Quality-of-life and cost-effectiveness assessment in lung cancer

Quality of life measurement in cancer patients receiving palliative radiotherapy for symptomatic lung cancer: a literature review

Approximately 27% of North American cancer deaths are attributable to cancer of the lung. Many lung cancers are found at an advanced stage, rendering the tumours inoperable and the patients palliative. Common symptoms associated with palliative lung cancer include cough, hemoptysis, and dyspnea, all of which can significantly debilitate and diminish quality of life (QOL). In studies of the effects of cancer therapies, the frequent evaluative endpoints are survival and local control; however, it is imperative that clinical trials with palliative patients also have a QOL focus when a cure is unattainable. We conducted a literature review to investigate the use of QOL instrument tools in trials studying QOL or symptom palliation of primary lung cancer or lung metastases through the use of radiotherapy. We identified forty-three studies: nineteen used a QOL tool, and twenty-four examined symptom palliation without the use of a QOL instrument. The European Organization for Research and Treatment of Cancer (eortc) QLQ-C30 survey was the most commonly used QOL questionnaire (in thirteen of twenty trials). Of those thirteen studies, eight also incorporated the lung-specific QOL survey eortc QLQ-LC13 (or the eortc QLQ-LC17). A second lung-specific survey, the Functional Assessment of Cancer Therapy-Lung (fact-L) was used in only two of the twenty trials. In total, only ten of forty-three trials (23%) used a lung-specific QOL tool, suggesting that QOL was of low priority as an endpoint and that measures created for lung cancer patients are underused. We encourage investigators in future trials to include specific QOL instruments such as the eortc QLQ-LC13 or the fact-L for studies in palliative thoracic radiotherapy because those instruments provide a measure of QOL specific to patients with lung cancer or lung metastases.

The effect of smoking cessation on quality of life after lung cancer surgery

OBJECTIVE

This study aimed to evaluate the effect of smoking status on quality of life (QoL) after non-small-cell lung cancer surgery with the European Organisation for Research and Treatment of Cancer (EORTC) QoL Questionnaire-C30 and LC13.

METHODS

QoL was prospectively recorded in 70 consecutive patients undergoing lobectomy or pneumonectomy. Questionnaires were administered preoperatively and 1, 3, 6 and 12 months postoperatively (MPO).

RESULTS

Of all patients analysed, nine (13%) were non-smokers, 20 (29%) former smokers, six (8%) recent quitters and 35 (50%) current smokers. All four groups had comparable patients' characteristics and preoperative QoL scores, with exception of non-smokers who had significantly lower physical functioning, role functioning, cognitive functioning and a higher thoracic pain burden. In non-smokers, all QoL scores returned to baseline 3 months after surgery. Former smokers complained of a significant 3-month decrease in physical functioning (3 MPO, p = 0.01) and a 12-month decrease in role functioning (12 MPO, p = 0.01). Former smokers complained of a significant increase in dyspnoea (6 MPO, p = 0.001) during the first 6 months after surgery. Recent quitters had a longer impairment in physical functioning (6 MPO, p = 0.01) and a 3-month burden of dyspnoea (3 MPO, p=0.02). In current smokers, no return to baseline in physical (12 MPO, p = 0.01), role (12 MPO, p = 0.01) and social functioning (12 MPO, p = 0.02) and a persistent increase in dyspnoea (12 MPO, p = 0.04) were reported. Current smokers also complained of increased thoracic pain (12 MPO, p = 0.02). Except non-smokers, all patients complained of fatigue the first 3 months after surgery.

CONCLUSIONS

Smoking cessation is beneficial at any time point to lung cancer surgery and current smoking at the time of surgery is associated with a poor postoperative QoL.

Epidemiology of lung cancer prognosis: quantity and quality of life

Primary lung cancer is very heterogeneous in its clinical presentation, histopathology, and treatment response; and like other diseases, the prognosis consists of two essential facets: survival and quality of life (QOL). Lung cancer survival is mostly determined by disease stage and treatment modality, and the 5-Year survival rate has been in a plateau of 15% for three decades. QOL is focused on life aspects that are affected by health conditions and medical interventions; the balance of physical functioning and suffering from treatment side effects has long been a concern of care providers as well as patients. Obviously needed are easily measurable biologic markers to stratify patients before treatment for optimal results in survival and QOL and to monitor treatment responses and toxicities. Targeted therapies toward the mechanisms of tumor development, growth, and metastasis are promising and actively translated into clinical practice. Long-term lung cancer (LTLC) survivors are people who are alive 5 Years after the diagnosis. Knowledge about the health and QOL in LTLC survivors is limited because outcome research in lung cancer has been focused mainly on short-term survival. The independent or combined effects of lung cancer treatment, aging, smoking and drinking, comorbid conditions, and psychosocial factors likely cause late effects, including organ malfunction, chronic fatigue, pain, or premature death among lung cancer survivors. New knowledge to be gained should help lung cancer survivors, their healthcare providers, and their caregivers by providing evidence for establishing clinical recommendations to enhance their long-term survival and health-related QOL.

Quality of life evolution after lung cancer surgery: A prospective study in 100 patients

OBJECTIVE

To evaluate quality of life (QoL) evolution after thoracic surgery for lung cancer with the European Organisation for Research and Treatment of Cancer (EORTC) QoL Questionnaire-C30 and the lung cancer specific module LC13.

METHODS

A prospective QoL registration started in 2002 for all patients undergoing major pulmonary surgery for malignant disease. Between January 2002 and November 2004, 100 patients were included. Questionnaires were administered pre-operatively and 1, 3, 6 and 12 months post-operatively (MPO) with response rates of 100%, 71%, 77%, 83% and 76%, respectively.

PROCEDURES

lobectomy 61%, pneumonectomy 17%, and wedge resection 22%. Approaches: anterolateral thoracotomy 79%, posterolateral thoracotomy 13% and video-assisted thoracic surgery (VATS) 8%.

RESULTS

Lobectomy and wedge resection are comparable in QoL evolution. Both resections are characterized by a 1 month temporary decrease in QoL functioning scores and an increase in pain symptoms. Lobectomy patients report an increase in dyspnea in the first month post-operatively, not seen after wedge resection. With exception of thoracic pain after lobectomy, QoL scores approximated baseline values 3MPO indicating good recovery. After pneumonectomy, there is no return to baseline in physical functioning, role functioning, pain, shoulder function and dyspnea in a 12 months follow-up period. Other QoL scores were comparable with baseline values. Pneumonectomy was significantly associated with a less favorable QoL score evolution when compared with lobectomy. Comparing antero- and posterolateral thoracotomy, significant differences in pain and dyspnea were seen in favor of the anterolateral technique. Comparing thoracotomy to VATS, significant differences were seen in physical functioning, QoL and thoracic pain in favor of VATS.

CONCLUSIONS

The present study documented QoL evolution profiles comparing pre-operative status with deficits and changes at 1, 3, 6 and 12 months after pulmonary surgery. Lung cancer surgery is well tolerated by the majority of patients. Lobectomy patients have a more favorable physical functioning and less thoracic pain, compared to pneumonectomy. Antero- and posterolateral thoracotomy are comparable for QoL evolution. After posterolateral thoracotomy more post-operative pain and dyspnea was seen. Post-operative physical functioning, pain and QoL are in favor of VATS.

Effect of lung cancer surgery on quality of life

BACKGROUND

Health related quality of life (HRQOL) after surgery is important, although very limited data are available on the QOL after lung cancer surgery.

METHODS

The effect of surgery on HRQOL was assessed in a prospective study of 110 patients undergoing potentially curative lung cancer surgery at Papworth Hospital, 30% of whom had borderline lung function as judged by forced expiratory volume in 1 second. All patients completed the EORTC QLQ-C30 and LC13 lung cancer module before surgery and again at 1, 3 and 6 months postoperatively.

RESULTS

On average, patients had high levels of functioning and low levels of symptoms. Global QOL had deteriorated significantly 1 month after surgery (p = 0.001) but had returned to preoperative levels by 3 months (p = 0.93). Symptoms had worsened significantly at 1 month after surgery but had returned to baseline levels by 6 months. Low values on the preoperative HRQOL scales were not significantly associated with poor surgical outcome. However, patients with low preoperative HRQOL functioning scales and high preoperative symptom scores were more likely to have poor postoperative (6 months) QOL. The only lung function measurement to show a marginally statistically significant association with quality of life at 6 months after surgery was percentage predicted carbon monoxide transfer factor (Tlco).

CONCLUSION

Although surgery had short term negative effects on quality of life, by 6 months HRQOL had returned to preoperative values. Patients with low HRQOL functioning scales, high preoperative symptom scores, and preoperative percentage predicted Tlco may be associated with worse postoperative HRQOL.

Endoscopic laser ablation as palliative treatment of endobronchial, nonresectable, or recurrent lung cancer: assessment of its impact on quality of life

Laser ablation (LA) is currently used in our institute as palliative treatment for endobronchial nonresectable or recurrent lung cancer. The objective of this study was to assess the impact of LA on the quality of life (QOL) in a large group of patients with endobronchial obstructions due to nonresectable or re-current lung cancer. Evaluation was based on Eastern Cooperative Oncology Group performance status (ECOG PS) for the "objective" assessment of QOL and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30 version 1.0 (EORTC QLQ-C30(v1)) for the "subjective" assessment of QOL. From May 1994 to June 1997, 133 LAs were performed using neodymium: yttrium-aluminum garnet (Nd:YAG) laser at low power settings (< 30W) on 89 evaluable patients (Male/Female 78/11, mean age 63.5/62.8 years, range 42-82/47-73). The QOL was evaluated by ECOG PS and QLQ-C30(v1) at baseline (3 days before LA), t1 (7 days after LA), and t2 (1 month after LA). The objective tumor response was evaluated at t2. The objective tumor response to LA intervention was "excellent," ie, complete response (CR), in 33 (24.8%) patients and "fair," ie, partial response (PR), in 97 (72.9%) patients, with an overall response rate (ORR) of 97.7%. A highly significant decrease in high score (ECOG PS 3-4) was registered from baseline to t1 and from t1 to t2. However, at the same time a significant increase of low score (ECOG PS 0-2) was observed. The comparison of patient QOL assessment by QLQ-C30(v1) at different times during the study was also made; the functioning scales, the global QOL scale, and the symptom scales/items showed a highly significant improvement at t1 compared to baseline (P < 0.001), whereas only global QOL improved at t2 compared to t1. A comparison of baseline ECOG PS scale with QLQ-C30(v1) scale revealed a strong relationship between PS and the symptom "fatigue." Our study demonstrates that dramatic clinical improvement obtained by an effective though palliative treatment such as LA improves QOL based on both physician-rated (PS) and mostly self-rated (QLQ-C30(v1)) assessment.

The silent epidemic: tobacco and the evolution of lung cancer and its treatment

Considered a rare disease during the 19th century, lung cancer became the most virulent and lethal cause of cancer mortality by the end of the 20th century. In this paper, lung cancer and its treatment are addressed within the social, cultural, economic, and political context of the last century. Because lung cancer is related to the consumption of cigarettes, the battles over tobacco control are highlighted. Four time periods are addressed: the early years (1900-1930), beginning of the epidemic (1930-1960), defining the problem (1960-1980), and expanding options (1980-1990s). Although improvements have been made in science and technology, attempts at finding curative treatments have met with little success. Smoking cessation and efforts to control tobacco (especially among children and adolescents) remain the most important factors if the incidence of lung cancer is to be curtailed in the future. Providing care to individuals with the illness is a current challenge. Research examining the efficacy of treatments and their effect on survival, health-related quality of life, and cost outcomes is essential and can be best achieved through the efforts of multidisciplinary teams.

Quality of life in patients with lung cancer: a review of literature from 1970 to 1995

A review of the literature was carried out covering the last 25 years (1970 to 1995) by searching through the MEDLINE and manually. The review consists of two companion parts. The first includes studies of quality of life in lung cancer patients in general, while the second part is restricted to defined samples of small and non-small cell lung cancer patients. Excluding non-English and review articles, in total 151 citations were identified and all have been reviewed. Over 50 instruments were used to measure quality of life in lung cancer studies. Of these, the European Organisation for Research and Treatment of Cancer Quality of Life Lung Cancer Questionnaire (EORTC QLQ-LC13) in conjunction with the core cancer questionnaire (QLQ-C30) was found to be the best developed instrument, although there were two other lung cancer-specific measures with good reliability and validity. Several topics in this chapter have been highlighted, including the importance of regularly measuring quality of life in lung cancer patients. Progress and achievements in areas such as performance status as a proxy of quality of life measure, psychological morbidity and symptom distress as predictive factors of quality of survival, and communication problems in quality of life studies of lung cancer patients have been emphasized and their implications in lung cancer care discussed. It is argued that palliation of symptoms, psychosocial interventions, and understanding patients' feelings and concerns all contribute to improving quality of life in lung cancer patients. It is concluded that the future challenge in treatment of lung cancer lies not only in improving the survival, but mainly the patients' quality of life regardless of cell type. Clinical trial and epidemiologic population-based outcome studies are recommended to provide this and to allow a better understanding of the contribution of the socioeconomic characteristics of the patients to their pretreatment and posttreatment quality of life.

Gemcitabine. A review of its pharmacology and clinical potential in non-small cell lung cancer and pancreatic cancer

Gemcitabine [2'-deoxy-2',2'-difluorocytidine monohydrochloride (beta isomer); dFdC] is a novel deoxycytidine analogue which was originally investigated for its antiviral effects but has since been developed as an anticancer therapy. Gemcitabine monotherapy produced an objective tumour response in 18 to 26% of patients with advanced non-small cell lung cancer (NSCLC) and appears to have similar efficacy to cisplatin plus etoposide. Objective response rates ranging from 26 to 54% were recorded when gemcitabine was combined with cisplatin, and 1-year survival duration after such treatment ranged from 35 to 61%. Improvements in a range of NSCLC disease symptoms and/or in general performance status occurred in many patients who received gemcitabine, with or without cisplatin, in 3 clinical trials. Gemcitabine appears to be cost effective compared with best supportive care for NSCLC. In addition, direct costs associated with administration of gemcitabine monotherapy may be lower than those for some other NSCLC chemotherapy options, according to retrospective cost-minimisation analyses. The combination of gemcitabine plus cisplatin was associated with a lower cost per tumour response than cisplatin plus etoposide or cisplatin plus vinorelbine, according to a retrospective cost-effectiveness analysis. In a single comparative study in patients with advanced pancreatic cancer, gemcitabine was more effective than fluorouracil with respect to survival duration and general clinical status. It also showed modest antitumour and palliative efficacy in patients refractory to fluorouracil. Gemcitabine appears to be well tolerated, although further comparisons with other chemotherapy regimens are required. The available data indicate that gemcitabine monotherapy is better tolerated than cisplatin plus etoposide in patients with NSCLC. Data from noncomparative studies suggest that the combination of gemcitabine and cisplatin has an acceptable tolerabilty profile. In a single trial in patients with pancreatic cancer, fluorouracil was better tolerated than gemcitabine; however, gemcitabine was generally well tolerated overall in this study. Thus, gemcitabine (with or without cisplatin) may prove attractive to patients with advanced NSCLC, given their limited life expectancy and the toxicity associated with many other chemotherapy regimens. More detailed characterisation of its risk-benefit profile compared with those of current and developing regimens for NSCLC should be possible once results from several ongoing studies are available. Gemcitabine is a valuable new chemotherapy option for patients with advanced pancreatic cancer, a disease considered incurable at present. Its apparent survival and palliative benefits over fluorouracil require confirmation, but are encouraging, as the need to improve both the duration and quality of survival in these patients is well recognised.

Non-small cell lung cancer: an overview of current management

Non-small cell lung cancer (NSCLC) will remain a worldwide health problem for the foreseeable future. Unfortunately, local treatment of this disease is disappointing as most patients develop uncontrollable locally advanced or distant metastatic disease. The recent meta-analysis using updated patient data has suggested a potential role for adjuvant cisplatin-based chemotherapy (CT) in early stage disease, and has shown a significant, albeit modest, improvement in survival when combined with radiotherapy in locally advanced disease and as a single modality in metastatic disease. Although quality and cost of extra life with this more aggressive treatment need to be defined in prospective studies, CT should be considered standard treatment for patients with locally advanced and metastatic NSCLC able to receive cisplatin-based CT. Its role in stage I and II disease is under current investigation. Ongoing clinical studies with more active agents, novel combined modality treatment strategies and laboratory discoveries continue to emerge which may lead to valuable new treatment options to extend this survival advantage.

Dose-intense therapy with etoposide, ifosfamide, cisplatin, and epirubicin (VIP-E) in 100 consecutive patients with limited- and extensive-disease small-cell lung cancer

BACKGROUND

We conducted a phase I/II trial to assess the feasibility and activity of VIP-E chemotherapy in small-cell lung cancer. End-points were treatment-related morbidity and mortality, response to treatment. duration of response, and survival.

PATIENTS AND METHODS

Two cycles of combination chemotherapy followed by granulocyte colony-stimulating factor (G-CSF) were given at a dose of etoposide (500 mg/m2), ifosfamide (4000 mg/m2), cisplatin (50 mg/m2), and epirubicin (50 mg/m2) to 100 consecutive patients with SCLC. Thirty patients (19 with LD, and 11 with ED SCLC) proceeded to VIC-E high-dose chemotherapy with autologous peripheral blood stem cell transplantation (PBSCT) at a cumulative dose of etoposide 1500 mg/m2, ifosfamide 12,000 mg/m2, carboplatin 750 mg/m2 and epirubicin 150 mg/m2 (VIC-E). Surgical resection of primary tumor was attempted at the earliest feasible point. Thoracic irradiation was given after completion of chemotherapy. RESULTS of conventional-dose VIP-E: 97 patients were evaluable for response. Objective response rate was 81% in LD-SCLC (33% CR, 48% PR; excluding patients in surgical CR) and 77% in ED-SCLC (18% CR, 58% PR). Treatment mortality was 2%. Median survival was 19 months in LD-SCLC and 6 months in ED-SCLC. Two-year survival was 36% in LD and 0% in ED SCLC. RESULTS OF HIGH-DOSE VIC-E: All 30 patients improved on or maintained prior responses. Four patients (13%) died of treatment-related complications. Median survival was 26 months in LD-SCLC and 8 months in ED-SCLC. Two-year survival was 53% in LD and 9% in ED SCLC.

CONCLUSION

VIP-E chemotherapy is an effective induction therapy for SCLC. Compared with traditional protocols such as ACO or carboplatin/etoposide, response rates are slightly improved, while survival is not different. In the LD SCLC subgroup, high-dose chemotherapy improved response rates and survival, especially for patients in surgical CR prior to high-dose therapy. In ED SCLC, however, higher response-rates did not translate into improved survival. Selected LD-SCLC patients with good partial or complete remissions after prior therapy may benefit from HDC and PBSCT.

Dose-intense therapy with etoposide, ifosfamide, cisplatin, and epirubicin (VIP-E) in 107 consecutive patients with limited- and extensive-stage non-small-cell lung cancer

BACKGROUND

We conducted a phase I/II trial to assess the feasibility and activity of combination chemotherapy with etoposide, ifosfamide, cisplatin, and epirubicin in limited-stage (LS, stage I-IIIB) and extensive-stage (ES, stage IV) non-small-cell lung cancer (NSCLC). End-points were treatment-related morbidity and mortality, response rate, duration of response, and survival.

PATIENTS AND METHODS

Chemotherapy followed by granulocyte colony-stimulating factor was given at a dose of etoposide (500 mg/m2), ifosfamide (4000 mg/m2), cisplatin (50 mg/m2), and epirubicin (50 mg/m2) (VIP-E) to 107 patients with NSCLC. Twenty-five patients with qualifying responses proceeded to high-dose chemotherapy with autologous peripheral blood stem cell transplantation after etoposide (1500 mg/m2), ifosfamide (12,000 mg/m2), carboplatin (750 mg/m2) and epirubicin (150 mg/m2) (VIC-E) conditioning. RESULTS OF CONVENTIONAL-DOSE VIP-E: 35 of 102 (34%) evaluable patients responded (2 CR's, 33 PR's), 33/102 patients (33%) showed no change (NC); the remainder of patients progressed with therapy (PD). Objective response rate was 68% (4% CR, 64% PR) in LS-NSCLC and 23% (1.4% CR, 21.4% PR) in ES-NSCLC. Median duration of survival was 13 months in LS-NSCLC and 5.5 months in ES-NSCLC. Two-year survival was 26% in LS and 2% in ES-NSCLC. RESULTS OF HIGH-DOSE VIC-E: 23 of 24 evaluable patients improved or maintained prior responses (92%), I patient showed NC. Treatment mortality was 4%. Median duration of survival was 17 months in LS-NSCLC and 10 months in ES-NSCLC. Two-year survival was 30% in LS and 8% in ES-NSCLC.

CONCLUSION

Response-rates and survival after conventional-dose VIP-E chemotherapy are comparable to other published trials of combination chemotherapy in NSCLC. Toxicity and mortality is acceptable in limited stage, but unacceptably high in extensive stage NSCLC. Although better response-rates were achieved in the high-dose arm, they did not translate into improved survival. Most stage IV NSCLC-patients will neither benefit from VIP-E conventional dose, nor from VIC-E high dose chemotherapy. Whether selected LS-patients with partial or complete responses to VIP-E induction chemotherapy could benefit from dose intensification in an adjuvant or neo-adjuvant setting remains to be determined.

Initial prognostic factors in small-cell lung cancer patients predicting quality of life during chemotherapy. Swiss Group for Clinical Cancer Research (SAKK)

The question of whether initial prognostic factors in small-cell lung cancer patients have a predictive value for patients' quality of life (QL) during chemotherapy is addressed in the context of a randomised clinical trial comparing early and late alternating chemotherapy (SAKK protocol 15/84). The relative impact of initial tumour stage and performance status, previous weight loss, sex and age on patient-rated QL was analysed over six chemotherapy cycles in 124-130 patients (according to available QL data) with more than 400 questionnaires. Fatigue/malaise, personal functioning, emotional and general well-being were prospectively selected as QL indicators. Predefined summary measures (average QL score over chemotherapy cycles, 'minimum', 'maximum' and 'final' improvement) were analysed separately by scale in various patient groups. General linear models adjusted for treatment arm and response were used to confirm the univariate findings. Within the overall sample, the average QL scores over six cycles were predicted by initial prognostic factors. Patients with poor prognostic factors reported worse QL. Within a limited sample (with baseline QL), patients with poor prognostic factors reported worse QL at baseline and greater improvement under treatment. Graphical comparison of QL patterns over cycles showed permanent discrimination by levels of prognostic factors. The impact of initial prognostic factors was consistently confirmed in the three analyses. Levels of performance status and weight loss best discriminated QL. Initial tumour stage, performance status and previous weight loss can predict QL in small-cell lung cancer during chemotherapy, even after controlling for response to treatment. Our results may contribute to clinical decision-making with regard to the intensity of chemotherapy and QL outcome, especially in patients with extensive disease.