Assessment of Quality Of Life in patients treated with Chemo and Radiotherapy for Gastric Cancer: A Systematic Review Authors: Turma 14 Supervisors: Mário

Assessment of Quality Of Life in patients

treated with Chemo and Radiotherapy for

Gastric Cancer: A Systematic Review

Authors: Turma 14

Supervisors: Mário Dinis Ribeiro

Cláudia Camila Dias

Professor Doutor Altamiro da Costa Pereira

MaleFemale

Cumulative risk, 0-64 years

Eucan - Database

Stomach adenocarcinoma is the most common form of gastric cancer

(95% of the cases).11

1- Crew KD, Epidemiology of upper gastrointestinal malignancies. Seminin Oncol 2004; 31: 450–464.

Background Gastric Cancer European Distribution

QoL after Chemo/Radiotherapy in Gastric Cancer

Background

31

14

109 8

4 4 3

1 0 0 0 0

108

68

4

0

3 3 21 1

13

8

4

16

0

5

10

15

20

25

30

35

Lung

Stom

ach

Live

rCCR

Oesop

hagu

s

Pros

tate

Panc

reas

Leuk

emia

NHLSk

in

Thyr

oid

Breas

t

Uteru

s

Ovary

Men Women

850 000 deaths worlwide each year cause due to 850 000 deaths worlwide each year cause due to

gastric cancergastric cancer

World, age-standardized rates (per 100.000 persons.year)

Eucan - Database

Gastric Cancer Incidence


31

14

109 8

4 4 3

1 0 0 0 0

108

68

4

0

3 3 21 1

13

8

4

16

0

5

10

15

20

25

30

35

Lung

Stom

ach

Live

rCCR

Oesop

hagu

s

Pros

tate

Panc

reas

Leuk

emia

NHLSk

in

Thyr

oid

Breas

t

Uteru

s

Ovary

Men Women

850 000 deaths worlwide each year cause due to 850 000 deaths worlwide each year cause due to

gastric cancergastric cancer

World, age-standardized rates (per 100.000 persons.year)

Eucan - Database

Aproximately 1,440,000 cases worlwide per year

BackgroundIncidence Gastric Cancer


Treatment for gastric cancer often

involves surgery, usually a partial

or a total gastrectomy (removal of

stomach tissue).22

Chemotherapy and radiotherapy

are standard for some stages of

stomach cancer.22

2-Ross P. Prospective randomized trial comparing mitomycin, cisplatin, and protracted venous-infusion fluorouracil (PVI 5-FU) with epirubicin, cisplatin and PVI 5-FU in advanced esophagogastric cancer. Journal of Clinical Oncology, Vol. 20, Issue 8 (April), 2002.

BackgroundTreatments


http://images.google.pt/imgres?imgurl=http://www.netikka.net/hans.bjorknas/yn0022.jpg&imgrefurl=http://www.netikka.net/hans.bjorknas/pan-018.htm&h=500&w=560&sz=18&tbnid=h2lfGA8Jp3EJ:&tbnh=116&tbnw=131&hl=pt-PT&start=4&prev=/images%3Fq%3Dgastric%2Bcancer%26svnum%3D10%26hl%3Dpt-PT%26lr%3D%26sa%3DG

Chemotherapy is the use of

chemical agents to stop cancer

cells from growing.33

Chemotherapy is considered a

systemic treatment.33

Radiotherapy uses high energy x-

rays to destroy cancer cells.44

A small dose of radiotherapy may

be very helpful to relieve pain.44

3-Janunger KG. A Systematic Overview of Chemotherapy Effects in Gastric Cancer. Acta Oncologica, Vol. 40, No. 2/3, pp. 309-326, 2001.

4-Kim GE. The role of radiation treatment in management of extrahepatic biliary tract metastasis from gastric carcinoma. Int. J. Radiation Oncology Biol. Phys., Vol. 28, No. 3, pp.711-717, 1994.

BackgroundChemo and Radiotherapy


Schipper et al. proposed:

“the functional effect of illness and its consequent therapy upon a patient, as

perceived by the patient”.55

5- Schipper H. Definitions and conceptual issues. In: Spilker B, ed. Quality of Life and pharmacoeconomics. in clinical trials, Philadephia : Lippincott- Raven, 1996: 11-24

6-WHOQoL Group (1993)

World Health Organization proposed:

“Quality of life is defined as the individual's perception of their position in life in

the context of the culture and value systems in which they live and in relation to

their goals, expectations, standards and concerns. It is a broad ranging concept

affected in a complex way by a person's physical health, psychological state,

level of independence and their relationships to salient features of their

environment”.

Some definitions

BackgroundQuality of Life


Schipper et al. proposed:

“the functional effect of illness and its consequent therapy upon a patient, as

perceived by the patient”.55

World Health Organization proposed:

“Quality of life is defined as the individual's perception of their position in life in

the context of the culture and value systems in which they live and in relation to

their goals, expectations, standards and concerns. It is a broad ranging concept

affected in a complex way by a person's physical health, psychological state,

level of independence and their relationships to salient features of their

environment”.

Some definitions

BackgroundQuality of Life


5- Schipper H. Definitions and conceptual issues. In: Spilker B, ed. Quality of Life and pharmacoeconomics. in clinical trials, Philadephia : Lippincott- Raven, 1996: 11-24

6-WHOQoL Group (1993)

Aim

__________________________________________________________________________

• Summarize the QoL of patients with gastric cancer after treatment with

chemo and radiotherapy

• Clarify the validity/validation of instruments used

• Summarize the QoL of patients with gastric cancer according to the

instrument.

__________________________________________________________________________


Methods

Inclusion Criteria of the article:

- Patients with gastric

cancer;

- Patients submitted to

chemo or radiotherapy;

- QoL evaluated by the

patients;

- QoL measured with an

appropriate instrument;

- More than one participant.

0102030405060708090

100

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Patie

nts

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Patie

nts

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itted

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OL

Inclusion criteriaN

o. o

f inc

lude

d ar

ticle

sThese data refers to 97 articles

Type of Study: Systematic reviewType of Study: Systematic review


The Query used was:

◊ ″Gastric cancer AND (Quality of Life OR Psychology)

AND (Radiotherapy OR Chemotherapy)”

Literature searches were conducted in Medline.

Article Search:

Limits:

Publication Date until September 2005.

Only items with an abstract.

Humans.

MethodsQoL after Chemo/Radiotherapy in Gastric Cancer

Methods

Exclusion criteria of the article:

- Articles based on mixed diagnostic groupings (in the article these have to be approached separately);

- Articles in which QoL was measured but only symptoms were studied;

- Articles that referred to patients submitted to a surgery during or before treatment.

0

5

10

15

20

25

30

35

40

Mixed groups Only the symptoms weremeasured

Patients submitted to surgery

Exclusion criteria

No. o

f exc

lude

d ar

ticle

s

These data refers to 97 articles


FluxogramBeginning

Read title and abstract

Excluded by 2 reviewers ?

Exclude article

Included by 2 reviewers ?

End

Opinion of a third reviewer

no

Include article

yes

Read complete

article

Introduce data in the SPSS

Yes No

Discuss until reviewers agreement

Exclude article

Include article

MethodsQoL after Chemo/Radiotherapy in Gastric Cancer

Methods

Validation Papers

o A second search was conducted, to discover if the

instruments used in the included articles were

valid. To find the validation papers we search the

questionnaire title through Google and Medline


ResultsSearches


StartSearch in Pubmed

116 articles found

Apply inclusion and exclusion

criteria

11 were included

86 were excluded

19 couldn’t be used

Search for the validation

paper

All the instruments had a validation paper

End

A summary of the data extracted from the included articles A summary of the data extracted from the included articles

In the following TableIn the following Table

Is presented

ResultsIncluded Articles


Park SH, 2005EORTC QLQ-C30;

HADS Patients submitted to second-line chemotherapy

Patients not submitted to chemotherapy

Locally advanced or

metastic disease

QoL increases with second-line

chemotherapy

Teunissen JJ, 2004 EORTC QLQ-C30 Patients not submitted to chemotherapy

Patients treated with [177Lu-

DOTA0,Tyr3]octreotate

Metastic tumor (GEP)

QoL increases in patients treated with

[177-Lu-DOTA0,Tyr3]octreotate

Tebbutt NC 2002 EORTC QLQ-C30 Patients submitted to protracted venous infusion (PVI) 5-

fluorouracil (5-FU)

Patients submitted to PVI 5-FU plus mitomycin C

Locally advanced or

metastic disease

No differences in QoL

Bramhall SR 2002 EORTC QLQ-C30 Placebo Patients submitted to

chemotherapy

Locally advanced or

metastic disease


Ross P, 2002 EORTC QLQ-C30 Patients submitted to

mitomycin, cisplatin, and protracted venous-

infusion fluorouracil (PVI 5-FU)

Patients submitted to epirubicin, cisplatin, and

PVI 5-FU

Inoperable adenocarcino

ma

QoL increases if we use epirubicin, cisplatin,

and PVI 5-FU

Nordin K, 2001 EORTC QLQ-C30 Patients submitted to chemotherapy without best supportive care

Patients submitted to chemotherapy with best

supportive care

Advanced gastric cancer

QoL increases in chemotherapy with

best supportive care

Katarina H, 1998 EORTC QLQ-C30 Patients not submitted to chemotherapy

Patients submitted to second-line chemotherapy



chemotherapy

Glimelius B, 1997 EORTC QLQ-C30 Best supportive careChemotherapy and best

suportive care

Locally advanced or

metastic disease



Bamias A, 1996 EORTC QLQ-C30 Patients submitted to a treatment with epirubicin

and cisplatin

Patients submitted to a venous infusion of 5-

fluorouracil

Locally advanced or

metastic disease

QoL increases in both groups

Scieszka M, 1998 FACT Patients submitted to chemotherapy

Patients submitted to palliative care



Findlay M, 1994 Rotterdam

Symptom Checklist Patients submitted to a

treatment with epurubicin and cisplatin in

combination with infusion 5-fluorouracil

Patients not submitted to this treatment

Locally advanced or

metastic disease


Control groupPatients stage

ResultsFist author and Publication date of the

articleInstrument Validation paper of

the instruments

Group in study




Locally advanced or

metastic disease


chemotherapy








fluorouracil (5-FU)


Locally advanced or

metastic disease



chemotherapy

Locally advanced or

metastic disease






PVI 5-FU


ma


and PVI 5-FU



supportive care








chemotherapy


suportive care

Locally advanced or

metastic disease




and cisplatin


fluorouracil

Locally advanced or

metastic disease











Locally advanced or

metastic disease





the instruments

Group in study




Locally advanced or

metastic disease


chemotherapy








fluorouracil (5-FU)


Locally advanced or

metastic disease



chemotherapy

Locally advanced or

metastic disease






PVI 5-FU


ma


and PVI 5-FU



supportive care








chemotherapy


suportive care

Locally advanced or

metastic disease




and cisplatin


fluorouracil

Locally advanced or

metastic disease











Locally advanced or

metastic disease





the instruments

Group in study

Discussion

Lack of information

due to:

Many articles in japanese

Most of the papers focus on surgery

Because

Surgery is the only potencially curative treatment

in gastric cancer.88

Japan is a country with a high

incidence of gastric cancer.77

Understandable

once

7-IARC Scientific Publications. In: Whelan SL, Parkin DM, Masuyer E, eds. Trends in Cancer Incidence and Mortality. Lyon: WHO Publications, 1993;102.

8-Wilke Hj, Van Cutsem E. Current treatments and future perspectives in colorectal and gastric cancer . Ann Oncol, 2003;14: 49-55.

Search Limitations Related with


Discussion

Chemo and radiotherapy are considered:

Adjuvant therapies (before or after surgery)88

Palliative treatments77

8-Current treatments and future perspectives in colorectal and gastric cancer .

TreatmentLimitations Related with


Discussion

Just a few could be included

Some of the causes:

Studies just evaluated differences on survival

time according to treatment

Only the physical parameters were considered

Limitations Related withPapers


Discussion

Just a few could be included

Some of the causes:

Studies just evaluated differences on survival

time according to treatment

Only the physical parameters were considered

QoL is still a minor concern!

Limitations Related withPapers


Discussion

Therefore:

It was impossible to achieve a meta analysis with the obtained data

Evaluation of QoL is qualitative, although a

scale exists in every instrument

Meta analysisQoL after Chemo/Radiotherapy in Gastric Cancer

Discussion

Therefore:

It was impossible to achieve a meta analysis with the obtained data

More research is needed

Evaluation of QoL is qualitative, although a

scale exists in every instrument

Meta analysisQoL after Chemo/Radiotherapy in Gastric Cancer

Discussion

Questionnaire Number of Items Areas Measured

FACT-Ga 28physical, functional, social, and

emotional

EORTC QLQ-C30 30physical, functional, social, and

emotional

RSCL 30 psychological and physical

HADS 14 psychological

Questionnaires usedQoL after Chemo/Radiotherapy in Gastric Cancer

Discussion

Items removed from the applied Items removed from the applied questionnairesquestionnaires

Do you have any trouble taking a long

walk?

you limited in pursing your hobbies or

other leisure time activities?

I am satisfied with my sex life I am able to enjoy life

Lack of sexual interest

Maybe this isn’t the best approach...

Items of the questionnaires for Items of the questionnaires for patients under palliationpatients under palliation

Approximately how many hours per day (8

a.m. to 8 p.m.) have you been lying down? How much help have you needed with

dressing and hygiene?

How much pain have you had last week?

How many days during the past week have

you spent in a hospital/nursing home?

Some differencesQuestionnaires


Discussion

Questionnaire Number of Items Areas Measured

AQEL 36physical, psychological,

social, existential

EORTC QLQ-C15-PAL 15Functional, choice of

treatment, psychological

PQLI 28functional, symptom, choice

of treatment scale, psychological

McGill 16

physical symptoms, psychological symptoms,

outlook on life, and meaningful existence

FLIC 22

physical well-being and ability, emotional state,

sociability, family situation and nausea

Questionnaires proposedQoL after Chemo/Radiotherapy in Gastric Cancer

Discussion

When chemo and radiotherapy are used as

treatment

The instrument to measure QoL should not be the same used with

the other treatments

The most appropriate option is a The most appropriate option is a

Questionnaire to Patients under PalliationQuestionnaire to Patients under Palliation

A Systematic Review about these instruments can be

consulted to better understand their characteristics

Final RemarksQoL after Chemo/Radiotherapy in Gastric Cancer

Discussion

When chemo and radiotherapy are used as

treatment

The instrument to measure QoL should not be the same used with

the other treatments

The most appropriate option is a The most appropriate option is a

Questionnaire to Patients under PalliationQuestionnaire to Patients under Palliation

““Instruments for assessing quality of life in palliative care settings.” Instruments for assessing quality of life in palliative care settings.”

Massaro T, McMillan SC; Int J Palliat Nurs.; 2000 Oct; 6(9):429-33Massaro T, McMillan SC; Int J Palliat Nurs.; 2000 Oct; 6(9):429-33

Final RemarksQoL after Chemo/Radiotherapy in Gastric Cancer

Web SiteQoL after Chemo/Radiotherapy in Gastric Cancer

Trabalho anual - FMUP- Faculdade de Medicina da Universidade do Porto

Acknowledgments

We acknowledge the help of:We acknowledge the help of:

Cláudia Camila Dias

Mário Dinis Ribeiro

We are also very grateful to:We are also very grateful to:

Professor Doutor Altamiro da Costa Pereira

All the authors that have promptly fournished the articles

necessary for the succes of our work


Not forgetting:Not forgetting:

Documents

Assessment of Quality Of Life in patients treated with Chemo and Radiotherapy for Gastric Cancer: A Systematic Review Authors: Turma 14 Supervisors: Mário