Travado, L

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Placing Quality of Life Assessments on Oncologists' Agenda

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Support Care Cancer (2006) 14: 979–981DOI 10.1007/s00520-006-0130-x EDITORIALLuzia TravadoReceived: 2 July 2006Accepted: 5 July 2006Published online: 26 August 2006# Springer-Verlag 2006Placing quality of life assessmentson oncologists’ agendaThe last two decades have witnessed adramatic growth in interest in theassessment of quality of life (QoL) inboth oncology research and practice[1–3]. The availability of reliable,cancer-specific instruments for usewith cancer patients (e.g., EORTCQLQ-C30, FACT), the changing atti-tude towards a more biopsychosocialoriented model of clinical practice, aswell as the demand by patientsthemselves and consumer advocacyorganizations to address their psycho-social needs as part of quality cancercare have served to bring QoL as-sessment into the oncologists’ agenda.Side effects of treatments have longbeen a concern for cancer cliniciansand were traditionally assessed as away to understand the impact oftherapy and monitor (and when nec-essary manage) its efficacy. But theQoL concept has evolved from alargely unidimensional biologicalconstruct, focused basically on phys-ical symptoms and functional ability,to a multidimensional construct thatincludes in its definition assessment ofother dimensions such as psycholog-ical well-being, social functioning,spirituality, etc. [4–6]. Patient’s sub-jective perceptions of their QoL havecome to play an important role asmedicine has become more patient-centered and patients have becomemore educated and informed abouttheir illness and treatment options.Increasingly partners in the clinicaldecision-making process, patients andclinicians strive to balance the variousdemands of a given therapy with thepersonal preferences of the patient inchoosing a specific treatment. It is nolonger acceptable to pursue “blindsurvival at all costs” (at the expense ofQoL). The European Cancer PatientCoalition (http://www.ecpc-online.org) motto of Nothing About UsWithout Us illustrates how muchadvocacy organizations emphasize theimportance of bringing patients’ viewsinto the decision arena, whether it bethe singular patient perspective andparticipating–partnering with clini-cians in all decisions affecting theirwell-being or as Patients’ Organiza-tions (Associations or Coalitions)demanding the opportunity to partici-pate in policy-making.Even if we have come a long wayscientifically with respect to the de-velopment of reliable instruments tomeasure patients’ QoL, much remainsto be done as far as the regular inclu-sion of these in oncology clinicalpractice, research, and clinical trials[7]. Regulatory agencies (e.g., FDA,EMEA, etc.), by recognizing QoL asan important endpoint in clinicalresearch, have helped promote thevalue of QoL assessments, althoughuse of these is not mandatory [8].Furthermore, the wide range of in-struments now available to assess QoLand the lack of guidelines for which tochoose in a given clinical or researchscenario or how to interpret theresulting data have been a deterrent inthis process.The paper featured in this issue ofSupportive Care in Cancer, “Theclinical significance of quality of lifeassessments in oncology: a summaryfor clinicians,” is an important con-L. Travado (*)Clinical Psychology Unit,Centro Hospitalar de Lisboa(Zona Central),Hospital de São José,Rua José António Serrano,1150-199 Lisbon, Portugale-mail: luzia.travado@chlisboa-zc.min-saude.ptTel.: +351-218-841579Fax: +351-218-841079tribution to reduce this gap. Theauthors, Jeff Sloane et al., are part ofthe Clinical Significance ConsensusMeeting Group. The group comprisedof 30 QoL research experts, who firstmet in 1999 and then again in 2000 atthe Mayo Clinic in Rochester, Min-nesota, with the express purpose ofdiscussing these issues and reachingsome consensus guidelines about QoLassessments and interpretation thatwould facilitate their use for clini-cians, researchers, and regulators [9].As a result, six articles were publishedconcerning the state of the scienceof QoL assessments in oncology in2002 at the Mayo Clinic Proceedings[10–15] in a special section dedicatedto the Symposium on Quality of Lifein Cancer Patients.In the present paper, a more readilydigestible, updated and summarizedversion of the more extensive set ofarticles, the authors intend to provideclinicians with simplified informationthat would help them better under-stand QoL assessments and influencetheir decision to include these rou-tinely in their clinical practice andresearch. Core issues for QoL assess-ment and interpretation are addressedand recommendations are illustratedwith a practical application of a lungcancer clinical trial example, whichpromotes a better understanding forthe clinician of the more theoreticalcontent explained and its applicability.The 63 references provided are alsorich resources for those who want tofurther delve into certain topics, andthe tables and figures are provided toclarify some of the concepts.The paper highlights six key chal-lenges to QoL assessment as delin-eated by the Consensus MeetingGroup in each of the articles:(1) Methods to explain the clinicalsignificance of QoL measures inwhich the difference betweenstatistical significance and clinicalsignificance is clarified, and use-ful strategies used to date arepresented to facilitate the inter-pretation of QoL results.(2) Group vs individual approachesto understanding the clinicalsignificance of differences orchanges in QoL clarifies themethods that can be used, induc-tive or deductive, in interpretingindividual data.(3) Assessing the clinical significanceof single items relative to sum-mated scores presents the pros,cons and specific indications ofchoosing a single item question-naire (like VAS) or a multi-itemquestionnaire.(4) Patient, clinician, and populationperspectives on determining theclinical significance of QoLscores pertains to how thesedifferent perspectives, each onehaving their own standards andvalues, perceive change in QoL.(5) Assessing meaningful change inQoL over time: a user’s guide forClinicians addresses relevantissues to help clinicians in thedecision-making process regard-ing the selection of the optimaltreatment for each patient and howto do so from understanding andinterpreting longitudinal QoL datapresented in the literature.(6) The clinical significance of QoLresults: practical considerationsfor specific audiences introducesthe meaning or interpretation ofdifferent QoL outcomes from thepatients’, clinicians’, and policy-makers’ perspective, and how thisclinical significance can best becommunicated to patients ashealth-relevant information thatcould assist the treatment deci-sion-making process, in a suc-cessful way for both patient andclinician and their relationship.Hopefully, after reading this paperclinicians will have greater confidencein their ability to use QOL assess-ments and appreciation of the utilityof the data they provide in helpingthem facilitate shared decision-making with patients and improvetreatment compliance. It is also hopedthat the information provided willencourage readers to recognize thatthe current QoL measures are scien-tifically reliable tools with the poten-tial, when incorporated into researchand clinical trials protocols, to yieldadded benefits for patients and onco-logic science alike.In conclusion, the incorporation ofQoL assessments and endpoints intoclinical research and practice is awinning situation for all the partnersinvolved. For the patients, it addressestheir perceptions of well-being andbrings their perspective into play,conveying the message that they are atthe center of care, their opinionmatters, and that the focus of treatmentand health care is appropriately ontheir personal sense of well-being. Useof these evaluations also serves tofoster patients’ awareness andresponsiveness to their QoL aspectsand promotes an informed participa-tive and partnership attitude. Forprofessionals, use of QoL assessmentsgives them outcome data that can bemeaningful for them and the patientsthey treat to apply in treatmentdecisions. It also heightens theirawareness of patients’ well-being andfacilitates discussion of QoL issues[16]. Because emotional and socialdimensions are a standard part of QoLassessment, use of these tools can alsoprovide a way to screen for distress,affording clinicians a means to sys-tematically recognize psychosocialproblems or morbidity associated withillness and treatment (a problemaddressed elsewhere [17]), and makethe proper referrals for evaluation orsupport, thereby contributing to abetter quality of life for their patients.Addressing these often neglected as-pects of patients’ functioning can inturn have positive implications forpatients’ overall well-being, their sa-tisfaction with care, and given thatmental health interventions have beenshown to reduce health care utiliza-tion, potentially, health care costs.Placing QoL assessments on oncol-ogists’ agenda is thus a step forwardin reaching better quality, patient-centered care.980References1. 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Placing Quality of Life Assessments on Oncologists' Agenda

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