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In Reply:

Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada

We thank Efficace and Bottomley for their thoughtful letter. Their report¹ examining prognostic effects of health-related quality of life (HRQOL) in a population similar to ours (but also including women with inflammatory breast cancer) yielded similar results to ours.² These two reports are consistent with earlier reports (eg, Coates et al³) and, taken together, they emphasize the apparent absence of a prognostic effect of HRQOL in nonmetastatic breast cancer. We agree that there is growing evidence that HRQOL may contribute to prognostication in metastatic breast cancer. HRQOL in that setting may reflect tumor burden in critical sites, an attribute that may not be well quantified by traditional prognostic variables, hence the independent predictive value of HRQOL.

In contrast to the growing evidence that HRQOL contributes important prognostic information in the metastatic setting, the same cannot be said for psychosocial attributes. In our report,² we found no convincing evidence that psychosocial attributes were prognostic in early breast cancer. Butow et al⁴ suggested that minimization of the impact of metastatic cancer might be associated with longer survival; however, others⁵ have found that lifestyle and psychosocial factors were not prognostic in the metastatic setting. Butler et al⁶ reported increased psychological distress and pain before death in metastatic breast cancer patients, suggesting that changes in these factors may reflect progression of the underlying cancer. In addition, and perhaps more importantly, there is little evidence that group interventions addressing psychological distress in the metastatic setting influence survival.⁷

The challenge at this point is to better understand the contribution that HRQOL makes to the prediction of outcome in metastatic breast cancer. Research to understand the nature of this relationship is needed. Does HRQOL simply reflect underlying tumor burden, or is it associated with specific pathophysiologic changes that are amenable to modification? If so, what interventions could be undertaken to reverse these changes and improve QOL? Demonstration of the absence of a prognostic effect of these factors in early-stage breast cancer in well-designed studies promotes shifts in research focus to more salient areas such as these.

Authors' Disclosures of Potential Conflicts of Interest

The authors indicated no potential conflicts of interest.

REFERENCES

1. Efficace F, Therasse P, Piccart MJ, et al: Health-related quality of life parameters as prognostic factors in a nonmetastatic breast cancer population: An international multicenter study. J Clin Oncol 22:3381-3388, 2004[Abstract/Free Full Text]

2. Goodwin PJ, Ennis M, Bordeleau LJ, et al: Health-related quality of life and psychosocial status in breast cancer prognosis: Analysis of multiple variables. J Clin Oncol 22:4184-4192, 2004[Abstract/Free Full Text]

3. Coates A, Gebski V, Signorini D, et al: Prognostic value of quality-of-life scores during chemotherapy for advanced breast cancer: Australian New Zealand Breast Cancer Trials Group. J Clin Oncol 10:1833-1838, 1992[Abstract]

4. Butow PN, Coates AS, Dunn SM: Psychosocial predictors of survival: Metastatic breast cancer. Ann Oncol 11:469-474, 2000[Abstract/Free Full Text]

5. Cassileth BR, Lusk EJ, Miller DS, et al: Psychosocial correlates of survival in advanced malignant disease? N Engl J Med 312:1551-1555, 1985[Abstract]

6. Butler LD, Koopman C, Cordova MJ, et al: Psychological distress and pain significantly increase before death in metastatic breast cancer patients. Psychosom Med 65:416-426, 2003[Abstract/Free Full Text]

7. Smedslund G, Ringdal GI: Meta-analysis of the effects of psychosocial interventions on survival time in cancer patients. J Psychosom Res 57:123-131, 2004[CrossRef][Medline]

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Related Correspondence

• Toward a Clearer Understanding of the Prognostic Value of Health-Related Quality-of-Life Parameters in Breast Cancer
  Fabio Efficace and Andrew Bottomley
  JCO 2005 23: 1335-1336 [Full Text]

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