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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 4  |  Issue : 2  |  Page : 58-64

Assessment of quality of life in patients with lung cancer and correlation with staging of disease at time of diagnosis in a tertiary care hospital


1 Department of Pulmonary Medicine and critical care, AANCH Hospital, Jaipur, Rajasthan, India
2 Metro Centre for Respiratory Diseases, Metro Multispeciality Hospital, Noida, India
3 Department of Pulmonary Medicine and Critical Care Medicine, Yashoda Superspeciality Hospital, Kaushambi, Uttar Pradesh, India

Date of Submission14-Oct-2021
Date of Decision01-Dec-2021
Date of Acceptance07-Dec-2021
Date of Web Publication21-Jan-2022

Correspondence Address:
Pallavi Periwal
Department of Pulmonary Medicine and Critical Care, AANCH Hospital, Jaipur, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/japt.japt_44_21

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  Abstract 


Background: Lung cancer is the leading cause of the cancer-related deaths in developed countries. In India, it is usually diagnosed in the advanced stages. Quality of life (QOL) is an important factor to be assessed to aid the therapeutic decisions and know the prognosis of the disease. This study is aimed at the assessment of QOL in patients at the time of diagnosis of lung cancer and correlating them with the stage of lung cancer. There is the paucity of similar data from the Indian subcontinent and the Western world on these issues. To the best of our knowledge, this is the first such paper correlating QOL with the stage of disease, in lung cancer patients. Materials and Methods: A retrospective observational study was conducted on 87 newly diagnosed patients with lung cancer at the Department of Respiratory, Sleep, Allergy, and Critical Care Medicine at the Metro Centre for Respiratory Diseases, Metro Hospital, Noida. Data were collected between January 2015 and June 2015. The QOL data was collected using questionnaires filled at the time of diagnosis of lung cancer and were correlated with the stage of lung cancer. Results: About 81.6% of lung cancer patients were male and 81.6% of patients were smokers. Most of our patients (93.1%) presented with advanced-stage lung cancer and 61.8% already had distant metastasis at the time of presentation. Data from QOL questionnaires revealed lower scores as compared to the Western population, indicating much poorer QOL at the time of diagnosis of lung cancer. Indian patients have more severe and distressing symptoms in comparison to the Western population. Patients had worse symptoms in Stage 3 B or 4, i.e., at the onset of the diagnosis. Conclusion: Lung cancer patients are diagnosed at advanced stages of the disease and have a significantly poor QOL as compared to their Western counterparts. A majority of these patients have a poor QOL that precludes definitive therapy.

Keywords: Lung cancer, quality of life, quality of life in lung cancer


How to cite this article:
Periwal P, Prajapat DK, Khanna A, Talwar D. Assessment of quality of life in patients with lung cancer and correlation with staging of disease at time of diagnosis in a tertiary care hospital. J Assoc Pulmonologist Tamilnadu 2021;4:58-64

How to cite this URL:
Periwal P, Prajapat DK, Khanna A, Talwar D. Assessment of quality of life in patients with lung cancer and correlation with staging of disease at time of diagnosis in a tertiary care hospital. J Assoc Pulmonologist Tamilnadu [serial online] 2021 [cited 2022 May 16];4:58-64. Available from: http://www.japt.com/text.asp?2021/4/2/58/336173




  Introduction Top


According to the recent GLOBOCAN 2020 report, lung cancer is the most common cancer, causing deaths worldwide.[1] India showed 51,675 new lung cancer cases among males and 20,825 cases among females in 2020.[1]

The prognosis of lung cancer depends not only on histological characteristics and staging of cancer at the time of diagnosis but also on the quality of life (QOL).[2],[3],[4] More than 90% of lung cancer in India is diagnosed in stages III and IV. Tolerability of treatment modalities then depends on the general condition of the patient, which is usually poor.

QOL is defined as an individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards, and concerns. It is a broad-ranging concept affected in a complex way by the person's physical health, psychological state, level of independence, social relationships, and their relationship to salient features of their environment.[5] Studies have shown that QOL in lung cancer patients is a significant predictor of survival and therefore it should be considered as a clinical status that has to be established by physicians before treatment starts.[6] QOL assessment also helps in comparing different therapeutic regimes, thus allowing the selection of appropriate modalities.[7]

The European Organization for Research and Treatment of Cancer QOL, Lung Cancer Questionnaire (EORTC QLQ-LC13) in conjunction with the core cancer questionnaire (QLQ-C30) was found to be the best-developed instrument to assess QOL.[8] QOL is now being considered an essential component of lung cancer management and should be performed routinely.

The current study is designed to assess the QOL and correlation it with the stage of lung cancer at the time of diagnosis which may, in turn, provide an aid to further management of these patients in local settings as they may differ from the Western population.


  Materials and Methods Top


Detailed demographic data, medical history, results of physical examination, and other investigational data including radiological findings of high-resolution computed tomography (CT) contrast-enhanced computed tomography of the chest and abdomen and positron emission tomography (PET) CT along with the histopathological diagnosis was collected from records. The QOL questionnaire and PS (assessed by ECOG and the KPS scales) were also noted. The TNM staging was done using the 8th edition of the TNM classification based on tumor size and extension (T), lymph nodal involvement (N), and presence of distant metastasis (M) based on PET-CT scans.

If the prevalence of lung cancer is 0.3% and the true odds ratio in participants is 0.2, we were required to study 49 patients to be able to reject the null hypothesis, that this odds ratio equals 1 with probability (power) 0.8. The Type I error probability associated with this test of this null hypothesis is 0.05.

Statistical analysis of data was performed using IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY, USA. The clinical profile, performance status, comorbidities, and QOL of patients were analyzed using the Chi-square test for qualitative variables and the Student's t-test for quantitative variables. Correlation between quantitative and qualitative outcomes was assessed using Pearson/Spearman correlation. 5% probability level was considered as statistically significant, i.e., P < 0.05.

Approval was taken from the ethics committee.

Inclusion criteria

All new patients with lung cancer, diagnosed at our center. Patients who were diagnosed with lung cancer before the start of our study or those who had already taken any treatment were excluded.


  Results Top


Out of the 87 patients, 71 (81.6%) were male and 16 (18.4%) were female. The mean age of the patients was 65.32 for males and 56.12 for female patients. Seventy-one (81.6%) patients were smokers, 77% being male, while 16 (18.4%) were nonsmokers.

According to the 8th TNM classification, only 6 (6.9%) patients were diagnosed at Stage 2B, 13 (14.9%) each were at Stage 3A and 3B, while nearly 2/3rd (55/87) patients were at stage 4 with distant metastasis on PET scan in 61.8% (34/55) and 18.2% patients (10/55) even had brain metastasis as demonstrated by magnetic resonance imaging brain. None were in Stage 1.

Data to assess the QOL in patients with lung cancer were collected on the basis of EORTC QLQ-C30 version 3.0 and EORTC LC-13. A high score for a functional scale represents a healthy level of functioning, a high score for the global health status (GHS)/QOL represents a high QOL, but a high score for a symptom scale represents a high level of symptomatology in a given patient.

Interpretation of the European organization for research and treatment of cancer QLQ-C30, version-3.0, questionnaire

The mean GHS/QOL was 32.47 ± 22.67, the mean physical functioning (PF) 47.96 ± 26.66, role functioning (RF) 44.64 ± 29.14, emotional functioning 68.0 ± 23.45, and the mean cognitive functioning scale 76.05 ± 20.28. A score of <50 represents a poor QOL.

Symptom scale includes fatigue (mean value of 55.9 ± 28.1), nausea and vomiting 18.3 ± 22.4, pain 34.8 ± 25.2, dyspnea 63.5 ± 29.0, insomnia 33.3 ± 24.9, loss of appetite 46.35 ± 30.2, constipation 22.59 ± 24.6, diarrhea7.66 ± 18.8, and financial difficulty had mean of 45.2 ± 28.3. Indicating patients had more pain, dyspnea, loss of appetite, and financial problems by the time lung cancer was diagnosed.

Single items scoring [Table 1] and [Table 2]
Table 1: Lung cancer patients of all stages: Single items

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Table 2: Lung cancer patients of all stages: Overall health and QOL

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About 63.2% of our patients were unable to do strenuous activity, 41.4% were unable to go for long walk, 19.2% were not even being able to manage short walk and 6.9% of patients were in bed or chair most of the time. 3.4% were not able to take care of themselves while 40.2% could do so comfortably. About 95.4% of patients reported limitation in work while 90.8% reported limitation in leisure.

Dyspnea was reported by 97.7%, pain by 72.8%, and 94.2% of patients needed to rest. Appetite loss was present in 83.4% of patients and nausea and vomiting in 51.4% of patients. 50.6% had constipation while diarrhea was seen in only 24.1% of patients. Tiredness was reported in 83.6%, 73.6% reported pain interference and 69% had difficulty in concentrating.

58.2% were both tense and worried and 62.7% were irritable due to the illness. Forty-six percent patients were depressed at the time of diagnosis and memory trouble was reported in 53% of patients. Family life was disturbed in 82% of patients, social activities limited in 91.8% of patients and 82.8% faced financial difficulty.

Global health status/quality of life [Table 2]

Approximately 50% of patients had a score <4 but >1, indicating poor QOL and it was “very poor” in 19.5% of patients.

Scoring of individual scales

Global health status/quality of life scale

In our study, 82% of patients in GHS/QOL scale had a score of <50 suggesting a poor QOL. Out of them, 8% had score of zero indicating very poor QOL.

Functional scales

Physical functioning

Fifty percent of patients had a score of <50. 2.3% had a score of zero, 5.7% had 6.7, 11.5% had 13.3, 5.7% had a score of 20, 2.3% had 26.7, 10.3% had 33.3, 6.9% had 40, 5.7% had a score of 46.7. The rest of the patients had a score of more than 50, including 4.6% with a score of 53.3, 5.7% with 60, 12.6% with 66.7, 10.3% with 73.3, 9.2% had 80, 5.7% had 86.7, 1.1% had score of 100.

Role functioning

Fifty-six percent of patients had a score of 50 or <50.16.1% had a score of zero, 13.8% had 16.7, 16.1% had 33.3, and 10.3% had a score of 50. Rest of the 54% patients had a score of more than 50, which included 29.9% with a score of 66.7, 11.2% had a score of 83.3, and 2.3% had a score of 100.

Emotional functioning

Thirty-two percent had a score of 50 or <50. 6.9% had a score of 25, 5.7% of 33.3, 9.2% of 41.7 and 50 each, respectively. Rest of the 68% had a score of more than 50, including 9.2% with 58.3, 10.3% with 66.7, 8% with 75, and 91.7 score each, respectively, 18.4% with 83.3, and 14.9% with a score of 100.

Cognitive functioning

Score of 50 or <50 was seen in 18% of patients, including 6.9% of patients with a score of 33.3, 11.5% with 50. The rest of the 82% had a score of more than 50, with score of 66.7 in 28.7% of cases, 83.3 in 24.2% of cases, and 100 in 28.7% of cases.

Social functioning

Score of 50 or <50 in 65% cases. Of these 65% cases, 23% had a score of zero, 10.3% of 16.7, 17.2% of 33.3, and 14.9% of 50. Rest 35% had a score of more than 50, including 19.5% of patients with a score of 66.7, 11.5% with 83.3, and 3.4% had a score of 100.

Symptom scales

Highers score indicates poorer QOL.

Fatigue

Forty-one percent patients had a score of <50, including the 2.3% patients with score of zero, 9.2% of 11.1, 5.7% of 22.2, 16.1% of 33.3, and 8% with a score of 44.4. The remaining 59% of patients had score of more than 50. Of these 59%, 9.2% had score of 55.6, 18.4% of 66.7, 12.6% of 77.8, 8% of 88.9, and rest 10.3% had a score of 100.

Nausea and vomiting

It occurred in 47.1% of patients. Only 10.3% of patients had score of more than 50 i.e., 66.7. Rest 36.8% had a score of 50 or less than 50, including 5.7% with score of 16.7, 29.9% of 33.3, and 1.1% of 50.

Pain

About 80.5% of patients had pain, with score of 66.7 in 6.9% of patients and 83.3 in 10.3% patients. Rest 63% had score of 50 or less than 50, including 12.6% with score of 16.7, 34.5% of 33.3, and 16.1% of 50.

Single item scales

Dyspnea was reported in 97.7% of patients, with score of 66.7 and 100 in 31% of patients each. 35.6% of patients had score of 33.3. Insomnia in 74.7% of patients, with score of 66.7 in 20.7% of patients, 100 in 2.3% of patients, and 51.7% of patients had score of 33.3. Appetite loss was reported in 82.8% of patients, with score of 66.7 in 33.3% of patients, 100 in 11.5% patients and 37.9% of patients had score of 33.3. Constipation in 51.7% of patients, with score of 66.7 in 16.1% of patients, 33.3 in 35.6% of patients. Diarrhea was present in 16.1% of patients, with score of 66.7 in 6.9% of patients, 33.3 in 9.2% of patients. About 85.1% of patients had financial difficulty, with score of 66.7 in 32.2% of patients, 100 in 9.2% of patients, and 33.3 in 43.7% of patients.

The correlation between stage of lung cancer and different parameters of QOL of EORTC QLQ-C-30 version 3.0 questionnaire [Table 3].
Table 3: The correlation between stage of lung cancer and different parameters of quality of life of European organization for research and treatment of cancer quality of life, lung cancer questionnaire - C-30 version 3.0 questionnaire

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There is a positive correlation between the limitation in work, limitation in leisure, dyspnoea, pain, need to rest, insomnia, weakness, appetite loss, nausea, vomiting, diarrhea, tiredness, pain interference, anxiety, depression tension, concentration, family life, social activity and the stage of lung cancer. There is a negative correlation between strenuous activity, long walk, short walk, self-care and bed or chair (PF) overall health, overall QOL, and the stage of lung cancer. All these are statistically significant.

Assessment of quality of life using the European organization for research and treatment of cancer LC 13 questionnaire single item score

[Table 4] shows cough was present in all 87 patients. Hemoptysis was present in 37.93%. Chest pain in 70.9%, pain at other sites except chest was present in 34.4%, 65.5% had dyspnoea even at rest, 94.25% developed dyspnea on walking, and 98.8% of patients became dyspnoeic on climbing upstairs. Sore mouth was present in 2528.7% of patients and dysphagia was present in 18.39% of patients.
Table 4: European organization for research and treatment of cancer LC13 questionnaire single item score

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There is positive correlation between chest pain, pain at other sites excluding chest, shortness of breath on climbing upstairs, on walk and on rest and the stage of lung cancer and all are statistically significant [Table 5].
Table 5: The correlation between stage of lung cancer and different parameters of quality of life of European organization for research and treatment of cancer quality of life, lung cancer questionnaire LC13 questionnaire

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  Discussion Top


About 81.6% were male with a mean age of 65.32 and most of them were smokers (77.0%). Previous Indian studies indicated, male predominance.[9] The age pattern was also similar to data from Western world.[9] Smoker to nonsmoker ratio of 2.7:1 reported earlier was observed in our study too.[9]

Most patients presented in the advanced stage of the disease, 63.2% were in stage 4 lung cancer and 61.8% had distant metastasis at diagnosis. Prior data from PGIMER Chandigarh in 1990 also showed the same.[9]

QOL is closely linked to symptom burden and severity of lung cancer.[10] EORTC QLQ-LC13 in conjunction with EORTC QLQ-C30 was found to be the best-developed instrument[8] and the English and Hindi-language version of the same has been validated for use in India.

In our study, data from the EORTC QLQ-C30 questionnaire, [Table 6] shows that in Indian patients the mean values of all functional scales are lower as compared to the western population, indicating much poorer QOL[11] at the time of diagnosis of lung cancer and hence they may have adverse outcomes of treatment interventions. Furthermore, there is a negative correlation between functional scales and stage of lung cancer, which is statistically significant in comparison to European data.
Table 6: Comparison of quality of life of all stage lung cancer patients on the basis of mean scores of functional scales in study and European organization for research and treatment of cancer reference group

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Individual symptom scales in these questionnaires [Table 7] show that Indian patients have more severe and distressing symptoms in comparison to the Western population.[11] All symptom scales had a positive statistically significant correlation with the stages of lung cancer and since most of our patients were in Stage 3 B or 4, they had worse symptoms at the onset of the diagnosis itself which needs to be kept in mind while planning therapy.
Table 7: Comparison of quality of life of all stage lung cancer patients on the basis of mean scores of symptom scales in study and European organization for research and treatment of cancer reference group

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As shown in [Table 8], the mean scores of single-item scales were statistically significantly worse in comparison to European (EORTC) data except for diarrhea and all single-item scales had positive correlation with the stages of lung cancer. In comparison to previous studies[11] dyspnea, appetite loss, and financial difficulties are much more severe in Indian patients posing extra burden of disease on them, whereas symptoms such as insomnia, constipation, and diarrhea were comparable to Western world.
Table 8: Comparison of quality of life of all stage lung cancer patients on the basis of mean scores of single item scales in study and European organization for research and treatment of cancer reference group

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The mean value of the GHS/QOL scale in our study was 32.47 ± 22.67 which is much lower in comparison to data from the European population (56.6 ± 24.3)[11] and statistically significant suggesting a poor overall QOL. Furthermore, there was a statistically significant negative correlation between GHS/QOL with the stages of lung cancer.

EORTC LC-13 Questionnaire data revealed troublesome cough was present in all patients with 49.4% scoring it to be “very much” while EORTC (European) data suggest “very much” cough to be present in only 6% of patients.[11] There was significantly more hemoptysis in Indian patients versus Western population (38% vs. 14%).[11] Sore mouth and dysphagia were “very much” present in 3.4% and 2.3% of patients, respectively, versus 21% and 36% patients in other study, respectively.[11] Such a difference in these symptoms may be related to ethnicity. Although, the correlation between all these parameters and the stage of lung cancer was not statistically significant, trends toward more symptomatology in Indian patients are likely to be due to delayed diagnosis or late reporting by patients to health caregivers.

Similarly, chest pain was present in 70.9% of our patients versus 43% in previous reports.[11] Pain in other parts of the body was absent in 65.5% versus 60% and was comparable to prior reports.[11] SOB at rest and on the walk was absent in only 34.5% and 5.7% of patients versus 69% and 35%, respectively.[11] Furthermore, SOB on climbing stairs was scored “very much” by 58.6% in our patients versus 15% by the comparative population[11] again retaliating the fact that our patients were more symptomatic both in frequency as well as the severity of symptoms. The correlation between chest pain, pain in other body parts, SOB at rest, on walk and on climbing stairs is statistically significant with worsening at higher stages of lung cancer.

The EORTC (QLQ-LC13) was the first EORTC module developed for use in international clinical trials. Since its publication in 1994, major treatment advances with possible effects on QOL have occurred. These changes called for an update and so the QLQ-LC29 was developed. The updated module contains a total of 29 items, retained 12 of the 13 original items.[12]

Quality of life in different stages of lung cancer

Since very few patients were diagnosed at Stage 1 or 2, data were insufficient to compare with any reference population. In our study, majority (81/87) were diagnosed at advanced stages, i.e., either with Stage 3 or 4 hence, we compared the mean score values of our study group for different scales of the EORTC QLQ C-30 questionnaire with standard EORTC reference values[11] as shown in [Table 9]. In advanced stages, the mean GHS/QOL and the mean PF, RF, SF scores were lower and statistically significant in the study group as compared to the European population. Hence, our patients with advanced-stage lung cancer had poor functional status.
Table 9: Comparison of quality of life of stage 3 and 4 patients on the basis of mean scores of individual scales in study and European organization for research and treatment of cancer reference group

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Symptom scale and Single item scales [Table 9] in our study were statistically significantly higher as reported from Western studies indicating more symptom burden in our population of lung cancer.

Our data show, that the patients of lung cancer are diagnosed at advanced stages of lung cancer and have significantly poor QOL as compared to their Western counterparts. There is wide variation in the symptoms both in frequency and severity among our patients versus the developed world. This heterogeneity could be due to the difference in the stage of presentation of lung cancer, level of education, and understanding of the questionnaire by the patients at the time of filling and subjective assessment of the symptoms. A large chunk of these patients had a poor QOL, which precludes definitive chemotherapy, radiotherapy, or surgical therapy. Hence, definitive therapy of lung cancer patients should target, not only the medical aspect of the disease but also to improve QOL, addressing co-morbidities, without worsening of their performance status.


  Conclusion Top


Our study shows that majority of our patients presented with advanced-stage lung cancer. They had a significantly poorer QOL as compared to their western counterparts and hence were likely to have much more adverse outcomes of treatments being offered to them. Our patients had more symptoms both in frequency as well as severity as compared to the developed world.

The limitations of this study are that it is a Single Center study at tertiary care center where patients are often referred late. Hence, referral bias is likely to influence the outcomes of the study. Larger studies are further required to validate and support our data.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ferlay J, Ervik M, Lam F, Colombet M, Mery L, Piñeros M, et al. Global Cancer Observatory: Cancer Today. Lyon, France: International Agency for Research on Cancer; 2020. Available from: https://gco.iarc.fr/today. [Last accessed on 2021 Jul 08].  Back to cited text no. 1
    
2.
National Collaborating Centre for Acute Care. The Diagnosis and Treatment of Lung Cancer: Methods, Evidence and Guidance. London: National Collaborating Centre for Acute Care; 2005. Available from: http://www.nice.org.uk/nicemedia/pdf/cg024fullguideline. [Last accessed on 2013 Jul 25].  Back to cited text no. 2
    
3.
Janssen-Heijnen ML, Houterman S, Lemmens VE, Louwman MW, Maas HA, Coebergh JW. Prognostic impact of increasing age and co-morbidity in cancer patients: A population-based approach. Crit Rev Oncol Hematol 2005;55:231-40.  Back to cited text no. 3
    
4.
Read WL, Tierney RM, Page NC, Costas I, Govindan R, Spitznagel EL, et al. Differential prognostic impact of comorbidity. J Clin Oncol 2004;22:3099-103.  Back to cited text no. 4
    
5.
WHOQOL Group. Study protocol for the World Health Organization project to develop a Quality of Life assessment instrument (WHOQOL). Qual Life Res 1993;2:153-9. [doi: 10.1007/BF00435734].  Back to cited text no. 5
    
6.
Montazeri A, Milroy R, Hole D, McEwen J, Gillis CR. Quality of life in lung cancer patients: As an important prognostic factor. Lung Cancer 2001;31:233-40.  Back to cited text no. 6
    
7.
Anant M, Guleria R, Pathak AK, Bhutani M, Pal H, Charu M, et al. Quality of life measures in lung cancer. Indian J Cancer 2005;42:125-32.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Hollen PJ, Gralla RJ. Comparison of instruments for measuring quality of life in patients with lung cancer. Semin Oncol 1996;23:31-40.  Back to cited text no. 8
    
9.
Jindal SK, Behera D. Clinical spectrum of primary lung cancer – Review of Chandigarh experience of 10 years. Lung India 1990;8:94-8.  Back to cited text no. 9
  [Full text]  
10.
Montazeri A, Milroy R, Gillis CR, McEwen J. Quality of life: Perception of lung cancer patients. Eur J Cancer 1996;32A: 2284-9.  Back to cited text no. 10
    
11.
Scott NW, Fayers PM, Aaronson NK, Andrew B, Graeff AD, Mogens G, et al. On Behalf of the EORTC Quality of Life Group: EORTC QLQ-C30 Reference Values. Brussels: EORTC; 2008.  Back to cited text no. 11
    
12.
Koller M, Shamieh O, Hjermstad MJ, Hornslien K, Young T, Chalk T, et al. Psychometric properties of the updated EORTC module for assessing quality of life in patients with lung cancer (QLQ-LC29): An international, observational field study. Lancet Oncol 2020;21:723-32.  Back to cited text no. 12
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]



 

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