Measuring health-related quality of life in high-grade glioma patients at the end of life using a proxy-reported retrospective questionnaire

Quality of life in patients with glioblastoma and their relatives

OBJECTIVES

Glioblastoma is the most aggressive primary brain tumour in adults. The rapid decline of physical and cognitive functions is likely to affect patients and relatives during the entire course of disease. The aim of this study was to describe and compare (a) health-related quality of life (HRQoL) and psychological symptoms between patients with glioblastoma and their relatives, and (b) HRQoL between patients and a general population over time.

METHODS

At baseline, 63 patients and 63 relatives were included. The participants completed the Short Form Health Survey (SF-36) and the Hospital Anxiety and Depression scale (HADS) at seven different occasions from pre-surgery until two years post-surgery. A comparison of SF-36 was made between patients and an age- and gender-matched control group. Descriptive analysis, effect size and Wilcoxon signed-rank test were used.

RESULTS

Relatives scored lower health-related quality of life (HRQoL) and higher symptoms of anxiety than patients, whilst patients scored worse in the physical parts of the SF-36. Three weeks post-surgery, relatives scored their lowest HRQoL and had the highest risk of anxiety symptoms. Comparing patients with controls, the patients rated worse in both the mental and physical component summaries in HRQoL at most time points.

CONCLUSION

Both patients and relatives showed deterioration of HRQoL. In addition, relatives showed high frequency of anxiety symptoms. Our data reveal that relatives of patients with glioblastoma need attention throughout the disease trajectory and they also need support at the right time point.

Notable response of a young adult with recurrent glioblastoma multiforme to vincristine-irinotecan-temozolomide and bevacizumab

Glioblastoma multiforme is a malignant central nervous system (CNS) disease with dismal prognosis. Current treatment modalities only offer modest activity and usually of short duration, so there is an urgent need for the conduct of clinical trials exploring new treatment options and modalities. The vincristine-irinotecan-temozolomide and bevacizumab (VITb) regimen is an option of special interest, as it has produced encouraging results in young patients with various relapsed/refractory childhood and adolescence solid tumors, with an acceptable toxicity profile. With the current report, we present the case of a young male patient who was treated for GBM in second relapse at out institution, after previous surgical attempts and two radiotherapy sessions in conjunction with temozolomide and experienced a major and long-lasting response, weaned off steroids, to the VITb regimen followed by bevacizumab maintenance. The above case is discussed in the context of the existing literature regarding available evidence of synergy between the drugs used and the activity of certain components of the combination (i.e. combination of temozolomide-irinotecan ± vincristine, or bevacizumab-irinotecan in GBM) or the complete VITb regimen in other pediatric/adolescence solid tumors and the few cases reported with GBM.

Health-related quality of life and emotional well-being in patients with glioblastoma and their relatives

PURPOSE

The health-related quality of life (HRQoL) for patients with glioblastoma is known to be largely affected. Little is known about the HRQoL for relatives and the relationship between these two. To optimize family care, such issues need to be addressed early on, preferably from the time of diagnosis. This study aimed to describe and compare the HRQoL of patients with glioblastoma and their relatives before surgery.

METHODS

A prospective cohort study including 89 patients diagnosed with glioblastoma and their relatives. HRQoL (Short Form Health Survey, SF-36) and emotional well-being (hospital anxiety and depression scale, HADS) were analysed with descriptive, comparative and multivariable regression analyses.

RESULTS

Relatives scored worse for mental HRQoL (p < 0.001) and for symptoms of anxiety (p < 0.001) and depression (p = 0.022) compared to patients. The multivariable regression showed an increased risk of affected mental HRQoL in relatives of patients with poor functional status (WHO) (p = 0.01) and higher levels in symptoms of anxiety (p = 0.03), or when relatives had low physical HRQoL themselves (p = 0.01). There was increased risk of affected mental HRQoL in patients with comorbidities (p = 0.003), and when the respective relative showed higher levels in symptoms of anxiety (p = 0.005).

CONCLUSION

Relatives scored worse for mental HRQoL and emotional well-being than patients, suggesting that HRQoL in patients and relatives might be connected to symptoms of anxiety in the respective individual at disease onset. The results illustrate the need to screen HRQoL and emotional well-being in both patients and relatives from an early stage-before surgery.

End-of-Life Care for Patients with Glioma

OBJECTIVE

To describe best practices and guidelines in symptom management at the end of life for adults with malignant glioma.

DATA SOURCES

Journal articles, evidence-based reviews, textbooks, and clinical guidelines.

CONCLUSION

Symptom management is an essential element of end-of-life care that aims to preserve dignity and quality of life for patients with glioma and their family caregivers.

IMPLICATIONS FOR NURSING PRACTICE

Advance care planning using a holistic approach to the patient's symptoms experience and goals of care are necessary to develop, implement, and evaluate outcomes of an evidence-based plan of care tailored for each patient and family.

Compliance with patient-reported outcome assessment in glioma patients: predictors for drop out

Background

Patient-reported outcomes are of high importance in clinical neuro-oncology. However, assessment is still suboptimal. We aimed at exploring factors associated with the probability for a) drop out of study and b) death during follow-up.

Methods

Patients were assessed twice during follow-up visits scheduled within 3 to 5 months of each other by using 3 validated patient-reported outcome measures (t1: first assessment, t2: second assessment). As "death" was seen as a competing risk for drop out, univariate competing risk Cox regression models were applied to explore factors associated with dropping out (age, gender, WHO grade, living situation, recurrent surgery, Karnofsky Performance Status, time since diagnosis, and patient-reported outcomes assessed by Distress Thermometer, EORTC-QLQ-C30, EORTC-QLQ-BN20, and SCNS-SF-34G).

Results

Two hundred forty-six patients were eligible, 173 (70%) participated. Patients declining participation were diagnosed with glioblastomas more often than with other gliomas (56% vs 39%). At t2, 32 (18%) patients dropped out, n = 14 death-related, n = 18 for other reasons. Motor dysfunction (EORTC-QLQ-BN20) was associated with higher risk for non-death-related drop out (HR: 1.02; 95% CI, 1.00-1.03; P = .03). Death-related drop out was associated with age (HR: 1.09; 95% CI, 1.03-1.14; P = .002), Karnofsky Performance Status (HR: 0.92; 95% CI, 0.88-0.96; P < .001), lower physical functioning (EORTC-QLQ-C30; HR: 0.98; 95% CI, 0.96-1.00; P = .04) and lower motor functioning (EORTC-QLQ-BN20; HR: 1.020; 95% CI, 1.00-1.04; P = .02).

Conclusion

Patients with motor dysfunction and poorer clinical condition seem to be more likely to drop out of studies applying patient-reported outcome measures. This should be taken into account when planning studies assessing glioma patients and for interpretation of results of patient-reported outcome assessments in clinical routine.

Family Functioning Predicts End-of-Life Care Quality in Patients With Cancer: Multicenter Prospective Cohort Study

BACKGROUND

Treating patients with cancer within a family setting is the accepted standard of care and a hallmark of end-of-life (EoL) quality of care (QoC).

OBJECTIVE

The aim of this study was to determine whether family caregiver functioning predicts EoL QoC received by terminally ill patients with cancer.

METHODS

Family caregivers of terminally ill patients with cancer (n = 264) were enrolled from oncology inpatient and outpatient units of 12 large hospitals located in different regions throughout South Korea. Caregivers were administered self-reported questionnaires about family functioning and EoL QoC at the time of an incurable cancer diagnosis, 4 to 6 weeks later, and again 2 to 3 months later. Family functioning and QoC were measured using the family Apgar and Quality Care Questionnaire-End of Life scales, respectively.

RESULTS

Improved adaptability to resource sharing and attention received predicted improved family relationships for the 3 time points. Increased participation in decision making and communication predicted improved individualized care and family relationships for the 3 time points. Increased affection predicted improvements in dignity-conserving care and family relationships for the 3 time points. Improved resolution regarding sharing time and satisfaction with commitments predicted increases in all QoC domains for the 3 time points, including dignity-conserving care, care by healthcare professionals, individualized care, and family relationships.

CONCLUSIONS

Family functioning may contribute to improved EoL QoC of patients with terminal cancer.

IMPLICATIONS FOR PRACTICE

Patients' family caregivers are a valued source of affection and communicative support, improving EoL QoC. More family-oriented cancer support systems can better maintain the effectiveness of QoC until EoL.

Life beyond a diagnosis of glioblastoma: a systematic review of the literature

BACKGROUND

The median survival of glioblastoma is 12-14 months with less than 10% of patients surviving at least 2 years from diagnosis. Patients diagnosed with glioblastoma face poor prognosis, significant symptom burden, and high care needs. The aim of this study is to undertake a literature review to document the issues encountered by long-term survivors of glioblastoma, a small but important subset of patients.

METHODS

MEDLINE, PsychInfo, and EMBASE were searched with core concepts: (1) glioblastoma, (2) survivor, and (3) terms pertaining to survivorship issues. A thematic analysis was undertaken of the three included studies.

RESULTS

Long-term survivors of glioblastoma encounter neurologic deficits, impairment in cognition, psychological distress, reduced social function, and future uncertainty. These issues result in the inability to return to work and financial difficulties. Independence in activities of daily living, working memory, and overall quality of life appears to be preserved.

CONCLUSIONS

Long-term survivors of glioblastoma continue to have significant symptom burden and care needs. There is currently a paucity of literature surrounding this topic. Further research is required to accurately describe these issues in order for improved supportive care to be implemented in the community and the outpatient setting.

IMPLICATIONS FOR CANCER SURVIVORS

Understanding the issues faced by long-term survivor of glioblastoma will provide insight into the care needs of patients as well as support networks required for patients and their carers.

The characteristics of patients who discontinue their dying process - an observational study at a single university hospital centre

Background

End-of-life integrated care plans are used as structuring tools for the care of the dying. A widely adopted example is the Liverpool Care Pathway for the Dying Patient (LCP). Recently, several concerns were raised about LCP care, such as a worry that diagnosis of dying might be leading to a self-fulfilling trajectory, including hastening of death. However, data on rates of discontinuation of LCP care are lacking. In an observational study, we therefore investigated the incidence, features and trajectory of patients who were discontinued from the LCP. We hypothesised that (1) it is common to discontinue patients from the LCP, (2) quality of life does not decrease for discontinued LCP patients, and (3) discontinued patients live longer than patients who remain within LCP care.

Methods

All adult patients who were diagnosed as dying in a German university hospital specialized palliative care unit were included in 2013 and 2014. Actuarial estimation of survival prognostication tools and a number of quality of life indicators were used for data collection. Survival time was analysed using Kaplan-Meier estimates. Group differences in quality of life were tested using multivariate analysis of variance.

Results

159 patients were included in a digital version of the LCP. 15 patients (9.4 %) were discontinued later. Quality of life did not decrease for discontinued patients during LCP care (p = 0.16). LCP discontinued patients lived significantly longer than the remaining LCP subgroup (difference of means 296 hours, 95 % confidence interval 105.5 to 451.5 hours; difference of survival function estimates p < 0.0001).

Conclusions

When patients are diagnosed as dying, death is not the inevitable outcome of an end-of-life integrated care plan such as the LCP. Instead, it is common to discontinue the LCP care. Regular careful interprofessional assessments are important for identifying those patients who need to be discontinued from their end-of-life care plan. In this study, we found no evidence for harm by the LCP. We conclude that a correctly applied integrated care plan can be useful to provide good and safe care for the dying.

Trial registration

Internal Clinical Trial Register of the Medical Faculty, Heinrich Heine University Düsseldorf, No. 2015053680 (22 May 2015).

Validating self-report and proxy reports of the Dexamethasone Symptom Questionnaire -Chronic for the evaluation of longer-term corticosteroid toxicity

PURPOSE

In brain tumours, brain metastases or advanced cancer; treatment with corticosteroids, side effects can add to symptoms. These are best assessed by patients, complementing clinical assessment. We assessed the feasibility and validity of the Dexamethasone Symptom Questionnaire-Chronic (DSQ-Chronic), patient and caregiver versions.

METHODS

A longitudinal cohort study was conducted, collecting clinician-rated toxicity, performance status, dexamethasone dose and DSQ-Chronic (patient and caregiver versions) at baseline, then 2, 4 and 8 weeks later. Patients had a primary malignant brain tumour, brain metastases, or advanced cancer; Karnofsky Performance Status ≥40 and predicted survival ≥8 weeks. Analysis included questionnaire completion rates, frequency and severity of dexamethasone-attributable side effects, agreement between patient and caregiver ratings, comparison with clinician-rated toxicity and correlation with performance status.

RESULTS

Sixty-six patients were recruited (mean age 60 years), with their caregivers. Completion of questionnaires was over 90% for the dyad at baseline but dropped over time, with caregiver completion rates higher at all timepoints. Agreement between patients and proxies was fair to moderate, and while proxies systematically overestimated symptom severity on DSQ-chronic total scores, the bias was less than 10 points. Patient and clinician agreement was higher for more objective symptoms.

CONCLUSION

The DSQ-Chronic is feasible when the patient is relatively well. As capacity to complete the DSQ-Chronic diminishes, caregivers can be proxy-raters. Clinicians capture corticosteroid toxicities, which may not be obvious to the patient. The DSQ-Chronic, patient and caregiver versions, are useful tools to be used with clinician assessment.

Management of Gliomas: Overview of the Latest Technological Advancements and Related Behavioral Drawbacks

The advancements in basic sciences and the availability of sophisticated technological aids to surgical removal of gliomas have led over the last few years to the rise of innovative surgical strategies, the identification of better prognostic/predictive biomolecular factors, and the development of novel drugs and all are meant to profoundly impact the outcome of patients diagnosed with these aggressive tumours. Unfortunately, the treatment protocols available nowadays still confer only a small survival advantage at a potentially high cost in terms of overall well-being. In this review we identified the potential and limits of the most promising research trends in the management of glioma patients, also highlighting the related externalities. Finally, we focused our attention on the imbalance between the technical and behavioral aspects pertinent to this research area, which ultimately represent the two sides of the same coin.