Quality of life research in head and neck cancer: a review of the current state of the science

Quality of life (QOL) has become an increasingly important outcome measure for patient's undergoing treatment for a wide array of illnesses. QOL is a global construct that reflects a patient's general sense of well being. It is by definition multi-dimensional and reflective of the patient's point of view. Health related issues are among the many factors that may influence QOL. Since head and neck cancer (HNC) affects structures that are critical for normal functions such as speech and swallowing, and treatment may lead to deformities that adversely impact psychosocial functioning, there is particular interest in assessing QOL in this cohort of patients. In order to interpret the HN QOL literature, it is important to have an understanding of the significance and limitations of QOL assessments in the head and neck patient population as well as an appreciation for the currently available measurement tools. Unfortunately, the HNC QOL literature has many limitations including: small sample size, lack of prospective data and poor study design. None-the-less, important insights can be obtained by review of the current literature. First, it is important that QOL studies be reported in such a way as to provide clinically meaningful data to clinicians. Linking measurements with clinical benchmarks is one way to accomplish this goal. In addition, both general and HNC specific measures are needed in order to provide a comprehensive assessment of global health and tumor specific issues. In general, QOL declines immediately after therapy and returns toward baseline by 1 year. Several factors have been identified that may predict for worse QOL outcomes including: the presence of a feeding tube, co-morbid disease, tracheotomy, site and stage. Data correlating QOL with functional outcome and symptom burden fails to demonstrate a consistent relationship. This may be attributed to methodological issues in study design or the patient's ability to adapt to functional and symptom control problems. Whether routine use of QOL measures in the clinical setting is beneficial to patients has yet to be determined. Further studies are warranted as currently available instruments may not be valid for repeated clinical use.     

Quality of life in elderly heart failure patients

Quality of life(QOL),as a relevant area of research in the understanding of heart failure(HF)patient outcomes,has been increasingly studied during the last two decades.The purposes of this review article are to (1)describe QOL in older adults with HF,(2) identify and critique research designed to test interventions to improve QOL,(3)identify gaps in the literature,and (4)provide recommendations for future research.Seventeen studies describing QOL in older adults with HF were identified.Elderly HF patient QOL has been reported to be fair to poor and is worse as compared to a healthy control group.Furthermore,there is some evidence that suggests that QOL is better in older adults than younger adults and worse in women(both older and younger)than in men,although these findings are not consistent across studies.Predictors of QOL and its dimensions in older HF patients included demographic,clinical,and psychosocial variables.Sixteen interventional studies were identified that reported QOL as an outcome in older adults.Findings among randomized clinical trials(RCTs)to improve QOL outcomes in elderly HF patients do not allow strong conclusions about the benefits of the interventions.It must be noted,though,that while not all studies reported improvements in QOL(either significant or as a trend), no studies reported deterioration in QOL with randomization to an intervention versus control.These studies were limited by several methodological issues.While there has been some research of QOL in this elderly cohort,it is paramount that we address methodological issues and thereby improve the scientific rigor of our research,continue to explore QOL in elderly HF patients,and design intervention trials for elders at risk for poor QOL.     

Systematic review of patient‐reported outcome measures in the surgical treatment of patients with esophageal cancer

Esophageal cancer is currently the eighth most common cancer worldwide. Improvements in operative techniques and neoadjuvant therapies have led to improved outcomes. Resection of the esophagus carries a high risk of severe complications and has a negative impact on health‐related quality of life (QOL). The aim of this study was to assess which patient‐reported outcome measures (PROMs) are used to measure QOL after esophagectomy for cancer. A comprehensive search of original articles was conducted investigating QOL after surgery for esophageal carcinoma. Two authors independently selected relevant articles, conducted clinical appraisal, and extracted data (PJ and JS). Out of 5893 articles, 58 studies were included, consisting of 41 prospective and 17 retrospective cohort studies, including a total of 6964 patients. These studies included 11 different PROMs. The existing PROMs could be divided into generic, symptom‐specific, and disease‐specific questionnaires. The European Organisation for Research and Treatment of Cancer (EORTC) QOL Questionnaire Core 30 (QLQ C‐30) along with the EORTC QLQ‐OESophagus module OES18 was the most widely used; in 42 and 32 studies, respectively. The EORTC and the Functional Assessment of Cancer Therapy (FACT) questionnaires use an oncological module and an organ‐specific module. One validation study was available, which compared the FACT and EORTC, showing moderate to poor correlation between the questionnaires. A great variety of PROMs are being used in the measurement of QOL after surgery for esophageal cancer. A questionnaire with a general module along with a disease‐specific module for assessment of QOL of different treatment modalities seem to be the most desirable, such as the EORTC and the FACT with their specific modules (EORTC QLQ‐OES18 and FACT‐E). Both are developed in different treatment modalities, such as in surgical patients. With regard to reproducibility of current results, the EORTC is recommended.     

Comprehensive assessment of clinical outcome and quality of life after total shoulder arthroplasty: usefulness and validity of subjective outcome measures

OBJECTIVE: To explore the physiometric and psychometric properties of clinical, generic, and condition-specific assessment instruments. To describe patients' outcome after total shoulder arthroplasty. METHODS: Forty-three patients were assessed in a 5-6-year cross-sectional catamnesis. RESULTS: With regard to shoulder joint stability, pain, general physical health, and mental health, the patients showed scores comparative to normative scores. Significant functional limitation was evidenced by low mean scores on the specific function scales (e.g., Disability of the Arm, Shoulder and Hand questionnaire score = 64.0, normative score = 86.6). There were high correlations among the joint-specific scales (up to 0.93) and moderate correlations between these and the generic and clinical scales. Factor analysis identified 3 different assessment domains. CONCLUSION: The patients' quality of life (QOL) was high and not affected by impairment in some specific functional abilities. Physical QOL, mental QOL, clinical assessment, condition-specific measures, and generic measures were identified as separate domains, all of which are required for a comprehensive and sophisticated assessment in practical clinical routine.     

Assessing quality of life in primary biliary cirrhosis.

BACKGROUND AND AIMS: Assessment of health-related quality of life (HRQOL) is not routinely reported in the literature on chronic liver disease (CLD). Few studies have examined quality of life (QOL) in patients with primary biliary cirrhosis (PBC) despite its significant functional impact. One of the reasons for the lack of HRQOL measurement in patients with PBC may be the absence of a well-recognized and widely used measure that clinicians can use in ordinary clinical practice. The aim of this study is to evaluate HRQOL measures used in patients with PBC and examine the suitability of the measures for these patients. METHODS: A literature search identified reports that focused on any aspect of QOL in patients with PBC. Key texts were identified containing generic, domain-specific, and condition-specific measures. The identified measures were systematically evaluated for appropriateness, acceptability, reliability, validity, precision, and responsiveness. RESULTS: Twenty measures were identified from 9 key texts. Six of the measures were previously validated generic measures; 10 were domain-specific measures previously used to measure fatigue, depression, and psychological distress in general and psychiatric populations; and 4 measures had been developed in patients with CLD. Reporting of reliability and validity generally was consistent for all measures used. However, reporting of the remaining criteria was variable, particularly in relation to responsiveness over time and acceptability of the measures to patients with PBC. CONCLUSIONS: A clearer and more rigorous approach is needed in reporting the properties of HRQOL measures used in patients with PBC to help clinicians decide which measures are most suitable for these patients.     

Health-related quality of life among patients with idiopathic pulmonary fibrosis

The hallmark of idiopathic pulmonary fibrosis (IPF) is relentless and progressive breathlessness culminating in respiratory failure and death. Clinicians and investigators are increasingly aware that many patients with chronic diseases, like IPF, value the quality of their lives as much or more than their length of survival. Despite this growing awareness, little research has focused on quality of life (QOL) in IPF patients. Nevertheless, the few studies that have been performed uniformly show the negative impacts of IPF on QOL, particularly in the areas of physical health, energy, and symptoms. To fill important knowledge gaps, more research is needed. For example, future studies in well-defined IPF patient populations should rigorously assess the psychometric properties of different measures of QOL. Currently, there is no disease-specific instrument for use in patients with IPF. A carefully developed, IPF-specific instrument that includes items most relevant to IPF patients should be more sensitive to change than existing generic or non-IPF respiratory disease-specific instruments. Longitudinal assessments are needed to map the trajectory of QOL in relation to disease progression and to reveal whether different aspects of QOL become impaired over time. Addressing these research opportunities will markedly improve our knowledge of this outcome, which is highly valued by patients. These endeavors will also help clinicians who care for patients with IPF to develop a better understanding of its profound negative impact, and it will help future IPF clinical investigators to select the most valid, reliable, and appropriate QOL instrument to fill the roles their studies require.     

The expression of GAGE gene can predict aggressive biologic behavior of intestinal type of stomach cancer

BACKGROUND/AIMS: There is still little information on the function of GAGE gene in stomach cancer except for cancer-specific gene expression recognized by autologous T lymphocytes. This study attempted to detect GAGE expression in stomach cancer to evaluate its clinical implication as a tumor marker or prognosticator as well as to find the candidate for immunotherapy. METHODOLOGY: Tumor samples from 60 patients and gastric juices from 18 patients with gastric cancer were studied by using RT-PCR with common primer. In-situ RT-PCR and southern blotting were performed to confirm the RT-PCR products. RESULTS: No expression of GAGE was observed in non-neoplastic juices and tissues. Fifteen out of 60 tumor tissues expressed GAGE (25.0%) mRNA, of which 13 cases (86.7%) were intestinal type and only 2 cases (13.3%) were diffuse type. In gastric juice, 22.2% (4/18) showed mRNA expression, all of which were intestinal type. GAGE expressions in both cancer tissues and gastric juices had a significant tendency to be higher by stage and lymph node metastasis (p<0.05). However, they did not show a significant relationship with tumor cell differentiation and vascular and perineural invasions. CONCLUSIONS: These results suggest that GAGE gene might have an important role in the development and progression of intestinal type of stomach cancer and the detection of GAGE mRNA may be eligible to the panel of molecular markers for aggressive behavior as well as being useful to a molecule for cancer-specific immunotherapy.     

Pathohistological classification systems in gastric cancer:Diagnostic relevance and prognostic value

Several pathohistological classification systems exist for the diagnosis of gastric cancer.Many studies have investigated the correlation between the pathohistological characteristics in gastric cancer and patient characteristics,disease specific criteria and overall outcome.It is still controversial as to which classification system imparts the most reliable information,and therefore,the choice of system may vary in clinical routine.In addition to the most common classification systems,such as the Laurén and the World Health Organization(WHO)classifications,other authors have tried to characterize and classify gastric cancer based on the microscopic morphology and in reference to the clinical outcome of the patients.In more than 50 years of systematic classification of the pathohistological characteristics of gastric cancer,there is no sole classification system that is consistently used worldwide in diagnostics and research.However,several national guidelines for the treatment of gastric cancer refer to the Laurén or the WHO classifications regarding therapeutic decision-making,which underlines the importance of a reliable classification system for gastric cancer.The latest results from gastric cancer studies indicate that it might be useful to integrate DNA-and RNA-based features of gastric cancer into the classification systems to establish prognostic relevance.This article reviews the diagnostic relevance and the prognostic value of different pathohistological classification systems in gastric cancer.     

Improved quality of life in patients with gastric cancer after esophagogastrostomy reconstruction

AIM： To compare postoperative quality of life （QOL） in patients with gastric cancer treated by esophagogastrostomy reconstruction after proximal gastrectomy. METHODS： QOL assessments that included functional outcomes （a 24-item survey about treatment- specific symptoms） and health perception （Spitzer QOL Index） were performed in 149 patients with gastric cancer in the upper third of the stomach, who had received proximal gastrectomy with additional esophagogastrostomy. RESULTS： Fifty-four patients underwent reconstruction by esophagogastric anterior wall end-to-side anastomosis combined with pyloroplasty （EA group）; 45 patients had reconstruction by esophagogastric posterior wall end-to-side anastomosis （EP group）; and 50 patients had reconstruction by esophagogastric end-to-end anastomosis （EE group）. The EA group showed the best postoperative QOL, such as recovery of body weight, less discomfort after meals, and less heart burn or belching at 6 and 24 mo postoperatively. However, the survival rates, surgical results and Spitzer QOL index were similar among the three groups. CONCLUSION： Postoperative QOL was better in the EA than EP or EE group. To improve QOL after proximal gastrectomy for upper third gastric cancer, the EA procedure using a stapler is safe and feasible for esophagogastrostomy.     

Endoscopic treatment of early oesophageal or gastric cancer.

BACKGROUND AND AIMS: Endoscopic treatment has become increasingly popular in recent years as an alternative to surgical treatment with the hope of offering superior quality of life (QOL) for the patient. The results of endoscopic treatment of mucosal lesions of mostly early oesophageal or gastric cancer performed in 145 patients (155 lesions) over the past eight years were reviewed from the standpoint of QOL. RESULTS: In 56 patients who underwent radical resection of the oesophageal mucosa, no serious complications and symptoms occurred, with epithelialisation completed within about a month. Patients also showed good results regarding dietary intake and performance status (PS), and all are currently alive without any sign of recurrence. One time fractionated endoscopic resection was carried out in about 40% of the 57 patients who underwent gastric mucosal resection. In these 57 patients, an artificial ulcer measuring 3 cm or more was formed, resulting in a favourable outcome after healing. An overwhelming proportion of these subjects had no symptoms and good PS after the treatment. CONCLUSIONS: The introduction of this method, endoscopic mucosal resection using a cap fitted panendoscope, is expected to permit additional indications for endoscopic treatment. Endoscopic Nd-YAG laser irradiation was applied mainly to early gastric cancer lesions (32 patients), usually for relative indications for endoscopic treatment. This procedure is safe and advantageous in that it requires no hospitalisation, permits fractionated irradiation, and secures good QOL.     

Effects of Traditional Chinese Patent Medicine on Essential Hypertension: A Systematic Review

Traditional Chinese patent medicine (TCPM) is widely used for essential hypertension (EH) in China. However, there is no critically appraised evidence, such as systematic reviews or meta-analyses, regarding the potential benefits and disadvantages of TCPM to justify their clinical use and recommendation. The aim of this review was to systematically evaluate and meta-analyze the effects of TCPM for EH.Seven databases, the Cochrane Library, PubMed, EMBASE, the China National Knowledge Infrastructure, the Chinese Scientific Journal Database, the Chinese Biomedical Literature Database, and the Wanfang Database, were searched from their inception to August 2014 for relevant studies that compared one TCPM plus antihypertensive drugs versus antihypertensive drugs alone. The methodological quality of the included trials was assessed using the Cochrane risk-of-bias tool. The primary outcome measures were mortality or progression to severe complications and adverse events. The secondary outcome measures were blood pressure (BP) and quality of life (QOL).Seventy-three trials, which included 8138 patients, on 17 TCPMs were included. In general, the methodological quality was low. Two trials evaluated the effects of TCPMs on mortality and the progression to severe complications after treatment, and no significant difference was identified compared with antihypertensive drugs alone. No severe adverse events were reported. Thirteen TCPMs used in complementary therapy significantly decreased systolic BP by 3.94 to 13.50 mmHg and diastolic BP by 2.28 to 11.25 mmHg. QOL was significantly improved by TCPM plus antihypertensive drugs compared with antihypertensive drugs alone.This systematic review provided the first classification of clinical evidence for the effectiveness of TCPM for EH. The usage of TCPMs for EH was supported by evidence of class level III. As a result of the methodological drawbacks of the included studies, more rigorously designed randomized controlled trials that focus on mortality and cardiovascular events during long-term follow-up are warranted before TCPM can be recommended for hypertensive patients. Two TCPMs, Song ling xue mai kang capsules and Yang xue qing nao granules, should be prioritized for further research.     

Prognostic factors in patients with gastric adenocarcinoma using competing-risk analysis: a study of cases in the SEER database

Background: Accurate prognostic factors for gastric adenocarcinoma are still lacking in clinical practice, which contributes to inappropriate treatment. Applying the widely used Cox-proportional hazards model to describe survival trends and identify prognostic factors has limitations that result in a risk of bias. A competing-risk model was therefore adopted in this study to identify the significant prognostic factors and evaluate the cumulative incidence of cause-specific death for gastric adenocarcinoma, which can be used to guide clinical treatments.

Methods: All of the cases analyzed in this study were extracted from the SEER (Surveillance, Epidemiology, and End Results) database. Using the competing risk approach, we calculated the cumulative incidence function (CIF) for cause-specific death and death from other causes at each time point. The Fine and Gray’s proportional subdistribution hazard model was then applied in the univariate analysis and multivariate analysis to test the differences in CIF between different groups and obtain independent prognostic factors.

Results: The univariate analysis showed that patients with characteristics of advanced pathology grade, lymph node involvement, and metastasis, were at risk of increasing cancer-specific mortality. Primary-site surgery, radiation with surgery, and chemotherapy, were associated with decreased cancer-specific mortality. The multivariate analysis showed that pathology grade, primary-site surgery, radiation with surgery, and chemotherapy, could significantly affect the cancer-specific mortality and were independent prognostic factors in patients with gastric adenocarcinoma.

Conclusions: Using a competing-risk model, this study obtained more-accurate estimates for the cumulative incidence of cancer-specific death and identified the prognostic factors more accurately for gastric adenocarcinoma.     

Symptom-based outcome measures for dyspepsia and GERD trials: a systematic review

BACKGROUND: Symptom assessment using questionnaires has been recommended as the primary outcome measure in clinical gastroesophageal reflux and dyspepsia trials. Questionnaires should have proven reliability, validity, and responsiveness, and may assess the frequency and/or severity of dyspepsia symptoms. Although a number of measures have been developed, it remains unclear which of these should be used in new trials. OBJECTIVE: To describe existing questionnaire outcome measures that assess symptoms of gastroesophageal reflux dyspepsia for use in clinical trials. METHODS: Studies were identified from Medline, Embase, the Cochrane library, and reference lists. The inclusion criterion was that the study assessed a questionnaire, which measured the frequency or severity of dyspepsia or gastroesophageal reflux symptoms, in a sample of patients. RESULTS: No direct comparison between questionnaires was possible due to methodological heterogeneity. Thirty-seven studies describing 26 questionnaires met the inclusion criteria. Twelve were unidimensional (assessed symptoms only) and 14 were multidimensional (also assessed quality of life). Eleven questionnaires assessed both frequency and severity of dyspepsia, and 10 had proven reliability, validity, and responsiveness. No studies compared different questionnaires. CONCLUSIONS: Future gastroesophageal reflux and dyspepsia clinical trials should use unidimensional or multidimensional outcome measures that assess both the frequency and severity of symptoms, and have proven reliability, validity, and responsiveness. Further research is necessary to compare existing outcome measures to determine which are the most reliable, valid, and responsive instruments.     

Assessing weight-related quality of life in obese persons with type 2 diabetes

Because approximately 80% of individuals with type 2 diabetes are obese, we examined weight-related QOL in obese persons with diabetes using the Impact of Weight on Quality of Life-Lite (IWQOL-Lite) questionnaire. Study participants were enrolled in a clinical trial for an obesity medication or a clinical study of gastric bypass surgery. Psychometric properties of the IWQOL-Lite were evaluated separately for obese persons with (n = 225) and without (n = 972) type 2 diabetes. Internal consistency reliabilities were similar for persons with and without diabetes (0.981 versus 0.980). Correlations between IWQOL-Lite scores and body mass index were significant and comparable for persons with and without diabetes. The IWQOL-Lite factor structure was similar for both the diabetic and non-diabetic subjects and consistent with earlier studies. There was no difference between diabetic and non-diabetic subjects on weight-related QOL as measured by the IWQOL-Lite; however, subjects in this study had more impaired weight-related QOL relative to a reference sample of overweight/obese community persons. We recommend the use of weight-related QOL measures in addition to generic and diabetes-specific measures when assessing quality of life in type 2 diabetes, particularly when patients are overweight or obese.     

The effect of a psychosocial intervention and quality of life after acute myocardial infarction: the Enhancing Recovery in Coronary Heart Disease (ENRICHD) clinical trial

PURPOSE: The Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) clinical trial was designed to test whether intervening on depression or low perceived social support reduces mortality and reinfarction in patients with acute myocardial infarction (MI). This report analyzes the effect of the intervention on quality of life (QOL), which was an important secondary outcome. METHODS: ENRICHD was a randomized controlled clinical trial comparing a psychosocial intervention based on cognitive behavioral therapy to usual medical care in 2,481 patients from 8 clinical centers. Patients with acute MI were included if they met criteria for depression, low perceived social support, or both. QOL was assessed at the 6-month clinic visit in the first 1,296 patients. QOL measures included the Medical Outcomes Study Short Form summary measures of physical functioning (SF12-PCS) and mental functioning (SF12-MCS), a Life Satisfaction Scale (LSS), and a measure of overall QOL based on the ladder of life (LOL) technique. RESULTS: There were significant treatment differences on the SF12-MCS (difference 2.2, 95% confidence interval [CI] 1.2-3.2), the LSS (difference 1.0, 95% CI 0.5-1.5), and the LOL (difference 0.3, 95% CI 0.1-0.6), but not on the SF12-PCS (difference 0.8; 95% CI = -0.5-2.0). Effect sizes for the intervention on QOL outcomes were modest. CONCLUSIONS: Psychosocial interventions of limited duration confer modest QOL benefits in post-MI patients who are depressed or have low perceived social support. Interventions of longer duration or greater intensity may be required to produce more substantial improvements in QOL in these patients.     

The characteristics of quality of life impairment in adult growth hormone (GH)-deficient survivors of cancer and their response to GH replacement therapy

We studied 50 (27 women and 23 men) GH-deficient (GHD) cancer survivors and 47 (24 women and 23 men) GHD patients with pituitary pathologies. All GHD patients were considered for GH replacement on the basis of subjectively poor quality of life (QOL). Primary outcome measures were scores of QOL instruments psychological general well-being schedule (PGWB) and assessment of GH deficiency in adults (AGHDA) at baseline and early (6-13 months) and long-term (24-77 months) treatment follow-up. Of secondary interest were six PGWB domains. Linear mixed effect regression was used to model each QOL outcome. The groups differed with respect to three covariates: age, gender, and body mass index. These variables were included in all fitted models. Baseline scores for PGWB and AGHDA were not different between groups. Ranking of PGWB domains were similar between groups at baseline (lowest domain, vitality). The pattern of change in mean scores for all outcome measures from baseline did not differ between groups (P = 0.86). All QOL variables improved significantly with treatment [estimated mean change +/- se: PGWB, 16.2 +/- 1.7; AGHDA, -6.2 +/- 0.6; PGWB domains (transformed percentage scales): anxiety, 12.4 +/- 1.7; depression, 14.1 +/- 2.1; health, 12.4 +/- 1.7; self-control, 11.3 +/- 2.0; well-being, 15.2 +/- 1.7; vitality, 22.5 +/- 2.0 (vitality, greatest change)]. There was no evidence of group difference in early follow-up or long-term follow-up means for any outcome variable. The QOL in adult GHD cancer survivors was comparable to that in GHD adults with pituitary pathologies and improved with GH replacement in a similar manner. We conclude that QOL impairment in adult GHD cancer survivors appears mainly related to GHD rather than cancer diagnosis and treatment.     

Impact of breast cancer survivorship on quality of life in older women

Quality of life (QOL) is an important outcome for cancer survivors; but although age is a major risk factor, most breast cancer survivorship studies are conducted with younger women. The objective of our study was to compare QOL in a sample of older breast cancer survivors to a sample of older women who were never diagnosed with breast cancer. A sample of 127 older breast cancer survivors as identified by a cancer registry was compared to a demographically equated sample of 87 older women participating in an epidemiological study. Both groups completed a questionnaire and participated in an interview to measure QOL. The older breast cancer survivors scored worse in the Medical Outcomes Study-Short Form, a measure of health-related QOL. Survivors reported no more depressive symptoms or anxious mood than the comparison group, but scored lower in measures of positive psychosocial well-being, including life satisfaction, mastery, and spiritual well-being, and reported more depressed mood and days affected by fatigue. Older breast cancer survivors show multiple indications of decrements in their health-related quality of life, and lower psychosocial well-being than the comparison group. These decrements may represent deficits in reserve capacity that predispose older cancer survivors to functional disability but may not be readily detected in typical clinical evaluations given the multiple impairments common in geriatric populations. Results suggest a need for greater attention to promoting functioning and psychological well-being among older cancer survivors, even when they may not have obvious cancer-related medical complications.     

Quality of life in long term survivors of colorectal cancer

OBJECTIVES: We aimed to determine the quality of life (QOL) for long term survivors of colorectal cancer. METHODS: Persons with colorectal cancer who had survived at least 5 yr from diagnosis were recruited from a local cancer registry to answer questions about general QOL and colon cancer-specific issues. Before the general survey, focus group interviews with long term survivors were conducted to select survey questions from a pool of general and cancer-specific QOL questionnaires. The survey included the Health Utilities Index, the Center for Epidemiological Studies Depression Scale, and questions from the Short Form 36 and Functional Assessment of Cancer Therapy-Colorectal Cancer. After permission was obtained from their primary physicians, long term survivors from the registry were mailed invitation letters, then telephoned. Those agreeing were mailed self-administered questionnaires with stamped return envelopes. RESULTS: Two hundred twenty-seven respondents (average age = 74 yr, 46% female) completed the survey. Survivors reported a relatively uniform and high QOL, irrespective of stage at diagnosis and time from diagnosis. Non-cancer related comorbid conditions and low income status had more influence on overall QOL than initial stage of colorectal cancer or time since diagnosis. Compared to age-matched populations, long term survivors reported higher overall QOL, but had higher rates of depression. Sixteen percent reported three or more bowel movements a day; 49% reported chronic recurrent diarrhea. CONCLUSIONS: Those who achieve long term remission from colorectal cancer may experience a relatively high QOL, although physical symptoms such as diarrhea and depressive symptoms remain a problem.     

Evidence-based examination of the African enigma in relation to Helicobacter pylori infection

OBJECTIVE: The African enigma describes the dissociation between the prevalence of Helicobacter pylori infection and H. pylori-related diseases. The aim of this study was to use an evidence-based review of endoscopic data from African countries to test whether there are data to support the concept of an African enigma. MATERIAL AND METHODS: A Medline search was carried out to identify prospective endoscopic studies in African populations. Data collected included: the number of endoscopies, age range (or mean age if available), indications for endoscopy, country, years during which data were collected, male to female ratio, and specific outcome of duodenal ulcer, gastric ulcer, or gastric cancer. RESULTS: Forty prospective endoscopic studies from 17 African countries were identified (20,531 patients) and evaluated between 1972 and 2001. Mean ages ranged from 31 to 53.1 years and male to female ratios from 0.67:1 to 4.64:1. H. pylori-related clinical outcomes were common; duodenal ulcers in 4326 patients (21.1%), gastric ulcers in 691 patients (3.4%), and gastric cancers in 503 patients (2.4%). CONCLUSIONS: Prospective upper endoscopic trials suggest that the clinical outcomes associated with H. pylori infection in Africa are similar to those seen in industrialized countries. No dissociation between the prevalence of H. pylori infection and H. pylori-related diseases existed; the African enigma as such does not exist and the continued study of the mechanism of a non-existent phenomenon is a misuse of resources. The myth resulted from reliance on anecdotal data and selection bias in populations with extremely limited access to health care and a relatively short life expectancy.