Quality of life in elderly patients with acute myeloid leukemia: patients may be more accurate than physicians

Background

The aim of this study was to evaluate changes in quality of life scores and their association with therapy and survival in unselected elderly patients with acute myeloid leukemia.

Design and Methods

From February 2003 to February 2007, 113 patients aged more than 60 years with de novo acute myeloid leukemia were enrolled in a prospective observational study. Two different quality of life instruments were employed: the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire – C30 (EORTC QLQ-C30) and a health-related quality of life questionnaire for patients with hematologic diseases (QOL-E).

Results

Forty-eight patients (42.4%) received intensive chemotherapy and 65 (57.6%) were given palliative treatments. Age greater than 70 years (P=0.007) and concomitant diseases (P=0.019) had a significant impact on treatment allocation. At diagnosis, general quality of life was affected [median QOL-E standardized score 54, interquartile range 46–70; median EORTC global score 50, interquartile range 41–66]. Most patients were given a good ECOG Performance Status (< 2), which did not correlate with the patients’ perception of quality of life. At multivariate analysis, palliative approaches (P=0.016), age more than 70 years (P=0.013) and concomitant diseases (P=0.035) each had an independent negative impact on survival. In a multivariate model corrected for age, concomitant diseases and treatment option, survival was independently predicted by QOL-E functional (P=0.002) and EORTC QLQ-C30 physical function (P=0.030) scores.

Conclusions

Quality of life could have an important role in elderly acute myeloid leukemia patients at diagnosis as a prognostic factor for survival and a potential factor for treatment decisions.     

Serum calcium is an independent predictor of quality of life in multiple myeloma

Bone disease is an important feature of multiple myeloma, and hypercalcaemia is a frequent complication of this disease. We examined the association between serum calcium and quality of life (QOL) scores of 686 multiple myeloma patients at the time of diagnosis. Data from two Nordic studies using the EORTC QLQ-C30 questionnaire were analysed by means of linear regression analysis and a curve fitting program. Serum calcium was independently related to appetite loss, nausea/vomiting and physical functioning (P < 0.001) and to cognitive functioning (P = 0.001), i.e. scores reflecting symptoms that are well known in non-malignant hypercalcaemia. In addition, we found a highly significant independent relationship between serum calcium and the scores for fatigue and pain (P < 0.001). Serum calcium appeared to be as strong a predictor for fatigue as the concentration of haemoglobin. A cubic model (y = a + bx3) fitted the data slightly better than the simple linear model (y = a + bx) and suggested worsening QOL scores at levels of serum calcium above 2.5-3.0 mmol/L. Hypercalcaemia in patients with multiple myeloma seems to be associated with the same symptoms as in non-malignant hypercalcaemia. In addition, an increased level of serum calcium may aggravate the pain and fatigue caused by the skeletal disease itself.     

Quality of life and recovery after graft-versus-host disease

Acute and chronic graft versus host disease (GVHD) has a significant impact on short- and long-term morbidity as well as mortality in patients undergoing hematopoietic-cell transplantation (HCT). As a result of the physical as well as emotional aspects of the transplant process and development of GVHD, quality of life (QOL) in transplant survivors can be adversely affected. The strongest association between reduced QOL and impaired functional status following HCT is the presence of chronic GVHD. Chronic GHVD can have a negative impact on an individual's general health and mental health, and can lead to the development of functional impairments and activity limitations. In HCT survivors without chronic GVHD, self-reported QOL tends to be very similar to that in comparison groups by 1-2 years after HCT. In addition, in individuals who have been successfully treated for chronic GVHD, QOL and overall health status are not different from those with no history of chronic GVHD. These findings suggest that effective new therapies for chronic GVHD are essential, as are standardized tools for the assessment of QOL and functional outcomes in HCT survivors with chronic GVHD in order to gain a better understanding of the overall impact of the condition, as well as the effectiveness of new treatments.     

Development of an EORTC questionnaire module to be used in health-related quality-of-life assessment for patients with multiple myeloma. European Organization for Research and Treatment of Cancer Study Group on Quality of Life

A multiple myeloma-specific quality-of-life questionnaire module has been designed in collaboration with the EORTC Quality-of-Life Study Group to be used in clinical trials with the EORTC QLQ-C30, a general cancer questionnaire. Strict methodology was employed to ensure thorough and appropriate development of the module. An extensive literature review was performed to identify health-related quality-of-life issues relevant to patients with multiple myeloma. Semi-structured interviews were then carried out in several European countries with health-care providers experienced in the treatment of patients with multiple myeloma, and with a group of patients with multiple myeloma, to identify the issues which were most important to patients. A questionnaire was devised from the list of issues, using a 1-week time-frame and response categories consistent with the EORTC QLQ-C30. The provisional questionnaire and the EORTC QLQ-C30 were administered to patients with multiple myeloma in each participating country with further semi-structured interviews to refine the content and design of the questionnaire. A review of the results obtained in each stage of development resulted in a 24-item myeloma-specific module, the EORTC QLQ-MY24, which assesses disease-specific symptoms and their impact on everyday life, treatment side-effects, social support, and future perspective. The module is currently undergoing further international field-testing to assess its psychometric properties.     

Bortezomib is associated with better health-related quality of life than high-dose dexamethasone in patients with relapsed multiple myeloma: results from the APEX study

Health-related quality of life (HRQL) was prospectively measured during the phase III APEX trial of bortezomib versus dexamethasone in relapsed multiple myeloma patients. The European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire - Core (QLQ-C30) and Functional Assessment of Cancer Therapy/Gynecologic Oncology Group-Neurotoxicity (NTX) side-effects questionnaires were administered at baseline and every 6 weeks up to 42 weeks. Patients receiving bortezomib (1.3 mg/m(2), days 1, 4, 8 and 11 for eight 3-week cycles, then days 1, 8, 15 and 22 for three 5-week cycles; n = 296) demonstrated significantly better mean Global Health Status over the study versus patients receiving dexamethasone (40 mg/d, days 1-4, 9-12, and 17-20 for four 5-week cycles, then days 1-4 only for five 4-week cycles; n = 302), plus significantly better physical health, role, cognitive, and emotional functioning scores, lower dyspnoea and sleep symptom scores, and better NTX questionnaire score, using multiple imputation to account for missing data. Results were similar using available-data analyses. Sensitivity analyses suggested that improved HRQL with bortezomib is at least partially explained by improved survival. These results show that bortezomib was associated with significantly better multidimensional HRQL compared with dexamethasone, consistent with the better clinical outcomes seen with bortezomib.     

Linking changes in quality of life to haematologic response and survival in systemic immunoglobulin light-chain amyloidosis

This study reports health-related quality of life (HRQL) among newly-diagnosed immunoglobulin light-chain (AL) patients (n = 914) treated with a bortezomib-based regimen and its association with response depth and survival. Haematologic response/HRQL were assessed over 24 months in an ongoing, prospective study. HRQL change was calculated across haematologic/cardiac response levels. The relationship between baseline HRQL and survival was evaluated by the Cox proportional-hazard model (PH). Shared-random-effects models (SREMs) estimated time-to-death conditional on current HRQL/longitudinal HRQL trajectory. At 3 months, there was consistent decline in 5/8 HRQL domains across all haematologic response levels. By 12 months, 3/5 declining domains improved among complete response (CR) patients. In contrast, the mean change in less-than-CR patients did not indicate improvement. Under the Cox PH, having a baseline HRQL score five points higher than the sample mean was associated with 20% lower mortality risk. SREMs indicated a five-point greater HRQL score at the event time correlated with an approximately 30% decrease in mortality risk. For each one-point increase in HRQL score trajectory slope, mortality risk decreased by approximately 88%. Only CR patients had HRQL improvement, while partial response patients had less decline but no meaningful improvements. These data show the importance of HRQL serial assessments of AL patients and its importance as an end-point.     

Quality of life: a potentially useful measure to indicate subclinical flares in Crohn disease

Background: While quality of life (QoL) is a well‐recognised outcome measure of Crohn disease (CD) activity, its influence on other outcome measures, including exacerbation of CD is poorly understood. If QoL measures were to be associated with intestinal inflammatory activity, they might be useful for early detection of subclinical flares. Aims: We hypothesised that low QoL might be associated with subsequent CD flares. Methods: A cohort of 318 adult CD patients was observed for 1 year after assessment of baseline characteristics. Data were collected in Swiss university hospitals, regional hospitals and private practices. At inclusion, patients completed the Inflammatory Bowel Disease QoL Questionnaire (gastrointestinal QoL; range: 32 to 224 points) and the Short Form‐36 Health Survey (general QoL; range: 35 to 145 points). During follow up, flares were recorded. Binary logistic regression was performed to estimate the relation between QoL and the odds of subsequent flares. Results: A twofold decrease in the odds of flares (99% CI: 1.1; 4.0) per standard deviation of gastrointestinal QoL and a threefold decrease (99% CI: 1.5; 6.2) per standard deviation of general QoL were observed. Conclusions: The close association between QoL and subsequent flares suggests that QoL measures might be useful in detecting upcoming flares before they become clinically apparent.     

Quality of life in elderly diabetic patients with peripheral arterial disease

Aim: To study the impact of peripheral arterial disease (PAD) on quality of life and functional status in Egyptian elderly diabetic patients. Methods: This case–control study included 90 non‐demented patients aged 60 years and older. Quality of life assessment was carried out using the Short Form 36 health survey (SF‐36), Arterial duplex for diagnosis of peripheral arterial disease; Mini‐Mental State Examination, Geriatric Depression Scale, Activity of Daily Living and Instrumental Activity of Daily Living were used. Results: SF‐36 domains (except emotional well‐being) were significantly affected in diabetic patients with PAD compared with the diabetic patients without PAD. Most of functional assessment items were significantly affected in diabetic patients with PAD compared with diabetic patients without PAD. Increasing PAD severity and presence of PAD symptoms had a significant negative impact on SF‐36 scores. Among diabetic complications in PAD patients, cardiovascular disease or stroke significantly affected quality of life. Conclusion: PAD significantly affects quality of life and functional status in elderly diabetic patients. Geriatr Gerontol Int 2013; 13: 443–450 .     

Measurement of health-related quality of life in multiple myeloma

When a randomized trial (NMSG 4/90) comparing treatment with melphalan/prednisone to melphalan/prednisone + interferon α-2b in newly diagnosed multiple myeloma was inititated in 1990, a quality-of-life assessment was integrated into the study. We used the questionnaire (QLQ-C30) developed by the European Organization of Research and Treatment of Cancer (EORTC) Study Group on Quality of Life. The QLQ-C30 incorporates five functional scales, three symptom scales, a global health and quality-of-life scale and some single symptom measures. The questionnaire was completed prior to treatment and after 1, 6, 12, 24, 36 and 48 months. 524 (90.2%) of 581 patients enrolled in the NMSG 4/90 completed the first questionnaire, and 484 (83.3%) completed all questionnaires given to them. All but one of the scales met the minimum criteria of reliability (Cronbach's alpha ≥0.70). Validity was shown by (1) the ability of the scales to discriminate clearly between patients differing in clinical status as defined by pre-treatment W.H.O. performance index and Durie & Salmon stage, and (2) the sensitivity to changes in objective disease status (response and relapse). This is the first report of the measurement of health-related quality of life in a prospective clinical trial in multiple myeloma. The results demonstrate that the QLQ-C30 is a reliable and valid instrument for the measurement of quality of life in these patients. The data will be used for a cost–utility analysis of the results of the NMSG 4/90 trial.     

Quality of life and adherence to antiretroviral therapy in Southern Brazil

The absence of or limited adherence to treatment is the main cause for the failure of Highly Active Antiretroviral Therapy (HAART). In Brazil, adherence to antiretroviral therapy has been lower than the recommended levels. Although HAART may produce adverse reactions, failure to comply with it may aggravate patients' health status and impair Quality of Life (QoL). The QoL of individuals living chronically with HIV and AIDS has been considered one of the main treatment outcomes. This study is part of a 225-day prospective trial in which participants were enrolled in two different modalities of follow-up: the usual model medical follow-up or an intervention based on the Medication Adherence Training Instrument (MATI). The WHOQOL-HIV BREF questionnaire was used to evaluate QoL of research participants in both groups on the 15th and 225th days of follow-up after the baseline assessment. The result of this study revealed no significant differences of WHOQOL-HIV BREF scores between participants allocated to MATI and non-MATI groups in the first assessment. However, there was a significant difference between the scores obtained on the 15th and 225th days in the domain related to spirituality and personal beliefs irrespective of the modality of follow-up. Other domains of the WHOQOL-HOV BREF remained unchanged. These results indicate that, in this sample, personal beliefs and spirituality may be relevant subjects to explain sustained levels of adherence to HAART.     

Quality of life and diabetes

Quality of life is an important health outcome in its own right, representing the ultimate goal of all health interventions. This paper reviews the published, English‐language literature on self‐perceived quality of life among adults with diabetes. Quality of life is measured as physical and social functioning, and perceived physical and mental well‐being. People with diabetes have a worse quality of life than people with no chronic illness, but a better quality of life than people with most other serious chronic diseases. Duration and type of diabetes are not consistently associated with quality of life. Intensive treatment does not impair quality of life, and having better glycemic control is associated with better quality of life. Complications of diabetes are the most important disease‐specific determinant of quality of life. Numerous demographic and psychosocial factors influence quality of life and should be controlled when comparing subgroups. Studies of clinical and educational interventions suggest that improving patients' health status and perceived ability to control their disease results in improved quality of life. Methodologically, it is important to use multidimensional assessments of quality of life, and to include both generic and disease‐specific measures. Quality of life measures should be used to guide and evaluate treatment interventions. Copyright © 1999 John Wiley & Sons, Ltd.     

Assessment of early paraprotein response to vincristine-doxorubicin-dexamethasone chemotherapy may help guide therapy in multiple myeloma

Vincristine, doxorubicin and dexamethasone (VAD) are commonly used as the initial chemotherapy in myeloma patients prior to high-dose therapy and autologous stem cell transplantation. We reviewed monoclonal protein responses and survival of 62 patients treated in this way. Among patients with IgG paraprotein, achievement of at least 50% reduction in paraprotein after the first cycle of VAD correlated with significantly better event-free survival at 3 years, compared with those having less than 50% response. We postulate that early paraprotein response may be used to identify high risk patients.     

Health-related quality of life assessed before and during chemotherapy predicts for survival in multiple myeloma

Measurement of health-related quality of life was integrated into a randomized trial (NMSG 4/90) comparing melphalan/prednisone to melphalan/prednisone + interferon α-2b in newly diagnosed multiple myeloma. One of the aims of the study was to assess the prognostic significance of quality-of-life scores, using the EORTC QLQ-C30 questionnaire. Univariate analysis showed a highly significant association with survival from the start of therapy for physical functioning as well as role and cognitive functioning, global quality of life, fatigue and pain. In multivariate analysis, physical functioning and W.H.O. performance status were independent prognostic factors ( P values=0.001 for both) when analysed in a Cox regression model with the somatic variables β-2 microglobulin, skeletal disease and age. The best prediction for survival from the start of therapy was obtained by combining the β-2 microglobulin and physical functioning scores in a variable consisting of three risk factor levels with an estimated median survival of 17, 29 and 49 months, respectively. At a 12 months landmark analysis, the relative risk for patients with physical functioning score 0–20 v 80–100 was 5.63 (99% CI 2.76–11.49), whereas the relative risk for patients without an objective response to chemotherapy compared to those with at least a minor response was 2.32 (99% CI 1.44–3.74). Quality-of-life assessment may be an independent and valuable addition to the known prognostic factors in multiple myeloma.     

Quality of life in chronic kidney disease

Background — Quality of life (QOL) is suboptimal in end‐stage renal disease. However, studies indicate that QOL is already impaired prior to the initiation of renal replacement therapy, implying that the initial decline originates in the chronic kidney disease (CKD) phase of the renal disease trajectory. Given the significance of QOL as a clinical outcome, there is a paucity of QOL research in CKD. Aims — To measure QOL at three distinct phases (based on creatinine clearance — Ccr) of the disease trajectory in CKD: normal renal function (NRF) with underlying renal disease, moderate CKD, and advanced CKD (Ccr ≥75, 40–60, and ≤30 ml/minute, respectively), and to establish if QOL is different between these groups. Methods — Data was collected from 25 patients from each of the Ccr bands (N=75). We measured self‐reported QOL (Schedule for the Evaluation of Individual Quality of Life — SEIQOL), uraemic symptoms (Leicester Uraemic Symptom Scale — LUSS), and laboratory variables. Results — SEIQOL was significantly lower (p<0.001), and symptom number, frequency, and intrusiveness significantly higher (all p<0.001) in the advanced CKD group when compared to the NRF group. Although SEIQOL and symptom intrusiveness did not differ between the advanced and moderate CKD groups, SEIQOL was significantly lower (p<0.05) and symptom intrusiveness significantly higher (p<0.05) in the moderate CKD group when compared to the NRF group. Conclusion — QOL is already impaired in moderate CKD. The significant difference in QOL and symptom intrusiveness between the moderate CKD and NRF groups may denote a causal relationship between symptom intrusiveness and QOL early in CKD.     

Quality of life and obesity

Interest in the quality of life of patients with different diseases continues to grow. Recent years have witnessed a dramatic rise in the prevalence of obesity worldwide, stimulating interest in the health and quality of life consequences of this phenomenon. The body of research on the quality of life of obese individuals has grown to a point that a review of this literature is warranted. Numerous studies have demonstrated that obese persons experience significant impairments in quality of life as a result of their obesity, with greater impairments associated with greater degrees of obesity. Weight loss has been shown to improve quality of life in obese persons undergoing a variety of treatments. Further research is needed to clarify whether quality of life differs among subsets of obese persons. Until recently, there has been little standardization of quality of life measures in obesity. The SF‐36 has been used in a number of studies of obese persons. Several obesity‐specific instruments have also been developed and have shown great promise. The quality of life of obese individuals is an important issue that should be included in weight management treatment and research.