Wednesday, October 25, 2006

Prognosis in recently diagnosed incurable cancer; making sense of quality of life assessments

Two articles from October's Supportive Care in Cancer

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First is a systematic review of prognostic factors in patients with recently diagnosed incurable cancer. While most of us are familiar with prognosis in patients with advanced cancer, and the supreme importance of functional status in prognostication, we (at least I am) are much less familiar and skilled with prognostication for people earlier on in their disease (i.e. at the point of first diagnosis, when their ECOG scores are still 0-1). I have always been taught, and continue to believe, that in these circumstances tumor characteristics (type of cancer such as lung vs. breast, histologic grade, tumor burden, early response to chemotherapy, etc.) are more important than patient characteristics (functional status) and this review overall bears that out, although they do find that functional status is important early on as well. The review is not helpful for actual bedside prognostication unfortunately (that would be too easy)--it is more of an academic overview of what is known. One surprising finding is that advanced patient age doesn't consistently indicate worse prognosis across the studies they looked at (this does, I guess, further highlight the importance early on of tumor & not patient characteristics).

This is their graphic conceptualization of factors influencing prognosis (& yes, 'treatment' is misspelled):



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Second is a review looking at the clinical significance of quality of life assessments in cancer patients. I was hoping this was going to be the holy grail of qol assessment reviews which I could stick on my desk and every time I read an article whcih reports a change of X on the EORTC-CQC-QOL-30-version 2.3-modified-FACIT-Lung-Combined quality of life I could reach to this article, flip a few pages, and conclude, "Oh, a change of X is a really good outcome," or some such thing. Naive? Indeed. The review is actually a well-balanced look at the difficulties of interpreting and applying quality of life assessments to clinical practice. It basically gives a nod to my previously described wish and then notes that is impossible with the current state of the science for most of the (and there are so bloody many) quality of life scales/tools used in cancer research. The article is a helpful introduction as to why this is a difficult task, and to me highlights the need to use qol tools in clinical trials which are clinically interpreter to the non-qol-researcher.

If anyone out there has a good resource about qol scales/tools please leave a comment. Besides curiosity I have selfish motives here: I run the journal club for the palliative medicine fellowship at my institution and have identified this as a curriculum need (interpreting qol findings in cancer and palliative care-relevant research). It's a mountain of a subject that I'd rather not climb at all, or at least alone....

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