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EDITORIALS |
From The University of Texas, M. D. Anderson Cancer Center, Dallas, Texas.
Correspondence: Address correspondence to: Matthew T. Ballo, MD, Department of Radiation Oncology, UTMD Anderson Cancer Center, 1515 Holcombe Blvd., Box 97, Houston, TX 77030; Fax: 713-563-2331; Email: mballo{at}mdanderson.org
The analysis of functional impairment reported by Gerrand et al. in this issue of the Annals of Surgical Oncology, examines the relationship between anatomic tumor location and impairment or disability following surgical resection of lower extremity soft tissue sarcoma. After categorizing tumors according to anatomic region, the study examines the responses of patients to two previously described measures of disability and impairment, the Toronto Extremity Salvage Score (TESS) and the Musculoskeletal Tumor Society rating scale (MSTS 1993), to evaluate change in functional ability over time.1
This analysis represents a refinement of earlier work where tumor location was categorized by proximity to the nearest major joint.2 Although in this previous study several clinical- and treatment-related features correlated with lower MSTS and TESS scores after treatment, proximity to the nearest major joint did not. The current study confirms that resection of a motor nerve is associated with lower postoperative MSTS and TESS scores; however, anatomic location as defined by the authors is not a predictor of overall scores. Further analysis of patients with deep tumors demonstrates variations within individual item scores across anatomic locations. Specifically, patients with groin or femoral triangle primary tumors have significant postoperative variations in gait handicap or limp and difficulty putting on pants, socks or stockings; getting in and out of the bath; or bending to pick something up off the floor. Also, patients with posterior thigh or anterolateral leg tumors have significant postoperative impairment in getting in and out of the bath and patients with buttock and posterior thigh tumors have difficulty bending to pick something up off the floor. As anticipated, no significant decrease is found in MSTS or TESS scores for superficial tumors.
Although the conclusions of this study are of interest to clinicians providing preoperative counseling to similar patients, another important element of this study is the quality of the data collected. The authors evaluated their hypothesis by defining anatomic regions a priori and then evaluated functional outcome using prospectively collected data from disease-specific instruments. The group’s efforts to develop this questionnaire prospectively with subsequent formal psychometric validation should be applauded and held as an example for other investigators.3,4 The TESS instrument has demonstrated sensitivity to changes in physical ability over time in a heterogeneous group of patients and is easy to deliver. In addition, unlike the MSTS, the patient completes the TESS, representing his or her perception of functional ability. Whereas the MSTS assesses pain, range of motion, strength, joint stability, deformity, emotional acceptance of the surgical procedure, and general functional ability, it does so from the perspective of the clinician rather than the patient. The inability of clinicians to estimate a patient’s health status accurately is well documented.5 As a result, the TESS questionnaire should be regarded as the instrument of choice for evaluating postoperative function in patients with extremity tumors.
The rationale for quality-of-life (QOL) measurement in the health field is based on evidence that health-related QOL, particularly among patients with cancer, is an independent predictor of survival and response to therapy.6–10 QOL assessments provide essential information on the impact of a disease and of its treatment from a patient’s perspective.11 Although the authors of the current study focus on physical well-being, this is only one of the four principal dimensions that define health-related QOL. The other primary domains are functional well-being, emotional well-being, and social and family well-being.12 The ability of a patient to cope with physical impairment can be as important as the disability itself, which is not measured in the current study. In addition, the diagnosis of cancer is typically associated with anxiety, which one could postulate would be heightened among patients with adverse prognostic factors. In this context, a more global QOL instrument such as the Functional Assessment of Cancer Therapy (FACT)13 or the European Organization for Research and Treatment of Cancer (EORTC)14–16 questionnaires might provide additional insight into this patient population’s perception of treatment outcome.
In addition to using these questionnaires as research tools, a role may exist for the TESS questionnaire (or another instrument) in daily clinical practice that might identify patients who do not achieve the anticipated functional outcome and who could benefit from early physical or occupational therapy. It might also identify patients in whom treatment should be modified according to some pretreatment characteristic.
Despite that the current study showed no statistically significant variations in aggregated scores of disability and impairment according to anatomic tumor location, measuring a patient’s perceptions of functional ability is clearly of value. As noted by the authors, their findings may have been limited by the number of patients in each group, but the item response data still allow clinicians to inform patients of likely treatment sequelae according to tumor, treatment, and patient characteristics.
Received for publication March 1, 2004. Accepted for publication March 5, 2004.
REFERENCES
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