Prospective Longitudinal Assessment of Quality of Life for Liver Cancer Patients Treated With Stereotactic Body Radiation Therapy

Abstract

Stereotactic body radiation therapy (SBRT) is increasingly prescribed for liver cancer patients ineligible for other treatments. Quality of life (QOL) is an important outcome due to poor long term survival. We evaluated the effect of liver SBRT on the QOL of patients in phase I/II trials. Three trials of image-guided SBRT using individualized dose prescriptions in 6 fractions over 2 weeks enrolled 222 patients with hepatocellular carcinoma (HCC), liver metastases (LM) and intrahepatic cholangiocarcinoma (IC). Doses from 24-60 Gy were delivered based on the volume of irradiated liver (Veff) and proximity to normal tissues. Patients with Child Pugh A liver function who understood any language with available EORTC QLQ-C30 and/or FACT-Hep v4 were eligible for QOL assessment. Questionnaires were given at baseline and at 1, 3, 6, and 12 months after treatment. Compliance at each time point was calculated by dividing the number of questionnaires completed by the number of patients eligible, alive, and continuing in the trial. Overall survival (OS) was analyzed by the univariate Cox model. Of 205 patients eligible for the QLQ-C30 (48% HCC, 42% LM, 10% IC), 196 were eligible for FACT-Hep (49% HCC, 41% LM, 10% IC). Compliance with the QLQ-C30 and FACT-Hep was 91% and 92%, respectively, at baseline, 78% at 3 months and 60% and 61% at 1 year. Median survival for all 205 patients was 17.0 months (95% CI = 12.3-19.8). Survival was 58% (95% CI = 51-65%) at 1 year and 10% (95% CI = 3-23%) at 5 years. No difference in baseline mean FACT-Hep score (p = 0.13) or OS (p = 0.09) was seen between the HCC, LM and IC cohorts. At 3 months, about half of the patients reported stable QOL (51% on FACT-Hep, 50% on QLQ-C30 Global Health). About a third of patients reported clinically meaningful worsening (36% and 34%, respectively); a small proportion improved (13%, 16%). At 12 months, 54% of patients reported stable QOL on FACT-Hep and 38% on QLQ-C30 Global Health. Worsening was seen in 27% and 39%, respectively; 19% and 23% improved. Appetite loss and fatigue measured by QLQ-C30 showed a clinically significant decline 1 month after treatment. Both domains improved by 3 months after treatment and returned to baseline by 1 year. No other subscale of either instrument showed a clinically significant change from baseline at any measured time point. Higher baseline scores on FACT-Hep and QLQ-C30 Global Health were associated with improved OS. Hazard ratios for death, per 10 unit increase in QOL, were 0.90 (95% CI = 0.83-0.98, p = 0.001) and 0.88 (95% CI = 0.82-0.95, p = 0.001), respectively. SBRT for liver cancer temporarily worsens appetite and fatigue, but is not associated with clinically significant worsening of overall QOL. Higher baseline QOL significantly predicts improved overall survival.