August 2003
Dear Readers: Here's the Article for this Month:
Name of article:
Assessment of Quality of Life in Outpatients with Advanced Cancer: The Accuracy of Clinician Estimations and the Relevance of Spiritual Well-Being – A Hoosier Oncology Group Study
Author(s): Fisch MJ, Titzer ML, Kristeller JL, Shen J, Loehrer PJ, Jung S-H, Passik SD, and Einhorn LH
Reference: J Clinical Oncology 2003; 21: 2754-9
Abstract:
Quality of life (QOL) has become an important concept in the treatment and care of cancer patients. Clinical studies have shown that changes in QOL are associated with changes in clinical variables and survival. Several QOL assessment tools are now available but not routinely used in clinical practice. There are data supporting the idea that the QOL assessment could improve communication without increasing consultation time. However, clinicians, more frequently, rely on their subjective evaluation of the patients’ QOL.Increasing attention has recently been paid to the importance of spiritual well-being (SWB) (considering spirituality as different from religion), as an aspect of QOL in chronically ill patients, including cancer patients.The idea of measuring the SWB and thus, consequently, developing assessment tools of the SWB, comes from qualitative research regarding patients’ viewpoints on QOL and showing that SWB is reported to be one of the most underestimated aspects.Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being (FACIT-Sp) is a simple, self-administered 12-item instrument with acceptable psychometric properties for measuring SWB in cancer patients (Copyright 1993, 1997, David Cella). The FACIT-Sp is divided into 3 subscales regarding "Meaning", "Peace" and "Faith". The items are scored on a 5-point scale ranging from "Not at All" to "Very Much".The aims of this study, carried out by Michael and Colleagues, were to evaluate the association between QOL impairment and SWB as reported by the patients and QOL impairment as judged by nurses or physicians in respect to that reported by the patients.163 out-clinic advanced cancer patients, with an expected survival between 3 and 24 months, were enrolled from 15 sites of the Hoosier Oncology Group Study.QOL was measured by means of the Functional Assessment of Cancer Therapy-General Version (FACT-G), that is a 34-item instrument assessing physical well-being, social and family well-being, emotional well-being and functional well-being. The FACT-G doesn’t consider spiritual well-being.At the time of study entry, patients completed the FACT-G (version 3) and the FACIT-Sp.The clinicians estimated the patients’ impairment of QOL (rated as mild, moderate or severe), the performance status and survival for each patient.The results of the study showed that:
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QOL of the patients under study was not associated with life expectancy, marital status, level of education and performance status.there was a significant correlation between the FACIT-Sp score and the FACT-G score (r= 0.56, p<.0001). The correlation was more strongly for the "Meaning and Peace" subscales (r= 0.64, p<.001) than for "Faith" subscale (r= 0.28, p<.0004).clinicians estimates of QOL impairment were "accurate" in more than 60% of patients
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although the data shows a strong correlation between the QOL and the SWB, the accuracy of clinicians estimates was not associated with the level of SWB reported by the patients
however, a subset analysis of the "inaccurate" estimates showed an association between lower SWB and clinician underestimation of QOL impairment (r=0.39, p=.0025).
Why I chose this article.
In the palliative care setting, the expression "Total Pain" is very often quoted to explain in a comprehensive way, the physical, emotional, social, and spiritual suffering.When people speak about the "person in se", the body, the mind, the psyche, the soul and the world of relationship are considered as a whole.In our clinical practice we almost always use QOL assessment tools to measure physical and psychological symptoms, emotions, performance status, the feeling of well-being and relationships with other people.
This study shows us that also the spiritual dimension of our patients should be evaluated and taken into consideration if we wish to have a "holistic" approach toward the patients and their well-being. "Being in mind that the same can also be said for most of us".
Regards,
Carla Ripamonti, MD
Member of the Board of Directors, IAHPC
