Change in quality of life in patients with acromegaly after treatment with octreotide LAR: first application of AcroQoL in Korea

Patient-reported outcomes in refractory hormone-producing pituitary adenomas: an unmet need

PURPOSE

To describe quality and outcomes of patient-reported outcome (PRO) measures (PROMs) used in patients with refractory hormone-producing pituitary adenomas, and to provide an overview of PROs in these challenging pituitary adenomas.

METHODS

Three databases were searched for studies reporting on refractory pituitary adenomas. For the purpose of this review, refractory adenomas were defined as tumors resistant to primary therapy. General risk of bias was assessed using a component approach and the quality of PROM reporting was assessed using the International Society for Quality of Life Research (ISOQOL) criteria.

RESULTS

20 studies reported on PROMs in refractory pituitary adenomas, using 14 different PROMs, of which 4 were disease specific (median general risk of bias score: 33.5% (range 6-50%) and ISOQOL score: 46% (range 29-62%)). SF-36/RAND-36 and AcroQoL were most frequently used. Health-related quality of life in refractory patients (measured by AcroQoL, SF-36/Rand-36, Tuebingen CD-25, and EQ-5D-5L) varied greatly across studies, and was not always impaired compared to patients in remission.

CONCLUSION

There is a scarcity of data on PROs in the subset of pituitary adenomas that is more difficult to treat, e.g., refractory and these patients are difficult to isolate from the total cohort. The patients' perspective on quality of life, therefore, remains largely unknown in refractory patients. Thus, PROs in refractory pituitary adenomas require adequate analysis using properly reported disease specific PROMs in large cohorts to enable appropriate interpretation for use in clinical practice.

Clinical Applicability of Patient- and Clinician-Reported Outcome Tools in the Management of Patients with Acromegaly

OBJECTIVE

We aimed to assess treatment outcomes and disease control status in patients with acromegaly by patient- and clinician-reported outcome tools and to analyse correlations among different components of both tools.

METHODS

Cross-sectional study included 72 patients from the national referral centre with a median follow up of 8 (5-12) years. Baseline SAGIT at the diagnosis was determined retrospectively, while the follow up SAGIT and AcroQoL results were assessed at the most recent visit and by additional telephone interviews.

RESULTS

All SAGIT subscores significantly lowered from baseline to follow up (global score from 14 to 4 (P<0.001)). SAGIT at baseline did not discriminate the current disease control status. However, higher baseline SAGIT score and subscore T were associated with uncontrolled disease after the first-line treatment. Diagnostic delay correlated with baseline S, A, G, and global SAGIT scores. At follow up, global SAGIT score discriminated between cured/controlled and uncontrolled groups (4 vs. 6 (P=0.007)). AcroQoL score was 69.3, with »Personal relations subscale« being the least and »Physical scale« the most affected. There was no difference in AcroQoL between patients classified as uncontrolled or cured/controlled. At baseline and follow up, there were significant negative correlations between S and A subscores and AcroQoL. Higher BMI, presence of swelling, joint symptoms, headaches, sleep apnea, and hypertension significantly impaired QoL.

CONCLUSION

Our results emphasised the complementary nature of patient- and clinician-reported outcome tools in acromegaly management. We identified modifiable signs, symptoms, and comorbidities as treatment targets that might help clinicians improve QoL in this population.

Validation of Acromegaly Quality of Life Questionnaire (AcroQoL) for the Iranian population

Background

Acromegaly is a chronic disease significantly affects the physical, emotional, and health-related aspects of patients' life. This study aimed to validate the Acromegaly Quality of Life Questionnaire (AcroQoL) for the Persian-speaking population.

Methods

This cross-sectional study recruited 73 Iranian patients with a confirmed diagnosis of acromegaly. The content validity of the scales was evaluated by an expert panel of eight endocrinologists applying content validity index (CVI) and content validity ratio (CVR). Construct validity was assessed by using confirmatory factor analysis. Internal consistency was assessed on the basis of Cronbach’s alpha, and a goodness-of-fit (GoF) index was calculated to display whether the model fitted the data.

Results

CVI and CVR yielded values of 0.85 and 0.80, respectively (Acceptable CVI: > 0.78 and CVR: > 0.75). The average variances extracted (AVE) from physical and psychological dimensions were 0.520 and 0.462, respectively, exceeding the minimum criterion of 0.40. Cronbach’s alpha for physical and psychological dimensions equaled 0.868 and 0.866, respectively, indicating the adequate internal consistency of multiple items for each construct. The subscales’ R square and path coefficient were greater than the recommended threshold as 0.75 (physical dimension: 0.778, psychological dimension: 0.873), demonstrating the suitability of this criterion. Finally, the GoF value of 0.29 indicated the model's moderate fit.

Conclusions

The findings revealed that the Persian version of AcroQoL is of adequate validity and reliability for evaluating the quality of life of Iranian people with acromegaly.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40359-022-00781-0.

Correlation Between Clinical and Biochemical Markers in Patients With Acromegaly on Different Modalities of Treatment

Background

Acromegaly is a disabling disease caused by growth hormone (GH) over-secretion, associated with increased morbidity and mortality through different metabolic and somatic consequences involving soft tissue, acral overgrowth, and skin thickening, which will lead to different clinical manifestations. The study aimed to assess the correlation between biochemical markers of acromegaly with different clinical findings and biochemical control with the clinical findings.

Methods

A cross-sectional study was done on 56 patients with acromegaly attending a tertiary center for diabetes, endocrine, and metabolism in Southern Iraq Basrah. They were 32 (57.1%) males. Fatigue, headache, excessive sweating, joint pain, backache, soft tissue swelling, numbness, snoring, and visual problems were assessed on a four-point Likert scale. In addition, biochemical dynamic GH testing was done using a five-point random GH curve and/or standard GH suppression under the oral glucose tolerance test (OGTT).

Results

No significant correlation was found between symptoms severity and five-point GH parameters in respect of mean, peak, and nadir. Only backache showed a significant correlation with GH under OGTT suppression parameters in respect to mean, peak, and nadir (P-values < 0.01, < 0.01, and < 0.01), respectively. No particular biochemical control cut-off value in the 9 am random GH, mean five-point GH curve, or nadir GH under OGTT was correlated with the degree of severity for any of the clinical symptoms, as there was no difference between the biochemically controlled and uncontrolled groups in respect to any of the clinical symptom’s severity scale.

Conclusion

Only backache correlated with the biochemical tests of disease activity in the form of GH under OGTT. It appears in this study that the severity of the clinical symptoms does not correlate with biochemical control so that thorough evaluation and treatment of clinical complaints besides biochemical control is an essential part of the management plan in patients with acromegaly.

Surgically treated acromegaly patients have a similar quality of life whether controlled by surgery or requiring additional medical therapy (QuaLAT Study)

PURPOSE

There is no consensus on quality of life (QOL) in patients with acromegaly requiring medical treatment after surgery compared with those achieving remission by surgery alone.

METHODS

QuaLAT is a cross-sectional study comparing QOL in surgery-only treated acromegaly patients versus those requiring medical treatment post-surgery. Patients attending clinics were identified and divided into-Group 1: patients who had surgery only and were in biochemical remission, Group 2: all patients on medical treatment post-surgery, Group 3: patients from Group 2 with biochemical control. Participants were asked to fill three questionnaires; Acromegaly Quality of Life Questionnaire (ACROQOL), 36-Item Short Form Survey (SF36), and Fatigue Severity Scale (FSS).

RESULTS

There were 32 patients in Group 1 and 25 in Group 2. There was no difference in QOL scores between groups 1 and 2, as measured by ACROQOL (mean difference [MD] = - 2.5, 95% CI - 16.6 to 11.6; p = 0.72), SF36v2 [Physical component score (PCS) MD = - 4.9, 95% CI - 10.9 to 1.2; p = 0.12; mental component score MD = - 3.0, 95% CI - 10.5 to 4.4; p = 0.44], or FSS (MD = - 0.004, 95% CI - 1.14 to 1.33; p = 0.1). Comparison between groups 1 and 3 however showed that PCS (and 3 subdomains) was significantly better in group 3 (MD = - 8.3, 95% CI - 14.8 to -1.8; p = 0.01). All three QOL scores were lower when compared with healthy controls.

CONCLUSIONS

Medical treatment not only achieves a QOL comparable to surgery, it may also be associated with better QOL in physical subdomains. When compared with healthy controls, QOL remains worse in treated acromegaly patients compared to controls.

Improvement in Symptoms and Health-Related Quality of Life in Acromegaly Patients: A Systematic Review and Meta-Analysis

BACKGROUND

Whereas biochemical response is often used as a primary study outcome, improvement in symptoms and health-related quality of life (HRQoL) is the relevant goal for patients to consider treatment successful. We performed a systematic review and meta-analysis to assess the effect of treatment on symptoms and HRQoL in acromegaly.

METHODS

Seven electronic databases were searched for longitudinal studies assessing patient-reported symptoms or HRQoL in acromegaly. Meta-analyses were performed to assess differences during treatment for the Acromegaly Quality of Life Questionnaire (AcroQoL) and Patient-Assessed Acromegaly Symptom Questionnaire (PASQ), and standardized mean difference (SMD) for individual symptoms (interpretation: 0.2 small, 0.5 moderate, and 0.8 large effect). Treatment-naive and previously treated patients were assessed separately.

RESULTS

Forty-six studies with 3301 patients were included; 24 contributed to quantitative analyses. Thirty-six studies used medication as main treatment, 1 transsphenoidal adenomectomy, and 9 various treatments. Symptoms and HRQoL both improved: AcroQoL increased 2.9 points (95% CI, 0.5 to 5.3 points), PASQ decreased -2.3 points (95% CI, -1.3 to -3.3 points), and individual symptom scores decreased for paresthesia -0.9 (95% CI, -0.6 to -1.2), hyperhidrosis -0.4 (95% CI, -0.1 to -0.6), fatigue -0.3 (95% CI, -0.1 to -0.6), arthralgia -0.3 (95% CI, -0.1 to -0.5), headache -0.3 (95% CI, 0.0 to -0.6), and soft-tissue swelling -0.2 (95% CI, 0.0 to -0.4).

CONCLUSION

Symptoms and HRQoL improved during acromegaly treatment. Consensus is needed on which symptoms should be included in a potential core outcome set, taking into account symptom frequency, severity, and sensitivity to change, which can be used in clinical practice and as outcome in trials.

Quality of Life and its Determinants in Patients With Treated Acromegaly: A Cross-Sectional Nationwide Study in China

CONTEXT

Quality of life (QoL) continues to be impaired in acromegaly after treatment.

OBJECTIVE

We conducted the first nationwide survey assessing QoL status among Chinese patients with treated acromegaly and explored correlations with clinical parameters, treatment modalities, and outcomes.

DESIGN

Cross-sectional study.

SETTING

Survey via Chinese Association of Patients with Acromegaly (CAPA) online platform.

PATIENTS

Treated patients from CAPA.

MAIN OUTCOME MEASURES

QoL was assessed using acromegaly QoL questionnaire (AcroQoL), 5-level EuroQoL five-dimensional questionnaire (EQ-5D-5L), and 12-item short-form health survey questionnaire (SF-12).

RESULTS

Complete, valid questionnaires from 327 patients (mean age: 39.2 years, 61.5% females) at a mean of 10 years after treatment were included. Biochemical control was satisfied in 52.9% of these patients. The controlled patients had significantly better QoL than the uncontrolled patients in all AcroQoL dimensions, most SF-12 dimensions, and pain/discomfort and anxiety/depression dimensions of the EQ-5D-5L. Patients with either controlled or uncontrolled acromegaly had significantly worse QoL than the age- and sex-adjusted population reference in most SF-12 dimensions except for physical functioning. More acromegaly-associated symptoms and comorbidities at follow-up were independent risk factors for decreased QoL across all questionnaires. Medical treatment, especially with somatostatin analogs (SSAs), and radiotherapy were predictors of worse QoL. Female patients had lower scores of physical-related QoL than male patients.

CONCLUSIONS

Our study suggests that biochemical control improved but did not normalize QoL in acromegaly. Numbers of symptoms and comorbidities at follow-up, sex, radiotherapy, and medical treatment with SSAs were factors determining QoL of patients with treated acromegaly.

Updates in rare and not-so-rare complications of acromegaly: focus on respiratory function and quality of life in acromegaly

Acromegaly is a complex disease with excessive growth hormone and insulin-like growth factor 1 (IGF-1) causing multisystem effects, particularly cardiovascular, respiratory, and metabolic. Psychological concerns and poor quality of life (QoL) are also major disease consequences. This review is intended for clinicians and focuses on the latest developments related to respiratory and QoL effects of long-term growth hormone excess. Along with biochemical disease control, patient treatment satisfaction and outcomes have become major treatment objectives; current knowledge and tools to evaluate and manage this aspect of the disease are described. Sleep apnea syndrome and other derangements of lung function and apparatus, from pathophysiology to treatment, and evaluation tools and determinants of QoL in patients with acromegaly are discussed.

Systemic Complications of Acromegaly and the Impact of the Current Treatment Landscape: An Update

Acromegaly is a chronic systemic disease with many complications and is associated with increased mortality when not adequately treated. Substantial advances in acromegaly treatment, as well as in the treatment of many of its complications, mainly diabetes mellitus, heart failure, and arterial hypertension, were achieved in the last decades. These developments allowed change in both prevalence and severity of some acromegaly complications and furthermore resulted in a reduction of mortality. Currently, mortality seems to be similar to the general population in adequately treated patients with acromegaly. In this review, we update the knowledge in complications of acromegaly and detail the effects of different acromegaly treatment options on these complications. Incidence of mortality, its correlation with GH (cumulative exposure vs last value), and IGF-I levels and the shift in the main cause of mortality in patients with acromegaly are also addressed.

The effectiveness of a therapist-oriented home rehabilitation program for a patient with acromegaly: A case study

BACKGROUND

Acromegaly causes numerous functional limitations that negatively impact patients' performance of activities of daily living (ADLs) and contribute to the deterioration of health-related quality of life (HRQoL). Thus, the purpose of the present case study was to evaluate the effect of therapist-oriented home rehabilitation (TOHR) for a patient with acromegaly.

CASE DESCRIPTION

We report the case of a 53-year-old man who was diagnosed with primary acromegaly 17 years ago. He complained of difficulties performing tasks that involved his hands, pain in the lower limbs, and fatigue when he climbed a few flights of stairs. Although he performed ADLs independently, he reported some difficulties or discomfort when performing them.

INTERVENTION AND OUTCOME

The patient underwent a booklet-guided physical exercise program that lasted two months (three times per week, 60 minutes per session). The activities included overall stretching, muscle strengthening, and endurance exercises, along with aerobic conditioning through functional circuit training. After two months of exercise, he reported improved HRQoL as assessed with the Acromegaly Quality of Life Questionnaire, with increases in quadriceps muscle strength and 6-min walking distance. However, none of these benefits remained when the patient was assessed after a 1-month washout period.

CONCLUSION

This study showed that patients with acromegaly may benefit markedly from TOHR, which could provide a novel therapeutic approach as an adjunct to hormone control therapy.

A Consensus Statement on acromegaly therapeutic outcomes

The 11th Acromegaly Consensus Conference in April 2017 was convened to update recommendations on therapeutic outcomes for patients with acromegaly. Consensus guidelines on the medical management of acromegaly were last published in 2014; since then, new pharmacological agents have been developed and new approaches to treatment sequencing have been considered. Thirty-seven experts in the management of patients with acromegaly reviewed the current literature and assessed changes in drug approvals, clinical practice standards and clinical opinion. They considered current treatment outcome goals with a focus on the impact of current and emerging somatostatin receptor ligands, growth hormone receptor antagonists and dopamine agonists on biochemical, clinical, tumour mass and surgical outcomes. The participants discussed factors that would determine pharmacological choices as well as the proposed place of each agent in the guidelines. We present consensus recommendations highlighting how acromegaly management could be optimized in clinical practice.

Cognitive-behavioral therapy improves the quality of life of patients with acromegaly

BACKGROUND

The delayed diagnosis, altered body image, and clinical complications associated with acromegaly impair quality of life.

PURPOSE

To assess the efficacy of the cognitive-behavioral therapy (CBT) technique "Think Healthy" to increase the quality of life of patients with acromegaly.

METHODS

This non-randomized clinical trial examined ten patients with acromegaly (nine women and one man; mean age, 55.5 ± 8.4 years) from a convenience sample who received CBT. The intervention included nine weekly group therapy sessions. The quality of life questionnaire the 36-Item Short Form Survey (SF-36) and the Beck Depression Inventory (BDI) were administered during the pre- and post-intervention phases. The Wilcoxon signed-rank test was performed to assess the occurrence of significant differences.

RESULTS

According to the SF-36, the general health domain significantly improved (d'  = - 0.264; p = 0.031). The mental health domain improved considerably (d'  = - 1.123; p = 0.012). Physical functioning showed a non-significant trend toward improvement (d'  = - 0.802; p = 0.078), although four of the five patients who showed floor effects improved and remained at this level. Regarding emotional well-being, five patients showed floor effects and four improved, and the condition did not change among any of the four patients who showed ceiling effects. No significant changes were found with regard to the other domains. No significant differences in the BDI were found before or after the intervention.

CONCLUSION

The technique presented herein effectively improved the quality of life of patients with acromegaly with different levels of disease activity, type, and treatment time.

Higher Income and Integration into the Workforce Are the Main Factors Associated with Quality of Life in Acromegalic Patients in Northeastern Brazil

OBJECTIVE

To identify the factors associated with quality of life in patients with acromegaly with follow-up at the referral service in neuroendocrinology of the state of Maranhão, northeast Brazil.

METHODS

The Acromegaly Quality of Life Questionnaire (Acro-QoL) was used. Factors independently associated with quality of life were identified using multivariate linear regression, with p values < 0.05 considered significant.

RESULTS

The multivariate linear regression analysis indicated a positive association between being integrated into the job market and quality of life scores in the overall domain (β = 0.288, p = 0.003), psychological domain (β = 0.291, p = 0.032), and personal relationship domain (β = 0.314, p = 0.019). We also observed a positive association with income and the quality of life scores in all domains as follows: overall domain (β = 0.037, p = 0.003), physical domain (β = 0.988, p = 0.001), psychological domain (β = 0.342, p = 0.008), physical appearance domain (β = 0.270, p = 0.049), and personal relationship domain (β = 0.315, p = 0.012).

CONCLUSION

For patients with acromegaly living in one of the least developed regions of Brazil, integration into the job market and a higher income were associated with a better quality of life.

Predictors of Quality of Life in Acromegaly: No Consensus on Biochemical Parameters

BACKGROUND

Quality of life (QoL) in patients with acromegaly is reduced irrespective of disease state. The contributions of multifactorial determinants of QoL in several disease stages are presently not well known.

OBJECTIVE

To systematically review predictors of QoL in acromegalic patients.

METHODS

Main databases were systematically searched using predefined search terms for potentially relevant articles up to January 2017. Inclusion criteria included separate acromegaly cohort, non-hereditary acromegaly, QoL as study parameter with clearly described method of measurement and quantitative results, N ≥ 10 patients, article in English and adult patients only. Data extraction was performed by two independent reviewers; studies were included using the PRISMA flow diagram.

RESULTS

We identified 1,162 studies; 51 studies met the inclusion criteria: 31 cross-sectional observational studies [mean AcroQoL score 62.7 (range 46.6-87.0, n = 1,597)], 9 had a longitudinal component [mean baseline AcroQoL score 61.4 (range 54.3-69.0, n = 386)], and 15 were intervention studies [mean baseline AcroQoL score 58.6 (range 52.2-75.3, n = 521)]. Disease-activity reflected by biochemical control measures yielded mixed, and therefore inconclusive results with respect to their effect on QoL. Addition of pegvisomant to somatostatin analogs and start of lanreotide autogel resulted in improvement in QoL. Data from intervention studies on other treatment modalities were too limited to draw conclusions on the effects of these modalities on QoL. Interestingly, higher BMI and greater degree of depression showed consistently negative associations with QoL. Hypopituitarism was not significantly correlated with QoL in acromegaly.

CONCLUSION

At present, there is insufficient published data to support that biochemical control, or treatment of acromegaly in general, is associated with improved QoL. Studies with somatostatin receptor ligand treatment, i.e., particularly lanreotide autogel and pegvisomant have shown improved QoL, but consensus on the correlation with biochemical control is missing. Longitudinal studies investigating predictors in treatment-naive patients and their follow-up after therapeutic interventions are lacking but are urgently needed. Other factors, i.e., depression and obesity were identified from cross-sectional cohort studies as consistent factors associated with poor QoL. Perhaps treatment strategies of acromegaly patients should not only focus on normalizing biochemical markers but emphasize improvement of QoL by alternative interventions such as psychosocial or weight lowering interventions.