HEALTH RELATED QUALITY OF LIFE AMONG WOMEN WITH ADVANCED BREAST CANCER

Health Related Quality of Life (HRQoL) is understood in this study as a subjective and multidimensional concept, the main dimensions being physical state, psychological wellbeing, social relations and functional capacity. In the absence of curative therapies, the therapy goals for patients with advanced breast cancer include the prolongation of survival, the alleviation of symptoms, and HRQoL. Therefore, the efficacy of therapeutic interventions should be evaluated in terms of their effect on both the quantity and quality of life. The purpose of the present study was to investigate HRQoL among patients with advanced breast cancer. The QoL effects of two different treatments were compared. Specific emphasis was placed on comparing the patients’ HRQoL over time, on the relationship between toxicity variables, physical performance and HRQoL, on assessing the prognostic value of HRQoL in terms of overall survival and time to disease progression, and on the importance of the exact timing of the HRQoL assessments. Furthermore, qualitative methods were used to gain a deeper understanding of personal meanings related to the experience and treatment of cancer. The participants of the study were, 283 patients with metastatic breast cancer, who were randomly assigned either docetaxel (T) or sequential methotrexate and 5-fluorouracil (MF) treatment. EORTC QLQ-C30 was used to measure HRQoL. The HRQoL data and the clinical data were merged. The results of the study showed no major advantage of either treatment over the other. In addition, most of the variance in HRQoL could not be explained by treatment toxicity and physical performance as assessed by the physician. There was only mild to moderate correlation between the physician-assessed toxicity and the patient-assessed toxicity variables. Pain did have a prognostic value for the patients’ overall survival. However, no other HRQoL variables were shown to be significant prognostic factors for treatment response or for overall survival. Furthermore, the patients’ change scores from the baseline did not predict either survival or time to disease progression. Erroneous timing affected the HRQoL findings in both treatment groups. There were statistically and clinically significant differences between the responses to the ill-timed and the correctly timed questionnaires at baseline and over time. Thus, the study demonstrated the importance of correct timing in QoL assessment. From the results of the qualitative study, three dominant themes of personal experience emerged over the normative psychometric dimensions of HRQoL: ensuring feelings of autonomy by controlling the illness experience, experienced personal growth, and hope. In summary, in future assessments of and research in HRQoL, it would be useful to complement traditional psychometric methods with more individualised qualitative methods. keywords: Health Related Quality of Life, advanced breast cancer, qualitative, EORTC, prognostic, meaning, timing, toxicity LIST OF ORIGINAL PUBLICATIONS (I-V) The thesis is based on the following publications, which are referred to in the text with Roman numerals I-V I L. Hakamies-Blomqvist , M-L. Luoma , J. Sjostrom , A. Pluzanska , M. Sjodin , H. Mouridsen , B. Ostenstad, I. Mjaaland , S. Ottosson-Lonn , J. Bergh, P-O. Malmstrom, C. Blomqvist (2000) Quality Of Life in Patients with Metastatic Breast Cancer Receiving either Docetaxel or Sequential Methotrexate and 5-Fluorouracil. A Multicentre Randomised Phase III Trial by the Scandinavian Breast Group. European Journal of Cancer, (36), 1411-1417 II L. Hakamies-Blomqvist, M-L. Luoma, J. Sjostrom, A. Pluzanska, M. Sjodin , H. Mouridsen , B. Ostenstad, I. Mjaaland, S. Ottosson, J. Bergh, P-O. Malmstrom, C. Blomqvist (2001) Timing of Quality of life (QoL) assessments as a source of error in oncological trials. Journal of Advanced Nursing, 35, 709-716 III M-L. Luoma, L. Hakamies-Blomqvist J. Sjostrom, H. Mouridsen, A. Pluzanska, P. Malmstrom, N.O Bengtsson, R. Hultborn, B. Ostenstaad, I. Mjaaland, V. Valvere, E Wist, G. Baldursson, J.Ahlgren & C.Blomqvist (2002) Physical performance, toxicity, and quality of life as assessed by the physician and the patient. Acta Oncologica, 41(1), 44-49. IV M-L Luoma, Hakamies-Blomqvist L. , Sjostrom J , Pluzanska A., Hultborn R., Mouridsen H., Bengtsson NO. Bergh J. , Malmstrom P-O. Palm-Sjovall M, Valvere V. , Tennvall L., Blomqvist C (2003) Prognostic value of quality of life scores for time to progression (TTP) and overall survival time (OS) in advanced breast cancer. Eur J Cancer, 39 (10), 1370-6. V Minna-Liisa Luoma & Liisa Hakamies-Blomqvist. The meaning of quality of life in patients being treated for advanced breast cancer: A qualitative study. In press PsychoOncology Reprints were made with the permission of the publishers. ABBREVIATIONS AT doxorubicin and paclitaxel CR complete response CRF clinical research form EORTC European Organization for Research and Treatment of Cancer EORTC QLQ-C30 European Organization for Research and Treatment of Cancer Quality of Life core Questionnaire-C30 FAC 5-fluorouracil, doxorubicin, and cyclophosphamide FACT-G Functional Assessment Cancer Therapy FDA U.S. Food and Drug Administration HRQoL Health Related Quality of Life KPS the Karnofsky Performance Status LASA linear analog self-assessment technique M-F methotrexate and 5-fluorouracil OS overall survival PR partial response QLI quality of life index QoL Quality of Life SBG Scandinavian Breast Cancer Group T docetaxel TTP time to disease progression WHOQOL World Health Organisation Quality of Life Assesment Abbreviations within EORTC QLQ-C30 PF physical functioning RF role functioning CF cognitive functioning EF emotional functioning SF social functioning GQoL global quality of life PA pain FA fatigue NV nausea/vomiting DY dysopnea SL insomnia AP appetite loss CO constipation DI diarrhoea FI financial difficulties