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Alor SK, Glozah FN, Kretchy IA, Adongo PB. Assessing health-related quality of life and clinical outcomes of patients with diabetes accessing healthcare in two public hospitals in south-eastern Ghana: a cross-sectional descriptive study. Qual Life Res 2024; 33:1095-1105. [PMID: 38326547 DOI: 10.1007/s11136-023-03589-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2023] [Indexed: 02/09/2024]
Abstract
BACKGROUND Diabetes is a significant contributor to kidney failure, heart attack, strokes, lower limb amputation, blindness, and other complications that negatively impact health-related quality of life (HRQOL). This study assessed the HRQOL and clinical outcomes of patients with diabetes accessing healthcare in south-eastern Ghana. METHODS This was a hospital-based cross-sectional descriptive study conducted in the Ho Municipal and Ho Teaching Hospitals in Ghana among patients with type 2 diabetes who were seeking healthcare at both hospitals for at least 12 months. Systematic random sampling technique was used to select 310 respondents out of the total sample size of 326 patients with type 2 diabetes and data were collected using diabetes-39 questionnaire. The data were analysed using STATA 16.0. Socio-demographic and clinical variables were expressed as frequencies and percentages. Differences between proportions were tested using Chi-square to identify predictors of poor HRQOL and Pearson correlation for association. The p < 0.05 was considered significant. RESULTS Out of 310 respondents, 171 (55.0%) had poor HRQOL. The predictors of poor HRQOL were age (p < 0.008), education (p < 0.028), employment (p < 0.001), residence (p < 0.01), duration of diabetes (p < 0.002), diabetes education (p < 0.001), BMI (p < 0.005), and glycaemic control (p < 0.001). Energy and mobility (63.2%), anxiety and worry (53.9%), and diabetes control (49.6%) dimensions were the most prevalent of poor HRQOL. Diabetes education, complications, being diabetic for 16 years and above, earning income, resident in rural area, being married, being pensioner and national Service Personnel, and diabetes comorbidities were significantly associated with HRQOL. CONCLUSIONS More than half of the respondents had poor HRQOL. Clinical and public health efforts should focus on effective control and screening measures for the individual patients and general population.
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Affiliation(s)
- Stanley Kofi Alor
- Department of Social and Behavioural Sciences, School of Public Health, University of Ghana, Legon, Accra, Ghana.
- Nursing and Midwifery Training College, 37 Military Hospital, Neghelli Barracks, Accra, Ghana.
| | - Franklin N Glozah
- Department of Social and Behavioural Sciences, School of Public Health, University of Ghana, Legon, Accra, Ghana
| | - Irene Akwo Kretchy
- Department of Pharmacy Practice and Clinical Pharmacy, School of Pharmacy, University of Ghana, Legon, Accra, Ghana
| | - Philip Baba Adongo
- Department of Social and Behavioural Sciences, School of Public Health, University of Ghana, Legon, Accra, Ghana
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2
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Crane JC, Gordon MJ, Basen-Engquist K, Ferrajoli A, Markofski MM, Lee CY, Fares S, Simpson RJ, LaVoy EC. Relationships between T-lymphocytes and physical function in adults with chronic lymphocytic leukemia: Results from the HEALTH4CLL pilot study. Eur J Haematol 2023; 110:732-742. [PMID: 36946440 PMCID: PMC10929688 DOI: 10.1111/ejh.13958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 03/15/2023] [Accepted: 03/20/2023] [Indexed: 03/23/2023]
Abstract
OBJECTIVE Examine physical function and T-cell phenotype in patients with chronic lymphocytic leukemia (CLL) before and after a physical activity (PA) intervention. METHODS Physical function measures and blood samples were collected from CLL patients (Rai stage 0-4, 50% receiving targeted therapy, N = 24) enrolled in a 16-week intervention of at-home aerobic and/or resistance exercise. Flow cytometry characterized T-cells in cryopreserved peripheral blood cells. Wilcoxon signed-rank test compared physical function and T-cell phenotype at baseline and 16-weeks; Kendall's Tau assessed associations between variables. RESULTS Godin leisure-time PA score increased from baseline to 16-weeks (mean difference: 14.61, p < .01) and fatigue decreased (mean difference: 6.71, p < .001). At baseline, lower fatigue correlated with a lower proportion of CD8+ T-cells (τ = 0.32, p = .03) and cardiorespiratory fitness (CRF) inversely correlated with the percentage of PD-1+CD8+ T-cells (τ -0.31, p = .03). At 16-weeks, CRF inversely correlated with the proportion of PD-1+CD4+ T-cells (τ -0.34, p = .02). Reduced fatigue at 16-weeks correlated with an increased CD4:CD8 ratio (τ = 0.36, p = .02) and lower percentage of HLA-DR+PD-1+CD4+ T-cells (τ = -0.37, p = .01). CONCLUSIONS This intervention increased leisure-time PA and decreased fatigue in CLL patients. These changes correlated with an increased CD4:CD8 T-cell ratio and reduced proportion of T-cells subsets previously associated with poor outcomes in CLL patients. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02194387.
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Affiliation(s)
- Justin C. Crane
- Department of Health and Human Performance, University of Houston; Houston, TX, USA
| | - Max J. Gordon
- The University of Texas MD Anderson Cancer Center; Houston, TX, USA
| | - Karen Basen-Engquist
- The University of Texas MD Anderson Cancer Center; Houston, TX, USA
- Department of Behavioral Science, Division of Cancer Prevention and Population Services, The University of Texas MD Anderson Cancer Center; Houston, TX, USA
- Center for Energy Balance in Cancer Prevention and Survivorship, Division of Cancer Prevention and Population Sciences, The University of Texas MD Anderson Cancer Center; Houston, TX, USA
- Department of Health Promotion and Behavioral Sciences, The University of Texas School of Public Health; Houston, TX, USA
- Department of Kinesiology, Rice University; Houston, TX, USA
| | - Alessandra Ferrajoli
- The University of Texas MD Anderson Cancer Center; Houston, TX, USA
- Department of Leukemia, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center; Houston, TX, USA
| | - Melissa M. Markofski
- Department of Health and Human Performance, University of Houston; Houston, TX, USA
| | - Che Young Lee
- The University of Texas MD Anderson Cancer Center; Houston, TX, USA
- Department of Behavioral Science, Division of Cancer Prevention and Population Services, The University of Texas MD Anderson Cancer Center; Houston, TX, USA
| | - Sara Fares
- The University of Texas MD Anderson Cancer Center; Houston, TX, USA
- Department of Behavioral Science, Division of Cancer Prevention and Population Services, The University of Texas MD Anderson Cancer Center; Houston, TX, USA
| | - Richard J Simpson
- School of Nutritional Sciences and Wellness, The University of Arizona; Tucson, AZ, USA
- Department of Pediatrics, The University of Arizona; Tucson, AZ, USA
- Department of Immunobiology, The University of Arizona; Tucson, AZ, USA
- The University of Arizona Cancer Center; Tucson, AZ, USA
| | - Emily C. LaVoy
- Department of Health and Human Performance, University of Houston; Houston, TX, USA
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Anghelina M, Naughton MJ, Zhao Q, Ruppert AS, Neal J, Rogers KA, Blachly JS, Lozanski G, Bhat SA, Kraut E, Epperla N, Mathur P, Zent CS, Banerji V, Dearden C, Hutchinson T, Grever M, Andritsos LA. Patient-driven research: Initial results from a prospective health-related quality of life study performed at the request of patients living with hairy cell leukemia. Leuk Res 2022; 120:106919. [PMID: 35870292 DOI: 10.1016/j.leukres.2022.106919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 07/11/2022] [Accepted: 07/12/2022] [Indexed: 11/28/2022]
Abstract
A diagnosis of leukemia can have a profound effect on patients' health-related quality of life (HRQoL), however this has not been measured prospectively in patients with hairy cell leukemia (HCL). At the request of patients living with HCL who had identified this gap in knowledge about the disease, we conducted a longitudinal study of HRQoL among patients enrolled in the HCL Patient Data Registry (PDR). From September 1, 2018 to September 1, 2020, 165 patients were enrolled in the study and completed the baseline survey. The Functional Assessment of Cancer Therapy - Leukemia (FACT-Leu) was used to measure patients' HRQoL. Results show that newly diagnosed HCL patients reported the lowest HRQoL, followed by patients in relapse and those on "watch and wait." Factors associated with higher (better) FACT-Leu total scores in the multivariable analysis included older age, higher social support, and greater physical activity. These same factors were associated with lower levels of fatigue. In rare diseases where it is difficult to perform large prospective studies, patient/researcher collaborations are critical for the identification of studies that are of importance to patients and their families in order to maximize the benefits of the research and improve the lives of patients living with HCL.
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Affiliation(s)
- Mirela Anghelina
- Division of Hematology, Department of Internal Medicine, Comprehensive Cancer Center, The Ohio State University, Columbus, OH, United States; Department of Biomedical Informatics, The Ohio State University, Columbus, OH, United States.
| | - Michelle J Naughton
- Division of Cancer Prevention and Control, The Ohio State University, Columbus, OH, United States
| | - Qiuhong Zhao
- Division of Hematology, Department of Internal Medicine, Comprehensive Cancer Center, The Ohio State University, Columbus, OH, United States
| | - Amy S Ruppert
- Division of Hematology, Department of Internal Medicine, Comprehensive Cancer Center, The Ohio State University, Columbus, OH, United States
| | - Jasmine Neal
- Comprehensive Cancer Center, The Ohio State University, Columbus, OH, United States
| | - Kerry A Rogers
- Division of Hematology, Department of Internal Medicine, Comprehensive Cancer Center, The Ohio State University, Columbus, OH, United States
| | - James S Blachly
- Division of Hematology, Department of Internal Medicine, Comprehensive Cancer Center, The Ohio State University, Columbus, OH, United States
| | - Gerard Lozanski
- Department of Pathology, The Ohio State University, Columbus, OH, United States
| | - Seema A Bhat
- Division of Hematology, Department of Internal Medicine, Comprehensive Cancer Center, The Ohio State University, Columbus, OH, United States
| | - Eric Kraut
- Division of Hematology, Department of Internal Medicine, Comprehensive Cancer Center, The Ohio State University, Columbus, OH, United States
| | - Narendranath Epperla
- Division of Hematology, Department of Internal Medicine, Comprehensive Cancer Center, The Ohio State University, Columbus, OH, United States
| | - Puneet Mathur
- Department of Research Information Technology, College of Medicine, The Ohio State University, Columbus, OH, United States
| | - Clive S Zent
- Wilmot Cancer Institute, University of Rochester, Rochester, NY, United States
| | - Versha Banerji
- CancerCare Manitoba Research Institute (Formerly, Manitoba Institute of Cell Biology), Winnipeg, MB, Canada; Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
| | | | - Terri Hutchinson
- WJB Dorn Veterans Administration Medical Center, SC, United States
| | - Michael Grever
- Division of Hematology, Department of Internal Medicine, Comprehensive Cancer Center, The Ohio State University, Columbus, OH, United States
| | - Leslie A Andritsos
- Division of Hematology/Oncology, University of New Mexico, Albuquerque, NM, United States
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Improvements in Health-related Quality of Life and Symptoms in Patients With Previously Untreated Chronic Lymphocytic Leukemia: Final Results From the Phase II GIBB Study of the Combination of Obinutuzumab and Bendamustine. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2021; 22:121-128. [PMID: 34674981 DOI: 10.1016/j.clml.2021.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 09/02/2021] [Accepted: 09/08/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND We evaluated health-related quality of life (HRQoL) in patients with chronic lymphocytic leukemia (CLL) receiving first-line chemoimmunotherapy in the GIBB single-arm, Phase II study of obinutuzumab plus bendamustine (BG). MATERIALS AND METHODS Patients received six 28-day cycles of BG and were followed for up to 27 months. HRQoL was assessed using the European Organization for Research and Treatment of Cancer Quality of Life Core 30 (EORTC QLQ-C30) and EORTC QLQ Chronic Lymphocytic Leukemia 16 (QLQ-CLL16) questionnaires. Scores were linear-transformed to a 100-point scale, with clinically meaningful responses defined as a ≥ 10-point change from baseline. RESULTS The patient-reported outcome (PRO) population comprised 98 patients (68.4% male; median age 61 years). EORTC QLQ-C30 global health status improvements were noted at all follow-up visits and were clinically meaningful 2 to 3 months after induction and at 3- and 27-months' follow-up. Clinically meaningful improvements were also observed for the EORTC QLQ-C30 role functioning, emotional functioning, fatigue and insomnia scales and the EORTC QLQ-CLL16 fatigue, disease symptoms and future health worries scales. Global health status was maintained throughout follow-up, and no clinically relevant deterioration in other HRQoL parameters was observed. CONCLUSION PRO data from the GIBB study show improved overall HRQoL in patients with CLL who received first-line chemoimmunotherapy with BG.
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Zeng X, Sui M, Liu R, Qian X, Li W, Zheng E, Yang J, Li J, Huang W, Yang H, Yu H, Luo N. Assessment of the health utility of patients with leukemia in China. Health Qual Life Outcomes 2021; 19:65. [PMID: 33639980 PMCID: PMC7913428 DOI: 10.1186/s12955-021-01711-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 02/18/2021] [Indexed: 12/09/2022] Open
Abstract
OBJECTIVES This study aimed to assess the health utility of leukemia patients in China using the EQ-5D-5L, compare it with the population norms, and identify the potential factors associated with health utility. METHODS A hospital based cross-sectional survey was conducted in three tertiary hospitals from July 2015 to February 2016. A total of 186 patients with leukemia completed the EQ-5D-5L and their health utility scores were calculated using the Chinese value set. EQ-5D-5L utility and dimensions scores of leukemia patients were compared with China's population norms using Kruskal-Wallis test and chi square test. Potential factors associated with health utility were identified using Tobit regression. RESULTS The mean EQ-5D-5L utility scores of patients with leukemia, grouped by either gender or age, were significantly lower than those of the general population (p < 0.001). The same results were found for individual dimensions of EQ-5D-5L, where leukemia patients reported more health problems than the general population (p < 0.001). The utility score of leukemia patients was found to be significantly related to medical insurance, religious belief, comorbidities, social support and ECOG performance status. CONCLUSION This study indicated that leukemia patients have worse health status compared to the general population of China and that multiple factors affect the health utility of the patients. The utility scores reported in this study could be useful in future cost-utility analysis.
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Affiliation(s)
- Xueyun Zeng
- School of Health Management, Harbin Medical University, Harbin, 150086, China
| | - Mingjie Sui
- School of Health Management, Harbin Medical University, Harbin, 150086, China
| | - Rui Liu
- School of Health Management, Harbin Medical University, Harbin, 150086, China
| | - Xinyu Qian
- National University Singapore Saw Swee Hock School of Public Health, Singapore, 117549, Singapore
| | - Wenfeng Li
- Department of Hematology, The First Affiliated Hospital of Harbin Medical University, Harbin, 150001, China
| | - Erwei Zheng
- First Affiliated Hospital of Harbin Medical University, Harbin, 150001, China
| | - Jinjin Yang
- School of Health Management, Harbin Medical University, Harbin, 150086, China
| | - Jinmei Li
- Public Health Education and Information Center of Heilongjiang Province, Harbin, 150063, China
| | - Weidong Huang
- School of Health Management, Harbin Medical University, Harbin, 150086, China.
| | - Hongbin Yang
- Department of Medical Oncology, Third Affiliated Hospital of Harbin Medical University, Harbin, 150081, China.
| | - Hongjuan Yu
- Department of Hematology, The First Affiliated Hospital of Harbin Medical University, Harbin, 150001, China. .,Southern University of Science and Technology Hospital, Shenzhen, 518055, China.
| | - Nan Luo
- National University Singapore Saw Swee Hock School of Public Health, Singapore, 117549, Singapore
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6
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Eek D, Blowfield M, Krogh C, Chung H, Eyre TA. Development of a Conceptual Model of Chronic Lymphocytic Leukemia to Better Understand the Patient Experience. THE PATIENT 2021; 14:75-87. [PMID: 32808103 PMCID: PMC7794108 DOI: 10.1007/s40271-020-00440-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVE Understanding the patient experience is important for identifying the unmet need in chronic lymphocytic leukemia. The current study aimed to develop a comprehensive chronic lymphocytic leukemia conceptual model. METHODS The conceptual model was based on literature searches, review of chronic lymphocytic leukemia patient blogs/forums, and interviews with five expert clinicians, with 20 patients who received at most one treatment (first line) for their chronic lymphocytic leukemia, and with 20 patients with relapsed or refractory chronic lymphocytic leukemia. De-identified interviews were transcribed, coded, and evaluated using qualitative data analysis software. RESULTS Thirty-five prevalent chronic lymphocytic leukemia-related symptom and impact concepts were identified from literature searches, patient blogs/forums, and clinician interviews. Patient interviews confirmed the identified concepts and revealed five additional concepts. Fatigue-related sub-components were identified from how patients described their fatigue, covering symptoms (tiredness/need for sleep, lack of energy, weakness, cognitive fatigue), and impacts (decreased ability to maintain their social, familial, or professional role, decreased physical functioning, frustration). Three versions of the conceptual model were created: an overall model with all concepts; a model highlighting the most prominent concepts in first line; and a model highlighting the most prominent concepts in relapsed or refractory disease. Prominent concepts in both first line and relapsed or refractory disease were fatigue-related symptoms and impacts, muscle/joint aches, night sweats, bruising, fever, recurrent infections/illness, insomnia, decreased cognitive/emotional functioning, anxiety/worry, stress, depression, financial difficulty, and fear of death. Dyspnea and cough were prominent in first line only, and enlarged lymph nodes, headaches, pain/discomfort, weight loss, nausea/vomiting, and infusion reactions were prominent in relapsed or refractory disease only. CONCLUSIONS The results show that fatigue is a dominant issue affecting patients with chronic lymphocytic leukemia. The three versions of the conceptual model can help researchers to understand patients' unmet needs and guide the patient-reported outcome strategy for clinical trials.
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Affiliation(s)
- Daniel Eek
- AstraZeneca Gothenburg, Pepparedsleden 1, SE 431 83, Mölndal, Sweden.
| | | | | | | | - Toby A Eyre
- Oxford Cancer and Haematology Centre, Churchill Hospital, Oxford, UK
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Waweru C, Kaur S, Sharma S, Mishra N. Health-related quality of life and economic burden of chronic lymphocytic leukemia in the era of novel targeted agents. Curr Med Res Opin 2020; 36:1481-1495. [PMID: 32634056 DOI: 10.1080/03007995.2020.1784120] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To quantify the health-related quality of life (HRQoL) and economic burden of chronic lymphocytic leukemia (CLL). METHODS Studies were searched through Embase, MEDLINE, PubMed, and Cochrane Library, as well as conference abstracts (1 January 2000-2 June 2019). RESULTS Overall, 12 and 17 primary studies were included in the HRQoL and economic burden reviews, respectively. Patients with CLL reported impairment in various quality of life domains when compared with healthy controls, including fatigue, anxiety, physical functioning, social functioning, depression, sleep disturbance, and pain interference. Key factors associated with a negative impact on the HRQoL burden of CLL included female gender, increased disease severity, and the initiation of multiple lines of therapy. Economic burden was assessed for patients with CLL based on disease status and the treatment regimen received. The main cost drivers related to CLL were outpatient and hospitalization-related costs, primarily incurred as a result of chemo/chemoimmunotherapy, adverse events (AEs), and disease progression. Treatment with targeted agents, i.e. ibrutinib and venetoclax, was associated with lower medical costs than chemoimmunotherapy, although ibrutinib was associated with some increased AE costs related to cardiac toxicities. Cost studies of targeted agents were limited by short follow-up times that did not capture the full scope of treatment costs. CONCLUSIONS CLL imposes a significant HRQoL and economic burden. Our systematic review shows that an unmet need persists in CLL for treatments that delay progression while minimizing AEs. Studies suggest targeted therapies may reduce the economic burden of CLL, but longer follow-up data are needed.
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Affiliation(s)
| | - Simarjeet Kaur
- Parexel Access Consulting, Parexel International, Mohali, India
| | - Sheetal Sharma
- Parexel Access Consulting, Parexel International, Mohali, India
| | - Namita Mishra
- Parexel Access Consulting, Parexel International, Mohali, India
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Sharman JP, Cocks K, Nabhan C, Lamanna N, Kay NE, Grinblatt DL, Flowers CR, Davids MS, Kiselev P, Swern AS, Sullivan K, Gharibo MM, Flick ED, Trigg A, Mato A. Longitudinal health-related quality of life in first-line treated patients with chronic lymphocytic leukemia: Results from the Connect ® CLL Registry. EJHAEM 2020; 1:188-198. [PMID: 35847738 PMCID: PMC9176138 DOI: 10.1002/jha2.67] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 07/10/2020] [Accepted: 07/12/2020] [Indexed: 06/15/2023]
Abstract
Health-related quality of life (HRQoL) in patients with chronic lymphocytic leukemia (CLL) is important in guiding treatment decisions. However, the impact of CLL treatment initiation on HRQoL is unclear. We assessed HRQoL using the FACT-Leu and EQ-5D-3L questionnaires in the Connect ® CLL Registry, a large, US-based, multicenter, prospective observational study of CLL patients enrolled between 2010 and 2014, prior to the introduction of novel therapies. Among 889 patients initiating first-line therapy with chemoimmunotherapy or rituximab monotherapy, questionnaire completion rates were 95.7% and 95.8% at enrollment, and 70.8% and 69.4% at 12 months, for FACT-Leu Total and EQ-5D-3L, respectively. For 849 patients completing all five FACT-Leu components, average total scores were 135.7 at enrollment and 141.6 at 12 months. Among 526 patients with FACT-Leu Total scores at enrollment and 12 months, clinically meaningful (≥11-point) improvements or reductions were observed in 179 (34.0%) and 88 (16.7%) patients, respectively. Mean EQ-5D-3L index scores were 0.87 at enrollment and 12 months. Among 513 patients completing EQ-5D-3L at enrollment and 12 months, clinically meaningful (≥0.06-point) improvements or reductions were observed in 125 (24.4%) and 116 (22.6%) patients, respectively. In the Connect® CLL Registry, HRQoL remained stable or slightly improved after 12 months of follow-up.
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Affiliation(s)
- Jeff P. Sharman
- Willamette Valley Cancer InstituteUS OncologyEugeneOregonUSA
| | | | - Chadi Nabhan
- Caris Life SciencesDallasTexasUSA
- University of South CarolinaColumbiaSouth CarolinaUSA
| | - Nicole Lamanna
- Division of Hematology and OncologyDepartment of MedicineNew York‐Presbyterian/Columbia University Medical CenterNew YorkNew YorkUSA
| | - Neil E. Kay
- Division of HematologyMayo ClinicRochesterMinnesotaUSA
| | | | | | - Matthew S. Davids
- Department of Medical OncologyDana‐Farber Cancer InstituteBostonMassachusettsUSA
| | | | | | | | | | | | | | - Anthony Mato
- Memorial Sloan Kettering Cancer CenterNew YorkNew YorkUSA
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Golicki D, Jaśkowiak K, Wójcik A, Młyńczak K, Dobrowolska I, Gawrońska A, Basak G, Snarski E, Hołownia-Voloskova M, Jakubczyk M, Niewada M. EQ-5D-Derived Health State Utility Values in Hematologic Malignancies: A Catalog of 796 Utilities Based on a Systematic Review. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2020; 23:953-968. [PMID: 32762998 DOI: 10.1016/j.jval.2020.04.1825] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 03/14/2020] [Accepted: 04/06/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES We performed a systematic review of health state utility values (HSUVs) obtained using the EQ-5D questionnaire for patients with hematologic malignancies. METHODS The following databases were searched up to September 2018: MEDLINE, EMBASE, The Cochrane Library, and the EQ-5D publications database on the EuroQol website. Additional references were extracted from reviewed articles. Only studies presenting EQ-Index results were incorporated. In view of the heterogeneity across the included publications, we limited ourselves to a narrative synthesis of original HSUVs found. RESULTS Fifty-nine studies (described in 63 articles) met the inclusion criteria. Data from 21 635 respondents provided 796 HSUV estimates for hematologic malignancy patients. EQ-Index scores ranged from -0.025 to 0.980. The most represented area was multiple myeloma (4 studies, 11 112 patients, and 249 HSUVs). In clinical areas such as chronic myeloid leukemia, acute myeloid leukemia, chronic lymphocytic leukemia, non-Hodgkin lymphoma, and mantle cell lymphoma, we described over 50 health utilities in each. In contrast, we identified only 13 HSUVs (based on 4 studies and the data of 166 patients) for Hodgkin lymphoma. Areas without EQ-5D-based health utilities comprised: polycythemia vera, primary myelofibrosis, essential thrombocythemia, mastocytosis, myeloid sarcoma, chronic myelomonocytic, eosinophilic leukemia, and neutrophilic leukemia. CONCLUSIONS There is a wide range of HSUVs available for hematologic cancer patients with different indications. The review provides a catalog of utility values for use in cost-effectiveness models for hematologic malignancies.
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Affiliation(s)
- Dominik Golicki
- Department of Experimental and Clinical Pharmacology, Medical University of Warsaw, Poland; HealthQuest Spółka z ograniczoną odpowiedzialnością Sp. k., Warsaw, Poland.
| | | | - Alicja Wójcik
- HealthQuest Spółka z ograniczoną odpowiedzialnością Sp. k., Warsaw, Poland
| | - Katarzyna Młyńczak
- Department of Experimental and Clinical Pharmacology, Medical University of Warsaw, Poland; HealthQuest Spółka z ograniczoną odpowiedzialnością Sp. k., Warsaw, Poland
| | - Iwona Dobrowolska
- HealthQuest Spółka z ograniczoną odpowiedzialnością Sp. k., Warsaw, Poland
| | | | - Grzegorz Basak
- Department of Hematology, Oncology and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Emilian Snarski
- Department of Hematology, Oncology and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Malwina Hołownia-Voloskova
- Department of Experimental and Clinical Pharmacology, Medical University of Warsaw, Poland; Scientific and Practical Center for Clinical Research and Health Technology Assessment, Moscow Department of Healthcare, Moscow, Russia
| | - Michał Jakubczyk
- HealthQuest Spółka z ograniczoną odpowiedzialnością Sp. k., Warsaw, Poland; Decision Analysis and Support Unit, SGH Warsaw School of Economics, Warsaw, Poland
| | - Maciej Niewada
- Department of Experimental and Clinical Pharmacology, Medical University of Warsaw, Poland; HealthQuest Spółka z ograniczoną odpowiedzialnością Sp. k., Warsaw, Poland
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Solvik E, Ytrehus S, Utne I, Grov EK. Pain, fatigue, anxiety and depression in older home-dwelling people with cancer. Nurs Open 2020; 7:430-438. [PMID: 31871728 PMCID: PMC6918018 DOI: 10.1002/nop2.406] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 10/07/2019] [Indexed: 11/22/2022] Open
Abstract
Aim Globally, cancer incidence counts for more than 14 million cases and the number increases with age. The aim of this study was to investigate the occurrence of pain, fatigue, anxiety and depression in association with demographic and clinical factors. Design A cross-sectional descriptive design was used. Methods We performed descriptive statistics to analyse the questionnaires completed from 174 older home-dwelling people with cancer. Results The people with cancer reported low occurrence of pain, fatigue, anxiety and depression. We found strong correlation between anxiety and depression. Women reported significantly higher scores of anxiety and depression than men. A higher pain score was associated with higher scores of fatigue and anxiety. Conclusions Home care personnel meeting older home-dwelling people with cancer should emphasize these people' mental health problems and be aware that pain, fatigue and anxiety may occur at the same time.
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Affiliation(s)
- Elena Solvik
- Department of Emergency ReceptionOstfold Hospital Trust, KalnesGrålumNorway
| | - Siri Ytrehus
- Faculty of HealthWestern Norway University of Applied SciencesBergenNorway
| | - Inger Utne
- Faculty of Health SciencesInstitute of Nursing and Health PromotionOslo Metropolitan UniversityOsloNorway
| | - Ellen Karine Grov
- Faculty of Health SciencesInstitute of Nursing and Health PromotionOslo Metropolitan UniversityOsloNorway
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11
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Sheehan JP, Grills I, Chiang VL, Dong H, Berg A, Warnick RE, Kondziolka D, Kavanagh B. Quality of life outcomes for brain metastasis patients treated with stereotactic radiosurgery: pre-procedural predictive factors from a prospective national registry. J Neurosurg 2019; 131:1848-1854. [PMID: 30579284 DOI: 10.3171/2018.8.jns181599] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 08/03/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Stereotactic radiosurgery (SRS) is increasingly used for the treatment of brain metastasis. To date, most studies have focused on survival, radiological response, or surrogate quality endpoints such as Karnofsky Performance Scale status or neurocognitive indices. The current study prospectively evaluated pre-procedural factors impacting quality of life in brain metastasis patients undergoing SRS. METHODS Using a national, cloud-based platform, patients undergoing SRS for brain metastasis were accrued to the registry. Quality of life prior to SRS was assessed using the 5-level EQ-5D (EQ5D-L) validated tool; additionally, patient and treatment attributes were collected. Patient quality of life was assessed as part of routine follow-up after SRS. Factors predicting a difference in the aggregate EQ5D-L score or the subscores were evaluated. Pre-SRS covariates impacting changes in EQ5D-L were statistically evaluated. Statistical analyses were conducted using multivariate linear regression models. RESULTS EQ5D-L results were available for 116 patients. EQ5D-L improvement (average of 0.387) was noted in patients treated with earlier SRS (p = 0.000175). Worsening overall EQ5D-L (average of 0.052 per lesion) was associated with an increased number of brain metastases at the time of initial presentation (p = 0.0399). Male sex predicted a risk of worsening (average of 0.347) of the pain and discomfort subscore at last follow-up (p = 0.004205). Baseline subscores of pain/discomfort were not correlated with pain/discomfort subscores at follow-up (p = 0.604), whereas baseline subscores of anxiety/depression were strongly positively correlated with the anxiety/depression follow-up subscores (p = 0.0039). CONCLUSIONS After SRS, quality of life was likely to improve in patients treated early with SRS and worsen in those with a greater number of brain metastases. Sex differences appear to exist regarding pain and discomfort worsening after SRS. Those with high levels of anxiety and depression at SRS may benefit from medical treatment as this particular quality of life factor generally remains unchanged after SRS.
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Affiliation(s)
- Jason P Sheehan
- 1Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Inga Grills
- 5Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Veronica L Chiang
- 3Department of Neurological Surgery, Yale University, New Haven, Connecticut
| | - Huamei Dong
- 2Penn State Medical Center, Hershey, Pennsylvania
| | - Arthur Berg
- 2Penn State Medical Center, Hershey, Pennsylvania
| | | | - Douglas Kondziolka
- 4Department of Neurological Surgery, New York University, New York, New York
| | - Brian Kavanagh
- 6Department of Radiation Oncology, University of Colorado, Denver, Colorado; and
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12
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Geue K, Götze H, Friedrich M, Leuteritz K, Mehnert-Theuerkauf A, Sender A, Stöbel-Richter Y, Köhler N. Perceived social support and associations with health-related quality of life in young versus older adult patients with haematological malignancies. Health Qual Life Outcomes 2019; 17:145. [PMID: 31438983 PMCID: PMC6704656 DOI: 10.1186/s12955-019-1202-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 07/18/2019] [Indexed: 01/23/2023] Open
Abstract
Background This study compared the perceived social support of young and older adult cancer patients, examining possible influencing factors as well as associations with health-related quality of life. Methods A total of 179 young patients (18–39 years) and 200 older adult patients (> 70 years) with haematological malignancies completed questionnaires on their perceived social support (ISSS-8, scales: Positive Support and Detrimental Interactions, range 0–16) and health-related quality of life (EORTC QLQ-C30). Tests for mean differences, correlations and regression analyses to determine associated variables of social support were performed. Results No difference was reported between young (M = 13.40, SD = 2.81) and older adult patients (M = 13.04, SD = 3.82; p = .313) for Positive Support. However, young patients (M = 4.16, SD = 3.10) reported having had more Detrimental Interactions than older patients did (M = 1.63, SD = 2.42; p < .001, Cohen’s d = .910). Comparison of the EORTC QLQ-C30 Function scales showed poorer outcomes for young patients on Emotional, Cognitive and Social Functions and a higher outcome on Physical Function compared with older adult patients. Regression analyses indicated that age (young vs. older adult patients) significantly explained proportions of variance in all models, with young age having a negative impact on Emotional, Cognitive and Social Functions and a positive impact on Physical and Role Functions compared with old age. Significant associations between Detrimental Interactions and all the scales examined except Cognitive Function were found. Conclusions The difference in negative perceptions of social support in young vs. older adult patients and its impact on health-related quality of life emphasises the necessity of differentiating between positive and negative social support. Negative interactions should be addressed through psychosocial care, particularly with young cancer patients.
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Affiliation(s)
- Kristina Geue
- Department of Medical Psychology and Medical Sociology, University of Leipzig, Philipp-Rosenthal-Str. 55, 04103, Leipzig, Germany.
| | - Heide Götze
- Department of Medical Psychology and Medical Sociology, University of Leipzig, Philipp-Rosenthal-Str. 55, 04103, Leipzig, Germany
| | - Michael Friedrich
- Department of Medical Psychology and Medical Sociology, University of Leipzig, Philipp-Rosenthal-Str. 55, 04103, Leipzig, Germany
| | - Katja Leuteritz
- Department of Medical Psychology and Medical Sociology, University of Leipzig, Philipp-Rosenthal-Str. 55, 04103, Leipzig, Germany
| | - Anja Mehnert-Theuerkauf
- Department of Medical Psychology and Medical Sociology, University of Leipzig, Philipp-Rosenthal-Str. 55, 04103, Leipzig, Germany
| | - Annekathrin Sender
- Department of Medical Psychology and Medical Sociology, University of Leipzig, Philipp-Rosenthal-Str. 55, 04103, Leipzig, Germany
| | - Yve Stöbel-Richter
- University of Zittau / Goerlitz, Faculty of Managerial and Cultural Studies, 30 06 48, Goerlitz, Germany
| | - Norbert Köhler
- University of Leipzig, Clinical Trial Centre Leipzig, Coordinating Centre for Clinical Trials, Härtelstraße 16/18, 04107, Leipzig, Germany
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13
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Westbrook TD, Morrison EJ, Maddocks KJ, Awan FT, Jones JA, Woyach JA, Johnson AJ, Byrd JC, Andersen BL. Illness Perceptions in Chronic Lymphocytic Leukemia: Testing Leventhal's Self-regulatory Model. Ann Behav Med 2019; 53:839-848. [PMID: 30590383 DOI: 10.1093/abm/kay093] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Leventhal's Self-regulatory Model proposes that somatic characteristics of a health threat (e.g., symptom severity), and prior experience with the threat (e.g., unsuccessful treatment), are determinants of illness perceptions. Chronic lymphocytic leukemia (CLL) is appropriate for test of these postulates, having three phases differing in symptom severity and prior treatment experiences: indolent disease requiring no treatment (active surveillance; AS), symptomatic disease requiring a first treatment (FT), and highly symptomatic disease in those who have relapsed and/or failed to respond to prior treatments (relapsed/refractory; RR). PURPOSE To test symptom severity and prior treatment experiences as determinants of illness perceptions, illness perceptions were characterized and contrasted between CLL groups. METHODS Three hundred and thirty CLL patients (AS, n = 100; FT, n = 78; RR, n = 152) provided illness perception data on one occasion during a surveillance visit (AS) or prior to beginning treatment (FT, RR). RESULTS Analysis of variance with planned comparisons revealed that consequences, identity, and concern were least favorable among RR patients, followed by FT, then AS (ps < .01). AS patients endorsed the lowest levels of coherence (ps < .01), and the most chronic illness timeline (ps < .01). FT patients endorsed the highest levels of personal and treatment control (ps < .01). CONCLUSIONS Data provide preliminary empirical support for Self-regulatory Model postulates that symptom severity and prior disease experiences influence illness perceptions. Unique knowledge needs for AS patients and elevated psychological/physical symptoms for later-stage CLL patients may warrant clinical attention.
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Affiliation(s)
| | | | - Kami J Maddocks
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus
| | - Farrukh T Awan
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus
| | - Jeffrey A Jones
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus
| | - Jennifer A Woyach
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus
| | - Amy J Johnson
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus
| | - John C Byrd
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus
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14
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Robbertz AS, Weiss DM, Awan FT, Byrd JC, Rogers KA, Woyach JA. Identifying risk factors for depression and anxiety symptoms in patients with chronic lymphocytic leukemia. Support Care Cancer 2019; 28:1799-1807. [PMID: 31332513 DOI: 10.1007/s00520-019-04991-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 07/11/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE This study assessed whether empirically supported risk factors can identify future depression and anxiety symptoms in a specific cancer type, chronic lymphocytic leukemia (CLL). METHODS Patients enrolled in a CLL treatment clinical trial (N = 106) participated at baseline following informed consent and prior to treatment initiation. Risk factors with empirical support (personal or family psychiatric history, recurrent, advanced or progressive disease, low socioeconomic status, gender, medical comorbidities, and single marital status) and additional risk factors (cancer-specific stress, social contacts, negative life events, absolute lymphocyte counts, treatment group, and fatigue) were measured at baseline to predict depression and anxiety symptoms at 12 months. RESULTS Data show 14% (n = 15) and 12% (n = 13) of patients experienced moderate-severe depression and anxiety symptoms, respectively. Multiple linear regression analyses found medical comorbidities predicted 12-month anxiety symptoms (p < 0.05). Also, negative life events predicted depression and anxiety symptoms and fatigue predicted depression symptoms (p < 0.05). CONCLUSION Empirically supported risk factors associated with depression and anxiety symptoms are limited in predicting future depression and anxiety symptoms beyond initial screening in patients with CLL. In addition to levels of depression and anxiety symptoms at baseline, negative life events, higher levels of fatigue, and greater medical comorbidities were associated with future depression or anxiety symptoms in patients with CLL.
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Affiliation(s)
- Abigail S Robbertz
- Department of Psychology, The Ohio State University, 1835 Neil Avenue, Columbus, OH, 43210, USA.
| | - David M Weiss
- Department of Psychology, The Ohio State University, 1835 Neil Avenue, Columbus, OH, 43210, USA
| | - Farrukh T Awan
- Department of Psychology, The Ohio State University, 1835 Neil Avenue, Columbus, OH, 43210, USA
| | - John C Byrd
- Department of Psychology, The Ohio State University, 1835 Neil Avenue, Columbus, OH, 43210, USA
| | - Kerry A Rogers
- Department of Psychology, The Ohio State University, 1835 Neil Avenue, Columbus, OH, 43210, USA
| | - Jennifer A Woyach
- Department of Psychology, The Ohio State University, 1835 Neil Avenue, Columbus, OH, 43210, USA
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15
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Andersen BL, Goyal NG, Weiss DM, Westbrook TD, Maddocks KJ, Byrd JC, Johnson AJ. Cells, cytokines, chemokines, and cancer stress: A biobehavioral study of patients with chronic lymphocytic leukemia. Cancer 2018; 124:3240-3248. [PMID: 29757455 DOI: 10.1002/cncr.31538] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Revised: 03/21/2018] [Accepted: 04/05/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Chronic lymphocytic leukemia (CLL) is the most prevalent adult leukemia, with profound disease-related cellular, humoral, and innate immune suppression. The objective of this study was to study the correlations between stress and disease-specific, negative prognostic cellular, cytokine, and chemokine markers in patients with CLL. METHODS A single-group, observational design was used. Patients with relapsed/refractory CLL (N = 96) who were entering a phase 2 trial of an experimental therapy (ibrutinib) were studied. Before the first dose, a validated self-report measure of stress (the Impact of Event Scale) was completed, and blood was drawn for absolute lymphocyte counts (ALCs) and for cytokine and chemokine enzyme-linked immunosorbent assays. Multiple linear regression models tested stress as a concurrent predictor of ALCs; of cytokines (tumor necrosis factor α [TNFα], a proliferation-inducing ligand [APRIL], B-cell activating factor [BAFF], interleukin 6 [IL-6], IL-10, IL-16, and vascular endothelial growth factor [VEGF]); and of the chemokine (C-C motif) ligand 3 (CCL3). RESULTS Controlling for relevant demographic variables, comorbidities, CLL genetic risk (deletion of the short arm of chromosome 17 [del17p]), and correlates of inflammation, stress predicted higher ALCs (P < .05), and higher levels of TNFα (P < .05), IL-16 (P < .01), and CCL3 (P < .05). Stress was not associated with APRIL, BAFF, IL-6, IL-10, or VEGF. CONCLUSIONS Novel biobehavioral data from patients with relapsed/refractory CLL demonstrate that stress is related to heightened levels of cellular, cytokine, and chemokine markers associated previously with progressive disease in CLL. The current results indicate that stress is related to immune and inflammatory processes that contribute to cancer cell proliferation and survival. These data provide a first look into these processes. Cancer 2018. © 2018 American Cancer Society.
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Affiliation(s)
| | | | - David M Weiss
- Department of Psychology, The Ohio State University, Columbus, Ohio
| | | | - Kami J Maddocks
- The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - John C Byrd
- The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Amy J Johnson
- The Ohio State University Wexner Medical Center, Columbus, Ohio
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16
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Köhler N, Mehnert A, Götze H. Psychological distress, chronic conditions and quality of life in elderly hematologic cancer patients: study protocol of a prospective study. BMC Cancer 2017; 17:700. [PMID: 29070033 PMCID: PMC5655829 DOI: 10.1186/s12885-017-3662-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 09/28/2017] [Indexed: 02/07/2023] Open
Abstract
Background Similar to most solid tumors, the incidence of hematologic malignancies has been rising. Although the median age at diagnosis is about 70 years, little is known about psychosocial aspects and comorbid conditions in elderly patients with hematologic cancers. The main objectives of our study are to assess the prevalence of psychological distress, chronic conditions, functional disabilities, and quality of life in both elderly hematologic cancer patients aged ≥70 years and an age-matched comparison sample of the general population. Methods We conduct a prospective study with three measuring points (t_1: ≥5 years after first time hematologic cancer diagnosis / relapse; t_2 and t_3 six months and 1 year after t_1). In addition, we use a cross sectional study design to recruit a comparison sample of the general population matched by age and sex. Both samples, patients and the comparison group complete validated questionnaires measuring psychological distress, chronic conditions, functional disabilities, and quality of life as well as health care needs and health care utilization. Discussion Our study will provide both a data set offering detailed information about elderly hematologic cancer patients’ physical, psychological and demographic characteristics, and reference data of the elderly general population. Furthermore, the study will provide important information for the development and implementation of psychooncological support offers and survivorship care plans.
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Affiliation(s)
- Norbert Köhler
- Department of Medical Psychology and Medical Sociology, University Medical Center Leipzig, Philipp-Rosenthal-Strasse 55, 04103, Leipzig, Germany.
| | - Anja Mehnert
- Department of Medical Psychology and Medical Sociology, University Medical Center Leipzig, Philipp-Rosenthal-Strasse 55, 04103, Leipzig, Germany
| | - Heide Götze
- Department of Medical Psychology and Medical Sociology, University Medical Center Leipzig, Philipp-Rosenthal-Strasse 55, 04103, Leipzig, Germany
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17
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Differences in demographic, clinical, and symptom characteristics and quality of life outcomes among oncology patients with different types of pain. Pain 2017; 157:892-900. [PMID: 26683234 DOI: 10.1097/j.pain.0000000000000456] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The purposes of this study, in oncology outpatients receiving chemotherapy (n = 926), were to: describe the occurrence of different types of pain (ie, no pain, only noncancer pain [NCP], only cancer pain [CP], or both CP and NCP) and evaluate for differences in demographic, clinical, and symptom characteristics, and quality of life (QOL) among the 4 groups. Patients completed self-report questionnaires on demographic and symptom characteristics and QOL. Patients who had pain were asked to indicate if it was or was not related to their cancer or its treatment. Medical records were reviewed for information on cancer and its treatments. In this study, 72.5% of the patients reported pain. Of the 671 who reported pain, 21.5% reported only NCP, 37.0% only CP, and 41.5% both CP and NCP. Across the 3 pain groups, worst pain scores were in the moderate to severe range. Compared with the no pain group, patients with both CP and NCP were significantly younger, more likely to be female, have a higher level of comorbidity, and a poorer functional status. In addition, these patients reported: higher levels of depression, anxiety, fatigue, and sleep disturbance; lower levels of energy and attentional function; and poorer QOL. Patients with only NCP were significantly older than the other 3 groups. The most common comorbidities in the NCP group were back pain, hypertension, osteoarthritis, and depression. Unrelieved CP and NCP continue to be significant problems. Oncology outpatients need to be assessed for both CP and NCP conditions.
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18
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Jain P, Keating M, Renner S, Cleeland C, Xuelin H, Gonzalez GN, Harris D, Li P, Liu Z, Veletic I, Rozovski U, Jain N, Thompson P, Bose P, DiNardo C, Ferrajoli A, O'Brien S, Burger J, Wierda W, Verstovsek S, Kantarjian H, Estrov Z. Ruxolitinib for symptom control in patients with chronic lymphocytic leukaemia: a single-group, phase 2 trial. LANCET HAEMATOLOGY 2017; 4:e67-e74. [PMID: 28089238 PMCID: PMC5356368 DOI: 10.1016/s2352-3026(16)30194-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 11/04/2016] [Accepted: 11/10/2016] [Indexed: 12/17/2022]
Abstract
Background Disease-related symptoms impair the quality of life of countless patients with chronic lymphocytic leukemia (CLL) who do not require systemic therapy. Currently available therapies are not specifically aimed at symptom control. Because stimulation of the B-cell receptor activates Janus kinase (JAK)-2 in CLL cells and the JAK2 inhibitor ruxolitinib improves symptoms of patients with myelofibrosis, we hypothesized that ruxolitinib would improve disease-related symptoms in CLL patients. Methods Ruxolitinib (10 mg twice daily) was administered to symptomatic CLL patients who did not require systemic therapy for CLL. Scores on the brief fatigue inventory (BFI), CLL module of the MD Anderson symptom inventory (MDASI) and symptom-associated interference in daily activities (interference score; IS), were assessed prior to treatment and after 3 months of treatment. Plasma cytokine/chemokine levels were measured at baseline and at 3 months. Findings Forty-one CLL patients (25 untreated and 16 previously treated) were enrolled. Thirty-two (78%) of the participants experienced ≥20% reduction in the average BFI score or in the average MDASI score. 59% of the participants had ≥2 units reduction in worst fatigue score in 24 hours as assessed by the BFI. The mean percentage reductions in BFI, MDASI, and IS scores were >42% (p<0.0001). Improvements in the three symptom scores correlated with reductions in levels of IL-6, C-reactive protein, CXCL10, osteopontin, TNF-α, ICAM-1/CD54, VCAM-1/CD106, and beta-2 microglobulin. Furthermore, treatment with ruxolitinib increased and then decreased lymphocyte counts to baseline levels or lower. Grade 3/4 cytopenias were recorded in three patients. Interpretation In CLL patients, ruxolitinib significantly improved disease-related symptoms, reduced cytokine and chemokine levels, and increased and then decreased lymphocyte counts, likely through mobilization followed by apoptosis of CLL cells. Further studies aimed at testing the therapeutic efficacy of ruxolitinib in CLL are warranted. Funding Supported by the Incyte Corp., MD Anderson Cancer Center Support Grant CA016672 and Award Number P01 CA049639 from the National Cancer Institute.
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Affiliation(s)
- Preetesh Jain
- Departments of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michael Keating
- Departments of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sarah Renner
- Departments of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Charles Cleeland
- Symptom Research, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Huang Xuelin
- Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - David Harris
- Departments of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ping Li
- Departments of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Zhiming Liu
- Departments of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ivo Veletic
- Departments of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Uri Rozovski
- Departments of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nitin Jain
- Departments of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Phillip Thompson
- Departments of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Prithviraj Bose
- Departments of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Courtney DiNardo
- Departments of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Alessandra Ferrajoli
- Departments of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Susan O'Brien
- Departments of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jan Burger
- Departments of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - William Wierda
- Departments of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Srdan Verstovsek
- Departments of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hagop Kantarjian
- Departments of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Zeev Estrov
- Departments of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Morrison EJ, Flynn JM, Jones J, Byrd JC, Andersen BL. Individual differences in physical symptom burden and psychological responses in individuals with chronic lymphocytic leukemia. Ann Hematol 2016; 95:1989-1997. [PMID: 27539615 DOI: 10.1007/s00277-016-2790-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Accepted: 08/06/2016] [Indexed: 10/21/2022]
Abstract
Chronic lymphocytic leukemia (CLL) is an incurable illness, with some patients requiring no treatment until disease progression. Burden from physical symptoms has been associated with depression, anxiety, and stress in cancer patients. Additionally, patient factors, i.e., individual differences, have been associated with worse psychological outcomes. There are few psychological studies of CLL, with no examination of individual differences. A cross-sectional design studied the covariation of symptom burden with depressive and anxiety symptoms and cancer-specific stress, and tested patients' individual differences as predictors and as moderators. CLL patients (N = 112) receiving active surveillance participated. They were Caucasian (100 %) and predominately male (55 %) with a mean age of 61; most (62.5 %) had stage 0 disease. A composite measure of physical symptom burden (CLL symptoms, fatigue, pain, impaired functional status) was tested as a predictor of psychological responses. Individual differences in psychiatric history and social support were tested as moderators. Using multiple linear regression, greater symptom burden covaried with higher levels of depressive and anxiety symptoms and cancer stress (ps < .05). Those with a psychiatric history, low social support, and low relationship satisfaction with one's partner reported greater symptom burden and more psychological symptoms and stress (ps < .05). Findings suggest that CLL patients in surveillance with a psychiatric history and/or low social support are at risk for greater distress when coping with high symptom burden. These new data clarify the experience of CLL surveillance and identify characteristics of patients with heightened risk for symptom burden, stress, and anxiety or depressive symptoms.
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Affiliation(s)
- Eleshia J Morrison
- Department of Psychiatry and Psychology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Joseph M Flynn
- Norton Cancer Institute, 234 E Gray St, Louisville, KY, 40202, USA
| | - Jeffrey Jones
- Division of Hematology, The Ohio State University, Starling Loving Hall, 320 W 10th Avenue, Columbus, OH, 43210, USA
| | - John C Byrd
- Division of Hematology, The Ohio State University, Starling Loving Hall, 320 W 10th Avenue, Columbus, OH, 43210, USA
| | - Barbara L Andersen
- Department of Psychology, The Ohio State University, 1835 Neil Avenue, Columbus, OH, 43210, USA
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20
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Efficace F, Breccia M, Cottone F, Okumura I, Doro M, Riccardi F, Rosti G, Baccarani M. Psychological well-being and social support in chronic myeloid leukemia patients receiving lifelong targeted therapies. Support Care Cancer 2016; 24:4887-4894. [PMID: 27448405 DOI: 10.1007/s00520-016-3344-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 07/10/2016] [Indexed: 01/09/2023]
Abstract
PURPOSE The main objective of this study was to investigate whether social support is independently associated with psychological well-being in chronic myeloid leukemia (CML) patients. Secondary objectives were to compare the psychological well-being profile of CML patients with that of their peers in general population and to examine possible age- and sex-related differences. PATIENTS AND METHODS Analysis was performed on 417 patients in treatment with lifelong molecularly targeted therapies. Mean age of patients analyzed was 56 years (range 19-87 years) and 247 (59 %) were male and 170 (41 %) were female. Social support was assessed with the Multidimensional Scale of Perceived Social Support and psychological well-being was evaluated with the short version of the Psychological General Well-Being Index. Descriptive statistics and multivariate logistic regression analyses were used. RESULTS Multivariate logistic regression analysis revealed that a greater social support was independently associated with lower anxiety and depression, as well as with higher positive well-being, self-control, and vitality (p < 0.001). Female patients reported statistically significant worse outcomes in all dimensions of psychological well-being. Age- and sex-adjusted comparisons with population norms revealed that depression (ES = -0.42, p < 0.001) and self-control (ES = -0.48, p < 0.001) were the two main impaired psychological dimensions. CONCLUSION This study indicates that social support is a critical factor associated with psychological well-being of CML patients treated with modern lifelong targeted therapies.
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Affiliation(s)
- Fabio Efficace
- GIMEMA Data Center and Health Outcomes Research Unit, Italian Group for Adult Hematologic Diseases (GIMEMA), Via Benevento, 6, 00161, Rome, Italy.
| | - Massimo Breccia
- Department of Biotechnologies and Hematology, University of Rome Sapienza, Rome, Italy
| | - Francesco Cottone
- GIMEMA Data Center and Health Outcomes Research Unit, Italian Group for Adult Hematologic Diseases (GIMEMA), Via Benevento, 6, 00161, Rome, Italy
| | - Iris Okumura
- Unidade de Hematologia, Hemoterapia e Oncologia (UHHO), Serviço de Transplante de Medula Óssea (STMO), Complexo Hospital de Clínicas da Universidade Federal do Paraná, Curitiba, Brazil
| | - Maribel Doro
- Unidade de Hematologia, Hemoterapia e Oncologia (UHHO), Serviço de Transplante de Medula Óssea (STMO), Complexo Hospital de Clínicas da Universidade Federal do Paraná, Curitiba, Brazil
| | | | - Gianantonio Rosti
- Department of Hematology-Oncology, University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Michele Baccarani
- Department of Hematology-Oncology, University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy
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Kutsch N, Busch R, Bahlo J, Mayer J, Hensel M, Hopfinger G, Hess G, von Grünhagen U, Wendtner CM, Maria Fink A, Fischer K, Hallek M, Eichhorst B. FCR front-line therapy and quality of life in patients with chronic lymphocytic leukemia. Leuk Lymphoma 2016; 58:399-407. [PMID: 27357445 DOI: 10.1080/10428194.2016.1190966] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The chemoimmunotherapy FCR (fludarabine and cyclophosphamide with rituximab) is the standard first-line treatment for physically fit chronic lymphocytic leukemia (CLL) patients. To assess the risks and benefits, we investigated health-related quality of life (HRQOL). 817 untreated CLL patients received either FC or FCR within the GCLLSG CLL8 trial. The European Organization for Research and Treatment of Cancer Quality of life Questionnaire C30 was sent to all patients at baseline, after 3, 6, and 12 months and then yearly as follow-up. A total of 769 (94%) of 817 patients completed at least one questionnaire. Comparing HRQOL of CLL patients with the general German population, CLL patients' health declined in most scales except for global health and pain. No major differences in HRQOL were found during treatment or follow-up between both treatment arms. Females were more likely to have treatment-related symptoms than males. Although FCR was associated with more side effects, this did not influence HRQOL. During follow-up after FCR only minor improvement of HRQOL compared with FC was assessed.
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Affiliation(s)
- Nadine Kutsch
- a Department I of Internal Medicine and Center of Integrated Oncology Cologne Bonn , University Hospital of Cologne , Cologne , Germany
| | - Raymonde Busch
- b Institute of Medical Statistics and Epidemiology , Technical University , Munich , Germany
| | - Jasmin Bahlo
- a Department I of Internal Medicine and Center of Integrated Oncology Cologne Bonn , University Hospital of Cologne , Cologne , Germany
| | - Jiri Mayer
- c Department of Internal Medicine, Hematology and Oncology , University Hospital Brno , Brno , Czech Republic
| | - Manfred Hensel
- d Internal Medicine V , University of Heidelberg , Heidelberg , Germany
| | - Georg Hopfinger
- e Department of Internal Medicine I, Vienna General Hospital, Medical University of Vienna , Vienna , Austria
| | - Georg Hess
- f Department of Hematology and Oncology , Johannes Gutenberg-Universitat , Mainz , Germany
| | | | - Clemens-Martin Wendtner
- a Department I of Internal Medicine and Center of Integrated Oncology Cologne Bonn , University Hospital of Cologne , Cologne , Germany.,h Department of Hematology, Oncology, Immunology, Palliative Care, Infectious Diseases and Tropical Medicine , Klinikum Schwabing , Munich , Germany
| | - Anna Maria Fink
- a Department I of Internal Medicine and Center of Integrated Oncology Cologne Bonn , University Hospital of Cologne , Cologne , Germany
| | - Kirsten Fischer
- a Department I of Internal Medicine and Center of Integrated Oncology Cologne Bonn , University Hospital of Cologne , Cologne , Germany
| | - Michael Hallek
- a Department I of Internal Medicine and Center of Integrated Oncology Cologne Bonn , University Hospital of Cologne , Cologne , Germany
| | - Barbara Eichhorst
- a Department I of Internal Medicine and Center of Integrated Oncology Cologne Bonn , University Hospital of Cologne , Cologne , Germany
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22
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West C, Paul SM, Dunn L, Dhruva A, Merriman J, Miaskowski C. Gender Differences in Predictors of Quality of Life at the Initiation of Radiation Therapy. Oncol Nurs Forum 2016; 42:507-16. [PMID: 26302279 DOI: 10.1188/15.onf.507-516] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
PURPOSE/OBJECTIVES To evaluate gender differences in quality of life (QOL), demographic, clinical, and symptom characteristics.
DESIGN Prospective, observational.
SETTING Two radiation oncology departments in northern California.
SAMPLE 185 patients before initiation of radiation therapy (RT).
METHODS At their RT simulation visit, patients completed a demographic questionnaire, a measure of QOL, and symptom-specific scales. Backward elimination regression analyses were conducted to determine the significant predictors of QOL
. MAIN RESEARCH VARIABLES QOL, gender, and 20 potential predictors
. FINDINGS In women, depressive symptoms, functional status, age, and having children at home explained 64% of the variance in QOL. In men, depressive symptoms, state anxiety, number of comorbidities, being a member of a racial or ethnic minority, and age explained 70% of the variance in QOL
. CONCLUSIONS Predictors of QOL differed by gender. Depressive symptom score was the greatest contributor to QOL in both genders.
. IMPLICATIONS FOR NURSING Nurses need to assess for QOL and depression at the initiation of RT. Knowledge of the different predictors of QOL may be useful in the design of gender-specific interventions to improve QOL.
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23
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Frey S, Blankart CR, Stargardt T. Economic Burden and Quality-of-Life Effects of Chronic Lymphocytic Leukemia: A Systematic Review of the Literature. PHARMACOECONOMICS 2016; 34:479-98. [PMID: 26739956 DOI: 10.1007/s40273-015-0367-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
BACKGROUND Chronic lymphocytic leukemia (CLL) is the most prevalent type of leukemia in the Western hemisphere. The disease affects quality of life (QOL) and poses an economic burden on patients, payers, and society. The objective of this review was to quantify the economic burden and quality-of-life effects and identify the gaps that should be addressed by future research. METHODS Free-text and subject heading searches in MEDLINE, EMBASE, the Cochrane Library, the University of York Centre for Reviews and Dissemination Database, and the Web of Science Core Collection database were conducted to identify observational and interventional studies reporting costs and/or quality-of-life effects published up to 2 October 2015. Studies were included irrespective of whether they were conducted prospectively or retrospectively. The focus population consisted of adult patients aged 18 years or older affected by any stage of CLL. Studies were included regardless of whether the underlying population was treated at baseline or not. Risk of bias was assessed using a quality checklist developed by the Effective Public Health Practice Project for (randomized) controlled trials, cohort studies, and cross-sectional studies. Economic evaluations were rated using a checklist developed by Stuhldreher et al. (Int J Eat Disord 45:476-91, 2012). RESULTS From 2451 records identified, 27 studies were found to be eligible for inclusion. Studies were heterogeneous with respect to methodology, perspective, and data used. Annual direct costs per person ranged from US$4491 in Germany to US$43,913 in the USA. The share of costs attributable to drug treatment varied between 26.2 and 79 %. Indirect costs amounted to US$4208. Severity of disease was a predictor for quality of life, whereas differences by age and sex were mainly present in subdomains. Comparisons of treated and untreated populations resulted in an increase of quality of life in favor of treated populations in the long-term perspective. Differences between treatments were small. Consequently, cost effectiveness in decision-analytic models did not depend on whether quality of life or survival are used to describe the benefits of treatment. CONCLUSIONS Although the quantity and the quality of health economic and quality-of-life evidence have substantially increased, there is still a need for studies that take a patient or societal perspective. Factors that influence costs and the quality of life of patients seem to be well-established, while longitudinal lifetime cost studies at the population level are still scarce.
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Affiliation(s)
- Simon Frey
- Hamburg Center for Health Economics, Universität Hamburg, Esplanade 36, 20354, Hamburg, Germany
| | - Carl R Blankart
- Hamburg Center for Health Economics, Universität Hamburg, Esplanade 36, 20354, Hamburg, Germany
- Center for Gerontology and Health Care Research, School of Public Health, Brown University, Providence, RI, USA
| | - Tom Stargardt
- Hamburg Center for Health Economics, Universität Hamburg, Esplanade 36, 20354, Hamburg, Germany.
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24
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Holtzer-Goor KM, Schaafsma MR, Joosten P, Posthuma EFM, Wittebol S, Huijgens PC, Mattijssen EJM, Vreugdenhil G, Visser H, Peters WG, Erjavec Z, Wijermans PW, Daenen SMGJ, van der Hem KG, van Oers MHJ, Uyl-de Groot CA. Quality of life of patients with chronic lymphocytic leukaemia in the Netherlands: results of a longitudinal multicentre study. Qual Life Res 2015. [PMID: 26205768 PMCID: PMC4615661 DOI: 10.1007/s11136-015-1039-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Purpose To describe the health-related quality of life (HRQoL) of an unselected population of patients with chronic lymphocytic leukaemia (CLL) including untreated patients. Methods HRQoL was measured by the EORTC QLQ-C30 including the CLL16 module, EQ-5D, and VAS in an observational study over multiple years. All HRQoL measurements per patient were connected and analysed using area under the curve analysis over the entire study duration. The total patient group was compared with the general population, and three groups of CLL patients were described separately, i.e. patients without any active treatment (“watch and wait”), chlorambucil treatment only, and patients with other treatment(s). Results HRQoL in the total group of CLL patients was compromised when compared with age- and gender-matched norm scores of the general population. CLL patients scored statistically worse on the VAS and utility score of the EQ-5D, all functioning scales of the EORTC QLQ-C30, and the symptoms of fatigue, dyspnoea, sleeping disturbance, appetite loss, and financial difficulties. In untreated patients, the HRQoL was slightly reduced. In all treatment stages, HRQoL was compromised considerably. Patients treated with chlorambucil only scored worse on the EORTC QLQ-C30 than patients who were treated with other treatments with regard to emotional functioning, cognitive functioning, bruises, uncomfortable stomach, and apathy. Conclusions CLL patients differ most from the general population on role functioning, fatigue, concerns about future health, and having not enough energy. Once treatment is indicated, HRQoL becomes considerably compromised. This applies to all treatments, including chlorambucil, which is considered to be a mild treatment. Electronic supplementary material The online version of this article (doi:10.1007/s11136-015-1039-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- K M Holtzer-Goor
- Department of Health Policy and Management, Erasmus University Rotterdam, Institute for Medical Technology Assessment, P.O. Box 1738, 3000DR, Rotterdam, The Netherlands.
| | | | - P Joosten
- Medisch Centrum Leeuwarden, Leeuwarden, The Netherlands
| | - E F M Posthuma
- Leiden University Medical Center, Leiden, The Netherlands.,Reinier de Graaf Groep, Delft, The Netherlands
| | - S Wittebol
- Meander Medisch Centrum, Amersfoort, The Netherlands
| | - P C Huijgens
- VU University Medical Center, Amsterdam, The Netherlands
| | | | - G Vreugdenhil
- Máxima Medisch Centrum, Veldhoven, The Netherlands.,MUMC+, Maastricht, The Netherlands
| | - H Visser
- Medisch Centrum Alkmaar, Alkmaar, The Netherlands
| | - W G Peters
- Catharina-ziekenhuis, Eindhoven, The Netherlands
| | - Z Erjavec
- Ommelander Ziekenhuis Groep, Delfzijl, The Netherlands
| | | | - S M G J Daenen
- UMCG, University of Groningen, Groningen, The Netherlands
| | | | - M H J van Oers
- Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - C A Uyl-de Groot
- Department of Health Policy and Management, Erasmus University Rotterdam, Institute for Medical Technology Assessment, P.O. Box 1738, 3000DR, Rotterdam, The Netherlands
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