Symptom Burden and Health-Related Quality of Life in Patients with Aggressive Non-Hodgkin Lymphoma in China: A Cross-Sectional Study
Authors: Jin Jiayue , Ren Simeng , Zhang Wei , Yang Ping , Yang Jingqi , Xu Hongkun , Han Baojin , Zhang Wenzheng , Liu Jie - 
Published: December 2024

BACKGROUND From 1990 to 2019, the disease burden of lymphoma in China increased more significantly than that in the world. However, patient-reported health-related quality of life (HRQoL) impacted by symptom burden is predictive of overall survival in patients with aggressive lymphoma. This cross-sectional study investigated the main symptom burden significantly affecting the HRQoL in patient with aggressive Non-Hodgkin lymphoma (NHL) in China and identify a single cutpoint to separate clinical difference.
METHOD Patients with aggressive NHL were identified at Guang'anmen Hospital and China Academy of Chinese Medical Sciences between December 2022 and January 2024 received HRQoL questionnaires. The EQ-5D-5L was used to assess HRQoL, and the MD Anderson Symptom Inventory-Traditional Chinese Medicine (MDASI-TCM) was used to assess the symptom burden, physical functioning and psychological functioning. A moderate-to-severe symptom burden was defined as any symptom scored as 4-10 on a 0-10 scale. Descriptive statisticsc were used to summarize the participants' demographic factors and patient-reported outcomes. The symptoms with top 10 both in the proportion of moderate-to-severe symptoms and mean symptom scores on MDASI-TCM at any stage of treatment (undergoing or completing) were defined as the main symptom burden. A multivariate linear regression model was used to identify associations between the main symptom burden and HRQoL. Receiver operating characteristic (ROC) curves were used to identify optimum cutpoint considered the grading scale (0 vs. 1-3) of the Eastern Cooperative Oncology Group (ECOG) as the anchor.
RESULTS Total 116 eligible patients with aggressive NHL were analyzed. The majority of patients were under 50 years old (n = 43, 62.7%) and 49.1% (n = 57) of patients were female. The most patients were married (n = 93, 80.2%) and covered by medicare (n = 98, 84.5%). Patients were predominantly B-cell lymphoma (n=99, 85.3%), and most had diffuse large B-cell lymphoma (n=91, 78.4%). 57 patients(49.1%) were at Ann Arbor stage III-IV. 75.9% of patients (n = 88) had completed the treatment and the median time since completed was 191.5 days. More than half had an ECOG PS of 1-3 (n = 68, 58.6%) and comorbidity(n = 63, 54.3%, including diabetes, hypertension, cardiac disease, etc). A total of 116 patients completed the MDASI -TCM. The common top 10 symptoms both in the proportion of moderate-to-severe symptoms and mean symptom scores at any stage of treatment (undergoing, completing and total) were disturbed sleep (Total: 47.4%, Mean[SD]: 3.28[2.92]), fatigue (Total: 44.3%, Mean[SD]: 3.30[2.66]), difficulty remembering (Total: 40.9%, Mean[SD]: 3.34 [2.73]), dry mouth (Total: 32.8%, Mean[SD]: 2.66 [2.64]) and distress (feeling upset) (Total: 30.2%, Mean[SD]: 2.39 [2.79]). For EQ-5D-5L, 74.1% (n = 86) of patient completed the questionnaires. The distribution of the index scores and EQ VAS was negatively skewed. There was a gap between -0.294 and 1.0 in EQ-5D index scores and the median of EQ VAS was 80(Interquartile: 25). 22.4% of patient had “11111” (meaning no problem of mobility, self-care, activity, pain and anxiety) health state. The multivariate linear regression model demonstrated a significant influence in physical functioning scores(B = 0.477, 95%CI 0.300-0.653 ,P &lt; 0.001; with adjustment for marital status, medical insurance status and ECOG), psychological functioning scores(B = 0.737, 95%CI 0.566-0.908 ,P &lt; 0.001; with adjustment for gender and ECOG), EQ-5D index scores (B = -0.016, 95%CI [-0.028]-[-0.003] ,P = 0.014; with adjustment for Ann Arbor stage and ECOG) and EQ VAS (B = 0.487, 95%CI 0.363-0.611, P &lt; 0.001; with adjustment for age, medical insurance status, ECOG and comorbidity) attributed by the main symptom burden (mean of disturbed sleep, fatigue, difficulty remembering, dry mouth and distress [feeling upset]). The best cutpoint to differentiate clinically significant main symptom burden was 2.10, with a sensitivity of 86.8% and specificity of 66.7%.
CONCLUSIONS The main symptom burden of patients in aggressive NHL in China is disturbed sleep, fatigue, difficulty remembering, dry mouth and distress (feeling upset), which impacted their HRQoL (physical functioning, psychological functioning, EQ-5D index scores and EQ VAS) significantly. The main symptom burden score of 2.10 or higher implied to be emphasized because of its clinical difference measured by ECOG.