Review Article
Systematic review recommends the European Organization for Research and Treatment of Cancer colorectal cancer–specific module for measuring quality of life in colorectal cancer patients

https://doi.org/10.1016/j.jclinepi.2014.09.021Get rights and content

Abstract

Objectives

To critically appraise the measurement properties of standardized health-related quality of life (HRQOL) instruments for colorectal cancer (CRC) patients and to provide recommendations on the choice of HRQOL instruments.

Study Design and Setting

Systematic review of English language literature published between January 1985 and May 2014 identified through a database search of PubMed, Web of Science, Embase, and Ovid MEDLINE. HRQOL instruments were rated on methodological quality and overall levels of evidence using a Consensus-based Standards for the selection of health Measurement Instrument checklist.

Results

Internal consistency and hypothesis testing were evaluated most frequently in 63 studies identified. The Functional Assessment of Cancer Therapy-Colorectal (FACT-C) was the most extensively evaluated. The highest number of positive ratings in the overall level of evidence was found in the CRC-specific quality of life questionnaire module (QLQ-CR38) in European Organization for Research and Treatment of Cancer (EORTC) module, followed by the Memorial Sloan Kettering Cancer Center Bowel instrument, FACT-C, and Quick-FLIC. The EORTC QLQ-CR38 had the most positive ratings on measurement property and was recommended.

Conclusion

The EORTC QLQ-CR38 was recommended to assess HRQOL in patients with CRC, regardless of disease stage and primary tumor site.

Introduction

What is new?

Key findings

  1. The EORTC QLQ-CR38 had the greatest number of positive ratings and the most positive ratings on measurement property according to quality assessment criteria.

  2. The EORTC QLQ-CR38 was recommended to measure health-related quality of life (HRQOL) in patients with CRC, regardless of disease stage and location of primary tumor site.

What this adds to what was known?
  1. There is a shortage of a perfect methodological quality for measurement property of HRQOL instrument used in CRC patients, despite the large amount of instruments available.

What is the implication and what should change now?
  1. There is a need for an improvement in the reporting quality of measurement properties in newly developed or translated instruments. Efforts on the universal consensus on whether the measurement properties met the acceptable quality criteria, especially construct validity and responsiveness, should be commenced.

Colorectal cancer (CRC) is one of the major cancer deaths worldwide [1], being the third leading cause of cancer death in the United States [2], [3]. Previous studies suggested that there is a growing trend of CRC incidence rates in some economically developing countries, which involves a rapid transition in dietary style and exercise patterns [2], [3]. Emerging medical treatment of CRC has contributed to the extension on prolonged survivals. In addition to disease survivals, health-related quality of life (HRQOL) is becoming a standard outcome measurement of the impact of illness and treatment for CRC in clinical care and research. Among cancer survivors living with disease, certain aspects of HRQOL (ie, physical, psychological, social and so forth) were challenged by the impairment in the ability to perform daily activities and the presentation of symptoms arising from disease and treatment [4]. The appropriate usage and adoption of instruments to evaluate HRQOL were considered important for the better assessment of rehabilitation needs and treatment benefits from the standpoint of patients, clinicians, and health policy makers [5].

Classical literature of HRQOL has classified instruments [6], [7] into two major types: generic and condition-specific (or disease-specific) instruments. Generic instruments are designed for assessing HRQOL in a wide range of clinical settings and used in various areas of health conditions in a population. They allowed for cross-cultural and international comparisons of HRQOL from one population to another. Condition-specific instruments measure more aspects unique to the HRQOL in patients with specific condition and have generally been reported to be more responsive than generic instruments [8]. Measurement properties are important to support the evidence-based selection of the best instrument for a particular purpose or population, and quality assurance criteria [9] have been recommended by Scientific Advisory Committee of the Medical Outcomes Trust [10]. Comprehensive quality assessment of measurement properties for available HRQOL instruments is presented based on a wide range of cancer populations [11], [12], [13], but there is little evidence concerning HRQOL instruments in CRC [14]. In spite of multiple instruments had developed for the measurement of HRQOL in patients with CRC, clinicians and researchers urged for the most recommended and appropriate HRQOL instruments under a comprehensive process of psychometric quality assessment. A recent literature review [15] across a wide range of HRQOL instruments administered in CRC patients, sourcing from Ovid searching engine and several key journals, recommended SF-12 for generic measure, EQ-5D for preference-based measure, and European Organization for Research and Treatment of Cancer Core Quality-of-Life Questionnaire (QLQ-C30) and Functional Assessment of Cancer Therapy-Colorectal (FACT-C) for condition-specific measures. The aforementioned review was, however, limited by the inclusion of studies with English-speaking populations only. Articles concerning the target population of other language speakers were still relevant. Yet, no systematic review synthesized evidence on the critical appraisal of the measurement properties of generic and condition-specific HRQOL instruments that have been validated for use in patients with CRC. The aim of this article was to conduct a systematic literature review on the measurement properties of standardized HRQOL instruments for CRC, providing recommendations on the HRQOL instrument through collective evidence from previous studies.

Section snippets

Search engines and strategies

A series of systematic literature search was conducted in databases of PubMed, Web of Science using Web of Knowledge platform, Embase, and MEDLINE using Ovid searching platform to identify studies that investigated the HRQOL of colorectal neoplasm patients. The Medical Subject Heading “quality of life” was combined with “colon neoplasm,” “colon cancer,” “rectal cancer,” “rectal neoplasm,” and “colorectal cancer.” Studies were limited to English language, and the years were between January 1985

Results

Fig. 1 lists the process of literature identification, screening for eligibility, and selection of studies during the literature search presented in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram [20]. The literature search was completed in June 2014 and identified a total of 7,553 potentially relevant studies (PubMed: 1,349; Web of Science: 2,318; MEDLINE: 1,735; and Embase: 2,151) that met the searching criteria in four bibliographic databases. After the

Discussions

This systematic review evaluated the measurement properties of 37 standardized HRQOL instruments used in CRC patients among 63 eligible studies identified in the full-text assessment stage. None of the instruments were adequately evaluated for all nine measurement properties recommended by COSMIN [17]. Compared with other instruments, EORTC QLQ-CR38 and FACT-C were more comprehensively evaluated as each of them obtained eight ratings in all the nine measurement properties. Moreover, the number

Conclusion

This systematic review draws out an attention to the shortage of a perfect methodological quality for measurement property of HRQOL instrument used in CRC patients, despite the large amount of instruments available. There is a need for an improvement in the reporting quality of measurement properties in newly developed or translated instruments. Efforts on the universal consensus on whether the measurement properties met the acceptable quality criteria, especially construct validity and

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    Funding: This work was supported by Health and Health Services Research Fund (project number 08090851) from the Food and Health Bureau of the Hong Kong SAR.

    Conflict of interest: None.

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