Higher Quality of Life = Longer Survival

[CaroleHammett]

Numerous research studies document that for those of us with Lung Cancer, the higher our Quality of Life, the longer our Survival Rates.

One of the more recent studies, published October 27, 2007, showed that the Quality of Life of Lung Cancer patients was a greater factor than either the cancer's stage or the patient's physical performance levels (this same study showed that those of us with spouses or partners also tended to survive longer).

Despite the overall legitimacy of the study (which followed standard research study protocols), subjectivity does remain a factor in that neither the definition of Quality of Life nor the responses to the questions asked, by virtue of their very nature, could be totally objective.

Upon locating and studying the actual survey questionnaires, it became quickly apparent, for example, that the authors seemed to be defining Quality of Life for lung cancer patients primarily on "physical" factors (comparing the performance status of lung cancer patients to that of "normal" (healthy) individuals) as versus a combination of physical, emotional, mental and spiritual levels.

Nevertheless, the study's results are exciting in that they offer a potential "roadmap" for Lung Cancer patients who desire to take positive steps of their own to extend their overall survival, and to do so in a way that allows them to have a higher Quality of Life (as versus buying non-quality time that is spent in a fog of morphine or pain).

The following data includes an abstract of the October 2007 study as well as copies of the questionnaires used.

Quality of Life (QOL) Supercedes the Classic Predictors of Survival in Locally Advanced Non-Small Cell Lung Cancer (NSCLC): An Analysis of Radiation Therapy Oncology Group (RTOG) 9801

Authors: N. Nicolaou*1, J. Moughan*2, L. Sarna*3, C. Langer*1, M. Werner-Wasik*4, R. Komaki*5, M. Machtay*6, T. Wasserman*7, D. Bruner*8, B. Movsas*9, et al.,

1Fox Chase Cancer Center, Philadelphia, PA, 2Radiation Therapy Oncology Group, Philadelphia, PA, 3Univ of California Los Angeles, Los Angeles, CA, 4Thomas Jefferson Univ., Philadelphia, PA, 5MD Anderson Cancer Center, Houston, TX, 6Thomas Jefferson Univ, Philadelphia, PA, 7Washington Univ, St. Louis, MO, 8Univ of Pennsylvania, Philadelphia, PA, 9Henry Ford Health System, Detroit, MI.

Abstract:

Purpose/Objective(s): This analysis was conducted to determine the added value of QOL as a prognostic factor for overall survival (OS) for patients (pts) with locally advanced NSCLC treated on RTOG 9801.

Materials/Methods: The following pre-treatment factors were analyzed as predictors for OS on univariate and multivariate analysis (MVA): KPS [{Karnofsky Performance Status}] (70-80 vs. 90-100), AJCC stage (II/IIIA vs. IIIB), gender, age, race, marital status, histology (squamous vs. other), tumor location (lower vs. other), hemoglobin (<12>= 12 g/dL), treatment arm (amifostine [AM] vs. no-AM) and global QOL score (from the EORTC-QLQ-C30 instrument). Only pts with <5>0.05.

Results: Of the 239 analyzable patients, 91% had pre-treatment QOL. The median follow-up time for patients still alive was 58.7 months (mo) and 17.3 mo for all patients. The median baseline global QOL score was 66.7 on both treatment arms. Whether the global QOL score was treated as a dichotomized variable (based on the median score of 66.7) or a continuous variable, all other variables fell out of the MVA for OS, except for the global QOL score.

Patients with a global QOL score less than the median (66.7) had a 69% higher rate of death than patients with a QOL score >= 66.7 (p=0.002). A clinically meaningful increase in the QOL score (of 10 points) corresponded to a decrease in the hazard of death by 10% (p=0.002). Patients who were married or had a partner had higher QOL scores than those who were not (p=0.004).

Conclusions: When added to known prognostic factors, the baseline global QOL score replaced them all as the sole predictor of OS for patients with locally advanced NSCLC. This highlights the need to incorporate QOL measures into clinical oncology trials. The significantly lower QOL score for single/divorced/widowed patients deserves further study.

Source: http://www.newswise.com/articles/view/534699/

More information about the above-referenced "EORTC-QLQ-C30 instrument" (quality of life survey) is located at http://www.eortc.be/home/qol/ExplQLQ-C30.htm, including a sample of the survey and a "validated module" for lung cancer.

The questions asked in the surveys (one general survey and one lung cancer module) are as follows:

__________________________________________________________

I. Extracted from EORTC QLQ-C30 (Version 3):

1 Not at All

2 A Little

3 Quite a Bit

4 Very Much

1. Do you have any trouble doing strenuous activities, like carrying a heavy shopping bag or a suitcase? 1 2 3 4

2. Do you have any trouble taking a long walk? 1 2 3 4

3. Do you have any trouble taking a short walk outside of the house? 1 2 3 4

4. Do you need to stay in bed or a chair during the day? 1 2 3 4

5. Do you need help with eating, dressing, washing yourself or using the toilet? 1 2 3 4

During the past week:

6. Were you limited in doing either your work or other daily activities? 1 2 3 4

7. Were you limited in pursuing your hobbies or other leisure time activities? 1 2 3 4

8. Were you short of breath? 1 2 3 4

9. Have you had pain? 1 2 3 4

10. Did you need to rest? 1 2 3 4

11. Have you had trouble sleeping? 1 2 3 4

12. Have you felt weak? 1 2 3 4

13. Have you lacked appetite? 1 2 3 4

14. Have you felt nauseated? 1 2 3 4

15. Have you vomited? 1 2 3 4

16. Have you been constipated? 1 2 3 4

17. Have you had diarrhea? 1 2 3 4

18. Were you tired? 1 2 3 4

19. Did pain interfere with your daily activities? 1 2 3 4

20. Have you had difficulty in concentrating on things, like reading a newspaper or watching television? 1 2 3 4

21. Did you feel tense? 1 2 3 4

22. Did you worry? 1 2 3 4

23. Did you feel irritable? 1 2 3 4

24. Did you feel depressed? 1 2 3 4

25. Have you had difficulty remembering things? 1 2 3 4

26. Has your physical condition or medical treatment interfered with your family life? 1 2 3 4

27. Has your physical condition or medical treatment interfered with your social activities? 1 2 3 4

28. Has your physical condition or medical treatment caused you financial fficulties? 1 2 3 4

For the following questions please circle the number between 1 (very poor) and 7 (excellent) that best applies to you:

29. How would you rate your overall health during the past week? 1 2 3 4 5 6 7

30. How would you rate your overall quality of life during the past week? 1 2 3 4 5 6 7

© Copyright 1995 EORTC Study Group on Quality of Life. All rights reserved. Version 3.0

Source: http://www.eortc.be/home/qol/Specimens% ... LQ-C30.pdf

__________________________________________________________

II. Extracted from EORTC QLQ - LC13 (Lung Cancer module):

Patients sometimes report that they have the following symptoms or problems. Please indicate the extent to which you have experienced these symptoms or problems during the past week. Please answer by circling the number that best applies to you.

1 Not at All

2 A Little

3 Quite a Bit

4 Very Much

During the past week:

31. How much did you cough? 1 2 3 4

32. Did you cough up blood? 1 2 3 4

33. Were you short of breath when you rested? 1 2 3 4

34. Were you short of breath when you walked? 1 2 3 4

35. Were you short of breath when you climbed stairs? 1 2 3 4

36. Have you had a sore mouth or tongue? 1 2 3 4

37. Have you had trouble swallowing? 1 2 3 4

38. Have you had tingling hands or feet? 1 2 3 4

39. Have you had hair loss? 1 2 3 4

40. Have you had pain in your chest? 1 2 3 4

41. Have you had pain in your arm or shoulder? 1 2 3 4

42. Have you had pain in other parts of your body? 1 2 3 4

If yes, where ____________________________________

43. Did you take any medicine for pain? 1 No 2 Yes

If yes, how much did it help? 1 2 3 4

© QLQ-C30-LC13 Copyright 1994 EORTC Study Group on Quality of life. All rights reserved

Source: http://www.eortc.be/home/qol/Specimens% ... Q-LC13.pdf

__________________________________________________________

It is not clear how the scoring is calculated (the study's median score was 66.7%, but I was unable to determine how this figure was reached). I also noticed that answers to the surveys questions can be quite subjective; i.e., my "a little" might well be someone else's "quite a bit," depending on our respective pain thresholds, definitions, etc. (Is the glass half full or half empty?)

I located RTOG 9801 at rtog.org's website, along with other forms used for this study (see http://www.rtog.org/members/forms/9801/main.html ), including the Lung Cancer module.

The only differences between the RTOG Quality of Life (QOL) form and the EORTC forms posted above are minimal; i.e.:

27. "Has your physical condition or medical treatment interfered with your social activities?" instead reads "Has your physical condition or medical treatment interfered with your social life?"

and

38. "Have you had tingling hands or feet?" instead reads "Have you had tingling of your hands or feet?"

The RTOG 9801 website also discusses scoring in http://www.rtog.org/pdf_file2.html?file ... TC-QLQ.pdf

According to another document on this website, the QoL survey was given to participating lung cancer patients (stages II-IIIab) pre-treatment, during treatment and 6 weeks post-treatment; however, this may not reflect later contact made during follow-up.

My "bible" since my dx has been _Lung Cancer: Myths, Facts, Choices--and Hope_, Claudia I. Henschke, Ph.D., M.D. and Peggy McCarthy with with Sarah Wernick, W.W. Norton & Co., NY, 2002. In Chapter 17, "Optimizing the Quality of Your Life," sub-sections are Fatigue, Breathlessness (dypsnea or shortness of breath), Pain, Depression and Anxiety and Sexual Problems. The chapter ends with the following advice:

"Among leading cancer experts, quality of life has become an increasing focus. Unfortunately, physicians don't always offer treatment that could bring relief. We urge you to advocate for yourself if necessary. Many cancer patients have discovered that the disease is a continuing lesson in assertiveness training--and their lives are better for it."

What all of this tells me is that a Lung Cancer diagnosis does not have to result in a lack of control over the rest of our lives. Instead, we have the very significant option of doing whatever it takes to make the rest of our lives as meaningful and precious as possible, and in doing so, we are not only increasing the odds that there will be more days, but are also ensuring that they are the best days of our lives.

Prepared and submitted by Carole on June 24,2008