Quality of Life in NSCLC May Be Difficult to Measure

CHICAGO--Monitoring instruments that evaluate the symptoms and psychosocial problems of patients with non-small-cell lung cancer (NSCLC) may not provide clear answers regarding the quality of patients’ lives because they are difficult to analyze and they measure aspects of quality that are not affected by chemotherapy, said Richard Gralla, MD, chief of immunology and oncology and director of the Ochsner Cancer Center, New Orleans.

Regardless of which chemotherapy regimen is chosen, patients with stage III or IV NSCLC live only about 9 to 12 months. During that time, these patients have many symptoms.

The most common presenting symptoms for 673 stage III or IV patients seen at 30 medical centers in North America were dyspnea (87%), cough (86%), pain (81%), loss of appetite (75%), and hemoptysis (41%), Dr. Gralla said at the 1998 International Conference of the American Thoracic Society and American Lung Association.

Although patients who respond to chemotherapy experience improvement in all these symptoms, they do not necessarily have a better quality of life because, in addition to symptom control, quality of life involves physical, functional, psychological, social, and spiritual dimensions, he said.

Three Monitoring Instruments

There currently are three patient monitoring instruments that provide objective means of assessing these characteristics--the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30; the FACT-L (Functional Assessment of Cancer Therapy-Lung); and the LCSS (Lung Cancer Symptom Scale).

The instrument used by the EORTC and the FACT-L instrument are similar; they both have general modules that look at many aspects of health, as well as specific items that relate to lung cancer.

These instruments include many items that are not influenced by the choice of chemotherapy, however, such as feelings of regret over ever beginning to smoke. "If something is not going to change with chemotherapy, you will get relatively similar scores with these instruments," Dr. Gralla said.

The LCSS monitoring tool captures in detail the areas that are likely to change because of chemotherapy, but it lacks detail in many of the other dimensions of quality of life, such as social, spiritual, and psychological parameters.

Findings from these instruments are difficult to interpret because of attrition, he noted. Typically, older patients and those who have the most severe symptoms are lost to follow-up in long-term quality of life assessments.

It also is unclear whether all items of analysis included in these instruments should have the same weight and be used to develop an aggregate score, or whether some individual items should have greater weight than others. "The area is not well defined by statisticians," Dr. Gralla said.

When evaluating patients’ quality of life, "it is not a problem to look at improvement of symptoms," he said. The more active the chemotherapy regimen and the greater the response, the more likely it is that patients will have less pain and require less pain medication. "But quality of life is a different story," Dr. Gralla added.

Thus, he emphasized, before outcomes researchers choose a patient monitoring instrument, they need to decide on their specific question of interest, whether the instrument will be used in an ongoing clinical trial of chemotherapy, and how they will assess the results.