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Synopsis: Although objective responses are low, active palliation with chemotherapy is associated with substantive improvement in patients’ emotional function and global QL, with overall costs that seem relatively modest.
Source: Doyle C, et al. J Clin Oncol. 2001;19:1266-1274.
Doyle and associates evaluated patient expectations, palliative outcomes of chemotherapy, and the inherent resource use in patients undergoing second- or third-line chemotherapy for recurrent or refractory advanced ovarian cancer. They used the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30 (EORTC QLQ C30) and Functional Assessment of Cancer Therapy-Ovarian (FACT-O) questionnaires to assess palliative benefit and an in-house questionnaire to gauge patient expectations. The minimal clinically important difference (MCID) was calculated by asking women to make a global rating of change and correlating this to the EORTC QLQ C30. Twenty-seven patients were accrued. Objective response was documented on 7 of 27. The median survival was 11 months. Sixty-five percent of women expected that chemotherapy would make them live longer and 42% believed that it would cure them. After 2 cycles, quality of life (QL) improvement was seen particularly in global function (11 of 21), and emotional function was sustained for a median of 2 and 3 months, respectively, in these categories. The MCID was calculated to be 0.39 on a 7-point scale for physical function and 0.13 for global function. The mean total cost per patient for the study period was Can $12,500. Doyle et al concluded that patient expectations from these treatments are often unrealistic. Although objective responses are low, active palliation with chemotherapy is associated with substantive improvement in patients’ emotional function and global QL, with overall costs that seem modest.
Comment by David M. Gershenson, MD
When patients with epithelial ovarian cancer develop a recurrence, we know that the primary objective is palliation since only a tiny fraction is cured. The average survival after diagnosis of recurrence is in the range of 1 year. At each point in their course of relapse, patients and their physicians must weigh the benefits of treatment against the risks and toxicities. There is an increasing body of literature on the quality of life of patients with ovarian cancer, both during primary treatment and during treatment of relapsed disease. Although this study contains a small number of patients, the observations are consistent with my perceptions of treating this disease for the past 2 decades. It is of utmost importance for physicians to be completely honest in counseling patients and their families about treatment, side effects, probability of response, and prognosis. However, one must balance truth with hope. How much information does the patient want? Certainly, not all patients request or desire details and statistics about prognosis. Interestingly, the majority had hope of prolonged survival, but a high proportion of patients had unrealistic expectations about cure. A significant proportion of patients derived palliation from chemotherapy. As Doyle et al point out, however, we usually think of "palliation" as relief of physical symptoms; they include improvement in emotional well being as palliation, and I definitely agree with their assessment. Studies such as this will continue to improve the knowledge base of caregivers of ovarian cancer patients and will translate into an enhanced doctor-patient relationship for those who listen.