MINI-SYMPOSIA Tuesday, June 28, 1994

Chemotherapy II-New Agents II

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QUALITY OF LIFE ISSUES IN LUNG CANCER TREATMENT AND RESEARCH Patricia A. Ganz, M.D., University of California, Los Angeles, California 90024, USA.

Quality of life (QL) has been an implied outcome of medical care since the time of Hippocrates. Physicians are taught to accept responsibility for maximizing the welfare of their patients through relief of suffering and cure of illness whenever possible. Recently the paternalistic role of the physician in determining what is best for the patient has been questioned by increasing patient autonomy and participation in health care. This changing relationship between physician and patient has occurred during a period in which there has been growing interest in measuring the health outcomes of medical treatments. These historic and new developments set the stage for the increasing interest in the measurement of QL in cancer patients.

During the past decade there have been many advances in the science of measuring health- related quality of life (see Guyatt, et al.). There is increasing agreement on the dimensions of QL that are essential to consider. These include physical functioning (performance of self-care activities, functional status, mobility, physical activities, and role activities such as work or household responsibilities); disease and treatment-related symptoms (specific symptoms from the disease such as pain or shortness of breath, or side effects of drug therapy such as nausea, hair loss, impotence or sedation); psychologicalfunctioning(anxiety or depression; positive well-being); social functioning (disruptions in normal social activities). Additional considerations in the evaluation of QL may include spiritual or existential concerns, sexual functioning and body image, and satisfaction with health care. Several generic and cancer-specific instruments are available to measure the QL of patients. Examples include the Medical Outcomes Study (MOS) Instruments, the EORTC-Quality of Life Questionnaire, the Functional Living Index-Cancer (FLIC), the &cer Rehabilitation Evaluation System (CARES), and the Functional Assessment of Cancer Therapy (FACT). All of these instruments have been used with cancer patients, and in particular, several have been extensively used with lung cancer patients.

There are several reasons for considering the assessment of QL in lung cancer patients: 1) to measure outcome in a clinical trial; 2) to describe the impact of the disease and treatment on patient function; 3) to monitor clinical care; 4) to predict survival. Lung cancer patients have been the target of QL studies for all of these reasons, primarily because of the serious symptoms related to the disease and its treatment, as well as the challenge of finding effective therapies.

Nevertheless, there have been a number of obstacles to measurement of QL with lung cancer patients. In spite of the enthusiasm for adding QL as an outcome in lung cancer treatment trials, a number of investigators have had difficulties with incomplete QL data collection. As patients deteriorate clinically, it becomes more difficult to obtain their cooperation in completing paper and pencil tests. Often adequate resources have not been available to collect QL data in a timely fashion. In addition, the brief survival time of patients with advanced lung cancer can lead to differential attrition and loss of data for the QL study. This situation complicates the data analysis process, since only survivors are available for QL assessments.

In spite of these difficulties, QL assessment is now regularly discussed as a measurable outcome in cancer treatment. Clinicians and researchers should familiarize themselves with the tools and procedures for measuring QL and should consider the inclusion of a QL assessment for evaluating the treatment, symptoms, or quality of care of patients with lung cancer.

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