Abstracts
OBJECTIVE:
Non-small cell lung carcinoma (NSCLC) is the most common type of lung cancer. Most patients are diagnosed at an advanced stage, palliative chemotherapy therefore being the only treatment option. This study was aimed at evaluating the health-related quality of life (HRQoL) of advanced-stage NSCLC patients receiving palliative chemotherapy with carboplatin and paclitaxel.
METHODS:
This was a multiple case study of advanced-stage NSCLC outpatients receiving chemotherapy at a public hospital in Rio de Janeiro, Brazil. The European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire was used in conjunction with its supplemental lung cancer-specific module in order to assess HRQoL.
RESULTS:
Physical and cognitive functioning scale scores differed significantly among chemotherapy cycles, indicating improved and worsened HRQoL, respectively. The differences regarding the scores for pain, loss of appetite, chest pain, and arm/shoulder pain indicated improved HRQoL.
CONCLUSIONS:
Chemotherapy was found to improve certain aspects of HRQoL in patients with advanced-stage NSCLC.
Carcinoma, non-small-cell lung; Quality of life; Palliative care; Carboplatin; Paclitaxel
OBJETIVO:
O carcinoma pulmonar de células não pequenas (CPCNP) é tipo mais comum de câncer de pulmão. Como a maioria dos pacientes é diagnosticada em estágio avançado, a quimioterapia paliativa é a única opção de tratamento. Este estudo avaliou a qualidade de vida relacionada à saúde (QVRS) de pacientes com CPCNP avançado no decorrer da quimioterapia paliativa com carboplatina e paclitaxel.
MÉTODOS:
Trata-se de um estudo de casos múltiplos de pacientes ambulatoriais com CPCNP em estágio avançado recebendo quimioterapia em um hospital público no Rio de Janeiro (RJ). Para a avaliação da QVRS, foram usados o European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire e seu módulo específico para câncer de pulmão.
RESULTADOS:
Houve diferenças significativas na pontuação nas escalas de capacidade física e cognitiva durante a quimioterapia, indicando melhora e piora da QVRS, respectivamente. As diferenças na pontuação nos itens dor, perda de apetite, dor no tórax e dor no braço ou ombro indicaram melhora da QVRS.
CONCLUSÕES:
Observou-se que a quimioterapia melhora alguns aspectos da QVRS de pacientes com CPCNP avançado.
Carcinoma pulmonar de células não pequenas; Qualidade de vida; Cuidados paliativos; Carboplatina; Paclitaxel
Introduction
For 2015, the estimated incidence of tracheal, lung, and bronchial cancer in the
Brazilian population is 27,330 cases.(
11 Brasil. Ministério da Saúde. Instituto Nacional de Câncer José Alencar
Gomes da Silva [homepage on the Internet]. Rio de Janeiro: INCA [cited 2014 Oct 30].
Estimativas 2014: Incidência de câncer no Brasil. Available from:
http://www1.inca.gov.br/vigilancia/incidencia.asp
http://www1.inca.gov.br/vigilancia/incid...
) Lung neoplasms are the most common cancers in the world, accounting for
nearly 15% of all cancers; the death rate is high, and the 5-year survival rate is less
than 15%.(
22 Ettinger DS. Lung cancer and other pulmonary neoplasms. In: Goldman L,
Schafer AI [editors]. Goldman's Cecil Medicine. 24th ed., vol 2. New York: Elsevier;
2012. p. 1264-71.
)
Non-small cell lung carcinoma (NSCLC) has the highest incidence of all lung neoplasms,
accounting for 80-85% of all cases of lung cancer. (
22 Ettinger DS. Lung cancer and other pulmonary neoplasms. In: Goldman L,
Schafer AI [editors]. Goldman's Cecil Medicine. 24th ed., vol 2. New York: Elsevier;
2012. p. 1264-71.
) The biology of NSCLC and delayed diagnosis are the main reasons why NSCLC
is the leading cause of cancer death worldwide.(
33 Goldstraw P, Crowley J; IASLC International Staging Project. The
International Association for the Study of Lung Cancer International Staging Project
on Lung Cancer. J Thorac Oncol. 2006;1:281-6.
http://dx.doi.org/10.1097/01243894-20060...
)
It is believed that 70% of patients present with advanced disease at
diagnosis,(
44 Brabo EP, Paschoal ME, Biasoli I, Nogueira FE, Gomes MC, Gomes IP, et
al. Brazilian version of the QLQ-LC13 lung cancer module of the European Organization
for Research and Treatment of Cancer: preliminary reliability and validity report.
Qual Life Res. 2006;15(9):1519-24.
http://dx.doi.org/10.1007/s11136-006-000...
) and palliative chemotherapy is often indicated.(
55 Matsuda A, Yamaoka K, Tango T. Quality of life in advanced non-small
cell lung cancer patients receiving palliative chemotherapy: A meta-analysis of
randomized controlled trials. Exp Ther Med. 2012;3(1):134-40.
) Its goal is to control the signs and symptoms of advanced disease, which
can affect the performance status, quality of life, and survival of
patients.(
44 Brabo EP, Paschoal ME, Biasoli I, Nogueira FE, Gomes MC, Gomes IP, et
al. Brazilian version of the QLQ-LC13 lung cancer module of the European Organization
for Research and Treatment of Cancer: preliminary reliability and validity report.
Qual Life Res. 2006;15(9):1519-24.
http://dx.doi.org/10.1007/s11136-006-000...
,
66 Azzoli CG, Baker S Jr, Temin S, Pao W, Aliff T, Brahmer J, et al.
American Society of Clinical Oncology Clinical Practice Guideline update on
chemotherapy for stage IV non-small-cell lung cancer. J Clin Oncol.
2009;27(36):6251-66.
http://dx.doi.org/10.1200/JCO.2009.23.56...
,
77 Thongprasert S, Permsuwan U, Ruengorn C, Charoentum C, Chewaskulyong B.
Cost-effectiveness analysis of cisplatin plus etoposide and carboplatin plus
paclitaxel in a phase III randomized trial for non-small cell lung cancer. Asia Pac J
Clin Oncol. 2011;7(4):369-75.
http://dx.doi.org/10.1111/j.1743-7563.20...
)
Currently, the palliative treatment of advanced-stage (stage IIIB and stage IV) NSCLC
frequently involves the use of platinum coordination compounds such as carboplatin in
combination with other antineoplastics, such as paclitaxel.(
22 Ettinger DS. Lung cancer and other pulmonary neoplasms. In: Goldman L,
Schafer AI [editors]. Goldman's Cecil Medicine. 24th ed., vol 2. New York: Elsevier;
2012. p. 1264-71.
) Nevertheless, the scientific literature is inconclusive regarding the
impact of these drugs on the quality of life of patients with advanced-stage
NSCLC,(
66 Azzoli CG, Baker S Jr, Temin S, Pao W, Aliff T, Brahmer J, et al.
American Society of Clinical Oncology Clinical Practice Guideline update on
chemotherapy for stage IV non-small-cell lung cancer. J Clin Oncol.
2009;27(36):6251-66.
http://dx.doi.org/10.1200/JCO.2009.23.56...
,
88 Moncharmont C, Auberdiac P, Mélis A, Afqir S, Pacaut C, Chargari C, et
al. Cisplatin or carboplatin, that is the question [Article in French]. Bull Cancer.
2011;98(2):164-75.
) which is an underexplored topic in clinical practice.
Health-related quality of life (HRQoL) can be described as the perception of patients of
their own physical well-being, daily activities, psychological well-being, social
relations, and disease symptoms.(
99 Fayers PM, Aaronson NK, Bjordal K, Groenvold M, Curran D, Bottomley A,
et al. The EORTC QLQ-C30 Scoring Manual. 3rd ed. Brussels: European Organization for
Research and Treatment of Cancer; 2001.
,
1010 Pimentel FL. Qualidade de vida e oncologia. 1st ed. Coimbra: Almedina;
2006.
) Assessment of patients with lung cancer is of great importance because of
the increased morbidity and mortality associated with NSCLC.(
1111 Grande G, Farquhar MC, Barclay SI, Todd CJ. Quality of life measures
(EORTC QLQ-C30 and SF-36) as predictors of survival in palliative colorectal and lung
cancer patients. Palliat Support Care. 2009;7(3):289-97.
12 Franceschini J, Jardim JR, Fernandes AL, Jamnik S, Santoro IL.
Reproducibility of the Brazilian Portuguese version of the European Organization for
Research and Treatment of Cancer Core Quality of Life Questionnaire used in
conjunction with its lung cancer-specific module. J Bras Pneumol.
2010;36(5):595-602.
http://dx.doi.org/10.1590/S1806-37132010...
-
1313 Li TC, Li CI, Tseng CH, Lin KS, Yang SY, Chen CY, et al. Quality of life
predicts survival in patients with non-small cell lung cancer. BMC Public Health.
2012;12:790.
http://dx.doi.org/10.1186/1471-2458-12-7...
)
Studies have indicated that quality of life assessment is the main predictor of
survival, describing it as a relevant outcome in the context of palliative
chemotherapy.(
44 Brabo EP, Paschoal ME, Biasoli I, Nogueira FE, Gomes MC, Gomes IP, et
al. Brazilian version of the QLQ-LC13 lung cancer module of the European Organization
for Research and Treatment of Cancer: preliminary reliability and validity report.
Qual Life Res. 2006;15(9):1519-24.
http://dx.doi.org/10.1007/s11136-006-000...
,
1313 Li TC, Li CI, Tseng CH, Lin KS, Yang SY, Chen CY, et al. Quality of life
predicts survival in patients with non-small cell lung cancer. BMC Public Health.
2012;12:790.
http://dx.doi.org/10.1186/1471-2458-12-7...
) The use of questionnaires and periodic review of HRQoL facilitate
communication between the health care team and the patients, optimizing the
treatment.(
1313 Li TC, Li CI, Tseng CH, Lin KS, Yang SY, Chen CY, et al. Quality of life
predicts survival in patients with non-small cell lung cancer. BMC Public Health.
2012;12:790.
http://dx.doi.org/10.1186/1471-2458-12-7...
)
The objectives of the present study were to evaluate the HRQoL of advanced-stage NSCLC patients receiving palliative chemotherapy with carboplatin-paclitaxel and to promote a scientific discussion of this issue, which is currently underexplored, particularly in Brazil.
Methods
This was a multiple case study with a prospective descriptive analytical design. The study was conducted between May and July of 2013 at the adult chemotherapy outpatient clinic of a public cancer hospital located in the city of Rio de Janeiro, Brazil. The study included advanced-stage lung cancer patients receiving chemotherapy with carboplatin (area under the curve = 4-6) and paclitaxel (175 mg/m2), with a 21-day interval between cycles. Patients with IIIB or IV stage NSCLC were sequentially enrolled in the study. Patients under 18 years of age were excluded, as were those who had undergone chemotherapy less than 5 years prior to the study, those who were diagnosed with a second primary malignancy, those who were unable to answer the questions clearly, and those who were already participating in another research protocol.
For the evaluation of quality of life, the instruments used were the European
Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire
(EORTC QLQ-C30) and its supplemental lung cancer-specific module (QLQ-LC13),(
1414 Aaronson NK, Ahmedzai S, Bergman B, Bullinger M, Cull A, Duez NJ, et al.
The European Organization for Research and Treatment of Cancer QLQ-C30: A
quality-of-life instrument for use in international clinical trials in oncology. J
Natl Cancer Inst.1993;85(5):365-76.
http://dx.doi.org/10.1093/jnci/85.5.365...
) both of which had previously been translated into Portuguese and validated
for use in Brazil.(
1212 Franceschini J, Jardim JR, Fernandes AL, Jamnik S, Santoro IL.
Reproducibility of the Brazilian Portuguese version of the European Organization for
Research and Treatment of Cancer Core Quality of Life Questionnaire used in
conjunction with its lung cancer-specific module. J Bras Pneumol.
2010;36(5):595-602.
http://dx.doi.org/10.1590/S1806-37132010...
) The EORTC QLQ-C30 consists of five functional scales evaluating physical,
role, emotional, cognitive, and social functioning; global health status/QoL; three
scales measuring symptoms (nausea/vomiting, fatigue, and pain); and 6 items assessing
the occurrence and severity of symptoms related to cancer and its treatment.
(
44 Brabo EP, Paschoal ME, Biasoli I, Nogueira FE, Gomes MC, Gomes IP, et
al. Brazilian version of the QLQ-LC13 lung cancer module of the European Organization
for Research and Treatment of Cancer: preliminary reliability and validity report.
Qual Life Res. 2006;15(9):1519-24.
http://dx.doi.org/10.1007/s11136-006-000...
,
1111 Grande G, Farquhar MC, Barclay SI, Todd CJ. Quality of life measures
(EORTC QLQ-C30 and SF-36) as predictors of survival in palliative colorectal and lung
cancer patients. Palliat Support Care. 2009;7(3):289-97.
,
1212 Franceschini J, Jardim JR, Fernandes AL, Jamnik S, Santoro IL.
Reproducibility of the Brazilian Portuguese version of the European Organization for
Research and Treatment of Cancer Core Quality of Life Questionnaire used in
conjunction with its lung cancer-specific module. J Bras Pneumol.
2010;36(5):595-602.
http://dx.doi.org/10.1590/S1806-37132010...
) The QLQ-LC13 consists of 13 questions regarding the symptoms associated
with lung cancer and the most common reactions to the medical treatment of lung cancer.
All HRQoL scores were calculated in accordance with the rules established by the
EORTC.(
99 Fayers PM, Aaronson NK, Bjordal K, Groenvold M, Curran D, Bottomley A,
et al. The EORTC QLQ-C30 Scoring Manual. 3rd ed. Brussels: European Organization for
Research and Treatment of Cancer; 2001.
) Higher scores on the functional and quality of life scales translated to
better HRQoL, whereas higher scores on the symptom scales translated to worse HRQoL. For
a better understanding of the results, the symptom scales and items were inverted so
that higher scores translated to fewer reports of symptoms and better quality of
life.(
1515 Koller M, Lorenz W. Quality of life research in patients with rectal
cancer: traditional approaches versus a problem-solving oriented perspective.
Langenbecks Arch Surg. 1998;383(6):427-36.
http://dx.doi.org/10.1007/s004230050155...
)
In each chemotherapy cycle, all HRQoL evaluations were used as a unit of analysis. The questionnaires were completed by the patients themselves before the 1st, 2nd, and 4th cycles of chemotherapy in order to compare pre-chemotherapy HRQoL, HRQoL during chemotherapy, and post-chemotherapy HRQoL. When asked to, the interviewer read the questions out to patients.
We collected data on the following sociodemographic and clinical variables: age; gender; self-reported race; marital status; number of years of schooling (0-7 years or ≥ 8 years); occupation; histological type; clinical stage; performance status; comorbidities; number of drugs used (≤ 4, 5-7, or 8-10); self-reported allergies; family history of cancer; smoking; daily cigarette consumption (< 20 cigarettes/day, low or medium consumption; ≥ 20 cigarettes/day, high consumption); and alcoholism.
For statistical analysis of the data, we used the IBM SPSS Statistics software package, version 20.0 (IBM Corporation, Armonk, NY, USA). Descriptive statistics included measures of central tendency and dispersion for continuous variables and absolute and relative frequencies for categorical variables.
In order to assess HRQoL during chemotherapy, we subtracted the mean functional and symptom scale scores for the 2nd chemotherapy cycle from those for the 1st cycle; those for the 4th cycle from those for the 2nd cycle; and those for the 4th cycle from those for the 1st cycle. In order to evaluate the changes in mean scores between cycles, we used the Wilcoxon signed-rank test, the level of significance being set at p < 0.05. In order to interpret the changes in mean HRQoL scores between chemotherapy cycles, we used the criteria proposed by Osoba et al.,( 1616 Osoba D, Rodrigues G, Myles J, Zee B, Pater J. Interpreting the significance of changes in health-related quality-of-life scores. J Clin Oncol. 1998;16(1):139-44. ) changes of 5-10 points in the mean scores being considered small, changes of 10-20 points being considered moderate, and changes of more than 20 points being considered large.
All ethical principles for research involving human subjects were followed. The study was approved by the Research Ethics Committee of the José Alencar Gomes da Silva National Cancer Institute (Protocol no. CAEE 14472813.9.0000.5274).
Results
A total of 18 patients completed the EORTC QLQ-C30 and the QLQ-LC13 for the evaluation of HRQoL before the 1st cycle of chemotherapy. Of those 18 patients, 2 were excluded during the study (1 because of a change in the chemotherapy protocol and 1 because of outpatient treatment discontinuation during the 2nd cycle of chemotherapy), 16 patients remaining in the study. Because of clinical worsening, 3 patients did not receive the 4th cycle of chemotherapy and therefore did not complete the EORTC QLQ-C30 or the QLQ-LC13 for the evaluation of HRQoL.
The median age of the participants was 63.7 years (mean age, 66 ± 11.1 years), and 56.3% were male. Table 1 shows the sociodemographic and clinical characteristics of the study population.
Adenocarcinoma was the most prevalent type of NSCLC in the study population, being found in 56.3% of the participants. In addition, 62.5% had stage IV NSCLC.
Most (75%) of the participants were found to have a performance status of 1 before the 1st cycle of chemotherapy. In addition, nearly 56% had previously diagnosed chronic diseases and were on polypharmacy (≥ 5 different types of drugs).
Of the 16 participants, 13 (81.3%) declared themselves to be smokers or former smokers and 7 (53.9%) reported smoking at least 20 cigarettes per day. In addition, 50% reported consuming or having consumed alcoholic beverages.
The mean scores on the EORTC QLQ-C30 functional and quality of life scales were ≥ 59.8. This indicates that the study participants had lower HRQoL scores in the 1st cycle of chemotherapy (Table 2).
Mean European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire and European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire supplemental lung cancer-specific module scores during chemotherapy.
Figure 1 shows a comparison of the mean EORTC QLQ-C30 functional scale scores in each treatment cycle. There were no significant differences among the scores, the exception being the physical functioning scale scores in the 1st and 2nd cycles (p = 0.002; Figure 1A), showing improved HRQoL in the 2nd cycle of chemotherapy, and in the 1st and 4th cycles (p = 0.028; Figure 1C), showing improved HRQoL in the 4th cycle of chemotherapy.
Changes in mean European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire (EORTC QLQ-C30) functional scale scores. In A, differences in mean EORTC QLQ-C30 scores between the 1st and 2nd cycles of chemotherapy (n = 16); in B, differences in mean EORTC QLQ-C30 scores between the 2nd and 4th cycles of chemotherapy (n = 13); and in C, differences in mean EORTC QLQ-C30 scores between the 1st and 4th cycles of chemotherapy (n = 13). QoL: quality of life.
Taking into consideration the criteria proposed by Osoba et al.( 1616 Osoba D, Rodrigues G, Myles J, Zee B, Pater J. Interpreting the significance of changes in health-related quality-of-life scores. J Clin Oncol. 1998;16(1):139-44. ) for interpreting the significance of changes in HRQoL scores and the different numbers of patients at each assessment time point, we found a moderate change (of 11.7 points) in the role functioning score between the 1st and 4th cycles of chemotherapy (Figure 1C), a finding that shows a trend toward an improvement in HRQoL.
There were no changes in the global quality of life/QoL scores between the 2nd and 4th cycles of chemotherapy. However, there was a small change (of 6.3 points) in the global quality of life/QoL scores between the 1st and 2nd cycles of chemotherapy (Figure 1A).
The symptom scale scores and the scores on the items assessing the occurrence and severity of cancer-related symptoms were higher at the first assessment of quality of life, the exception being the scores for diarrhea. This indicates that the HRQoL of the study participants was worse at that time (Table 2).
Figure 2 shows a comparison of the mean EORTC QLQ-C30 symptom scores in each cycle of chemotherapy. There was little or no change in the scores during chemotherapy. There were significant differences in pain scores between the 1st and 2nd cycles of chemotherapy (p = 0.027; Figure 2A), as well as in the scores for loss of appetite between the 1st and 2nd cycles (p = 0.037; Figure 2A) and between the 1st and 4th cycles (p = 0.026; Figure 2C). There was a large change in the scores for constipation between the 1st and 4th cycles of chemotherapy (Figure 2C). There were moderate changes in the scores for fatigue, insomnia, and financial difficulties between the 1st and 4th cycles of chemotherapy. These changes suggest an improvement in all of the aforementioned HRQoL aspects except insomnia, which was reported more frequently in the 4th cycle of chemotherapy.
Changes in mean European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire (EORTC QLQ-C30) symptom scores. In A, differences in mean EORTC QLQ-C30 scores between the 1st and 2nd cycles of chemotherapy (n = 16); in B, differences in mean EORTC QLQ-C30 scores between the 2nd and 4th cycles of chemotherapy (n = 13); and in C, differences in mean EORTC QLQ-C30 scores between the 1st and 4th cycles of chemotherapy (n = 13).
The QLQ-LC13 scores for dyspnea, cough, sore mouth, chest pain, arm/shoulder pain, and body pain were lower at the first assessment of HRQoL (i.e., in the 1st cycle of chemotherapy). Hemoptysis and alopecia were found to be more common and more severe at the second assessment of HRQoL, whereas dysphagia and peripheral neuropathy were found to be worse in the 4th cycle of chemotherapy.
Figure 3 shows a comparison of the mean QLQ-LC13 scores in each chemotherapy cycle. There was a significant improvement in chest pain between the 1st and 2nd cycles (p =0.016; Figure 3A). There were significant differences in the scores for alopecia between the 1st and 2nd cycles, as well as between the 1st and 4th cycles. There were moderate changes (of 10.4 and 18.8 points, respectively) in the scores for cough and pain in other body parts between the 1st and 2nd cycles of chemotherapy. These changes indicate an improvement in the aforementioned aspects of HRQoL (Figure 3A).
Changes in mean European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire supplemental lung cancer-specific module (EORTC QLQ-LC13) scores. In A, differences in mean EORTC QLQ-LC13 scores between the 1st and 2nd cycles of chemotherapy (n = 16); in B, differences in mean EORTC QLQ-LC13 scores between the 2nd and 4th cycles of chemotherapy (n = 13); and in C, differences in mean EORTC QLQ-LC13 scores between the 1st and 4th cycles of chemotherapy (n = 13).
Discussion
In the study population, there was a predominance of White, married, male smokers or
former smokers, with stage IV adenocarcinoma. The median age was 63.7 years. Although
the logistics and operational aspects of data collection represented a limitation to the
selection of study participants, the clinical and sociodemographic characteristics of
the participants were consistent with those reported in the literature,(
22 Ettinger DS. Lung cancer and other pulmonary neoplasms. In: Goldman L,
Schafer AI [editors]. Goldman's Cecil Medicine. 24th ed., vol 2. New York: Elsevier;
2012. p. 1264-71.
,
1717 Maric D, Jovanovic D, Golubicic I, Dimic S, Pekmezovic T. Health-related
quality of life in lung cancer patients in Serbia: correlation with socio-economic
and clinical parameters. Eur J Cancer Care (Engl).
2010;19(5):594-602.
http://dx.doi.org/10.1111/j.1365-2354.20...
18 Nowak AK, Stockler MR, Byrne MJ. Assessing quality of life during
chemotherapy for pleural mesothelioma: feasibility, validity, and results of using
the European Organization for Research and Treatment of Cancer Core Quality of Life
Questionnaire and Lung Cancer Module. J Clin Oncol.
2004;22(15):3172-80.
http://dx.doi.org/10.1200/JCO.2004.09.14...
19 Park S, Kim IR, Baek KK, Lee SJ, Chang WJ, Maeng CH, et al. Prospective
analysis of quality of life in elderly patients treated with adjuvant chemotherapy
for non-small-cell lung cancer. Ann Oncol. 2013;24(6):1630-9.
http://dx.doi.org/10.1093/annonc/mds649...
20 EORTC [homepage on the Internet]. Brussels: EORTC Quality of Life Group
[cited 2012 Jul 31].EORTC QLQ-C30: Reference values. Jul 2008 [Adobe Acrobat
document, 419p. ] Available
from:http://groups.eortc.be/qol/sites/default/files/img/newsletter/reference_values_manual2008.pdf
.
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2121 Sloan J, Zhao X, Novotny PJ, Wampfler J, Garces Y, Clark MM, et al.
Relationship between deficits in overall quality of life and non-small-cell lung
cancer survival. J Clin Oncol. 2012;30(13):1498-504.
http://dx.doi.org/10.1200/JCO.2010.33.46...
) ensuring the external validity of the study.
The use of structured methods for collecting data and the interpretation of the data brought internal validity to our conclusions, as did the use of multiple sources of evidence and the consistency between such evidence and the results of the study. The possibility of reproducing the present study and the use of statistical analysis brought greater reliability to the study, allowing us to make inferences. Therefore, the present study presents relevant data for the evaluation of clinical oncology patients and raises new hypotheses regarding the possible connections of clinical and sociodemographic variables with the quality of life of patients with advanced-stage NSCLC.
With regard to the EORTC QLQ-C30 functional scale scores, we noted a trend toward
stability at all assessment time points. Wintner et al.(
2222 Wintner L, Giesinger JM, Zabernigg A, Sztankay M, Meraner V, Pall G, et
al. Quality of life during chemotherapy in lung cancer patients: results across
different treatment lines. Br J Cancer. 2013;109(9):2301-8.
http://dx.doi.org/10.1038/bjc.2013.585...
) stated that chemotherapy alone, regardless of the number of cycles, had no
impact on the quality of life of patients with lung cancer. The authors found that the
HRQoL scores remained unchanged throughout the treatment period, a finding that is
consistent with ours.
Despite the demonstrated trend toward stability, a significant difference was observed
regarding physical function improvement and cognitive function worsening. Braun et
al.(
2323 Braun DP, Gupta D, Staren ED. Quality of life assessment as a predictor
of survival in non-small cell lung cancer. BMC Cancer. 2011;11:353.
http://dx.doi.org/10.1186/1471-2407-11-3...
) demonstrated that improvement in physical function was a predictor of
survival in patients with lung cancer, confirming that every 10-point increase in
physical function is associated with a 10% increase in survival time. However, the
changes in the aforementioned aspects might have been influenced by factors such as the
use of antineoplastic drugs and drugs for the management of symptoms, as well as by
variables such as age, gender, performance status, histological type, stage of the
disease, and preexisting comorbidities.
Grønberg et al.(
2424 Grønberg BH, Sundstrøm S, Kaasa S, Bremnes RM, Fløtten O, Amundsen T, et
al. Influence of comorbidity on survival, toxicity and health-related quality of life
in patients with advanced non-small-cell lung cancer receiving platinum-doublet
chemotherapy. Eur J Cancer. 2010;46(12):2225-34.
http://dx.doi.org/10.1016/j.ejca.2010.04...
) reported that, among NSCLC patients receiving platinum-based chemotherapy,
clinical complications appear to be more common in those with severe comorbidities than
in those without. Larsson et al.(
2525 Larsson M, Ljung L, Johansson B. Health-related quality of life in
advanced non-small cell lung cancer: correlates and comparisons to normative data.
Eur J Cancer Care (Engl). 2012;21(5):642-9.
http://dx.doi.org/10.1111/j.1365-2354.20...
) demonstrated significant associations of HRQoL with performance status,
age, gender, and disease stage, as well as with EORTC QLQ-C30 and QLQ-LC13 symptom
scales and items. Quinten et al.(
2626 Quinten C, Coens C, Mauer M, Comte S, Sprangers MA, Cleeland C, et al.
Baseline quality of life as a prognostic indicator of survival: a meta-analysis of
individual patient data from EORTC clinical trials. Lancet Oncol.
2009;10(9):865-71.
http://dx.doi.org/10.1016/S1470-2045(09)...
) found a correlation between patient-reported physical function and
performance status, raising questions regarding the association between self-reported
quality of life and the prediction of survival. However, further studies are needed in
order to confirm these hypotheses.
In the present study we found moderate changes in the mean global health status/QoL
scores between chemotherapy cycles, with a trend toward improved quality of life, when
we used the criteria of Osoba et al.(
1616 Osoba D, Rodrigues G, Myles J, Zee B, Pater J. Interpreting the
significance of changes in health-related quality-of-life scores. J Clin Oncol.
1998;16(1):139-44.
) These findings differ from those of Braun et al.,(
2323 Braun DP, Gupta D, Staren ED. Quality of life assessment as a predictor
of survival in non-small cell lung cancer. BMC Cancer. 2011;11:353.
http://dx.doi.org/10.1186/1471-2407-11-3...
) who demonstrated that HRQoL is worse in previously treated patients than in
newly diagnosed patients, suggesting that chemotherapy has a negative impact on HRQoL.
With regard to the most common signs and symptoms experienced by the NSCLC patients
investigated in the present study, the results showed an improvement in fatigue, pain,
and appetite during chemotherapy, indicating low HRQoL at the first evaluation. Park et
al.(
1919 Park S, Kim IR, Baek KK, Lee SJ, Chang WJ, Maeng CH, et al. Prospective
analysis of quality of life in elderly patients treated with adjuvant chemotherapy
for non-small-cell lung cancer. Ann Oncol. 2013;24(6):1630-9.
http://dx.doi.org/10.1093/annonc/mds649...
) evaluated the HRQoL of NSCLC patients treated with chemotherapy after a
surgical intervention and found no significant changes in fatigue or pain. However,
appetite improved during treatment, a result that is similar to ours. Increased loss of
appetite has been reported to be associated with shorter survival.(
2323 Braun DP, Gupta D, Staren ED. Quality of life assessment as a predictor
of survival in non-small cell lung cancer. BMC Cancer. 2011;11:353.
http://dx.doi.org/10.1186/1471-2407-11-3...
) Maric et al.(
1717 Maric D, Jovanovic D, Golubicic I, Dimic S, Pekmezovic T. Health-related
quality of life in lung cancer patients in Serbia: correlation with socio-economic
and clinical parameters. Eur J Cancer Care (Engl).
2010;19(5):594-602.
http://dx.doi.org/10.1111/j.1365-2354.20...
) reported that although chemotherapy had beneficial effects on fatigue,
dyspnea, insomnia, and appetite loss, NSCLC patients undergoing chemotherapy had higher
pain scores than did newly diagnosed NSCLC patients. Lin et al.(
2727 Lin S, Chen Y, Yang L, Zhou J. Pain, fatigue, disturbed sleep and
distress comprised a symptom cluster that related to quality of life and functional
status of lung cancer surgery patients. J Clin Nurs.
2013;22(9-10):1281-90.
http://dx.doi.org/10.1111/jocn.12228...
) demonstrated that concomitant occurrence and increased severity of the
aforementioned symptoms have a negative impact on HRQoL.
We found no significant changes in the scores for nausea/vomiting and diarrhea when we
compared the scores obtained at the first HRQoL assessment with those obtained
subsequently. This might be due to the pharmacological characteristics of the drugs in
the chemotherapy protocol. Literature data show a low incidence of the aforementioned
symptoms when platinum coordination compounds are used in combination with paclitaxel, a
factor that should be considered in the choice of drug therapy because it affects the
quality of life of patients.(
2828 Ohe Y, Ohashi Y, Kubota K, Tamura T, Nakagawa K, Negoro S, et al.
Randomized phase III study of cisplatin plus irinotecan versus carboplatin plus
paclitaxel, cisplatin plus gemcitabine, and cisplatin plus vinorelbine for advanced
non-small-cell lung cancer: Four-Arm Cooperative Study in Japan. Ann Oncol.
2007;18(2):317-23.
http://dx.doi.org/10.1093/annonc/mdl377...
)
Alopecia is a very common side effect of antineoplastic drugs. The study participants reported increased occurrence of alopecia after the 1st chemotherapy cycle, a result that indicates low HRQoL. According to Bonassa and Molina,( 2929 Bonassa EM, Molina P. Toxicidade dermatológica. In: Bonassa EM, Gato MI [editors]. Terapêutica oncológica para enfermeiros e farmacêuticos. 4th ed. São Paulo: Atheneu; 2012. p. 406. ) hair loss is the most devastating effect and can directly affect social and emotional aspects of the quality of life of patients undergoing chemotherapy.
Our finding of a moderate improvement in cough during chemotherapy is consistent with
those of Rolke et al.(
3030 Rolke HB, Bakke PS, Gallefoss F. HRQoL changes, mood disorders and
satisfaction after treatment in an unselected population of patients with lung
cancer. Clin Respir J. 2010;4(3):168-75.
http://dx.doi.org/10.1111/j.1752-699X.20...
) and Park et al.,(
1919 Park S, Kim IR, Baek KK, Lee SJ, Chang WJ, Maeng CH, et al. Prospective
analysis of quality of life in elderly patients treated with adjuvant chemotherapy
for non-small-cell lung cancer. Ann Oncol. 2013;24(6):1630-9.
http://dx.doi.org/10.1093/annonc/mds649...
) who reported that cough tends to improve during chemotherapy. Given that
cough negatively influences HRQoL, there is a need for therapeutic interventions for the
management of this symptom.(
3131 Yang P, Cheville AL, Wampfler JA, Garces YI, Jatoi A, Clark MM, et al.
Quality of life and symptom burden among long-term lung cancer survivors. J Thorac
Oncol. 2012;7(1):64-70.
http://dx.doi.org/10.1097/JTO.0b013e3182...
)
Rapid detection of the emergence or worsening of a sign or symptom through periodic
assessment of HRQoL allows therapeutic interventions to be performed in a more immediate
way, optimizing the treatment of cancer patients and, consequently, impacting their
survival.(
1010 Pimentel FL. Qualidade de vida e oncologia. 1st ed. Coimbra: Almedina;
2006.
,
1313 Li TC, Li CI, Tseng CH, Lin KS, Yang SY, Chen CY, et al. Quality of life
predicts survival in patients with non-small cell lung cancer. BMC Public Health.
2012;12:790.
http://dx.doi.org/10.1186/1471-2458-12-7...
) However, the assessment of quality of life in daily clinical practice is
little discussed in the literature, despite its recognized importance for monitoring the
disease and improving communication between the health care team and the
patient.(
1010 Pimentel FL. Qualidade de vida e oncologia. 1st ed. Coimbra: Almedina;
2006.
,
2323 Braun DP, Gupta D, Staren ED. Quality of life assessment as a predictor
of survival in non-small cell lung cancer. BMC Cancer. 2011;11:353.
http://dx.doi.org/10.1186/1471-2407-11-3...
,
3232 Lemonnier I, Guillemin F, Arveux P, Clément-Duchêne C, Velten M,
Woronoff-Lemsi MC, et al. Quality of life after the initial treatments of non-small
cell lung cancer: a persistent predictor for patients' survival. Health Qual Life
Outcomes. 2014;12:73.
http://dx.doi.org/10.1186/1477-7525-12-7...
)
The present study explored self-reported quality of life in advanced NSCLC patients receiving chemotherapy, with the objective of gaining a better understanding of how chemotherapy with carboplatin and paclitaxel influences HRQoL. The importance of patient perception of their own health is highlighted within the context of the complexity of cancer, which is a disease that affects every dimension of life and the way in which individuals perceive the environment, the diagnosis, and the therapy.( 1010 Pimentel FL. Qualidade de vida e oncologia. 1st ed. Coimbra: Almedina; 2006. ) Therefore, the combination of periodic quality of life assessments and clinical practice should be more extensively discussed in the scientific literature in order to improve the understanding of aspects that define patient health and the benefits arising from it. Although the changes in HRQoL scores between chemotherapy cycles were small, chemotherapy was found to improve the HRQoL of the study participants, having a greater impact on physical and cognitive functioning and on cancer-related symptoms such as pain and loss of appetite.
With regard to the state of the art, the present study can be considered innovative because it provides elements that are essential to the assessment of quality of life in clinical practice. Further studies should be conducted in order to evaluate the association of sociodemographic and clinical variables such as polypharmacy and comorbidities with aspects of the quality of life of patients undergoing chemotherapy. Because of their extensive knowledge of drugs and their toxicity profile, pharmacists should be involved in studies of quality of life assessment, analyzing the connection between drug therapy and the severity of signs and self-reported symptoms, given their impact on certain aspects of HRQoL.
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» http://dx.doi.org/10.1111/jocn.12228 -
28Ohe Y, Ohashi Y, Kubota K, Tamura T, Nakagawa K, Negoro S, et al. Randomized phase III study of cisplatin plus irinotecan versus carboplatin plus paclitaxel, cisplatin plus gemcitabine, and cisplatin plus vinorelbine for advanced non-small-cell lung cancer: Four-Arm Cooperative Study in Japan. Ann Oncol. 2007;18(2):317-23.
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29Bonassa EM, Molina P. Toxicidade dermatológica. In: Bonassa EM, Gato MI [editors]. Terapêutica oncológica para enfermeiros e farmacêuticos. 4th ed. São Paulo: Atheneu; 2012. p. 406.
-
30Rolke HB, Bakke PS, Gallefoss F. HRQoL changes, mood disorders and satisfaction after treatment in an unselected population of patients with lung cancer. Clin Respir J. 2010;4(3):168-75.
» http://dx.doi.org/10.1111/j.1752-699X.2009.00171.x -
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» http://dx.doi.org/10.1097/JTO.0b013e3182397b3e -
32Lemonnier I, Guillemin F, Arveux P, Clément-Duchêne C, Velten M, Woronoff-Lemsi MC, et al. Quality of life after the initial treatments of non-small cell lung cancer: a persistent predictor for patients' survival. Health Qual Life Outcomes. 2014;12:73.
» http://dx.doi.org/10.1186/1477-7525-12-73
-
*
Study carried out at the José Alencar Gomes da Silva National Cancer Institute, Rio de Janeiro, Brazil.
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Financial support: None.
Publication Dates
-
Publication in this collection
Mar-Apr 2015
History
-
Received
14 July 2014 -
Accepted
12 Dec 2014