EuroQol and survival prediction in terminal cancer patients: a multicenter prospective study in hospice-palliative care units

Global quality of life and mortality risk in patients with cancer: a systematic review and meta-analysis

PURPOSE

This systematic review and meta-analysis aimed to examine the impact of global quality of life (QOL) on mortality risk in patients with cancer, considering cancer type and timepoint of QOL assessment.

METHODS

A systematic search was conducted using Cumulated Index to Nursing and Allied Health Literature, PubMed/MEDLINE, and Scopus databases from inception to December 2022. Observational studies that assessed QOL and examined mortality risk in patients with cancer were extracted. Subgroup analyses were performed for cancer types and timepoints of QOL assessment.

RESULTS

Overall, global QOL was significantly associated with mortality risk (hazard ratio: 1.06, 95% confidence interval: 1.05-1.07; p < 0.00001). A subgroup analysis based on cancer type demonstrated that lung, head and neck, breast, esophagus, colon, prostate, hematologic, liver, gynecologic, stomach, brain, bladder, bone and soft tissue, and mixed type cancers were significantly associated with mortality risk; however, melanoma and pancreatic cancer were not significantly associated with mortality risk. Additionally, global QOL was associated with mortality risk at all timepoints (pretreatment, posttreatment, and palliative phase); pretreatment QOL had the largest impact, followed by posttreatment QOL.

CONCLUSION

These findings provide evidence that QOL is associated with mortality risk in patients with cancer at any timepoint. These results indicate the importance of evaluating the QOL and supportive interventions to improve QOL in any phase.

Health-Related Quality of Life Scores and Values as Predictors of Mortality: A Scoping Review

Health-related quality of life (HRQoL) can be assessed through measures that can be generic or disease specific, encompass several independent scales, or employ holistic assessment (i.e., the derivation of composite scores). HRQoL measures may identify patients with differential risk profiles. However, the usefulness of generic and holistic HRQoL measures in identifying patients at higher risk of death is unclear. The aim of the present study was to undertake a scoping review of generic, holistic assessments of HRQoL as predictors of mortality in general non-patient populations and clinical sub-populations with specified conditions or risk factors in persons 18 years or older. Five databases were searched from 18 June to 29 June 2020 to identify peer-reviewed published articles. The searches were updated in August 2022. Reference lists of included and cited articles were also searched. Of 2552 articles screened, 110 met criteria for inclusion. Over one-third of studies were from North America. Most studies pertained to sub-populations with specified conditions and/or risk factors, almost a quarter for people with cardiovascular diseases. There were no studies pertaining to people with mental health conditions. Nearly three-quarters of the studies used a RAND Corporation QoL instrument, predominantly the SF-36, and nearly a quarter, a utility instrument, predominantly the EQ-5D. HRQoL was associated with mortality in 67 of 72 univariate analyses (92%) and 100 of 109 multivariate analyses (92%). HRQoL was found to be associated with mortality in the general population and clinical sub-populations with physical health conditions. Whether this relationship holds in people with mental health conditions is not known. HRQoL assessment may be useful for screening and/or monitoring purposes to understand how people perceive their health and well-being and as an indicator of mortality risk, encouraging better-quality and timely patient care to support and maximize what may be a patient's only modifiable outcome.

Prediction of Survival Time in Advanced Lung Cancer: A Retrospective Study in Home-Based Palliative Care Unit

Background: There is a large group of patients suffering from lung cancer and receiving home hospice care in China. However, little is known about the prediction of their survival time. The purpose of this study was to determine whether quality of life independently predicts survival among advanced lung cancer survivors who are receiving home-based palliative care. Methods: In this retrospective study, we analyzed data from 937 advanced lung cancer patients who had received home-based palliative care between March 2010 and March 2020. We used Kaplan-Meier survival curves to determine the factors associated with survival time and applied the Cox proportional hazards model to examine the effect of quality of life on survival. Results: The study included 928 patients with a mean age of 63 years; and 72.1% of them were men. Factors associated with shortened survival included age, sex, place of residence, weight loss, anorexia, nausea, edema, quality of life, and Karnofsky performance status. After adjusting for other variables in a multivariate Cox proportional hazards model, we found that quality of life was an independent positive predictor of survival. Conclusions: As an independent factor predicting the survival of advanced lung cancer patients, quality of life should be taken seriously. Medical staff and healthcare workers need to pay special attention to this predictive factor since it may serve as early risk identification indicator for professionals who provide home-based palliative care, helping them to create effective personalized care plans.

Replacing performance status with a simple patient-reported outcome in palliative radiotherapy prognostic modelling

Background and purpose

Prognostication is key to determining care in advanced incurable cancer. Although performance status (PS) has been shown to be a strong prognostic predictor, inter-rater reliability is limited, restricting models to specialist settings. This study assessed the extent to which a simple patient-reported outcome measure (PROM), the EQ-5D, may replace PS for prognosis of patients with bone metastases.

Materials and methods

Data from 1,011 patients in the Dutch Bone Metastasis Study were used. Cox proportional hazards models were developed to investigate the prognostic value of models incorporating PS alone, the EQ-5D SC dimension alone, all EQ-5D dimensions and EQ-VAS, and finally all dimensions and PS. Three prognostic groups were identified and performance assessed using the Harrell's C-index and Altman-Royston index of separation.

Results

Replacing performance status (PS) with the self-care (SC) dimension of the EQ-5D provides similar model performance. In our SC-based model, three groups are identified with median survival of 86 days (95 % CI 76-101), 174 days (95 % CI 145-213), and 483 days (95 % CI 431-539). Whilst not statistically significantly different, the C-index was 0.706 for the PS-only model, 0.718 for SC-only and 0.717 in our full model, suggesting patient-report outcome models perform as well as that based on PS.

Conclusion

Prognostic performance was similar across all models. The SC model provides prognostic value similar to that of PS, particularly where a prognosis of<6 months is considered. Larger, more contemporaneous studies are needed to assess the extent to which PROMs may be of prognostic value, particularly where specialist assessment is less feasible.

Patient-reported symptoms and problems at admission to specialized palliative care improved survival prediction in 30,969 cancer patients: A nationwide register-based study

BACKGROUND

Large, nationally representative studies of the association between quality of life and survival time in cancer patients in specialized palliative care are missing.

AIM

The aim of this study was to investigate whether symptoms/problems at admission to specialized palliative care were associated with survival and if the symptoms/problems may improve prediction of death within 1 week and 1 month, respectively.

SETTING/PARTICIPANTS

All cancer patients who had filled in the EORTC QLQ-C15-PAL at admission to specialized palliative care in Denmark in 2010-2017 were included through the Danish Palliative Care Database. Cox regression was used to identify clinical variables (gender, age, type of contact (inpatient vs outpatient), and cancer site) and symptoms/problems significantly associated with survival. To test whether symptoms/problems improved survival predictions, the overall accuracy (area under the receiver operating characteristic curve) for different prediction models was compared. The validity of the prediction models was tested with data on 5,508 patients admitted to palliative care in 2018.

RESULTS

The study included 30,969 patients with an average age of 68.9 years; 50% were women. Gender, age, type of contact, cancer site, and most symptoms/problems were significantly associated with survival time. The predictive value of symptoms/problems was trivial except for physical function, which clearly improved the overall accuracy for 1-week and 1-month predictions of death when added to models including only clinical variables.

CONCLUSION

Most symptoms/problems were significantly associated with survival and mainly physical function improved predictions of death. Interestingly, the predictive value of physical function was the same as all clinical variables combined (in hospice) or even higher (in palliative care teams).

Cancer cachexia: Diagnosis, assessment, and treatment

Cancer cachexia is a multi-factorial syndrome, which negatively affects quality of life, responsiveness to chemotherapy, and survival in advanced cancer patients. Our understanding of cachexia has grown greatly in recent years and the roles of many tumor-derived and host-derived compounds have been elucidated as mediators of cancer cachexia. However, cancer cachexia remains an unmet medical need and attempts towards a standard treatment guideline have been unsuccessful. This review covers the diagnosis, assessment, and treatment of cancer cachexia; the elements impeding the formulation of a standard management guideline; and future directions of research for the improvement and standardization of current treatment procedures.

An Evaluation of Half-Body Irradiation in the Treatment of Widespread, Painful Metastatic Bone Disease

Aims

Evaluation of analgesic uptake, pain intensity, and quality-of-life changes after half-body irradiation of patients with bone metastases.

Material and Methods

Ninety-five patients (97 irradiations) were treated with single half-body irradiation fraction (3–8 Gy). Thirty-three patients had upper-half-body irradiation, 55 lower-half-body irradiation and 9 middle-half-body irradiation. The patients were examined on the day of irradiation, 2 and 4 weeks later, and then once a month. The intake of analgesics, pain level (from 0 to 10), and the quality of life (EORTC QLQ-C30) were evaluated. The fluctuations of pain levels and the particular scaling values of QLQ-C30 during a one-year period were analyzed (Kendall t correlation).

Results

Over the course of 5 months, the incidence of patients using strong opioids decreased from 43.8% to 33.3%, and the incidence of patients who did not need to resort to analgesics increased from 6.7% to 25%. The mean pain level decreased from 6.1 points (half-body irradiation) to 3.1 points 2 weeks later. An inverse correlation between pain level readings and time was statistically significant. An increase was observed in the values of the five functional scales as reflected on the EORTC QLQ-C30 questionnaire (four of which correlated significantly with the observation time). A similar situation prevailed with respect to global health status. A decrease was observed in most of the values on the symptoms scales; 6 saw a significant decrease, in correlation with the follow-up. Correlations were also found between pain intensity and functionality, and between symptoms scales readings and global health status.

Conclusions

Half-body irradiation of cancer patients suffering from painful multiple bone dissemination is an effective and simple treatment modality that affords significant quality-of-life improvement and pain relief, thus allowing for a reduction in the use of strong analgesics.

Multicenter, cross-sectional observational study of the impact of neuropathic pain on quality of life in cancer patients

PURPOSE

Neuropathic cancer pain (NCP) is a common and potentially debilitating symptom in cancer patients. We investigated the prevalence of NCP, as well as its management and association with QOL.

METHODS

Cancer patients with pain ≥1 on the visual analogue scale (VAS) were surveyed with the Douleur Neuropathique (DN4) questionnaire, the Brief Pain Inventory-Short Form (BPI-SF), and the EuroQOL five dimensions (EQ-5D) questionnaire. The associations between NCP and pain severity or NCP and QOL, while controlling for variables relevant to QOL, were then analyzed.

RESULTS

A total of 2003 patients were enrolled in this survey; the prevalence of NCP was 36.0% (n = 722, 95% CI, 32.5-39.5). We found that NCP in cancer patients was closely correlated to a higher pain severity (BPI-SF; 4.96 ± 1.94 versus 4.24 ± 2.02, p < 0.001), and in patients with NCP, pain more severely interfered with daily living, as compared to those without NCP (BPI-SF; 4.86 ± 2.71 versus 4.41 ± 2.87, p < 0.001). Patients with NCP also had worse QOL than those without NCP, as measured by EQ-5D index score (0.47 ± 0.30 vs. 0.51 ± 0.30, p = 0.005), and this was confirmed using multivariate analysis (p < 0.001), even after controlling for other variables such as age, sex, disease stage, cancer duration, radiotherapy, chemotherapy, and comorbidities. Importantly, adjuvant analgesics were used in less than half of patients with NCP (n = 358, 46.4%).

CONCLUSIONS

We found that NCP in cancer patients was significantly associated with a worsened QOL, and current management is inadequate. Therefore, future research aimed at developing improved strategies for management of NCP is required.

Update on Prevalence of Pain in Patients With Cancer: Systematic Review and Meta-Analysis

CONTEXT

Cancer pain has a severe impact on quality of life and is associated with numerous psychosocial responses. Recent studies suggest that treatment of cancer pain has improved during the last decade.

OBJECTIVES

The aim of this review was to examine the present status of pain prevalence and pain severity in patients with cancer.

METHODS

A systematic search of the literature published between September 2005 and January 2014 was performed using the databases PubMed, Medline, Embase, CINAHL, and Cochrane. Articles in English or Dutch that reported on the prevalence of cancer pain in an adult population were included. Titles and abstracts were screened by two authors independently, after which full texts were evaluated and assessed on methodological quality. Study details and pain characteristics were extracted from the articles with adequate study quality. Prevalence rates were pooled with meta-analysis; meta-regression was performed to explore determinants of pain prevalence.

RESULTS

Of 4117 titles, 122 studies were selected for the meta-analyses on pain (117 studies, n = 63,533) and pain severity (52 studies, n = 32,261). Pain prevalence rates were 39.3% after curative treatment; 55.0% during anticancer treatment; and 66.4% in advanced, metastatic, or terminal disease. Moderate to severe pain (numerical rating scale score ≥5) was reported by 38.0% of all patients.

CONCLUSION

Despite increased attention on assessment and management, pain continues to be a prevalent symptom in patients with cancer. In the upcoming decade, we need to overcome barriers toward effective pain treatment and develop and implement interventions to optimally manage pain in patients with cancer.

Use of instruments to measure quality of life among healthy and ill adults in community settings

International interest in quality of life (QoL) has been affected by patients' prolonged survival, the increasingly aging population, the increase in chronic conditions and the increasing costs of health care. This has also led to the development of QoL instruments that meet the psychometric criteria necessary for reliable and valid outcome measures in research, health policy decision-making and, increasingly, in clinical practice. Despite the proliferation of QoL instruments available to inform best practice, clinicians seldom routinely apply them. One of the barriers to using QoL instruments is the unfamiliarity nurses have with existing instruments. In order to increase community health nurses' familiarity with existing QoL assessments, the aim of this paper is to describe five instruments and modules that have been developed by the World Health Organization's Quality of Life Assessment Group for the assessment of QoL among healthy and ill adults and to describe how their applicability could enhance evidence-based practice in community nursing.

A Pilot Randomized Controlled Trial of a Holistic Needs Assessment Questionnaire in a Supportive and Palliative Care Service

CONTEXT

At present, there is no widely used systematic evidence-based holistic approach to assessment of patients' supportive and palliative care needs.

OBJECTIVES

To determine whether the use of a holistic needs assessment questionnaire, Sheffield Profile for Assessment and Referral for Care (SPARC), will lead to improved health care outcomes for patients referred to a palliative care service.

METHODS

This was an open, pragmatic, randomized controlled trial. Patients (n = 182) referred to the palliative care service were randomized to receive SPARC at baseline (n = 87) or after a period of two weeks (waiting-list control n = 95). Primary outcome measure is the difference in score between Measure Yourself Concerns and Wellbeing (MYCAW) patient-nominated Concern 1 on the patient self-scoring visual analogue scale at baseline and the two-week follow-up. Secondary outcomes include difference in scores in the MYCAW, EuroQoL (EQ-5D), and Patient Enablement Instrument (PEI) scores at Weeks 2, 4, and 6.

RESULTS

There was a significant association between change in MYCAW score and whether the patients were in the intervention or control group (χ(2)trend = 5.51; degrees of freedom = 1; P = 0.019). A higher proportion of patients in the control group had an improvement in MYCAW score from baseline to Week 2: control (34 of 70 [48.6%]) vs. intervention (19 of 66 [28.8%]). There were no significant differences (no detectable effect) between the control and intervention groups in the scores for EQ-5D and Patient Enablement Instrument at 2-, 4-, or 6-week follow-up.

CONCLUSION

This trial result identifies a potential negative effect of SPARC in specialist palliative care services, raising questions that standardized holistic needs assessment questionnaires may be counterproductive if not integrated with a clinical assessment that informs the care plan.

Health-related quality of life as a prognostic factor in patients with advanced cancer

BACKGROUND

Evidence continues to accumulate regarding the association between health-related quality of life (HRQoL) and survival across chronic diseases. The objectives of the current study were to investigate the prognostic value of HRQoL in patients with hepatocellular carcinoma and cholangiocarcinoma after adjusting for sociodemographics, disease-related factors, and treatment-related factors.

METHODS

A total of 321 patients diagnosed with hepatocellular or cholangiocarcinoma were administered the Functional Assessment of Cancer Therapy-Hepatobiliary instrument. Cox regression and Kaplan-Meier survival analyses were performed to test the association between the 5 domains of HRQoL and survival.

RESULTS

Using Cox regression, overall HRQoL was found to be significantly associated with survival (P = .003) after adjusting for demographics, disease-specific factors, and treatment. Subscales of the Functional Assessment of Cancer Therapy-Hepatobiliary, including the Physical Well-Being (P = .02) and the Symptoms and Side Effects subscales (P = .05), were also found to be significantly associated with survival after adjusting for demographics, disease-specific factors, and treatment.

CONCLUSIONS

HRQoL was found to be prognostic of survival in patients with hepatocellular and cholangiocarcinoma while covarying for demographics, disease-specific factors, and treatment. Stratifying patients based on HRQoL when testing novel treatments may be recommended. Health-related quality of life was found to be prognostic of survival in patients with hepatocellular and cholangiocarcinoma while controlling for demographics, disease-specific factors, and treatment-related factors.

Comparing health-related quality of life of cancer patients under chemotherapy and of their caregivers

Introduction. Cancer is a major disorder physically and psychologically affecting both patients and their caregivers. In this study, health-related quality of life (HRQoL) of patient-caregiver dyads during the period of chemotherapy was assessed. Material and Methods. Two hundred twenty-two cancer patient-caregiver dyads were enrolled in the study, which was conducted from October 2008 to March 2009. HRQoL was evaluated with EQ-5D. Results. The mean age of the sample was 57.4 and 48.9 for patients and caregivers, respectively. The EQ-5D descriptive system indicates that female patients more frequently experience anxiety and depression than male patients. Male and higher-education caregivers had higher VAS scores, while demographic factors did not seem to influence patients' HRQoL. Anxiety and depression of caregivers were correlated with patients' problems in self-care and usual activities. Conclusions. Quality of life is highly influenced during the period of chemotherapy for both patients and caregivers and is often under reported. Interventions that can improve HRQoL, especially in the domain of mental health for both cancer patients and their caregivers, need to be implemented.

Virologic response to therapy increases health-related quality of life for patients with chronic hepatitis B

BACKGROUND & AIMS

We evaluated changes in health-related quality of life (HRQoL) in a longitudinal study of patients given antiviral therapy for chronic hepatitis B (CHB).

METHODS

We analyzed changes in HRQoL reported by 2856 Korean patients with CHB who started first-line or rescue antiviral therapy from January 2007 to June 2007; the mean age of the study subjects was 43.3 years, 72% were male, 80% were positive for hepatitis B e antigen, 20% had cirrhosis, and 13% had concomitant disease. These subjects all completed the translated version of the Chronic Liver Disease Questionnaire (CLDQ) and the EuroQol-5 Dimension (EQ5D) when the study began (baseline), and at the end of a 24-week follow-up period. We analyzed changes in utility scores from baseline to 24 weeks of antiviral treatment.

RESULTS

After 24 weeks of antiviral therapy, patients had significant improvements in liver function and reduced mean levels of hepatitis B virus DNA (from 6.3 to 3.9 log(10) copies/mL). Utility scores from the visual analogue scale and EQ5D improved after 24 weeks of antiviral therapy (from 0.84 ± 0.19 to 0.94 ± 0.14; P < .0001). Improved CLDQ scores were associated with virologic response (level of hepatitis B virus DNA, <4 log(10) copies/mL); scores increased from 5.21 ± 0.99 at baseline to 6.09 ± 0.72 after 24 weeks of antiviral therapy in responders, but from 5.31 ± 0.94 at baseline to 6.06 ± 0.66 in nonresponders (P = .003).

CONCLUSIONS

Patients with CHB who have a virologic response to 24 weeks of antiviral therapy also have significant improvements in HRQoL, measured by EQ5D and CLDQ.

Does health-related quality of life improve for advanced pancreatic cancer patients who respond to gemcitabine? Analysis of a randomized phase III trial of the cancer and leukemia group B (CALGB 80303)

CONTEXT

Gemcitabine for advanced pancreatic cancer (APC) is palliative and the prognosis is poor, making health-related quality of life (HRQOL) particularly important.

OBJECTIVES

We evaluated HRQOL with the EuroQol (EQ-5D™) in patients with APC participating in Cancer and Leukemia Group B 80303, a multicenter, double-blind, randomized trial comparing overall survival (OS) between two treatment arms: gemcitabine with bevacizumab or gemcitabine with placebo.

METHODS

A consecutive subsample of patients was invited to complete the EQ-5D surveys. Because neither clinical nor HRQOL outcomes differed based on the study arm, analyses were pooled. Changes in mean scores from baseline to eight weeks and the prognostic value of the EQ-5D were evaluated.

RESULTS

Mean index scores remained stable (0.78 at baseline [n=267], 0.79 at eight weeks [n=186], P=0.34, Wilcoxon signed rank test), attributable to a modest deterioration of physical function domain scores coincident with small improvements in pain and anxiety/depression scores. A small decline in visual analogue scale scores was observed (70.7 vs. 68.2, P=0.026). HRQOL changes within chemotherapy response strata revealed stable index scores but a trend of worsened physical function among patients with disease progression compared with those with stable or improved disease. Visual analogue scale scores trended downward over time irrespective of chemotherapy response status, with a statistically meaningful deterioration in patients who progressed (68.9 vs. 64.4, P=0.029). Baseline scores from both EQ-5D scales were significant predictors of OS in Cox proportional hazard models.

CONCLUSION

Response to gemcitabine treatment in APC is not associated with appreciable improvement of global HRQOL. Small improvements in pain and mood are observed despite progressive functional decline. Those who respond to gemcitabine may experience a slight slowing of functional deterioration.

Population health status in China: EQ-5D results, by age, sex and socio-economic status, from the National Health Services Survey 2008

PURPOSE

To measure and analyse national EQ-5D data and to provide norms for the Chinese general population by age, sex, educational level, income and employment status.

METHODS

The EQ-5D instrument was included in the National Health Services Survey 2008 (n = 120,703) to measure health-related quality of life (HRQoL). All descriptive analyses by socio-economic status (educational level, income and employment status) and by clinical characteristics (discomfort during the past 2 weeks, diagnosed with chronic diseases during the past 6 months and hospitalised during the past 12 months) were stratified by sex and age group.

RESULTS

Health status declines with advancing age, and women reported worse health status than men, which is in line with EQ-5D population health studies in other countries and previous population health studies in China. The EQ-5D instrument distinguished well for the known groups: positive association between socio-economic status and HRQoL was observed among the Chinese population. Persons with clinical characteristics had worse HRQoL than those without.

CONCLUSIONS

This study provides Chinese population HRQoL data measured by the EQ-5D instrument, based on a national representative sample. The main findings for different subgroups are consistent with results from EQ-5D population studies in other countries, and discriminative validity was supported.

Asymptomatic pancreatic cystic neoplasms: maximizing survival and quality of life using Markov-based clinical nomograms

BACKGROUND & AIMS

The natural history and management of pancreatic cysts, especially for branch duct intraductal papillary mucinous neoplasms (BD-IPMNs), remain uncertain. We developed evidence-based nomograms to assist with clinical decision making.

METHODS

We used decision analysis with Markov modeling to compare competing management strategies in a patient with a pancreatic head cyst radiographically suggestive of BD-IPMN, including the following: (1) initial pancreaticoduodenectomy (PD), (2) yearly noninvasive radiographic surveillance, (3) yearly invasive surveillance with endoscopic ultrasound, and (4) "do nothing." We derived probability estimates from a systematic literature review. The primary outcomes were overall and quality-adjusted survival. We depicted the results in a series of nomograms accounting for age, comorbidities, and cyst size.

RESULTS

Initial PD was the dominant strategy to maximize overall survival for any cyst greater than 2 cm, regardless of age or comorbidities. In contrast, surveillance was the dominant strategy for any lesion less than 1 cm. However, when measuring quality-adjusted survival, the do-nothing approach maximized quality of life for all cysts less than 3 cm in patients younger than age 75. Once age exceeded 85 years, noninvasive surveillance dominated. Initial PD did not maximize quality of life in any age group or cyst size.

CONCLUSIONS

Management of pancreatic cysts can be guided using novel Markov-based clinical nomograms, and depends on age, cyst size, comorbidities, and whether patients value overall survival vs quality-adjusted survival. For patients focused on overall survival, regardless of quality of life, surgery is optimal for lesions greater than 2 cm. For patients focused on quality-adjusted survival, a 3-cm threshold is more appropriate for surgery except for the extreme elderly.

Determining prognosis and predicting survival in end-of-life care

PURPOSE OF REVIEW

The purpose of this article is to review some recent studies referred to prognosis factors and our capacity to predict death during the final stages of disease.

RECENT FINDINGS

Recent studies show significant approaches through the use of some instruments (especially self-assessment tools), which we will analyze herein.

SUMMARY

In many cases of clinical practice, this prediction capacity based on solid elements may be key to determine or contraindicate certain therapeutic resources. Such is the case, for example, when it is necessary to define the transfer of a patient to a proper specialized center, under family or legal circumstances demanding a clarification on this point, or for handling the dialog with the patients and/or their relatives. According to recent findings, we should include some elements of self-assessment in our instruments to predict death in palliative care.

Appraising the quality of care in surgery

There is currently no validated measurement system available for quality of care assessment in surgery despite all of the inherent benefits of such an approach. A structured quality framework needs to be developed and incorporate measures that are truly reflective of several important dimensions of care within the entire treatment episode. Presently this has been only partially addressed. These measures of quality can be categorized into clinical pathway measures (structure of care, process of care, outcome of care, and economic measures of care) and patient-reported measures (patient-reported treatment outcomes, health-related quality of life measures, and patient satisfaction). Combining these measures to create an overall composite quality score can be made feasible only if it is supported by the use of robust statistical methodology. It is important to use appropriate display of performance data to facilitate provider engagement in quality improvement initiatives. This article was designed to present such a structured approach of a quality framework, which is required to appraise the quality of care in surgery to enhance future quality improvement programmes.

[The decline of health-related quality of life associated with some diseases in Korean adults]

OBJECTIVES

This study was conducted to measure the decline in the health-related quality of life (HRQoL) associated with some diseases in South Korean adults.

METHODS

The EQ-5D health states in the 2005 National Health and Nutrition Examination Survey (NHNES) and the Korean EQ-5D valuation set were used to obtain the EQ-5D indexes of the study subjects. Each disease group was defined when the subjects reported to the NHNES that they were diagnosed with the corresponding disease during the previous 1 year by physicians. Since the distributions of the EQ-5D indexes in each subgroup were negatively skewed, median regression analysis was used to estimate the effects of specific diseases on the HRQoL. Median regression analysis produced estimates that approximated the median of the EQ-5D indexes and there are more robust for analyzing data with many outliers.

RESULTS

A total of 16,692 subjects (6,667 patients and 10,025 people without any disease) were included in the analysis. As a result of the median regression analysis, stroke had the strongest impact on the HRQoL for both males and females, followed by osteoporosis, osteoarthritis, rheumatic arthritis, and herniation of an intervertebral disc. While asthma had a significant impact on the HRQoL only in men, cataract, temporo-mandibular dysfunction, and peptic ulcer significantly affected the HRQoL only in women.

CONCLUSIONS

Stroke and musculoskeletal diseases were associated with the largest losses of the HRQoL in Korean adults.

Using the EQ-5D index score as a predictor of outcomes in patients with type 2 diabetes

OBJECTIVE

To examine whether index scores based on the EQ-5D, a 5-item generic health status measure, are an independent predictor of vascular events, other major complications and mortality in people with type 2 diabetes and to quantify the relationship between these scores and future survival.

SUBJECTS

Five-year cohort study involving 7348 patients with type 2 diabetes, aged between 50-75 years who had been recruited to the FIELD (Fenofibrate Intervention and Event Lowering in Diabetes) study from Australia and New Zealand.

MEASURES

Multivariate Cox proportional hazard regression models were used to estimate the hazard ratio associated with index scores derived from the EQ-5D on: (1) cardiovascular events (including coronary heart disease event, stroke, hospitalization for angina, or cardiovascular death); (2) other major diabetes-related complications (heart failure, amputation, renal dialysis, and lower extremity ulcer); and (3) death from any cause. Life table methods were used to derive expected survival for patients with different index scores.

RESULTS

After adjusting for standard risk factors, a 0.1 higher index score (derived from the UK algorithm) was associated with an additional 7% (95% CI: 4-11%) lower risk of vascular events, a 13% (95% CI: 9-17%) lower risk of complications, and up to 14% (95% CI: 8-19%) lower rate of all-cause mortality.

CONCLUSIONS

Index scores derived from the EQ-5D are an independent predictor of the risk of mortality, future vascular events, and other complications in people with type 2 diabetes. This should be taken into account when extrapolating health outcomes such as quality-adjusted life years (QALYs).

Impact of nutrition on quality of life during cancer

PURPOSE OF REVIEW

This review addresses the relationship between nutritional intervention and quality of life in oncology patients.

RECENT FINDINGS

Nutrition related symptoms, such as anorexia and weight loss, reflect impaired nutritional status, which is often associated with reduced quality of life. Malnutrition can be related to reduced response or tolerance to cancer treatment. Early nutritional intervention may positively impact on quality of life and enhance clinical response in oncology patients.

SUMMARY

Nutritional intervention should be considered as a supportive measure within the global oncology strategy. In curative oncology care, it contributes to reduced postoperative infection rate, better control of cancer-related symptoms, shortened length of hospital stay and improved tolerance to treatment. In palliative care, the nutritional intervention focuses on controlling symptoms, thus improving quality of life. The evaluation of nutritional status should include an assessment of quality of life in order to optimize nutritional treatment for patients' individual requirements. Because of the potentially clinically relevant impact of nutritional intervention on quality of life, nutritional care should be included in any antineoplastic strategy.

[General population time trade-off values for 42 EQ-5D health states in South Korea]

OBJECTIVES

This study was conducted to elicit quality weights for 42 EQ-5D health states with the time trade-off (TTO) method from the general population of South Korea.

METHODS

We selected the same EQ-5D health states as those in the UK MVH study. The Korean version of EQ-5D questionnaire and TTO method were used for the valuation process. We interviewed 500 people as a representative sample of the general population in Seoul and Gyeonggi-do. The result was compared with those from UK, Japan, and USA by Spearman's rank correlation and t-test.

RESULTS

TTO values for 42 EQ-5D health states and 'unconscious' state were obtained from the general South Korean population. The best one was '11112' state and the worst one was 'unconscious' state. The states worse than death were '33323', '33333', and 'unconscious' states, which had negative TTO values. There was a strong correlation between TTO values of the EQ-5D health states and those of their corresponding states from UK, Japan, and USA (Spearman's correlation coefficient: 0.885, 0.882, and 0.944, respectively, p <0.001). However, absolute TTO values of most EQ-5D health states were significantly different from those of their corresponding states in other foreign studies (UK: 41/42, USA: 32/42, Japan: 15/17).

CONCLUSIONS

We found that the Korean general population TTO values for EQ-5D health states were different from those of other foreign studies, suggesting that a specific Korean valuation set should be developed and used for economic evaluation studies in South Korea.

Nutritional intervention and quality of life in adult oncology patients

The evaluation of quality of life (QoL) assesses patients' well-being by taking into account physical, psychological and social conditions. Cancer and its treatment result in severe biochemical and physiological alterations associated with a deterioration of QoL. These metabolic changes lead to decreased food intake and promote wasting. Cancer-related malnutrition can evolve to cancer cachexia due to complex interactions between pro-inflammatory cytokines and host metabolism. Beside and beyond the physical and the metabolic effects of cancer, patients often suffer as well from psychological distress, including depression. Depending on the type of cancer treatment (either curative or palliative) and on patients' clinical conditions and nutritional status, adequate and patient-tailored nutritional intervention should be prescribed (diet counselling, oral supplementation, enteral or total parenteral nutrition). Such an approach, which should be started as early as possible, can reduce or even reverse their poor nutritional status, improve their performance status and consequently their QoL. Nutritional intervention accompanying curative treatment has an additional and specific role, which is to increase the tolerance and response to the oncology treatment, decrease the rate of complications and possibly reduce morbidity by optimizing the balance between energy expenditure and food intake. In palliative care, nutritional support aims at improving patient's QoL by controlling symptoms such as nausea, vomiting and pain related to food intake and postponing loss of autonomy. The literature review supports that nutritional care should be integrated into the global oncology care because of its significant contribution to QoL. Furthermore, the assessment of QoL should be part of the evaluation of any nutritional support to optimize its adequacy to the patient's needs and expectations.