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Palliative Medicine The Research Journal of the EAPC
Article Reviews
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Article Reference |
Reviewer
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| 2003 17(8): |
H. Knobel, J.H. Loge, E. Brenne et al.: The validity of EORTC QLQ-C30 fatigue scale in advanced cancer patients and cancer survivors.
Palliative Medicine 2003; 17: 664-672 |
Franco De Conno, Milan, Italy |
| Summary |
In cancer patients with advanced disease fatigue is frequently reported (more than 70%) and rarely relieved. Fatigue has a major negative impact on cancer patients quality of life. Many authors regard fatigue as a multidimensional phenomenon grounded on theoretical and empirical data from cancer patients, non malignant diseases and disease-free cancer survivors.
However, the number and types of dimensions are disputed, which is reflected in the various instruments used to measure fatigue. Most instruments include physical and mental fatigue as separate constructs. The European Organization for Research and Treatment of Cancer Quality of Life Core Questionnaire (EORTC QLQ-C30) is a health-related quality of life (HRQOL) instrument developed for use in clinical trials in cancer patients. Fatigue is included as a subscale with three items.
The aim of this study was to validate the EORTC QLQ-C30 fatigue scale (FA) against the Fatigue Questionnaire (FQ). The FQ is frequently used and was developed to measure fatigue in both cancer and non cancer populations. The FQ measures physical (PF, seven items) and mental fatigue (MF, four items).
The study population included two different cohorts: A) patients with advanced metastatic cancer included in a prospective randomized study of palliative radiotherapy (n=238); B) patients with leukaemia and malignant lymphoma curatively treated with stem-cell transplantation and high-dose chemotherapy (n=128). The analysis demonstrated that the FA correlated higher with the PF scale (r=0.67-0.75) as compared with the MF scale (r=0.49-0.61). The item-scale correlations between FA items and the PF scale were consistently higher than between FA items and the MF scale. A factor analysis including all the items within the FA and the FQ identified two factors. All FA items loaded on a PF factor (0.70-0.85). A floor ceiling effect, indicating a high number of respondents with lowest, respectively, highest scores was observed more frequently in the FA as compared with the FQ. The PF discriminated better between diagnostic groups with different levels of fatigue than the FA did. In conclusion, the EORTC QLQ-C30 fatigue scale is measuring physical fatigue. A floor ceiling effect seems to appear for the EORTC QLQ-C30 fatigue scale. The validity of the EORTC QLQ-C30 fatigue scale is to be questioned for use in palliative care patients. In studies with fatigue as a defined end point, a domain-specific instrument should, therefore, be added.
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| Clinical Aspects |
| Fatigue is the most frequent symptom in advanced cancer patients. It is important to give more attention to all the invalidating symptoms and for this is important to have validated instruments for assessment. This study idetifies fatigue as a significant clinical phenomenon in palliative care and assessment tool is a valid new instrument because permit to have information not only of physical but also of mental fatigue as separate constructs. |
| Methods and study design |
| The validation of assessment instruments is a complex procedure especially in advanced cancer patients. This study is an important example of how to realise this kind of project. The methodology of this article is particularly helpful as it addresses a comparison between advanced cancer patients and patients cured of cancer in assessing a symptom which can be regarded as affecting most people depending on many different factors. Of note the identification of a floor ceiling effect which undermines the sensibility of the EORTC FA scale, in comparison with a specific fatigue assessment tool, speaks against the use of questionnaires designed to assess quality of life to evaluate specific symptoms. |
| Suggestions for further development / Open Questions |
| In palliative care one of the most important problem to resolve is to give attention to all the needs of the patient, not only to physical symptoms. The attention to details is paramount in terminal cancer patients.For this reason we need to develop new methods of assessment. These methods need to be easy and quick in the execution and able to capture all the clinically meaningful aspects of the important symptom. This is one of the future challenge for research in palliative care. |
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