Quality of survival in patients with surgically treated bronchial carcinoma

Measuring symptoms as a critical component of drug development and evaluation in hematological diseases

With the rapid development of new therapies for patients with hematological malignancies, there is an increasing need for patient report of symptom status during all phases of drug testing. The patient's perspective on new treatments reflects treatment tolerability as well as symptom benefit, and may assist patients and clinicians in choosing treatments. Inclusion of patient-reported outcomes, more common in solid-tumor than hematological trials, provides early information about symptoms to guide decisions about appropriate dosing and supportive care needs. We provide a historical overview of the use of patient-reported outcomes and symptom assessment in solid-tumor and hematological drug development, and offer recommendations about methodological issues in the monitoring of symptoms in the drug development process in hematological clinical trials.

The validity and reliability of the Turkish version of the University of Washington Quality of Life Questionnaire for patients with head and neck cancer

PURPOSE

The University of Washington Quality of Life Questionnaire (UW-QOL) is an English-language survey used to assess the quality of life of patients with head and neck cancer. The present study aimed to translate this widely used questionnaire into Turkish according to international guidelines and to statistically determine its validity and reliability by administering it to native Turkish-speaking patients.

MATERIALS AND METHODS

This prospective study was performed at Hacettepe University, Faculty of Medicine, Turkey. The study included patients newly diagnosed as having head and neck cancer. Translation and cultural adaptation of the questionnaire were performed first. Then, the translated version was tested on a consecutive series of patients seen in the department of otorhinolaryngology head and neck surgery and the department of radiation oncology between September 2006 and February 2008. The patients were asked to complete 3 sets of questionnaires. The first set was completed 1 day before the beginning of treatment, the second 3 months after the completion of treatment, and the third 10 days after the second questionnaire was completed. The first and second sets included the European Organization for Research and Treatment of Cancer Quality of Life Core Questionnaire-Turkish version and UW-QOL-Turkish version. The third set included the Turkish UW-QOL only. Performance status was assessed and rated by a physician using the Karnofsky and ZEW (Zubrod/The Eastern Cooperative Oncology Group (ECOG)/World Health Organization) performance scales, synchronous with the first and second sets of questionnaires.

RESULTS

The original English version of UW-QOL was carefully translated into Turkish, and a final Turkish version of UW-QOL was developed in an iterative fashion. To determine its validity and reliability, 67 patients were included in the study. Internal consistency (Cronbach α = .757) was adequate, and test-retest reliability (interclass correlation coefficient, 0.941) was excellent. The composite scores of the translated UW-QOL were compared statistically with the European Organization for Research and Treatment of Cancer Quality of Life Core Questionnaire scores, Karnofsky and ZEW performance scales, T stage of the disease, and UW-QOL global questions scores to support the scale's construct validity, and statistically significant associations were observed.

CONCLUSIONS

The Turkish UW-QOL appears to be a valid and reliable tool for use with Turkish patients with head and neck cancer; it can also be used in clinical investigations and routine clinical practice in Turkey.

Evaluating quality of life and pulmonary function of long-term survivors of non-small cell lung cancer treated with radical or postoperative radiotherapy

BACKGROUND

Our aim in the present study was to describe the quality of life (QOL), evaluate pulmonary function, and compare demographic and clinical characteristics with QOL in long-term survivors of non-small cell lung cancer treated with radical or postoperative radiotherapy.

METHODS

Twenty-eight patients were recruited in the study. QOL was evaluated using The European Organization for Research and Treatment of Cancer, Quality of Life Core Questionnaire (EORTC QLQ-C30, v.3). Statistical analysis was performed by SPSS 14.

RESULTS

Patients' files were reviewed in October 2006. Median duration of follow-up was 46 months (range: 25-125 months). Seven of 9 scales were found to meet the minimal reliability limit (Cronbach's alpha >0.70). The lowest and highest reliability coefficients were 0.56 and 0.93 for social and role functioning, respectively. All interscale correlations were statistically significant (P < 0.01). The strongest positive correlation was found between physical functioning and, role and cognitive functioning (r = 0.59, r = 0.37 or P = 0.01, P = 0.05, respectively). The highest correlation of EORTC QLQ-C30 and the Karnofsky performance scale (KPS) during the questionnaire was found to be with physical functioning and constipation (r = 0.41, r = 0.44 or P = 0.02, P = 0.01, respectively). When the effect of various demographic and clinical parameters on QOL was evaluated; initial KPS, age, educational level, health insurance status, stage, chemotherapy, comorbid disease, and passive smoking were determined as significant factors influencing QOL. Physical, role, cognitive, and emotional functions were found to be significantly lower in the presence of dyspnea (r = 0.42, r = 0.58, r = 0.50, r = 0.63 or P = 0.02, P < 0.01, P < 0.01, P < 0.05, respectively). Regarding the symptom scales, dyspnea was found to be correlated with increasing of fatigue, pain, insomnia, and appetite loss (r = 0.52, r = 0.40, r = 0.64, r = 0.38 or P < 0.01, P = 0.03, P < 0.05, P = 0.04, respectively). The parameters of pulmonary function tests (FEV1, FVC, and FEV1/FVC) did not show any significant relation with any scale of QOL.

CONCLUSION

Overall, we found that QOL of our patients who survived at least 2 years after radiotherapy, was good. The Turkish version of the EORTC QLQ-C30, v.3 is a valid and reliable instrument for Turkish lung cancer patients and can be used in clinical studies. We believe further studies are needed to have a better understanding of patients' pretreatment and posttreatment QOLs.

The European Organization for Research and Treatment of Cancer QLQ-C30: an examination into the cultural validity and reliability of the Turkish version of the EORTC QLQ-C30

The Turkish version of the European Organization for Research and Treatment of Cancer Quality of Life Core Questionnaire version 2.0 (EORTC QLQ-C30 v.2.0) has started to be used in clinical trials recently. The objective of the study was to evaluate the validity and reliability of the Turkish version of the EORTC QLQ-C30 v.2.0 and the correlation between the Karnofsky Performance Scale (KPS) and the EORTC QLQ-C30. Two hundred and two lung cancer patients were included in the study between January and March 2000. All the subscales met the minimal standards of reliability (Cronbach's alpha > or = 0.70). Only the role functioning scale differed among the three disease stages of patients (local, locoregional and metastatic). There was no statistically significant difference among therapy types. All interscale correlations were statistically significant (P < 0.01). The strongest correlations were found among the physical functioning, role functioning and fatigue scales. Social functioning was closely related with physical, role, emotional and cognitive functioning. The weakest correlations were between nausea/vomiting and the other scales. Global quality of life (QOL) was substantially correlated with most of the scales except cognitive functioning. The coefficients for the correlation between the items differed between 0.12 and 0.97 and all the subscales were strongly correlated with the scales which they formed. The highest correlation between the EORTC QLQ-C30 and KPS was for physical functioning (r = 0.62, P < 0.05). The Turkish version of the EORTC QLQ-C30 is a valid (by means of interscales validity) and reliable instrument for Turkish lung cancer patients and can be used in clinical studies but needs supporting by the reference data on the QOL of the Turkish population.

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.

Quality of life after tailored combined surgery for stage I non–small-cell lung cancer and severe emphysema

BACKGROUND

We analyzed the early and long-term quality of life changes occurring in 16 patients undergoing tailored combined surgery for stage I non-small-cell lung cancer (NSCLC) and severe emphysema.

METHODS

Mean age was 65 +/- 5 years. All patients had severe emphysema with severely impaired respiratory function and quality of life. Tumor resection was performed with sole lung volume reduction (LVR) in 5 patients, separate wedge resection in 3 patients, segmentectomy in 2 patients, and lobectomy in 6 patients. A bilateral LVR was performed in 5 patients. Quality of life was assessed at baseline and every 6 months postoperatively by the Short-form 36 (SF-36) item questionnaire.

RESULTS

Mean follow-up was 44 +/- 21 months. All tumors were pathologic stage I. There was no hospital mortality nor major morbidity. Significant improvements occurred for up to 36 months in the general health (p = 0.02) domain and for up to 24 months in physical functioning (p = 0.02), role physical (p = 0.005), and general health (p = 0.01) SF-36 domains. Associated improvements regarded dyspnea index (-1.3 +/- 0.6) forced expiratory volume in one second (+0.28 +/- 0.2L), residual volume (-1.18 +/- 0.5L) and 6-minute-walking test distance (+86 +/- 67 m). Actuarial 5-year survival was similar to that of patients with no cancer undergoing LVRS during the same period (68% vs 82%, p = not significant).

CONCLUSIONS

Our study suggests that selected patients with stage I NSCLC and severe emphysema may significantly benefit from tailored combined surgery in terms of long-term quality of life and survival.

Mental adjustment after surgery for non-small cell lung cancer

Objective:Although surgery for early-stage non-small cell lung cancer (NSCLC) is generally considered curative, the outcome is still unsatisfactory, leaving patients faced with uncertainty and fear of recurrence for a long time after surgery. The purpose of this study was to clarify the course of patients' mental adjustment after surgery for NSCLC and to identify predictors of long-term outcome.

Methods:A total of 205 patients completed a baseline interview for patient characteristics at 1 month after curative resection of NSCLC and for social support at 3 months, and the Mental Adjustment to Cancer scale at 3 and 12 months. Univariate and multivariate analyses were used to identify predictors of their psychological outcome.

Results:The helplessness/hopelessness subscale score improved slightly after curative resection (p< .001), but the score on the fighting spirit subscale score was unchanged (p= .659). Significant predictors of helplessness/hopelessness at 12 months included helplessness/hopelessness at 3 months and advanced disease stage, and satisfaction with confidants. Significant predictors of fighting spirit at 12 months included fighting spirit at 3 months existence of confidants.

Significance of results:The results suggested that mental adjustment improved slightly after curative resection for NSCLC. They also suggested the need to maintain continuity of psychosocial care that provides social support, and that an approach that includes careful attention to patients with advanced stage disease may be a strategy for improving mental adjustment after surgery for NSCLC.

Depression and psychological distress in patients during the year after curative resection of non-small-cell lung cancer

PURPOSE

There have been few psychosocial studies of patients after curative resection of non-small-cell lung cancer (NSCLC). The purpose of this study was to clarify the clinical course of depression and psychological distress of such patients during the year after surgery and to identify predictors of their long-term outcome.

PATIENTS AND METHODS

A total of 212 patients completed assessments during a 12-month follow-up period after curative resection of NSCLC. Psychological measurements at 1, 3, and 12 months after surgery were conducted using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (ed 3), Revised, and the Profiles of Mood States (POMS) scale. Univariate and multivariate analyses were used to identify predictors of psychological outcome according to these two methods of assessment.

RESULTS

The prevalence of depression did not change during the year after curative resection (range, 4.7% to 8.0%). The total POMS score was also unaltered during the year after surgery: the anger-hostility (P <.001) and tension-anxiety subscale scores (P <.026) had increased at 12 months, but the vigor-activity subscale score had also increased (P <.001). All predictors of psychological outcome at 12 months included a depression episode after the diagnosis of lung cancer or at 1 month after surgery. Less-educated status was also a significant predictor of depression at 12 months.

CONCLUSION

These results suggest the need for psychosocial support even after curative resection of NSCLC and indicate that an approach that includes repetitive perioperative assessment of depression and careful attention to less-educated patients might be of benefit to patients in ameliorating depression and psychological distress during the year after curative resection.

Pretreatment quality of life of inoperable non-small cell lung cancer patients referred for primary radiotherapy

This study examined the association between the most important prognostic factors in non-small cell lung carcinoma (NSCLC) and self-reported pretreatment quality of life (QoL) and the impact of the presence, severity and changes in respiratory symptoms on general symptoms and QoL. The study included 262 patients. The European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 and EORTC QLQ-LC13 were used to assess symptoms and QoL before radiotherapy. Patients with inoperable NSCLC showed major differences in self-reported QoL as a function of clinical prognostic factors. A significant association was found between World Health Organization (WHO) performance status and QoL but not other prognostic factors. Dyspnoea was the only respiratory symptom associated significantly with general symptoms, physical and psychosocial functioning and QoL. Furthermore, changes in dyspnoea were associated significantly with changes in physical and role functioning, global QoL and fatigue as assessed 6 weeks after radiotherapy. These results indicate that palliation of dyspnoea may have a significant beneficial effect on QoL and that palliation of other respiratory symptoms is not necessarily associated with improvement of general symptoms, physical and psychological functioning or global QoL.

Depression after successful treatment for nonsmall cell lung carcinoma

BACKGROUND

There have been few studies of depression in nonsmall cell lung carcinoma (NSCLC) patients after successful treatment. The purpose of the study was to clarify the prevalence and the correlated factors of depression after surgery.

METHODS

A structured interview was conducted for patient characteristics and social support with NSCLC patients at baseline. One-month prevalence of depression at 1 and 3 months after surgery was obtained by follow-up interviews at 1 and 3 months after surgery, respectively, whereas that of depression at 2 months after surgery was by the latter interview retrospectively. Three-month prevalence of depression was determined as presence of depression during any month in of a period of 3 months after surgery. A logistic analysis was used to examine the correlated factors of depression during the 3 months after surgery.

RESULTS

Of 223 consecutive cancer patients who participated in the study between June 1996 and April 1999, 33 (14.8%) met the criteria for major or minor depression during the 3 months after surgery. One-month prevalence of depression at 1, 2, and 3 months after surgery were 9.0%, 9.4%, and 5.8%, respectively. The results of logistic regression analysis revealed that only satisfaction with confidants before surgery, of patient characteristics and social support factors, was significantly associated with depression during the 3 months after surgery.

CONCLUSIONS

These results suggest that depression is not rare after successful treatment for NSCLC and that social support may play an important role for NSCLC patients with depression after successful treatment.

Temporal differences in coping, mood, and stress with chemotherapy

This longitudinal study examined relations among mood, coping, perceived stress, and side effects from chemotherapy in 50 individuals with stages III and IV adenocarcinoma of the lung over four consecutive combination chemotherapy courses. Results indicated that perceived stress was moderately high only at the time of pretreatment, and four coping strategies were used: seeking social support, planful problem solving, self-control, and positive reappraisal. No relations existed between coping strategies and side effects from chemotherapy, coping and perceived stress, mood and side effects, and perceived stress and side effects. Seven side effects occurred: leukopenia, decreased activity, nausea, loss of appetite, fatigue, constipation, and taste changes. In summary, receiving chemotherapy is stressful at the time of pretreatment, so nursing interventions need to be concentrated at that point.

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.

Psychosocial issues and lung cancer: a behavioral approach

OBJECTIVES

To examine the psychosocial issues related to lung cancer with a specific focus on women and quality of life. To review the role of behavioral medicine as an approach to treatment, including individual, family, and group interventions.

DATA SOURCES

Review articles, book chapters, and research studies pertaining to the psychosocial issues encountered by patients with lung cancer and behavioral medicine interventions.

CONCLUSIONS

Behavioral interventions, used in addition to medical treatment, have been shown to reduce the nausea and vomiting associated with chemotherapy, decrease suffering from pain, and diminish anxiety associated with dyspnea. These mind/body approaches help to reduce emotional distress, promote improved quality of life, enhanced coping, a sense of control, and hopefulness.

IMPLICATIONS FOR NURSING PRACTICE

Nurses can play an active role in helping patient's and family members learn new coping skills that will help promote a sense of competence, control, and support. Relaxation, mediation, distraction, social support, and cognitive therapies are a few of the interventions to help enrich the lives of patients and their families.

Quality-of-life following thoracotomy for lung cancer

Contrary to the issues of perioperative morbidity and survival following surgery for lung cancer, little attention has been given to quality-of-life. To address this, quality-of-life was assessed preoperatively and 1, 3, 6 and 9 months postoperatively in a cohort of 117 consecutive subjects who underwent thoracotomy with a certain or presumptive diagnosis of lung cancer. Those with cancer (n = 91) confirmed at thoracotomy were contrasted to those without (n = 26). Moderate to severe dyspnea, reported in 14% preoperatively, increased to 34% at 1 and 3 months (p < 0.005) but returned to approximately 10% at 6 and 9 months. Similarly, activities of daily living were impaired in 11% preoperatively; this disability increased to 21% at 1 month (p < 0.005), and returned to baseline at 6 and 9 months. Those with cancer compared to those without a postoperative diagnosis of cancer had similar quality-of-life preoperatively but deteriorated more in the postoperative period. This study demonstrates that important deterioration in quality-of-life occurs during the first 3 months postoperatively in those with a final diagnosis of cancer but improvement back to baseline can be expected thereafter.

Quality of life of patients with acute myeloid leukaemia

In a prospective study of 27 patients with acute myeloid leukaemia (AML) quality of life was studied using three different instruments, Life Ingredient Profile, Karnofsky Performance Scale and Vitagram. The course of the disease was followed during the induction period, remission, relapse and in the terminal phase. We found that induction treatment entailed physical and psychological distress with decreased quality of life but with continued ability to enjoy various leisure activities. Patients who survived experienced a change of attitude with regard to what was important in their lives. They reverted to their earlier lifestyle within 2 years.

Palliation of symptoms in non-small cell lung cancer: a study by the Yorkshire Regional Cancer Organisation Thoracic Group

BACKGROUND

Although most treatment for non-small cell lung cancer is palliative, data on the adequacy of symptom control are scanty and there has been little discussion about the appropriate indices.

METHODS

Two hundred and eighty nine unselected patients presenting sequentially to six specialists were studied; 242 cases were confirmed histologically and all were managed as non-small cell lung cancer. At presentation and two monthly for one year or until death each of 12 symptoms was graded by a physician at a clinic interview on a four point scale as absent, mild, moderate, or severe. For each symptom a palliative index (median duration of control/median duration of survival) was calculated, where control was defined as an improvement in symptoms of any severity by one grade or more.

RESULTS

Sixty four (22%) patients had surgery, 15 (5%) radical and 107 (37%) palliative radiotherapy, and 103 (36%) best supportive care. Analysis showed that most symptoms inexorably worsened with time. The palliation index for haemoptysis was 86%, chest pain 73%, cough 34%, and breathlessness 30%; for systemic symptoms it was 54% for anorexia and 47% for malaise. Palliation was poor in many patients after surgery. Breathlessness was a particular problem in the group having best supportive care.

CONCLUSIONS

The frequency of most symptoms in non-small cell lung cancer increases inexorably with time until malaise and anorexia are almost universal. Haemoptysis and chest pain are better palliated than cough and breathlessness. Present treatments fail to give adequate palliation for many patients, and the emphasis in future therapeutic studies should be on the relief of the more severe symptoms.

Statistical analysis of quality of life data in cancer clinical trials

In clinical trials endpoints other than total and/or disease-free survival are gaining more and more interest. In particular, quality of life (QOL) or the well-being of patients has emerged as a synonym for variables describing the subjective reactions of patients towards their disease and its treatment. The statistical analysis of such QOL data is complicated firstly by the large number of variables measured and their obvious lack of objectivity. The construction of suitable aggregate measures allowing a reduction of the measurements into a (preferably) unidimensional index are discussed in the context of an analysis at a fixed time point during the course of treatment. A second problem arises from the consideration that a patient's well-being is subject to changes over time. We discuss the modelling of QOL by suitable stochastic processes which are extensions of a multistate disease process. This allows QOL events to be incorporated into methods of survival analysis by either estimating the relevant transition probabilities between states or calculating quality-adjusted survival times. Finally, some brief guidelines for the planning of clinical trials including QOL measurements will be proposed.

Using permutation tests and bootstrap confidence limits to analyze repeated events data from clinical trials

In clinical trials comparing treatments for superficial bladder cancer, patients are at risk of repeated recurrences of their disease. Statistical methods of analyzing such data are required. This article presents a nonparametric approach. A statistical test to compare the recurrence or tumor rates in two treatment groups, using the randomization distribution, is described. Confidence intervals for the rate ratio are determined from the bootstrap distribution. The implementation of both requires Monte Carlo methods. Computer simulations support the use of these nonparametric methods when there are more than 60 recurrences in each treatment group. An example illustrating their use is given. The strategy adopted for analysis of these data could be applied to other clinical trials where standard methodology is inappropriate.

Quality of life during chemotherapy in non-small cell lung cancer patients

To evaluate the usefulness of chemotherapy in non-small cell lung cancer, objective response, length of remission and survival have been considered the main yardsticks. Subjective improvement and gain in Karnofsky performance status have attracted very little attention. Thirty-one patients with stages III and IV underwent combination chemotherapy with high-dose cisplatin, and were assessed with categorical scales and 100 mm visual analogue scales used by patients themselves to report on several symptoms of their illness. After chemotherapy 17 of 19 patients (89%) gained weight; 20 presented anorexia, 10 of those (50%) improved; 15 had pain, 7 of those (47%) were alleviated; cough was reported in 22, in 10 (45%) it was ameliorated; hemoptysis disappeared in 10 of 11 patients (91%); of the 9 patients who had dyspnea, 7 improved (78%); and astenia was attenuated in 8 of 16 patients (50%). Quality of life was reported improved in 75% of those patients who had considered themselves seriously affected prior to the treatment. When compared with Karnofsky performance status, no relationship was found (r = 0.31). It is concluded that, apart from the objective response achieved, a significant proportion of patients did benefit from treatment as demonstrated by a marked relief of symptoms.

Evaluating the impact of medical treatment on the quality of life: a 5-year update

A comparison of the studies investigating the impact of medical care on quality of life over a recent 5-year period (1980-1984) with those appearing during the preceding 5 years from 1975 to 1979 [1]reveals; that (a) 3 times as many (69 as compared to 23) appeared during the time span, that (b) almost two-thirds (60%) of the recent studies included a subjective measure of quality of life as compared to only 1 in 10 for the previous 5-year period, but that (c) one-shot, case studies designs still predominate. On the other hand, (d) the use of control groups doubled from 1981 to the present, although (c) the majority of studies continues to use samples of convenience (e.g. consecutive patients or treatment survivors) rather than employing random assignments or random sampling. Nevertheless, (f) the average size of samples has doubled from 90 to 178, and (g) whereas almost all of the studies in the earlier review concluded that the intervention being studied improved quality of life, now approx. 1 in 5 report negative outcomes with another 30% reporting mixed results. It is concluded that in spite of increasing methodological sophistication, investigation of the impact of medical care on quality of life will be hindered until there is better agreement as to what constitutes adequate assessment of the construct. Suggestions for how a consensus might be attained are discussed.

Quality of life of cancer patients at different stages in the disease trajectory

Building on prior work with cancer patients, our analyses sought to determine whether the process of decline in quality of life identified for patients served by hospices applied to those in nursing homes; and to relate these findings to the broader community cancer population. We found the change in quality of life to be similar for terminal cancer patients in nursing homes and in the community. Findings from the broader spectrum of cancer patients in the community suggest that cancer patients tend to undergo serious reductions in life quality prior to the last 12 weeks of life, followed by another major loss during the last few weeks of life. Finally, we were unable to identify a sizable subgroup of cancer patients with positive quality of life scores in the period immediately preceding death. Further research is needed to specify the process of decline prior to the last few months during which diminution of life quality occurs.

The quality of life of cancer patients: a review of the literature

In recent years the necessity of including quality of life (QL) measurement in cancer research has been stressed. In this paper an overview is given of the results of studies into the QL of cancer patients. From descriptive studies it appears that the quality of certain domains of life is impaired by cancer treatment. Results from studies in which two or more groups of cancer patients are being compared are not consistent. The expectation that the QL of patients is impaired more negatively by certain treatment modalities is confirmed in some studies but not in several others. Even the assumption that the QL of cancer patients is worse than the QL of the normal population is not substantiated. In this paper explanations for these unexpected results are forwarded. First, the definition and operationalization of the concept QL differs from one study to another. QL may either refer to an overall evaluation or to the evaluation of certain domains of life, and, either to the subjective experience of the patient or the evaluation of the situation by others. Secondly, other methodological difficulties especially with respect to reliability, validity and design are described. Finally, it is suggested that psychological mechanisms may account for the absence of differences between cancer patients and others and may therefore, on theoretical grounds, explain the established inconsistencies.

The natural five-year course in bronchial carcinoma. Epidemiologic results

A series of 273 unselected patients with bronchial carcinoma, comprising a total prospective 5-year study from a Swedish county with an observed 5-year survival of 7.0%, is presented. The autopsy rate in deceased patients was 94%. All diagnoses were histologically or cytologically verified. The 5-year survival rates for squamous cell carcinoma, small cell carcinoma, adenocarcinoma, and large cell carcinoma were 7.5%, 0%, 11.7%, and 3.8%, respectively. In 73% of all survivors, and in all survivors of adenocarcinoma, the disease was discovered by accident. It is concluded that the intensified search for bronchial carcinoma on chest x-rays taken because of suspicion of other diseases may have contributed to the observed survival gains as compared with other studies. The observed "real" 5-year survival rate, with inclusion, as "survivors," of patients dying of other diseases without remaining bronchial carcinoma at autopsy was 8.8%. The corresponding Kaplan-Meier product limit estimated 5-year survival was 7.7%. The study is considered to reflect as well as possible the natural 5-year course of the disease and the results cannot be repeated because of the new therapeutic possibilities introduced during the last years.

Measuring and analysing quality of life in cancer clinical trials: a review

After brief consideration of the definition of the term 'quality of life', methods previously adopted and problems encountered in assessing and evaluating quality of life in clinical studies of cancer are reviewed. Desirable properties of any such assessment methods and approaches to the analysis of quality of life data are discussed. Illustrations are provided by reference to the methods of assessment of quality of life incorporated in two recently-initiated studies of cancer treatment.