Prospective evaluation of quality of life effects in patients undergoing palliative radiotherapy for brain metastases

Diana Steinmann, Yvonne Paelecke-Habermann, Hans Geinitz, Raimund Aschoff, Anja Bayerl, Tobias Bölling, Elisabeth Bosch, Frank Bruns, Ute Eichenseder-Seiss, Johanna Gerstein, Nadine Gharbi, Juliane Hagg, Matthias Hipp, Irmgard Kleff, Axel Müller, Christof Schäfer, Ursula Schleicher, Susanne Sehlen, Marilena Theodorou, Hans-Joachim Wypior, Franz Zehentmayr, Birgitt van Oorschot, Dirk Vordermark, Diana Steinmann, Yvonne Paelecke-Habermann, Hans Geinitz, Raimund Aschoff, Anja Bayerl, Tobias Bölling, Elisabeth Bosch, Frank Bruns, Ute Eichenseder-Seiss, Johanna Gerstein, Nadine Gharbi, Juliane Hagg, Matthias Hipp, Irmgard Kleff, Axel Müller, Christof Schäfer, Ursula Schleicher, Susanne Sehlen, Marilena Theodorou, Hans-Joachim Wypior, Franz Zehentmayr, Birgitt van Oorschot, Dirk Vordermark

Abstract

Background: Recently published results of quality of life (QoL) studies indicated different outcomes of palliative radiotherapy for brain metastases. This prospective multi-center QoL study of patients with brain metastases was designed to investigate which QoL domains improve or worsen after palliative radiotherapy and which might provide prognostic information.

Methods: From 01/2007-01/2009, n=151 patients with previously untreated brain metastases were recruited at 14 centers in Germany and Austria. Most patients (82 %) received whole-brain radiotherapy. QoL was measured with the EORTC-QLQ-C15-PAL and brain module BN20 before the start of radiotherapy and after 3 months.

Results: At 3 months, 88/142 (62 %) survived. Nine patients were not able to be followed up. 62 patients (70.5 % of 3-month survivors) completed the second set of questionnaires. Three months after the start of radiotherapy QoL deteriorated significantly in the areas of global QoL, physical function, fatigue, nausea, pain, appetite loss, hair loss, drowsiness, motor dysfunction, communication deficit and weakness of legs. Although the use of corticosteroid at 3 months could be reduced compared to pre-treatment (63 % vs. 37 %), the score for headaches remained stable. Initial QoL at the start of treatment was better in those alive than in those deceased at 3 months, significantly for physical function, motor dysfunction and the symptom scales fatigue, pain, appetite loss and weakness of legs. In a multivariate model, lower Karnofsky performance score, higher age and higher pain ratings before radiotherapy were prognostic of 3-month survival.

Conclusions: Moderate deterioration in several QoL domains was predominantly observed three months after start of palliative radiotherapy for brain metastases. Future studies will need to address the individual subjective benefit or burden from such treatment. Baseline QoL scores before palliative radiotherapy for brain metastases may contain prognostic information.

Figures

Figure 1
Figure 1
Self-assessed QoL in preselected QLQ scales before and 3 months after start of RT. a) EORTC QLQ C15-PAL: global QoL, physical function (higher score better), and fatigue (higher score worse). b) EORTC BN20: motor dysfunction, headaches and hairloss (all higher score worse) (*p < .05, ** p < .01, ***p < .001; paired-t-test, one-tailed).
Figure 2
Figure 2
Differences in pre-treatment QoL between 3-month surviviors vs. non-survivors. a )EORTC QLQ-C15-PAL: physical function (higher score better), fatigue and pain (both: higher score worse). b) EORTC BN20: motor dysfunction, headaches and hairloss (higher score worse) (*p < .05, ** p < .01, ***p < .001; paired-t-test, one-tailed).

References

    1. Steinmann D, Schäfer C, van Oorschot B, Wypior HJ, Bruns F, Bölling T, Sehlen S, Hagg J, Bayerl A, Geinitz H, Hipp M, Vordermark D. Effects of radiotherapy for brain metastases on quality of life (QoL). Prospective pilot study of the DEGRO QoL working party. Strahlenther Onkol. 2009;185:190–197. doi: 10.1007/s00066-009-1904-0.
    1. Wong J, Hird A, Kirou-Mauro A, Napolskikh J, Chow E. Quality of life in brain metastases radiation trials: a literature review. Curr Oncol. 2008;15(5):25–45.
    1. Wong J, Hird A, Zhang L, Tsao M, Sinclair E, Barnes E, Danjoux C, Chow E. Symptoms and quality of life in cancer patients with brain metastases following palliative radiotherapy. Int J Radiat Oncol Biol Phys. 2009;75(4):1125–1131. doi: 10.1016/j.ijrobp.2008.12.013.
    1. Caissie A, Nguyen J, Chen E, Zhang L, Sahgal A, Clemons M, Kerba M, Arnalot PF, Danjoux C, Tsao M, Barnes E, Holden L, Danielson B, Chow E. Quality of Life in Patients with Brain Metastases Using the EORTC QLQ-BN20+2 and QLQ-C15-PAL. Int J Radiat Oncol Biol Phy. 2011. Dec 13. [Epub ahead of print]
    1. Chow E, Davis L, Holden L, Tsao M, Danjoux C. Prospective assessment of patient-rated symptoms following whole brain radiotherapy for brain metastases. J Pain Symptom Manage. 2005;30(1):18–23. doi: 10.1016/j.jpainsymman.2005.02.009.
    1. Barnes EA, Chow E, Tsao MN, Bradley NM, Doyle M, Li K, Lam K, Danjoux C. Physician expectations of treatment outcomes for patients with brain metastases referred for whole brain radiotherapy. Int J Radiat Oncol Biol Phys. 2010;76(1):187–192. doi: 10.1016/j.ijrobp.2009.01.035.
    1. Temel JS, Greer JA, Admane S, Gallagher ER, Jackson VA, Lynch TJ, Lennes IT, Dahlin CM, Pirl WF. Longitudinal perceptions of prognosis and goals of therapy in patients with metastatic non-small-cell lung cancer: results of a randomized study of early palliative care. J Clin Oncol. 2011;29(17):2319–2326. doi: 10.1200/JCO.2010.32.4459.
    1. Gaspar L, Scott C, Rotman M, Asbell S, Phillips T, Wasserman T, McKenna WG, Byhardt R. Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy Oncology Group (RTOG) brain metastases trials. Int J Radiat Oncol Biol Phys. 1997;37(4):745–751. doi: 10.1016/S0360-3016(96)00619-0.
    1. Gaspar LE, Scott C, Murray K, Curran W. Validation of the RTOG recursive partitioning analysis (RPA) classification for brain metastases. Int J Radiat Oncol Biol Phys. 2000;47(4):1001–1006. doi: 10.1016/S0360-3016(00)00547-2.
    1. Meyer A, Steinmann D, Malaimare L, Karstens JH, Bremer M. Prediction of prognosis regarding fractionation schedule and survival in patients with whole-brain radiotherapy for metastatic disease. Anticancer Res. 2008;28(6B):3965–3969.
    1. Rades D, Dziggel L, Haatanen T, Veninga T, Lohynska R, Dunst J, Schild SE. Scoring systems to estimate intracerebral control and survival rates of patients irradiated for brain metastases. Int J Radiat Oncol Biol Phys. 2011;80(4):1122–1127. doi: 10.1016/j.ijrobp.2010.03.031.
    1. Sperduto CM, Watanabe Y, Mullan J, Hood T, Dyste G, Watts C, Bender GP, Sperduto P. A validation study of a new prognostic index for patients with brain metastases: the Graded Prognostic Assessment. J Neurosurg. 2008;109(Suppl):87–89.
    1. Mahoney FI. BARTHEL DW: Functional Evaluation: the Barthel Index. Md State Med J. 1965;14:61–65.
    1. Aaronson NK, Ahmedzai S, Bergman B, Bullinger M, Cull A, Duez NJ, Filiberti A, Flechtner H, Fleishman SB, de Haes JC. The European Organization for Research and Treatment of Cancer QLQ-C30: a quality-of-life instrument for use in international clinical trials in oncology. J Natl Cancer Inst. 1993;85(5):365–376. doi: 10.1093/jnci/85.5.365.
    1. Groenvold M, Petersen MA, Aaronson NK, Arraras JI, Blazeby JM, Bottomley A, Fayers PM, de Graeff A, Hammerlid E, Kaasa S, Sprangers MA, Bjorner JB. EORTC Quality of Life Group: The development of the EORTC QLQ-C15-PAL: a shortened questionnaire for cancer patients in palliative care. Eur J Cancer. 2006;42(1):55–64. doi: 10.1016/j.ejca.2005.06.022.
    1. Fayers PM. Interpreting quality of life data: population-based reference data for the EORTC QLQ-C30. Eur J Cancer. 2001;37(11):1331–1334. doi: 10.1016/S0959-8049(01)00127-7.
    1. Slotman BJ, Mauer ME, Bottomley A, Faivre-Finn C, Kramer GW, Rankin EM, Snee M, Hatton M, Postmus PE, Collette L, Senan S. Prophylactic cranial irradiation in extensive disease small-cell lung cancer: short-term health-related quality of life and patient reported symptoms: results of an international Phase III randomized controlled trial by the EORTC Radiation Oncology and Lung Cancer Groups. J Clin Oncol. 2009;27(1):78–84.
    1. Osoba D, Rodrigues G, Myles J, Zee B, Pater J. Interpreting the significance of changes in health-related quality-of-life scores. J Clin Oncol. 1998;16(1):139–144.
    1. Addeo R, Caraglia M, Faiola V, Capasso E, Vincenzi B, Montella L, Guarrasi R, Caserta L, Del Prete S. Concomitant treatment of brain metastasis with whole brain radiotherapy [WBRT] and temozolomide [TMZ] is active and improves quality of life. BMC Cancer. 2007;7:18. doi: 10.1186/1471-2407-7-18.
    1. Bezjak A, Adam J, Barton R, Panzarella T, Laperriere N, Wong CS, Mason W, Buckley C, Levin W, McLean M, Wu JS, Sia M, Kirkbride P. Symptom response after palliative radiotherapy for patients with brain metastases. Eur J Cancer. 2002;38(4):487–496. doi: 10.1016/S0959-8049(01)00150-2.
    1. Sehlen S, Lenk M, Hollenhorst H, Schymura B, Aydemir U, Herschbach P, Duhmke E. Quality of life (QoL) as predictive mediator variable for survival in patients with intracerebral neoplasma during radiotherapy. Onkologie. 2003;26(1):38–43. doi: 10.1159/000069862.
    1. Taphoorn MJ, Claassens L, Aaronson NK, Coens C, Mauer M, Osoba D, Stupp R, Mirimanoff RO, van den Bent MJ, Bottomley A. EORTC Quality of Life Group, and Brain Cancer, NCIC and Radiotherapy Groups: An international validation study of the EORTC brain cancer module (EORTC QLQ-BN20) for assessing health-related quality of life and symptoms in brain cancer patients. Eur J Cancer. 2010;46(6):1033–1040. doi: 10.1016/j.ejca.2010.01.012.
    1. Roos DE, Wirth A, Burmeister BH, Spry NA, Drummond KJ, Beresford JA, McClure BE. Whole brain irradiation following surgery or radiosurgery for solitary brain metastases: mature results of a prematurely closed randomized Trans-Tasman Radiation Oncology Group trial (TROG 98.05) Radiother Oncol. 2006;80(3):318–322. doi: 10.1016/j.radonc.2006.08.004.
    1. Gerrard GE, Prestwich RJ, Edwards A, Russon LJ, Richards F, Johnston CF, Kwok-Williams MC. Investigating the palliative efficacy of whole-brain radiotherapy for patients with multiple-brain metastases and poor prognostic features. Clin Oncol (R Coll Radiol) 2003;15(7):422–428. doi: 10.1016/S0936-6555(03)00148-1.
    1. Sperduto PW, Berkey B, Gaspar LE, Mehta M, Curran W. A new prognostic index and comparison to three other indices for patients with brain metastases: an analysis of 1,960 patients in the RTOG database. Int J Radiat Oncol Biol Phys. 2008;70(2):510–514. doi: 10.1016/j.ijrobp.2007.06.074.
    1. Sperduto PW, Chao ST, Sneed PK, Luo X, Suh J, Roberge D, Bhatt A, Jensen AW, Brown PD, Shih H, Kirkpatrick J, Schwer A, Gaspar LE, Fiveash JB, Chiang V, Knisely J, Sperduto CM, Mehta M. Diagnosis-specific prognostic factors, indexes, and treatment outcomes for patients with newly diagnosed brain metastases: a multi-institutional analysis of 4,259 patients. Int J Radiat Oncol Biol Phys. 2010;77(3):655–661. doi: 10.1016/j.ijrobp.2009.08.025.
    1. Koyfman SA, Tendulkar RD, Chao ST, Vogelbaum MA, Barnett GH, Angelov L, Weil RJ, Neyman G, Reddy CA, Suh JH. Stereotactic radiosurgery for single brainstem metastases: the cleveland clinic experience. Int J Radiat Oncol Biol Phys. 2010;78(2):409–414. doi: 10.1016/j.ijrobp.2009.07.1750.
    1. Feyer P, Sautter-Bihl ML, Budach W, Dunst J, Haase W, Harms W, Sedlmayer F, Souchon R, Wenz F, Sauer R. Breast Cancer Expert Panel of the German Society of Radiation Oncology (DEGRO): DEGRO Practical Guidelines for palliative radiotherapy of breast cancer patients: brain metastases and leptomeningeal carcinomatosis. Strahlenther Onkol. 2010;186(2):63–69. doi: 10.1007/s00066-010-2100-y.
    1. Tang V, Rathbone M, Park Dorsay J, Jiang S, Harvey D. Rehabilitation in primary and metastatic brain tumours: impact of functional outcomes on survival. J Neurol. 2008;255(6):820–827. doi: 10.1007/s00415-008-0695-z.
    1. Lagerwaard FJ, Levendag PC, Nowak PJ, Eijkenboom WM, Hanssens PE, Schmitz PI. Identification of prognostic factors in patients with brain metastases: a review of 1292 patients. Int J Radiat Oncol Biol Phys. 1999;43(4):795–803. doi: 10.1016/S0360-3016(98)00442-8.
    1. Eichler AF, Kuter I, Ryan P, Schapira L, Younger J, Henson JW. Survival in patients with brain metastases from breast cancer: the importance of HER-2 status. Cancer. 2008;112(11):2359–2367. doi: 10.1002/cncr.23468.
    1. Li J, Bentzen SM, Renschler M, Mehta MP. Regression after whole-brain radiation therapy for brain metastases correlates with survival and improved neurocognitive function. J Clin Oncol. 2007;25(10):1260–1266. doi: 10.1200/JCO.2006.09.2536.
    1. Movsas B, Moughan J, Sarna L, Langer C, Werner-Wasik M, Nicolaou N, Komaki R, Machtay M, Wasserman T, Bruner DW. Quality of life supersedes the classic prognosticators for long-term survival in locally advanced non-small-cell lung cancer: an analysis of RTOG 9801. J Clin Oncol. 2009;27(34):5816–5822. doi: 10.1200/JCO.2009.23.7420.
    1. Montazeri A, Milroy R, Hole D, McEwen J, Gillis CR. Quality of life in lung cancer patients: as an important prognostic factor. Lung Cancer. 2001;31(2–3):233–240.
    1. Montazeri A. Quality of life data as prognostic indicators of survival in cancer patients: an overview of the literature from 1982 to 2008. Health Qual Life Outcomes. 2009;7:102. doi: 10.1186/1477-7525-7-102.
    1. Gotay CC, Kawamoto CT, Bottomley A, Efficace F. The prognostic significance of patient-reported outcomes in cancer clinical trials. J Clin Oncol. 2008;26(8):1355–1363. doi: 10.1200/JCO.2007.13.3439.
    1. Brown PD, Ballman KV, Rummans TA, Maurer MJ, Sloan JA, Boeve BF, Gupta L, Tang-Wai DF, Arusell RM, Clark MM, Buckner JC. Prospective study of quality of life in adults with newly diagnosed high-grade gliomas. J Neurooncol. 2006;76(3):283–291. doi: 10.1007/s11060-005-7020-9.
    1. Sundaresan P, Yeghiaian-Alvandi R, Gebski V. Prognostic index to identify patients who may not benefit from whole brain radiotherapy for multiple brain metastases from lung cancer. J Med Imaging Radiat Oncol. 2010;54(1):69–75. doi: 10.1111/j.1754-9485.2010.02140.x.

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