Quality of life in Brazilian MM patients Etto LY et al. and the hospital, transportation difficulties for disable patient, the absence of a caregiver, and poor family support related to social problems. Because of these difficulties, we believe that it is important to evaluate whether high-dose chemotherapy followed by autologous hematopoietic stem cell transplantation (ASCT), could improve the QoL of our patients (other than clinical benefits and disease control). Therefore, the aim of this study was to characterize the impact of MM in the QoL of patients treated in two public institutions in Sa˜o Paulo State, Brazil, using a generic Short Form 36 Health Survey and a questionnaire specific for oncologic patients (QLQ-C30) upon diagnosis, after the clinical treatment, and at day +100 after ASCT. We also evaluated whether ASCT improves the QoL of our economically challenged population. METHODS Study design. Between March 2006 to August 2007, we evaluated 49 MM patients who were treated at Disciplina de Hematologia e Hemoterapia, Universidade Federal de Sa˜o Paulo Sa˜o Paulo/UNIFESP (a total of 26 patients) and Santa Casa de Miserico´rdia de Sa˜o Paulo (a total of 23 patients). We did not include patients with solitary plasmacytoma or monoclonal gammopathy of undetermined significance or patients without a physical/emotional condition for a 30- minute interview. Patients who were more than 70 years old, had chronic renal insufficiency requiring dialysis, congestive cardiac insufficiency, or cardiac amyloidosis did not undergo high-dose chemotherapy followed by ASCT. Written informed consent was obtained from all of the patients, and the study was approved by the ethics committees of these two institu- tions (CEP no. 0249/06 and CEP no. 374/06, respectively). Economic class assessment. A questionnaire that defined the economic classes of each of the 49 MM patients was applied using Brazil’s Economic Classification (www.ibope.com.br). This classification was created in 2000 and considers how many bathrooms, color TVs, radios, cars, vacuum cleaners, washing machines, DVD players, refrigerators, freezers and housemaids are in the patient’s household. It also considers the highest education level of any household member (not necessarily the MM patient). The final score classifies the patient within one of seven economic classes (A1/2, B1/2, C, D, or E). Based on the dollar value in 2000, an A1-class patient has a family budget of US $5,000/month, and an E- class patient has a family budget of US $130/month. Quality-of-life questionnaires. Two quality-of-life instruments were used in this study: the Short Form 36 Health Survey (SF- 36)2 and the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire- C30 (QLQ-C30).3 The SF-36 is an internationally validated instrument that can be self-administered or administered over the phone by trained health professionals. It includes a multi- item scale that assesses the following eight health domains: physical function, role-physical, bodily pain, general health, vitality, social function, role-emotional, and mental health. The physical and mental components are summaries of the eight domains in the SF-36 questionnaire. These domains have final scores between 0 and 100, where zero corresponds to the worst health state, and 100 corresponds to the best health state.2 This question- naire has been adapted and validated in Portuguese since 1999.2 The EORTC QLQ-C30 questionnaire is an internationally validated instrument in Portuguese (Brazilian) and incorpo- rates nine multi-item scales: five functional scales (physical, role, 1856 CLINICS 2011;66(11):1855-1859 cognitive, emotional and social); three symptom scales (fatigue, pain, and nausea and vomiting); and global health and quality-of- life scales (dyspnea, insomnia, lack of appetite, constipation, diarrhea, and financial difficulty).3 These scales have final scores between 0 and 100, where high scores indicate better outcomes for the functional scales and global health and worse outcomes for the symptom and quality-of-life scales. Authorizations for the use of the SF-36 and QLQ-C30 questionnaires (Portuguese [Brazilian] version) were given by Dr. Marcos Bosi Ferraz and Dr. Rozana M. Ciconelli and the EORTC Quality of Life Group, respectively, in May 2006. These questionnaires were administered to patients upon diagnosis, after the clinical treatment (post-treatment/pre-ASCT), and at day +100 after ASCT (D+100 ASCT). Of the 49 patients, 29 were evaluated upon diagnosis, 27 were evaluated post-treatment/pre-ASCT (9 patients were also evaluated at diagnosis), and 14 were evaluated at D+100 ASCT (12 patients were also evaluated post-treatment/pre-ASCT). Thus, the 49 MM patients gener- ated 70 total completed interviews, as depicted in the flow diagram of the study design (Figure 1). All of the interviews were conducted by one of the principal researchers (V.C.S.), and the average time required to complete the questionnaires was approximately 30 minutes (while the patient was waiting for the physician consultation). Statistical analysis. The sample classification (according to sex, isotype, disease stage, and the International Staging System [ISS]) was expressed as absolute numbers and as relative percentages. Chi-squared tests were used to compare the categorical variables among the groups. The ages were expressed as means ¡ standard deviations. For the SF-36 and QLQ-30 questionnaire score analyses, we followed all of the directions provided by each responsible group.2,4,5 The interviews that were generated by the quality-of-life questionnaires upon diagnosis, post-treat- ment/pre-ASCT and at D+100 ASCT were compared using ANOVA (for comparisons of the three groups), post hoc tests (for two-by-two comparisons of the three groups) and paired t-tests (the same case at two different times). The level of significance for all of the statistical tests was 5%. RESULTS There were no statistically significant differences among the three evaluated groups with respect to sex, age, isotype, clinical stage, and ISS (Table 1). With respect to economic class, the following classification was obtained: 4.0% in B1, 8.2% in B2, 63.3% in C, 22.5% in D, and 2.0% in E. According to our classification, 87.8% of the included patients had a familial budget of less than US $600 per month (i.e., economic classes C, D, or E). The generic SF-36 question- naire demonstrated that physical function, role-physical, and bodily pain were statistically different across all three groups and favored the D+100 ASCT group (ANOVA; Table 2). The physical component portion of the SF-36 had borderline statistical significance and favored the D+100 ASCT, which corresponds to the physical function, role-physical, and bodily pain domains. The QLQ-C30 questionnaire confirmed the SF-36 results with respect to physical function and bodily pain and improved role functioning, fatigue, the lack of appetite and constipation and usually favored the D+100 ASCT group (ANOVA; Table 3). The significant results obtained using the post hoc tests (two-by-two comparisons of the three groups,) are shown in Table 4. The outcomes were better after treatment (including ASCT). Paired t-tests (comparing