Transcript Gastric cancer AND - Medicina

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
Background
Gastric Cancer
European Distribution
QoL after Chemo/Radiotherapy in Gastric Cancer
Cumulative risk, 0-64 years
Female
Male
Eucan - Database
 Stomach adenocarcinoma is the most common form of gastric cancer
(95% of the cases).1
1- Crew KD, Epidemiology of upper gastrointestinal malignancies. Seminin Oncol 2004; 31: 450–464.
Gastric Cancer
Incidence
Background
QoL after Chemo/Radiotherapy in Gastric Cancer
35
31
30
850 000 deaths worlwide each year cause due to gastric cancer
25
20
16
14
15
10
13
10
10
8
8
9
8
8
6
5
0
4
4
3
4
3
0
Men
Women
3
2
4
1 1
0 1
0
0
0
Eucan - Database
World, age-standardized rates (per 100.000 persons.year)
Gastric Cancer
Incidence
Background
QoL after Chemo/Radiotherapy in Gastric Cancer
Aproximately 1,440,000 cases worlwide per year
35
31
30
850 000 deaths worlwide each year cause due to gastric cancer
25
20
16
14
15
10
13
10
10
8
8
9
8
8
6
5
0
4
4
3
4
3
0
Men
Women
3
2
4
1 1
0 1
0
0
0
Eucan - Database
World, age-standardized rates (per 100.000 persons.year)
Background

Treatments
QoL after Chemo/Radiotherapy in Gastric Cancer
Treatment for gastric cancer often
involves surgery, usually a partial
or a total gastrectomy (removal of
stomach tissue).2

Chemotherapy
and
radiotherapy
are standard for some stages of
stomach cancer.2
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.
Background
Chemo and Radiotherapy
QoL after Chemo/Radiotherapy in Gastric Cancer

Chemotherapy
is
the
use
of
chemical agents to stop cancer
cells from growing.3

Chemotherapy
is
considered
a
systemic treatment.3

Radiotherapy uses high energy xrays to destroy cancer cells.4

A small dose of radiotherapy may
be very helpful to relieve pain.4
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.
Background
Quality of Life
QoL after Chemo/Radiotherapy in Gastric Cancer
Some definitions
Schipper et al. proposed:
“the functional effect of illness and its consequent therapy upon a patient, as
perceived by the patient”.5
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”.
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)
Background
Quality of Life
QoL after Chemo/Radiotherapy in Gastric Cancer
Some definitions
Schipper et al. proposed:
“the functional effect of illness and its consequent therapy upon a patient, as
perceived by the patient”.5
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”.
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
QoL after Chemo/Radiotherapy in Gastric Cancer
__________________________________________________________________________
•
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
QoL after Chemo/Radiotherapy in Gastric Cancer
Article Search:
 The Query used was:
◊
″Gastric cancer AND (Quality of Life OR Psychology)
AND
(Radiotherapy OR Chemotherapy)”
 Literature searches were conducted in Medline.
Limits:
 Publication Date until September 2005.
Only items with an abstract.
Humans.
Methods
Fluxogram
QoL after Chemo/Radiotherapy in Gastric Cancer
Beginning
Read title and
abstract
Excluded by 2
reviewers ?
Yes
No
Exclude
article
yes
Included by 2
reviewers ?
Include
article
no
Opinion of a
third reviewer
Read
complete
article
Discuss until
reviewers
agreement
Introduce data in
the SPSS
Include
article
End
Exclude
article
Methods
QoL after Chemo/Radiotherapy in Gastric Cancer
 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
Results
QoL after Chemo/Radiotherapy in Gastric Cancer
Type of Study: Systematic review
to
chemo or radiotherapy;
- QoL
evaluated
by
the
with
an
patients;
- QoL
measured
appropriate instrument;
- More than one participant.
Inclusion criteria
Instrument
to measure
QOL
submitted
QOL
evaluated by
the patient
- Patients
Patients
submitted to
chemo or
radiotherapy
cancer;
Patients with
gastric
cancer
gastric
More than
one
participant
with
100
90
80
70
60
50
40
30
20
10
0
Evaluation of
QOL
- Patients
No. of included articles
 Inclusion Criteria of the
article:
These data refers to 97 articles
Results
QoL after Chemo/Radiotherapy in Gastric Cancer
 Exclusion criteria of the
article:
40
- Articles in which QoL was
measured
but
only
symptoms were studied;
35
No. of excluded articles
- Articles based on mixed
diagnostic groupings (in
the article these have to
be
approached
separately);
30
25
20
15
10
5
0
- Articles that referred to
patients submitted to a
surgery during or before
treatment.
Mixed groups
Only the symptoms were
measured
Exclusion criteria
Patients submitted to surgery
These data refers to 97 articles
Results
Start
Search in
Pubmed
116
articles
found
Searches
Apply inclusion
and exclusion
criteria
11 were
included
86 were
excluded
QoL after Chemo/Radiotherapy in Gastric Cancer
19
couldn’t
be used
Search for the
validation
paper
All the
instruments had a
validation paper
End
Results
Included Articles
QoL after Chemo/Radiotherapy in Gastric Cancer
A summary of the data extracted from the included articles
Is presented
In the following Table
Fist author and Publication date of the
article
Instrum ent
Validation paper of
the instrum ents
Group in study
Control group
Patients
stage
Results
Park SH, 2005
EORTC QLQ-C30;
HADS

Patients submitted to
second-line chemotherapy
Patients not submitted to
chemotherapy
Locally
advanced or
metastic
disease
QoL increases w ith
second-line
chemotherapy
EORTC QLQ-C30

Patients not submitted to
chemotherapy
Patients treated w ith
[177LuDOTA0,Tyr3]octreotate
Metastic
tumor (GEP)
QoL increases in
patients treated w ith
[177-LuDOTA0,Tyr3]octreotate
Teunissen JJ, 2004
Tebbutt NC 2002
EORTC QLQ-C30

Patients submitted to
protracted venous
infusion (PVI) 5fluorouracil (5-FU)
Bramhall SR 2002
EORTC QLQ-C30

Placebo
Ross P, 2002
EORTC QLQ-C30
Nordin K, 2001
EORTC QLQ-C30
Katarina H, 1998
EORTC QLQ-C30
Glimelius B, 1997
EORTC QLQ-C30
Bamias A, 1996
Chau I, 2004
Findlay M, 1994



Locally
Patients submitted to PVI 5- advanced or
FU plus mitomycin C
metastic
disease
Locally
Patients submitted to
advanced or
chemotherapy
metastic
disease
Patients submitted to
mitomycin, cisplatin, and
Patients submitted to
protracted venousepirubicin, cisplatin, and
infusion fluorouracil (PVI 5PVI 5-FU
FU)
Patients submitted to
Patients submitted to
chemotherapy w ithout
chemotherapy w ith best
best supportive care
supportive care
No differences in QoL
No differences in QoL
Inoperable
QoL increases if w e
adenocarcino use epirubicin, cisplatin,
ma
and PVI 5-FU
Advanced
gastric
cancer
Advanced
gastric
cancer
Locally
advanced or
metastic
disease
Locally
advanced or
metastic
disease
QoL increases in
chemotherapy w ith
best supportive care
QoL increases w ith
second-line
chemotherapy
Patients not submitted to
chemotherapy
Patients submitted to
second-line chemotherapy

Best supportive care
Chemotherapy and best
suportive care
EORTC QLQ-C30

Patients submitted to a
treatment w ith epirubicin
and cisplatin
Patients submitted to a
venous infusion of 5fluorouracil
EORTC QLQ-C30

Patients submitted to
chemotherapy
Patients submitted to
fluoreouracil-based
combination chemotherapy
Inoperable
carcinoma
No differences in QoL

Patients submitted to a
treatment w ith epurubicin
and cisplatin in
combination w ith infusion
5-fluorouracil
Patients not submitted to
this treatment
Locally
advanced or
metastic
disease
No differences in QoL
Rotterdam
Symptom Checklist
QoL increases in
chemotherapy w ith
best supportive care
QoL increases in both
groups
Fist author and Publication date of the
article
Instrum ent
Validation paper of
the instrum ents
Group in study
Control group
Patients
stage
Results
Park SH, 2005
EORTC QLQ-C30;
HADS

Patients submitted to
second-line chemotherapy
Patients not submitted to
chemotherapy
Locally
advanced or
metastic
disease
QoL increases w ith
second-line
chemotherapy
EORTC QLQ-C30

Patients not submitted to
chemotherapy
Patients treated w ith
[177LuDOTA0,Tyr3]octreotate
Metastic
tumor (GEP)
QoL increases in
patients treated w ith
[177-LuDOTA0,Tyr3]octreotate
Teunissen JJ, 2004
Tebbutt NC 2002
EORTC QLQ-C30

Patients submitted to
protracted venous
infusion (PVI) 5fluorouracil (5-FU)
Bramhall SR 2002
EORTC QLQ-C30

Placebo
Ross P, 2002
EORTC QLQ-C30
Nordin K, 2001
EORTC QLQ-C30
Katarina H, 1998
EORTC QLQ-C30
Glimelius B, 1997
EORTC QLQ-C30
Bamias A, 1996
Chau I, 2004
Findlay M, 1994



Locally
Patients submitted to PVI 5- advanced or
FU plus mitomycin C
metastic
disease
Locally
Patients submitted to
advanced or
chemotherapy
metastic
disease
Patients submitted to
mitomycin, cisplatin, and
Patients submitted to
protracted venousepirubicin, cisplatin, and
infusion fluorouracil (PVI 5PVI 5-FU
FU)
Patients submitted to
Patients submitted to
chemotherapy w ithout
chemotherapy w ith best
best supportive care
supportive care
No differences in QoL
No differences in QoL
Inoperable
QoL increases if w e
adenocarcino use epirubicin, cisplatin,
ma
and PVI 5-FU
Advanced
gastric
cancer
Advanced
gastric
cancer
Locally
advanced or
metastic
disease
Locally
advanced or
metastic
disease
QoL increases in
chemotherapy w ith
best supportive care
QoL increases w ith
second-line
chemotherapy
Patients not submitted to
chemotherapy
Patients submitted to
second-line chemotherapy

Best supportive care
Chemotherapy and best
suportive care
EORTC QLQ-C30

Patients submitted to a
treatment w ith epirubicin
and cisplatin
Patients submitted to a
venous infusion of 5fluorouracil
EORTC QLQ-C30

Patients submitted to
chemotherapy
Patients submitted to
fluoreouracil-based
combination chemotherapy
Inoperable
carcinoma
No differences in QoL

Patients submitted to a
treatment w ith epurubicin
and cisplatin in
combination w ith infusion
5-fluorouracil
Patients not submitted to
this treatment
Locally
advanced or
metastic
disease
No differences in QoL
Rotterdam
Symptom Checklist
QoL increases in
chemotherapy w ith
best supportive care
QoL increases in both
groups
Fist author and Publication date of the
article
Instrum ent
Validation paper of
the instrum ents
Group in study
Control group
Patients
stage
Results
Park SH, 2005
EORTC QLQ-C30;
HADS

Patients submitted to
second-line chemotherapy
Patients not submitted to
chemotherapy
Locally
advanced or
metastic
disease
QoL increases w ith
second-line
chemotherapy
EORTC QLQ-C30

Patients not submitted to
chemotherapy
Patients treated w ith
[177LuDOTA0,Tyr3]octreotate
Metastic
tumor (GEP)
QoL increases in
patients treated w ith
[177-LuDOTA0,Tyr3]octreotate
Teunissen JJ, 2004
Tebbutt NC 2002
EORTC QLQ-C30

Patients submitted to
protracted venous
infusion (PVI) 5fluorouracil (5-FU)
Bramhall SR 2002
EORTC QLQ-C30

Placebo
Ross P, 2002
EORTC QLQ-C30
Nordin K, 2001
EORTC QLQ-C30
Katarina H, 1998
EORTC QLQ-C30
Glimelius B, 1997
EORTC QLQ-C30
Bamias A, 1996
Chau I, 2004
Findlay M, 1994



Locally
Patients submitted to PVI 5- advanced or
FU plus mitomycin C
metastic
disease
Locally
Patients submitted to
advanced or
chemotherapy
metastic
disease
Patients submitted to
mitomycin, cisplatin, and
Patients submitted to
protracted venousepirubicin, cisplatin, and
infusion fluorouracil (PVI 5PVI 5-FU
FU)
Patients submitted to
Patients submitted to
chemotherapy w ithout
chemotherapy w ith best
best supportive care
supportive care
No differences in QoL
No differences in QoL
Inoperable
QoL increases if w e
adenocarcino use epirubicin, cisplatin,
ma
and PVI 5-FU
Advanced
gastric
cancer
Advanced
gastric
cancer
Locally
advanced or
metastic
disease
Locally
advanced or
metastic
disease
QoL increases in
chemotherapy w ith
best supportive care
QoL increases w ith
second-line
chemotherapy
Patients not submitted to
chemotherapy
Patients submitted to
second-line chemotherapy

Best supportive care
Chemotherapy and best
suportive care
EORTC QLQ-C30

Patients submitted to a
treatment w ith epirubicin
and cisplatin
Patients submitted to a
venous infusion of 5fluorouracil
EORTC QLQ-C30

Patients submitted to
chemotherapy
Patients submitted to
fluoreouracil-based
combination chemotherapy
Inoperable
carcinoma
No differences in QoL

Patients submitted to a
treatment w ith epurubicin
and cisplatin in
combination w ith infusion
5-fluorouracil
Patients not submitted to
this treatment
Locally
advanced or
metastic
disease
No differences in QoL
Rotterdam
Symptom Checklist
QoL increases in
chemotherapy w ith
best supportive care
QoL increases in both
groups
Limitations Related with
Search
Discussion
QoL after Chemo/Radiotherapy in Gastric Cancer
Lack of information
due to:
Japan is a country with a high
Many articles in japanese
incidence of gastric cancer.7
Most of the papers focus on surgery
Because
Surgery is the only potencially curative treatment
in gastric cancer.8
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.
Discussion
Limitations Related with
Treatment
QoL after Chemo/Radiotherapy in Gastric Cancer
Chemo and radiotherapy are considered:
 Adjuvant therapies (before or after surgery)8
 Palliative treatments7
8-Current treatments and future perspectives in colorectal and gastric cancer .
Discussion
Limitations Related with
Papers
QoL after Chemo/Radiotherapy in Gastric Cancer
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
Discussion
Limitations Related with
Papers
QoL after Chemo/Radiotherapy in Gastric Cancer
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!
Discussion
Meta analysis
QoL after Chemo/Radiotherapy in Gastric Cancer
Evaluation of QoL is qualitative, although a
scale exists in every instrument
Therefore:
It was impossible to achieve a meta analysis with the obtained data
Discussion
Meta analysis
QoL after Chemo/Radiotherapy in Gastric Cancer
Evaluation of QoL is qualitative, although a
scale exists in every instrument
Therefore:
It was impossible to achieve a meta analysis with the obtained data
More research is needed
Discussion
Questionnaires used
QoL after Chemo/Radiotherapy in Gastric Cancer
Questionnaire
Number of Items
Areas Measured
EORTC QLQ-C30
30
physical, functional, social, and
emotional
RSCL
30
psychological and physical
HADS
14
psychological
Discussion
Questionnaires
Some differences
QoL after Chemo/Radiotherapy in Gastric Cancer
Maybe this isn’t the best approach...
Items removed from the applied
questionnaires

Do you have any trouble taking a long
Items of the questionnaires for
patients under palliation

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
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?
Discussion
Questionnaires proposed
QoL after Chemo/Radiotherapy in Gastric Cancer
Questionnaire
Number of Items
Areas Measured
AQEL
36
physical, psychological,
social, existential
EORTC QLQ-C15-PAL
15
Functional, choice of
treatment, psychological
PQLI
28
McGill
16
FLIC
22
functional, symptom, choice
of treatment scale,
psychological
physical symptoms,
psychological symptoms,
outlook on life, and
meaningful existence
physical well-being and ability,
emotional state, sociability,
family situation and nausea
Discussion
Final Remarks
QoL after Chemo/Radiotherapy in Gastric Cancer
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
Questionnaire to Patients under Palliation
A Systematic Review about these instruments can be
consulted to better understand their characteristics
Discussion
Final Remarks
QoL after Chemo/Radiotherapy in Gastric Cancer
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
Questionnaire to Patients under Palliation
“Instruments for assessing quality of life in palliative care settings.”
Massaro T, McMillan SC; Int J Palliat Nurs.; 2000 Oct; 6(9):429-33
Web Site
QoL after Chemo/Radiotherapy in Gastric Cancer
Trabalho anual - FMUP- Faculdade de Medicina da Universidade do Porto
Acknowledgments
QoL after Chemo/Radiotherapy in Gastric Cancer
We acknowledge the help of:
 Cláudia Camila Dias
 Mário Dinis Ribeiro
We are also very grateful to:
 Professor Doutor Altamiro da Costa Pereira
Not forgetting:
All the authors that have promptly fournished the articles
necessary for the succes of our work