|Ahead of print publication
Functional Status, Supportive Care Needs, and Health-Related Quality of Life in Advanced Lung Cancer Patients Aged 50 and Older
Zhe-Peng Huang1, Hui-Lin Cheng2, Soon Yue Loh1, Karis Kin Fong Cheng3
1 National Cancer Centre, The Hong Kong Polytechnic University, Hong Kong, China
2 School of Nursing, The Hong Kong Polytechnic University, Hong Kong, China
3 Alice Lee Centre for Nursing Studies, National University of Singapore, Singapore
|Date of Submission||13-Jun-2019|
|Date of Acceptance||06-Aug-2019|
|Date of Web Publication||10-Jan-2020|
School of Nursing, The Hong Kong Polytechnic University, Hong Kong
Source of Support: None, Conflict of Interest: None
Objective: This study aimed to examine the levels of functional status, supportive care needs, and health-related quality of life (HRQOL), and their relationships reported by advanced lung cancer patients aged 50 and older. Methods: A cross-sectional descriptive correlational study was conducted with 103 participants recruited from a cancer center in Singapore. Functional status, supportive care needs, and HRQOL were measured using validated instruments. Descriptive statistics were used to describe the sample profiles. Univariate and multivariate regression analyses were adopted to determine factors that were associated with HRQOL. Results: About 70.9% of participants were dependent in at least one instrumental activities of daily living (IADL). The mean number of unmet needs rated by participants was 9 (range = 0–28). The top three ranked items with moderate-to-severe unmet needs were “not being able to do things you used to do” (28.2%), “fear about cancer spreading” (25.3%), and “lack of energy/tiredness” (25.2%). Higher IADL scores were significantly associated with better HRQOL, whereas higher levels of supportive care needs, particularly in psychological domain significantly predicted poorer HRQOL in most domains. Conclusions: This study found that poor functional status and unmet supportive care needs are common in advanced lung cancer patients. Psychological needs and functional status are associated with patients' HRQOL. Future interventions incorporating functional assistance and psychological support may increase HRQOL in this population.
Keywords: Functional status, health-related quality of life, instrumental activities of daily living, Lung cancer, supportive care needs
|How to cite this URL:|
Huang ZP, Cheng HL, Loh SY, Cheng KK. Functional Status, Supportive Care Needs, and Health-Related Quality of Life in Advanced Lung Cancer Patients Aged 50 and Older. Asia Pac J Oncol Nurs [Epub ahead of print] [cited 2020 Feb 27]. Available from: http://www.apjon.org/preprintarticle.asp?id=275630
| Introduction|| |
Lung cancer is the most commonly diagnosed cancer globally, with an estimated 2.1 million new cases in 2018. Nearly 95% of lung cancers are found in patients after 50 years old and mostly at advanced stages., These patients generally have limited treatment options and very poor prognosis with a median survival time of 12 months. They are also vulnerable to physical, psycho-social, and functional impairment due to disease and treatment.,, Maximizing health-related quality of life (HRQOL) and thereby becomes, especially important for this population.
HRQOL is a multidimensional concept representing patients' perceived impact of disease and its treatment on functional health. Lung cancer patients generally have lower levels of HRQOL in the physical and emotional domains than those of healthy controls., Nonetheless, HRQOL ratings in different domains may vary according to patients' sociodemographic and clinical characteristics, including age, gender, marital status, ethnicity, staging and duration of disease, surgery, receipt of adjuvant treatment, and comorbidity.,,, As these factors are nonmodifiable, supportive care for lung cancer patients has focused on improving HRQOL through managing physical and psychological symptoms. However, little attention has been directed to the issues of poor functional status and unmet supportive care needs, which may signal new directions for optimizing HRQOL for patients.
Functional status is operationalized as an individual's ability to perform activities of daily living. According to a systematic review (n = 43 studies), 36.7% and 54.6% of cancer patients reported difficulties in performing basic and instrumental activities of daily living (IADL), respectively. Furthermore, these patients are prone to experience decline in functional status over time., However, few studies have examined the association between functional status and HRQOL among lung cancer patients.
The assessment of supportive care needs by health-care providers aims to identify patients' desire for actual services or resources in satisfying physical and daily living, psychological, sexual, patient care as well as health system and information needs. Unmet needs often occur when patients perceive a lack of care or support that is necessary to achieve optimal well-being. Lung cancer patients have greater supportive care needs as compared to those with other cancer types and rate the highest unmet needs in physical and psychological domains., Despite mounting evidence suggests that greater care needs are associated with impaired HRQOL in cancer patients, little is known specifically for lung cancer patients.
For lung cancer patients at advanced stages, the goal of cancer treatments and care is to ensure the benefit of HRQOL. A better understanding of the relationships between functional status, supportive care needs, and HRQOL would assist health care providers in identifying a vulnerable subgroup of patients for timely intervention. Therefore, this study aimed to examine the levels of functional status, supportive care needs and HRQOL, and their relationships reported by advanced lung cancer patients aged 50 and older.
| Methods|| |
This is a cross-sectional descriptive correlation study.
Setting and participants
Between December 2015 and January 2016, eligible participants were recruited using convenience sampling from a national cancer center in Singapore. Inclusion criteria were as follows: (1) aged 50 or above, (2) a diagnosis of lung cancer (Stage III–IV), and (3) being able to speak or read English/Chinese. Participants were excluded if they had psychiatric and cognitive disorders (e.g., schizophrenia and dementia). The sample size was estimated using a power analysis where a medium correlation coefficient is 0.3, power is 0.8, and alpha is 0.05, thus at least 85 participants were required.
Functional status was measured using two scales, including the Eastern Cooperative Oncology Group Performance Scale (ECOG-PS) and the Lawton and Brody's index of IADL. The ECOG-PS is a single-item measure of an individual's ability to perform daily and physical activities. It is rated from 0 (fully active) to 5 (dead). As the most commonly used cutoff for ECOG-PS is 2, a score of ≥2 indicates poor functional status. The scale is reported with good predictive validity and inter-rater reliability., The ECOG-PS score of each patient is rated based on a general impression of his or her activity by oncology nurses and extracted from his/her medical record by the researcher.
The Lawton and Brody's index of IADL was used to assess the level of functional dependence when an individual performs IADLs. It includes eight items, covering the ability to use the telephone, shopping, food preparation, housekeeping, doing household laundry, transportation, taking medications as prescribed, and managing personal finances. Each item is scored as either 0 (dependent) or 1 (independent). Scores of all eight items are summed to yield a total score (range: 0–8), with a higher score indicating better functional status. IADL dependency is defined if a total score is <8. Considerable evidence exists supporting good reliability and validity of the scale and the Chinese version of the scale has a Cronbach's alpha of 0.87.,
Supportive care needs were assessed using the 34-item Supportive Care Needs Survey Short Form (SCNS-SF34). The SCNS-SF34 consists of five domains: psychological (10 items), health system and information (11 items), physical and daily living (5 items), patient care and support (5 items), and sexuality (3 items). Each item is rated on a 5-point scale (1 = not applicable, 2 = satisfied, 3 = low need, 4 = moderate need, 5 = high need), with a score of ≥3 indicating the presence of an unmet needs and a score of ≥4 representing a unmet needs at moderate-to-severe level Domain scores are calculated by adding up scores of related items and transformed into a 0–100 scale based on the instrument guide. Psychometric properties of the English and Chinese versions of the SCNS-SF34 are well-documented; with Cronbach's alphas ranging between 0.88–0.96 and 0.75–0.92, respectively.,
HRQOL was evaluated using the European Organization for Research and Treatment of Cancer Quality of Life Core 30 Questionnaire (EORTC QLQ-C30) in conjunction with its lung cancer module (EORTC QLQ-L13)., The EORTC QLQ-C30 is a 30-item cancer-specific HRQOL scale and incorporates five functional domains (physical, role, emotional, cognitive, and social), three symptom scales (fatigue, nausea/vomiting, and pain), six single items (dyspnea, insomnia, appetite loss, constipation, diarrhea, and financial difficulty), and a global health scale. The EORTC QLQ-L13 is a 13-item scale measuring dyspnea and other symptoms resulting from lung cancer and its treatment. According to the scale scoring guideline, each functional domain or symptom scale/item is transformed on a 0–100 scale. Higher scores represent either better HRQOL on functional scales/global health scale, or worse symptoms on symptom scales/items. The English versions of the EORTC QLQ-C30 and the EORTC QLQ-LC13 demonstrated good reliability and validity., The Chinese versions of the two scales are reported with good internal consistency reliability (Cronbach's alpha >0.7) as well as established convergent validity and contrasted-group validity.
Sociodemographic and clinical data were obtained from patient self-reports or medical records. Sociodemographic characteristic included age, gender, marital status, ethnicity, education level, employment status, and religion. Clinical data were cancer stage, time since diagnosis, surgery, systematic treatment, number of comorbidities, and type of caregivers.
Data collection procedure
Participants were identified through nurse managers in various departments of the cancer center, including an outpatient clinic, ambulatory treatment unit, and radiotherapy clinic. After screening the eligibility of patients who attended oncologist consultations, nurse managers referred eligible participants to the researcher with participants' consent for study briefing. Once participants agreed to join, they were asked to sign on the consent forms. Questionnaires were subsequently administered either by the participants or using face-to-face interviews by the researcher.
Data were entered and analyzed using the SPSS 24.0 software (IBM Corp., Armonk, NY, USA). Descriptive statistics were used to describe the sociodemographic and clinical characteristics and main study variables of the sample. To investigate factors that were associated with HRQOL, univariate and multivariate analyses were adopted. Univariate analyses were performed to investigate the associations between HRQOL (including global health and five functional domains only) with selected sociodemographic and clinical characteristics (based on prior literature),,,,, functional status and supportive care needs. Student's t-tests or Pearson's correlation tests were used when appropriate. Those variables with P < 0.25 in univariate analyses were considered as candidate variables for stepwise multivariate regression analyses. The variance inflation factors of the independent variables are <2, thus no multicollinearity among study variables was detected. All statistical tests were two-sided, and P < 0.05 was considered statistically significant.
The Institutional Ethical Committee of the hospital approved the study. All participants signed the informed consent forms before commencement of the study. They were informed of the voluntary participation and the right to withdraw from the study anytime, as well as the right of keeping personal information data confidential.
| Results|| |
A total of 103 participants consented to join the study and the mean age was 65.1 (SD = 7.5, range = 50–83). Majority of them was married (85.4%), diagnosed with Stage IV (87.4%) and had not received surgery (85.2%). The sociodemographic and clinical profiles of the participants are depicted in [Table 1].
About 43.7% (n = 45) of participants had an ECOG-PS score of ≥2 and 70.9% (n = 73) was dependent in at least one IADL. The most frequently affected IADLs were shopping (n = 56, 54.4%) followed by food preparation (n = 55, 53.4%).
Supportive care needs
Participants rated the highest mean ratings of supportive care needs in the physical and daily living domain (38.0 ± 20.9) and psychological domain (34.6 ± 20.7), whereas the sexuality domain (5.3 ± 9.7) had the lowest level of needs.
The mean number of unmet needs rated by participants was 9 (range = 0–28). Almost all of participants reported at least one unmet needs; 36%, 19%, 20%, 17%, and 5% reported 1–5, 6–10, 11–15, 16–20, and >20 unmet needs, respectively. All SCNS-SF34 needs items sorted by domains are presented in [Table 2]. The top three ranked items with moderate-to-severe unmet needs were “not being able to do things you used to do” (28.2%), “fear about the cancer spreading” (25.3%), and “lack of energy/tiredness” (25.2%). which were from either physical and daily living domain or psychological domain.
|Table 2: Prevalence of unmet needs as measured by 34-item supportive care needs survey short form (n=103) [n (%)]|
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Health-related quality of life
As shown in [Table 3], the mean global health score was 57.2 (standard deviation [SD] = 21.4). Among five functional domains of EORTC QLQ-C30, cognitive functioning had the highest mean score of 86.4 (SD = 20.3), and while role functioning had the lowest mean score of 63.6 (SD = 24.7). For the symptom scales, the top highest mean score items were insomnia (34.6 ± 28.7), financial difficulty (34.0 ± 28.0), and fatigue (32.8 ± 23.6). In the EORTC QLQ-L13 scale, the highest mean scores were noted for the items coughing (43.0 ± 25.0) and dyspnea (25.6 ± 19.6).
Predictors of health-related quality of life
Univariate and multivariate analysis results are shown in [Table 4]. Variables showing P < 0.25 in univariate analyses, including marital status (being married), ethnicity (Chinese), cancer stage (Stage IV), receipt of surgery (yes), number of comorbidities, ECOG-PS score (≥2), IADL scores, and supportive care needs (excluding sexual domain) were tested as candidate predictors of HRQOL in multivariate analysis.
|Table 4: Associations between health.related quality of life, functional status, and unmet supportive care needs (n=103)|
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Multivariate analyses revealed that global health was significantly predicted by cancer stage only. Regarding physical functioning, IADL score (β = 3.84, P < 0.001) was significantly associated with better physical functioning, whereas higher levels of physical (β = –0.21, P < 0.05) and psychological needs (β = –0.23, P < 0.05) predicted poorer physical functioning. Role functioning was found to be significantly and positively associated with IADL score (β = 4.55, P < 0.01) and being married (β = 13.36, P < 0.01), but was negatively related to greater physical needs (β = –0.35, P < 0.01). For emotional functioning, participants with receipt of surgery (β = –10.38, P < 0.05), comorbidities (β = –4.93, P < 0.05), and psychological needs (β = –0.71, P < 0.001) tended to report poorer emotional functioning. Concerning cognitive and social functioning, IADL score and psychological needs were found as significant factors (P < 0.05–0.001). In addition, health system and information needs were significantly and negatively associated with cognitive functioning (β = –0.29, P < 0.001).
| Discussion|| |
This is one of the few studies to investigate the relationships between functional status, supportive care needs, and HRQOL among patients with advanced lung cancer. The study showed that 43.7% of the patients had an ECOG-PS score s2 and 70.9% was dependent in at least one IADL. This is partly in line with a study showing that 69.9% of lung cancer patients was IADL-dependent and 30.2% had poor functional status as measured by ECOG-PS scale. When compared with those (33.8% for ECOG-PS and 62.9% for IADL, respectively) reported in another study of advanced lung cancer patients, the results of this study are higher. Inconsistent findings across studies might be due to different patient profiles as our patients are younger (65.1 vs. 77 vs. 76 years old) and exclusively diagnosed at an advanced stage (100% vs. 77.2% vs. 86.6%). We also found that the most frequently affected IADLs were shopping and food preparation; both of which are household tasks requiring the physical and cognitive function to perform, suggesting the patients' needs for assisted services in household management to maintain an independent living in the community.
Almost all of the patients in this study had at least one unmet needs and the mean number of unmet needs was 9. This is higher than a study of lung cancer patients reporting that 78% of them had at least one unmet needs; although, the average number of unmet needs is similar across two studies (9 vs. 8). Furthermore, participants reported the greatest unmet needs in the physical and daily living domain and psychological domain. This is a consistent finding in the literature, highlighting a priority for support in these two domains when a diagnosis of lung cancer is made.,,
Consistent with the literature, the role functioning had the lowest mean score among the five domains of HRQOL.,, The mean scores of HRQOL were comparable or better when compared with the reference values by the EORTC organization or published data on the same population, with one exception (social functioning).,, Poor social functioning of patients identified from this study is not surprising as this reflects patients' limitations in doing social and work-related activities associated with advanced disease and complex treatments.
This study showed the higher scores for symptoms, including fatigue, insomnia, cough, and dyspnea, all of which are common symptoms experienced by lung cancer patients., Noteworthy, the mean score of the item financial difficulties was much higher than published data in Western countries., Although similar findings have been previously reported in China and India,, where social welfare systems are not well-established, this is not expected in a developed country alike to Singapore. A previous study in Singapore reported that old cancer patients, particularly those on target therapies or complementary and alternative medicine reported medical costs higher than expected. As data on financial impact of cancer in Singapore are limited, more study is needed.
In line with the literature, cancer stage was found as a significant factor of global health., We found that IADL score significantly predicted HRQOL in four of five domains except for emotional functioning, but ECOG-PS was not a significant factor of HRQOL in any domain. Evidence suggests that deficits in IADLs can occur earlier in the trajectory of the disease, whereas disability in daily and physical activities of living is often present until the disease is progressed. Thus, decline in IADLs may be early signs of functional impairment, consequently deteriorating HRQOL.
Among the five needs domains, only physical and daily living, psychological, and health system and information needs were significantly associated with poorer HRQOL in at least one domain. These results lend further support to the accumulating evidence that addressing supportive care needs could maximize the HRQOL of lung cancer patients. Noteworthy, patients with greater psychological needs had poorer HRQOL in most domains. Thus, when planning for palliative or supportive care for this population, psychological needs should be prioritized.
This study has a few limitations. First, the generalizability of the study findings might be limited as the study was conducted on a conveniently selected small sample from a cancer center in Singapore. Second, the study was a cross-sectional survey with data collected at one time point, thus a dynamic understanding of inter-relationships among variables is impossible. Finally, although the Lawton and Brody's IADL index is the most widely used scale for measuring functional status in cancer patients, this might be subjected to bias due to its potential gender differences in IADLs. For example, laundry and food preparation are considered as female tasks, particularly in Asian culture.
Implications for nursing practice
To improve HRQOL of advanced lung cancer patients, supportive care needs are recommended to be integrated as part of routine assessments by health care providers for the early identification of a subgroup of patients for timely intervention. Ongoing assessment of psychological needs is particularly considered as an effective strategy to ensure the adequate care that is delivered to advanced lung cancer patients. Furthermore, health-care providers should be aware of the importance of poor functional status in reducing HRQOL of patients, Great efforts should be directed to meet the patients' needs for services or help in household management. Future interventions incorporating functional assistance and psychological support may increase HRQOL in this population. There is a need for research on the type and level of assisted services or rehabilitation programs that can improve functional status for lung cancer patients.
| Conclusion|| |
This study found that poor functional status and supportive care needs, particularly in physical and psychological domains are common in advanced lung cancer patients. Higher level of psychological needs and functional status are associated with HRQOL in most domains. These findings should be useful for health-care providers in developing appropriate supportive or palliative care interventions for patients with advanced lung cancer.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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| Authors|| |
[Table 1], [Table 2], [Table 3], [Table 4]