Original Paper
Quality of life assessment in daily clinical oncology practice: a feasibility study

https://doi.org/10.1016/S0959-8049(98)00018-5Get rights and content

Abstract

Quality of life (QL) assessments are increasingly being included in clinical trials, but their use in clinical practice is still uncommon. The objectives of this study were to investigate the feasibility of introducing individual QL assessments into the daily routine of an out-patient oncology clinic, and the potential impact of such assessments on doctor–patient communication. The study sample included six physicians and 18 of their patients from the out-patient clinic of the Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital in Amsterdam, The Netherlands. For each patient, three follow-up consultations were observed. The first visit was employed for the purpose of a baseline measurement. At the two subsequent visits, the patients were asked to complete the EORTC QLQ-C30, a standardised cancer-specific QL questionnaire. The patients’ responses were computer-scored and transformed into a graphic summary. The summary included current scores as well as those elicited at the previous visit. Both the physicians and the patients received a copy of the summary just prior to the medical consultation. Completing, scoring and printing the QL data could be done during waiting room time. The availability of the summary did not lengthen the average consultation time. A small increase was noted in the average number of QL issues discussed per consultation. However, the most notable trend was the increased responsibility taken by the physicians in raising specific QL issues for discussion. When the QL summary was available, the physicians raised three times as many topics than was the case prior to its use (P<0.05). All six physicians and the majority of patients believed that the QL summary facilitated communication, and expressed interest in continued use of the procedure. The introduction of individual QL assessments in routine out-patient oncology practice is feasible and appears to stimulate physicians to inquire into specific aspects of the health and well-being of their patients. However, given the methodological limitations of this pilot study, the results should be interpreted with caution.

Introduction

In recent years, major strides have been made in developing brief, easy to complete, self-report questionnaires that yield valid and reliable information on patients’ health status and quality of life (QL). Typically, such questionnaires address an array of topics, including recently experienced symptoms, current levels of physical, psychological and social functioning, as well as overall perceived health status and QL. The majority of work in this area has focused on QL questionnaires as tools for use in clinical research. More recently, a number of studies have investigated their potential use in daily clinical practice in monitoring disease progression or therapeutic response, screening for physical or psychosocial problems and improving the delivery of care1, 2, 3, 4, 5.

The use of standardised QL information in facilitating communication between physicians and patients can be seen as a first step toward its use in the care process, in that the form, content and quality of such communication may influence decisions about treatment[6]. Especially in the case of cancer, a disease which has a major impact on all aspects of patients’ lives, physicians need to be well-informed about the range of physical, functional and psychosocial problems confronting their patients.

Of course, QL considerations have always played a role in oncology care, albeit often implicitly and informally. The typical question asked by a doctor at the beginning of a medical visit—‘How are you feeling?’—can be viewed as a global inquiry into the patient’s QL. More targeted questions about the patient’s symptoms and level of functioning, as well as the patient’s spontaneous remarks or questions, form an integral component of doctor–patient communication. However, the available literature suggests that physicians vary widely in their ability to elicit relevant information from their patients, and patients vary in their ability to articulate their problems and concerns7, 8, 9, 10, 11, 12. The resulting situation is one in which physicians are often inadequately informed about the nature and extent of their patients’ problems13, 14, 15, 16, 17. Physicians frequently underestimate their patients’ level of physical functioning and the severity of important symptoms, such as pain, yet they also tend to rate their patients as having a more compromised QL than do the patients themselves18, 19. Additionally, physicians often fail to recognise the presence of heightened levels of psychological distress in their patients11, 20, 21, 22.

To structure and facilitate doctor–patient communication and increase physicians’ awareness of their patients’ concerns, it could be helpful to direct concrete attention to particular aspects of patients’ QL. More specifically, the availability of standardised QL information might form a useful basis for identifying issues of concern to patients and thereby provide physicians with potential topics to discuss during medical consultations.

A number of studies have reported positive effects of standardised QL information on physicians’ perceived awareness of their patients’ problems and concerns23, 24, 25, 26. To our knowledge, however, only one study has investigated the impact of such information on physicians’ actual behaviour during medical consultations. Street and colleagues[27]found that the standard provision of QL information had little effect on the communication between obstetricians and their (pregnant) patients. However, the authors suggested that this may have been due to the specific patient and physician sample under study. The patients were healthy, pregnant women, 50% of whom expressed little or no desire for their doctor to inquire specifically about psychosocial issues. The physicians were residents in obstetrics and gynaecology with relatively little experience in routine prenatal care.

In the pilot study reported here, the focus is on patients with more serious medical conditions, and on medical specialists with extensive clinical experience. The primary objectives of the study were: (1) to determine the feasibility, in a practical sense, of administering a brief, self-report QL questionnaire to patients in the course of routine daily practice in an out-patient oncology clinic; (2) to investigate whether the information generated by such a questionnaire increases physicians’ awareness of the physical and psychosocial problems of their patients, and facilitates doctor–patient communication regarding these problems; and (3) to evaluate patients’ and physicians’ attitudes toward incorporating such standardised QL information into routine out-patient oncology care.

Section snippets

Study sample

The study was carried out at the Antoni van Leeuwenhoek Hospital, a specialised cancer treatment centre located in Amsterdam. The physician sample included six medical specialists; two from each of the three major disciplines involved in the care of patients with cancer: medical oncology, surgery and radiotherapy. 20 out-patients participated in the study; 10 under the care of the medical oncologists, 5 surgical patients and 5 radiotherapy patients. These patients were selected consecutively

Patient sample characteristics

During the study period, 2 of the 20 patients discontinued their participation (one changed to another physician; the other was admitted to the hospital on an in-patient basis). The mean age of the participating patients was 58 years (range 29–85 years). 11 of the 18 patients were female. 10 of the patients had breast cancer, 5 head and neck cancer, and 3 cancer of the lymphatic system. 9 of the patients were receiving chemotherapy or hormonal therapy; 4 patients were undergoing radiotherapy

Discussion

The results of this small study support the feasibility of introducing standardised QL assessments into the daily routine of an out-patient oncology clinic. The QL questionnaire employed in this study could be completed by the large majority of patients quickly and without assistance, and the results were available in a matter of minutes. Administration and scoring of the questionnaire could always be accomplished during the time that the patients were waiting to see their doctor.

One of the

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