ORIGINAL ARTICLE
JOP. J Pancreas (Online) 2013 Jan 10; 14(1):21-30.
Post-Frey Procedure Quality of Life in South African Patients with Painful Chronic Pancreatitis
Cara Yvonne Jeppe1, Piet Becker2, Martin Derrick Smith1,3
1Department of Surgery, Chris Hani Baragwanath Academic Hospital; 2South African Medical Research Council; 3Department of Surgery, University of the Witwatersrand. Johannesburg, South Africa
ABSTRACT
Context Pre- and post-Frey procedure data assessing quality of life in South African patients with painful chronic pancreatitis were compared using two instruments of measure. Objective The objective was to evaluate the post-Frey procedure quality of life and to evaluate which of the two instruments was most appropriate in such patients. Methods A prospective, observational, longitudinal study using the EORTC QLQ-C30 and a locally developed structured interview was performed. Results Between January 2002, when the QLQ-C30 was introduced, and February 2009, 45 consecutive patients underwent a Frey procedure at the Chris Hani Baragwanath Hospital in Soweto, Johannesburg, South Africa. Thirteen of these patients were lost to follow up. Thirty two participants answered both instruments before and after the procedure. Follow up data were analyzed until June 2009. The mean follow up was 24.8 months ranging from 1 to 83 months. There were clinically relevant improvements in most QLQ-C30 domains and structured interview items at the last post-operative visit. The mean pain levels (VAS 0-10 and QLQ-C30 PA) were significantly reduced post-operatively. Twenty five participants answered both instruments within six months and again later at a minimum of six months after surgery with no significant differences in the overall QLQ-C30 functional (P=0.967) and symptom (P=0.253) scale scores between the two time periods. In general, outcomes measured by the two instruments were similar. Conclusions Although the follow up period was short, results suggest that benefits were mostly made manifest within six months post-operatively and were sustained during the follow up period. The structured interview included a counseling component and locally pertinent issues not addressed in the QLQ-C30 and it is therefore recommended as the instrument of choice in this setting.
INTRODUCTION
Quality of life (QoL) is a subjective concept. QoL measures, however focused on need-satisfaction and relatively less subjective they may therefore be, may not address the issues relating to a specific intervention such as the Frey procedure in the South African population drawn mainly from the black townships. The socio-economic situation of these people is invariably very poor which may itself impact on the outcome of the surgery. The patients experience a host of problems that either result from chronic pancreatic pain or from their own life circumstances that may lead to substance abuse. Depression and low self-esteem arising from poor education and unemployment are associated with high risk behaviors such as substance abuse according to Petersen [1]. Gastric pain in South Africa tends to be treated empirically and presumed to be due to peptic ulcer disease. Consequently the diagnosis of chronic pancreatitis is often made at advanced stages of the disease once absenteeism and job loss have occurred, and post-surgical QoL improvements are measured from a very low baseline.
The classical symptoms of chronic pancreatitis are pain and exocrine and endocrine insufficiency. Other dimensions of concern include weight loss, inability to work, early retirement, and addiction to opioids. In 1987 Frey and Smith described an operation for chronic pancreatitis that combined drainage and organ-preserving resection: local resection of the pancreatic head with lateral pancreaticojejunostomy [2]. A number of studies have found this Frey procedure to be effective in the management of painful chronic pancreatitis [3, 4, 5, 6].
AIMS AND OBJECTIVES
The objectives of this study were to facilitate long-term follow-up of patients undergoing the Frey procedure; to compare their pre- with their post-surgical physical, role, emotional, cognitive, and social functioning, as well as symptoms and global health status/QoL and to relate the findings of this self-administered QLQ-C30 to those of a face-to-face locally developed structured interview that included some issues not addressed in the QLQ-C30 (Appendix). Predictors capable of modifying the outcome of the intervention were considered and the focus was on extracting information relevant to the improvement of QoL in patients undergoing the Frey procedure.
PATIENTS AND METHODS
Patients
The Frey procedure was performed on 112 patients in the Hepato-Pancreato-Biliary (HPB) Unit of the University of the Witwatersrand from 1998 to 2009. The structured interview was developed in the HPB Unit in 1999 and the QLQ-C30 was introduced in January 2002. Forty five consecutive candidates underwent a Frey procedure between January 2002 and February 2009 at the HPB Unit of the Department of Surgery of the University of the Witwatersrand, Gauteng Province, Republic of South Africa. Surgery was performed at the Chris Hani Baragwanath Hospital in Soweto, Johannesburg. Confirmation of a diagnosis of painful chronic pancreatitis was based on a clinical history, physical examination, ultrasonography, computed tomography scan, an endoscopic retrograde or a magnetic resonance pancreatography, and histology.
Only patients who answered the QLQ-C30 and the structured interview pre- and post-operatively were included in the study. Thirteen patients were lost to follow-up, including two patients who died within a month of surgery, one who died in a motor vehicle accident, one who declined participation in the study, and one who did not understand the QLQ-C30 at all. Therefore, thirty two answered the QLQ-C30 and the structured interview before and after the Frey procedure. Data up to June 2009 were analyzed. There were 25 men and 7 women. Mean±SD age at surgery was 42.5 ±7.11 years (range: 31-61 years). Mean follow-up period was 24.8 months ranging from one to 83 months.
Questionnaires
The comparison of pre- and post-Frey procedure pain in a prospective, observational, longitudinal study of South African patients with painful chronic pancreatitis was undertaken and included a number of other dimensions of QoL, the improvement of which is the goal of the procedure. Outcomes in terms of the possible achievement and sustainability of improved global health status, protective influences, and risks associated with poor post-surgical outcome were analyzed.
Structured interviews were conducted by a single researcher not involved in treatment decisions with the aid at times of a translator. The interviewer had no interpretive agenda and treating surgeons did not have access to the responses of participants.
European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 Questionnaire
The QLQ-C30 version 3 comprises a functional scale with a high score representing a healthy level as does a high score for the global health status/QoL (QL2). A high score for the symptom scale represents a high level of problems [7]. The English version of the QLQ-C30 was adopted and a number of participants required assistance understanding and answering the QLQ-C30 questions. For illiterate patients verbal translations were done in IsiZulu and Setswana.
The functional, symptom and global health scales were linearly transformed to 0-100 in order to obtain the standardized scores according to the EORTC QLQ-C30 general principles of scoring. The overall functional, symptom, and global health status scale scores were computed as means of the overall set of scores. Global health status/QoL score was also dichotomized as “Good” (equal to, or greater than, 50) and “Poor” (less than 50). The structured interview variables were also observed as dichotomous (i.e.: “Absent”, less than 50; “Present”, equal to, or greater than, 50).
As stipulated in the QLQ-C30 title of measure, changes in QoL scores were categorized into three groups: clinically relevant improvement, clinically relevant deterioration, and no change [8, 9]. The foremost category was considered clinically relevant if the follow-up score exceeded the previous score by at least ten points. Deterioration was considered clinically relevant if the difference was at least ten points less than the previous score. Failure to meet either criterion was interpreted as no change in the third category. With symptom scales an increase of ten points or more in the level of symptoms implied deterioration.
Structured Interview
A face-to-face locally developed structured interview included some issues not addressed in the QLQ-C30 (Appendix). In addition to the visual analogue scale (VAS 0-10: 0 indicating no pain and 10 indicating unbearable pain) for pain, self-reported judgment of pain intensity (none, mild, moderate, severe), use of analgesics (yes, no), and pre-surgical pain duration, the structured interview included questions relating to issues such as ability to work, employment, disability grants, retirement, alcohol consumption (nil, special occasions, weekends only, daily, alcoholic), smoking (0, 1-5, 6-10, 11-20, >20 cigarettes per day), good or bad feelings about life, hopelessness or hopefulness, loss or gain of weight, non-insulin or insulin dependent diabetes mellitus (NIDDM, IDDM, respectively), clinically evaluated steatorrhea, nausea and vomiting, and whether the surgery benefited the patient from her or his perspective.
ETHICS
Approval of the study was obtained from the Human Research Ethics Committee (Medical) of the University of the Witwatersrand, protocol number M050425. All participants provided written informed consent. The study protocol conforms to the ethical guidelines of the “World Medical Association (WMA) Declaration of Helsinki - Ethical Principles for Medical Research Involving Human Subjects” adopted by the 18th WMA General Assembly, Helsinki, Finland, June 1964 and amended by the 59th WMA General Assembly, Seoul, South Korea, October 2008
STATISTICS
The Wilcoxon matched pairs sign-rank test was employed to compare pre- and post- (last visit) operative QLQ-C30 global health status/QoL scores, functional scale scores, overall functional scale scores, symptom scale scores, overall symptom scale scores, and comparisons of overall functional and symptom scale scores within six months versus at least six months post-operatively. Association between structured interview parameters, e.g. categorical with continuous, continuous with continuous, were assessed using the Spearman’s rank correlation coefficients and the Mann-Whitney U-test. To assess agreement between structured interview and QLQ-C30 variables, the kappa statistic was used and percentages of agreement and disagreement were also reported. Dichotomous data were analyzed by means of the Fisher’s exact or the McNemar tests when paired or unpaired data were involved. Testing was done at the two-tailed 0.05 level of significance. Stata (release 11, StataCorp LP, College Station, TX, USA) statistical software was used for data analysis.
RESULTS
EORTC QLQ-C30 Questionnaire
There was a statistically significant improvement at last post-operative visit in the score of QLQ-C30 global health status/QoL (P<0.001) in the 32 participants compared with their pre-operative scores. The improvement in global health status/QoL was clinically relevant (Table 1).
|
Table 1. QLQ-C30 pre-operative and last visit scores (n=32). |
||||
|
EORTC QLQ-C30 scores |
Pre-operative |
Last visit |
Difference |
P value a |
|
Global health status/QoL score (QL2) |
27.4±23.2 |
54.0±27.1 |
26.6±33.3 |
<0.001 |
|
Functional scores |
|
|
|
|
|
- Physical functioning (PF2) |
65.0±24.9 |
64.2±19.2 |
0.85±24.7 |
0.524 |
|
- Role functioning (RF2) |
48.9±35.4 |
64.1±29.1 |
15.2±52.3 |
0.090 |
|
- Emotional functioning (EF) |
34.1±25.4 |
49.5±27.5 |
15.4±33.7 |
0.017 |
|
- Cognitive functioning (CF) |
47.4±27.8 |
55.7±33.5 |
8.3±39.7 |
0.263 |
|
- Social functioning (SF) |
50.0±37.9 |
71.3±31.5 |
21.4±31.2 |
0.001 |
|
Overall functional score |
49.1±21.0 |
61.0±21.0 |
11.9±26.1 |
0.040 |
|
Symptom scores |
|
|
|
|
|
- Fatigue (FA) |
70.0±24.7 |
56.8±30.4 |
-13.2±30.2 |
0.004 |
|
- Nausea and vomiting (NV) |
54.7±33.1 |
35.9±37.7 |
-18.8±44.4 |
0.023 |
|
- Pain (PA) |
80.2±24.1 |
55.7±33.8 |
-24.5±34.9 |
0.001 |
|
- Dyspnea (DY) |
50.0±37.9 |
37.5±39.5 |
-12.5±44.6 |
0.267 |
|
- Insomnia (SL) |
56.3±38.3 |
42.7±39.9 |
-13.5±48.5 |
0.066 |
|
- Appetite loss (AP) |
69.8±34.3 |
37.5±40.4 |
-32.3±48.3 |
0.004 |
|
- Constipation (CO) |
64.6±38.8 |
29.2±32.5 |
-35.4±43.1 |
<0.001 |
|
- Diarrhea (DI) |
13.5±25.2 |
27.1±34.3 |
13.5±40.5 |
0.068 |
|
- Financial difficulties (FI) |
74.0±37.6 |
55.2±43.7 |
-18.8±43.9 |
0.026 |
|
Overall symptom score |
59.2±18.4 |
42.0±24.8 |
-17.3±21.4 |
<0.001 |
|
a Wilcoxon matched pairs test |
||||
As far as the functional scores are concerned, there was a statistically significant improvement at last post operative visit in emotional and social functioning while no significant modifications were observed in physical functioning, role functioning, and cognitive functioning in comparison with the QLQ-C30 pre-operative answers. The improvements in role, emotional, and social functioning were clinically relevant. In addition, the overall QLQ-C30 functional score at last visit was compared with that of the pre-operative score and the improvement was found to be both statistically significant and clinically relevant (Table 1).
Apart from diarrhea that increased, there was a clinically relevant reduction of all QLQ-C30 symptom items post-operatively. Reductions in dyspnea and insomnia were not statistically significant while the increase in diarrhea was near the significant limit (P=0.068). The overall QLQ-C30 symptom scale score at the last visit improved significantly when compared with the pre-operative value (Table 1).
Taking into account QLQ-C30 global health status/QoL, functional, and symptom scale scores, they did not differ significantly between the two post-operative time periods (P=0.839, P=0.967, and P=0.253, respectively). The percentage benefits within the first six months over the pre-operative scores of 25.3%, 47.5%, and 58.7%, respectively, seem to have been sustained in the second period (mean follow-up: 31 months, range 6-83 months; Table 2).
|
Table 2. Comparison of overall scores between values observed within 6 months and those observed with a minimum of 6-month follow-up post-operatively (data for both time periods were available in 25 participants only). |
|||
|
Quality of life scores |
Follow up |
P value a |
|
|
|
0-6 months |
>6 months |
|
|
Global health status/QoL |
49.7±29.8 |
53.2±28.9 |
0.839 |
|
Overall functional scores |
62.6±19.5 |
62.7±20.7 |
0.967 |
|
Overall symptom scores |
46.1±21.7 |
41.0±25.5 |
0.253 |
|
a Wilcoxon matched pairs test |
|||
Structured Interview
Apart from two patients (6.3%) who reported having moderate pain pre-operatively the other thirty (93.8%) had self-reported severe pain during the structured interview. The mean±SD VAS score pre-operatively was 8.5±1.3 and it fell to a mean of 3.8±3.2 post-operatively at last visit (P<0.001). Median pain duration prior to surgery in the 32 participants was 72 months ranging from 10 to 264 months. Fifteen participants (46.9%) had been diagnosed with peptic ulcer disease prior to admission to the surgical HPB Unit. There was no significant correlation between the pre-operative pain duration and the pain VAS score (rs=0.181; P=0.338) or the self-reported judgment of pain intensity (rs=0.281; P=0.119) of the structured interview pre-operatively. There was significant correlation between the VAS score for pain of the structured interview and the symptom scale for pain (PA) of the QLQ-C30 at the last visit (rs=0.705; P<0.001).
Participants who continued drinking after surgery did not differ from those who stopped drinking with respect to pain measured on the VAS scale of the structured interview (P=0.903; 3.83±4.40 versus 3.82±2.90) or on the pain score of the QLQ-C30 (P=0.695; 50.0±46.0 versus 57.1±31.3). There was an association between the post-operative use of analgesics and a higher VAS score for pain (P<0.001; 5.43±2.60 versus 1.46±2.30) and a higher pain score of the QLQ-C30 (P=0.039; 65.8±29.1 versus 41.0±35.8). Mean VAS scores for pain of the structured interview were significantly lower for good global health status/QoL (i.e., QL2 score equal to, or greater than, 50) of the QLQ-C30 at last visit (P=0.028; 2.65±3.18 versus 4.85±2.80 for poor global health status/QoL, i.e., QL2 score less than 50). A similar association was found for the QLQ-C30 pain score and the QL2 score (P=0.019; 41.1±36.7 versus 68.6±25.6 for good and poor global health status/QoL, respectively).
Only nine of the 32 (28.1%) were employed prior to surgery and ten (31.3%) were employed at last visit. There was a significant association between employment and the ability to work well (P=0.001) at last visit, i.e. among the 19 participants with poor ability to work only 3 (15.8%) had employment while all 5 who reported ability to work well were employed (data on ability to work were available in 24 cases only). Among the 22 unemployed participants, 11 (50.0%) were receiving disability grants at last visit.
Diabetes was defined clinically by the use of anti-diabetic medication. Three participants (9.4%) had diabetes pre-operatively: two participants had NIDDM and one had IDDM. At the last visit there was one participant with NIDDM and five with IDDM (6/32, 18.8%). Fifteen participants (46.9%) had pre-operative steatorrhea and post-operatively at the last visit 17 (53.1%) were found to have steatorrhea during the structured interview while 16 (50.0%) reported having diarrhea at the QLQ-C30 questionnaire. A poor agreement was found (59.4%; 19 cases: 9 negative and 10 positive; kappa=0.188) between the two instruments of measure with regard to this symptom of pancreatic exocrine insufficiency. There was no bias towards a particular instrument (P=0.782; McNemar test for symmetry); in fact 7/32 (21.9%) cases were positive at the structured interviews and negative at QLQ-C30 while in 6/32 (18.8%) cases it was the other way round.
Four continuous QLQ-C30 scores recorded at the last visit, corresponding to some variables of the structured interview, were dichotomized (cut-off point 50%) and then compared with those recorded in the interview: role functioning (RF2 vs. ability to work), global health status/QoL (QL2 vs. feel good about life), nausea and vomiting (NV vs. nausea and vomiting), and appetite loss (AP vs. loss of weight). Overall the QLQ-C30 dichotomized scales variables and the structured interview did not agree well. Best agreement was observed for nausea and vomiting and feel good about life (Table 3).
|
Table 3. Comparison between structured interview (SI) and QLQ-C30 variables. |
||||
|
|
Role functioning (RF2) vs. ability to work b |
Global health status/QoL (QL2) vs. feel good about life c |
Nausea and vomiting (NV) vs. nausea and vomiting |
Appetite loss (AP) vs. loss of weight |
|
Agreement: |
10/24 (41.7%) |
23/28 (82.1%) |
25/32 (78.1%) |
20/32 (62.5%) |
|
Disagreement: |
14/24 (58.3%) |
5/28 (17.9%) |
7/32 (21.9%) |
12/32 (37.5%) |
|
P value (discordance) a |
<0.001 |
0.655 |
0.257 |
0.066 |
|
Kappa |
0.123 |
0.643 |
0.563 |
0.259 |
|
Comment/bias |
QLQ-C30 was more prone to “Present” than SI |
No marked bias |
No marked bias |
Trend of SI to be more prone to “Present” than QLQ-C30 |
|
a McNemar test for symmetry b Ability to work had information on both scales for 24 participants only c Feel good about life’ had information on both scales for 28 participants only |
||||
Finally, global health status/QoL categories (good and poor) at last visit were compared with structured interview categorical parameters. The proportions of participants who used analgesics or alcohol, who smoked, who were retired, who had diabetes and steatorrhea were not significantly different between the two global health status/QoL groups. Participants employed, together with those able to work well, were significantly more frequent in the good global health status/QoL group, as well as participants with disability grant were significantly less frequent in this group. A significantly larger proportion of participants of the good global health status/QoL group reported that they benefited from the Frey procedure than those of the poor global health status/QoL group (100% versus 58.8%) (Table 4).
|
Table 4. Relationship between interview parameters and dichotomized global health status/QoL (QL2) (n=32). |
|||
|
Structured interview at last visit |
Global health status/QoL |
P value a |
|
|
Good: |
Poor: |
||
|
Analgesics |
7 (46.7%) |
12 (70.6%) |
0.280 |
|
Alcohol |
4 (26.7%) |
2 (11.8%) |
0.383 |
|
Cigarettes |
13 (86.7%) |
15 (88.2%) |
1.000 |
|
Employed |
8 (53.3%) |
2 (11.8%) |
0.021 |
|
Ability to work well |
5 (33.3%) |
0 |
0.015 |
|
Retired |
0 |
1 (5.9%) |
1.000 |
|
Disability grant |
2 (13.3%) |
9 (52.9%) |
0.028 |
|
NIDDM |
0 |
1 (5.9%) |
1.000 |
|
IDDM |
3 (20%) |
2 (11.8%) |
0.645 |
|
Steatorrhea |
7 (46.7%) |
10 (58.8%) |
0.723 |
|
Benefited from surgery |
15 (100%) |
10 (58.8%) |
0.008 |
|
a Fisher’s exact test NIDDM: non insulin dependent diabetes mellitus IDDN: insulin dependent diabetes mellitus |
|||
DISCUSSION
Seventeen years ago the reliability and validity of the European Organisation for Research and Treatment of Cancer’s Quality of Life Questionnaire (EORTC QLQ-C30 version 3) was endorsed in clinical studies of patients with chronic pancreatitis before and after duodenum-preserving resection of the head of the pancreas [10]. The QLQ-C30 was originally formulated with the QLQ-PAN26 to assess oncology interventions and appeared to Fitzsimmons et al. “to be an appropriate assessment system for chronic pancreatitis” [11]. In their 1993 study of the natural course of chronic pancreatitis Lankisch et al. found that “Pancreatic surgery led to pain relief immediately after operation, but later pain course between operated and non-operated patients was not significantly different” [12]. Strate et al. stressed “the development of pancreatic insufficiency probably develops independent of the surgical procedure and seems to be related to the chronic feature of the disease”. They found a marked reduction of pain and improved QoL post-operatively despite reduced exocrine and endocrine pancreatic function [13].
The surgical HPB Unit of the University is a centre of choice for the surgical management of chronic pancreatitis in the public health service in the region. Consequently many patients were referred from outlying districts for surgery and were unavailable for follow up, as well as a number of patients who returned to the private sector for their post-surgical care. Despite attempts to contact participants by phone and/or mail their visits to the HPB outpatient clinic were erratic and unpredictable.
There was duplication of some issues addressed in dissimilar ways in the two instruments of measure. When participants required help from the interviewer in answering the QLQ-C30 questions there was no way of gauging if there could have been a degree of critical inter-subjectivity.
The VAS for pain is a simple way of quantifying pain. The participant marks pain level on the blank side of a rule with 0 indicating no pain and 10 unbearable pain. The QLQ-C30 pain scale is a combination of answers to the questions “Have you had pain?” and “Did pain interfere with your daily activities?”. The answers to the questions are chosen from “Not at all” (1), “A little” (2), “Quite a bit” (3), and “Very much” (4). Both measures are influenced by past memories of pain and other subjective factors such as reporting severe pain in order to be prescribed opiates. During the face-to-face interview the participant was asked to score specific pancreatic pain whereas the QLQ-C30 pain measurement was non-specific. There was moderate correlation between the two instruments with regard to pain and significantly reduced mean post-operative levels at last visit.
The long period of pre-operative pain and the presentation of many participants with a prior diagnosis of peptic ulcers endorses the observation that a diagnosis of chronic pancreatitis was often delayed resulting in unemployment for a number of participants and increasing the risk of opiate dependence. Vigilance at primary and secondary levels of heath care would ameliorate the problem. A common complaint was an inability to lift heavy things post-operatively making heavy manual work difficult, impinging on employment, and necessitating disability grants. The evaluation of the outcome of the Frey procedure indicated that employment predicts a better post-operative QoL in this population of working class chronic pancreatic patients. Ironically exposure to many workplace hydrocarbons has been posited as a cause of pancreatitis and preventative measures are essential [14]. The high unemployment rate in the country compounds the problems faced by those with chronic disease. Occupational rehabilitation for educationally disadvantaged adults is a universal challenge that requires particular attention in the case of those with chronic pancreatitis.
There was sustained improvement in QLQ-C30 overall functional and symptom scale domains that was mostly manifested within six months post-operatively. The finding that last visit diarrhea (QLQ-C30) and steatorrhea (structured interview) were associated in the entire group of 32 suggests that the increase in diarrhea at last visit was caused in large part by steatorrhea. Pancreatic enzyme replacement therapy has not been consistently available with dosage schedules having not been uniformly applied, and therefore evaluation of its efficacy in reducing steatorrhea and weight loss, and improving QoL was not feasible. Poverty made regular healthy meals unaffordable for many.
The role played by post-Frey procedure alcohol use is equivocal with traditionalists assuming that abstinence mitigates pain and others suggesting that poor pain control might lead to alcohol misuse. It has been postulated that abstinence contributes to survival rather than to pain relief [15]. This study had limited mortality data but found that continued alcohol consumption (as admitted by respondents at last visit) was not implicated in pain aggravation. Furthermore the proportion of participants who drank post-operatively was greater in the good global health status/QoL category.
Despite limiting post-operative QoL issues such as continued use of analgesics, unemployment, an inability to work well, dependence on a disability grant, diabetes, and steatorrhea, the majority (25/32) of participants reported that they benefited substantially from the surgery that is therefore not necessarily contraindicated for indigent patients. In their recent study of 414 patients with self-identified pain and chronic pancreatitis, Mullady et al. found “no association between the duration of the disease and the quality or severity of the pain” [16]. This study concurs with Mullady’s finding suggesting that deferment of surgery in anticipation of future pain “burn-out” is probably not valid. This inference was recently suggested by Liu et al. [17].
The structured interview was essentially descriptive, narrative, and included a counseling element. However, as the need to test the relevance of universalist conceptions of well being and QoL in low or no income societies became increasingly pertinent, the EORTC QLQ-C30 was introduced as a more quantitative instrument to be combined with that of the less positivist interview. The majority of participants were manual workers, some of whom were illiterate who had difficulty understanding some of the QLQ-C30 concepts without explanation from the interviewer. Tension, irritability, and depression of the QLQ-C30, for instance, are not African concepts with direct translations. It was necessary in many instances for the interviewer to go through the QLQ-C30 with the participant when understanding was limited and African translations did not help those who could not read. In such instances the QLQ-C30 effectively became a structured interview. Without a relevant gold standard it was not possible to evaluate which of the two instruments was more reliable and valid, nor whether possible inter-subjectivity amounted to bias. In general outcomes measured by the two instruments were similar with regard to comparable issues. However, the structured interview included some pertinent issues not considered in the QLQ-C30 and participant/interviewer interaction was considered useful. It is therefore proposed that in the context of this population of chronic pancreatic patients the structured interview be the measure of choice, and that suitable methods be devised to transform it into a fully quantitative instrument while retaining its narrative essence.
Received June 12th, 2012 – Accepted October 8th, 2012
Keywords Pancreatitis, Chronic; Quality of Life
Abbreviations EORTC: European Organisation for Research and Treatment of Cancer
Previous presentation Prize presentation at the 9th Congress of the European-African Hepato-Pancreato-Biliary Association (E-AHPBA), Cape Town, South Africa, 12-16 April 2011
Funding No funding was required for the study
Conflict of interest declared None
Correspondence
Martin
Derrick Smith
Chris Hani Baragwanath Academic Hospital
University of the Witwatersrand
Private Bag X01 Pimville
Johannesburg, Soweto 1808
South Africa
Phone: +27-11.933.9267
Cell: +27-83.253.8280
Fax: +27-11.938.2002
E-mail: martin.smith@wits.ac.za
References
1. Petersen, I. At the heart of development: an introduction to mental health promotion and the prevention of mental disorders in scarce-resource contexts. In: Promoting mental health in scarce-resource contexts. Emerging evidence and practice. Ed. Inge Petersen, Arvin Bhana, Alan J Flisher, Leslie Swartz and Linda Richter. HSRC Press, Cape Town, 2010, pp 3 – 4.
2. Frey CF, Smith GJ. Description and rationale of a new operation for chronic pancreatitis. Pancreas. 1987;2:701-7. [PMID 3438308]
3. Falconi M, Bassi C, Casetti L, Mantovani W, Mascetta G, Sartori N, et al. Long-term results of Frey’s procedure for chronic pancreatitis: a longitudinal prospective study on 40 patients. J GIT Surg. 2006;10,4:504-510. [PMID 16627215]
4. Pessaux P, Kianmanesh R, Regimbeau J-M, Sastre B, Delcenserie R, Sielezneff I, et al. Frey procedure in the treatment of chronic pancreatitis: short term results. Pancreas. 2006;33,4:354-358. [PMID 17079939]
5. Chiang K-C, Yeh C-N, Hsu J-T, Chen H-M, Chen H-Y, Hwang T-L, Jan Y-Y, Chen M-D. Pancreaticoduodenectomy versus Frey’s procedure for chronic pancreatitis: preliminary data on outcome and pancreatic function. Surg Today. 2007;37,11:961-966. [PMID 17952526]
6. Strate T, Bachmann K, Busch P, Mann O, Schneider C, Bruhn JP, et al. Resection vs drainage in treatment of chronic pancreatitis: long-term results of a randomized trial. Gastroenterology. 2008;134:1406-1411. [PMID 18471517]
7. Aaronson NK, Ahmedzai S, Bergman B, Bullinger M, Cull A, Duez NJ, et al. EORTC QLQ-C30: A quality-of-life instrument for use in international clinical trials in oncology. Journal of the National Cancer Institute. 1993; 85: 365-376.
8. Fayers PM, Aaronson NK, Bjordal K, Groenveld M, Curran D, Bottomley A, on behalf of the EORTC Quality of Life Group. The EORTC QLQ-C30 Scoring Manual (3rd Edition.) Published by: European Organisation for Research and Treatment of Cancer; Brussels, Belgium 2001.
10. Bloechle C, Izbicki JR, Knoefel WT, Kuechler T and Broelsch CE. Quality of life in chronic pancreatitis: results after duodenum-preserving resection of the head of the pancreas. Pancreas. 1995; 11:77-85. [PMID 7667246]
11. Fitzsimmons D, Kahl S, Butturini G, van Wyk M, Bornman P, Bassi C, et al. Symptoms and quality of life in chronic pancreatitis assessed by structured interview and the EORTC QLQ-C30 and QLQ-PAN26. Am J Gastroenterol. 2005; 100(4): 918-926. [PMID 15784041]
12. Lankisch PG, Lohr-Happe A, Otto J, Creutzfeldt W. Natural course in chronic pancreatitis. Pain, exocrine and endocrine pancreatic insufficiency and prognosis of the disease. Digestion. 1993; 54:148-155. [PMID 8359556]
13. Strate T, Taherpour Z, Bloechle C, Mann O, Bruhn JP, Schneider C, et al. Long-term follow-up of a randomized trial comparing the Beger and Frey procedures for patients suffering from chronic pancreatitis. Ann Surg. Apr 2005; 241,4:591-8. [PMID 15798460]
14. Jeppe CY, Smith MD. Transversal descriptive study of xenobiotic exposures in patients with chronic pancreatitis and pancreatic cancer. [Letter] J Pancreas (Online) March 2008; 9, 2:235-239. http://www.joplink.net [Pubmed]
15. Negi S, Singh A, Chaudhary A. Pain relief after Frey’s procedure for chronic pancreatitis. Br J Surg. 2010;97:1087-1095. [PMID 20632276]
16. Mullady DK, Yadav D, Amann ST, O’Connell MR, Barmada MM, Elta GH, et al. Type of pain, pain-associated complications, quality of life, disability and resource utilization in chronic pancreatitis: a prospective cohort study. Gut. 2011;60,1: 77-84. [PMID 21148579]
17. Liu LS, Shenoy M, Pasricha PJ. Substance P and calcitonin gene related peptide mediate pain in chronic pancreatitis and their expression is driven by nerve growth factor. J Pancreas (Online) 2011;12,4:389-394. http://www.joplink.net/prev/201107/05.html
Appendix 1
CHRONIC PANCREATITIS PATIENTS’ INTERVIEW
(PRE LR-LPJ)
DATE OF INTERVIEW_________________________
NAME_____________________________________
FEMALE___MALE___ HOSPITAL NUMBER____________________
DATE OF BIRTH___________________
PLACE OF BIRTH_____________________________
AGE AT MIGRATION TO JOHANNEBURG_____ (YEARS)
NATIONALITY_______________________HOME LANGUAGE___________________________
MARITAL STATUS____________________NUMBER OF DEPENDENTS____________________
ADDRESS___________________________________________________________________
TEL. NO. (H)___________________(W)_____________________CELL__________________
NEXT OF KIN/CONTACT PERSON______________________________TEL._______________
CURRENTLY EMPLOYED: YES__ NO__
RETIRED: YES__NO__
EMPLOYMENT HISTORY
|
EMPLOYER/INDUSTRY |
OCCUPATION |
DATES OF SERVICE |
REASON FOR LEAVING |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
EXPOSURE TO RISK SUBSTANCES
ALCOHOL: YES__ NO__ BEER__ WINE__ SPIRITS__
SPECIAL OCCASIONS__ WEEKENDS ONLY__ DAILY__ ALCOHOLIC__
DURATION (YEARS) _______
DRUGS/NARCOTICS: YES__NO__ TYPE____________________________________________
DURATION (YEARS) _________
CIGARETTES: YES__ NO__ 1-5/DAY__ 6-10/DAY__ 11-20/DAY__ >20/DAY
DURATION (YEARS) ______
PASSIVE SMOKING: YES__ NO__ DURATION (YEARS)_______
ORAL/INJECTABLE CONTRACEPTIVES: YES__ NO__ DURATION (YEARS)______
BURNING FIREWOOD: YES__ NO__ SOURCE________________________________________
VEHICLE EMISSIONS: YES__ NO__
UNSATURATED FATTY ACID COOKING OILS________________________________________
PETROLEUM PRODUCTS: PARAFFIN: YES__ NO__ SOURCE____________________________
BENZENE: YES__ NO__ SOURCE_____________________________
OTHER_________________________________________________
SOLVENTS: THINNERS: YES__ NO__
TURPENTINE: YES__ NO__
OTHER_________________________________________
PAINT: YES__ NO__ MASKED__ UNMASKED__ DOMESTIC__ WORK__
DIESEL: YES__ NO__
NUTRITION
CHILDHOOD: POOR__ OK__ GOOD__
ADULT: POOR__ OK__ GOOD__
BADLY AFFECTED BY CP: YES__ NO__
BADLY AFFECTED BY ALCOHOL: YES__ NO__
PSYCHOMETRY
WORK PERFORMANCE/ABILITY TO WORK _________________________________________
FAMILY AND SOCIAL INTERACTION ______________________________________________
FEEL GOOD ABOUT LIFE: YES__ NO__
FEEL BAD ABOUT LIFE: YES__ NO__
HOPELESS __ HOPEFUL__
CLINICAL INFORMATION
DATE OF CP PAIN ONSET______________
ORIGINAL DIAGNOSIS______________________________SOURCE____________________
DATES OF FIRST AND SUBSEQUENT HOSPITAL/CLINIC ADMISSIONS____________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
DATE OF FIRST CP DIAGNOSIS___________________ SOURCE________________________
DATE OF PRESENTATION AT CHB HPB UNIT_______________________
PAIN DETAILS BEFORE HOSPITAL ADMISSION
LOCATION OF PAIN: EPIGASTRIC__ LUQ__ RUQ__ RADIATING TO BACK__
INTENSITY: ABSENT__ MILD__ MODERATE__ SEVERE__
INTERMITTENT__ FREQUENT__ PERSISTENT__ INCREASING OVER TIME__ DECREASING OVER TIME__
PAIN MEDICATION USE: NSAIDS__ NARCOTICS__ ANALGESICS__
EFFECTIVE: YES__ NO__
NON-PANCREATIC CAUSES OF ABDOMINAL PAIN____________________________________
PAIN SCALE (0-10) _______
SEQUELAE
STEATORREA: YES__ NO__ STOOLS/DAY______
PANCREATIC ENZYME SUBSTITUTES: YES__ NO__
DIABETES: YES__ NO__ IDDM__ NIDDM__
HYPOGLYCAEMIC AGENTS______________________________________________________
SPECIAL DIET________________________________________________________________
NAUSEA: YES__ NO__ VOMITING: YES__ NO__
LOSS OF WEIGHT____ WEIGHT GAIN____ FLUCTUATING WEIGHT____
Appendix 2
CHRONIC PANCREATITIS PATIENTS’ INTERVIEW
(POST LR-LPJ)
DATE OF INTERVIEW _____________________________
NAME_____________________________________
FEMALE ___ MALE __ HOSPITAL NUMBER ____________________
DATE OF BIRTH _______________
MARITAL STATUS ______________________ NO. OF DEPENDENTS __________
ADDRESS ______________________________________________________________
TEL. NO. (H) _________________ (W) __________________ CELL _______________
NEXT OF KIN/CONTACT PERSON ______________________ TEL.__________________\
CURRENTLY EMPLOYED: YES__ NO__ RETIRED: YES__ NO__
POST SURGICAL EMPLOYMENT
|
EMPLOYER/INDUSTRY |
OCCUPATION |
DATES OF SERVICE |
REASON FOR LEAVING |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
WORKMEN’S COMPENSATION: YES__ NO__
UIF: YES__ NO__
DISABILITY GRANT: YES__ NO__
PENSION: STATE__ PRIVATE__
POST LR-LPJ EXPOSURE TO RISK SUBSTANCES
ALCOHOL: YES__ NO__ BEER__ WINE__ SPIRITS__
SPECIAL OCCASIONS__ WEEKENDS ONLY__ DAILY__ ALCOHOLIC__
DURATION SINCE SURGERY ________
CIGARETTES: YES__ NO__ 1-5/DAY__ 6-10/DAY__ 11-20/DAY__ >20/DAY__
DURATION SINCE SURGERY_________
PASSIVE SMOKING: YES__ NO__
ORAL/INJECTABLE CONTRACEPTIVES: YES__ NO__
BURNING FIREWOOD: YES__ NO__ SOURCE__________________
VEHICLE EMISSIONS: YES__ NO__
UNSATURATED FATTY ACID COOKING OILS________________________________________
PETROLEUM PRODUCTS: PARAFFIN: YES__ NO__ SOURCE____________________________
BENZENE: YES__ NO__ SOURCE_____________________________
OTHER: ________________________________________________
SOLVENTS: THINNERS: YES__ NO__
TURPENTINE: YES__ NO__
OTHER ___________________________________________________________
PAINT: YES__ NO__ MASKED__ UNMASKED__ DOMESTIC__ WORK__
DIESEL: YES__ NO__
NUTRITION
POOR__ OK__ GOOD__
FOODS AVOIDED_____________________________________________________________
BADLY AFFECTED BY SURGERY: YES__ NO__
BADLY AFFECTED BY ALCOHOL: YES__ NO__
PSYCHOMETRY
WORK PERFORMANCE/ABILITY TO WORK__________________________________________
FAMILY AND SOCIAL INTERACTION_______________________________________________
FEEL GOOD ABOUT LIFE: YES__ NO__
FEEL BAD ABOUT LIFE: YES__ NO__
HOPELESS__ HOPEFUL__
POST LR-LPJ PAIN
HAVE YOU HAD PAIN AROUND THE STOMACH? YES__ NO__
WAS IT THE SAME AS THE PAIN IN YOUR PANCREAS? YES__ NO__
IF YES, WHEN DID THE PAIN COME?______________________________________________
WOUND PAIN? _______________________________________________________________
LOCATION OF PAIN: EPIGASTRIC__ LUQ__ RUQ__ RADIATING TO BACK__
INTENSITY: ABSENT__ MILD__ MODERATE__ SEVERE__
INTERMITTENT__ FREQUENT__ PERSISTENT__ INCREASING OVER TIME__ DECREASING OVER TIME__
PAIN MEDICATION USE: NSAIDS__ NARCOTICS__ ANALGESICS__
EFFECTIVE: YES__ NO__
POST CODEINE CONSTIPATION: YES__ NO__
NON-PANCREATIC CAUSES OF ABDOMINAL PAIN_______________________________________
PAIN SCALE (0-10) ___________
SEQUELAE
STEATORRHEA: YES__ NO__ STOOLS/DAY______________
PANCREATIC ENZYME SUBSTITUTES: YES__ NO__
DIABETES: YES__ NO__ IDDM__ NIDDM__
HYPOGLYCAEMIC AGENTS______________________________________________________
SPECIAL DIET________________________________________________________________
NAUSEA: YES__ NO__ VOMITING: YES__ NO__
LOSS OF WEIGHT__ WEIGHT GAIN__ FLUCTUATING WEIGHT__
DO YOU THINK THE PANCREAS OPERATION HELPED YOU?
YES__ NO__ MAYBE__
COMMENTS__________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________