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
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
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.