Today, more emphasis is being placed on quality of life assessment in
the evaluation of the efficacy of medical care.[1,2] A new study, described
below, along with other international quality of life studies, suggests
that physicians and their patients may place different values on different
health outcomes of treatment, depending on socioeconomic status and cultural
For some patients, the chance of extending survival may override all
other considerations, while for others, a shorter life with higher quality
may be more important. A new research method, known as quality assessment
(described below), now allows the patient's value system to be quantified
in such a way as to help the patient and physician come to a decision about
treatment of advanced cancers.
How Patients View Quality of Life
The way patients view their quality of life depends not only on the
physical presence of a disease but also on the psychological and social
responses to symptoms caused by that disease. Cancer is an example of
a chronic disease whose treatment and prevention goals are to extend life
expectancy while improving patient quality of life.
Patients' experience and evaluation of their cancer are known to vary
significantly according to patient characteristics such as age, gender,
ethnicity, and socioeconomic status. Similarly, an individual's value and
interpretation of quality of life is largely determined by personal, interpersonal,
and cultural aspects that make up a person's values, expectations, and
Because of the effect of different cultural backgrounds on the patient's
perception of quality of life, recent studies have focused on cross-cultural
assessments of the impact of diseases. The two main types of international
quality of life studies are described below, with examples of each.[7-11]
International Quality of Life Studies
The first type of international quality of life study evaluates comparisons
A review of combined data from several similar studies showed that participants
In these studies, there is relatively more agreement for items that
The second type of study compares opinions of people from two or more
Large differences have been observed, however, in the opinions of subjects
While it is important to qualitatively evaluate patient attitudes toward
cancer, use of additional quantitative data can enhance comparisons between
groups of patients. Such information, however, is often difficult to obtain.
One method that has been widely used to quantitatively interpret patient
attitudes toward various aspects of cancer is utility assessment.
A utility score is a quantitative measure of the strength of a person's
preference for a specified health outcome. Utility scores are measured
on a scale of 0 to 1, in which 0 represents death and 1 represents perfect
Typically, utility scores are determined by asking a series of questions
about a health state to find out how much a person would be willing to
risk to improve that health state. For example, patients may be asked how
much time they would give up to improve quality of life. The point of indifference
occurs when the patient rates shortened life expectancy with perfect quality
of life the same as longer life expectancy with lower quality of life.
In an effort to assess the utility of health states related to cancer
and its treatments, many studies have looked at responses to utility instruments
from oncologists on behalf of their patients.
In one case study, 33 physicians from 14 different (primarily European)
countries were presented with scenarios of alternative health states associated
with cis-platinum chemotherapy. The physicians were asked to estimate patient
prefer-ences for the likely health states associated with the cancer chemotherapy
and chemotherapy-related toxicities. This is one of the first studies to
consider international utility assessments.
The toxicities examined in this study were neurotoxicity and nephrotoxicity,
which are the most common and most severe side effects of cis-platinum
chemotherapy. For each scenario corresponding to a particular toxicity,
five health states of increasing severity were defined for the physician
respondents. For each health state, the physicians were asked to respond
to a sequence of questions to identify the lowest amount of full-quality
life-months a typical patient would consider to be comparable to living
one year in the defined state.
The responses were then converted into utility scores by dividing the
number of months indicated by the physicians for each health state by 12
months. For example, if the physician indicated that 11 months of full-quality
life was equivalent to one year with numbness due to mild neurotoxicity,
the utility for that health state was 11/12 or 0.92.
In other words, the higher the utility score, the more the physician
feels that the health state is an acceptable trade-off between benefit
(greater survival with treatment) and risk (side effects).
Participating physicians were categorized into two subgroups based on
the Gross Domestic Product (GDP) and health care expenditure per capita
of the countries in which they were practicing (Table
Comparison by Country's GDP
The 22 physicians from countries in the "higher GDP" group
represented Germany, Denmark, Finland, the United Kingdom, Italy, Spain,
Greece, and Portugal. The 11 physicians from countries in the "lower
GDP" group represented the Czech Republic, the Slovak Republic, South
Africa, Hungary, Argentina, and India. Physician responses were compared
for the two toxicities both within and between the two groups.
Worse health states were consistently associated with lower utility
assessments. As utility scores decreased, the range of scores became wider,
indicating less agreement among respondents.
The mean responses were calculated for the two subgroups of physicians
from countries with higher and lower GDPs (Table
2). Within each subgroup, the responses tended to be similar, especially
for the mild health states (95% confidence intervals were less than ±
However, physicians from the higher GDP countries valued individual
health states with lower utility scores (implying a less favorable view
of the particular health state) than those given by the physicians from
the lower GDP countries.
For example, physicians from higher GDP countries viewed mild neurotoxicity
with cis-platinum therapy as having a score of 0.83 vs 0.91 given by the
physicians from lower GDP countries.
This study has important results with possible applications to clinical
practice. First, the data provide empirical support for including health
status and utility assessments when considering chemotherapeutic options.
Second, there were significant international variations between the two
groups. Thus, within broad cultural categories, there is likely to be some
general consensus on preferences for particular health states, yet cultural
groups are likely to view illness differently.
International quality of life studies are important in evaluating cancer
treatments. While previous studies have focused on past and present quality
of life, few have included utility assessments, which incorporate expectations
for quality of life in the future.
The utility assessment study discussed here shows that subjects from
countries with higher per capita GDP have markedly different evaluations
of health states than do subjects from countries with lower GDPs. Cultural
differences in attitudes need to be understood to make the most appropriate
care and treatment decisions for patients in different countries.
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