Quality of life as an outcome in clinical trials and cancer care: a primer for surgeons

Comparing quality of life in lower extremity tumor patients undergoing limb salvage surgery and amputation: a meta-analysis

Purpose

Limb salvage surgery and amputation are two commonly performed procedures for lower extremity tumors. When comparing these procedures in tumor patients, it is important to consider their impact on quality of life (QOL) and functional mobility. These patients often experience physical, emotional, and psychological challenges, making these factors crucial in determining the most suitable treatment approach.

Method

The outcomes of lower extremity tumors patients for QOL were collected from PubMed, MEDLINE, EMBASE, Cochrane, and Google Scholar until 28 February 2023. The physical function, mental health, role function, social function, emotional function, Toronto Extremity Salvage Score, and Musculoskeletal Tumor Society Score outcomes were analyzed to determine the differences between the two procedures.

Results

Five articles were included according to the selection criteria with a total of 245 patients. The standard mean difference (SMD) values of each parameter were slightly higher in limb salvage surgery patients but not higher enough to produce statistically significant results; the SMD values for physical function and mental health were 0.72 and 0.04, respectively. This study did not report any heterogeneity or publication bias.

Conclusions

QOL is a large and enhanced term, which carries its importance and is challenging to compare between any procedures. The minimal rise in SMD of different QOL parameters highlighted only a slight advantage of limb salvage surgery over amputation. Therefore, further research is required to explore the impact of this crucial topic.

Quality of Life and Satisfaction in Transgender Men After Phalloplasty in a Retrospective Study

BACKGROUND

Partly as a result of the increasing attention directed toward transgender individuals and despite much research work on the topic of quality of life (QOL) of transgender, there is still a lack of studies using standardized questionnaires in their evaluation.

AIMS

We designed a survey to evaluate the influence of surgery after phalloplasty (osteofasciocutaneous fibula free flap or osteofasciocutaneous radial free forearm flap) on QOL, emotional stability, self-esteem, and psyche of postoperated transgender men.

METHODS

The present study included 32 transgender men who had undergone gender-affirming surgery (GAS) exclusively in our department between 2000 and 2012. Apart from our self-developed, indication-specific questionnaire with questions on socioeconomic and demographic data as well as postoperative satisfaction, the testing instrument included 4 frequently used, standardized testing instruments, which we compared with normative data. These included (a) a self-assessment test Fragebogen zur Lebenszufriedenheit with questions on QOL consisting of 3 modules (general satisfaction, satisfaction with health, and satisfaction with body image/outer appearance), (b) the Freiburg Personality Inventory, (c) the Rosenberg Self-Esteem Questionnaire, and (d) the Patient Health Questionnaire 4.

FINDINGS

Our self-developed, indication-specific questionnaire showed that 88% of our patients were very satisfied with the aesthetic result, 75% have had sex after surgery, and 72% were very satisfied with sexual function after GAS. Eighty-one percent had a strong improvement of QOL, and 91% would undergo the same treatment again. Eighty-four percent would recommend GAS to others. All patients lived as men fulltime.

DISCUSSION

Our study reveals that GAS plays an important part in the interdisciplinary treatment of transgender individuals as it improves the QOL in transgender men in most aspects of everyday life and has a positive influence on the patients' psyche and self-esteem in a retrospective study.

Quality of life, body image and self-esteem in patients with unilateral transtibial amputations

Amputation represents a drastic impact on the patient’s body and perception. This cross-sectional study aims to analyse the aesthetic concern represented by body image, self-esteem and quality of life in patients with unilateral transtibial amputations of lower limbs compared to control group. People living with amputations present lower average levels than controls in all subscales of the SF-36 (Short Form 36 Health Survey) quality of life questionnaire, and in both the physical component summary and the mental component summary, although the difference is not statistically significant in the latter. These patients present a significantly lower mean score (p = 0.002) in the MBSRQ (Body-Self Relations Questionnaire) body image questionnaire: 2.64 ± 0.49 opposed to 3.16 ± 0.55 in controls. People living with amputations had a lower mean score on the Rosenberg Self-Esteem scale than controls (34.44 ± 4.61 v 36.04 ± 3.63). The results also show that amputation has a significant influence on the BI (Body image) of patients with unilateral transtibial amputations. SE (Self-Esteem) seems to be an aspect that is not significantly affected by lower limb amputation, although these patients scored a lower mean on the RSE scale compared to the control group. We consider it is highly relevant to assess QoL (Quality of life), BI and SE in patients after a lower limb amputation process.

Idiographic quality of life assessment before radical cystectomy

BACKGROUND

We sought to determine if idiographic, or self-defined, measures added to our understanding of patients with bladder cancer's quality of life (QOL) prior to radical cystectomy (RC). We tested whether idiographic measures increased prediction of global QOL beyond standard (nomothetic) measures of QOL components.

METHODS

We administered the European Organization for Research and Treatment of Cancer Quality of Life Questionnaires (QLQ)-C30 and QLQ-BLM30, and our own idiographic Quality of Life Appraisal Profile prior to RC. Idiographic measures included number of goal statements, distance from goal attainment, and ability to complete goal attainment activities. Multivariate linear regression was used to predict measures of global QOL and related constructs of life satisfaction and mental health.

RESULTS

Two hundred fiftheen patients reported a median of 8 (interquartile range [IQR] 6, 11) goals and half had an average goal attainment rating above 6.9 out of 10 (IQR 5.5, 8.2). On multivariable analysis, QLQ-C30 role functioning and QLQ-BLM30 future perspective explained 15.7% of the variability in preoperative global QOL. Including goal attainment and activity difficulty explained an additional 12% of global QOL variance. Smaller gains were seen on measures of global health, life satisfaction, mental health, and activity, suggesting that idiographic measures capture aspects of QOL distinct from health and functional status defined by nomothetic scales.

CONCLUSIONS

Idiographic assessment of QOL added to prediction of global QOL above and beyond health-related components measured using nomothetic instruments. This self-defined information may be valuable in communicating with cancer patients about their QOL. Copyright © 2015 John Wiley & Sons, Ltd.

Body image and self-esteem in lower-limb amputees

Background

Limb amputation is often an inevitable procedure in the advanced condition of various diseases and poses a dramatic impact on a patient's life. The aim of the present study is to analyze the impact of lower-limb amputations on aesthetic factors such as body image and self-esteem as well as quality of life (QoL).

Methods

298 patients (149 uni- or bilateral lower-limb amputees and 149 controls) were included in this cross-sectional study in three centers. Demographic data was collected and patients received a 118-item questionnaire including the Multidimensional Body-Self Relations Questionnaire (MBSRQ), the Rosenberg Self-esteem (RSE) scale and the SF-36 Health Survey (QoL). ANOVA and student's t-test were used for statistical analysis.

Results

Unilateral lower-limb amputees showed a significant lower MBSRQ score of 3.07±0.54 compared with 3.41±0.34 in controls (p<0.001) and a lower score in the RSE compared to controls (21.63±4.72 vs. 21.46±5.86). However, differences were not statistically significant (p = 0.36). Patients with phantom pain sensation had a significantly reduced RSE (p = 0.01). The SF-36 health survey was significantly lower in patients with lower-limb amputation compared to controls (42.17±14.47 vs. 64.05±12.39) (p<0.001).

Conclusion

This study showed that lower-limb amputations significantly influence patients' body image and QoL. Self-esteem seems to be an independent aspect, which is not affected by lower-limb amputation. However, self-esteem is influenced significantly by phantom pain sensation.

Does abdominoplasty have a positive influence on quality of life, self-esteem, and emotional stability?

BACKGROUND

In a previous prospective study, the authors evaluated the quality of life in patients undergoing aesthetic surgery. In this survey, the authors split up the operative indication and analyzed quality of life, self-esteem, and emotional stability after abdominoplasty alone.

METHODS

Sixty-three patients participated in the study. The testing instrument consisted of a self-developed questionnaire to collect demographic and socioeconomic data and a postoperative complication questionnaire developed especially for abdominoplasties. In addition, a standardized self-assessment test on satisfaction and quality of life (Questions on Life Satisfaction), the Rosenberg Self -Esteem Questionnaire, and the Freiburg Personality Inventory were used.

RESULTS

Significantly increasing values in some items of the standardized self-assessment test on satisfaction and quality of life were found: sum scores of the General Life Satisfaction showed a significant improvement (p = 0.004) and the scores of the items housing/living conditions (p = 0.000) and family life/children (p = 0.000). Within the Satisfaction with Health module, a significant improvement in the items mobility (p = 0.02) and independence from assistance (p = 0.01) was found. Values in the module Satisfaction with Appearance (Body Image) increased regarding satisfaction with the abdomen (p = 0.001). Over 84 percent were very satisfied with the aesthetic result, 93.4 percent would undergo the same treatment again, and 88.9 percent would further recommend the operation. Data revealed that participants' self-esteem was very high and their emotional stability was very well balanced.

CONCLUSIONS

This study demonstrates that abdominoplasty increases most aspects of quality of life, particularly family life, living conditions, mobility, and independency from assistance. Also, patient self-esteem and emotional stability ratings are very high postoperatively.

Quality of life among Iranian adults before and after rhinoplasty

BACKGROUND

Despite developments in the therapeutic field of cosmetic surgery, there is a little information about the effects of cosmetic procedures on quality of life (QOL), especially in Iran. Rhinoplasty is one of the most common cosmetic surgeries. This type of surgery has remarkable effects on physical and mental health and also improves nasal functioning. The purpose of this study was to survey QOL among Iranian adults before and after rhinoplasty.

METHODS

In this descriptive and analytical cross-sectional study, from March 2009 to March 2010, data were collected from 75 subjects, 16 years old and above, before and 6 months after rhinoplasty. A trained interviewer interviewed and completed standardized questionnaires investigating QOL, including the SF-36 version 2, NOSE, and Rosenberg questionnaires. Data analysis was conducted using SPSS ver. 16. Results before and after surgery were compared.

RESULTS

The mean age of the subjects was 26.05 ± 7.78 years, with a median of 24 years. The female-to-male ratio was 4.35:1. In all cases and all questionnaires, QOL was improved after rhinoplasty. Significant differences were observed on the NOSE questionnaire (p = 0.005) and the Rosenberg questionnaire (p = 0.002). On the SF-36 questionnaire, significant differences were observed in four subscales, including physical functioning (p = 0.047), role of emotion (p = 0.01), bodily pain (p = 0.01), and vitality (p = 0.05).

CONCLUSIONS

According to this study, QOL is improved after rhinoplasty in Iranian adult patients. With proper patient selection and a successful operation, improvement of physical and mental health can be expected.

Quality of life after rectal resection and multimodality therapy

Modern management of locally advanced rectal cancer requires a multimodality approach. This includes radical surgery, pelvic radiotherapy, and systemic chemotherapy. It can require a permanent colostomy and result in significant bowel, sexual, and urinary dysfunction. In order to determine the effectiveness of various multimodality regimens it is important to not only assess conventional oncologic outcomes but also the impact on patient's quality of life.

Quality of life following aesthetic plastic surgery: a prospective study

BACKGROUND

The objective of this study was the prospective evaluation of quality of life in patients undergoing aesthetic plastic surgery procedures. We examined pre- and postoperative changes in quality of life, and performed a comparison of our data with a representative random sample.

METHOD

228 patients agreed to participate in the present study. Measurements were taken preoperatively as well as 3 and 6 months postoperatively. One hundred and thirty two patients completed the three months postoperative evaluation (T1), 82 answered the 6 months follow-up evaluation (T2). The testing instrument included a standardised self-assessment test on satisfaction and quality of life (FLZ(M)), consisting of three modules: satisfaction with general life, health and appearance. Further, a postoperative complication questionnaire was used in order to evaluate the satisfaction with the surgical outcome and to estimate postoperative complications and side effects.

RESULTS

Significantly increasing values in two aspects of quality of life were found: health and appearance. Whereas the positive influence on health is persistent, there is a diminishing influence of appearance 6 months postoperatively. Although higher values for some of the individual items of the FLZ(M) modules of the norm data were found in comparison to our study group, a general preoperative lower level of quality of life of the aesthetic surgery patients could not be confirmed. Over 84% were satisfied or very satisfied with the aesthetic result. 85% would undergo the same treatment again and 94% of the patients would further recommend their operation. More than half of the study group did not report a decrease in physical fitness or reduced social contacts in the direct postoperative period.

CONCLUSION

Our study reveals that aesthetic plastic surgery increases most aspects of quality of life, especially regarding body satisfaction and health. It is very well tolerated by the patients and is therefore a recommended option.

Psychometric properties of the Arabic version of Quality of Life Index

AIM

This paper reports a study to translate the English language version of the Quality of Life Index into Arabic and estimate its reliability and content validity.

BACKGROUND

Quality of life has become an important concern in health care and social policy. It is a difficult construct to define and measure, as it is determined by cultural, ethical, personal and religious values. The generic Ferrans and Powers Quality of Life Index was developed to measure quality of life of healthy individuals. Specific versions of the index were developed for particular diseases, such as diabetes, cancer and end-stage kidney disease. The instruments were initially developed for English-speaking clients and were later translated into several languages and used within a variety of cultures. However, there were no Arabic versions of the tool available to measure the quality of life of general populations or of people with particular diseases.

METHOD

The Quality of Life Index was translated into Arabic using two of the techniques suggested in the literature for translation - back translation and bilingual technique. The same process was followed in the translation of the original scale and various disease-specific versions of the instrument. The work took place between 1995 and 2004.

FINDINGS

The translated Arabic Quality of Life Index demonstrated a high degree of accuracy of translation and estimates of content validity. Subsequent to the translation of the original scale into Arabic, 13 disease-related versions of the instrument were translated and are ready for use with clients who speak Arabic. Four of the versions have been used to collect data from clients. The results revealed high estimates of reliability for the generic, diabetes, cancer and dialysis versions.

CONCLUSION

The Arabic version of the Quality of Life Index is highly reliable and has sufficient content validity for measuring quality of life of Arabic-speaking clients.

Assessment of quality of life outcomes in the treatment of advanced colorectal malignancies

QOL assessment in oncology has made great strides in recent years. There was a difficult time initially, during which QOL tools were "thrown in" to many clinical trials as an afterthought, without a pre-specified scientific question. As expected from such a scattershot approach, the results were underwhelming and disappointing. The disappointing results from this period led many practitioners to question the value added by QOL assessment in oncology clinical trials. This healthy skepticism has led to a renaissance period, in which situation-specific and disease-specific QOL assessments have been developed and have contributed substantial information to the cause of the disease, the effects of treatments, and the experiences of cancer patients. Today, there is a dawning recognition that asking the patient directly about their QOL using the same scientific rigor required of other clinical outcomes can provide valuable data for prognosis, treatment, symptom management, and supportive care. With time and further successful experiences like those cited in this article, QOL assessment may eventually become as routinely collected and integrated into oncology clinical practice as pain and blood pressure assessments are today.

The experience of fatigue, other symptoms and global quality of life during radiotherapy for uterine cancer

This paper reports on how patients with uterine cancer, receiving radiotherapy, experience fatigue, other symptoms and global quality of life. The results showed that fatigue increased significantly during the therapy. Also the other symptoms; loss of appetite, nausea/vomiting and diarrhoea increased significantly and were significantly correlated to general fatigue. Global quality of life decreased significantly during treatment compared to baseline. The variation of the level in general fatigue after completed therapy was only explained by the level of general fatigue experienced at baseline. The result can lead to a better understanding of the severity of symptoms experienced by patients with uterine cancer treated with radiotherapy.

Quality of life after lung cancer resection

Lung cancer continues to be the most common cancer in the world, with the highest cancer mortality rate by far. Although resection remains the treatment of choice in early-stage NSCLC, the prognosis remains grim even after surgical treatment. In a patient population with such a high mortality rate, evaluation and preservation of QOL after treatment is imperative. Early-stage lung cancer patients already have significantly lower QOL when compared with the normal population before surgical treatment, with significant impairment in physical and emotional functioning. Lung cancer resection causes further deterioration of QOL, especially in the first 3 to 6 months after surgery. While some studies suggest that QOL returns to baseline levels at 6 to 9 months postoperatively, others report that QOL is still significantly impaired at 6 months and 1 year after surgery. Although prospective studies analyzing long-term postoperative QOL are not available, retrospective data suggest that long-term survivors after lung cancer surgery enjoy good QOL despite impaired physical functioning. QOL studies on VATS lung cancer resection are extremely limited. More prospective, longitudinal studies with larger study populations and longer follow-up periods are needed to portray the course of QOL in lung cancer patients more accurately and to improve postoperative care. Furthermore, comparative studies between VATS and the standard thoracic incisions (including QOL assessments) must be performed to guide clinical decision making regarding selection of optimal access modality for performing lung cancer resection.

Fatigue, psychological distress, coping and quality of life in patients with uterine cancer

BACKGROUND

Cancer-related fatigue (CRF) is a subjectively experienced symptom that is multidimensional and multifactorial. Patients with cancer have identified fatigue as one of the major troubling symptoms and the primary cause of distress in their lives.

AIMS

The major aim of the study was to examine how patients diagnosed with uterine cancer describe their experience of fatigue, psychological distress, coping resources and quality of life. A secondary aim was to describe the relationship between selected variables.

METHOD

A descriptive and correlational design was used and the study was conducted at a university hospital in Sweden. The study population consisted of women, diagnosed with uterine cancer, who where scheduled to receive curative external radiation therapy. Sixty women participated in the study and data were collected through self-report instruments. Demographic and clinical data were extracted from patient records. The data were collected during year 2000-2002. The Conceptual Model of Symptom Management was used as a framework to guide the study.

FINDINGS

Patients experienced a low grade of fatigue and psychological distress, but their functional status and global quality of life was high. Significant correlations were found between general fatigue and anxiety and also between general fatigue and depression. There was a significant negative correlation between general fatigue and coping resources. Depression explained 44% of the variance in general fatigue.

CONCLUSIONS

The findings provide knowledge about predictors of CRF in women with uterine cancer, and can serve as a basis for future longitudinal studies in which different prophylactic strategies against therapy-related fatigue are prospectively studied.

Surgical palliation in advanced disease: recent developments

Despite many valuable technical innovations for the relief of suffering in advanced disease over the past few years, only recently have surgical oncologists attempted to more clearly define palliation. Previous definitions have been misleading, creating confusion about the merits of surgery in many situations and difficulty in posing questions for future prospective clinical trials. This report outlines recent progress in identifying and refining a philosophy of palliative surgery that would align it with the consensus of nonsurgical opinion summarized by the 1990 World Health Organization definition of palliative care and the emerging consensus among the medical specialties in the United States concerning principles of care at the end of life. Selected controversies and recent innovations, as well as guidelines for palliative surgery, are discussed.