press release: Moffitt Cancer Center researchers: Quality of life as important as quantity of life

Moffitt Cancer Center researchers: Quality of life as important as quantity of life

"The question of how well people are surviving cancer is as important as how long they survive cancer," .....


Prolonged fatigue after treatment


In a recent study published in Cancer, researchers from Moffitt found that when patients treated with chemotherapy or chemotherapy and radiation for breast cancer were compared to a control group who had not had cancer, the patients who had experienced chemotherapy and/or radiotherapy had more fatigue. These patients also had fatigue that lasted years after their therapy.
"This finding was contrary to our expectations," Jacobsen said. "Conventional thinking is that patients receiving chemotherapy would, over time, experience less fatigue and would eventually see their fatigue diminish to the levels of controls who had not had cancer, or to the level of fatigue they had prior to their chemotherapy.".......

abstract: A systematic review evaluating the relationship between progression free survival and post progression survival in advanced ovarian cancer

 Blogger's Note:
this is and has been an ongoing issue in clinical trials as most use still use overall survival (OS) (as per this paper and others)  as the endpoint as opposed to progression free survival; it is a technical debate having wide implications for ovarian cancer treatments/patients, without access to the full text paper and based on the abstract alone,  one outstanding issue would be the impact of QOL/side effects/number of prior treatments, so in plain english as an example - clinical trial x includes standard treatment vs other, no more than eg. 3 prior chemos would be a component of the clinical trial - therefore - what was/is the mix of patients in the trial - all of which impact survival ratios irrespective of PFS/OS; opinions as usual are welcome
                                      ~~~~~~~~~~~~~~~~~

A systematic review evaluating the relationship between progression free survival and post progression survival in advanced ovarian cancer:




Objective 
Although overall survival is the ultimate goal of cancer therapy, many clinical and health economic decisions are taken when only progression free survival (PFS) data are available. This study evaluates the relationship between PFS and post progression survival (i.e. the time between disease progression and death) to estimate how many months a new drug for ovarian cancer might add to overall survival if the number of months the drug added to PFS (relative to a standard drug) was already known.

Methods 
A literature search was conducted over Medline for randomised controlled trials published between January 1990 and July 2010 that evaluated the effect of a drug treatment in comparison to alternative drug treatment in patients with either advanced stage primary or recurrent ovarian cancer.
A systematic review of progression free and post progression survival (PPS) was performed. The relationship between PFS and PPS was evaluated by a graphical method and standard statistical tests.

Results
Thirty-seven trials involving 15,850 patients met the inclusion criteria. The review found that increases in median PFS generally lead to little change in post-progression survival. Percentage gains in PFS are generally associated with no percentage gains or with very slight percentage gains or losses in post-progression survival

Conclusion
If the effect of a new drug treatment for ovarian cancer is to extend median PFS by x months, then it is reasonable to estimate that the treatment will also extend median overall survival by x months. This information will be useful for individual and collective decision making.

abstract: Management of highly emetogenic chemotherapy

Management of highly emetogenic chemotherapy. [Curr Opin Oncol. 2012] - PubMed - NCBI

 Definition for emetogenic:

Web definitions:

Vomiting (known medically as emesis and informally as throwing up and a number of other terms) is the forceful expulsion of the contents... en.wikipedia.org/wiki/Emetogenic

                       ~~~~~~~~~~~~~~~~~~

Abstract

PURPOSE OF REVIEW:

This review updates the clinical data on antiemetic therapy for chemotherapy classified as highly emetogenic.

RECENT FINDINGS:

A meta-analysis demonstrated that palonosetron was superior to other 5-hydroxytryptamine3 (5-HT3) receptor antagonists at least in the absence of aprepitant. Two major guideline groups have reclassified all chemotherapy that contains cyclophosphamide and an anthracycline as 'highly emetogenic'. Although recommended prophylaxis for drugs in that category includes aprepitant, phase II studies with cyclophosphamide, doxorubicin, vincristine and prednisone (CHOP) and doxorubicin, bleomycin, vincristine and dacarbazine (ABVD) demonstrated that single agent palonosetron alone provided control of emesis over 85% of patients. A randomized phase III trial of olanzapine versus aprepitant found that the control of emesis was similar and nausea was significantly better controlled with olanzapine. Two studies showed that there is no impact of the moderate cytochrome P450 3A4 (CYP3A4) inhibitor aprepitant on the pharmacokinetics of cyclophosphamide. Surveys in the United States and Europe demonstrated that antiemetic prescribing practices often do not adhere to guidelines even for highly emetogenic chemotherapy.

SUMMARY:

The major guideline groups recommend a combination of a 5-HT3 receptor antagonist, dexamethasone and aprepitant ('triple therapy') for treatment categorized as highly emetogenic. Recent data suggest that, although classified as highly emetogenic, palonosetron may provide very good control of emesis for CHOP and ABVD.
Guidelines have not made firm recommendations for highly emetogenic chemotherapy administered over several days or stem cell transplant preparative regimens due to the lack of published randomized trials. Although well tolerated and effective, many patients receive suboptimal antiemetic therapy that includes aprepitant.

abstract: [Assessment of health-related quality of life in cancer outpatients treated with chemotherapy] Japanese study

[Assessment of health-related quality of life in cancer outpatients treated with chemotherapy].


Abstract
Purpose: 
Few studies have been conducted to elucidate the health-related quality of life(HR-QOL) of cancer outpatients treated with chemotherapy. In this study, we attempted to determine the physical and psychological distress of cancer outpatients treated with chemotherapy.

Methods:
Two-hundred and ninety-six outpatients with various malignancies, including malignant lymphoma, and esophageal, gastric, pancreatic, colon, lung, breast, ovarian, uterine and skin cancers, were investigated using the Japanese version of the M. D. Anderson symptom inventory from March through June 2010 in Tokyo Medical University Hospital.

Results:
The results of the survey questionnaire indicated that 59 patients suffered from fatigue, 56 experienced numbness or tingling, 48 felt drowsy, 39 had low moods, 40 felt distressed, 38 had no appetite, 38 had dry mouth, 37 were in pain, 37 had disturbed sleep, 31 had shortness of breath, 24 had nausea, 17 suffered from vomiting, and 13 patients had memory problems. Furthermore, these symptoms interfered with work(65 patients), walking(56 patients), mood(52 patients), life enjoyment(49 patients), general activity(49 patients), and relationships with other people(42 patients). Medications prescribed for HR-QOL control were non-steroidal anti-inflammatory drugs (93 patients), morphine(32 patients), and adjuvant analgesics(47 patients).

Conclusion:
The present findings may help in the development of management strategies for physical and psychological distress, and improve HR-QOL of cancer outpatients treated with chemotherapy.

Editorial: The Relationship Between Cost and Quality, No Free Lunch - March 14, 2012 — JAMA + link to original article

The Relationship Between Cost and Quality, March 14, 2012, Joynt and Jha 307 (10): 1082 — JAMA
 Editorial: The Relationship Between Cost and Quality 

No Free Lunch

Since this article does not have an abstract, we have provided the first 150 words of the full text. (Blogger's Note: subscription required to view $$$)

"For the past 30 years, research from investigators at Dartmouth has demonstrated large and persistent variations in costs and quality across the US health care system. Beyond simply showing that cost and quality vary by geography, the Dartmouth Atlas has demonstrated that in many communities, care is so fragmented and ineffective that greater spending on Medicare beneficiaries often leads to worse outcomes^1,2 because some patients receive services that are redundant and low value and that may even have substantial risks. 

However, some US policy makers have misinterpreted the Dartmouth research and in the troves of data have found what they believe to be a free lunch: given the inverse relationship between costs and quality, it follows that it should be possible to simultaneously reduce spending and improve care. Although this notion is attractive, much of the subtlety of the Dartmouth work has been lost in translation. What ....."

[Full Text of this Article] (subscription required to view)

Related article

• Association of Hospital Spending Intensity With Mortality and Readmission Rates in Ontario Hospitals  
   JAMA. 2012;307(10):1037-1045.doi:10.1001/jama.2012.265
  • Abstract
  • Full Text
  • Full Text (PDF)
  • eSupplement
  • Author Video/Audio Interview
  • JAMA Report Video

abstract: Patients and staff perceptions of cancer patients' quality of life

Patients and staff perceptions of cancer patients' quality of life


Background
Discrepancies exist in estimation of quality of life (QL) by patients and caregivers but underlying factors are incompletely characterised.

Methods
QL of 153 patients was estimated by themselves, by 70 nurses and by 53 physicians in a cross-sectional study. Variables which could influence inter-rater agreement were evaluated.

Results
Inter-rater agreement of QL was fair (r = .292) between patients and nurses and between patients and physicians (r = .154). Inter-rater agreement with nurses was significantly lower concerning fatigue and pain for patients with a Karnofsky Index <50 when compared to patients with a KI >50. Their inter-rater agreement with physicians was significantly lower for fatigue, pain and physical functioning. Agreement on the degree of anxiety was significantly (p = .009) better for female patients. Agreement on the need for social assistance (p = .01) and physical functioning (p = .03) was significantly better for male patients. Agreement with patients on their physical functioning was significantly (p = .03) better for male nurses and male physicians (r = .944) than for female nurses and female physicians (r = .674).

Conclusions
Our study showed that estimation of overall QL of patients by professional caregivers is inaccurate. Inter-rater agreement was influenced by KI of patients, by gender of patients and caregivers and by professional experience of nurses.

abstract: Cognitive function and quality of life in ovarian cancer- Gynecologic Oncology (chemobrain)

Objectives

As advances in treatment have prolonged survival for many patients with ovarian cancer, there has been growing interest in assessing the adverse effects of disease and treatment. The aim of this study was to review the literature on cognitive function and quality of life (QOL) in this population.

Results

The small number of studies including formal evaluations of neurocognitive function suggests that many ovarian cancer patients experience cognitive difficulties associated with their disease and treatment. Several studies described declines in self-reported cognitive function that may impact QOL, but the results were not consistent across studies.

---

Highlights

► The literature suggests that many patients with ovarian cancer experience cognitive difficulties associated with their disease and treatment.
► Several studies reported declines in self-reported cognitive function that may impact QOL, but the results were inconsistent across studies.

abstract: Quality of life of parents diagnosed with cancer: change over time and influencing factors.

"Suffering from cancer while having parental responsibilities can amplify the psychosocial strain that the disease puts on the individual as well as on the whole family system.
Our longitudinal study examines changes in the quality of life of cancer patients in relation to parenthood. The quality of life of cancer patients is assessed with the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire 30-item version during the initial treatment period (T1) and compared to the quality of life 2 years later (T2). Two groups of patients are compared: those who have children below the age of 18 years (n= 41) and those who do not have children (n= 28). Shortly after being diagnosed with cancer (T1), both groups report a similarly low quality of life. Two years later (T2), individuals with children below the age of 18 report better quality of life on the majority of the dimensions assessed. However, variance analysis did not show that this is an independent effect of parenthood. In fact, having a partner and being female proved to impact the quality of life. These findings support the existing body of research on the influence of social support and gender on quality of life. The resulting limitations and suggestions on how to overcome them in further research are discussed."

abstract: The association between quality of life domains and overall survival in ovarian cancer patients during adjuvant chemotherapy: patients from GOG 172 trial

Highlights

► Physical QOL is associated with OS in ovarian cancer patients receiving adjuvant chemotherapy.
► Poor physical well-being at baseline is associated with risk of death in patients undergoing adjuvant chemotherapy for advanced ovarian cancer.
► Identifying modifiable characteristics that are associated with survival offers the potential for providing support that may improve outcomes.

abstract: Health-related quality of life in recurrent platinum-sensitive ovarian cancer—results from the CALYPSO trial

Background: In the CALYPSO trial, carboplatin–pegylated liposomal doxorubicin (CD) demonstrated superior therapeutic index versus carboplatin–paclitaxel (CP) in patients with recurrent ovarian cancer. This paper reports the health-related quality of life (HRQoL) findings.

Conclusions: These patient-reported outcomes confirm the overall lower toxicity of CD versus CP. The improved disease-related outcomes achieved with CD were not at the expense of QoL.

abstract: Missing content from health-related quality of life instruments: interviews with young adult survivors of childhood cancer

Missing content from health-related quality of life instruments: interviews with young adult survivors of childhood cancer  

Results  

Respondents reported missing, relevant content among all three of the HRQoL instruments. Results identified three content areas of missing information: (1) Perceived sense of self, (2) Relationships, and (3) Parenthood.

abstract: All’s Well That Ends Well? Quality of Life and Physical Symptom Clusters in Long-Term Cancer Survivors Across Cancer Types (EORTC QLQ-C30)

Blogger's Note: per abstract it does not appear ovarian cancer patients were included in this study, full access requires subscription ($$$) 

 Conclusion

Contrary to expectations, no symptom clusters specific to one type of cancer were identified and survivors reported few cancer-related symptoms and high QoL. These results convey a strong “good news” message, providing health professionals with a sound foundation for making encouraging predictions about their patients’ long-term physical recovery after cancer. Cancer patients also will welcome the news that only a minority of five-year survivors experience long-term and late effects.

Impact of Chemotherapy-Induced Nausea and Vomiting on Quality of Life in Indonesian Patients With Gynecologic Cancer

Conclusions:
Patients reported a negative impact on the QoL of delayed emesis after chemotherapy. Poor prophylaxis of patients’ nausea and vomiting after chemotherapy interferes with patients’ QoL. Medical and behavioral interventions may help to alleviate the negative consequences of chemotherapeutic treatment in patients with gynecologic cancers treated with suboptimal antiemetics.

Paper: Analysis of Quality of Life in Cancer Patients by Structural Equation Model (technical)

Note: see Table 1 for criteria/index of variables

abstract: The use of Chinese herbal medicine to improve quality of life in women undergoing chemotherapy for ovarian cancer: a double-blind placebo-controlled randomized trial with immunological monitoring — Ann Oncol

Background: This study aimed to evaluate traditional Chinese medicine (TCM) in improving quality of life (QOL), reducing chemotoxicity and modulating immune function in patients undergoing chemotherapy.  

Health-related quality of life and cancer clinical trials — Therapeutic Advances in Medical Oncology

"...Health-related quality of life has become a more accurate predictor of survival than some other clinical parameters, such as performance status. The overall outlook for the routine assessment of patient-reported outcomes in clinical trials is assured and, eventually, it is likely to become a standard part of clinical practice. ...."

Surgical management of bowel obstruction in gynaecological malignancies.

Abstract

PURPOSE OF REVIEW: Bowel obstruction in gynaecological malignancies continues to present clinical challenges and a multidisciplinary approach to discuss management is crucial. Surgery, usually with palliative intent, is associated with significant morbidity and mortality. There is an absence of level 1 evidence and national guidelines, and only limited quality-of-life data.
RECENT FINDINGS: Acute bowel obstruction in gynaecological cancer patients is rare and surgery is associated with a higher morbidity and mortality rate. Less commonly, emergency bowel obstruction cases will have had radiotherapy or recent chemotherapy, which also increases surgical morbidity and mortality. However, most often, bowel obstruction in irradiated gynaecological cancer patients is not due to cancer. Ovarian cancer is the most common malignancy. Caution is needed in those EOC patients with ascites, short treatment-free interval, acute abdomen and chemoresistance. Comorbidities are frequent. The decision for surgery should be made on an individual basis. Palliative care input is important early in patient management as for most patients the surgical goal is palliation and not cure. There is still a paucity of published data on quality-of-life assessments.
SUMMARY: There is a need to identify those patients who may benefit from palliative surgical intervention and those who will not. Ideally, agreed national guidelines should be produced and regularly reviewed.

abstract: Health-related quality of life and cancer clinical trials — Therapeutic Advances in Medical Oncology

"The overall outlook for the routine assessment of patient-reported outcomes in clinical trials is assured and, eventually, it is likely to become a standard part of clinical practice. However, there is still a need for a clear method for determining the clinical meaningfulness of changes in scores. The answer will probably come from the greater use of patient-reported outcomes and the consequent growth of experience that is necessary to make such judgements"

abstract/full free access: Improving the interpretation of quality of life evidence in meta-analyses: the application of minimal important difference units

Abstract:

Systematic reviews of randomized trials that include measurements of health-related quality of life potentially provide critical information for patient and clinicians facing challenging health care decisions. When, as is most often the case, individual randomized trials use different measurement instruments for the same construct (such as physical or emotional function), authors typically report differences between intervention and control in standard deviation units (so-called "standardized mean difference" or "effect size"). This approach has statistical limitations (it is influenced by the heterogeneity of the population) and is non-intuitive for decision makers. We suggest an alternative approach: reporting results in minimal important difference units (the smallest difference patients experience as important). This approach provides a potential solution to both the statistical and interpretational problems of existing methods.

End of life 'quality' index | Open Medicine Blog The Quality of Death: Ranking end-of-life care across the world 2010 The Economist Intelligence Unit

"....Advancements in healthcare have been responsible for the most significant quality-of-life gains in the recent past: that humans are (on average) living longer, and more healthily than ever, is well established. But “quality of death” is another matter. Death, although inevitable, is distressing to contemplate and in many cultures is taboo......Few nations, including rich ones with cutting-edge healthcare systems, incorporate palliative care strategies into their overall healthcare policy—despite the fact that in many of these countries, increasing longevity and ageing populations mean demand for end-of-life care is likely to rise sharply. Globally, training for palliative care is rarely included in healthcare education curricula. Institutions that specialise in giving palliative and end-of-life care are often not part of national healthcare systems, and many rely on volunteer or charitable status...."cont'd