Information for Nurses and Physicians
Integrating Survival and Quality
of Life
Increasingly, the focus
of attention on patients' quality of life
is more appropriate due to advances in
treatments to prevent and manage the side
effects of cancer chemotherapy. Health-related
quality of life (HRQL) measurement tools
are yet to be integrated into daily community
medical practice, and the supportive therapies
that would most increase the quality of
life of chemotherapy patients are underutilized
for several reasons.
Often, younger, healthier-seeming
patients are provided treatment geared
toward aggressively attacking their cancer
in order to provide the patient with the
best chance to lead a cancer- free life.
Likewise, older patients with a shorter
life expectancy and multiple debilitating
problems may often be put into a less
aggressive chemotherapy program. What
is frequently discounted in situations
such as these, however, is the quality
of life of the patient undergoing chemotherapy.
At both extremes, supportive therapies
can improve quality of life as determined
by the patient. Regardless of the age,
stage of cancer, or treatment regimen
of the patient, supportive therapies should
be discussed and provided on an individual
basis.
In some cases, patients
can misinterpret the difference between
drug side effects and response to treatment.
Many patients are afraid to mention the
side effects because of two assumptions:
one being that they believe they have
mistaken the side effects as positive
signs that the treatment is working and
the other being that they are afraid that
treatment will be discontinued if they
mention the severity of the side effects.
The patient, family, and in some cases
the medical team can be overwhelmed by
the emotional and psychological stresses
caused by side effects. Some patients
defer or discontinue therapy because of
severe side effects.
There are many reasons which
serve to explain why quality of life is
not an issue on the forefront of care.
Physicians are restricted by the lack
of practical HRQL measurement instruments
that can be easily integrated into everyday
practice. Furthermore, attention devoted
to the treatment of cancer often overrides
attention to the patient's quality of
life. Time constraints often restrict
HRQL measurement -- physicians often do
not have adequate time to spend informing
patients of supportive treatment options
and designing individually balanced treatment
courses.
Insufficient use of supportive
therapies is also explained by patient
apprehension and lack of information about
side effect therapy. Patients are often
unaware of all the choices available to
address their health-related quality of
life issues and are usually unaccustomed
to voicing their complaints and concerns.
Patients are often silenced by their own
lack of information -- without knowing
of available resources, it is near impossible
for them to inquire about varying treatments
and programs.
The intrinsic "softer" outcomes
with therapies that improve patients'
perceptions and psychological tolerance
of therapy are often unacceptable to third-party
payers, whose main concern is with the
treatment of the cancer rather than the
treatment of the side effects of chemotherapy.
Because of this, they are often reluctant
to reimburse for supportive therapies.
The few studies that have
collected quality of life data have used
variables such as number of days on antibiotics
and number of hospital days. These indirect
measures of quality of life restrict supportive
therapy guidelines. Quality of life should
be measured from the patient's perspective.
A central challenge, however, is the creation
of an objective balance of patient's subjective
appreciation of his or her own quality
of life and chemotherapy decisions.
Discussion between patients
and physicians should not be limited to
the treatment of cancer, but should also
address supportive therapies that affect
quality of life. Patients and physicians
should be partners in integrating survival
and quality of life goals.
Source:
Benear, J.B. (1995). Cancer chemotherapy:
Integrating survival and quality of life.
Cope, (September/October), 26-27.
