Why measure QL

In a survey of oncologists and surgeons specializing in breast cancer, Saunders and Fallowfield [8] found that although they were familiar with some QL measures, most did not routinely use them and believed that QL could be assessed adequately without formal instruments. This suggests that many clinicians appear to believe that it is possible to assess the risks and benefits of treatment in an informal unstructured way. Comments made by the specialists surveyed included the statement that using QL questionnaires was too time consuming, did not add enough to justify the time, and increased patient anxiety.

But how good are clinicians at predicting the QL of their patients? In a situation where an aggressive treatment is being compared with a less-aggressive treatment, many people might predict that the aggressive treatment would cause greater side effects that would outweigh improvements in symptoms and result in a poorer QL. However, when QL has been assessed in a number of such trials, counter-intuitive results have been observed, suggesting that what is predicted by clinicians and researchers is not necessarily what is experienced by patients.

For example, in patients with metastatic breast cancer, chemotherapy is often given every three weeks until disease progression is evident (on average for six months). Such continuous treatment can place an enormous burden on patients. In 1987 Coates etal. [9] conducted a randomized trial comparing standard continuous chemotherapy versus intermittent therapy. Patients randomized to intermittent therapy received three cycles of chemotherapy, then stopped and only re-started when there was evidence of disease progression. The expectation was that patients on the intermittent policy would experience an improved QL in the period between completion of three cycles and progression. Patients completed questionnaires covering five aspects of QL and one for overall QL. Comparing the change between the score at the end of three cycles to the average score at each assessment up until progression, showed that all QL outcomes favoured continuous treatment. Thus, in this instance, it is likely that the palliative benefits of the continuous chemotherapy outweighed any side-effects and/or provided a level of reassurance for the patient.

Also in metastatic breast cancer, Tannock et al. [10] compared a high-dose chemotherapy regimen with one using half-dose chemotherapy, both given at 3-weekly cycles indefinitely. A subset of forty-nine patients completed questionnaires covering thirty-four aspects of QL. Although the scales confirmed greater toxicity in the high-dose arm, they also showed a trend towards improvement in general health and some disease-related indices with this regimen. Similar counter-intuitive results were seen in trials of planned treatment for small cell lung cancer compared to treatment 'as required,' [11] and, in the same disease, immediate treatment compared to selective palliative treatment [12].

Although several of these trials can be criticized on a number of counts such as small sample sizes, much missing data, and methods of analysis, a number of other studies have also suggested unexpected results (see Ref. [13]). All these results emphasize that it is not always easy to predict the likely impact of treatment on QL.

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