Compared with younger patients, older patients with cancer face unique challenges because many of them have age-related decreases in health-related quality of life. This can be a result of many factors, such as comorbidities, mental health, physical impairment, and financial stressors. A diagnosis of cancer often further decreases the quality of life of older patients.1 This has significant prognostic implications because decreases in quality of life can be associated with increased mortality in older adults, as seen in patients who experience depression2,3 or fatigue.4 Health-related quality of life has often been found to be a better predictor of survival than performance status, suggesting patient-reported outcomes should be considered in future cancer clinical trials.5
“Health-related quality of life has often been found to be a better predictor of survival than performance status.”— Mazie Tsang, MD, MS, and Kah Poh (Melissa) Loh, MBBCh, BAO
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What Exactly Is Quality of Life?
Quality of life encompasses a broad range of objective and subjective measures of life domains and individual values. It is multidimensional and can be categorized into the following five dimensions: physical well-being, material well-being, social well-being, emotional well-being, and development/activity.6 Each dimension is interconnected and can be affected by the underlying cancer or its treatment.7
Formally measuring health-related quality of life can be difficult, because there are numerous health-related quality-of-life scales, and it is difficult to know which scale to select. The various tools can be categorized into overall quality-of-life questionnaires, cancer-specific questionnaires, and symptom-focused questionnaires. We recommend referring to helpful articles when deciding which scale to select; the choice of scale ultimately depends on the purpose of the scale and how the evaluator tends to use it.8
Mazie Tsang, MD, MS
Kah Poh (Melissa) Loh, MBBCh, BAO
How Can We Better Incorporate Quality-of-Life Measures Into Clinical Practice?
The typical health-related quality-of-life questionnaire covers most of the domains of physical, material, social, and emotional well-being. The properties of a good questionnaire depend on the purpose of the questionnaire. Dr. Tsang uses questionnaires in a longitudinal manner, so she uses a short and easy-to-complete form that is relevant to her patients’ clinical condition. She prefers the core questionnaire for patients with cancer, the European Organisation for the Research and Treatment of Cancer (EORTC) QLQ-C30.
The EORTC QLQ-C30 covers nine multi-item scales, including five functional scales (physical, role, cognitive, emotional, and social), three symptom scales (fatigue, pain, and nausea/vomiting), and a global health and quality-of-life scale.7 Dr. Tsang uses these data to address any symptoms and to assess how patients respond to therapy. Studies have shown that health-related quality-of-life scales can be clinically useful in prognostication.
Additional questionnaires can be added to a core questionnaire to capture more specific symptoms. For example, for her patients with central nervous system (CNS) lymphomas, Dr. Tsang also utilizes the EORTC QLQ-BN20, which evaluates the effects of cancer and its therapies on the quality of life of patients with brain tumors. The questionnaires are administered immediately before or at the beginning of the visit, and patients typically take less than 5 minutes to complete them.
Assessing quality of life in older adults can be incorporated with the geriatric assessment. Although they may overlap, components assessed are distinct. The geriatric assessment is also a multidimensional diagnostic evaluation that identifies the vulnerabilities of older adults and guides subsequent management in the following domains: physical function, psychological health, comorbidities, nutrition, polypharmacy, and social support.7 Similar to health-related quality of life, the geriatric assessment (in this case focusing on cognition and physical function) can also be an independent predictor of survival in older patients and identify patients who might be at increased risk from toxicities related to treatment.9
“Assessing quality of life in older adults can be incorporated with the geriatric assessment. Although they may overlap, components assessed are distinct.”— Mazie Tsang, MD, MS, and Kah Poh (Melissa) Loh, MBBCh, BAO
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In Dr. Loh’s geriatric hematology clinic, older adults with a new cancer diagnosis, or those who require a change in therapy, generally receive a geriatric assessment along with the Functional Assessment of Cancer Therapy (FACT) instrument. With leukemia being the focus of practice, the FACT-Leu was selected. Therefore, the choice of instrument depends on the patient population. If a heterogeneous population is seen, general instruments such as FACT-General may be more appropriate. The geriatric and health-related quality-of-life assessments are mailed to patients before their appointments so they can complete them at home.
How Can We Better Incorporate Quality-of-Life Measures Into Research?
Although the use of health-related quality-of-life assessments is variable depending on the type of cancer, it generally has not been included in therapeutic trials. In our respective disease groups, we have not seen a consistent use of health-related quality-of-life measurements. For primary CNS lymphoma, for example, a systematic review on cognition and health-related quality of life showed that of the 42 studies meeting their inclusion criteria (“primary CNS lymphoma” and “cognition” or “health-related quality of life”), fewer than half included health-related quality of life as a patient-reported outcome. In most of these studies, health-related quality of life improved after induction therapy in patients with primary CNS lymphoma.9 Approximately 5% of these studies included the effects of treatment on health-related quality of life in older patients.10,11
As for acute myeloid leukemia (AML), there are fewer studies. For example, of 3,995 total references identified, 10 met the criteria for inclusion in a systematic review of health-related quality of life in patients with AML.12
Many therapeutic cancer clinical trials continue to lack high-quality data on health-related quality of life. In patients with AML and primary CNS lymphoma, for example, health-related quality-of-life data were generally not included in the clinical trials that led to drug approvals by the U.S. Food and Drug Administration, despite the fact that some of these trials were designed to evaluate an older patient population.7,13
There is also a gap in research on whether interventions that improve quality of life could also improve overall outcomes for older patients. One of the main barriers that prevents the integration of health-related quality of life in research is a lack of consistency in the analysis and interpretation of health-related quality of life and patient-reported outcomes, which makes it difficult to compare results across different studies and randomized controlled trials. International efforts are underway to develop standardized approaches to measure health-related quality of life and patient-reported outcomes, focusing on three key priorities: developing a taxonomy of patient-reported outcomes objectives, defining essential statistical methods for analysis, and determining how to evaluate missing data.14
Do Quality-of-Life Interventions Change Outcomes?
Quality-of-life assessments may be used to assess treatment tolerance and guide interventions that could potentially improve patients’ symptoms and quality of life. In our practice, patients appear to be adherent to their therapies and are likely not to require treatment reductions. Older adults often value quality of life as much as, if not more than, quantity of life. Therefore, incorporating quality-of-life assessments in routine care may promote patient-centered care and satisfaction.
“Incorporating quality-of-life assessments in routine care may promote patient-centered care and satisfaction.”— Mazie Tsang, MD, MS, and Kah Poh (Melissa) Loh, MBBCh, BAO
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There is a current gap in research on which interventions on quality of life have been most beneficial for older patients with cancer. For example, mindfulness-based interventions, such as yoga, have been shown to improve quality of life for patients with cancer by improving sleep.15 Cognitive behavioral therapy and exercise are other interventions that may improve health-related quality of life, although it is unclear how they affect survival.16,17
Early referral to palliative care has been shown to improve both quality of life and overall survival. In patients who receive outpatient palliative care compared with usual care, pooled data in a meta-analysis showed that outpatient palliative care improved quality of life and resulted in a 14% absolute increase in 1-year survival relative to controls (56% vs 42%; P < .001).18 Although oncologists can provide primary palliative care, referral to a palliative care specialist should be considered for patients who have poor quality of life, as measured by a high level of physical or emotional symptoms among others.
Because of the growth of our aging population, we need to better understand how best to treat older patients with cancer. In addition to increasing the representation of older patients on cancer clinical trials, we propose that future clinical trials also include high-quality patient-reported outcomes measurements as either primary or secondary outcomes. Because of the evolving treatment landscape for older patients and the fact that many therapies have similar efficacy, quality of life is important to help distinguish between two similarly effective therapies and to better inform older patients who may value quality of life as paramount.
In addition, because of the significant overlap between health-related quality of life and the geriatric assessment, studies involving older adults could consider incorporating both evaluations. Measuring patients’ quality of life in the clinic and also in cancer clinical trials provides more information for discussion with our older patients about their treatment options and factors that might be most important to them. Interventions that improve quality of life may have prognostic implications and should be considered as part of clinical practice, especially in the care of older adults.
Dr. Tsang is a third-year hematology/oncology fellow at the University of California San Francisco. She also completed her hospice and palliative medicine fellowship at the University of Michigan. Dr. Tsang is a member of ASCO’s Trainee Council. Dr. Loh is a geriatric hematologist and oncologist at the University of Rochester Medical Center, James P. Wilmot Cancer Institute. Dr. Loh was a member of ASCO’s Trainee Council and sits on the Clinical Practice Guidelines Committee.
DISCLOSURE: Dr. Tsang reported no conflicts of interest. Dr. Loh has had a consulting or advisory role with Pfizer and Seattle Genetics.
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