal cancer, but no direct comparison study of their efficacy on health-related quality of life has been published. The aim of this study was to compare survival, relief of dysphagia, quality of life, and cost in patients treated by thermal ablation or stent insertion.

METHODS

Sixty-five patients with histologically proven, inoperable esophageal and esophagogastric cancer were initially assessed by endoscopy, barium contrast radiography, and CT of the thorax and abdomen. Dysphagia and quality of life were serially assessed at monthly intervals. Patients were randomized to either repeated TTA or insertion of an expandable metal stent.

RESULTS

Median survival was significantly longer for patients who underwent TTA; 125 days (17-546) versus 68 days (8-602) for those in whom a stent was inserted (p < 0.05), although relief of dysphagia was disappointing in both groups. Several patients in both groups had serious treatment-related complications and required further therapy. Median length of hospital stay and cost were greater for patients treated by TTA. Health-related quality of life was globally impaired in both groups at randomization and deteriorated significantly in the stent group. Pain was reported more commonly by patients with stents.

CONCLUSIONS

The palliation of patients with advanced esophageal and esophagogastric cancer remains unsatisfactory. Health-related quality of life deteriorated in the stent group but not in the TTA group. Patients treated by TTA live longer than patients treated by stent insertion, but the cost of TTA is higher.

Measurement of outcome

The outcomes of treatment of oesophageal cancer include traditional biological and physical measures, such as mortality and morbidity data, disease free and overall survival, clinical and pathological response rates and symptom control. Such factors are essential and should be recorded prospectively for clinical audit. Using this type of information alone to evaluate effectiveness of treatment is inadequate, however, because the diagnosis and treatment of oesophageal cancer has a major impact on functional well-being (including psycho-social function), general health perceptions and overall quality of life (QL)/satisfaction with health and health care. These aspects of patients' well-being need to be considered, in addition to standard outcomes in the evaluation of treatment of oesophageal cancer. Recent needs to judge the economic efficiency of health care by comparing health outcomes with costs may also be part of treatment appraisal. This article reviews surgical, oncological, patient-based and economic outcomes in oesophageal cancer.

The prognostic value of quality of life scores during treatment for oesophageal cancer

BACKGROUND

Quality of life (QL) data are useful to evaluate the effectiveness of treatment. Accumulating evidence suggests that QL data may predict survival.

AIMS

In this study we investigated if baseline QL scores and changes in QL scores before and after intervention are prognostic for patients with oesophageal cancer.

PATIENTS

Between 1993 and 1995, 92 consecutive new patients with oesophageal cancer were studied; 89 were followed until death or the end of the study period (survival of seven patients was censored in May 1999).

METHODS

All patients completed the European Organisation for Research and Treatment of Cancer (EORTC) core questionnaire (EORTC QLQ-C30) and the dysphagia scale of the oesophageal module (EORTC QLQ-OES24) before treatment and at regular intervals throughout the study. Cox's proportional hazards models assessed the impact of baseline QL variables and changes in QL scores on survival.

RESULTS

Cox's proportional hazards models, adjusting for associations between QL scores, age, and TNM stage, found that physical function at baseline was significantly associated with survival (p=0.002). An increase in physical function score of 10 points corresponded to a 12% reduction in the likelihood of death at any given time (95% confidence intervals 4--18%). Further exploratory multivariable analyses suggested that improvement in emotional function six months after treatment was significantly related to longer survival (p<0.0001).

CONCLUSIONS

These data provide evidence to support a relationship between patient rated scores of QL and survival. Further understanding of the associations between QL and clinical variables is needed.

The EORTC quality of life questionnaire-head and neck 35 in Italian laryngectomized patients. European organization for research and treatment of cancer

The aim of this study was to test the validity and reliability of the European organization for research and treatment of cancer (EORTC) quality of life questionnaire (QLQ)-head and neck (H&N) 35 in Italian laryngeal cancer patients. The original questionnaire was developed by the EORTC quality of life (QoL) study group and tested in H&N cancer patients from Norway, Sweden, and the Netherlands. The Italian translation of the questionnaire used in this study was made by a team of the CRO, National Cancer Institute, using a double-back translation method between independent translators. The translated EORTC QLQ-H&N35 was given to 99 patients with H&N cancer who had undergone total laryngectomy 1-26 years before and had been then treated with radiotherapy and, in some cases, chemotherapy. The questionnaire was re-administrated to 33 patients after 1 month to test its stability over time. It was structurally made up of seven scales (pain, swallowing, sense, speech, social eating, social contact, and sexuality) and 11 single items that considered the most important clinical aspects characterizing the QoL in H&N cancer patients. The statistical analysis of the indexes of validity and reliability confirmed the results obtained with other linguistic versions of the questionnaire. Our Italian version of the EORTC QLQ-H&N35 proved to be a statistically valid instrument to assess QoL in laryngectomized patients.

Quality of life in patients with oesophageal cancer

There is a growing interest in assessing quality of life in patients with oesophageal cancer because it provides detailed information of the patients' perception of the benefits or harms of treatment. Yet few studies have prospectively measured quality of life using validated appropriate instruments. There are now several questionnaires for patients with cancer, although these are not sufficiently sensitive to small but clinically important changes in quality of life. It is therefore recommended that a disease-specific module is used in conjunction with generic measures. The European Organisation into Research and Treatment of Cancer (EORTC) QLQ-OES24 is currently completing an international validation study. It is used with the EORTC QLQ-C30 core instrument and is designed for patients undergoing potentially curative treatment or palliation of malignant dysphagia. Studies that have assessed quality of life after oesophagectomy have generally found that survivors do regain their former health. Little is known about the effect of neoadjuvant chemoradiation on patients' quality of life. Following endoscopic palliation of dysphagia, quality of life can be maintained and improvement of swallowing is seen. A validated appropriate assessment of quality of life should be included in future palliative trials and in studies of new treatments which may marginally influence survival but cause significant side effects.

Quality of life and home enteral tube feeding: a French prospective study in patients with head and neck or oesophageal cancer

A prospective study was conducted to evaluate the impact of home enteral tube feeding on quality of life in 39 consecutive patients treated for head and neck or oesophageal cancer at the Centre François Baclesse in Caen, France. Patients were taken as their own controls. Quality of life was evaluated using the EORTC QLQ-C30 core questionnaire, and the EORTC H&N35 and OES24 specific questionnaires. The feeding technique tolerance was evaluated using a questionnaire specifically developed for this study. Two evaluations were made, the first a week after hospital discharge (n = 39) and the second 3 weeks later (n = 30). Overall, the global health status/quality of life scale score slightly improved; among symptoms, scale scores that significantly improved (P < 0.05) concerned constipation, coughing, social functioning and body image/sexuality. The physical feeding technique tolerance was acceptable while the technique was psychologically less tolerated with two-thirds of the patients longing to have the tube removed. One third of the patients was also uncomfortable about their body image. Home enteral tube feeding was responsible for not visiting family or close relations in 15% of patients, and not going out in public in 23%. We conclude that home enteral tube feeding is a physically well accepted technique although a substantial proportion of patients may experience psychosocial distress.

Development of an EORTC questionnaire module to be used in health-related quality-of-life assessment for patients with multiple myeloma. European Organization for Research and Treatment of Cancer Study Group on Quality of Life

A multiple myeloma-specific quality-of-life questionnaire module has been designed in collaboration with the EORTC Quality-of-Life Study Group to be used in clinical trials with the EORTC QLQ-C30, a general cancer questionnaire. Strict methodology was employed to ensure thorough and appropriate development of the module. An extensive literature review was performed to identify health-related quality-of-life issues relevant to patients with multiple myeloma. Semi-structured interviews were then carried out in several European countries with health-care providers experienced in the treatment of patients with multiple myeloma, and with a group of patients with multiple myeloma, to identify the issues which were most important to patients. A questionnaire was devised from the list of issues, using a 1-week time-frame and response categories consistent with the EORTC QLQ-C30. The provisional questionnaire and the EORTC QLQ-C30 were administered to patients with multiple myeloma in each participating country with further semi-structured interviews to refine the content and design of the questionnaire. A review of the results obtained in each stage of development resulted in a 24-item myeloma-specific module, the EORTC QLQ-MY24, which assesses disease-specific symptoms and their impact on everyday life, treatment side-effects, social support, and future perspective. The module is currently undergoing further international field-testing to assess its psychometric properties.

The construction and testing of the EORTC colorectal cancer-specific quality of life questionnaire module (QLQ-CR38). European Organization for Research and Treatment of Cancer Study Group on Quality of Life

The objectives of the current study were to construct a colorectal cancer-specific quality of life (QL) questionnaire 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 in The Netherlands. Module construction took place following the EORTC guidelines for module development. The module--the QLQ-CR38--consists of 38 items covering symptoms and side-effects related to different treatment modalities, body image, sexuality and future perspective. This module was tested among 117 colorectal cancer patients on several occasions. The timing was prior to treatment with radiotherapy or chemotherapy, during treatment and 3 months following the second assessment. For purposes of test-retest reliability, a subsample of patients completed the QLQ-CR38 1 week following the third assessment. Multitrait scaling analysis confirmed the hypothesised scale structure of the function scales but not of the symptom scales. Cronbach's alpha coefficients for seven of the nine scales exceeded the 0.70 criterion at one or both assessments. The test-retest reliability for all scales and one single item was 0.78 or higher. The stability of the two remaining single items was lower. On the basis of known-groups comparisons, selective scales distinguished clearly between patients differing in disease stage, initial and on-treatment performance status and the presence of a stoma. Additionally, selective scales detected change over time as a function of change in performance status and treatment-induced change. These results lend support to the clinical validity of the QLQ-CR38 as a supplementary questionnaire for assessing specific QL issues relevant to patients with colorectal cancer. Additional efforts to test the module's cross-cultural validity are needed.

[Late morbidity after esophagectomy for cancer: is partial esophagectomy preferred?]

PURPOSE

The aim of this study is to report late postoperative complications occurring after oesophagectomy for cancer over a 12-month period and to compare the incidence of these complications according to the level of the anastomosis.

PATIENTS AND METHOD

This study included 106 consecutive patients 51% with subtotal oesophagectomy (thoracic anastomosis), and 49% with total oesophagectomy (cervical anastomosis). The two groups were comparable for age, mean weight loss before surgery, life expectancy, number of positive margins, TNM grading, size and tumour differentiation.

RESULTS

Late morbidity concerned 67.9% of the 106 patients. Predominant complications were dysphagia (32.1% of the 106), gastro-esophageal reflux (25.5% of the 106), and diarrhoea (18.8% of the 106). Among all the factors causing dysphagia, evaluated by logistic regression, the level of anastomosis was only found significant with a 20.4% occurrence for thoracic anastomosis and 44.2% for cervical anastomosis (P = 0.012). All the other complications were similar in the two groups.

CONCLUSION

Functional results of oesophagectomy for cancer are poor. As partial oesophagectomy morbidity is lower, total oesophagectomy should not be proposed in all cases of oesophageal cancer.

Cost-effectiveness in the management of patients with oesophageal cancer

BACKGROUND

The aim of this study was to assess the relationship between clinical outcome, quality of life and cost for treatment modalities commonly employed in the management of oesophageal carcinoma.

METHODS

A series of 51 patients diagnosed with oesophageal carcinoma in a 6-month period was used to derive a cost analysis profile for their treatment. All patients underwent quality of life assessment. Patients diagnosed in 1993 and managed in Newcastle upon Tyne were identified from the Northern Cancer Registry and Hospital Episode Statistics. Intervention profiles were documented for a 3-year follow-up period and cost analysis was conducted. A further 51 patients were recruited prospectively for quality-of-life studies.

RESULTS

Some 139 individuals were identified retrospectively. Median survival was significantly better in patients treated by resection (n=31; median 20 months) than in those receiving palliative treatments (n=108; median 6 months) (P < 00001). Median cost was significantly greater in individuals who underwent resection (8070 pound sterling) than for patients subjected to a palliative strategy (radiotherapy 4720 pound sterling, brachytherapy 1790 pound sterling, laser 3540 pound sterling, intubation 2450 pound sterling, no treatment 1390 pound sterling) (P < 0.01). When considering the median cost per month of life (after treatment) resection (457 pound sterling) compared favourably with the palliative options (range 342-1125 pound sterling).

CONCLUSION

Surgical resection for oesophageal carcinoma confers greatest benefit in terms of survival. Costs are inherently greater in individuals undergoing resection but, allowing for time, resection is at least as cost-effective as other treatment modalities.

Using reference data on quality of life--the importance of adjusting for age and gender, exemplified by the EORTC QLQ-C30 (+3)

Interpretation of health related quality of life (HRQOL) results in cancer patients is facilitated by knowledge of the levels of HRQOL in the general population. However, direct comparisons can be misleading unless age and gender are considered. We demonstrate the derivation of age- and gender-specific 'expected' values from population reference values by means of simple calculations. This survey included 3000 randomly selected Norwegians above 18 years of age who received the European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire (EORTC QLQ-C30 (+3) by mail. 1965 responses from 2,892 eligible persons (68%) were received. The population was divided into six disease groups based on self-reported health problems. The observed mean scale scores of the different groups deviated greatly from those obtained in the general population. The score for physical function, for example, was 72 for cancer patients and ranged from 73.3 to 82.5 in other disease groups, as opposed to 89.9 in the general population and 98.9 in those with no health problems. The range for one of the quality of life (QOL) scales was 57.7 to 84.7 compared with 73.7 in the general population. Expected mean scores for the patient groups were computed from the reference values, based on the concept of equivalence of age and gender. The differences between the observed mean scores and the reference values were strongly mediated by this method. The expected scores for physical function then ranged from 83.3 to 93.1 and from 70.3 to 75 for the QOL scale. The impact of age and gender on the reference data from the EORTC QLQ-C30 (+3) obtained in a general population shows that these variables must be considered when interpreting data on HRQOL for cancer patients. The demonstration of how to generate mean values which are adjusted according to the age and gender distribution of a population should increase the usefulness of this questionnaire among clinicians.

The European Organization for Research and Treatment of Cancer approach to developing questionnaire modules: an update and overview. EORTC Quality of Life Study Group

The European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Study Group has adopted a modular approach to quality of life (QoL) assessment in cancer clinical trials. The core instrument (the EORTC QLQ-C30) covers a range of QoL issues relevant to a broad spectrum of patients with cancer. The QLQ-C30 is designed to 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 established. The primary aim of these guidelines was to standardize the module development process in order to ensure uniformly high quality across modules. This paper gives an update of the work completed to date. First, while the guidelines proved practical for module development, producing modules that exhibit adequate levels of psychometric and cross-cultural validity, experience pointed to three areas where the guidelines required more precision. These amendments will be provided and include (1) stricter monitoring of the developmental process from within the study group, (2) the explicit requirement of involvement of the study group and (3) a more precise definition of the criteria to be fulfilled before modules are allowed to be called 'EORTC modules'. Second, an overview of the modules currently under development or available for general use is provided. These modules include those for body image, high-dose chemotherapy, leukaemia, myeloma, palliative care and the following cancers: bladder, brain, breast, colorectal, head and neck, lung, oesophageal, ophthalmic, ovarian, pancreas and prostate. Finally, the need for the coordination of efforts in module development, both from within and outside the EORTC, is discussed.

Cancer-specific quality of life questionnaires: the state of the art in Europe

Quality of life (QL) assessment is now regarded as desirable, if not mandatory, by agencies supporting cancer clinical trials around the world, yet doubts persist about the relevance of QL data to clinical practice. A plethora of QL measures is available but the quality of published work remains suboptimal. The appropriate choice of instrument is essential if outcome measures are to be valid and clinically meaningful. This paper reviews the considerations which should determine the choice of QL questionnaire and, taking the specific example of the EORTC approach, aims to provide users with an update on the current state of the art in the development of cancer-specific QL questionnaires.