The prognostic impact of quality of life assessed with the EORTC QLQ-C30 in inoperable non-small cell lung carcinoma treated with radiotherapy

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Abstract

Purpose: The purpose of this study was to assess the prognostic significance of pretreatment quality of life (QoL) scores and symptom scores in a group of patients treated with high dose radiotherapy.

Material and methods: A total of 198 patients treated with external irradiation (≥60 Gy) were included. In all these patients, baseline QoL was assessed using the EORTC QLQ-C30. The prognostic significance of a number of non-QoL and QoL parameters with regard to survival was estimated in both univariate and multivariate analyses.

Results: In a multivariate model including the non-QoL parameters, performance status, weight loss and N-classification were independent prognostic factors for survival. After entering the QoL parameters in the model, global QoL was the strongest prognostic factor, while performance status lost its significance. Subsequently, a significant interaction term was found between N-classification and global QoL, indicating that global QoL was an independent prognostic factor but that the effect varied as a function of N-status. In N+ patients, the median survival in the group with low scores for global QoL was 4.5 months, which was significantly worse (P<0.0001) compared with the high score group in which the median survival was 12.9 months.

Conclusion: Global QoL is a strong prognostic factor for survival in patients with NSCLC who have pathological lymph nodes at presentation and who are treated with radical or curative radiotherapy.

Introduction

Nowadays, a range of instruments is currently available which allow reliable and valid measurement of several aspects of quality of life (QoL) [1], [29], [30], [31], [34], [36]. Typically, patient-rated QoL has been used as an outcome parameter to compare different treatment approaches in clinical trials [8], [16], [20], [32]. A number of studies also reported on the correlation between several aspects of QoL and subsequent survival [6], [7], [9], [10], [11], [13], [15], [19]. In inoperable non-small cell lung carcinoma (NSCLC), performance status [2], [4], [5], [18], [22], [23], [24], [33], [35], weight loss [14], [22], [23], [24], [26], [35] and stage of disease [4], [5], [14], [18], [22], [24], [26], [33] are the most important and well-accepted prognostic factors. These factors are commonly used to select patients for different treatment approaches. Prognostic associations between QoL scores and survival duration have been reported for metastatic lung cancer [15], for inoperable NSCLC treated with chemotherapy and/or low dose radiotherapy [19] and for other primary sites [6], [9], [11]. However, no such data are available with regard to the prognostic significance of QoL scores in patients with inoperable NSCLC who are regarded to have a relatively good prognosis and, therefore, are candidates for radical radiotherapy.

The identification of prognostic factors in patients with inoperable non-small cell lung cancer (NSCLC) is important because they may provide insight into the disease process, providing direction for further studies, and may be important in defining the eligibility criteria for new clinical trials and stratifying patients by risk groups. Furthermore, prognostic factors are important when therapeutic options depend on pretreatment characteristics of the patients.

The primary objective of the current study was to assess the prognostic significance of pretreatment QoL scores and symptom scores, assessed with the EORTC QLQ-C30 in a group of patients treated with high dose radiotherapy. The hypothesis to be tested was that low scores for baseline QoL and high scores for general symptoms would be associated with worse survival. The secondary aim of this study was to identify a subset of patients with poor outcome despite high dose radiotherapy that would possibly benefit more from a shorter course of palliative radiotherapy.

Section snippets

Patients

Patients eligible for the study were those with stage I,II, IIIa or IIIb according to the UICC 1992 staging system [17], primarily treated with radical or curative radiotherapy (at least 60 Gy) and a WHO performance status ranging from 0 to 2. Patients with supraclavicular lymph node metastases, previously treated patients or patients treated with external irradiation in combination with endobronchial brachytherapy were excluded from the study.

Patients were included in a prospective,

Non-QoL prognostic factors

To identify non-QoL prognostic factors, a multivariate analysis was performed (the non-QoL model). The following potential prognostic variables were dichotomized and included in the regression model: T-classification (T1–T2 vs. T3–T4), N-classification (N0 vs. N+), WHO performance status (WHO 0 vs. WHO 1–2), weight loss (0–10% vs. >10%), histologic tumour type (squamous cell vs. non-quamous cell carcinoma), sex (male vs. female) and age (0–70 vs. >70 years). Following a forward stepwise

Prognostic value of QoL

In the univariate analysis, a significant association between global QoL and survival was observed (Table 3). The negative coefficient indicates that higher scores for QoL are associated with better survival. For role functioning, a borderline significance was found. Fatigue and appetite loss were also significantly associated with survival. The positive coefficient indicates that lower scores for these symptoms are associated with better survival. No association was observed between the

Discussion

In the present study, the prognostic significance of patient-rated QoL assessed with the QLQ-C30 was investigated in a group of patients with inoperable NSCLC selected for high dose radiotherapy. When only the non-QoL variables were taken into account, N-classification, weight loss and performance status were found to be independent prognostic factors. These variables are well known prognostic indicators in NSCLC. When the scores for several QoL domains were entered in the regression model, the

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