Introduction
Thirteen to fifteen percent of all lung cancer cases worldwide, are of small cell type (small cell lung cancers, SCLCs) with the median survival time, without any treatment, to be between two and four months [1, 2]. SCLC, like the non-small lung cancers, is strongly associated with tobacco smoking [2, 3]. The decrease of tobacco use in recent years led to a respective decrease of the overall incidence of the disease. However, because of the last decades tobacco use expanding among women, the incidence of SCLC in this subgroup has been increased [4, 5].
Symptoms of SCLC, along with the side-effects of treatment interventions (e.g. nausea and vomiting due to cytotoxic drugs), are supposed to influence negatively the health-related quality of life (HRQoL) of the patients [6-8].
The HRQoL concept was developed for meeting the need of measuring the subjective perception of a person's health. The World Health Organization (WHO), in 1948, influenced by the opinions of Sigerist [9, 10] defined health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” [9, 11]. This evolvement emerged the need of measuring the physical, mental and social well-being, concepts which are related to the subjective perception of the individual and are beyond, and many times superior, than the measuring ability of the biomedical indicators. For fulfilling the above need the concept of Health-Related Quality of Life was developed [12].
The HRQoL of SCLC patients has not been well investigated yet [8]. An understanding of the determinants of SCLC patients’ HRQoL could help health professionals in clinical decision making, screening and prediction of health outcomes.
The aim of this review was to identify the health-related quality of life determining factors of patients with small cell lung cancer.
Material and Methods
Search Strategy
This review was conducted by searching in the electronic database PubMed for the period 1991 to June 2015. PubMed is considered the optimal tool in health sciences electronic research [13].
The literature search was performed using the following string of terms: (((("small cell"[Title] OR "oat cell"[Title] OR "small-cell"[Title] OR "oat-cell"[Title])) AND ("lung cancer"[Title] OR "carcinoma"[Title])) AND "quality of life"[Title]) AND ("multivariate"[Title/Abstract] OR "multivariable"[Title/Abstract] OR "regression"[Title/Abstract] OR "ANOVA"[Title/Abstract]). The terms “multivariate”, “multivariable”, “regression” and “ANOVA” were used, with respect to the “Title/Abstract” search criterion, for identifying studies with multivariate analysis.
Eligibility Criteria
The selection of the studies conducted by two reviewers working independently (A. Kossioris, T. Karousi). Firstly, the articles which yielded through the literature search were evaluated, through reading of the articles’ titles, and the related to the purpose of the review primary studies were chosen. Afterwards, at the second phase of the selection process, a review of the full text of the publications was taken place (Figure 1).
Figure 1. Flow chart – Review process
For including a study in the review, the following criteria were set:
- Articles written in English language.
- Reference population: Persons with SCLC or LD SCLC.
- Outcome: The health-related quality of life measured by a reliable and valid instrument.
- Determinants: Factors concerning the health-related quality of life.
- Statistical analysis: Articles with multivariate analysis and
- Articles published in peer reviewed journals.
Data Extraction
The data which retrieved from the studies included in the review, came along after consensus of reviewers. The name of the study first author, measurement instrument, sample size, research design, gender, educational level, marital status, fatigue presence or absence, coughing presence or absence, walking capacity, awareness of drive to breath (increased or decreased drive), working status and smoking status were summarized (Tables 1 and 2).
Table 1. Summary of the studies included in the review
|
Study |
Country |
Sample |
Research design |
Measurement instrument |
|
Bergman et al. [6] |
Sweden |
62 patients with SCLC undergoing chemotherapy |
Randomized trial |
SIP, HAD |
|
Hürny et al. [7] |
Switzerland |
127 patients with SCLC undergoing chemotherapy |
Randomized trial |
EORTC QL questionnaire, Bf-S well-being scale, LASA general well-being scale |
|
Chen et al. [8] |
China |
223 patients with SCLC |
Analytical, retrospective, case-control |
LCSS, LASA, ECOG-PS, Appetite change since diagnosis item |
|
Wolfson et al. [14] |
USA |
265 patients with LD SCLC undergoing radiation therapy |
Randomized trial |
QLQ-C30, BN20 |
SIP, sickness impact profile; HAD, hospital anxiety and depression scale; QLQ-C30, european organization for research and treatment of cancer (EORTC) quality of life questionnaire; Bf-S, befindlichkeits-skala; LASA, linear-analogue self-assessment scale; LCSS, lung cancer symptom scale; ECOG-PS, eastern cooperative oncology group performance status; BN20, brain cancer module 20.
Table 2. Descriptive table of patients’ characteristics
|
Variables |
|
N |
Percentage |
|
Gender |
Male |
300 |
55.2 |
|
Female |
206 |
37.9 |
|
|
Missing values |
37 |
6.8 |
|
|
Total |
543 |
100 |
|
|
Educational level |
< high school |
21 |
3.9 |
|
> high school |
35 |
6.4 |
|
|
Missing values |
487 |
89.7 |
|
|
Total |
543 |
100 |
|
|
Marital status |
Married |
36 |
6.6 |
|
Single |
23 |
4.2 |
|
|
Missing values |
484 |
89.1 |
|
|
Total |
543 |
100 |
|
|
Fatigue |
Quite a bit or very much |
371 |
68.3 |
|
Not at all or a little |
172 |
31.7 |
|
|
Total |
543 |
100 |
|
|
Coughing |
Quite a bit or very much |
379 |
69.8 |
|
Not at all or a little |
164 |
30 |
|
|
Total |
543 |
100 |
|
|
Walk difficulty |
Yes |
230 |
42.4 |
|
No |
313 |
57.6 |
|
|
Total |
543 |
100 |
|
|
Dyspnea |
Yes |
364 |
67.0 |
|
No |
179 |
33.0 |
|
|
Total |
543 |
100 |
|
|
Work |
Light work |
378 |
69.6 |
|
Unable to work and worse |
165 |
30.4 |
|
|
Total |
543 |
100 |
|
|
Smoking status |
Never smoker |
69 |
12.7 |
|
Former smoker |
160 |
29.5 |
|
|
Current smoker |
118 |
21.7 |
|
|
Missing values |
196 |
36.1 |
|
|
Total |
543 |
100 |
Data Analysis
The Likelihood Ratio Chi-Square test was used for assessing the value of performing a diagnostic test and evaluate the goodness of fit of our model (χ2=221.249, p<0.001). The dependent variable of the linear model was the quality of life measurements mean score which was extracted of each study separately and is calculated massively.
Results
After the selection process (Figure 1) four studies were included in the review, three randomized trials and one of analytic, retrospective, case-control research design.
The studies of Bergman et al. [6] from Sweden, Hürny et al. [7] from Switzerland and Wolfson et al. [14] from the USA were the randomized trials, while the study of Chen et al. [8] from China was of the analytical, retrospective, case-control design (Table 1).
By the multivariate statistical analysis it was detected that more positive impact on SCLC patients’ HRQoL had the high school, and below, level of education (Wald Chi-Square=10.10, p=0.001), the substantial presence of coughing (quite a bit or very much) (χ2=80.86, p<0.001) and the smoking habit (χ2=12.29, p<0.001).
On the other hand, negative influence on SCLC patients’ HRQoL had the female gender (χ2=7.86, p=0.005), the quite a bit or very much tiredness (χ2=28.54, p<0.001), the walking difficulty (χ2=31,80, p<0,001) and the presence of dyspnea (χ2=47.52, p<0.001) (Tables 2 and 3).
Table 3. SCLC patients’ HRQoL determining factors
|
Factors |
B |
Wald Chi-Square |
P value |
|
|
Gender |
Male |
-0.18 |
5.21 |
0.022 |
|
Female |
-0.23 |
7.86 |
0.005 |
|
|
Educational level |
< high school |
0.80 |
10.09 |
<0.001 |
|
> high school |
0.72 |
10.32 |
<0.001 |
|
|
Marital status |
Married |
0.034 |
0.02 |
0.890 |
|
Single |
0.032 |
0.02 |
0.880 |
|
|
Fatigue
|
Quite a bit or very much |
-0.34 |
28.54 |
<0.001 |
|
Coughing |
Quite a bit or very much |
0.56 |
80.86 |
<0.001 |
|
Walk difficulty |
Yes |
-0.32 |
31.80 |
<0.001 |
|
Dyspnea |
Yes |
-0.43 |
47.52 |
<0.001 |
|
Work |
Light work |
0.01 |
0.02 |
0.900 |
|
Smoking status |
Never smoker |
-0.7 |
1.24 |
0.270 |
|
Former smoker |
0.18 |
4.44 |
0.035 |
|
|
Current smoker |
0.20 |
12.29 |
<0.001 |
|
Discussion
Symptoms of SCLC, in company with the side-effects of the cytotoxic medications, are supposed to affects negatively the HRQoL of the patients [6-8]. An understanding of the determining factors of SCLC patients’ HRQoL could guide health professionals in clinical decision making, screening and prognosis of health outcomes.
The most significant finding of this review, was the fact that dyspnea influences negatively the HRQoL. Dyspnea is a common symptom among lung cancer patients [15, 16]. According to the study done by Smith et al. [17], patients with high dyspnea scores had lower QoL (p=0.040). Additionally, the cross-sectional study of Sarna et al. demonstrated that dyspnea induces risk for decreased physical and social aspects of QoL [18].
In regard to the educational level, it was found that the high school, and below, level of education had more positive impact on HRQoL (B=0.795). This finding is, generally, in contrast with the literature. A Spanish study done by Regidor et al. [19] showed that perceived health status diminishes with decreasing educational level, with the exception of women with secondary education who had a higher mean scoring than women with higher education on diverse health dimensions. Furthermore, concordantly to Mielck et al. [20], low educational status groups are encountered with a double burden. Nevertheless, the outlandish finding of our study could be justified by the many missing values of the massive sample (n=487).
From the statistical analysis, it was detected that the quite a bit or very much coughing had affirmative effect on HRQoL. This finding is in contrast with the literature [21], in which coughing is considered an afflicting factor for life’s quality. However, this could be explained from the symptoms characteristics of the Chen et al. study [8], the main research from which the coughing data were retrieved. Chen et al. [8] found that the lowest coughing mean score (66.4) took place in the fourth follow-up year. Furthermore, in the same study [8] appears to be a proneness that as the years pass, the coughing scores decreases.
As for the smoking status, it was discovered that smoking habit has positive impact on HRQoL. This finding is also contradictory with the literature [22-26]. Smoking has been repeatedly associated with lower QoL. Nonetheless, this discrepancy could be explained by the fact that there were many missing values in the review sample (n=196).
In relation to the gender, the female gender had negative effect on HRQoL. This detection is in agreement with the study of Pud et al. [27] in which female cancer patients reported significantly lower psychological dimension of QoL than their male counterparts (p=0.009).
With regard to fatigue presence or absence, the quite a bit or very much tiredness was detected to be adversely associated with HRQoL. This finding is concordant with the literature [28, 29]. Fatigue has been acknowledged as a common and distressing symptom in cancer.
With respect to walking capacity, walking difficulty had negative impact on HRQoL. This detection is consonant to the recent study of Bindawas et al. [30] in which increased lower extremity performance was associated with slower rates of decrease in participants’ physical and mental HRQoL.
As for the awareness of drive to breath, it was detected that the presence of dyspnea had adverse influence on HRQoL. The aforementioned finding is in agreement with the study done by Smith et al. [17] in which patients with high dyspnea scores had lower QoL (p=0.040) such as with the study of Gupta et al. [31] which demonstrated that every ten unit increase in dyspnea score was statistically significantly associated with 0.81, 0.16, 0.47, and 0.47 unit decline in Ferrans and Powers [32] Quality of Life Index (QLI).
Conclusion
Health professionals could pay more attention to the management of cancer-related fatigue and dyspnea as well as to the enhancement of patients’ mobility through low-impact exercise programs or appropriate assistive devices.
Conflict of Interest
The authors declare that there are no conflicts of interest. The review was self-funding.
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Received 16 November 2015, Accepted 18 December 2015
© 2015, Kossioris A., Karousi T.
© 2015, Russian Open Medical Journal
Correspondence to Aristomenis Kossioris. Address: 43 Avgis Street, 14121, Iraklio Attikis, Athens, Greece. Phone: +302102820895. Fax: +30210283332. E-mail: akossioris@gmail.com
