Quality-of-Life and Health Behaviors in Survivors of Acute Leukemia Compared with the General Population: A Population-Based Matched Case-Control Study

Introduction

Although most of the studies about health related quality of life (HRQoL) focuses on acute leukemia survivors, few studies compared the HRQoL in acute leukemia survivors with that of the general population. The objective of the present study was to evaluate the HRQoL of acute leukemia survivors in a case-control study using The Sixth Korean National Health and Nutrition Examination Survey (KNHANES VI).

Method

We enrolled 149 acute leukemia survivors from three Korean tertiary care centers from 1983 through 2014. Survivors completed a set of questionnaires which included the EuroQOL five dimensions questionnaire (EQ-5D), the EORTC Quality of Life Core Questionnaire (QLQ-C30), Brief Fatigue Inventory (BFI), Hospital Anxiety and Depression Scale for Korean (HADS-K), Brief Encounter Psychosocial Instrument (BEPSI), Abbreviated Dyadic Adjustment Score (ADAS), and Family APGAR. We identified 447 control subjects matched for age, sex, education status, marital status, and presence of any comorbidity from KNHANES VI database. The scores for EQ-5D and health behaviors regarding rate of smoking, drinking, health medical examination, cancer screening, and vaccination were compared with the general population. Other survey results including EORTC QLQ-C30 were analyzed among the leukemia survivors, to evaluate the impact on QoL of postremission treatment strategy (SCT or chemotherapy). We compared the adjusted QoL mean across groups by analysis of covariance.

Result

Median age of the study participants was 44 years (range, 16 - 78), and there were 75 men (50%) and 74 women (50%). Majority of the patients had acute myeloid leukemia (n = 121); others had acute lymphoblastic leukemia (n = 24) and acute biphenotypic leukemia (n = 4). Among the survivors, 93 received chemotherapy and 56 received SCT as postremission treatment. Median duration of time between treatment completion and the study survey was 59 months.

Examination of each of the five dimensions of the EQ-5D showed that the acute leukemia survivor group was having more difficulties or problems compared with the general population. More than twice as many respondents with leukemia survivors reported having problems with usual activities (14.6% vs. 4.6%, p < 0.001), and anxiety or depression (23.6% vs. 9.1%, p < 0.001). Furthermore, a significant proportion of patients reported pain compared with their matched population (34.7% vs. 20.3%, p= 0.002).

Among the survivors, SCT group had clinically significantly worse problems with role functioning, fatigue, and insomnia than chemotherapy group, measured by the QLQ-C30. SCT group also had statistically significantly worse problems with global health status/QoL, physical and emotional functioning, pain, dyspnea, and appetite loss. Depression was higher in the SCT patients compared with the chemotherapy patients (mean HADS-depression score 4.99 vs. 6.56, p= 0.024). There was no difference in the HADS-anxiety score, BFI, BEPSI, dyadic adjustment and family function between the subgroups.

In terms of health behaviors, acute leukemia survivor group had lower rate of smoking (5.6% vs. 25.3%, p < 0.001) and drinking in recent 1 year (41.7% vs. 76.7%, p < 0.001), and higher rate of influenza vaccination (63.6% vs. 35.4%, p < 0.001). Only 17% of the leukemia survivors reported that they had been recommended to receive screening for other cancers from health care providers, and 27% and 40% reported that they thought they had lower risk and similar risk of other cancer than general population. However, this lack of a recommendation for second cancer screening and the misperception of second cancer risk did not have negative impact on cancer screening behaviors (cancer screening in recent 2 years, 45.9% for survivor group vs. 52.3% general population, p = 0.175; health examination, 61.0% vs. 63.2% for, p= 0.632).

Conclusion

These results indicate that, compared to the general population, survivors of acute leukemia have a significantly worse long-term impact on QoL. Moreover, patients who received SCT for postremission treatment had poorer QoL than those treated with chemotherapy. Health behaviors were comparable between the survivors and the general population. These results can increase the awareness of healthcare providers to the need for counseling and interventions among acute leukemia survivors and help them improve their impaired QOL.