FACULTY
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M EDIC INE – U NIVERSITY
OF
P ORTO
Department of Biostatistics and Medical Informatics
Introdução à Medicina 2005/2006
Assessment of Quality of Life in Patients treated with Chemo
and Radiotherapy for Gastric Cancer
Catarina Costa
Dalila Ruivo
Mafalda Couto
Manuel António
Campos
med05164@med.up.pt
dalila@med.up.pt
med05019@med.up.pt
med05020@med.up.pt
Márcio Tavares
Margarida Leite
Maria Alexandra
Maria Brandão
Rodrigues
med05021@med.up.pt med05022@med.up.pt med05023@med.up.pt
Maria João Abreu
Mariana Ferreira
Nuno Soares
med05028@med.up.pt med05035@med.up.pt med05244@med.up.pt
med05026@med.up.pt
Tiago Meirinhos
med05106@med.up.pt
Supervisors: Altamiro da Costa Pereira, MD, PhD, altamiro@med.up.pt; Mário Dinis Ribeiro,
MD, PhD, mario@med.up.pt; Cláudia Camila Dias, MSc, camila@med.up.pt;
Class: 14
Abstract
Introduction: Gastric cancer is one of the most frequent types of cancer. There is a variety of effective
treatment options for gastric cancer. Thus, there is a decreasing in the death rate of this type of cancer. At
the same time, the Quality of Life (QoL) of the patients after treatment, when compared with QoL before
treatment, acquires a large relevance.
Aim: To review which instruments were used to measure the QoL in patients with gastric cancer
submitted to chemo and radiotherapy and to summarize QoL measures across studies.
Methods: A systematic review was conducted on Medline. The query used was: ″Gastric cancer AND
(Quality of Life OR Psychology) AND (Radiotherapy OR Chemotherapy)”. After the literature search, the
titles of all the articles found were read and then all the abstracts were read too. Then the inclusion and
exclusion criteria were defined and applied to the articles.
Results: Starting with one hundred and sixteen articles, twenty were unavailable, so, ninety six were
submitted to our selection using the defined criteria. In the end, only eleven were fully analyzed. The
instruments used to access QoL (in almost every cases EORT-QLQ C30, but also HADS and RSCL) are
all validated. Although they have a scale, the values obtained are not showed in the articles. Only
qualitative analyses are presented. The patients submitted to the treatments in study have gastric cancer
in an advanced stage, many times metastic
Conclusion: It is clear that QoL isn’t the main concern of these papers. More research is needed in this
area, to analyse the effects of chemo and radiotherapy in these patients. The major problem is lack of
qualitative values (although their existence). Beside, when used alone, chemo and radiotherapy are used
as palliative treatments. Because of that fact, maybe the instruments used aren’t the most appropriate
choice, since there are validated instruments specifically developed for patients under palliation.
Key-words: Gastric cancer [MeSH], Quality of Life [MeSH], radiotherapy [MeSH], chemotherapy
[MeSH], systematic review [MeSH].
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Department of Biostatistics and Medical Informatics
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Introduction
Stomach cancer is a malignant cell growth that begins in the cells of the stomach and
invades the surrounding healthy cells [1]. Stomach adenocarcinoma is the most common
type of gastric cancer (95% of the cases) [2]. The exact causes of stomach cancer are
not fully understood [3]. It has a high incidence in world population and Portugal is the
European country where there are more people affected. Its death rate is high but has
decreased due to scientific development [4]; therefore QoL is an increasing concern.
Treatment for gastric cancer often involves surgery, usually a partial or a total
gastrectomy (removal of stomach tissue). Chemotherapy and radiotherapy are also a
standard treatment [45].
These multiple treatments have different consequences in the QoL of the patients.
QoL cannot be universally defined [5] but Schipper et al. suggested that QoL is the
functional effect of illness and its consequent therapy upon a patient, as perceived by
the patient [6]. Functional effects can be divided in three major categories:
physiological, psychological and social [5].
Is important to clarify not only if chemo and radiotherapy are worthy options to prolong
the life expectancy of the patients, but also the life changes that come with the
treatment. Analyse differences of the median of survival between the group submitted to
chemo and radiotherapy and the control group is effective to prove the efficacy of a
specific drug. However, only patients under that kind of treatment can provide us the
information necessary to realise if that drug is really efficient. That information is
collected using instruments to measure QoL. So, it is extremely important make sure
that the best choice is made, that the instrument is reproducible and valid. Otherwise the
results obtained won’t improve the knowledge of the area in study.
The purpose of this paper is to summarize (estimate in a single value) the QoL of
patients with gastric cancer after treatment with chemo and radiotherapy, carrying on a
meta-analysis. As a secondary aim we pretend clarify validity/validation of instruments
used and summarize (estimate in a single value) the QoL of patients with gastric cancer
according to instrument.
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Department of Biostatistics and Medical Informatics
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Participants and Methods
1. Systematic Review and meta-analysis
A systematic review was conducted by an overview of primary studies made in this
area. Then we tried to make a mathematical synthesis of the results of the included
articles, i.e., a meta-analysis.
2. Search Strategy (Limits)
Literature searches were conducted in Medline until September 2005. In our first
attempt the query used was - "stomach neoplasm AND quality of life AND
(radiotherapy AND chemotherapy)" - and we only obtained 15 articles. With the
following query - "stomach neoplasm AND quality of life AND (radiotherapy OR
chemotherapy)" - we achieved 98 articles. We moved on to another query - "gastric
cancer AND quality of life AND (radiotherapy OR chemotherapy)" - which resulted in
108 articles. Finally, we tried another query - "gastric cancer AND (quality of life or
psychology) AND (radiotherapy OR chemotherapy") - which become the basis of our
work with a total of 116 articles.
This query, without any kind of language limitations, resulted in 320 articles. From
these number, 158 (49%) were in Japanese; 116 (36%) in English; 8 (3%) in German; 4
(1%) in Italian; 3 (1%) in French; 3 (1%) in Russian and 1 was in Spanish; 27 (8%)
were in other languages.
The search was then limited to: articles referent to “Humans”, written in “English” and
“with available abstracts”. Articles were included or excluded after defining the proper
criteria. The articles found were read by six reviewers organized in three different
groups. In case of disagreement, was asked the opinion of a third reviewer.
a) Inclusion and Exclusion criteria
Paper inclusion criteria
Included were articles with more than one participant, in witch QoL was evaluated by
the patients, who had gastric cancer and were submitted to chemo or radiotherapy. QoL
must be measured with an appropriate instrument. (see Figure 1)
Paper exclusion criteria
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Excluded were articles based on mixed diagnostic groupings (in the article these have to
be approached separately) and those in which QoL was measure but only symptoms
were studied. Articles that referred to patients submitted to a surgery during or before
treatment were also excluded. (see Figure 1)
b) Validation Paper of Questionnaires
A second search was conducted, to discover if the instruments used in the included
articles were valid. To find the validation papers the questionnaire was searched through
Google. (see Table 1)
3. Statistical Analysis
For the recording of the data from the articles found was made a Database through
“SPSS 14.0 for Windows” software. About each article found were retained the title,
names of first and second author, name of the journal where it was published, volume
and year of publication. The database also gives information about the inclusion and
exclusion criteria for each article read, data related to the criteria and if the article was
included or not. For the included articles was also recorded the type of study, the
number of patients, the used instrument and if it is validated or not. (see Tables 2 and 3)
Results
One hundred and sixteen articles were found. However, our results are only referred to
ninety seven articles because we didn’t have access to nineteen articles.
1. Articles included
The titles and abstracts of all the articles were read and evaluated by reviewers. These
articles were essentially meta-analysis and clinical trials. Then, the articles were totally
read and, due to the application of the inclusion and exclusion criteria, the number of
included articles decreased to eleven. A scheme of the process is presented below, on
Figure 1.
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Start
Search in PubMed
116 articles were
found
19 were not available
97 articles were analised
38 articles were excluded because they did
not evaluate QOL (2, 4, 7, 8, 9, 20, 23, 24,
33, 36, 42, 47, 48, 51, 52, 53, 54, 55, 70,
72, 74, 75, 76, 81, 89, 90, 91, 93, 94, 97,
99, 100, 102, 105, 107, 109, 112, 113)
31 articled were excluded because QOL
was not evaluated by the patient ( 5, 16, 17,
21, 22, 27, 29, 30, 32, 34, 40, 41, 46, 50,
56, 64, 66, 68, 73, 78, 82, 85, 86, 87, 88,
95, 96, 98, 114, 115, 116)
6 were excluded because the patients were
not treated with chemo or radiotherapy ( 19,
31, 45, 77, 80, 83)
4 articles were excluded because the
patients didin´t have gastric cancer (13, 25,
28, 108)
2 articles were excluded because patients
were submitted to a surgery durins
treatment (59, 60)
2 articles were excluded because studies
were based on mixed diagnostic groups (6,
106)
2 were excluded because the authors did
not use na instrument to use the qol (10,
101)
1 articles were excluded because they had
only one participant (12)
11 articles were included
(3, 11, 14, 35, 37, 39, 43,
65, 79, 84, 92)
End
Figure 1. Description of the articles selection.
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2. Questionnaires
The questionnaires used in all the included articles have a validation paper. In the
following table the instrument and the validation paper are presented.
Table 1. Questionnaires present in the included articles and their respective validation papers.
Questionnaire
EORTC QLQ-C30
Rotterdam Symptom Checklist
HADS
Name of the validation paper
First author
Validation of the european organization for research and
treatment of cancer quality of life questionnaire (QLQ-C30) as a
measure of psychosocial function in breast cancer patients
Validation of a modified Rotterdam Symptom Checklist for use
with cancer patients in the United States
The Hospital Anxiety And Depression Scale
McLachlan SA
Stein KD
Zigmond AS
3. Summary of the extracted data
The results obtained with the analysis of the included articles (see Table 2) showed that
a quantitative measurement of QoL wasn’t made. Thus, we used the given qualitative
measurement, and divided it into three different categories related with an increasing,
decreasing or no different QoL after treatment with chemo or radiotherapy in gastric
cancer. That is showed on Table 3.
Table 2. Global features of the included articles.
Name of
the article
Quality of life in
patients with advanced
gastric cancer treated
with second-line
chemotherapy
Quality of life in
patients with
gastroenteropancreatic
tumors treated with
[177LuDOTA0,Tyr3]octreotate
Multivariate prognostic
factor analysis in
locally advanced and
metastatic esophagogastric cancer--pooled
analysis from three
multicenter,
randomized, controlled
trials using individual
patient data
A multicentre,
randomised phase III
trial comparing
protracted venous
infusion (PVI) 5fluorouracil (5-FU)
with PVI 5-FU plus
mitomycin C in patients
with inoperable
oesophago-gastric
cancer.
Marimastat as
maintenance therapy for
patients with advanced
gastric cancer: a
randomised trial.
Prospective randomized
trial comparing
mitomycin, cisplatin,
First
Author
Year of
publication
Number of
participants
Age of the
participants
Measure
of
central
tendency
used
Diagnostic
Type of
study
Questionnaire
used
to evaluate
QLQ
Validation
paper
Second
questionnaire
Park SH
2005
43
59,0
Median
Locally
advanced or
metastic disease
Clinical
Trial
EORTC-QLQC30
Yes
HADS
Yes
Teunissen
JJ
2004
50
58,3
Mean
Metastic tumor
(GEP)
Clinical
Trial
EORTC-QLQC30
Yes
No
No
Chau I
2004
1080
62,0
Median
Inoperable
adenocarcinoma
Randomized
Controlled
Trial
EORTC-QLQC30
Yes
No
No
Tebbutt
NC
2002
254
72,0
Mean
Locally
advanced or
metastic disease
Randomized
Controlled
Trial
EORTC-QLQC30
Yes
No
No
Bramhall
SR
2002
369
68,0
Mean
Locally
advanced or
metastic disease
Randomized
Controlled
Trial
EORTC-QLQC30
Yes
No
No
Ross P
2002
580
58,5
Mean
Inoperable
adenocarcinoma
Randomized
Controlled
Trial
EORTC-QLQC30
Yes
No
No
Validation
paper
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and protracted venousinfusion fluorouracil
(PVI 5-FU) With
epirubicin, cisplatin,
and PVI 5-FU in
advanced
esophagogastric cancer.
Alternative methods of
interpreting quality of
life data in advanced
gastrointestinal cancer
patients.
Evaluation of clinical
benefit of
chemotherapy in
patients with upper
gastrointestinal cancer.
Randomized
comparison between
chemotherapy plus best
supportive care with
best supportive care in
advanced gastric
cancer.
Epirubicin, cisplatin,
and protracted venous
infusion of 5fluorouracil for
esophagogastric
adenocarcinoma:
response, toxicity,
quality of life, and
survival.
A phase II study in
advanced gastroesophageal cancer using
epirubicin and cisplatin
in combination with
continuous infusion 5fluorouracil (ECF).
Nordin K
2001
120
64,0
Mean
Advanced
gastric cancer
Randomized
Controlled
Trial
EORTC-QLQC30
Yes
No
No
Hoffman
K
1998
61
64,0
Median
Advanced
gastric cancer
Randomized
Controlled
Trial
EORTC-QLQC30
Yes
No
No
Glimelius
B
1997
61
64,0
Mean
Locally
advanced or
metastic disease
Randomized
Controlled
Trial
EORTC-QLQC30
Yes
No
No
Bamias A
1996
235
59,0
Mean
Locally
advanced or
metastic disease
Clinical
Trial
EORTC-QLQC30
Yes
No
No
Findlay
M
1994
139
60,0
Mean
Locally
advanced or
metastic disease
Clinical
Trial
Rotterdam
Symptom
Checklist
Yes
No
No
Table 3. Features of the included articles related with QoL measurement.
Name of
the article
Quality of life in patients
with advanced gastric cancer
treated with second-line
chemotherapy
Quality of life in patients
with gastroenteropancreatic
tumors treated with [177LuDOTA0,Tyr3]octreotate
Multivariate prognostic
factor analysis in locally
advanced and metastatic
esophago-gastric cancer-pooled analysis from three
multicenter, randomized,
controlled trials using
individual patient data
A multicentre, randomised
phase III trial comparing
protracted venous infusion
(PVI) 5-fluorouracil (5-FU)
with PVI 5-FU plus
mitomycin C in patients with
inoperable oesophago-gastric
cancer.
Marimastat as maintenance
therapy for patients with
advanced gastric cancer: a
randomised trial.
Prospective randomized trial
comparing mitomycin,
cisplatin, and protracted
venous-infusion fluorouracil
(PVI 5-FU) With epirubicin,
cisplatin, and PVI 5-FU in
advanced esophagogastric
cancer.
Alternative methods of
interpreting quality of life
data in advanced
gastrointestinal cancer
patients.
First
Author
Year of
publication
First
Parameter
Second Parameter
Base
value
of
QoL
Final
value
of
QoL
Percentage
of patients
Results
Park SH
2005
Patients not
submitted to
chemotherapy
Patients submitted to
second-line chemotherapy
56,9
69,4
37,0
QoL increases with
second-line
chemotherapy
Teunissen
JJ
2004
Patients not
submitted to
chemotherapy
Patients treated with
[177LuDOTA0,Tyr3]octreotate
69,0
78,2
No values
QoL increases in patients
treated with [177-LuDOTA0,Tyr3]octreotate
Chau I
2004
Patients not
submitted to
chemotherapy
Patients submitted to
fluoreouracil-based
combination
chemotherapy
No
values
No
values
No values
No differences in QoL
Tebbutt
NC
2002
Patients
submitted to
protracted
venous infusion
(PVI) 5fluorouracil (5FU)
Patients submitted to PVI
5-FU plus mitomycin C
No
values
No
values
No values
No differences in QoL
Bramhall
SR
2002
Placebo
Patients submitted to
chemotherapy
No
values
No
values
No values
No differences in QoL
Patients submitted to
epirubicin, cisplatin, and
PVI 5-FU
No
values
No
values
No values
QoL increases if we use
epirubicin, cisplatin, and
PVI 5-FU
Patients submitted to
chemotherapy with best
supportive care
No
values
No
values
No values
QoL increases in
chemotherapy with best
supportive care
Ross P
2002
Nordin K
2001
Patients
submitted to
mitomycin,
cisplatin, and
protracted
venous-infusion
fluorouracil
(PVI 5-FU)
Patients
submitted to
chemotherapy
without best
supportive care
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Evaluation of clinical benefit
of chemotherapy in patients
with upper gastrointestinal
cancer.
Randomized comparison
between chemotherapy plus
best supportive care with
best supportive care in
advanced gastric cancer.
Epirubicin, cisplatin, and
protracted venous infusion of
5-fluorouracil for
esophagogastric
adenocarcinoma: response,
toxicity, quality of life, and
survival.
A phase II study in advanced
gastro-esophageal cancer
using epirubicin and
cisplatin in combination with
continuous infusion 5fluorouracil (ECF).
Hoffman
K
1998
Best supportive
care
Chemotherapy and best
suportive care
No
values
No
values
61,0
No differences in QoL
Glimelius
B
1997
Best supportive
care
Chemotherapy and best
suportive care
No
values
No
values
55,0
QoL increases in
chemotherapy with best
supportive care
Bamias A
1996
Patients
submitted to a
treatment with
epirubicin and
cisplatin
Patients submitted to a
venous infusion of 5fluorouracil
No
values
No
values
No values
QoL increases in both
groups
1994
Patients not
submitted to the
treatment
Patients submitted to a
treatment with epurubicin
and cisplatin in
combination with infusion
5-fluorouracil
27,9
28,0
No values
No differences in QoL
Findlay
M
Discussion
Although incidence of gastric carcinoma is on the decline, it remains the second most
common cause of death from malignant diseases. Nevertheless, incidence rates differ
from one geographical region to another, being rather high in Japan, China, Columbia,
and Costa Rica, and comparatively low in the United States [122].
QoL should be measured by an adequate instrument. The proper instrument for this is a
questionnaire. Nowadays, there are multiple options available to serve that purpose.
Although, there are many aspects to consider when the time to choose arrives. The most
important one is to make sure that the questionnaire chosen is the best for the group of
people in study. Beside, the questionnaire should be validated, because that proves it’s
reproducibility and guarantees that it is proper for the matter in study.
1. Articles Review
Having in mind the main aim of the current study -to assess QoL in patients treated with
chemo and radiotherapy for gastric cancer- papers dealing with the theme were
analysed.
A great amount of information could not be used due to language limitations.
Nowadays, Japan is the country most motivated to investigate this issue, wich is
reflected in the number of papers published. This fact is understandable due to the high
incidence of this disease in this country, although is important to mention it has been
progressively decreasing [122].
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From that analysis is possible to infer that the most part of the research made about this
issue focus mainly surgery as a treatment. A fact that is understandable since surgery is
a potentially curative for this kind of pathology [26]. Beside, some articles found
mentioned chemo and radiotherapy as treatment, but as an adjuvant therapy (after the
patients were submitted to surgery). So it was impossible to distinguish if the
differences in QoL results, before and after treatment, were due to chemo and
radiotherapy, surgery, or both.
Even the articles which refer chemo and radiotherapy as a single treatment, in many
cases didn’t use a proper instrument for its measurement. Its major concern is to assess
if the patients survival time has increased after treatment. There are also thirty six
articles that only make the analysis of the patient’s symptoms; this does not clearly
contribute to an assessment of QoL, as it is supposed to be measured as perceived by the
patient. Other studies predict the survival time of the patients only. These articles
weren’t used for this reason.
In spite of the fact that all the included articles evaluated QoL with an adequate
instrument, that measurement was merely qualitative; this clearly prevented us from
going into a meta-analysis, which was the second goal of this work.
2. Limitations to our work
After extract all the data necessary from the papers in study was possible to understand
the impossibility to perform a meta-analysis. In spite of all the included articles have
used a validated instrument to assess QoL, only a qualitative value was presented.
Besides, the number of papers included was very small.
It is yet impossible to determine a median value to QoL in patients treated with chemo
and radiotherapy in gastric cancer.
Is important to emphasise that scientists are trying to develop new combinations of
drugs and test their effects. So, the main objective today is to realize what the best
combination available is. From that point of view is understandable that the evaluation
of QoL appears qualitatively because there are two drugs being compared. And the QoL
of the patients differs from one combination to another.
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In future studies, the values obtained from the measure of QoL should be given as
results, so readers could understand what “QoL increased when patients were treated
with this combination” really means. With that kind of approach, those results could be
used for further investigation.
3. Questionnaires Description
- EORTC (European Organisation for Research and Treatment of
Cancer) QLQ-C30
The 30-item Quality-of-Life Questionnaire-Cancer (QLQ-C30) is a multidimensional
self-report measure of quality of life designed for use with clinical trials [124]. It reports
functional (physical, role, social, cognitive, and emotional) and financial aspects of QoL
as well as symptoms, global health, and global quality of life. Items are scaled from 0
(lowest on functional and symptom items) to 100 (best functioning but most symptoms).
This questionnaire is translated into other languages. Validity was evaluated with 305
patients in 13 countries. Generally 11 minutes are needed to complete the questionnaire
[123]. This instrument is validated [125].
- RSCL (Rotterdam Symptom Checklist)
The 30-item Rotterdam Symptom Checklist is a Cancer-specific questionnaire to
measure psychological and physical distress in cancer patients participating in clinical
research. Patients are asked to indicate the degree to which they have been bothered by
the indicated symptoms in the past week. Over the last years RSCL has been used in
numerous studies of oncology. This questionnaire is validated and available in other
languages [126] [127].
- HADS (Hospital Anxiety and Depression Scale)
The 14-item Hospital Anxiety and Depression Scale questionnaire is a self screening
questionnaire for depression and anxiety [128]. It reports seven items for anxiety and
seven for depression. The patients shouldn’t take too long giving their replies: their
immediate reaction to each item will probably be more sincere.
4. Questionnaires review
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Nowadays, chemo and radiotherapy given at an advanced stage of gastric cancer
(often metastic), when they are not combined with other treatments, are considered
palliative treatments [75]. Patients studied in the selected papers are at a final stage. The
review we carried on indicates that the used questionnaires have not been exclusively
conceived to be applied to palliative patients. In fact, many of the items (questions or
statements) aren’t appropriate to these patients and are totally disconnected from their
real health condition. Here are some of the questions we found: “Do you have any
trouble doing strenuous activities, like carrying a heavy shopping or a suitcase?”, “Do
you have any trouble taking a long walk?”, “Where you limited in doing your work or
other daily activities?”, “Where you limited in pursing your hobbies or other leisure
time activities?” [EORTC QLQ-C30]; “Lack of sexual interest” was also mentioned
[Rotterdam symptom checklist]. Being palliative patients, their scale of QoL should
probably be different from the one conceived for a patient with gastric cancer at an early
stage. In fact, the latter still have other optional treatments and their QoL can still be
compared to the one of someone who doesn’t suffer from this kind of pathology.
5. Questionnaires to be applied in patients under palliation
Another finding of this review showed that there are validated questionnaires proper to
palliative patients, available in several languages. Despite, neither of them achieved the
status of being a generally recommended instrument. These have more adequate
questions, like: “Approximately how many hours per day (8 a.m. to 8 p.m.) have you
been lying down?”, “How much help have you needed with dressing and hygiene?”,
“How much pain have you had last week?” and “How many days during the past week
have you spent in a hospital/nursing home?” [The AQEL questionnaire for assessment
of patient’s quality of life in palliative care] [123]. The time frame chosen for the
questions is often one to few weeks ago since this type of patients nearing the end of life
can have “good” days and “bad” days alternatively. Therefore, a time frame of one or a
few days may by chance cover only one extreme [123]. Besides, the ideal response
format has verbal extreme values, for example, 1 is defined as “no pain” and 10 as the
“worst possible pain”. This choice is based on the literature [123] and makes the
assisted completion easier in case of patients that are too weak to hold the pencil. The
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items should represent physical, psychological, social, existential, global aspects of
quality of life and accessibility of medical care [123] [129].
- AQEL (Assessment of Quality of life at the End of Life)
The 36-item Assessment of Quality of life at the End of Life questionnaire was made to
assess patient's quality of life in palliative care. Their items are divided by the mode of
administration: 19+3 (complementary questions) self administered and 14 proxyadministered (spouse). They measure the physical, psychological, social, existential,
and global aspects of quality of life. Their main headings are pathologies connected
with neoplasms. It’s only available in English and Swedish [123]. This instrument is
validated [123].
- EORTC (European Organisation for Research and Treatment of
Cancer) QLQ-C15-PAL
The 15-item EORTC QLQ-C15-PAL is a questionnaire developed to assess the quality
of life of palliative care cancer patients. Depending on the type of study in question, it
may be supplemented by additional items, modules or questionnaires [130]. The QLQC15-PAL includes those elements of the QLQ-C30 identified as most relevant and
important for palliative care, i.e., physical and emotional function, pain, fatigue,
nausea/vomiting, appetite, dyspnoea, constipation, sleeping difficulties, and overall
QoL. The QLQ-C15-PAL is recommended for use in patients with advanced, incurable,
and symptomatic cancer with a median life expectancy of a few months. However, this
instrument isn’t recommended for patients receiving palliative, anti-cancer treatments
including chemotherapy, radiotherapy, endocrine treatments, or palliative surgery. These
patients generally have a better prognosis and are able to complete the EORTC QLQC30 [129]. This is a validated questionnaire [130].
- PQLI (Palliative Care Quality of Life Instrument)
The 28-item Palliative Care Quality of Life Instrument is a reliable and valid measure
for the assessment of quality of life in patients with advanced stage cancer. It’s a
questionnaire composed by six multi-item scales (two functional scales, one symptom
scale, one choice of treatment scale and one psychological scale) and a single item scale
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(overall quality of life). The average time required to complete the questionnaire is
approximately 8 minutes [131]. This is a validated questionnaire [131].
- FLIC (Functional Living Index Cancer)
The 22-item Functional Living Index Cancer questionnaire is a cancer-specific,
functionally-oriented quality of life instrument. Their categories are: physical wellbeing and ability, emotional state, sociability, family situation and nausea. This
questionnaire allows assessing the effect of the symptoms of cancer and its treatment on
functional ability in all areas of life. The questionnaire is completed in less than ten
minutes and is available in other languages [131]. This is a validated questionnaire
[132] [133].
- McGill Quality of Life Questionnaire
The 16-item McGill Quality of Life Questionnaire is designed specifically to measure
quality of life for people with life-threatening illness. This instrument is acceptable to
oncology outpatients [134]. Four subscales were identified through factor analysis:
physical symptoms, psychological symptoms, outlook on life, and meaningful
existence. Both the sub-scale scores and the overall score can range from 0 to 10,
facilitating the identification of specific domains that need attention relative to overall
quality of life. This questionnaire differs from most others in three ways: the existential
domain is measured; the physical domain is important but not predominant; positive
contributions to quality of life are measured. It is available in many languages and takes
between 10 and 30 minutes to be completed [135]. This questionnaire is validated [136].
- POS (Palliative Care Outcome Scale)
The 12 item Palliative Care Outcome Scale questionnaire was made to help clinical
practitioners meet people's palliative care needs. It’s applied to terminal patients with
generic neoplasms. It is a multidimensional instrument covering physical, psychosocial,
spiritual, organizational, and practical concerns. Generally, this questionnaire is well
accepted by the patients and their questions are understandable. This is a validated
instrument, available in other languages [137].
6. Final remarks
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There are many differences between a patient with gastric cancer in an early stage and
in an advanced stage. Nowadays, there are questionnaires specific to terminal patients.
In the present study we’ve described some of the validated options available. It isn’t
clear yet witch one is the best option, but is extremely important that investigators start
to apply the same questionnaire. Only with a unique scale it is possible to clarify the
results obtained trough the different papers.
The differences in the questionnaires are particularly clear in the physical and emotional
dimensions, witch is understandable, given the limitations of each stage.
Nowadays, only a few papers focus only the advanced stage of gastric cancer. Generally
a study that mentions chemo and radiotherapy as the only treatment, also studies the
other treatments and consequently, every stages of the disease. That isn’t the best
approach, since the most adequate instruments are not the same to every stage. Ideally
there would be studies only about patients in an advanced stage of the disease, since the
most adequate instruments are not the same. When that is not possible, more than one
kind of instrument should be used, in order to achieve better conclusions.
The main concern of the studies that focus this stage of the disease is the survival time
of the patients submitted to the different treatments. Beside, there isn’t agreement if
chemo and radiotherapy treatments are better than supportive care alone. QoL is still a
minor issue, what is intriguing since these patients have the pathology in an incurable
stage; so, provide them the best QoL possible should be the major objective of the
medical care. From that point of view, assess QoL is essential to help physicians
choosing the treatment for their patients. In many cases, only an analysis of the changes
in physic symptoms is carried on (a task that any physician can perform): The patient
should be perceived as a person in every dimensions of the concept. So, QoL needs to
be determined covering as many aspects of that concept (not only the physical
condition), using the most accurate instrument as possible. And we must not forget that
QoL just makes sense only when evaluated by the person.
Acknowledgments
We acknowledge to Professor Dr. Altamiro da Costa Pereira for the helpful
commentaries. They really contributed for us to perform it better.
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We are also very grateful to Professor Dr. Mário Dinis Ribeiro and Dr. Camila for the
continuous help given through this year.
Not forgetting all the authors that have promptly furnished the articles necessary for the
success of our work.
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