A clinical model for quality of life assessment in cancer patients receiving chemotherapy.

BACKGROUND: The pattern of symptoms experienced by cancer patients during chemotherapy is very complex. Consequently, quality of life (QOL) assessment has to be carefully planned to capture clinically relevant changes. PATIENTS AND METHODS: A clinical model of changes in symptoms experienced by symptomatic metastatic patients during several courses of chemotherapy has been developed. The model differentiates cancer-related symptoms, acute side-effects, chronic side-effects and symptoms not related to cancer. The model was used to predict changes in each of these four symptom groups. Three time points were selected (post-cycle 2, pre-cycle 3, post-cycle 5) and an appropriate window around each time point was set. The model predictions were tested empirically with 56 patients with advanced ovarian cancer who completed the EORTC QLQ-C30 plus disease specific items during a six-cycle course of chemotherapy. RESULTS: The changes observed in the sample were in accordance with the changes predicted by the clinical model. Results from patients who did not complete the questionnaire within the specified time windows tended to dilute the findings from the group who did. CONCLUSIONS: A clinical model is useful in the planning of QOL assessments in order to capture clinically relevant effects. Such models also facilitate the interpretation of QOL studies, particularly when cyclic short-term effects and chronic side-effects are overlaid on disease symptoms, as is the case with chemotherapy for cancer.

Anxiety and depression in breast cancer patients at low risk of recurrence compared with the general population: a valid comparison?

Breast cancer and its treatment have been associated with psychological morbidity. In this study our aim was to quantify the excess anxiety and depression resulting from breast cancer. We compared 538 newly diagnosed breast cancer patients at low risk of recurrence (87.0% responded) to 872 women randomly selected from the Danish general population (69.7% responded) using the Hospital Anxiety and Depression Scale (HADS). Contrary to expectations, the proportions classified as "cases" of anxiety and depression were not significantly different in the two groups. The breast cancer patients' mean HADS scores were significantly lower than those in the general population sample (anxiety, P = 0.021; depression, P < 0.001), indicating less anxiety and depression. However, we question the validity of this comparison. The HADS may not be suitable for use in the general population and there may be methodological problems in comparisons of groups whose life situations are very different.

Validation of the EORTC QLQ-C30 quality of life questionnaire through combined qualitative and quantitative assessment of patient-observer agreement.

Patient-rated questionnaires are increasingly used to assess health-related quality of life. We studied one aspect of the validity of such measures that has rarely been investigated do patients interpret questionnaires in the same way as do the researchers reporting the results? If not, there may be a problem. We employed the EORTC QLQ-C30 quality-of-life questionnaire to study 95 cancer patients and measured the agreement between (1) the patient's self-assessment and (2) an observer's rating of the patient's open-ended responses to the same questionnaire administered as an interview. The observer made qualitative recordings describing potential misinterpretations. The agreement between patients' and observers' ratings was high (median kappa = 0.85, range 0.49-1.00). The qualitative data revealed a few minor validity problems. One of these, selective reporting, may lead to systematic errors; some patients reported only what they considered "relevant" symptoms. The combination of quantitative and qualitative methods proved useful for questionnaire validation.

[Treatment of cancer pain in Denmark. A questionnaire survey]. / Behandling af cancersmerter i Danmark. En spørgeskemaundersøgelse.

A questionnaire survey was carried out with the aim of evaluating knowledge about and practice of cancer pain treatment in Denmark. A questionnaire was sent to a 10% random sample of Danish physicians. Of these 1411 physicians, 1068 (76%) returned the questionnaires and after the exclusion of those doctors who never treated cancer patients, 577 (54%) were analyzed. Their knowledge of the principles and practice of cancer pain treatment was evaluated by means of 14 multiple-choice and open questions. Their ability to apply their knowledge in practice was evaluated by analyzing their suggested treatment of three simulated patient cases. Ninety-seven percent of the physicians recognized difficulties in cancer pain treatment, the most frequent being side effects of drugs and inadequate pain relief. It appeared from the proposals for pain treatment of the patient cases that the majority of the physicians could treat both pain from bone metastasis (75%) and visceral pain (78%) satisfactorily, while very few suggested coanalgesics for neuropathic pain (20%). Older physicians performed less satisfactorily than did their younger colleagues. Basic pain treatment skills have been acquired by the Danish physicians. However, in the future emphasis should be placed on the treatment of neuropathic pain with coanalgesics and the management of opioid side-effects.

[Junior physicians educate themselves. Educational value of trainees' work at a department of surgery]. / Reservelaeger uddanner sig selv. Uddannelsesvoerdi af arbejdet på en kirurgisk afdeling.

UNLABELLED: In order to investigate the educational value of trainee surgeons' work, all work done by trainees at a Department of Surgery was recorded in a prospective and consecutive way for four weeks. It was recorded as fixed categories divided into intervals of 15 minutes. The work could be classified in three dimensions: Character, educational value and geography. The youngest trainees performed routine work without educational value. They had some practical jobs which could be done by other personnel. The work did not fulfil the educational claims for a trainee surgeon in phase I. The second group of trainees performed much routine work without educational value. They had no practical jobs that could have been performed by non-doctors. They had some work with educational value but not enough to fulfil the goals of a trainee surgeon in phase II. CONCLUSION: Doctors' clinical education could be improved by giving them work with educational value and supervision. Supervision should be performed by specialists who should also contribute to the routine work without educational value.

Test for item bias in a quality of life questionnaire.

Item bias (differential item functioning) analysis examines whether the construction of an index from two or more variables results in bias in relation to sex, age, or other criteria. Item bias may lead to erroneous conclusions because of distortion or dilution of the effects measured. In comparing groups, item bias analysis, tests whether the information about possible differences between groups, obtained by the variables constituting an index, are correctly passed on by the index score. We examined a quality of life questionnaire answered by 1189 breast cancer patients. We found age-bias or bias in the comparison of groups receiving different treatments in three out of nine indexes. Recommendations for the interpretation of these indexes are made. Item bias analysis is a useful method examining an issue not covered by traditional psychometric tests.

[Physical, psychological and social conditions of patients with cancer as parameters in clinical examinations]. / Fysiske, psykiske og sociale forhold hos kraeftpatienter som parametre ved kliniske undersøgelser.

Measurement of the quality of life should be employed as a parameter of equal value to the response rate, duration of response and survival in clinically controlled investigations in cancer patients. The quality of life must be considered to be composed of a series of various key factors including functional status, physical symptoms, psychological problems, social interaction and the economical situation. Questionnaires which are completed by the patient are the best solution in clinically controlled investigations. These should be made specially for cancer patients and the questions should be made specially for cancer patients and the questions should have a limited number of well defined possible answers. Measurement of the quality of life is a technology under development and should, therefore, be assessed as regards validity and reliability. Investigations of the quality of life in cancer patients should be undertaken as longitudinal investigations among patients with the same diagnoses. Examples of measuring of the quality of life are Karnofsky & Burchenal's performance status which assesses the level of functional status, the Sickness Impact Profile which is a superior assessment of the general health and the "EORTC core questionnaire" which is an assessment of key factors of the quality of life adjusted specially for cancer patients.