Patient-reported outcomes have been described as key vital signs, with quality of life (QOL) having predictive value for patient survival. A recent study reported on 2,442 patients with non-small-cell lung cancer using a single-item measure of overall QOL within six months of lung cancer diagnosis. The study featured a single question, similar to the visual analog scale. A clinically deficient score (more than two points below average population) was associated with a median survival of 1.6 years versus 5.6 years for a nonclinically deficient score. Even after the performance status, age, gender, treatment factors, smoking history, and stage of disease were taken into account, single-item QOL remained a significant and independent prognostic factor for survival.1 Similar findings were reported for preoperative short form (SF36) scores for patients undergoing pancreatic cancer surgery with lower scores predicting survival of less than one year.2
Opportunities for QOL assessment in surgery
A PubMed search conducted January 24 illustrated surgeons’ growing interest in the topic. Including the terms “QOL and surgery” the search resulted in 5,185 citations, a dramatic increase from 18 citations in 1993 and 644 citations in 2013 (see figure).
Assessment of QOL in surgical practice can serve multiple purposes, including measuring whether a procedure improved the patient’s QOL and which operation has the greater effect on a patient’s QOL.3,4 It is amazing to realize that, as described earlier in this column, it is possible to predict patient survival using preoperative QOL. Postoperative QOL measures can serve as a guide to identify who may need additional interventions to support a successful recovery (for example, depression screening and anxiety intervention after cancer surgery). Most importantly, QOL brings the patient’s perspective into decision making. Patient and surgeon perspectives may be quite different, as demonstrated by recent data regarding patient symptoms and their impact on QOL after rectal cancer operations and other procedures.5-7
Surgeons may be uncertain about which QOL questions to ask and when. Following are some suggested guidelines:8-11
- The QOL domains should interest both the patient and the surgeon and be adaptable to the specific disease or treatment. Both general well-being and disease-specific issues are relevant.
- A QOL expert or QOL assessment repository, such as www.proqol.org, can identify measures for each domain of interest to the patient and surgeon, including general measures and disease-specific measures. The tool chosen should be mainly based on the link between the domain of interest and each question (item) asked. It is preferred that reasonable psychometric data be available for the QOL measure, but they are not critical to the choice as long as the topics covered (face validity) are appropriate for the setting. Previous use of a particular measure in a different setting does not necessarily make it the best choice for the current clinical setting. Each environment has unique goals and characteristics to address. Patients often prefer short questionnaires over comprehensive ones.
- Consider the following when reviewing the QOL assessment package: Are any questions confusing, controversial, or annoying? Are any questions redundant? Are any issues missing?
- After the QOL assessment package is assembled, it is helpful to construct a workflow diagram with all personnel involved to establish precisely when, who, and how the QOL measures will be performed. Running through the complete package with a clinician and test patients provides an estimate of time and workload involved. Lack of intimate staff involvement in the decision-making process may result in missing data and a poor-quality assessment.
Some oncologic practices now ask each patient not only for a pain score, but also for an assessment of overall QOL and fatigue. Collection of baseline QOL data can fit nicely into an established workflow, such as when taking the patient’s medication history or vital signs. This process may be completed electronically or on paper, depending on the available technology. Integrating the postoperative QOL data collection may be more challenging, as multiple health care providers are often involved in clinical care. Prepared questionnaires with return envelopes can be provided at hospital discharge for time points in the near future. Later time points can be obtained in person or by mail/phone, depending on the clinical situation.
Surgical QOL questions can be an important part of assessing the impact of changes in treatment and therefore can play a significant role in prospective clinical trials. Examples of currently open clinical trials with QOL components that are being conducted through the Alliance for Clinical Trials in Oncology include the following:
- 40903: Phase II study of neoadjuvant letrozole for postmenopausal women with estrogen receptor positive ductal carcinoma in situ
- 70807: The men’s eating and living study: A randomized trial of diet to alter disease progression in prostate cancer patients on active surveillance
- N1048: A phase II/III trial of neoadjuvant FOLFOX, with selective use of combined modality chemoradiation versus preoperative combined modality chemoradiation for locally advanced rectal cancer patients undergoing low anterior resection with total mesorectal excision
- N107C: A phase III trial of postoperative stereotactic radiosurgery compared with whole brain radiotherapy (WBRT) for resected metastatic brain disease
- Z11102: Impact of breast conservation surgery on surgical outcomes and cosmesis in patients with multiple ipsilateral breast cancers
Learning how to efficiently measure and integrate metrics that are important to surgical patients and their QOL will help us improve perioperative care and develop faster recovery pathways.
- Sloan JA, Zhao X, Novotny PJ, Wampfler J, Garces Y, Clark MM, Yang P. Relationship between deficits in overall quality of life and non-small-cell lung cancer survival. J of Clini Onc. 2012;30(13):1498-1504.
- Velanovich V. The association of quality-of-life measures with malignancy and survival in patients with pancreatic pathology. Pancreas. 2011;40(7):1063-1069.
- Stucky CC, Pockaj BA, Novotny PJ, Sloan JA, Sargent DJ, O’Connell MJ, Beart RW, Skibber JM, Nelson H, Weeks JC. Long-term follow-up and individual item analysis of quality of life assessments related to laparoscopic-assisted colectomy in the COST trial 93-46-53 (INT 0146). Ann of Surg Onc. 2011;18(9):2422-2431.
- Walter J, Nier A, Rose T, Broering DC, Schniewind B. Palliative partial pancreaticoduodenectomy impairs quality of life compared to bypass surgery in patients with advanced adenocarcinoma of the pancreatic head. Eur J Surg Oncol. 2011;37(9):798-804.
- Chen TY-T, Emmertsen KJ, Laurberg S. Bowel dysfunction after rectal cancer treatment: A study comparing the specialist’s versus patient’s perspective. BMJ Open. 2014;4(1):e003374. doi:10.1136/ bmjopen-2013-003374.
- Frost MH, Bonomi AE, Ferrans CE, Wong GY, Hays RD, Clinical Significance Consensus Meeting Group. Patient, clinician, and population perspectives on determining the clinical significance of quality-of-life scores. Mayo Clin Proc. 2002;77(5):488-494.
- Schnadig ID, Fromme EK, Loprinzi CL, Sloan JA, Mori M, Li H, Beer TM. Patient-physician disagreement regarding performance status is associated with worse survivorship in patients with advanced cancer. Cancer. 2008;113(8):2205-2214.
- Sloan JA. Challenges in QOL assessment. Overview and introduction. Curr Probl Cancer. 2005;29(6):274-277.
- Halyard MY, Ferrans CE. Quality-of-life assessment for routine oncology clinical practice. J Support Oncol. 2008;6(5):221-229, 233.
- Sprangers M, Moinpour C, Moynihan T, Patrick D, Revicki D, Clinical Significance Consensus Meeting Group. Assessing meaningful change in quality of life over time: A users’ guide for clinicians. Mayo Clin Proc. 2002;77(6):561-571.
- Efficace F, Bottomley A, Osoba D, Gotay C, Flechtner H, D’haese S, Zurlo A. Beyond the development of health-related quality-of-life (HRQOL) measures: A checklist for evaluating HRQOL outcomes in cancer clinical trials—Does HRQOL evaluation in prostate cancer research inform clinical decision making? J of Clin Onc. 2003;21(18):3502-3511.