1. Assessment of Quality Of Life in patients treated with Chemo and Radiotherapy for Gastric Cancer: A Systematic Review Authors: Turma 14 Supervisors: Mário Dinis Ribeiro Cláudia Camila Dias Professor Doutor Altamiro da Costa Pereira

2. Male Female Cumulative risk, 0-64 years Eucan - Database  Stomach adenocarcinoma is the most common form of gastric cancer 1 (95% of the cases). 1 1- Crew KD, Epidemiology of upper gastrointestinal malignancies. Seminin Oncol 2004; 31: 450–464. Background Gastric Cancer European Distribution QoL after Chemo/Radiotherapy in Gastric Cancer

3. Background 850 000 deaths worlwide each year cause due to gastric cancer World, age-standardized rates (per 100.000 persons.year) Eucan - Database Gastric Cancer Incidence QoL after Chemo/Radiotherapy in Gastric Cancer

4. 850 000 deaths worlwide each year cause due to gastric cancer World, age-standardized rates (per 100.000 persons.year) Eucan - Database Aproximately 1,440,000 cases worlwide per year Background Incidence Gastric Cancer QoL after Chemo/Radiotherapy in Gastric Cancer

5. 2  Treatment for gastric cancer often involves surgery, usually a partial or a total gastrectomy (removal of stomach tissue). 2 2  Chemotherapy and radiotherapy are standard for some stages of stomach cancer. 2 2-Ross P. Prospective randomized trial comparing mitomycin, cisplatin, and protracted venous-infusion fluorouracil (PVI 5-FU) with epirubicin, cisplatin and PVI 5-FU in advanced esophagogastric cancer. Journal of Clinical Oncology, Vol. 20, Issue 8 (April), 2002. Background Treatments QoL after Chemo/Radiotherapy in Gastric Cancer

6. 3  Chemotherapy is the use of chemical agents to stop cancer cells from growing. 3 3  Chemotherapy is considered a systemic treatment. 3 4  Radiotherapy uses high energy x- rays to destroy cancer cells. 4 4  A small dose of radiotherapy may be very helpful to relieve pain. 4 3-Janunger KG. A Systematic Overview of Chemotherapy Effects in Gastric Cancer. Acta Oncologica, Vol. 40, No. 2/3, pp. 309-326, 2001. 4-Kim GE. The role of radiation treatment in management of extrahepatic biliary tract metastasis from gastric carcinoma. Int. J. Radiation Oncology Biol. Phys., Vol. 28, No. 3, pp.711-717, 1994. Background Chemo and Radiotherapy QoL after Chemo/Radiotherapy in Gastric Cancer

7. Schipper et al. proposed: 5 “the functional effect of illness and its consequent therapy upon a patient, as perceived by the patient”. 5 5- Schipper H. Definitions and conceptual issues. In: Spilker B, ed. Quality of Life and pharmacoeconomics. in clinical trials, Philadephia : Lippincott- Raven, 1996: 11-24 6-WHOQoL Group (1993) World Health Organization proposed: “Quality of life is defined as the individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns. It is a broad ranging concept affected in a complex way by a person's physical health, psychological state, level of independence and their relationships to salient features of their environment”. Some definitions Background Quality of Life QoL after Chemo/Radiotherapy in Gastric Cancer

8. Schipper et al. proposed: 5 “the functional effect of illness and its consequent therapy upon a patient, as perceived by the patient”. 5 World Health Organization proposed: “Quality of life is defined as the individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns. It is a broad ranging concept affected in a complex way by a person's physical health, psychological state, level of independence and their relationships to salient features of their environment”. Some definitions Background Quality of Life QoL after Chemo/Radiotherapy in Gastric Cancer 5- Schipper H. Definitions and conceptual issues. In: Spilker B, ed. Quality of Life and pharmacoeconomics. in clinical trials, Philadephia : Lippincott- Raven, 1996: 11-24 6-WHOQoL Group (1993)

9. Aim __________________________________________________________________________ Summarize the QoL of patients with gastric cancer after treatment with chemo and radiotherapy Clarify the validity/validation of instruments used Summarize the QoL of patients with gastric cancer according to the instrument. __________________________________________________________________________ QoL after Chemo/Radiotherapy in Gastric Cancer

10.  The Query used was: ◊ ″Gastric cancer AND (Quality of Life OR Psychology) AND (Radiotherapy OR Chemotherapy)”  Literature searches were conducted in Medline. Article Search: Limits:  Publication Date until September 2005.  Only items with an abstract.  Humans. Methods QoL after Chemo/Radiotherapy in Gastric Cancer

11. Fluxogram Methods QoL after Chemo/Radiotherapy in Gastric Cancer

12. Methods  Validation Papers oA second search was conducted, to discover if the instruments used in the included articles were valid. To find the validation papers we search the questionnaire title through Google and Medline QoL after Chemo/Radiotherapy in Gastric Cancer

13. Results  Inclusion Criteria of the article: -Patients with gastric cancer; -Patients submitted to chemo or radiotherapy; -QoL evaluated by the patients; -QoL measured with an appropriate instrument; -More than one participant.  Type of Study: Systematic review QoL after Chemo/Radiotherapy in Gastric Cancer

14. Results  Exclusion criteria of the article: -Articles based on mixed diagnostic groupings (in the article these have to be approached separately); -Articles in which QoL was measured but only symptoms were studied; -Articles that referred to patients submitted to a surgery during or before treatment. QoL after Chemo/Radiotherapy in Gastric Cancer

15. Results Searches QoL after Chemo/Radiotherapy in Gastric Cancer

16. A summary of the data extracted from the included articles In the following Table Is presented Results Included Articles QoL after Chemo/Radiotherapy in Gastric Cancer

20. Discussion Lack of information due to:  Many articles in japanese  Most of the papers focus on surgery Because Surgery is the only potencially curative treatment 8 in gastric cancer. 8 7 Japan is a country with a high incidence of gastric cancer. 7 Understandable once 7-IARC Scientific Publications. In: Whelan SL, Parkin DM, Masuyer E, eds. Trends in Cancer Incidence and Mortality. Lyon: WHO Publications, 1993;102. 8-Wilke Hj, Van Cutsem E. Current treatments and future perspectives in colorectal and gastric cancer. Ann Oncol, 2003;14: 49-55. Search Limitations Related with QoL after Chemo/Radiotherapy in Gastric Cancer

21. Discussion Chemo and radiotherapy are considered: 8  Adjuvant therapies (before or after surgery) 8 7  Palliative treatments 7 8-Current treatments and future perspectives in colorectal and gastric cancer. Treatment Limitations Related with QoL after Chemo/Radiotherapy in Gastric Cancer

22. Discussion Just a few could be included Some of the causes:  Studies just evaluated differences on survival time according to treatment  Only the physical parameters were considered Limitations Related with Papers QoL after Chemo/Radiotherapy in Gastric Cancer

23. Discussion Just a few could be included Some of the causes:  Studies just evaluated differences on survival time according to treatment  Only the physical parameters were considered QoL is still a minor concern! Limitations Related with Papers QoL after Chemo/Radiotherapy in Gastric Cancer

24. Discussion Therefore: It was impossible to achieve a meta analysis with the obtained data Evaluation of QoL is qualitative, although a scale exists in every instrument Meta analysis QoL after Chemo/Radiotherapy in Gastric Cancer

25. Discussion Therefore: It was impossible to achieve a meta analysis with the obtained data More research is needed Evaluation of QoL is qualitative, although a scale exists in every instrument Meta analysis QoL after Chemo/Radiotherapy in Gastric Cancer

26. Discussion QuestionnaireNumber of ItemsAreas Measured EORTC QLQ-C30 30 physical, functional, social, and emotional RSCL 30 psychological and physical HADS 14 psychological Questionnaires used QoL after Chemo/Radiotherapy in Gastric Cancer

27. Discussion Items removed from the applied questionnaires  Do you have any trouble taking a long walk?  you limited in pursing your hobbies or other leisure time activities?  I am satisfied with my sex life  I am able to enjoy life  Lack of sexual interest Maybe this isn’t the best approach... Items of the questionnaires for patients under palliation  Approximately how many hours per day (8 a.m. to 8 p.m.) have you been lying down?  How much help have you needed with dressing and hygiene?  How much pain have you had last week?  How many days during the past week have you spent in a hospital/nursing home? Some differences Questionnaires QoL after Chemo/Radiotherapy in Gastric Cancer

28. Discussion QuestionnaireNumber of ItemsAreas Measured AQEL36 physical, psychological, social, existential EORTC QLQ-C15-PAL 15 Functional, choice of treatment, psychological PQLI28 functional, symptom, choice of treatment scale, psychological McGill16 physical symptoms, psychological symptoms, outlook on life, and meaningful existence FLIC22 physical well-being and ability, emotional state, sociability, family situation and nausea Questionnaires proposed QoL after Chemo/Radiotherapy in Gastric Cancer

29. Discussion When chemo and radiotherapy are used as treatment The instrument to measure QoL should not be the same used with the other treatments The most appropriate option is a Questionnaire to Patients under Palliation A Systematic Review about these instruments can be consulted to better understand their characteristics Final Remarks QoL after Chemo/Radiotherapy in Gastric Cancer

30. Discussion When chemo and radiotherapy are used as treatment The instrument to measure QoL should not be the same used with the other treatments The most appropriate option is a Questionnaire to Patients under Palliation “Instruments for assessing quality of life in palliative care settings.” Massaro T, McMillan SC; Int J Palliat Nurs.; 2000 Oct; 6(9):429-33 Final Remarks QoL after Chemo/Radiotherapy in Gastric Cancer

31. Web Site QoL after Chemo/Radiotherapy in Gastric Cancer Trabalho anual - FMUP- Faculdade de Medicina da Universidade do Porto Trabalho anual - FMUP- Faculdade de Medicina da Universidade do Porto

32. Acknowledgments We acknowledge the help of:  Cláudia Camila Dias  Mário Dinis Ribeiro We are also very grateful to:  Professor Doutor Altamiro da Costa Pereira All the authors that have promptly fournished the articles necessary for the succes of our work QoL after Chemo/Radiotherapy in Gastric Cancer Not forgetting: