gms | German Medical Science

Introduction: Quality of life (QoL) is routinely assessed in clinical trials, but not systematically utilized for therapy of the individual cancer patient. Therefore a three-component-outcome-model, comprising QoL, classic endpoints and an integrated value judgement on clinical relevance, has been implemented as a curing and caring system for breast cancer patients in a regional tumor center.

Methods: The multifaceted implementation procedure included the combination of outreach visits, opinion leaders and continuous medical education and PDCA (=plan,do,check,act)-methodology within a quality circle (Med. Care 39, Suppl. 2, 85, 2000).170 patients were treated by 10 clinicians in 5 hospitals, 38 practitioners, 75 specialists for therapeutic options, using a defined clinical path. The prospective study ran between Dec 2002 and July 2004. A QoL profile of each patient was derived from EORTC-QLQ-C30 and BR23 questionnaire. An expert report integrated this profile and recommended therapeutic options.Several cycles for quality improvement were performed: Identify therapeutic deficits in the region and create a list of specialists for therapeutic options. Develop quality indicators. Get advice and input from external experts, check quality of specialists.

Results: The sample of 170 patients showed baseline characteristics that were comparable to those of other breast cancer studies (age 34-86, median 58; point of follow-up examination 1-120 months, UICC 0-IV 4, 41, 41, 9, 7%, BET/ME rate 66/33%). Patients' reports of global QoL deviated from doctors' assessments in approximately half of the cases (93/170, ICC1=0,54). Interestingly, deviations were much more pronounced for patients with a critical deficit in global QoL (< 50): 30 patients felt ill and this was detected by doctors in only 8 cases (Chi²-Test 14.34, p<0.001)(see Fig. [Fig. 1]). Analyses of 170 expert reports showed that besides the 5 therapeutic options (pain-, psycho-and physiotherapy, nutrition and sports, social rehabilitation) additional recommendations, e.g. treatment of comorbidity, were necessary. Quality circles were founded for improvement in physiotherapy/lymph drainage, special short-time psychotherapy was introduced which was financed by the health insurance.

Conclusion: Essential information about the patients suffering was assessed and QoL was improved by implementing QoL diagnostics and therapy in a regional tumor center. A system for treatment of clinically relevant QoL deficits was achieved in breast cancer patients. The effectiveness of this approach is currently evaluated in a randomized clinical trial (135/200 patients recruited).