Psychosocial interventions often address only 1 domain of quality of life (QOL), are offered to patients with early-stage cancer, do not include the caregiver, and are delivered after cancer treatment has been completed.
Psychosocial interventions often address only 1 domain of quality of life (QOL), are offered to patients with early-stage cancer, do not include the caregiver, and are delivered after cancer treatment has been completed.
In the current randomized controlled trial, 131 patients with advanced cancer who received radiotherapy and their caregivers were randomly assigned to either a 6-session, structured, multidisciplinary intervention arm or a standard care arm. The average age of the patients was 58 years, the majority were male (63%), and tumor types varied (gastrointestinal [37%], brain [22%], head and neck [16%], lung [13%], and other [12%]). The six 90-minute sessions addressed the 5 domains of QOL: cognitive, physical, emotional, social, and spiritual. The in-person intervention was followed by 10 brief telephone counseling sessions that took place over the next 6 months.
Of the 117 patients who completed the study, overall QOL (assessed by Functional Assessment of Cancer Therapy-General [FACT-G]) at week 4 was significantly higher in the intervention group (n = 54) compared with the standard arm control group (n = 63) (75.2 vs 68.7; P = .02). The 10 brief telephone contacts did not appear to impact QOL because at week 27 the groups had identical QOL (means of 77.6 and 77.7, respectively). There was no effect of the intervention noted on caregiver QOL.
Participating in a 6-session multidisciplinary intervention was found to be effective in maintaining the QOL of patients with advanced cancer who were actively receiving radiotherapy. The QOL and symptom burden of this population is striking, making it important to identify effective QOL strategies to implement in conjunction with cancer care. Cancer 2013. © 2012 American Cancer Society.
Quality of life (QOL) can be defined as a hierarchical, multidimensional construct comprised of a primary overall QOL and 5 subdomains of cognitive, physical, emotional, social, and spiritual functioning.1, 2 Many cancer patients experience a reduction in their QOL during and after cancer treatment.3, 4 This reduction in QOL is understandable because during the intense period of cancer treatment, many patients will experience pain, fatigue, nausea, sleep disturbance, spiritual uncertainty, distress, mood disturbance, mental status difficulties, or relationship challenges.5-7
Given the symptom burden associated with cancer treatment, it is our premise that QOL interventions should be offered during this time.1 Unfortunately, many previous interventions have focused primarily on psychosocial issues (distress, education, coping skills, or communication)8 rather than seeking to most effectively improve patients' overall QOL by targeting all 5 QOL domains. Others who have adopted this approach (eg, an intervention designed to improve the QOL of women who were surgically treated for breast cancer) have included strategies for improving health behaviors, reducing stress, problem solving, support, assertiveness, increasing physical activity, coping with treatment side effects, and adhering to medical treatment.9 In a previous study of 103 patients with advanced cancer who underwent radiotherapy, it was found that participation in an 8-session, structured, multidisciplinary QOL intervention maintained QOL during cancer treatment,2 and the caregivers of these patients recommended that caregivers be included in the QOL intervention.10
Therefore, this primary objective of the current study was to replicate the previous finding that a multidisciplinary intervention can maintain the QOL of patients with advanced cancer who are actively receiving radiotherapy, providing further empirical support for the delivery of QOL interventions during active cancer treatment. The secondary aims were to positively impact caregiver QOL by including them in the intervention and to improve long-term patient QOL by providing ongoing support through regular telephone contact during the 6-month follow-up period.
A randomized, 2-group, controlled clinical trial was conducted to compare the efficacy of a 6-session, structured, multidisciplinary intervention including caregivers and 10 brief telephone counseling sessions with standard care in maintaining overall QOL in patients with advanced cancer undergoing radiotherapy. The primary endpoint was the patients' Functional Assessment of Cancer Therapy-General (FACT-G) score at week 4. The study was reviewed and approved by the Institutional Review Board of the Mayo Clinic.
Participants were recruited from adult patients with advanced cancer who were being treated at the cancer center and who were scheduled to undergo radiotherapy. Eligibility criteria included an age of ≥18 years; an initial diagnosis of cancer within the previous 12 months; intermediate to poor prognosis (0%-50% expected 5-year survival rate as judged by the primary radiation oncologist enrolling the participant); Eastern Cooperative Oncology Group (ECOG) performance status of 0, 1, or 2; the patient being scheduled for at least 1 week of radiotherapy; and a caregiver who was also willing to participate. Exclusion criteria included a Mini-Mental State Examination (MMSE) score <20, an expected survival of <6 months, active substance abuse (alcohol or drugs), participation in other psychosocial trials, active untreated thought disorder (eg, bipolar disorder or schizophrenia), suicide risk, or patients in need of psychiatric hospitalization. Participants receiving psychotropic medications or counseling were not excluded.
The study coordinator approached all patients meeting study eligibility criteria. Written informed consent was obtained from each participant (patients and caregivers) before study participation. A psychologist or psychiatrist screened potential participants for disqualifying psychiatric disorders and active suicidality. Participants were randomly assigned to either the structured intervention arm or the standard medical care arm. For intervention group participants, a physiatrist provided medical clearance and guidance for the physical therapy component. Stratification for type of primary malignant disease, ECOG performance status, age, and treatment planned was undertaken.
Participants provided demographic data at baseline (Table 1) and completed study questionnaires before starting the intervention. Because there was rolling entry onto the intervention group, participants attended the 6 sessions in no particular order. The intervention was delivered on Tuesdays, Wednesdays, and Thursdays; caregivers attended only the Tuesday and Thursday sessions. The number of patients in the intervention at any time ranged from 1 to 4 with up to an additional 4 caregivers. At baseline, week 4, and week 27, all participants received a study packet questionnaire. A study psychologist (master's or doctoral level) completed the majority of the structured brief telephone contacts. A physical therapist made the calls for week 8 and week 18. Intervention participants were included in the analysis for the primary endpoint if they completed at least 4 of the 6 sessions (two-thirds of the intervention) and completed both baseline and week 4 questionnaires.
|Characteristics||Intervention Group (n = 65)||Control Group (n = 66)|
|Mean age (SD), y||58.7 (10.6)||59.9 (10.9)|
|Female||24 (37%)||21 (32%)|
|Male||41 (63%)||45 (68%)|
|Race White||63 (97%)||64 (97%)|
|Yes||37 (57%)||40 (61%)|
|Married||59 (91%)||56 (85%)|
|Single||1 (2%)||2 (3%)|
|Widowed||5 (7%)||2 (3%)|
|Catholic||18 (28%)||28 (42%)|
|Protestant||39 (60%)||35 (53%)|
|None||5 (7%)||2 (3%)|
|Other||3 (5%)||1 (2%)|
|Mean MMSE score (SD)||29.1 (1.3)||29.2 (1.2)|
|ECOG PS, fully active||33 (51%)||31 (47%)|
|Mean Beck Depression||10.3 (7.0)||9.6 (4.9)|
|Brain||11 (17%)||18 (27%)|
|Gastrointestinal||25 (39%)||24 (36%)|
|Head and neck||10 (15%)||11 (17%)|
|Lung||10 (15%)||7 (11%)|
|Other||9 (14%)||6 (9%)|
|Current chemotherapy||56 (86%)||57 (86%)|
|Prior surgery||60 (92%)||64 (97%)|
|Currently employed||41 (63%)||40 (61%)|
|Divorced||3 (5%)||4 (6%)|
|Married||57 (87%)||58 (88%)|
|Single||3 (5%)||3 (4%)|
|Widowed||2 (3%)||1 (2%)|
The ECOG performance status is a numeric representation of an individual's ability to do daily work and their need for assistance. The scale ranges from 0 (normal with no complaints) to 5 (dead). The MMSE is the most widely used screening test for assessing mental status and dementia and includes items relating to orientation, memory, executive functions, and language.11 The Beck Depression Inventory-II (BDI-II) is a 21-item scale used to assess the current severity of depression symptomatology. The BDI-II closely corresponds to diagnostic criteria for depression12, 13; a study psychologist or psychiatrist reviewed the BDI-II with patients as part of the enrollment process.
The FACT-G (version 4)14, 15 is a well-validated, 28-item, general patient-rated QOL life measure for cancer patients with any tumor type. Each item is scored from 0 to 4, anchored from “not at all” to “very much.” There are 4 subscales: Functional Well-Being (7 items), Physical Well-Being (7 items), Social/Family Well-Being (7 items), and Emotional Well-Being (6 items). The FACT-G total score is the sum of the subscales, and ranges from 0 to 108. The FACT-G has been widely used in clinical trials, is easy to complete, and has demonstrated sensitivity according to performance status and extent of disease.
The Caregiver Quality of Life Index-Cancer Scale is a 35-item, 5-point Likert-type scale16 that assesses the physical, social, financial, psychological, caregiver burden, and family dimensions of QOL. Internal consistency has ranged from 0.87 to 0.90;, test-retest reliability from 0.69 to 0.95; and content, discriminant, and group validity in cancer populations has been established.17
Over a 57-month period, of a possible 946 radiation oncology patients being treated who met the criteria, 138 agreed to participate in the current study (Fig. 1). Information was not obtained from those patients who declined participation. Randomization was completed using standard Pocock-Simon randomization procedures.18 Nine participants did not complete randomization. Of the 129 randomized participants, 8 were excluded as a result of not attending at least 4 of the 6 intervention sessions (1 because of death and 7 because of illness). One control participant and 3 intervention participants were excluded for not completing the week 4 assessments. Between week 4 and the week 27 follow-up, 3 of the intervention participants and 4 of the control participants died.
The structured, multidisciplinary intervention focused on specific strategies to address all 5 QOL domains (Table 2).2 The content was developed by a multidisciplinary treatment team and designed to impact physical, mental, social, emotional, and spiritual QOL.2 The content of the 6 sessions was derived from our prior 8-session multidisciplinary intervention and from recommendations of these previous study participants.19, 20 The recommendations were that the intervention be modified to include caregivers10 and that substance use (alcohol and tobacco), mood disorders, anxiety disorders, sleep disorders, and sleep hygiene all be addressed.21 The patients also requested that some of the sessions be for patients only, so that they would feel comfortable disclosing their distress without being concerned about burdening their or other caregivers. Caregivers were invited to attend sessions 1, 3, 4, and 6. Each session was designed to stand alone to accommodate ongoing enrollment. Sessions were 90 minutes long, starting with 20 minutes of conditioning exercises led by a physical therapist22 followed by education, cognitive behavioral strategies for coping with cancer,23-25 open discussion, and support, and concluding with a 15-minute deep breathing or guided imagery relaxation segment. A clinical psychologist or psychiatrist led each session; other study staff members varied from an advanced practice nurse, a certified hospital chaplain, or a licensed independent clinical social worker, depending on the specific session content. Three sessions of the multidisciplinary intervention addressed spiritual QOL, during which a certified hospital chaplain asked 2 structured open-ended questions related to the day's topic (eg, life review, meaning and purpose, blessings and burdens) and invited study participants into conversation.26, 27 The chaplain's goal was to provide an invitation to discuss hopes and concerns in an accepting and supportive environment, engage in active listening, and provide appropriate counsel. Discussions of each spiritual topic lasted 20 to 30 minutes. To address fidelity of treatment, data projector images were used for each session, written materials were standardized and used at each session, participants received a 200-page manual, and all intervention staff received training. To promote long-term adoption of the coping strategies, participants received 10 brief structured telephone counseling sessions (Table 3).
|Time||Session 1: Caregivers Invited||Session 2: Patients Only||Session 3: Cargivers Invited||Session 4: Caregivers Invited||Session 5: Patients Only||Session 6: Caregivers Invited|
|15 min||Physical therapy||Physical therapy||Physical therapy||Physical therapy||Physical therapy||Physical therapy|
|30 min||Health behavior changes: how to eat healthy and to avoid alcohol and nicotine during cancer treatment||Mood management: distress, depression, anxiety disorders, and sleep disorders||Coping with cancer: the role of thoughts and behaviors||Social needs: advanced directives, finances, community resources||Defining your quality of life||Communication strategies with health care providers and your support system|
|30 min||Radiation and chemotherapy education topics: self-care and symptom management||Spirituality: life review||Spirituality: meaning and purpose||Record keeping: symptoms, food intake, pain, and health status||Spirituality: grief, loss, hope, and blessings||Maintenance: distress|
|Coping strategies||Health behaviors|
|Benefits of physical activity||Physical activity|
|15 min||Relaxation training||Relaxation training||Relaxation training||Relaxation training||Relaxation training||Relaxation training|
|Time Point||Brief Telephone Contact Topic||Mailing of Written Self-Help Material||Individually Tailored Questions|
|Week 5||Review of self-care: journaling relaxation||Relaxation CD||Are you using self-care strategies?|
|Week 6||Mood management skills||Extending a Hand of Hope (ACS)||How is your distress level?|
|Week 7||Spiritual needs||Taking Time: Support for People With Cancer and the People Who Care About Them (NIH)||How are you doing from a spiritual perspective?|
|Week 8||Physical therapy||Complete the exercise behavior measures with the participant|
|Week 10||Health behavior changes||How are your health behaviors (eg, diet, smoking)?|
|Week 12||Communication and social support||How is your support system?|
|Week 14||Social needs||Have you completed your advance directives? Have you been able to access community resources? Have you addressed your financial planning needs?|
|Week 16||Mood assessment||How is your distress level?|
|Week 18||Physical therapy||Complete the exercise behavior measures with the participant|
|Week 20||Questions for us/open agenda||What would you like to review today? How is your quality of life?|
|Week 27: all subjects||Thank you for your participation in our research protocol||Study questionnaires||Any feedback for us on your participation in the study? How is your quality of life?|
The control group received standard medical care as recommended by their radiation oncologist, including medical appointments and referrals to specialists such as medical oncology, surgery, primary care, neurology, gastroenterology, or pulmonary care when needed.
The primary endpoint was the participant's QOL at the end of the intervention, which was approximately week 4 after randomization. The intervention's short-term impact was measured by the QOL change from baseline as reported on the FACT-G at week 4; long-term impact was measured by changes at week 27. All assessments were scored according to the specific scoring algorithms. Scores were converted to a scale of 0 to 100 for comparability, with 100 being best QOL. Summary statistics were compiled to compare study arms. Kruskal-Wallis or chi-square methodology was used as appropriate. Supplementary analyses via analysis of variance/generalized estimating equations (ANOVA/GEE) modeling were used to determine associations between QOL scores and sociodemographic variables. Furthermore, the empirical rule of statistical theory and the work of Cohen in defining small-, moderate-, and large-effect sizes for behavioral endpoints were used.28 This approach defines 3%, 8%, and 12% shifts in the average QOL scores between study groups as indicative of these clinically important differences. Summary statistics of the effect size distribution per assessment were calculated. All hypothesis testing was performed using 2-tailed alternatives and a 5% type I error rate. The study was ensured to have 80% power to detect a clinically significant difference of 0.5 standard deviations (a shift of ≥ 8% on a 100-point scale) in QOL scores between study arms. Any smaller effect was likely to be unimportant and, for the pragmatic purposes of this intervention, not clinically meaningful. The study was powered to declare such a difference statistically significant as well. Hence, any statistically significant result gleaned from the current study will have inherent clinical significance.
Baseline characteristics were balanced across treatment arms (Table 1). On average, patients were aged in their late 50s (average age, 59.3 years), approximately two-thirds were male (65.6%), nearly all the patients were white (97%), greater than one-half were employed (58.8%), the majority were married (87%), and most reported their religious affiliation as Protestant (56.5%) followed by Catholic (35%). Tumor types were 37% gastrointestinal, 22% brain, 16% head and neck, 13% lung, and 12% other; nearly all patients had undergone surgery (95%); and >85% were also receiving chemotherapy. The majority of caregivers were the significant other (79%) and were employed (62%).
Total FACT-G scores were found to be significantly different between the study arms at week 4, with the intervention patients having a higher average overall QOL (mean, 74.2 vs 68.7; P = .02) (Tables 4 and 5). Change from baseline analysis indicated that the intervention arm maintained an overall QOL (mean change, -1.4; standard deviation, 24.25), whereas patients in the control arm experienced a reduction in overall QOL (mean change, −6.2; standard deviation, 19.93) (P = .01). In an intent-to-treat analysis, assuming that nonevaluable patients were failures (defined as having a clinically meaningful QOL decrease [8%] at week 4), no statistically significant difference was found between treatment arms (P = .54) (Table 6). Assuming that these patients were successes (ie, they maintained or improved their QOL), patients in the intervention arm had fewer failures than those in the standard care arm (14 vs 26; P = .02).
|Intervention||Control||Kruskal- Wallis P-value|
|Baseline, mean (SD)||75.2 (13.8) (n = 65)||74.8 (11.4) (n = 64)||.59|
|Week 4, mean (SD)||74.2 (12.6) (n = 54)||68.7 (13.1) (n = 63)||.02|
|Week 27, mean (SD)||77.6 (12.1) (n = 51)||77.7 (11.8) (n = 59)||.88|
|Subscale||Baseline||Week 4||Week 27|
|Intervention||71.9 (20.9)||67.7 (20.7)||76.4 (17.8)|
|Control||70.8 (17.1)||57.7 (21.7)b||76.7 (16.6)|
|Intervention||85.9 (11.8)||85.6 (12.4)||84.6 (14.4)|
|Control||84.4 (12.7)||83.7 (13.3)||82.5 (15.0)|
|Intervention||79.2 (17.5)||79.8 (15.5)||80.0 (12.6)|
|Control||81.4 (13.6)||78.4 (17.5)||81.2 (14.1)|
|Intervention||64.5 (20.3)||64.5 (17.8)||69.9 (19.4)|
|Control||63.6 (22.2)||57.1 (21.3)||71.4 (17.5)|
|Intervention Group (n = 65)||Control Group (n = 66)||Total (N = 131)||P|
|All missing are success||<.05|
|Fail||14 (21.5%)||26 (39.4%)||40 (30.5%)|
|Success||51 (78.5%)||40 (60.6%)||91 (69.5%)|
|25% of missing are assigned as failure||.11|
|Fail||17 (26.2%)||26 (39.4%)||43 (32.8%)|
|Success||48 (73.8%)||40 (60.6%)||88 (67.2%)|
|50% of missing are assigned as failure||.30|
|Fail||20 (30.8%)||26 (39.4%)||46 (35.1%)|
|Success||45 (69.2%)||40 (60.6%)||85 (64.9%)|
|75% of missing are assigned as failure||.64|
|Fail||23 (35.4%)||26 (39.4%)||49 (37.4%)|
|Success||42 (64.6%)||40 (60.6%)||82 (62.6%)|
|All missing are failure||.42|
|Fail||25 (38.5%)||30 (45.5%)||55 (42.0%)|
|Success||40 (61.5%)||36 (54.5%)||76 (58.0%)|
The Physical Well-Being subscale of the FACT-G was also found to be statistically significantly different between the study arms at week 4 (P < .01). Change from baseline indicated that patients in the intervention arm experienced a nonclinically significant reduction (4.2 points) in Physical Well-Being, whereas patients in the standard arm had a decline of 13.1 points (P < .01). The Functional Well-Being subscale change from baseline at week 4 was also statistically significant, with patients in the intervention arm maintaining their QOL whereas those in the standard care arm experienced a decreased QOL (mean, -0.3 vs -7.1; P = .02). There were no statistically significant or clinically meaningful differences noted with regard to total or change scores, either between or within the study arms, at week 27 (Tables 4–6).
Caregiver QOL (measured by the Caregiver Quality of Life Index-Cancer Scale) was maintained at a low level over time, both in the intervention and standard care arms, with the average QOL scores remaining in the 50s on the scale of 0 to 100 points throughout the study (Table 7).
|Scale||Intervention Caregivers||Control Caregivers|
|Baseline||55.5 (±20.7) (n = 65)||54.0 (±19.5) (n = 65)|
|Week 4||58.0 (±20.7) (n = 54)||57.7 (±19.6) (n = 62)|
|Week 27||58.5 (±20.3) (n = 52)||59.1 (±20.5) (n = 58)|
There were no between-group differences noted with regard to other study measures, which included the Profile of Mood States,29 Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being scale,30 Pittsburgh Sleep Quality Index,31 and Exercise Behaviors.32
Week 4 change from baseline was modeled using ANOVA/GEE procedures to determine whether there was a relation between baseline characteristics and study results. Study arm, tumor type, and ECOG performance status were all found to be significant contributors to the change from baseline, but the model itself was not a good fit, explaining only 27% of the variability in the change scores. The independent factors of cancer treatment regimen and age group were not found to be statistically significant.
QOL is important during active cancer treatment and through survivorship. In this randomized controlled trial of a multidisciplinary structured intervention targeting all 5 QOL domains, participants diagnosed with advanced cancer were able to maintain their QOL while receiving radiotherapy. In contrast, those in the standard care arm demonstrated a reduction in their QOL. Given the significant symptom burden and side effects associated with receiving radiotherapy combined with the side effects of surgery and chemotherapy, this is an important, clinically meaningful, and statistically significant outcome. This study involved a cancer population receiving limited psychosocial empirical attention; the majority of published psychosocial interventions are delivered after the completion of active cancer care, recruit patients with early-stage cancer, or have mostly female participants.
The finding that intervention participants were able to maintain their overall QOL during radiotherapy appears to be due in large part to the domain of physical QOL. Several of the interventional strategies may account for this significant difference in physical QOL. Perhaps foremost in impacting physical QOL was the physical therapy assessment and intervention. Participants met with a physiatrist, and each session began with 15 minutes of physical activity instructed by a physical therapist. A majority of patients with cancer, even those situated in rural areas, have access to physiatric and physical therapy services that are, at least partially, covered by third-party payers.33 The exercises included in the trial were designed to be simple and well within the purview of community-based therapists to ensure generalizability. Physician attention to a behavior has been shown to promote positive behavior change, and the advice from the study psychiatrist may have enhanced motivation for physical activity.34 In addition, the nurse educator provided information about the side effects of cancer treatment and strategies for symptom management that may have specifically impacted physical well-being. The participants were also taught the importance of record keeping and communication strategies with caregivers and health care providers to minimize pain and discomfort. The in-session relaxation training also might have helped participants to manage symptoms (eg, pain and nausea) and reduce stress levels. Maintaining physical activity levels during cancer treatment has been shown to reduce treatment-related fatigue; therefore, this dimension of the multidisciplinary intervention might have been the key component to maintaining overall QOL during radiotherapy.
The intention of the brief telephone contacts was to improve QOL once active cancer treatment was completed and to provide ongoing support to patients and caregivers. Telemedicine is an exciting new strategy for improving cancer care.35 Investigators discovered that providing telecare management can reduce pain and depression in patients with cancer.36 Although it is disappointing that QOL did not improve over the follow-up period, participants did maintain their QOL level throughout the study. In seeking sources of potential symptom burden, many participants continued to receive chemotherapy or undergo further surgery during study follow-up. In addition, the side effects of radiotherapy, surgery, and chemotherapy can have an extended negative impact on QOL. Perhaps the inability to improve QOL during a time of continued cancer-related symptom burden and side effects is understandable in a population of cancer patients still receiving cancer care and who have numerous ongoing health issues. If confirmed by other investigators, it is plausible that multidisciplinary interventions can be designed and delivered to improve the QOL of those individuals diagnosed with early-stage cancer, and that multidisciplinary interventions can be tailored to maintain the QOL of those diagnosed with advanced-stage cancer.
Because previous research has shown that caregivers can experience significant burden, it is disappointing that the intervention did not impact the QOL of caregivers.10 In this intervention, the strategies used to impact caregiver QOL were to improve patient QOL and to involve the caregiver in the intervention. At the study's end, many caregivers expressed the desire for 2 major changes. The first was that the caregivers believed their needs could have been better addressed in a separate caregivers-only group. Many stated they did not want to express how challenging it is to be a cancer caregiver around their loved ones, or even in the presence of other cancer patients, but believed discussing their burden with other caregivers would have been beneficial to them. Second, they inquired whether they could be taught (similar to our patient-focused interventions) specific strategies for improving their own QOL. Perhaps incorporating these 2 strategies would prove beneficial to the cancer caregivers' QOL.
The current study had several limitations. Because of the demographics of the cancer patient population at the cancer center, the sample population was primarily white, Christian, and Midwestern. Therefore, these findings might not apply to more diverse populations. The recruitment rate, although similar to most psychosocial interventions, was low: < 25% of those patients were eligible. Therefore, the identification of QOL enhancement strategies with greater appeal to cancer patients is needed. Finally, the cost and availability of a highly skilled multidisciplinary team might make the offering of this intervention possible only at large cancer centers or only through the exploration of telemedicine. Future research could also explore the delivery of a multidisciplinary development QOL intervention delivered by a trained facilitator to evaluate a cost-effective dissemination of the intervention.
Participation in a 6-session multidisciplinary intervention was found to be effective in maintaining the overall QOL in patients with advanced cancer who were receiving radiotherapy. The results were found in both genders and across patients with a range of tumor types. It is important to enhance the QOL of cancer survivors and their caregivers and therefore future studies should further explore strategies to impact the long-term QOL of patients with advanced cancer and begin identifying effective strategies for improving the QOL of cancer caregivers as well.
Supported by the Linse Bock Foundation and the Sponsorship Board, Saint Marys Hospital, Mayo Clinic.
CONFLICT OF INTEREST DISCLOSURES
The authors made no disclosures.