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Quality of Life of Long-Term Survivors of Non–Small-Cell Lung Cancer

From the School of Nursing, Departments of Surgery and Medicine, and Integrated Substance Abuse Program, University of California Los Angeles, Los Angeles; School of Nursing, California State University, Los Angeles; and School of Nursing, University of California San Francisco, San Francisco, CA.

Address reprint requests to Linda Sarna, DNSc, School of Nursing, University of California, Los Angeles, 700 Tiverton Ave, Box 956918, Factor 4-262, Los Angeles, CA 90095-6918; email: lsarna{at}sonnet .ucla.edu.

	ABSTRACT

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION REFERENCES

 
PURPOSE: To describe the quality of life (QOL) among survivors of non–small-cell lung cancer (NSCLC).

PATIENTS AND METHODS: One hundred forty-two 5-year minimum self-reported disease-free survivors of NSCLC completed QOL instruments (QOL-Survivor and Medical Outcomes Study 36-Item Short Form [SF-36]) and assessments of emotional distress (Center for Epidemiologic Studies Depression Scale [CES-D]), comorbid disease, and tobacco use. Pulmonary function was assessed with a hand-held spirometer. Multivariate regression methods were used on total QOL-Survivor scores and physical (PC) and mental (MC) component scores of the SF-36.

RESULTS: The majority (71%) of survivors described themselves as hopeful, and 50% viewed the cancer experience as contributing to positive life changes (QOL-Survivor). Comorbidity was common (60% one condition); 22% had distressed mood (CES-D 16). Most were former smokers (76%); 13% continued to smoke. Half had moderate/severe pulmonary distress (forced expired volume in 1 second [FEV₁] < 70% of predicted). Regression models including the set of variables (age, sex, living alone, education, smoking status, pulmonary function category, distressed mood, time since diagnosis, and comorbidity) accounted for 37%, 48%, and 29% in the QOL-total, MC, and PC scores, respectively. Primary predictors of lower QOL scores were white ethnicity and distressed mood (CES-D 16) (34% of the variance explained). The primary predictor of lower MC scores was distressed mood (R² = 0.45). Lower PC scores were associated with older age, living alone, FEV₁ less than 70% of predicted, distressed mood, time since diagnosis, and more comorbid diseases (R² = 0.28).

CONCLUSION: These findings provide the first description of the QOL of long-term survivors of lung cancer. Risk factors for poorer QOL are strongly linked to distressed mood, which is a potential target for intervention.

	INTRODUCTION

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION REFERENCES

 
LUNG CANCER IS one of the most common cancers affecting Americans, accounting for 14% of all cancers. Slightly more than half (54%) of lung cancers occur in men.¹ Self-reported multidimensional health-related quality-of-life (QOL) data describing physical, psychological, social, and spiritual well-being after the diagnosis of cancer have been increasingly published for the estimated 9 million cancer survivors in the United States.^2-5 However, information about lung cancer survivors, the great majority of whom have non–small-cell lung cancer (NSCLC), is almost nonexistent.⁵ Because of the generally poor prognosis for lung cancer, 14% 5-year survivorship for all stages combined, the overwhelming focus of QOL research in patients with lung cancer has been on patients with active advanced stage disease.⁶ Information about QOL of survivors of lung cancer can provide health care providers with a perspective of posttreatment recovery, including the positive aspects of long-term rehabilitation, and anticipated problems and issues that can be shared with patients and families. Factors that might put some survivors at a higher risk for diminished QOL can be identified, and rehabilitation programs and long-term surveillance can be tailored appropriately.

Curative treatment for NSCLC is almost exclusively surgical. Approximately 30% of patients with NSCLC have potential curable disease at the time of diagnosis; reported 5-year survival for stage I tumors is as high as 70% and as high as 30% for stage II tumors.^1,7 Long-term survival also can be seen for selected patients with stage IIIa disease who receive surgical resection.⁸ Fear of and uncertainty about recurrence are prevalent among cancer survivors.⁴ Recurrence of lung cancer most often occurs within the first 2 years after diagnosis^9,10 but continues to be a risk even after 10 years. Additionally, survivors may continue to be at risk for other tobacco-related primary cancers.

The survivor’s assessment of QOL can provide different data than that of a medical appraisal.^5,11,12 QOL end points have become important benchmarks for evaluating short- and long-term cancer treatment outcomes and have been used as an independent prognostic predictor^13,14 for lung cancer survival. In an extensive review of QOL literature (1970 to 1995)⁵ pertaining to NSCLC, 42 studies were identified; only one focused on QOL after thoracotomy,¹⁵ and none focused on long-term survivors.

QOL is generally conceptualized as a multidimensional construct with physical, psychological, and social domains and, depending on the instrument, spiritual or existential well-being.^2-5 The physical domain of QOL has received the most attention in assessments of patients with lung cancer, especially in the postoperative period.⁶ Diminished exercise capacity and restrictions in physical activities and day-to-day tasks have been identified as short-term consequences of lung cancer resection.^15-20 Decline in physical function, regardless of changes in pulmonary function after thoracotomy, is not inevitable.¹⁸ At least one study suggests that changes in physical function may persist,²⁰ and others have suggested that those with pulmonary decline may face serious problems in function,^19,21 especially among those patients receiving a pneumonectomy.¹⁸ Because lung cancer is more common in older adults, smoking-related chronic airflow obstruction and comorbid disease,²² especially that related to substantial tobacco use,²³ may contribute to compromised physical QOL of survivors.

Most of the literature on the emotional impact (psychological QOL) of lung cancer has focused on patients with advanced lung cancer.^5,24 Depression among patients with cancer, especially inoperable lung cancer, has been identified as a serious problem affecting multiple aspects of QOL,^25,26 but the incidence among survivors is unknown. As time from diagnosis lengthens, lung cancer survivors’ priorities may shift from illness and treatment-related problems to social and interpersonal concerns. The impact of lung cancer on the social aspects of QOL, including family life, have received little attention.⁶ Evidence is growing that the search for meaning or spiritual well-being is an important aspect of cancer survivorship.^2,27,28 Among lung cancer survivors, this might be especially relevant given the rarity of long-term survivorship.

The purposes of this study were to describe the QOL among long-term survivors of NSCLC and to explore the relationships of demographic, tobacco use, health status (comorbid conditions, pulmonary function, and depressed mood), and clinical characteristics with appraisals of QOL. We hypothesized that QOL would be different by sex, smoking status, and the presence of comorbidity. We also examined how perceptions of QOL of NSCLC survivors compared with published norms for older adults and people with chronic lung conditions. A cross-sectional approach was selected for this initial study because of the lack of descriptive information about QOL among long-term lung cancer survivors.

	PATIENTS AND METHODS

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION REFERENCES

 
Eligible participants who had been diagnosed with NSCLC at least 5 years previously and were, to their knowledge, free of lung cancer were identified through tumor registries and through thoracic surgical oncology practices in Southern California between 1998 and 2000. Patients who had experienced a recurrence of lung cancer or a second primary tumor lung cancer were eligible if the recurrence was more than 5 years previous to the interview and patients were disease-free from lung cancer. Participants with a history of nonpulmonary forms of cancer as well were allowed, regardless of when the second cancer was diagnosed. Exclusion criteria included diagnosis with small-cell lung cancer or other types of cancer involving the lung (eg, mesothelioma, lung metastasis, and carcinoid) and cognitive impairment. To determine representativeness of lung cancer survivors in this study, we compared our sample with nonrespondents from the Los Angeles Tumor Registry on the following characteristics: sex, age, and histology.

The study was approved by the institutional review board at the University of California Los Angeles (UCLA). Potential participants were recruited via letters describing the study and requesting their participation. Our institutional review board required potential participants to call us (at a toll-free number) if they were interested in participating or obtaining additional information. A telephone script was used to ensure consistent information about the study. Participants were paid $75 for their time and efforts. Interviews occurred in the subjects’ homes or in the research office. One week after the interview, a follow-up telephone call was made to complete two of the surveys if required to minimize subject fatigue. Information about the clinical characteristics of lung cancer and its treatment were obtained from the medical record.

QOL Questionnaires
QOL was assessed with both a generic and a cancer-specific instrument. The Rand-36 (also known as the Medical Outcomes Study 36-Item Short Form [SF-36], version 1.0) is a generic QOL instrument that assesses eight health concepts (physical function, role limitations caused by physical problems, role limitations caused by emotional problems, social function, emotional well-being, energy/fatigue, pain, and general health perceptions).²⁹ Higher scores indicate better QOL. Scores standardized to national norms and weighted averages are used to create summary physical component (PC) and mental component (MC) scores on a standard scale. These scores allowed us to compare our results with published findings in older adults and in a cohort with chronic lung disease (self-reported as bronchitis, asthma, or emphysema).³⁰ The SF-36 has well established reliability and has been reported to be sensitive to changes at 1, 6, and 12 months after thoracic surgery for NSCLC.²⁰ Cronbach’s alpha coefficient for all of the subscales for this study sample was more than 0.75.

The 41-item QOL (Cancer Patient Version) revised for cancer survivors (QOL-Survivors) was used as a cancer-specific measure of QOL.^2-4 The instructions to the survey include the statement "how your experience of having cancer affects your quality of life." Four subscales (physical, social, psychological, and spiritual well-being) assess the impact of cancer and cancer treatment on the QOL of cancer survivors. The QOL total score (average across items) and the four QOL subscale scores were used as outcomes. Transformations were performed such that higher scores indicated better QOL for all of the subscales. The reliability (Cronbach’s alpha coefficient) for this sample was more than 0.75 for all subscales except for the spiritual subscale (alpha = 0.69).

Tobacco Use
Assessment of tobacco history and current smoking status was obtained through self-report surveys based on questions from the Lung Health Survey.³¹ Self-reports of smoking behavior may be unreliable. However, if patients know that biochemical verification will occur, this tendency decreases. Biochemical validation of smoking status was performed at the time of the interview using a urine sample and cotinine dipstick (Serex, Inc, Maywood, NJ). Cotinine, the major metabolite of nicotine, has a half-life of approximately 19 hours and serves as a reliable and valid measure for distinguishing between smokers and nonsmokers.³² Smoking status was classified as current, former, and never smoker for this analysis. Pack years of smoking were calculated as the number of packs of cigarettes smoked per day during the years of smoking.

Health Status
Health status was evaluated in several ways. The presence of comorbid diseases was assessed by self-report based on a listing of 15 chronic conditions from the Lung Health Study assessment of comorbid conditions³¹ and by assessment of pulmonary function. Available medical chart data were reviewed to supplement data on the self-report. Three of the conditions (heart attack, unstable angina, and heart failure) were combined in a summary to measure heart disease. The presence of cancers other than lung cancer were noted, and the percentage of those commonly attributable to tobacco were identified. If a condition was present, participants were asked if the condition occurred after lung cancer treatment. The number of conditions present at the time of the interview was used in the analysis.

Assessment of pulmonary function allowed us a more objective measure of health status. Measurement of pulmonary function was performed using forced expiratory spirometry with determination of forced expired volume in 1 second (FEV₁), forced vital capacity, and FEV₁–forced vital capacity ratio. Spirometry was performed by specially trained research nurses using an automated flow-sensing spirometer (Spirovit-10; Schiller America, Tustin, CA) according to American Thoracic Society criteria.³³ Spirometry was performed at least in triplicate without bronchodilators using standardized procedures conforming to all American Thoracic Society recommendations for adequacy of spirometry performance.^34-36 Survivors were categorized by percent-predicted FEV₁ into better ( 70% predicted) and poorer pulmonary function categories (< 70% predicted) as potential predictors of QOL in this report.

Distressed mood was considered as a comorbid condition and was assessed using the Center for Epidemiologic Studies Depression Scale (CES-D).³⁷ Total possible scores can range from 0 to 60, with scores greater than 15 indicating significant levels of depression symptomatology and distressed mood, including anxiety. Acceptable reliability and validity including discrimination between normal and clinical samples have been reported.³⁸ A cut point for the CES-D was used to group survivors into two groups to indicate distressed mood (possible depression) ( 16) and not distressed groups (< 16).

Demographic and Clinical Variables
Demographic variables were collected on a self-report survey at study entry. Height and weight (with participant fully clothed) were measured at the time of interview, and body mass index (height in meters/weight in kilograms²) was calculated. Clinical characteristics assessed via the medical record included time since diagnosis, histologic type of NSCLC, stage of disease, extent of surgery, and other treatments.

Analyses
Descriptive statistics, as appropriate, were used to provide a profile of QOL and QOL dimensions. QOL analyses were carried out on the PC and MC scores (SF-36) and the global QOL-Survivor score as well as the four subscales (physical, psychological, social, and spiritual). Comparisons of the PC and MC scores were made between published normative data of the SF-36 by an older age group (> 65 years) and respondents who had a self-report of chronic lung disease.³⁰

QOL scores were compared by demographics (age, sex, race/ethnicity, education, income, Medicare only v other health coverage, and body mass index), tobacco use (never, former, and current), health status variables (number of comorbid conditions, heart disease group, other cancer group, emphysema/chronic obstructive pulmonary disease [COPD] group, pulmonary function category, and CES-D distressed mood category), and clinical characteristics (histology, time since diagnosis, and extent of resection). Additionally, we evaluated differences in demographic and clinical characteristics by sex. As a preliminary screen, we looked at the bivariate associations between each of the potential demographic, tobacco use, health status, and clinical predictors versus QOL (QOL-Survivor global score, physical, psychological, social, and spiritual subscales, and the PC and MC scores). We used analysis of variance methods for discrete predictors, such as smoking status, and Pearson’s or Spearman (rank order) correlations for continuous predictors, such as age. Regression analysis was used to examine multivariate models of the QOL-Survivor total score and the PC and MC scores, including demographic, tobacco use, health status, and clinical variables found to be at least modestly related to QOL in the preliminary analyses, or, in view of the investigators, to be clinically important (age, living status, tobacco status, and time since diagnosis).

To examine the prevalence of concerns among survivors, the responses to five individual items from the QOL-Survivor questionnaire pertaining to (1) specific fears about recurrence, (2) metastasis, (3) a second cancer, (4) positive changes after diagnosis, and (5) level of hopefulness were evaluated. Additionally, the frequency of distress (reversed ratings 0 to 4, with 0 the most distressing) among items in the QOL-Survivor physical, social, and psychological subscales reported by 20% or more of the sample was described. The spiritual well-being items were not included in this tabulation because these items assess the level of individual importance rather than distress. Because of the primary focus on exploration, no statistical adjustment for multiple tests was performed; thus conservative interpretation is suggested. Statistical analysis was carried out using SAS (SAS Institute, Cary, NC) and SPSS software (SPSS Inc, Chicago, IL).

	RESULTS

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Sample
Almost 1,000 letters (n = 995) requesting participation in the study were sent to survivors identified through the tumor registries at UCLA (n = 190), Los Angeles County (n = 775), and community oncology offices (n = 100). After accounting for returned mail (n = 108), the initial response was 195 (22%). Response rate was varied by recruitment site (UCLA, 61%; community practices, 26%; Los Angeles County Registry, 10%). Fifty-four potential subjects who contacted the office declined or were unable to participate because of the presence of exclusion criteria (n = 14, including eight who participated in an initial interview), lack of interest (n = 22), health limitations (n = 6), or other reasons (n = 11). The final sample of 142 was composed of survivors from the UCLA hospital tumor registry and UCLA physician offices (n = 77; 54%), the Los Angeles County tumor registry (n = 42; 30%), and community sites (n = 23; 16%). This comprised 79% of those who responded and 16% of all those solicited by mail. The sample in this study is not significantly different in sex distribution, age, or histology (adenocarcinoma or squamous cell) from nonresponders listed in Los Angeles County Tumor Registry.

The demographic characteristics of the sample are listed in Table 1. The majority (80%) of the sample was aged 65 years or older. Twelve percent had coverage by Medicare only. From available data (n = 79) describing pack year history of smoking, 60% had more than a 40-year pack year history. Forty percent reported smoking at the time of their diagnosis, and 44% described quitting before diagnosis. At the time of the interview, 9% reported that they were current smokers, 76% were former smokers, and 16% had never smoked. With verification of cotinine, an additional seven subjects were reclassified as smokers for a total of 13% current smokers.

Health status variables including comorbid conditions and pulmonary function at the time of the interview are listed in Table 3. At the time of the interview, participants had an average of 1.4 conditions (standard deviation, 1.4; range, 0 to 7). Thirty percent reported no comorbid conditions, 50% reported one or two conditions, 16% reported three or four conditions, and 4% reported five or more conditions. Thirty-four participants (24%) had a history of other cancers. Twelve (35%) of these were a second primary tumor or recurrent lung cancer more than 5 years before the interview. We were unable to determine from our chart review if these were new primary tumors or recurrent lung cancers. Other malignancies included breast cancer (n = 4), head and neck cancer (n = 4), prostate cancer (n = 3), lymphoma (n = 2), endometrial cancer (n = 2), colon cancer (n = 2), and others (n = 5). Fifty-two percent had moderate to severe compromise in pulmonary function (FEV₁ < 70%). Almost one (22%) of five participants scored at 16 or above on the CES-D (indicating depressed mood).

In both measures of psychological well-being, those in the distressed mood group had lower QOL scores (QOL-psychological, M = 5.26 v M = 7.21; MC, M = 38.45 v M = 55.92; t = 10.65; df = 137; P = < 0.001). Social QOL-Survivor scores were weakly and negatively related to a number of comorbid conditions. The depressed mood group reported poorer social QOL (M = 5.85 for depressed mood group v M = 8.33 not distressed).

The spiritual domain of QOL-Survivor was significantly different by sex, with women indicating better spiritual QOL-Survivor scores (M = 5.74 for women v M = 4.79 for men), by race/ethnicity, with nonwhite participants reporting higher scores (M = 6.34 for nonwhite v M = 5.10 for white), and by education, with those with less education having higher scores (M = 5.87 for high school or less v M = 5.09 for more than high school). Having fewer comorbid conditions was weakly related to better spiritual QOL-Survivor scores. Similar to the other dimensions of QOL, those in the distressed group reported lower scores in spiritual function (M = 4.47 v M = 5.52).

Comparisons of the SF-36 PC and MC aggregate norms scores were made for our sample with published scores for samples with cancer, older adults (aged 65 to 74 years old), and samples with chronic lung disease (Fig 1). The PC score was similar to the 50th percentile score for older adults but below that for people with chronic lung disease and with cancer, suggesting poorer physical function for lung cancer survivors. The MC score was similar to older adults and others with cancer and above that reported for those with chronic lung disease, indicating better mental health for lung cancer survivors.

View larger version (14K): [in this window] [in a new window]   Fig 1. Physical and mental QOL score comparisons.

The full model for QOL-Survivor global score with all predictor variables is displayed in Table 6; this model accounts for 37% of the variance (F = 7.25; df = 10,126; P < .001). In a parsimonious model (with only two predictors), race/ethnicity (P = .082) and depression status (P < .001) accounted for 34% of the variance (F = 35.04; df = 2,134; P < .001). White participants and those in the depressed category had poorer overall QOL.

For the full model for PC score, 29% of the variance was explained (F = 5.05; df = 126; P < .001). In the reduced model (R² = 0.28; F = 8.49; df = 6,130; P < .001), older age (P = .031), living alone (P = .088), more comorbid conditions (P = .004), having poorer pulmonary function (P = .055), being in the distressed mood group (P = .004), and more time since diagnosis (P = .052) contributed to poorer physical QOL ratings.

	DISCUSSION

TOP ABSTRACT INTRODUCTION PATIENTS AND METHODS RESULTS DISCUSSION REFERENCES

 
This study provides the first look at QOL and recovery after cancer through the perspective of long-term survivors of lung cancer. As demonstrated by these findings, NSCLC survivors are a diverse group with different levels of QOL and potentially different needs for rehabilitation. If only considering the cancer-specific QOL instrument (QOL-Survivor), our findings suggest that other than the spiritual domain, survivors of NSCLC have as high or higher ratings of QOL as other survivors of cancer,⁴ although the survivors are not comparable to published data in terms of time since diagnosis. When compared with a population-based measure of QOL (SF-36), lung cancer survivors seem to have similar physical QOL scores as other older men and women and worse than people with chronic lung disease and with cancer in general. Mental QOL scores were similar to other older adults, those with cancer, and better than those with chronic lung disease. Similarly, in a comparison of findings from patients with COPD and NSCLC, patients with COPD had significantly more disruptions in QOL.³⁹ Schag et al⁴⁰ reported that in comparison with other cancer survivors, lung cancer survivors (n = 57; 44% female) had more problems, including difficulty working and disruptions in day-to-day activity.

One of the threats to validity of this study is the low response rate. It is impossible to know the true number of potential subjects because of limitations in using a registry list in the initial mailed survey. This list might have included patients who moved or have died of lung cancer or other causes and thus were not able to respond, resulting in a much smaller denominator. The response rate from the UCLA patients was clearly higher than that from the community and Los Angeles County patients, and one might conclude that the personal contact letter from the treating physicians and familiarity with the research environment at UCLA were important in peaking interest in the study. In future studies, recruitment might be increased using a follow-up telephone call. Although our sample was not significantly different from registry characteristics, nonresponders may have had significant differences in QOL. This may have biased our results in important ways. Some nonresponders may have had significant limitations making participation difficult. Thus our results may portray a more positive image of QOL and health status than the typical survivor. Conversely, others may be doing well and not want to be reminded of a long ago cancer experience, thus our description of QOL would underestimate well-being. Additionally, survivors who continued to smoke may have been less likely to participate. Prospective studies are needed to follow survivors over time. Because we did not do a comprehensive medical assessment, some of these participants may have had recurrent undetected lung cancer.

In this cross-sectional study, we were not able to assess QOL changes before and after treatment, thus we are not able to determine how different QOL was before lung cancer treatment. Health-related QOL ratings may be influenced by diseases and treatments other than lung cancer. The majority of these survivors received surgical treatment alone. Future prospective studies also will need to consider the long-term effects of adjuvant chemotherapy and/or radiation therapy.

According to our assessment of pulmonary function, over 50% had moderate to severe functional impairment. Other studies of QOL and lung disease have not shown a consistent relationship between patient appraisals of QOL and pulmonary function.⁴¹ Two-thirds of the survivors had at least one comorbid condition; almost a quarter of our sample had experienced a second malignancy. This figure may be an underestimate because an unknown number of survivors who succumbed to a second malignancy would not have been considered in this study. As an independent predictor, number of comorbid conditions was linked to poorer ratings of overall QOL (QOL-Survivor global, physical, social, and spiritual subscales) and the psychological and physical dimensions of the SF-36 (PC and MC).

Being in the group with distressed mood (30% of the survivors) was the most important single predictor of lower health-related QOL among survivors. Depression occurs in 10% of the adult population and is not uncommon in patients with cancer (almost 25%).²⁵ Depression among patients with advanced lung cancer (with more than one third reporting depression before treatment) is strongly associated with functional impairment and symptom distress.²⁵ Psychological distress has been commonly reported in the aftermath of living with a diagnosis of cancer, but data are limited as to the frequency among lung cancer survivors.⁵ Our findings of distressed mood among survivors is lower than that reported in a small sample of survivors by Schag et al (> 50%).⁴⁰ Further study is needed to determine the time of occurrence and duration of depressed mood or if identification and treatment would result in different appraisals of QOL over time.

Perhaps not surprisingly, some survivors of lung cancer were not able to quit smoking. Smoking cessation after cancer can reduce morbidity and mortality. However, even in the face of diagnosis, patients may continue to be addicted to nicotine.^42-44 Lifetime smoking can affect pulmonary function²² as well as increase the incidence of other tobacco-attributable comorbidities, especially the progression of COPD.⁴⁵ In this study, tobacco status was not a significant predictor of QOL; however, a relatively small number of survivors continued to smoke. It is unknown how many may have quit in response to pulmonary symptoms that diminished QOL. Further study is needed to assess the QOL consequences of continued smoking after diagnosis, not only on survival, but also on the incidence of comorbid conditions and QOL.

As lung cancer continues to be the leading cause of cancer death among women, sex differences in lung cancer are important to consider. In this study, as has been reported previously, women differed from men as to histologic profile,⁴⁶ with a higher percentage of adenocarcinoma. Women also differed from men as to living situation (more lived alone), but they were similar to men in the majority of demographic, disease/treatment, and health status variables measured. Marital status has been associated in other studies with higher appraisals of QOL.¹³ Women did report significantly higher levels of spiritual QOL and may experience an existential meaning of lung cancer survivorship differently. Both sex and living status dropped out in the most parsimonious models of overall QOL.

Race/ethnicity was a predictor of QOL among lung cancer survivors. Our findings suggest that participants who were nonwhite reported higher levels of overall QOL (QOL-Survivor). As an independent predictor, nonwhite participants rated higher QOL-Survivor scores and better mental health; however, white participants rated higher physical function (SF-36). This observation is interesting because it has been suggested that nonwhites receive less opportunities for curative lung cancer treatment.⁴⁷ Although we were not able to assess income in the multivariate analysis, it was inversely related to physical QOL in the preliminary analysis. Low income has been reported as a predictor for poorer QOL in a diverse sample of women with lung cancer.⁴⁸ The complex interactions of QOL by race/ethnicity and socioeconomic status deserve further study.

Lung cancer will remain a major cancer-related cause of morbidity and mortality in the 21st century.⁴⁹ Hopefully, with increased emphasis on early detection and with innovative treatments, the proportion of long-term survivors will increase. This study provides insights about the QOL of an understudied group, long-term survivors of NSCLC. The majority of our participants described themselves as hopeful and viewed lung cancer as making a positive change in their lives. However, those survivors who experienced distressed mood have lower ratings of QOL and represent a potential target for intervention by health care providers. Further study is needed to explore potential interventions to assist those survivors with distressed mood and those affected by diminished pulmonary function, continued smoking, and other comorbid diseases. Continued surveillance of survivors long after the initial diagnosis and treatment for changes in QOL and for recurrence of new cancers is important. Surveillance of concerns of survivors from a QOL perspective is equally important.

	ACKNOWLEDGMENTS

 
Funding provided by the Office of Research and Women’s Health, National Cancer Institute grant no. R01 015726, awarded to L.S.

We thank Fred Grannis, MD, Sol Perez, RN, and Araceli Caldea, RN, MN, for their assistance with recruitment/data collection; Patricia Ganz, MD, and Betty Ferrell, RN, PhD, for manuscript review; and Jenny Chen, BS, for manuscript preparation.

	REFERENCES

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Submitted September 10, 2001; accepted March 5, 2002.

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