Searching for a simple assessment tool capable of estimating quality of life in palliative care clinical practice: is a feeling of well-being a good candidate tool as a single item?

Dear Editor: Patients with advanced cancer often experience physical, psychological, social and existential distress leading to impaired quality of life (QOL). The essential focuses of palliative care are to provide symptom relief and improve QOL through an interdisciplinary approach. For palliative care, assessment of QOL is necessary in order to evaluate treatment efficacy and monitor patients’ needs. Several instruments are available for evaluating QOL among patients with cancer. These are multi-item questionnaires encompassing different QOL domains. In general, they are troublesome for frail patients with advanced disease, precisely because of their multiple items and consequent time-consuming nature. Moreover, there are few palliative care-specific tools directed toward measuring QOL. Unfortunately, none of these palliative care questionnaires has been validated for routine use in Brazil. Efforts need to be made toward identifying a simple assessment tool that can be applied in clinical practice for such patients. It was with great interest that we read a recently published article in the Journal of Palliative Medicine. The authors made a correlation analysis between three different QOL questionnaires and the feeling of well-being (FWB) as a single item from the Minimal Documentation System (MIDUS). Two of the QOL questionnaires are commonly used in the literature: Functional Assessment of Cancer Therapy-General (FACIT-G) and European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30. Regarding EORTC-QLQ-C30, they found significant correlation coefficients between FWB-MIDUS and physical (r = 0.38, p < 0.01), cognitive (r = 0.34, p < 0.01), emotional (r = 0.33, P < 0.01) and role functioning (r = 0.26, p < 0.05) domains. There was no significant correlation regarding social functioning (r = 0.11, p = NS). Considering FACIT-G there were significant correlations for physical (r = 0.58, p < 0.01), functional (r = 0.42, p < 0.01) and emotional (r = 0.38, p < 0.01) domains. Again, there was no significant association between FWBMIDUS and the social domain (r = 0.01, p = NS). FWB assessed using the Edmonton Symptom Assessment System (ESAS) has been shown to be correlated with FACIT-G instrument scores in another recent article. The single-item FWBESAS was correlated with overall FACIT-G (r = 0.48, p < 0.0001) and the emotional (r = 0.33, p < 0.0001), physical (r = 0.45, p < 0.0001) and functional (r = 0.40, p < 0.0001) domains, but not with the social/family domain (r = 0.12, p = 0.08). We analyzed data on 40 consecutive patients from an ongoing prospective study in their first consultation at our Palliative Care Outpatient Clinic. QOL scores, measured using EORTC-QLQ-C30, were correlated with FWB-ESAS using the Spearman correlation test. There were 21 females (52%). The mean age (standard deviation [SD]) was 60.1 (12.3). There were 12 (30%), 15 (37.5%) and 13 (32.5%) patients presenting Karnofsky Performance Status less than 70%, between 70% and 80%, and 90%, respectively. The most common primary tumors were lung (10/40, 25%), head and neck (8/40, 20%), breast (4/40, 10%) and esophageal (4/40, 10%) cancers. The mean (SD) FWB score was 3.4 (0.5). Correlations between the EORTC-QLQ-C30 and the FWB-ESAS were as follows: overall health status (r = 0.57, p < 0.0001), overall functional scales (r = 0.56, p = 0.0002), physical functioning (r = 0.52, p = 0.0005), role functioning (r = 0.49, p = 0.001), emotional functioning (r = 0.41, p = 0.008), cognitive functioning (r = 0.38, p = 0.015), social functioning (r = 0.29, p = 0.066), overall symptom scales (r = 0.61, p < 0.0001) and financial difficulties (r = 0.18, p = 0.255). Taking together the data from published studies and our results, there are significant correlations—mainly with moderate coefficients—between QOL measured using multipleitem questionnaires and FWB as a single item. Therefore, we suggest that FWB-ESAS could be a simple tool for routine estimation of QOL within palliative care scenarios, with the aim in daily practice of identifying patients who need improvement in their QOL, particularly concerning the physical and functioning domains but not social traits. The addition of another question addressing social-related QOL could enhance the FWB-ESAS evaluation of QOL in broader terms. However, this hypothesis needs confirmation in future studies.