04.03.2020: MEASURING AND IMPROVING QUALITY OF LIFE
The impressive progress that Oncology has made during the last years along with the multimodality treatments that combine surgery, radiotherapy and novel drug therapy have significantly improved the prognosis of many forms of cancer. However, this success is not without cost. Acute, chronic or even delayed treatment toxicities characterize the outcome of many patients.
In addition, the often uncurable nature of cancer affect all patients. The combination of treatment and disease effect on patients consist the quality of life (QoL) of all cancer patients.
The term QOL, therefore, refers to a multidimantional concept, which includes, at least, the physical, psychological and social functioning of cancer patients.(1)
QOL is so important, that besides disease-free survival and overall survival, has become a significant outcome measure for cancer patients. An evaluation, measurement and documentation of patient’s QOL has become a necessary component to analyze the end-point of clinical trials. It is so important that, based on this, authorities approve new treatment modalities and physicians adapt their strategies.
There are several instruments that have been proposed and in evaluating QOL in cancer patients.(1) Most of them are hand-written, self-responds to specific questionnaire on retrospective basis. Because, there are several faces of cancer with peculiarities in each one, a core questionnaire exists in several instrument for all cancers and specific additional questions for each specific cancer (i.e breast cancer, colon cancer, head-neck cancer etc). Even within the same cancer type, disease and treatment affect the patients differently during the course of cancer. It is completely different in early disease during diagnosis or following surgery or after chemotherapy and radiotherapy. Additionally, the manifestation vary and the patients needs differ in one year or five years post-diagnosis or even in long-term survivors.
It is worth mentioning that the value of measuring QOL in cancers with different survival and aggressiveness of treatment is very much limited and non-comparable.
A typical example is the QOL in patients with colon cancer and Acute Myeloid Leukemia (AML)
QOL in patients with Colon Cancer
Colorectal cancer is a typical type of cancer which is common. There is progress in its treatment with long survival and several disease and treatment related effects on QOL.
Approximately 80% of patients survive the first year and 62% survive 5years, thanks to earlier diagnosis, adjuvant chemotherapy and improved treatment in metastatic disease.
All these patients experience side effects which vary during the course of the disease and overall their journey. In a study (2) which compared the QOL in patients with colorectal cancer 1 year after diagnosis with the general population several interesting points were found. No difference was identified in functional scores following surgery alone but patients were affected more (diarrhea, neuropathy etc) when chemotherapy and or radiotherapy was added. Additionally, one year after diagnosis cancer patients experienced more emotional and social functioning deficits. Also fatigue, dyspnea, insomnia, constipation, diarrhea and financial difficulties continued to affect QOL especially in younger patients.
In another study (3), the Health related quality of life in long-term survivors of colorectal cancer (median 6 years) was evaluated using the EORTC QLQ-C30 instrument and related to survival. Overall, the Health related quality of life (HRQOL) was satisfactory. Sex, age, education, tumor location, metastases, other cancers, type of therapy and current stoma were significantly correlated to HRQOL scale. The better HRQOL score the longer survival and vice versa. The HRQOL score was better in patients who had not received neoadjuvant or adjuvant chemotherapy or radiotherapy compared to those who did and also was lower in low or middle educational status.
In another study(4) the combination chemotherapy FOLFOX-Bevacizumab was associated with the best QOL whereas FOLFIRI-Cetuximab with the worst QOL score.
Therefore, it is more than evident that QOL measurement is of paramount importance for following up these cancer patients during their disease journey.
Because, using proper intervention programs such as physical activity, educational programs, proper nutrition, psychotherapy etc may improve QOL and prolong survival.
Quality of life in patients
With Acute Myeloid Leukemia(AML)
AML is an aggressive blood disease which affects mainly older people. It has an unfavorable prognosis with a 5 year survival of about 26%. Treatment varies from Intensive Chemotherapy (IC), Non-intensive chemotherapy (NIC) to Supportive care (BSC). There is also an option of bone marrow transplantation. The choice of treatment depends on several factors such as age, performance status, cytogenetics, comorbidity etc.(5)
The symptom burden for AMC patients are significant. General symptoms include weight loss, loss of appetite, fever, fatigue, tiredness, weakness, dyspnea, infection, excess bruising, bleeding disturbed sleep, dry mouth etc.
All these symptoms are usually related on red and white blood counts as well the platelets.
Overal physical function (PF) and fatigue are the prominent symptoms. Although treatment may prolong survival, toxicity is quite severe.
In some studies(5), less intensive treatment has been associated with general improvement of the prominent symptoms. Patients with AML on relapse or refractory disease have worse symptoms. Overall, the literature on Health related quality of life in AML patients is poor and certainly more work needs to be alone for effective intervention.(6)
1) Cella DF, Tulsky DS, Gray G et al: The functional Assessment of Cancer therapy scale: Development and validation of the General Measure. Journal of Clinical Oncology 11, 3: 570 – 579, 1993.
2) Arndt Volker et al: Quality of life in patients with colorectal cancer 1 year after diagnosis compared with the General population: A population – based study. Journal of Clinical Oncology 22, 23:4829-4836, 2004.
3) Ratjem Lika, Schafmayer C, Endene J et al: Health related quality of life in long-term survivors of colorectal cancer and its association with all-cause mortality: A German cohort study. BMC Cancer 18:1156,2018.
4) Quality of life in colorectal cancer patients during chemotherapy in the era of monoclonal antibody therapies. Journal of clinical oncology 33: 15 supl e14525, 2015.
5) Forsythe R, Kwon C, Bell T et al: Health-related quality of life in acute myeloid leukemia patients not eligible for intensive chemotherapy: results of a systemic literature review. Clinicoecon. Oucome Res 12:87-98, 2019.
6) Korol EE, Wang S, Johnston K, et al: Health related Quality of life of patients with Acute Myeloid Leukemia: A systematic literature review. Oncol Ther 5(1): 1 – 16, 2017