Quality-of-life issues in patients with ovarian cancer and their caregivers: a review

Caregiving Is a Marathon, Not a Road Race: Reenvisioning Caregiver Support Services in Gynecologic Oncology

OBJECTIVES

As gynecologic cancer care shifts to the outpatient setting, caregivers are instrumental in helping patients navigate the demands of the disease and treatment. Through social media, we aimed to understand the needs of caregivers of patients with gynecologic cancers and support services necessary to meet these needs.

METHODS

On January 10, 2018, a monthly Twitter discussion session was hosted by the GYNecologic Cancer Social Media community (handle @GYNCSM) using the hashtag #GYNCSM. Five topics regarding caregiver needs and support were discussed. Basic descriptive statistics, including means and frequencies of tweets, and a content analysis of the tweets were performed.

RESULTS

Forty-six participants posted a total of 471 tweets, with 1.725 million impressions. Four main themes of caregiver needs emerged, including accepting help from others, a need to care for themselves as caregivers, increased access to information and resources, and a need for the health care team to communicate with caregivers. Themes relating to barriers to obtaining support services included practical barriers, a lack of awareness, negative emotions, and a need to do it all themselves. Participants suggested that caregiver support programs include convenient resources, caregiver peer support programs, support for the "work" of caregiving, and support to improve the emotional and physical health of the caregiver.

CONCLUSIONS

Experts, patients, and caregivers effectively engaged in social media to identify a wide range of needs of caregivers of women with gynecologic cancers. Further research is needed to identify specific support services that could meet the priority needs of a broader network of caregivers.

Improving information to caregivers of cancer patients: the Herlev Hospital Empowerment of Relatives through More and Earlier information Supply (HERMES) randomized controlled trial

PURPOSE

The newly developed "Herlev Hospital Empowerment of Relatives through More and Earlier information Supply" (HERMES) intervention systematically identifies cancer caregivers' unmet needs for information from health care professionals (HCPs) and offers them the information they lack. The aim of this study was to investigate the effect of the HERMES intervention on caregivers' perception of information, communication, attention and help from HCPs, fulfillment of care needs, and anxiety and depression.

METHODS

A randomized intervention study with immediate intervention in the intervention group and delayed intervention (after follow-up) in the control group among caregivers of cancer patients starting chemotherapy.

RESULTS

Totally 199 caregivers were included (intervention group, n = 101; control group, n = 98). No intervention effect was found on overall satisfaction with information from HCPs (p = 0.1687) measured by a single item from the Cancer Caregiving Tasks, Consequences and Needs Questionnaire (CaTCoN) and chosen as primary outcome. However, positive effects were found on the CaTCoN subscales "Problems with the quality of information from and communication with HCPs" (p = 0.0279), "Lack of information from HCPs (HERMES)" (p = 0.0039), and "Lack of attention on the caregivers' wellbeing from HCPs" (p < 0.0001). No effect was found on the CaTCoN subscale "Need for help from HCPs", the Family Inventory of Needs subscale regarding fulfillment of care needs, or the Hospital Anxiety and Depression scale.

CONCLUSIONS

Although no effect was found on overall satisfaction with information, the HERMES intervention had positive effects on the caregivers' experiences of the amount of information and attention given to them and the quality of information and communication.

TRIAL REGISTRATION

ClinicalTrials.gov (Identifier: NCT02380469).

How family caregivers of cancer patients manage symptoms at home: A systematic review

INTRODUCTION

Cancer affects not only the patient, but also the whole family, especially when a member of the family assumes the role of the family caregiver. This puts an additional emotional, social and financial strain on the family caregivers. Family caregivers of cancer patients are actively involved in the care provided at the home setting through various ways including practical tasks, symptom management and care coordination. The focus of preceding studies on family caregivers and symptom management was either on pain or the patients' and family caregivers' experience of symptom management and coping. The aim of this review was to provide evidence on how family caregivers manage symptoms and side effects at home, in adult cancer patients throughout the disease trajectory.

METHODS

A systematic literature review was performed in PubMed, CINAHL, Web of Science and the Cochrane Central Register of Controlled Trials with a combination of keywords and MeSH terms for family caregivers, cancer, symptoms, side effects and management. Based on predetermined inclusion and exclusion criteria, a total of 1270 articles were screened and 20 studies were included in the analysis. A descriptive analysis was performed due to the heterogeneity of the findings.

RESULTS

The results showed that only a limited number of studies (3/20) explored how and what family caregivers do in symptom management as a primary outcome. Family caregivers provided psychosocial support, such as supporting and motivating the patient and maintaining social engagement. Caregivers provided physical support such as with the administration of medicine and tube feeding. As an integral part of managing the symptoms, family caregivers actively monitored and assessed symptoms to timely recognize any treatment related side effects, assess the response to therapeutic interventions and recognize possible deterioration in physical status. Furthermore, family caregivers were often the decision maker - being alert, watching and waiting and decided when to act and when not to act.

CONCLUSIONS

Family caregivers are doing work similar to healthcare professionals, when managing symptoms and side effects at home in patients with cancer. Advanced tasks such as assessing, monitoring and deciding when and how to act are included in the daily routine of family caregivers.

Factors Associated With Caregivers' Resilience in a Terminal Cancer Care Setting

BACKGROUND

Resilience implies characteristics such as self-efficacy, adaptability to change, optimism, and the ability to recover from traumatic stress. Studies on resilience in family caregivers (FCs) of patients with terminal cancer are rare. This study aims to examine the factors associated with FCs' resilience in a terminal cancer care setting.

METHODS

This is a cross-sectional study of 273 FCs from 7 hospice and palliative care units in Korea. Resilience was categorized as high and low, and factors associated with resilience were grouped or categorized into subscales. A multivariate logistic regression analysis was used to examine relevant factors.

RESULTS

High FCs' resilience was significantly associated with FCs' health status, depression, and social support. In a multivariate regression model, FCs' perception of good health (adjusted odds ratio [aOR] = 2.26, 95% confidence interval [CI] = 1.16-4.40), positive social support (aOR = 3.70, 95% CI = 1.07-12.87), and absence of depression (aOR = 3.12, 95% CI = 1.59-6.13) remained significantly associated with high FCs' resilience.

CONCLUSION

Lack of family support is associated with and may be a cause of diminished resilience. And more concern should be paid to FCs to improve FCs' health and emotional status. Education programs might be effective for improving caregivers' resilience. Further research with supportive interventions is indicated.

Trajectories of mental and physical functioning among spouse caregivers of cancer survivors over the first five years following the diagnosis

OBJECTIVE

Identify the trajectories of physical and mental functioning among spouse caregivers of patients with cancer over the first five years post-diagnosis and variables associated with low or deteriorating functioning.

METHODS

Caregivers completed a survey at 6 months and 1, 2, 3.5, and 5 years post-patient diagnosis, including the SF-12 for quality of life (QOL). SF-12 Mental Component Summary (MCS, n=299) and Physical Component Summary (PCS, n=300) scores were analyzed using SAS.

RESULTS

Five trajectories for PCS were identified, the top three were: (a) high PCS (53.0%); (b) steady decline in PCS (17.0%); and (c) steady increase, but remaining below population norm (16.7%). Five trajectories for MCS were also identified, the top two being: (a) high MCS (45.8%) and (b) MCS comparable to population norm (27.8%). Variables associated with low or deteriorating QOL included depression, social support, coping, burden, and/or unmet needs.

CONCLUSIONS

This is the first study to document spouse caregivers' QOL over the first five years post-patient diagnosis. Although many participants experienced high functioning, almost a third reported low or deteriorating mental or physical functioning.

PRACTICE IMPLICATIONS

Variables associated with low or deteriorating mental and physical functioning can be targeted in future interventions.

Caregiver Burden in End-Stage Ovarian Cancer

BACKGROUND

Caregiver burden associated with caring for women with ovarian cancer has received limited focus. However, these patients often have complex needs, requiring a high level of care at home and imposing substantial burdens on caregivers.

OBJECTIVES

This pilot study assessed the level of caregiver burden experienced by the primary caregivers of patients with end-stage ovarian cancer and identified variables associated with caregiver burden.

METHODS

Caregiver burden was assessed using the Caregiver Reaction Assessment. Fifty caregivers completed an anonymous and voluntary survey. Pearson correlations and independent samples t tests were used to analyze data.

FINDINGS

Most participants were Caucasian, married or living with a partner, and college graduates, with an annual household income of less than $90,000. Caregiver ages ranged from 29-81 years. Participants agreed most with the self-esteem scale, indicating they had pride in caring for their loved ones. Disrupted schedules and financial problems were the most burdensome factors in providing care. Because financial issues affected caregiver burden, nurses should facilitate interdisciplinary support. Future research is needed to determine the impact of nurse-led interventions to reduce caregiver burden.

Being the Next of Kin of an Adult Person With Muscular Dystrophy

A chronic disorder affects all members of the family in various ways. The aim of this study is to elucidate the next of kin's ( N= 36) experiences when an adult family member has muscular dystrophy. The relationships were partner (36%, n= 14), parent (18%, n= 7), child (21%, n= 8), sibling (15%, n= 6), and other relative (3%, n= 1). Latent content analysis is employed and involves an interpretation of the interviewtext. The results showthe meaning of being close to a person with muscular dystrophy through the themes that emerged: exposure of the family; the span between obligation and love; being vigilant, protective, and supportive; and striving for an ordinary life. This study reveals a need for healthcare staff to understand the next of kin's narrated meaning of changes when a family member has a progressive disease.

Implementing a home-based exercise program for patients with advanced, incurable diseases after discharge and their caregivers: lessons we have learned

BACKGROUND

Palliative care (PC) patients experience loss of physical function which usually impedes mobility, autonomy and quality of life. We aimed at examining the feasibility of a home-based exercise program for patients with advanced, incurable diseases after discharge.

RESULTS

This was a single-arm pilot study (WHO-ICTRP: DRKS00005048). The 12-week home-based program comprised strength, balance, flexibility and endurance components. Patients with a presumed life expectancy of 6-12 months were recruited during a 6-months period on a specialized PC and a radiation therapy ward. We chose the De Morton Mobility Index as primary outcome. Secondary outcomes were quality of life, 6-min walk test and others. A total of 145 patients were screened, 103 (98%) out of 105 patients on the specialized PC ward could not be included, mostly because of a low performance status [n = 94; 90%; Eastern Cooperative Oncology Group (ECOG) >2]. The only two eligible patients declined to participate. Eleven out of 40 patients (28%) were eligible on the radiation therapy ward. However, only one patient (9%) participated but dropped out 2 days later (upcoming surgery). Distance to the hospital (n = 3; 30%) and considering additional tasks as "too much" (n = 3; 30%) were most common reasons for non-participation.

CONCLUSIONS

Establishing a home-based exercise program for inpatients after discharge was not feasible mainly due to non-eligibility and lack of demand. For future trials, we suggest that choosing (1) outpatients with (2) an ECOG of ≤2 and (3) an estimated survival of ≥9 months could enhance participation in home-based exercise programs.

Cancer caregiving tasks and consequences and their associations with caregiver status and the caregiver's relationship to the patient: a survey

Background

Seriously ill patients often depend on their informal caregivers to help and support them through the disease course. This study investigated informal cancer caregivers’ experiences of caregiving tasks and consequences and how caregiver status (primary vs. non-primary caregiver) and the caregiver’s relationship to the patient (spouse/partner, etc.) are related to these experiences.

Methods

In a cross-sectional questionnaire study, randomly selected cancer patients with a range of diagnoses and disease stages were invited to pass on the ‘Cancer Caregiving Tasks, Consequences and Needs Questionnaire’ (CaTCoN) to 1–3 of their caregivers.

Results

A total of 590 caregivers related to 415 (55% of 752 eligible) cancer patients participated. Large proportions of caregivers experienced substantial caregiving workload, e.g., provision of psychological support (74%), as well as a range of negative consequences, most commonly stress (59%). Some caregivers experienced personal growth, but relatively large proportions did not. Caregiver status and the caregiver’s relationship to the patient were associated with some caregiving aspects. Primary caregivers experienced the highest caregiving workload, and non-primary caregivers experienced most problems with getting time off from work. Spouses/partners and/or parents experienced the highest workload, most lack of time for social relations, most financial difficulties, and had the greatest need for seeing a psychologist. They furthermore experienced the highest degree of personal growth and had the smallest need for living a normal life while being a caregiver. Yet, regarding the majority of caregiving aspects, no associations with caregiver status or the caregiver’s relationship to the patient were found.

Conclusions

Overall, the findings confirm that cancer caregiving is burdensome. The primary and the closest caregivers seemed to take on most caregiving tasks, but, contrary to expectations, regarding the majority of caregiving consequences non-primary and more distant caregivers were affected to the same degree as the primary and closest caregivers. Initiatives and interventions to support not only the primary caregivers are therefore warranted.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2407-14-541) contains supplementary material, which is available to authorized users.

The validity and reliability of the 'Cancer Caregiving Tasks, Consequences and Needs Questionnaire' (CaTCoN)

BACKGROUND

Caregivers are often involved in and affected by the patient's disease. The questionnaire 'Cancer Caregiving Tasks, Consequences and Needs Questionnaire' (CaTCoN) was developed to measure caregivers' experiences. The aim of this study is to evaluate the construct validity and reliability of the multi-item scales in the CaTCoN using psychometric analyses as well as tests of convergent and discriminant validity with the existing instruments FAMCARE and Family Inventory of Needs (FIN).

MATERIAL AND METHODS

Based on theoretical considerations, a subscale structure in the CaTCoN was hypothesized, and the subscales were tested by item-item correlations, followed by factor analysis, calculation of internal consistency by Cronbach's alpha, and multitrait-scaling analysis. Further, theoretically based hypotheses about convergence and divergence between CaTCoN and FAMCARE/FIN (sub)scales were formulated and tested.

RESULTS

Analyses were based on 590 caregivers' responses. Initially, 11 CaTCoN subscales were hypothesized. The item-item correlations and factor analysis lead to some revisions, but the analyses confirmed the hypothesized subscales to a large extent, resulting in nine CaTCoN subscales (Cronbach's alpha range 0.65-0.95). The hypothesized convergent CaTCoN and FAMCARE/FIN subscales correlated 0.59-0.74, and hypothesized divergent CaTCoN and FAMCARE/FIN subscales correlated -0.11-0.25, thus confirming the hypotheses concerning convergent and discriminant validity between CaTCoN and the existing questionnaires FAMCARE and FIN.

CONCLUSION

Taken together the psychometric analyses and tests of convergent and discriminant validity indicate that the validity and reliability of the CaTCoN are satisfactory.

The initial development of the 'Cancer Caregiving Tasks, Consequences and Needs Questionnaire' (CaTCoN)

AIMS

To develop a questionnaire for cancer patients' informal caregivers, measuring the caregiving tasks and consequences, and the caregivers' needs with a main focus on the interaction with the health care professionals. Such an instrument is needed to evaluate the efforts directed towards caregivers in the health care system.

MATERIAL AND METHODS

In order to identify themes relevant for the questionnaire, existing literature was reviewed and supplemented with focus group interviews with cancer patients' caregivers, cancer patients, clinicians, and cancer counselors. For each of the identified themes, one or more items were developed. During the development process, the items were evaluated by cognitive interviews in order to reduce problems with comprehension and response.

RESULTS

The literature review and eight focus group interviews with a total of 39 participants resulted in a list of relevant themes concerning the caregiving tasks and consequences, and the caregivers' needs. Subsequently, items were developed, covering each relevant theme, and the questionnaire draft was evaluated by cognitive interviews with 24 caregivers. All in all, eight versions of the full questionnaire were evaluated, and furthermore, two items in the final version were evaluated in eight additional interviews. The final version of the questionnaire, called the Cancer Caregiving Tasks, Consequences and Needs Questionnaire (CaTCoN), contains 41 items.

CONCLUSION

The CaTCoN aims to measure the extent of cancer caregiving tasks and consequences, and the caregivers' needs, mainly concerning information from and communication and contact with the health care professionals. The psychometric properties of the instrument need to be evaluated before the CaTCoN is ready for use.

Review of the literature on the effects of caring for a patient with cancer

OBJECTIVE

To adequately help family caregivers (FCs) of cancer patients, clinicians need to understand the complexity of the problems and responsibilities associated with cancer patients illness that FCs experience.

METHODS

This systematic review identified the types of problems and burdens that FCs of cancer patients experience during the patient's illness. We also analyzed the language caregivers use to communicate their problems and responsibilities related to caregiving for the cancer patient.

RESULTS

Of 2845 titles identified, 192 articles met the inclusion criteria and are included in this review. Of these, 164 were research-based. In addition to FC responsibilities and the impact of being a caregiver on daily life, a number of other physical, social, and emotional problems related to caregiving for these FCs were identified.

CONCLUSION

A substantial evidence base supports the conclusion that FCs experience many difficult problems and increased responsibilities during and after the patient is undergoing treatment and rehabilitation for cancer. The insights gained from this review will help researchers and clinicians to understand the complexity of problems and responsibilities FCs experience. This understanding may encourage them to include support for FCs as part of total or holistic patient care. However, more research is needed to better understand the variations in caregiving experiences over time; how the caregiving perspective is influenced by different cultural, ethnic, or socioeconomic backgrounds as well as gender and age; and how problems and responsibilities related to caregiving interfere with daily life.

Assessment of palliative care cancer patients' most important concerns

AIMS

Patients in the palliative care setting have a number of concerns not necessarily connected to their medical problems, such as spiritual and relationship issues. When these problems are not properly assessed and addressed, they may become a significant source of distress for patients and families. The aims of the present study were to assess the concerns of patients attending a palliative care clinic, to examine physicians' ratings of patient concerns, to access the concordance between patients' and physicians' ratings, and to assess the association between patients' concerns and their level of distress.

METHODS

We evaluated 137 patients attending a symptom control and palliative care clinic. Patients completed the Concerns Checklist, Hospital Anxiety and Depression Scale, and Cancer Behavior Inventory at the beginning of their visit. The Concerns Checklist was completed by the patient's clinic physician immediately after the visit and was used to estimate how accurate the physician was in identifying patients' concerns. We examined the correlation between the total number of patient concerns and their levels of anxiety, mood disturbance, and self-efficacy.

RESULTS

Patients were most concerned about loss of function, the future, and caring for themselves. Concordance between physician and patient rating of concerns was poor (all kappas, 0.26 or lower). Higher levels of patient concerns were associated with greater anxiety (r = 0.52) and depressive symptoms (r = 0.40) and lower self-efficacy (r = -0.37).

CONCLUSIONS

There was generally poor concordance between patients reporting of their concerns and physicians reporting of the patients' concerns. In addition, patients' with more concerns also had higher levels of anxiety and depressive symptoms. Thus, it is important to find strategies to more accurately identify patients' concerns, so that they can be adequately addressed.

The choices, choosing model of quality of life: description and rationale

AIM

This introductory paper offers a critical review of current models and measures of quality of life, and describes a choices and choosing (c-c) process as a new model of quality of life.

METHOD

Criteria are proposed for judging the relative merits of models of quality of life with preference being given to explicit mechanisms, linkages to a science base, a means of identifying deficits amenable to rational restorative interventions, and with embedded values of the whole person.

RESULT

A conjectured model, based on the processes of gaining access to choices and choosing among them, matches the proposed criteria. The c-c process is an evolved adaptive mechanism dedicated to the pursuit of quality of life, driven by specific biological and psychological systems, and influenced by social and environmental forces.

CONCLUSIONS

This model strengthens the science base for the field of quality of life, unifies approaches to concept and measurement, and guides the evaluation of impairments of quality of life. Corresponding interventions can be aimed at relieving restrictions or distortions of the c-c process; thus helping people to preserve and improve their quality of life. RELATED WORK: Companion papers detail relevant aspects of the science base, present methods of identifying deficits and distortions of the c-c model so as to open opportunities for rational restorative interventions, and explore empirical analyses of the relationship between health imposed restrictions of c-c and conventional indicators of diminished quality of life. [corrected]

Supportive care for women with gynecologic cancers

Supportive care is a multidimensional field, that involves caring for a patient's symptoms either during and/or after treatment. Ideally, once these supportive care needs are met, patients can enjoy an improved quality of life. Supportive care needs include all body systems, and are, therefore, difficult to manage, secondary to the fact that they require collaboration among multiple medical specialties. In this review, several components of supportive care are separated into two categories: tumor-related morbidities and treatment-related morbidities. Some of the themes discussed include nausea and vomiting, cancer pain, psychological distress, fatigue and anemia, small bowel obstruction and peripheral neuropathy. While all of these components are challenging to manage, it is perhaps the psychosocial realm that remains the most unmet need. Regardless, the oncologist must act as a facilitator who addresses these needs and, if unable to address the issue alone, knows how to steer the patient toward the appropriate provider. As these needs are met, the goal is for quality of life to improve; and with the improvement in quality of life we may expect to see improved survival outcomes.

Patient-reported outcomes: instrument development and selection issues

At its most elemental, patient-reported outcomes (PRO) assessment involves asking the patients questions and evaluating their answers. Instrument developers need to be clear about what they want to know, from whom they want to know it and why, whether what they learned is credible, and whether they can interpret what they learned in the context of the research objectives. Because credible instrument development is neither inexpensive nor technically trivial, researchers must first determine that no available measure meets their research objectives. We suggest that the tasks of either reviewing current instruments or developing new ones originate from the same basic premise: PRO assessment requires a well-articulated conceptual framework. Once defined in the context of the research objectives, the conceptual framework needs to be adapted to the population of interest. We discuss how qualitative methods enrich the conceptual framework and facilitate the technical measurement tasks of item development, testing, and reduction. We recognize that PRO assessment stands at a technological crossroads with the increasingly frequent application of "modern" psychometric methods and discuss how innovations such as item banks and computer-adaptive testing will influence PRO instrument development. Although items are the essential building blocks for instruments, scales are the primary unit of analysis for PRO assessment, and we discuss methods for scoring and combining them. Finally, PRO assessment is meaningless if the key figure chooses not to cooperate. We consider how respondent burden influences the quality of PRO assessment.

The prognostic effects of performance status and quality of life scores on progression-free survival and overall survival in advanced ovarian cancer

OBJECTIVE

Performance status (PS) is an important prognostic factor in advanced ovarian cancer. The purpose of this study was to evaluate the prognostic significance of PS and quality of life (QoL) assessment on progression-free survival (PFS) and overall survival (OS) in patients with advanced ovarian cancer.

METHODS

We studied Canadian patients participating in an intergroup study in ovarian cancer (NCIC-OV10), which randomized patients to receive either standard chemotherapy using cisplatin/cyclophosphamide or cisplatin/paclitaxel chemotherapy. QoL was assessed using the EORTC quality of life questionnaire (QLQ-C30+3). The effects of multiple variables including the relevant clinical variables, PS and QoL scores were analyzed by Cox stepwise regression at baseline and again 3 months after completion of chemotherapy.

RESULTS

At baseline and at 3 months after chemotherapy, there were 151 and 93 patients respectively who completed the QLQ-C30+3 questionnaires. Baseline PS, global QoL score and treatment were independent predictors for both PFS and OS. Baseline cognitive functioning score was also an additional independent predictor for OS. At 3 months after completion of chemotherapy global QoL score, PS and grade were significant independent predictors of OS; however, only physical functioning score, emotional functioning score and tumor grade predicted for PFS.

CONCLUSIONS

Performance status and global quality of life scores at baseline are prognostic factors in advanced ovarian cancer for both PFS and OS. Higher baseline cognitive functioning scores were also associated with improved survival. Global QoL scores at 3 following completion of chemotherapy proved to be of prognostic significance for OS but not PFS.

Quality of life for patients with epithelial ovarian cancer

Ovarian cancer is the sixth most common cancer worldwide and the seventh most common cause of deaths from cancer in women. Recent annual worldwide figures reflect 204,000 new cases of ovarian cancer and 125,000 deaths. Treatment of advanced ovarian cancer involves a combination of surgery and chemotherapy, both of which may impact a woman's physical, social, and emotional well-being. A woman's quality of life (QOL) is affected by disease site, and treatment-specific and patient-specific factors, but other common QOL issues include changes in physical functioning owing to side effects of treatment, psychological distress caused by fear and anxiety of recurrence, sexual dysfunction associated with anatomic and physiologic changes of treatment, and for younger women, loss of childbearing potential. As new diagnostic and treatment strategies for gynecologic malignancies are developed, research efforts should include QOL consequences. Further studies are needed to develop strategies for identifying women at risk for serious QOL disruption so that effective interventions to assist these women can be designed.

Quality of Life Considerations in Gynecologic Cancer

Quality of life (QOL) is a fundamental consideration for patients with life threatening diseases. Major evolving paradigms are discussed: improved QOL with laparoscopic surgery, the impact on QOL of intraperitoneal chemotherapy for optimally cytoreduced ovarian cancer, combination therapy, sexuality, and survivorship. The goals of treatment for many patients with gynecologic tumors remain largely palliative, and patient reported QOL is the primary outcome determining the utility of treatment. Particularly in this area, QOL endpoints are increasingly important in clinical trials. The QOL issues facing gynecologic cancer patients, the use of validated QOL instruments, recent advances in the evaluation of interventions, and changes in concepts related to QOL are reviewed.

Peritoneal carcinomatosis of colorectal origin: incidence and current treatment strategies

OBJECTIVE

To review the literature with regard to the incidence and prognostic significance of peritoneal seeding during surgery for primary colorectal cancer (CRC), the incidence of intraperitoneal recurrence of CRC, and the current treatment strategies of established PC of colorectal origin, with special focus on cytoreductive surgery and intraperitoneal chemotherapy (IPEC).

SUMMARY BACKGROUND DATA

Although hematogenous dissemination forms the greatest threat to patients with CRC, peritoneal carcinomatosis (PC), presumably arising from intraperitoneal seeding of cancer cells, is a relatively frequent event in patients with recurrent CRC.

METHODS

The PubMed and Medline literature databases were searched for pertinent publications regarding the incidence and prognostic significance of exfoliated tumor cells in the peritoneal cavity during curative surgery for primary CRC, the incidence of intraperitoneal recurrence of CRC, and the therapeutic results of systemic chemotherapy or cytoreductive surgery followed by IPEC.

RESULTS

The incidence of peritoneal seeding during potentially curative surgery for primary CRC, as reported in 12 patient series, varied widely, from 3% to 28%, which may be explained by differences in methods to detect tumor cells. PC is encountered in approximately 7% of patients at primary surgery, in approximately 4% to 19% of patients during follow-up after curative surgery, in up to 44% of patients with recurrent CRC who require relaparotomy, and in 40% to 80% of patients who succumb to CRC. The reported median survival after systemic 5-fluorouracil-based chemotherapy for PC varies from 5.2 to 12.6 months. Median survival after aggressive cytoreductive surgery followed by (hyperthermic) IPEC in selected patients, as reported in 16 patient series, tends to be better and varies from 12 to 32 months at the cost of morbidity and mortality rates of 14% to 55% and 0% to 19%, respectively. One randomized controlled trial has been published confirming the superiority of aggressive surgical cytoreduction and intraperitoneal chemotherapy over strictly palliative treatment.

CONCLUSIONS

Peritoneal seeding of cancer cells possibly leading to PC is a rather common phenomenon in patients with CRC. Cytoreductive surgery and adjuvant (hyperthermic) IPEC have been shown to be efficacious in selected patients and should therefore be considered in patients with resectable PC of colorectal origin.