Summarizing the Fifteen Scales of the EORTC QLQ-C30 Questionnaire by Five Aggregate Scales with Two Underlying Dimensions: A Literature Review and an Empirical Study

Fatigue in advanced disease associated with palliative care: A systematic review of non-pharmacological treatments

BACKGROUND

Fatigue is a common complaint reported by patients with advanced disease, impacting their daily activities and quality of life. The pathophysiology is incompletely understood, and evidence-based treatment approaches are needed.

AIM

This systematic review aims to evaluate the efficacy of non-pharmacological interventions as treatment for fatigue in advanced disease.

DESIGN

The review design follows the Cochrane guidelines for systematic reviews of interventions.

DATA SOURCES

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PsycINFO, PubMed, ClinicalTrials.gov and a selection of journals up to February 28th 2019, for randomised controlled trials (RCTs) investigating the effect of non-pharmacological treatments for fatigue in advanced disease associated with palliative care. Further potentially relevant studies were identified from the reference lists in relevant reviews, and in studies considered for this review.

RESULTS

We screened 579 publications; 15 met the inclusion criteria, with data from 1179 participants: 815 were treated with physical exercise, 309 with psycho-educational therapy and 55 with an energy restoration approach. Sources of potential bias included lack of description of blinding and allocation concealment methods, and small study sizes. Physical exercise as treatment for fatigue in patients with advanced cancer was supported by moderate-quality evidence.

CONCLUSION

Physical exercise should be considered as a measure to reduce fatigue in patients with advanced cancer, but data on other advanced diseases is lacking. Due to the differences between studies, no clear recommendations can be made with respect to the best type of physical therapy. Restoration exercise and psycho-educational therapy are promising treatment options, although further research is needed.

Pressurized Intraperitoneal Aerosol Chemotherapy Enhanced by Electrostatic Precipitation (ePIPAC) for Patients with Peritoneal Metastases

BACKGROUND

Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is a new mode of intraperitoneal chemotherapy administration that can potentially be improved by the addition of electrostatic precipitation (ePIPAC). This study aimed to describe the procedural details of ePIPAC and to analyze its safety for patients with nonresectable peritoneal metastasis as well as their tolerance and response to this treatment.

METHODS

This retrospective cohort study included consecutive patients treated with ePIPAC in three centers from April 2019 to April 2020. The toxicities of each patient were assessed using the Common Terminology Criteria for Adverse Events (CTCAE). Complications were documented according to the Clavien classification. Quality of life (QoL) was assessed using EORTC-QLQ-C30, and the peritoneal regression grading score (PRGS) was used to grade histologic responses. Further surrogates for responses were the Peritoneal Cancer Index (PCI), ascites, and symptoms.

RESULTS

Overall, 69 patients received 147 ePIPACs with oxaliplatin (n = 34) or cisplatin/doxorubicin (n = 35) mainly for colorectal (n = 25), ovarian (n = 14), and gastric (n = 13) primary cancers. Systemic chemotherapy was used in the treatment of 54 patients (76%). The median electrostatic therapy time was 12 min (range 6-30 min). The overall and major CTCAE toxicity rates were respectively 24.6% and 15.9%. The postoperative complications rate according to Clavien classification was 4.7%. The responses of 22 patients who had three or more ePIPAC treatments were evaluated as follows: PCI (16 vs 14; p = 0.4), ascites (320 vs 98 ml; p = 0.1), and PRGS (2.23 vs 1.73; p = 0.15). The complete (PRGS1) and major (PRGS2) histologic responses at the third ePIPAC were respectively 38.5% and 53.8%. Overall QoL was stable during the first ePIPACs.

CONCLUSION

Repetitive ePIPACs were safe and well tolerated for patients with unresectable peritoneal metastasis.

Underlying dimensions of the EORTC QLQ-C30 in a Cuban population of patients with advanced non-small cell lung cancer

BACKGROUND

Quality of Life Core Questionnaire of the European Organization for the Research and Treatment of Cancer (EORTC QLQ-C30) is one of the most used quality of life questionnaires in cancer studies. It provides scores for five functional scales, nine symptom scales, and two single items which assess overall health status and quality of life. However, high correlations among QLQ-C30 items suggest a reduced dimensionality for the scale.

OBJECTIVE

To assess the dimensionality of the EORTC QLQ-C30 using item response theory (IRT) in a training sample and confirmatory factor analysis (CFA) in a test sample.

METHODS

We analyzed responses to QLQ-C30 from 1,107 patients with advanced lung cancer who were included in five clinical trials of immunotherapy. We used non-parametric and parametric IRT models (Mokken, and Samejima's graded response) in a random training set (n = 332) for initial assessment of dimensions and item characteristics of the QLQ-C30. Finally, we used CFA in the test set (n = 775) to confirm the measurement domains.

RESULTS

Mokken model showed that QLQ-C30 fits a unidimensional scale, whereas Samejima model showed that most QLQ-C30 items present adequate difficulty and discrimination. All items showed adequate scalability indexes with an overall scalability of 0.47 (medium scale). The QLQ-C30-reduced dimensionality was confirmed by CFA (comparative fit index = 0.98, root mean square error of approximation = 0.055) with all items presenting factorial loadings > 0.40.

CONCLUSIONS

The EORTC QLQ-C30 fits a unidimensional latent construct identified with perceived quality of life in advanced lung cancer patients.

TRIAL REGISTRATION

RPCEC00000161, RPCEC00000181 and RPCEC00000205.

Pressurized intraperitoneal aerosol chemotherapy with low-dose cisplatin and doxorubicin (PIPAC C/D) in patients with gastric cancer and peritoneal metastasis: a phase II study

Background:

Efficacy of second-line systemic chemotherapy in recurrent gastric cancer with peritoneal metastasis (RGCPM) is limited. We assessed the feasibility, safety and possible efficacy of pressurized intraperitoneal aerosol chemotherapy (PIPAC) in patients with RGCPM after ⩾1 line of palliative intravenous chemotherapy.

Methods:

In this open-label, single-arm, monocentric phase II ICH-GCP clinical trial, patients were scheduled for three courses of PIPAC with cisplatin 7.5 mg/m² and doxorubicin 1.5 mg/m² (PIPAC C/D) every 6 weeks. Patients with bowel obstruction or extraperitoneal metastasis were ineligible. The primary endpoint was clinical benefit rate (CBR) by Response Evaluation Criteria in Solid Tumors based on clinical records. Secondary endpoints included overall survival (OS), median time to progression (TTP), peritoneal carcinomatosis index (PCI), histological regression and ascites volume. Safety and tolerability were assessed by Common Terminology Criteria for Adverse Events (CTCAE) version 4, quality of life (QoL) by EORTC-QLQ30 questionnaire.

Results:

A total of 25 patients were enrolled and available for the analysis of the primary endpoint. Of those 25 patients, 10 (40%) had a radiological complete, partial response or stable disease. Median OS [intention to treat (ITT)] was 6.7 months, median TTP was 2.7 months. Complete or major regression on histology were observed in 9/25 patients (36%, ITT) or 6/6 [100%, per protocol (PP)] patients. There were no suspected unexpected serious adverse reactions, no treatment-related deaths, no CTCAE grade 4 toxicity and three (12%) grade 3 toxicities. Changes in the QLQ-C30 scores during PIPAC C/D therapy were small and not significant.

Conclusions:

PIPAC C/D was well tolerated and active in patients with RGCPM. Survival was encouraging. Randomized controlled trials should now be designed in this indication.

Randomized control trial comparing quality of life of patients with end-stage peritoneal metastasis treated with pressurized intraperitoneal aerosol chemotherapy (PIPAC) and intravenous chemotherapy

Background

Peritoneal metastasis (PM) is a common occurrence in gynaecological and gastrointestinal cancers and is associated with poor survival. Patients typically present with ascites, abdominal pain, malnutrition, nausea, emesis, and bowel obstruction which significantly compromise the quality of life (QoL). The treatment remains a particular challenge, with palliative systemic chemotherapy being the standard of care. However, the efficacy of systemic chemotherapy is poor but with high potential for side effects and complications. QoL plays an important role in patients with PM and is deteriorating continuously until death. Thus, there is an obvious medical need for better therapeutic options in PM for prolonging survival and preserving QoL by reducing both disease-related symptoms and therapy side effects. Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is a novel technique for delivering pressurized normothermic chemotherapy into the abdominal cavity as an aerosol. This concept seems to enhance the effectiveness of intraperitoneal chemotherapy by taking advantage of the physical properties of gas and pressure by generating an artificial pressure gradient and enhancing tissue uptake and distributing drugs homogeneously within the closed and expanded peritoneal cavity.

Methods

The primary objective of this study is to assess QoL and symptoms in a consecutive cohort of patients with PM treated with PIPAC procedure in comparison with conventional systemic intravenous chemotherapy. QoL is assessed prospectively using European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30(Version 3.0) questionnaire. QLQ-C30 is a 30-question self-administered questionnaire inquiring about global health status, 9 individual symptoms, and 5 functional scales. Baseline QoL is measured using the global physical health functional score, and symptom scores derived from EORTC QLQ30 questionnaire before starting therapy, followed by at 60, 120, and 180 days after the first intervention. Calculated sample size is 119 and rounded to 120. For each treatment group, sample size of 60 will be enrolled; Intervention model: IV chemotherapy group (control group) and PIPAC group (experimental group); Study type: prospective randomized control intervention trial

Discussion

All consecutive patients diagnosed with advanced end-stage PM are randomized to be treated with PIPAC or IV chemotherapy. The primary objective of this study is to determine the QoL after three cycles of PIPAC in comparison with six cycles of systemic chemotherapy. The secondary outcome measures include morbidity and mortality. Analysis is by intention to treat.

Results

The effect of systemic chemotherapy remains limited on the peritoneum due to poor vascularization and low penetration. Side effects after systemic chemotherapy for PM are relatively frequent. QoL plays an important role in these patients and is deteriorating continuously due to the disease or therapy related. Thus, there is need for better therapeutic options for prolonging survival and preserving QoL by reducing both disease-related symptoms and therapy side effects. PIPAC is a novel minimally invasive repeatable treatment modality which demonstrated potentially encouraging tumour response and only minimal toxicity in patients with PM of various origins. It can optimize local drug delivery and improve clinical outcome due to superior pharmacological properties as compared to systemic chemotherapy.

Trial registration

REF/2018/08/021225 Registered on Clinical Trials Registry-India (CTRI); www.ctri.nic.in

Illness representations, coping, and illness outcomes in people with cancer: a systematic review and meta-analysis

OBJECTIVE

Cancer is associated with negative health and emotional outcomes in those affected by it, suggesting the need to better understand the psychosocial determinants of illness outcomes and coping. The common sense model is the leading psychological model of self-regulation in the face of illness and assumes that subjective illness representations explain how people attempt to cope with illness. This systematic review and meta-analysis examines the associations of the common sense model's illness representation dimensions with health and coping outcomes in people with cancer.

METHODS

A systematic literature search located 54 studies fulfilling the inclusion criteria, with 38 providing sufficient data for meta-analysis. A narrative review of the remaining studies was also conducted.

RESULTS

Random-effects models revealed small to moderate effect sizes (Fisher Z) for the relations between illness representations and coping behaviors (in particular between control perceptions, problem-focused coping, and cognitive reappraisal) and moderate to large effect sizes between illness representations and illness outcomes (in particular between identity, consequences, emotional representations, and psychological distress). The narrative review of studies with insufficient data provided similar results.

CONCLUSIONS

The results indicate how illness representations relate to illness outcomes in people with cancer. However, more high-quality studies are needed to examine causal effects of illness representations on coping and outcomes. High heterogeneity indicates potential moderators of the relationships between illness representations and health and coping outcomes, including diagnostic, prognostic, and treatment-related variables. This review can inform the design of interventions to improve coping strategies and mental health outcomes in people with cancer.

Pressurized intraperitoneal aerosol chemotherapy in women with recurrent ovarian cancer: A phase 2 study

OBJECTIVE

Recurrent ovarian, fallopian or peritoneal cancer with peritoneal carcinomatosis (ROCPC) is resistant to systemic chemotherapy. We assessed the safety and activity of laparoscopic pressurized intraperitoneal aerosol chemotherapy (PIPAC) in women with this cancer.

METHODS

In this open-label, single-arm phase 2 study, patients underwent 3 courses q 28-42 days of PIPAC with doxorubicin 1·5 mg/m(2) followed by cisplatin 7·5 mg/m(2). A pressure of 12 mm Hg and a temperature of 37 °C were applied for 30 min/course. The primary endpoint was the proportion of patients who had an objective tumor response (OTR) according to RECIST version 1.1 criteria. Analysis was by intention to treat. Secondary endpoints were tumor regression on histology, PC Index improvement on repeated video-laparoscopy, and quality of life measured with the EORTC QLQ-30 questionnaire.

RESULTS

Sixty-four patients were enrolled. Laparoscopic non-access rate was 11/64 (17%). 53 patients were eligible for analyses. 33/53 (62%) patients had an OTR - three had a partial response and 30 patients had stable disease. Tumor regression on histology and PC Index improvement were observed in 26/34 (76%) and in 26/34 (76%) patients who underwent all 3 PIPACs. There were no treatment-related deaths. No grade 4 toxicity was observed. Grade 3 toxicities were trocar hernia (n=2), bowel obstruction (n=2), abdominal pain (n=2), hematoma (n=1), intraoperative bleeding (n=1), and cystitis with urosepsis (n=1). EORTC QLQ-30 global physical health scores, nausea/vomiting, appetite loss, diarrhea, and constipation improved during therapy.

CONCLUSION

PIPAC is well tolerated and active in women with ROCPC and warrants further investigation in these patients.