Measuring the effect of cancer on health-related quality of life

Which aspects of an oral health-related quality of life measure are mainly associated with global ratings of oral health in children?

OBJECTIVES

To assess the associations of global subjective ratings of oral health with different aspects of an oral health-related quality of life measure, namely total Oral Impacts on Daily Performances (OIDP) and Child-Oral Impacts on Daily Performances (Child-OIDP) scores, extent and intensity of oral impacts, the different performance scores and oral impacts attributed to certain groups of oral conditions.

METHODS

This study was part of the Sixth Thailand National Oral Health Survey. One thousand and sixty-six 12-year-olds and 815 15-year-olds were interviewed on their OHRQoL using Child-OIDP and OIDP indices, respectively, and rated their overall oral problems on 3-point and 5-point scales, respectively. Associations of global rating of oral health with different Child-OIDP/OIDP outcome variables were estimated using Spearman's rank correlations and logistic regressions.

RESULTS

Child-OIDP/OIDP scores were significantly associated with global ratings. Intensity was associated with global ratings, whereas extent was not. Impacts of 'very little' intensity were associated with a slightly higher chance of having poorer oral health perceptions. Global ratings were associated most with oral impacts attributed to dental caries, but not with the impacts related to natural process, such as eruption. Eating, cleaning teeth, emotional stability and smiling, plus social contact in 15-year-olds were performances associated with global ratings. Fifteen-year-old girls were more likely to perceive more oral problems than boys.

CONCLUSIONS

Associations of global ratings of oral health with Child-OIDP/OIDP scores were mainly due to the intensity of impacts. Global ratings were related to multidimensional aspects of children's quality of life.

Disability and health-related quality of life in long-term survivors of cancer in childhood in Brazil

There is limited experience with patient-reported measurements of health status and health-related quality of life (HRQL) in survivors of cancer in childhood in low-income countries. The purposes of this study were to collect such measurements in Brazil, to test hypotheses about differences among diagnostic groups, and to compare results with those from other countries. Survivors were eligible if diagnosed with cancer in childhood, attending a long-term follow-up clinic, cancer free, literate, and at least 13 years of age. Health status measurements were collected using a Brazilian Portuguese Health Utilities Index questionnaire. Questionnaire responses were converted to scores for morbidity in individual health attributes and for overall HRQL. More than one-third of the 138 consecutive survivors who participated reported some cognitive disability or pain. Approximately one-quarter reported problems with vision, speech, or emotion. Mean HRQL was similar (P>0.05) among countries for survivors of acute lymphoblastic leukemia and Hodgkin disease. The results support the hypotheses that Brazilian survivors of cancer in childhood experience a wide range of disabilities and impaired HRQL, are similar to those in other countries, and should be assessed in long-term follow-up clinics.

Economic evaluation and health-related quality of life

Health-related quality of life (HRQL) is concerned with the opportunities that a person's health status affords, the constraints that it places upon the person and the value that a person places on his or her health status. The rationale for measuring HRQL falls into three categories: discrimination, evaluation, and prediction. Measures have to meet generally accepted psychometric criteria such as acceptability, reliability/reproducibility, responsiveness, validity, interpretability, and usefulness. HRQL instruments have been designed for self-administration or administration by interviews and some have been adapted to multiple cultural/linguistic needs. For adolescents and young adults with cancer several instruments are available. Overall HRQL is compromised, to varying degrees, in such survivors by comparison with peers in the general population; and the burden of morbidity is greatest after brain and bone tumors. As there is a burden of treatment-related morbidity and as the number of survivors within the health care system is growing, the economic dimension of care and cure has to be taken into consideration. Economic evaluation affords a comparison of the costs and consequences (effects) of relevant therapeutic alternatives. The future research activities with respect to HRQL have to consider these new dimensions of care.

The prognostic significance of patient-reported outcomes in cancer clinical trials

PURPOSE

Patient-reported outcomes (PROs), routinely collected as a part of cancer clinical trials, have been linked with survival in numerous clinical studies, but a comprehensive critical review has not been reported. This study systematically assessed the impact of PROs on patient survival after a cancer diagnosis within the context of clinical trials.

DESIGN

Cancer clinical trials that assessed baseline PROs and mortality were identified through MEDLINE (through December 2006) supplemented by the Cochrane database, American Society of Clinical Oncology/European Society for Medical Oncology abstracts and hand searches. Inclusion criteria were publication in English language and use of multivariate analyses of PROs that controlled for one or more clinical factors. Two raters reviewed each study, abstracted data, and assessed study quality; two additional raters verified abstractions.

RESULTS

In 36 of 39 studies (N = 13,874), at least one PRO was significantly associated with survival (P < .05) in multivariate analysis, with varying effect sizes. Studies of lung (n = 12) and breast cancer (n = 8) were most prevalent. The most commonly assessed PRO was quality of life, measured by the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30 in 56% of studies. Clinical variables adjusted for included performance status (PS), treatment arm, stage, weight loss, and serum markers. Results indicated that PROs provide distinct prognostic information beyond standard clinical measures in cancer clinical trials.

CONCLUSION

PROs might be considered for stratification purposes in future trials, as they were often better predictors of survival than PS. Studies are needed to determine whether interventions that improve PROs also increase survival and to identify explanatory mechanisms through which PROs relate to survival.

Measurement of health-related quality of life in survivors of cancer in childhood in Central America: feasibility, reliability, and validity

Cancer is the commonest cause of disease-related death in children over 5 years of age in various parts of Latin America, but the survival rates are improving. This study assessed the health status and health-related quality of life (HRQL) of more than 200 survivors of cancer in childhood in the countries of a Central American consortium devoted to pediatric hematology-oncology. Patients' self-reports and parental proxy assessments were collected using interviewer-administered Spanish-language questionnaires, and physicians provided assessments using self-complete questionnaires, based on the complementary Health Utilities Index (HUI) Mark 2 (HUI2) and Mark 3 (HUI3) health status classification systems. Inter-rater agreement, measured by intra-class correlation (ICC), was fair to moderate (0.34<ICC<0.55) between patients, parents, and physicians for HRQL scores. There was substantial or almost perfect agreement (ICC>0.60) for all 3 pairs of assessors for readily assessable attributes: HUI2 sensation, HUI3 vision, HUI3 hearing, and HUI3 ambulation. Less than 40% of the patients reported being in perfect health. More than 20% reported being in health states with HRQL scores corresponding to moderate or severe disability, notably in the attributes of emotion and cognition. The results reflect a common profile in survivors of cancer in childhood, including those from industrialized societies. This study illustrates the feasibility of collecting reliable and valid information on HRQL in the developing country context, raising the prospect that such information could be used to influence clinical practice.

The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-c30): validation of English version in Singapore

OBJECTIVE

This study aimed to validate the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30, English version 3.0) in Singaporean cancer patients.

METHODS

In a cross-sectional study, a heterogeneous sample of cancer patients (n = 57) self-administered a questionnaire containing the QLQ-C30, the Short Form 36 Health Survey (SF-36) and assessing health and sociodemographic status. Construct validity was assessed by testing a priori hypotheses that QLQ-C30 scales would be moderately or strongly correlated with SF-36 scales measuring similar dimensions of health-related quality of life (HRQoL) and that subjects reporting mild symptoms would have better HRQoL scores than those reporting severe symptoms. Internal consistency reliability was assessed using Cronbach's alpha.

RESULTS

Strength of Spearman's correlations between the QLQ-C30 and SF-36 scales assessing similar dimensions of HRQoL ranged from 0.35 to 0.67. Subjects with mild symptoms had better scores than those with severe symptoms for all six QLQ-C30 HRQoL scales (p < 0.05 for five scales, Mann-Whitney U tests). Cronbach's alpha ranged from 0.19 for the cognitive functioning scale to 0.91 for the global QoL scale.

CONCLUSION

This study provides preliminary evidence for the validity and reliability of the EORTC QLQ-C30 in English-speaking Singaporean cancer patients.

Psychosocial determinants of well-being in gynecologic cancer patients

The purpose of this study was to investigate the well-being of women with endometrial versus cervical cancer before treatment, and its determinants at 12 to 15 months follow-up. The subjects were interviewed before treatment, then 6 and 12 to 15 months after initiation of treatment. Simultaneously, they completed questionnaires on psychological symptoms and social support. It appeared that well-being at baseline and at the follow-ups were highly correlated. Furthermore, cervical cancer patients reported significantly more symptoms on all occasions. After discriminant function analysis, the following three variables remained in the analysis: (a) well-being before treatment, (b) diagnosis, and (c) children at home. This allowed 81% of the patients to be classified as having a favorable versus an unfavorable outcome. The results of this study highlight the importance of well-being before treatment as a predictor of well-being after treatment. The necessity of individualized intervention measures is warranted.

The use of quality of life data in clinical practice

A large amount of quality of life (QoL) information has been and is being collected in the oncology setting but it is unclear how such data influence decisions about the management of individual patients. A questionnaire designed specifically for the study was mailed to 260 senior oncologists to investigate how QoL data are being used outside the context of cancer clinical trials; replies were received from 154 (59%). Approximately 80% believed QoL information should be collected prior to the commencement of treatment, but less than 50% actually did so. Similarly, less than 50% assessed QoL as a method of monitoring the responses to treatment even when the treatment goal was palliation. The barriers to collecting such data were time and resource constraints, perceived lack of an appropriate instrument and a belief that QoL assessments were unnecessary. Other than making a subjective assessment based on examination and history, 73 (47%) used either standardized questionnaires or a system derived in their unit to assess the QoL of their patients. Given an appropriate instrument the majority believed that QoL data could be collected on a routine basis. The main barriers to collecting QoL data are logistic and the challenge remains to develop a method of collecting and analysing QoL information in a manner which enhances decision making.