Danish value sets for the EORTC QLU-C10D utility instrument.

PURPOSE: In this study, we developed Danish utility weights for the European Organisation for Research and Treatment of Cancer (EORTC) QLU-C10D, a cancer-specific utility instrument based on the EORTC QLQ-C30. METHODS: Following a standardized methodology, 1001 adult participants from the Danish general population were quota-sampled and completed a cross-sectional web-based survey and discrete choice experiment (DCE). In the DCE, participants considered 16 choice sets constructed from the key 10 dimensions of the QLU-C10D and chose their preferred health state for each one. Utility weights were calculated using conditional logistic regression with correction for non-monotonicity. RESULTS: The sample (n = 1001) was representative of the Danish general population with regard to age and gender. The domains with the largest utility decrements, i.e., the domains with the biggest impact on health utility, were physical functioning (- 0.224), pain (- 0.160), and role functioning (- 0.136). The smallest utility decrements were observed for the domains lack of appetite (- 0.024), sleep disorders (- 0.057), and fatigue (- 0.064). Non-monotonicity of severity levels was observed for the domains sleep disturbances, lack of appetite, and bowel problems. Deviations from monotonicity were not statistically significant. CONCLUSION: The EORTC QLU-C10D is a relatively new multi-attribute utility instrument and is a promising cancer-specific health technology assessment candidate measure. The country-specific Danish utility weights from this study can be used for cost-utility analyses in Danish patients and for comparison with other country-specific utility data.

The European Organisation for Research and Treatment of Cancer Quality of Life Utility-Core 10 Dimensions: Development and Investigation of General Population Utility Norms for Canada, France, Germany, Italy, Poland, and the United Kingdom.

OBJECTIVES: The European Organisation for Research and Treatment of Cancer Quality of Life Utility-Core 10 Dimensions (EORTC QLU-C10D) is a cancer-specific preference-based measure, providing health utilities for use in economic evaluations derived from the widely used health-related quality of life measure, EORTC QLQ-C30. Several EORTC QLU-C10D country-specific value sets are available. This article aimed to provide EORTC QLU-C10D general population utility norms for Canada, France, Germany, Italy, Poland, and the United Kingdom, to aid interpretability of obtained utilities in these countries. METHODS: Data were collected in aforementioned countries via a quota-sampled, cross-sectional online survey (n = 100/age-sex group; N = approximately 1000/country). Participants were asked to complete the EORTC QLQ-C30 and provide sociodemographic data. Country-specific utility norms were calculated using the respective country tariff on the country's EORTC QLQ-C30 data after weighting to achieve population representativeness for age and sex. Norm values are provided as means (SDs) by country, age, and sex groups. Tukey's multiple comparison test investigated mean differences among countries. The impact of country, age, and sex on utility values was investigated with a multiple linear regression model. RESULTS: Country-specific mean utilities range from 0.724 (United Kingdom) to 0.843 (Italy). Country-, sex-, and age-specific mean utilities range from 0.664 for 30- to 39-year-old male Canadians to 0.899 for > 70-year-old male Italians. Utilities were lower in females in 4 of 6 countries, and the impact of age differed among countries. Independent of the impact of age and sex, between-country differences were found (P ≤ .05). CONCLUSION: Results showed a varying impact of age and sex on EORTC QLU-C10D utilities and significant between-country differences. Using national utility norms and utility decrements is recommended.

Estimation of an EORTC QLU-C10 Value Set for Spain Using a Discrete Choice Experiment.

BACKGROUND: The EORTC QLU-C10D is a preference-based measure derived from the EORTC QLQ-C30. For use in economic evaluations, country-specific value sets are needed. This study aimed to generate an EORTC QLU-C10 value set for Spain. METHODS: A sample of the Spanish general population completed an online discrete choice experiment. An attribute-balanced incomplete block design was used to select 960 choice tasks, with a total of 1920 health states. Each participant was randomly assigned 16 choice sets without replacement. Data were modelled using generalized estimating equations and mixed logistic regressions. RESULTS: A total of 1625 panel members were invited to participate, 1010 of whom were included in the study. Dimension decrements were generally monotonic with larger disutilities at increased severity levels. Dimensions associated with larger decrements were physical functioning and pain, while the dimension with the smallest decrement was sleep disturbances. The PITS state (i.e. worst attainable health) for the Spanish population is - 0.043. CONCLUSIONS: This study generated the first Spanish value set for the QLU-C10D. This can facilitate cost-utility analyses when applied to data collected with the EORTC QLQ-C30.

French Value-Set of the QLU-C10D, a Cancer-Specific Utility Measure Derived from the QLQ-C30.

BACKGROUND AND OBJECTIVE: The EORTC Quality of Life Utility Measure-Core 10 Dimensions (QLU-C10D) is a new multi-attribute utility instrument derived from the EORTC Quality of Life Questionnaire-Core 30 (QLQ-C30), a widely used cancer-specific quality-of-life questionnaire. It covers ten dimensions: physical, role functioning, social, emotional functioning, pain, fatigue, sleep, appetite, nausea and bowel problems. To allow national health preferences to be reflected, country-specific valuations are being performed through collaboration between the Multi-Attribute Utility Cancer (MAUCa) Consortium and the EORTC. The aim of this study was to determine the utility weights for health states in the French version of the QLU-C10D. METHODS: Valuations were run in a web-based setting in a general population sample of 1033 adults. Utilities were elicited using a discrete-choice experiment (DCE). Data were analyzed by conditional logistic regression and mixed logits. RESULTS: The sample was representative of the general French population in terms of gender and age. Dimensions with the largest impact on utility weights were, in this order: physical functioning, pain and emotional functioning. The impact on utilities was lower for role functioning, nausea, bowel problems and social functioning. The dimensions of sleep, fatigue and lacking appetite were associated with the smallest utility decrement. CONCLUSION: The results of the present study provide utility weights for the QLU-C10D and offer interesting prospects, as some cancer-specific dimensions also received sizeable utility weights (nausea and bowel problems). In fact, the EQ-5D and the HUI 3 are recommended in France and commonly used for cancer-related CUA; however, both these instruments are generic. The availability of a new cancer-specific utility instrument, such as the QLU-C10D, could improve the quality and the pertinence of future CUA in oncology.

The EORTC CAT Core-The computer adaptive version of the EORTC QLQ-C30 questionnaire.

BACKGROUND: To optimise measurement precision, relevance to patients and flexibility, patient-reported outcome measures (PROMs) should ideally be adapted to the individual patient/study while retaining direct comparability of scores across patients/studies. This is achievable using item banks and computerised adaptive tests (CATs). The European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire Core 30 (QLQ-C30) is one of the most widely used PROMs in cancer research and clinical practice. Here we provide an overview of the research program to develop CAT versions of the QLQ-C30's 14 functional and symptom domains. METHODS: The EORTC Quality of Life Group's strategy for developing CAT item banks consists of: literature search to identify potential candidate items; formulation of new items compatible with the QLQ-C30 item style; expert evaluations and patient interviews; field-testing and psychometric analyses, including factor analysis, item response theory calibration and simulation of measurement properties. In addition, software for setting up, running and scoring CAT has been developed. RESULTS: Across eight rounds of data collections, 9782 patients were recruited from 12 countries for the field-testing. The four phases of development resulted in a total of 260 unique items across the 14 domains. Each item bank consists of 7-34 items. Psychometric evaluations indicated higher measurement precision and increased statistical power of the CAT measures compared to the QLQ-C30 scales. Using CAT, sample size requirements may be reduced by approximately 20-35% on average without loss of power. CONCLUSIONS: The EORTC CAT Core represents a more precise, powerful and flexible measurement system than the QLQ-C30. It is currently being validated in a large independent, international sample of cancer patients.

Australian Utility Weights for the EORTC QLU-C10D, a Multi-Attribute Utility Instrument Derived from the Cancer-Specific Quality of Life Questionnaire, EORTC QLQ-C30.

BACKGROUND: The EORTC QLU-C10D is a new multi-attribute utility instrument derived from the widely used cancer-specific quality-of-life (QOL) questionnaire, EORTC QLQ-C30. The QLU-C10D contains ten dimensions (Physical, Role, Social and Emotional Functioning; Pain, Fatigue, Sleep, Appetite, Nausea, Bowel Problems), each with four levels. To be used in cost-utility analysis, country-specific valuation sets are required. OBJECTIVE: The aim of this study was to provide Australian utility weights for the QLU-C10D. METHODS: An Australian online panel was quota-sampled to ensure population representativeness by sex and age (≥ 18 years). Participants completed a discrete choice experiment (DCE) consisting of 16 choice-pairs. Each pair comprised two QLU-C10D health states plus life expectancy. Data were analysed using conditional logistic regression, parameterised to fit the quality-adjusted life-year framework. Utility weights were calculated as the ratio of each QOL dimension-level coefficient to the coefficient on life expectancy. RESULTS: A total of 1979 panel members opted in, 1904 (96%) completed at least one choice-pair, and 1846 (93%) completed all 16 choice-pairs. Dimension weights were generally monotonic: poorer levels within each dimension were generally associated with greater utility decrements. The dimensions that impacted most on choice were, in order, Physical Functioning, Pain, Role Functioning and Emotional Functioning. Oncology-relevant dimensions with moderate impact were Nausea and Bowel Problems. Fatigue, Trouble Sleeping and Appetite had relatively small impact. The value of the worst health state was -0.096, somewhat worse than death. CONCLUSIONS: This study provides the first country-specific value set for the QLU-C10D, which can facilitate cost-utility analyses when applied to data collected with the EORTC QLQ-C30, prospectively and retrospectively.

Critical appraisal of health-state utility values used in breast cancer-related cost-utility analyses.

PURPOSE: To review the data sources of health-state utility values (HSUVs), as well as their elicitation and use, in 140 breast cancer-related cost-utility analyses (CUAs), and to provide a critical appraisal of these. METHODS: A checklist was developed to guide the process of the critical appraisal. It is divided into three parts: the data source (three questions), elicitation method (four questions), and use (ten questions) of HSUVs in CUAs. Two independent reviewers performed the data extraction. A consensus was reached in case of disagreements. Data sources were categorized as "original study," "derived from the literature," or "other." RESULTS: The data source of HSUVs was always specified. When HSUVs were derived from the literature (90% of cases), the authors referred to a median number of two references as data sources. The critical appraisal of the elicitation of HSUVs in CUAs revealed considerable variability in terms of the quality of the reporting of the data source selection of HSUV. More details were provided by authors when HSUVs were elicited from an original study rather than derived from the literature. The use of HSUVs elicited from an original study was generally better described in terms of the checklist than were those derived from the literature. CONCLUSIONS: Based on the developed checklist, we were able to highlight the challenges that authors are facing when trying to adequately report HSUV used in CUAs. Our proposed checklist offers a good starting point for encouraging more explicit and comprehensive reporting of HSUVs in CUAs.

Order of Presentation of Dimensions Does Not Systematically Bias Utility Weights from a Discrete Choice Experiment.

BACKGROUND: Discrete choice experiments (DCEs) are increasingly used to value aspects of health. An issue with their adoption is that results may be sensitive to the order in which dimensions of health are presented in the valuation task. Findings in the literature regarding order effects are discordant at present. OBJECTIVES: To quantify the magnitude of order effect of quality-of-life (QOL) dimensions within the context of a DCE designed to produce country-specific value sets for the EORTC Quality of Life Utility Measure-Core 10 dimensions (QLU-C10D), a new utility instrument derived from the widely used cancer-specific QOL questionnaire, the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30. METHODS: The DCE comprised 960 choice sets, divided into 60 versions of 16 choice sets, with each respondent assigned to a version. Within each version, the order of QLU-C10D QOL dimensions was randomized, followed by life duration in the last position. The DCE was completed online by 2053 individuals in France and Germany. We analyzed the data with a series of conditional logit models, adjusted for repeated choices within respondent. We used F tests to assess order effects, correcting for multiple hypothesis testing. RESULTS: Each F test failed to reject the null hypothesis of no position effect: 1) all QOL order positions considered jointly; 2) last QOL position only; 3) first QOL position only. Furthermore, the order coefficients were small relative to those of the QLU-C10D QOL dimension levels. CONCLUSIONS: The order of presentation of QOL dimensions within a DCE designed to provide utility weights for the QLU-C10D had little effect on level coefficients of those QOL dimensions.

Prescribing Practice in Inpatients Versus Outpatients With Schizophrenia Initiating Treatment With Second-Generation Antipsychotics: A Naturalistic Follow-Up Study.

OBJECTIVE: The primary objective of this study was to investigate whether the choice and dosage of antipsychotic medication differ between patients with schizophrenia starting treatment in an inpatient or outpatient unit. In addition, we investigated whether the reason for the introduction of new antipsychotic medication had an impact on the treatment setting and whether the use of benzodiazepines differed between inpatients and outpatients. METHOD: From October 1997 to September 2010, patients with a schizophrenia spectrum disorder according to the International Classification of Diseases, Tenth Revision aged between 18 and 65 years were allocated to a naturalistic drug-monitoring program when starting treatment with a second-generation antipsychotic drug. Psychopathological symptoms were rated at baseline and after 1, 2, 4, and 8 weeks of treatment using the Positive and Negative Syndrome Scale. Inpatients and outpatients were compared with regard to the use of antipsychotics and benzodiazepines. To compare different drugs, chlorpromazine and diazepam equivalents were calculated. RESULTS: Lack of efficacy and side effects were the main reasons for initiating new antipsychotic medication. Combined evaluation of all antipsychotic compounds by meta-analysis resulted in a significant effect of the treatment setting, with inpatients receiving higher doses than outpatients. In addition, inpatients were prescribed benzodiazepines more often and in higher doses than outpatients. CONCLUSIONS: Both antipsychotics and benzodiazepines were prescribed at higher doses in an inpatient setting. Moreover, benzodiazepines were prescribed more frequently to inpatients. Accordingly, the treatment setting needs to be taken into consideration in treatment recommendations for schizophrenia spectrum disorders.

Cost-utility analyses of drug therapies in breast cancer: a systematic review.

The economic evaluation (EE) of health care products has become a necessity. Their quality must be high in order to trust the results and make informed decisions. While cost-utility analyses (CUAs) should be preferred to cost-effectiveness analyses in the oncology area, the quality of breast cancer (BC)-related CUA has been given little attention so far. Thus, firstly, a systematic review of published CUA related to drug therapies for BC, gene expression profiling, and HER2 status testing was performed. Secondly, the quality of selected CUA was assessed and the factors associated with a high-quality CUA identified. The systematic literature search was conducted in PubMed, MEDLINE/EMBASE, and Cochrane to identify published CUA between 2000 and 2014. After screening and data extraction, the quality of each selected CUA was assessed by two independent reviewers, using the checklist proposed by Drummond et al. The analysis of factors associated with a high-quality CUA (defined as a Drummond score ≥7) was performed using a two-step approach. Our systematic review was based on 140 CUAs and showed a wide variety of methodological approaches, including differences in the perspective adopted, the time horizon, measurement of cost and effectiveness, and more specially health-state utility values (HSUVs). The median Drummond score was 7 [range 3-10]. Only one in two of the CUA (n = 74) had a Drummond score ≥7, synonymous of "high quality." The statistically significant predictors of a high-quality CUA were article with "gene expression profiling" topic (p = 0.001), consulting or pharmaceutical company as main location of first author (p = 0.004), and articles with both incremental cost-utility ratio and incremental cost-effectiveness ratio as outcomes of EE (p = 0.02). Our systematic review identified only 140 CUAs published over the past 15 years with one in two of high quality. It showed a wide variety of methodological approaches, especially focused on HSUVs. A critical appraisal of utility values is necessary to better understand one of the main difficulties encountered by authors and propose areas for improvement to increase the quality of CUA. Since the last 5 years, there is a tendency toward an improvement in the quality of these studies, probably coupled with economic context, a better and widely spreading of recommendations and thus appropriation by medical practitioners. That being said, there is an urgent need for mandatory use of European and international recommendations to ensure quality of such approaches and to allow easy comparison.

PPT and VES-13 in elderly patients with cancer: evaluation in multidimensional geriatric assessment and prediction of survival.

OBJECTIVES: The multidimensional geriatric assessment (MGA) detects impairments in the elderly and forms the basis for individualized treatment algorithms. Screening tools have been developed to detect patients in need of a full assessment. The aim of this pilot study was to evaluate the discriminative power and the prognostic impact of the screening scores for the Physical Performance Test (PPT) and the Vulnerable Elders Survey-13 (VES-13). MATERIALS AND METHODS: In 77 patients with cancer aged ≥60years (median 74years) from the Department of Internal Medicine V, Innsbruck Medical University, VES-13 and PPT were performed and compared with data from MGA and clinical outcomes. RESULTS: Overall, of the 77 patients 70% was deemed impaired, as defined by impairments in two or more scores of the MGA. The VES-13 showed 42% to be impaired, the PPT 79%. Using a cut-off of ≤19, the PPT exhibited better discriminative power than did the standard PPT (≤20). Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of VES-13, PPT≤20 and PPT≤19 in the detection of impairments were 56% (88%, 82%), 91% (45%, 75%), 94% (80%, 89%), and 45% (60%, 63%) respectively. The area under the curve was 0.73 (0.67, 0.79), respectively. Both impaired VES-13 and PPT significantly correlated with an unfavorable overall survival in both uni- and multivariate analysis. CONCLUSION: PPT (≤19) reveals favorable sensitivity, NPV and overall accuracy in elderly patients with cancer. Still, the NPV is too low to sufficiently discriminate between fit and frail patients. Both PPT and VES-13 are useful predictors for survival.

[The benefits of using patient-reported outcomes in cancer treatment: an overview]. / Verwendung und Nutzen von Patient-Reported Outcomes in der onkologischen Behandlung: eine Übersicht.

The patient's perspective evaluated by patient-reported outcomes (PROs) gains more and more importance, since treatment efficacy is no longer solely linked to clinical outcomes like cure and overall survival. Ailments like pain, fatigue and social isolation can only be assessed by patients' direct expression without any interpretation made by medical staff. PROs facilitate the disclosure of quality of life issues and patients feel a stronger support due to improved communication. PROs offer many further advantages like saving of time, cost and staff, targeted intervention and sensitizing of clinicians. Also, internationally validated questionnaires are available and the development of electronic PROs eases data-collection, calculation and storage. PROs collected within clinical routine are versatile concerning their applicability: They can be used for scientific analyses, quality assurance, and health technology assessment.

Do neurooncological patients and their significant others agree on quality of life ratings?

INTRODUCTION: Patients suffering from brain tumours often experience a wide range of cognitive impairments that impair their ability to report on their quality of life and symptom burden. The use of proxy ratings by significant others may be a promising alternative to gain information for medical decision making or research purposes, if self-ratings are not obtainable. Our study investigated the agreement of quality of life and symptom ratings by the patient him/herself or by a significant other. METHODS: Patients with primary brain tumours were recruited at the neurooncological outpatient unit of Innsbruck Medical University. Quality of life self- and proxy-ratings were collected using the EORTC QLQ-C30 and its brain cancer module, the QLQ-BN20. RESULTS: Between May 2005 and August 2007, 42 pairs consisting of a patient and his/her significant other were included in the study. Most of the employed quality of life scales showed fairly good agreement between patient- and proxy-ratings (median correlation 0.46). This was especially true for Physical Functioning, Sleeping Disturbances, Appetite Loss, Constipation, Taste Alterations, Visual Disorders, Motor Dysfunction, Communication Deficits, Hair Loss, Itchy Skin, Motor Dysfunction and Hair Loss. Worse rater agreement was found for Social Functioning, Emotional Functioning, Cognitive Functioning, Fatigue, Pain, Dyspnoea and Seizures. CONCLUSION: The assessment of quality of life in brain cancer patients through ratings from their significant others seems to be a feasible strategy to gain information about certain aspects of patient's quality of life and symptom burden, if the patient is not able to provide information himself.

Health-related quality of life assessment and reported outcomes in leukaemia randomised controlled trials - a systematic review to evaluate the added value in supporting clinical decision making.

Health-related quality of life (HRQOL) is increasingly reported as an important outcome in cancer clinical trials. However, very little evidence exists on the impact of such evaluation in randomised controlled trials (RCTs) of leukaemia patients. A systematic search of the literature from 1980 to 2007 was undertaken and studies were identified and evaluated independently, according to a pre-defined coding scheme, by three reviewers. Both HRQOL outcomes and traditional clinical reported outcomes were systematically analysed to evaluate their consistency and their relevance for supporting clinical decision making. Nine RCTs were identified, involving 3838 patients overall. There were four RCTs involving acute myeloid leukaemia patients (AML), three with chronic myeloid leukaemia (CML) and two with chronic lymphocytic leukaemia (CLL). Six studies were published after 2000 and provided fairly robust methodological quality. Imatinib greatly improved HRQOL compared to interferon based treatments in CML patients and fludarabine plus cyclophosphamide does not seem to have a deleterious impact on patient's HRQOL when compared to fludarabine alone or chlorambucil in CLL patients. This study revealed the paucity of HRQOL research in leukaemia patients. Nonetheless, HRQOL assessment is feasible in RCTs and has the great potential of providing valuable outcomes to further support clinical decision making.

Suicide victims' contacts with physicians during the year before death.

Suicide victims frequently have had contact with physicians during the last year before death. However, oftentimes suicidal ideation is not reported overtly. This study investigates the course of contact rates of suicide victims with physicians during the year before death. Official suicide data and insurance company data were linked for 317 subjects who had committed suicide between 1998 and 2002. Quarterly contact rates with physicians during the respective last year of life were compared. Contact rates of suicide victims with physicians varied considerably concerning age, gender and physicians' specialization. Contacts with 'any physician' and general practitioners generally increased over the year, most pronounced in men and in those older than 60 years. In contrast to males, female contacts to psychiatrists increased until one quarter before suicide and then dropped significantly shortly before suicide. A pattern of contacting more than one general practitioner per quarter occurred significantly more often in the suicide quarter than during the year before, predominantly in those older than 60 years. Such a 'doctor shopping' behavior may reflect an intensified patients' searching for adequate help. Taking contact behavior changes into account may increase the chance to identify individuals at risk and thus may contribute to suicide prevention.

Sublingual buprenorphine and methadone maintenance treatment: a three-year follow-up of quality of life assessment.

This study was conducted to compare long-term outcome effects on the quality of life (QOL) of oral methadone with sublingual buprenorphine maintenance treatment. The QOL status of opioid-dependent patients was assessed using the German version ("Berlin Quality of Life Profile") of the Lancashire Quality of Life Profile. Physical symptoms were measured using the Opiate Withdrawal Scale (OWS). Urine tests were carried out randomly to detect additional consumption. In the first study period, 53 opioid-dependent subjects were enrolled and 25 could be reached after 3 years. The retention rate was 50% for methadone and 45% for buprenorphine (p = 0.786). Baseline values of the total sample (completers and noncompleters) QOL and somatic complaints did not show significant differences between the two treatment groups. QOL characteristics at 6 months of treatment of the buprenorphine completer and noncompleter groups differed significantly regarding job (p = 0.013), family, and total score of physical symptoms (p = 0.002), in which the completer group showed the more favorable values. Concerning physical symptoms at 36 months, logistic regression revealed significantly less stomach cramps (p = 0.037) and fatigue and tiredness (p = 0.034) in buprenorphine compared to the methadone. Moreover, the buprenorphine-maintained group showed significantly less additional consumption of benzodiazepines (p = 0.015) compared with methadone participants. It is concluded that opioid addicts improved their QOL and health status when treated with methadone or buprenorphine. In summary, regarding QOL and health status, the present data indicate that buprenorphine is also a useful long-term alternative for maintenance treatment of opioid-dependent patients.

Is higher income and educational status associated with poorer outcome in patients with Hodgkin's disease?

OBJECTIVES: The aim of the study was to determine the impact of socioeconomic status on relapse-free survival (RFS) in patients with Hodgkin's disease. METHODS: A number of factors were analyzed for their impact on relapse-free and overall survival in Hodgkin's disease using Cox regression. These factors included socioeconomic status (as defined by education and income), different treatment modalities and established clinical risk factors [e.g. age at diagnosis, stage of disease, involvement of three or more lymph nodes, presence or absence of a large mediastinal mass, E stages or elevation of erythrocyte sedimentation rate (ESR)]. The study used an initial sample of 126 patients recruited between 1969 and 1995 and a larger sample of 218 patients (recruited until 2002). Clinical data on disease and treatment characteristics were collected from medical records. RESULTS: In a univariate analysis, the following parameters had impact on RFS: treatment modality (combined treatment resulted in an improved RFS compared with patients treated with chemo- or radiotherapy alone), educational status and income. The 5- and 10-yr relapse-free survival rates were found to increase with decreasing educational level and decreasing average income per month. These results were significant in the initial and total samples and were also significant using multivariate analysis (hazard ratio for highest vs. lowest education group: 5.88; 95% confidence interval 1.87-18.52; for highest vs. lowest income group: 4.36; 95% confidence interval 1.35-14.05). CONCLUSION: Hodgkin's disease appears to be a striking exception from the usual positive correlation between high socioeconomic status and favorable treatment outcome in patients suffering from tumor. It is suggested that future studies on tumor genetics and biology and more detailed analysis of further socioeconomic parameters may be useful in clarifying this observation.

Normative data for functional assessment of cancer therapy--general scale and its use for the interpretation of quality of life scores in cancer survivors.

The aims of this study were to derive population-based reference values for the Functional Assessment of Cancer Therapy Scale-General (FACT-G) and to investigate the impact of sociodemographic variables (e.g. age, sex, health status) on these quality of life (QOL) scores, and to compare the normative QOL scores with those of various groups of cancer survivors. A random sample of 2 000 members of the Austrian public were sent questionnaires containing the FACT-G and questions relating to demographic data and health status. A total of 968 questionnaires were returned giving an overall response rate of 50.6% (females 48.3%, age 49.3 +/- 16.8). Subjects with higher education reported higher QOL values; divorced and widowed persons had significantly lower QOL scores. Higher age was also associated with lower QOL scores. After bone marrow transplantation, patients generally showed lower QOL scores than the age- and sex-matched population-based sample, whilst in breast cancer survivors there was reduced QOL regarding social well-being. Survivors of Hodgkin's disease were found to have higher functional and social well-being scores than those of the general population sample. Sociodemographic variables should always be taken into consideration when interpreting QOL scores. Furthermore, unless patient data are compared with normative values, phenomena such as adaptation and response shift might be missed or misinterpreted.

Cognitive impairment: assessment with brain magnetic resonance imaging and proton magnetic resonance spectroscopy.

BACKGROUND: In vivo proton magnetic resonance spectroscopy is a safe and noninvasive tool that can be used to study aspects of brain chemistry and metabolism. This study was designed to evaluate its role in routine application to reveal the diagnostic reasons for cognitive impairment. METHOD: 37 Alzheimer's disease patients (NINCDS-ADRDA criteria), 31 patients with subcortical ischemic vascular dementia (Chui et al. criteria), and 13 subjects with subjective cognitive impairment (DSM-IV criteria) were included in this retrospective study. Magnetic resonance images were used for atrophy rating; additionally, proton magnetic resonance spectroscopy was performed. RESULTS: Significantly reduced N-acetylaspartate levels (p <.05) were found in both patients with Alzheimer's disease and patients with subcortical ischemic vascular dementia compared to the group with subjective memory complaints. The ratios of N-acetylaspartate/creatine and N-acetylaspartate/myo-inositol were significantly lower in Alzheimer's disease patients compared to patients with vascular dementia (p =.012) or patients with subjective memory impairment (p =.002). N-acetylaspartate/creatine and N-acetylaspartate/myo-inositol ratios were positively correlated to the degree of cerebral atrophy. Disoriented patients displayed a low N-acetylaspartate/creatine ratio. In contrast, we were not able to relate concurrent psychotic or behavioral symptoms to any spectroscopic parameter. CONCLUSION: This study indicates that proton magnetic resonance spectroscopy parameters could provide additional information in differentiating between Alzheimer's disease, subcortical ischemic vascular dementia, and subjective cognitive impairment. Therefore, this method can contribute to the routine diagnosis of dementia. Psychiatric and behavioral symptoms associated with dementia or due to a major psychiatric disorder cannot be related to changes in the measured proton magnetic resonance spectroscopy parameters.