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Quality of Life (QOL) in Patients with Acromegaly Is Severely Impaired: Use of a Novel Measure of QOL: Acromegaly Quality of Life Questionnaire

Department of Endocrinology (S.V.R., S.M.S., P.J.T.), Christie Hospital, Manchester M20 4BX, United Kingdom; Hospital Sant Pau (S.M.W.), Autonomous University of Barcelona, E-08025 Barcelona, Spain; Spanish Group for the Study of Methodology in Clinical Research (L.P.), 28108 Madrid, Spain; and Health Outcomes Research Europe Group (X.B.), 08201 Barcelona, Spain

Address all correspondence and requests for reprints to: Peter J. Trainer, Department of Endocrinology, Christie Hospital, Wilmslow Road, Manchester M20 4BX, United Kingdom. E-mail: peter.trainer{at}man.ac.uk.

	Abstract

Top Abstract Introduction Patients and Methods Results Discussion References

 
Acromegaly Quality of Life Questionnaire (AcroQoL) is a new disease-generated quality of life (QOL) questionnaire comprising 22 questions covering physical and psychological aspects of acromegaly and subdivided into "appearance" and "personal relations" categories. We have performed a cross-sectional study of QOL in 80 patients [43 male (mean age, 54.2 yr; range, 20–84); median GH, 0.93ng/ml (range, <0.3 to 23.7); IGF-I, 333.1 ng/ml (range, 47.7–899)] with acromegaly. In addition to AcroQoL, patients completed three generic QOL questionnaires: Psychological General Well-Being Schedule (PGWBS), EuroQol, and a signs and symptoms score (SSS). All three generic questionnaires confirmed impairment in QOL [mean scores: PGWBS, 69.6; EuroQol, visual analog scale, 66.4 (range, 20–100) and utility index, 0.7 (range, –0.07 to 0.92); and SSS, 12 (range, 0–27)]. There was no correlation between biochemical control and any measure of QOL. AcroQoL (57.3%; range, 18.2–93.2) correlated with PGWBS (r = 0.73; P < 0.0001); and in patients with active disease, AcroQoL-physical dimension correlated with SSS (r = –0.67; P < 0.0003). In all questionnaires, prior radiotherapy was associated with impaired QOL. In conclusion, these data underline the marked impact that acromegaly has on patients’ QOL and provide the first evidence validating AcroQoL against well-authenticated measures of QOL. This indicates the potential of AcroQoL as a patient-friendly measure of disease activity.

	Introduction

Top Abstract Introduction Patients and Methods Results Discussion References

 
ADVANCES IN SURGICAL technique, modalities of radiotherapy, and availability of potent medical therapy mean that we are entering an era when it will be possible to achieve biochemical disease control in virtually all patients with acromegaly and thereby restore life expectancy to normal (1, 2, 3, 4, 5). The challenge in the future will be developing treatment algorithms for individual patients that use the various modes of treatment in an optimal manner not only to establish biochemical control but also to achieve the other goals of therapy, such as controlling tumor growth, protecting vision, reversing soft tissue changes, preventing arthritis, and preserving pituitary function while ensuring the best possible quality of life (QOL) for the patient. The means of measuring biochemical markers have improved, but there is a lack of specific QOL measurement tools for patients with acromegaly and, as a consequence, a dearth of data relating QOL to biochemical parameters and modalities of treatment. Signs and symptoms scores (SSS) have been used as measures of efficacy in therapeutic intervention studies and, unsurprisingly, have been shown to improve as GH and IGF-I fall (6, 7). However, SSS have not been shown to relate, in cross-sectional studies, to biochemical measures of disease control and are not measures of QOL but rather are specifically designed to assess the reversible consequences of GH hypersecretion, such as perception of soft tissue swelling and sweating.

The Acromegaly Quality of Life Questionnaire (AcroQoL) was designed with the aim of creating a simple and valid instrument to assess QOL in people with acromegaly (8). It is intended to provide a cost-effective means to assess self-perceived status and to allow evaluation of interventions, in longitudinal research, and to identify patients who require further treatment. It was developed by semistructured, in-depth interviews of patients and endocrinologists to identify perceived domains of impact of acromegaly on QOL. Domains identified were: physical and psychological function, social and daily activities, symptoms, cognition, general health perception, sleep, sexual function, pain, energy, and body image. The items fall into two categories of physical and psychological function, the latter category being subdivided into areas addressing appearance and personal relationships. These data were pared down to 22 questions with five possible responses scoring 1–5 (maximum score, 110). Results are quoted as a percentage, with lower scores equating to poorer QOL. Originally developed in Spanish, AcroQoL has been translated into 12 languages (9).

The intention of this study was to assess the QOL of patients with acromegaly using well-authenticated generic measures of QOL and, for the first time in English patients, AcroQoL.

	Patients and Methods

Top Abstract Introduction Patients and Methods Results Discussion References

 
Patients

Eighty English-speaking patients [43 male; mean age, 54.2 yr (range, 20–84)] with acromegaly, attending for routine care at Christie Hospital, participated in this study (Table 1).

Questionnaires

Patients completed four questionnaires.

The Psychological General Well-Being (PGWB) Index. The PGWB Index is a 22-item questionnaire addressing both positive and negative affective states. Each item has six questions, answered on a scale of 0–5; the maximum score is 110, reflecting perfect QOL. The items divide into six subscales: anxiety, depressed mood, positive well-being, self-control, general health, and vitality. This questionnaire has been shown to have good validity, reliability, and internal consistency (10).

The SSS. The SSS is a disease-specific tool that consists of five questions, scoring 0–8, considering headache, perspiration, joint pain, fatigue, and soft tissue swelling. The maximum score of 40 is indicative of severe signs and symptoms.

AcroQoL. AcroQoL comprises 22 questions, each having five possible responses scored 1–5, the maximum score of 110 reflecting best possible QOL, and quoted as a percentage. The 22 items break down into two categories, physical and psychological function, the latter being further subdivided into areas addressing appearance and personal relationships.

EuroQol (EQ-5D). EQ-5D was designed specifically to complement other QOL instruments and generate a cardinal index of health (11, 12, 13). Described as a non-disease-specific tool, it has been well validated, and normative data exist. Divided into two parts, comprising a five-point CRS (category rating scale) addressing mobility/self-care/usual activities/pain and discomfort/anxiety and depression. One response from three options is selected for each of the five points. Two hundred forty-three permutations are possible, and the utility index (UI) is calculated using a regression equation (range, –0.59 to 0.92). Part 2 is a self-rated visual analog scale (VAS), a 20-cm thermometer scaled 0 (worst imaginable health state) to 100 (best imaginable health state).

Assays

Serum IGF-1 and GH were measured using the Nichols Advantage Method (Nichols Institute Diagnostics, Heston, Middlesex, UK), with an IGF-I intraassay CV of 7.4, 5.7, and 4.5% at 49, 229, and 493 µg/liter, respectively, and a GH intraassay CV of 7, 8.7, and 8.6% at 2.8, 7.0, and 13.3 ng/ml, respectively. GH was originally measured in milliunits per liter, and a conversion factor of 3 was used to convert to nanograms per milliliter.

Statistics

Statistical analysis was with SPSS/S Plus software packages. Linear regression was used to investigate the relationships between normally distributed parameters, and Spearman rank order correlation for nonparametric data. Statistical significance was set at the 5% level (P < 0.05).

	Results

Top Abstract Introduction Patients and Methods Results Discussion References

 
The median GH and IGF-I values were 0.93 ng/ml (range, <0.3 to 23.7) and 333.1 ng/ml (range, 47.7–899), respectively, with 27 of the 80 patients having an IGF-I within the age-related reference range and a GH level less than 1.6 ng/ml. The median scores for the generic, non-disease-specific measures of QOL were: for PGWB, a score of 69.6 (range, 21–104), with the subsets for vitality and general health having the greatest deficit (see Fig. 3 and Table 2); and for EuroQol, a VAS value of 66.4 (range, 20–100) and UI of 0.7 (range, –0.07 to 0.92). The median score for the disease-generated QOL tool AcroQoL was 57.3% (range, 18.2–93.2), whereas median SSS was 12 (range, 0–27). No difference was found in QOL between those patients with an IGF-I within the age- and sex-matched reference range plus a GH less than 1.6 ng/ml, and those with biochemically active disease. All patients either had received treatment for acromegaly in the past or were currently on medication at the time of questionnaire completion.

View larger version (21K): [in this window] [in a new window]   FIG. 3. PGWBS scores from community surveys and studies of patients with adult GHD, patients following therapy for nonfunctioning pituitary adenomas and acromegaly (redrawn from Ref. 17 ).

View larger version (12K): [in this window] [in a new window]   FIG. 1. AcroQoL scores in patients with acromegaly correlate with the generic measure of QOL PGWBS (r = 0.73; P < 0.0001)

View larger version (10K): [in this window] [in a new window]   FIG. 2. AcroQoL scores in patients with acromegaly correlate with the generic measure of QOL EQ-5 VAS (EQ-VAS) (r = 0.61; P < 0.0001)

	Discussion

Top Abstract Introduction Patients and Methods Results Discussion References

 
The recent series of consensus publications on the goals of treatment of acromegaly have concentrated on relating mortality to biochemical parameters to set targets of therapy (14). Mortality, GH, and IGF-I have the virtues of being easily measurable; but to patients, well-being is paramount, although more difficult to quantify. Advances in treatment options mean that it may be possible to achieve biochemical control in virtually all patients; and therefore, the challenge is to achieve that goal while ensuring optimal QOL for the individual patient (7). Many factors influence QOL, and it may be that the various modes of therapy impact on QOL differently. Recognition of the improvement in well-being with GH treatment is responsible for much of the momentum driving replacement therapy in patients with GH deficiency (GHD) (15). Many generic tools for measuring QOL have been used in adults with GHD; but because of its ease of completion, the disease-generated tool Adult GH Deficiency Assessment has been widely adopted (16, 17, 18, 19). Arising from an appreciation of the need to measure QOL in patients with acromegaly, AcroQoL was developed as a series of questions reflecting topics highlighted during structured interviews with patients and endocrinologists, and piloted in Spanish patients (9). This is the first study to report on the use of AcroQoL in English-speaking patients and to compare its performance against generic measures of QOL. Further validation of the English translation and general applicability of AcroQol is that the mean score in the Spanish patients (59.5%; range, 13.6–90.9) is very similar to the score in the patients reported here (57.3%; range, 18.2–93.2).

Confirmation of the severe impairment of QOL in acromegaly comes from comparison between the PGWB scores from our patients with normative data from population surveys, with the subdomain scores for vitality and general health being most impaired (20, 21, 22) (Table 2). Consistent with these findings was the impaired EQ-5D UI score of 0.7, compared with the population-based mean of 0.81 (23). These generic measures of QOL allow comparison of the QOL of patients with acromegaly to that of patients with other chronic disease. In our patients, the EQ-5D VAS score was 0.66, compared with 0.79 in asthmatics, 0.69 in angina, and 0.6 in patients with osteoarthritis (23, 24). A measure of the severity of the impairment of QOL of patients with acromegaly is that the mean PGWB score in our patients is worse than in any published series of adults with GHD, except that reported by Murray et al. (25), who specifically selected their cohort based on severely impaired QOL at interview (Fig. 3).

As a disease-generated measure of QOL, no population-derived control data are available for AcroQoL, but the close correlations demonstrated between AcroQoL scores and those of the generic tools PGWB and EQ-5D reinforce the concept that AcroQoL is a valid measure of disease activity, with the advantages of being focused on the areas of concern for patients with acromegaly and being patient friendly.

SSS focus on the most reversible aspects of acromegaly and, for that reason, have been used in many interventional studies; but their limited focus means that they are not measures of QOL. Furthermore, whereas therapy studies show an improvement in SSS that coincides with a reduction in GH and IGF-I, the changes in SSS do not correlate with the changes in GH and IGF-I. In other words, it is not the patients with the greatest biochemical improvement that experience the greatest improvement in SSS. For these reasons, SSS are of very limited value as measures of well-being in patients with acromegaly, either in a cross-sectional or longitudinal study.

This study was cross-sectional in design, with acromegaly having been diagnosed, on average, 12.7 yr earlier. A wide spectrum of disease activity existed among the patient cohort, although the median GH and IGF-I levels were 0.93 ng/ml and 333.1 ng/ml, respectively, i.e. virtually within the biochemical goals for therapy set out in the consensus statement on the treatment of acromegaly (14). A total of 34.2% of the patients had both GH and IGF-I levels within target; but despite this degree of biochemical control, measured QOL was significantly impaired with all generic well-being tools.

No relationship existed between either GH or IGF-I and any measure of QOL, and there was no difference in QOL score between those with active and inactive disease. The absence of a relationship between biochemical parameters and QOL should not be a surprise. Despite extensive investigation over the last decade of QOL in adults with GHD, and impairment of QOL being an indication for GH treatment, there have been no reports of a relationship between either GH or IGF-I levels and QOL at baseline, or during treatment of patients with GHD. The potential for observing a relationship between biochemical parameters and QOL in our patients with acromegaly is diminished by the relatively satisfactory GH and IGF-I levels. Many factors, other than circulating levels of GH and IGF-I, are likely to impact on QOL. In this study, stepwise forward linear regression identified previous radiotherapy as being associated with a significant worsening of QOL; but no effect of gender, age, years from diagnosis, or presence of hypopituitarism was seen. The relationship between prior radiotherapy and impairment of QOL in patients with acromegaly requires further exploration and does not prove radiotherapy to be the cause of impaired QOL because, for example, the patients treated with radiotherapy were diagnosed, on average, 11 yr previously, compared with 4 yr for those not treated with radiotherapy, and referral patterns for radiotherapy have evolved in the last decade. Interestingly, Page et al. (20) found the PGWB scores to be lower in patients with hypopituitarism who had received radiotherapy, compared with those who had not. In both studies, it is probable that it was the patients with larger and more aggressive tumors that were treated with radiotherapy.

In summary, all measures of QOL have been demonstrated to be significantly impaired in this cohort of patients with acromegaly, and to be worse than most adults with severe GHD. The close correlation of total score and the subsection for vitality with robust generic QOL tools confirms the validity of AcroQoL as a measure of disease activity. At this juncture, it would be premature to conclude that radiotherapy is responsible for impairing QOL in patients with acromegaly, and further studies are required to assess the causal factors. Prospective studies are on-going to see whether favorable changes in biochemical disease activity are reflected in improvement in AcroQoL score. The long-term goal of measurement of QOL is to allow selection of the modes of therapy that not only ensure biochemical control but also optimize QOL.

	Acknowledgments

 
We express our gratitude to Margaret Roberts (Research Nurse) for her diligence in overseeing the completion of the questionnaires and to David Ryder for statistical assistance.

	Footnotes

 
First Published Online March 8, 2005

Abbreviations: AcroQoL, Acromegaly Quality of Life Questionnaire; GHD, GH deficiency; PGWB, Psychological General Well-Being; PGWBS, PGWB Schedule; QOL, quality of life; SSS, signs and symptoms score(s); UI, utility index(s); VAS, visual analog scale.

Received August 5, 2004.

Accepted February 25, 2005.

	References

Top Abstract Introduction Patients and Methods Results Discussion References

 

1. Trainer PJ 2002 A giant’s step forward. Clin Endocrinol (Oxf) 56:423–425[CrossRef][Medline]
2. Beauregard C, Truong U, Hardy J, Serri O 2003 Long-term outcome and mortality after transsphenoidal adenomectomy for acromegaly. Clin Endocrinol (Oxf) 58:86–91[CrossRef][Medline]
3. Holdaway IM, Rajasoorya RC, Gamble GD 2004 Factors influencing mortality in acromegaly. J Clin Endocrinol Metab 89:667–674[Abstract/Free Full Text]
4. Serri O, Beauregard C, Hardy J 2004 Long-term biochemical status and disease-related morbidity in 53 postoperative patients with acromegaly. J Clin Endocrinol Metab 89:658–661[Abstract/Free Full Text]
5. Swearingen B, Barker FG, Katznelson L, Biller BM, Grinspoon S, Klibanski A, Moayeri N, Black PM, Zervas NT 1998 Long-term mortality after transsphenoidal surgery and adjunctive therapy for acromegaly. J Clin Endocrinol Metab 83:3419–3426[Abstract/Free Full Text]
6. Trainer PJ, Drake WM, Katznelson L, Freda PU, Herman-Bonert V, van der Lely AJ, Dimaraki EV, Stewart PM, Friend KE, Vance ML, Besser GM, Scarlett JA, Thorner MO, Parkinson C, Klibanski A, Powell JS, Barkan AL, Sheppard MC, Malsonado M, Rose DR, Clemmons DR, Johannsson G, Bengtsson BA, Stavrou S, Kleinberg DL, Cook DM, Phillips LS, Bidlingmaier M, Strasburger CJ, Hackett S, Zib K, Bennett WF, Davis RJ 2000 Treatment of acromegaly with the growth hormone-receptor antagonist pegvisomant. N Engl J Med 342:1171–1177[Abstract/Free Full Text]
7. van der Lely AJ, Hutson RK, Trainer PJ, Besser GM, Barkan AL, Katznelson L, Klibanski A, Herman-Bonert V, Melmed S, Vance ML, Freda PU, Stewart PM, Friend KE, Clemmons DR, Johannsson G, Stavrou S, Cook DM, Phillips LS, Strasburger CJ, Hackett S, Zib KA, Davis RJ, Scarlett JA, Thorner MO 2001 Long-term treatment of acromegaly with pegvisomant, a growth hormone receptor antagonist. Lancet 358:1754–1759[CrossRef][Medline]
8. Badia X, Webb SM, Prieto L, Lara N 2004 Acromegaly Quality of Life Questionnaire (AcroQoL). Health Qual Life Outcomes 2:13[Medline]
9. Webb SM, Prieto L, Badia X, Albareda M, Catala M, Gaztambide S, Lucas T, Paramo C, Pico A, Lucas A, Halperin I, Obiols G, Astorga R 2002 Acromegaly Quality of Life Questionnaire (AcroQol) a new health-related quality of life questionnaire for patients with acromegaly: development and psychometric properties. Clin Endocrinol (Oxf) 57:251–258[CrossRef][Medline]
10. Dupuy HJ 1984 The Psychological General Well-Being (PGWB) Index. In: Wenger NK, ed. Assessment of quality of life in clinical trials of cardiovascular therapies. New York: Le Jacq Publishing Inc.; 170–183
11. Dolan P 1997 Modeling valuations for EuroQol health states. Med Care 35:1095–1108[CrossRef][Medline]
12. Badia X, Herdman M, Schiaffino A 1999 Determining correspondence between scores on the EQ-5D "thermometer" and a 5-point categorical rating scale. Med Care 37:671–677[Medline]
13. Brooks R 1996 EuroQol: the current state of play. Health Policy 37:53–72[CrossRef][Medline]
14. Giustina A, Barkan A, Casanueva FF, Cavagnini F, Frohman L, Ho K, Veldhuis J, Wass J, von Werder K, Melmed S 2000 Criteria for cure of acromegaly: a consensus statement. J Clin Endocrinol Metab 85:526–529[Abstract/Free Full Text]
15. Holmes SJ, Shalet SM 1995 Characteristics of adults who wish to enter a trial of growth hormone replacement. Clin Endocrinol (Oxf) 42:613–618[Medline]
16. McKenna SP, Doward LC, Alonso J, Kohlmann T, Niero M, Prieto L, Wiren L 1999 The QoL-AGHDA: an instrument for the assessment of quality of life in adults with growth hormone deficiency. Qual Life Res 8:373–383[CrossRef][Medline]
17. Murray RD, Skillicorn CJ, Howell SJ, Lissett CA, Rahim A, Shalet SM 1999 Dose titration and patient selection increases the efficacy of GH replacement in severely GH deficient adults. Clin Endocrinol (Oxf) 50:749–757[CrossRef][Medline]
18. Murray RD, Shalet SM 1999 The use of self-rating questionnaires as a quantitative measure of quality of life in adult growth hormone deficiency. J Endocrinol Invest 22(5 Suppl):118–126
19. Monson JP 2000 Application of a disease-specific, quality-of-life measure (QoL-AGHDA) in growth hormone-deficient adults and a random population sample in Sweden: validation of the measure by Rasch analysis. Clin Endocrinol (Oxf) 52:141–142[Medline]
20. Page RC, Hammersley MS, Burke CW, Wass JA 1997 An account of the quality of life of patients after treatment for non-functioning pituitary tumours. Clin Endocrinol (Oxf) 46:401–406[CrossRef][Medline]
21. Andersson P, Olaison G, Bendtsen P, Myrelid P, Sjodahl R 2003 Health related quality of life in Crohn’s proctocolitis does not differ from a general population when in remission. Colorectal Dis 5:56–62[Medline]
22. McGauley GA, Cuneo RC, Salomon F, Sonksen PH 1990 Psychological well-being before and after growth hormone treatment in adults with growth hormone deficiency. Horm Res 33(Suppl 4):52–54
23. Burstrom K, Johannesson M, Diderichsen F 2001 Swedish population health-related quality of life results using the EQ-5D. Qual Life Res 10:621–635[CrossRef][Medline]
24. Brazier JE, Harper R, Munro J, Walters SJ, Snaith ML 1999 Generic and condition-specific outcome measures for people with osteoarthritis of the knee. Rheumatology (Oxford) 38:870–877
25. Murray RD, Skillicorn CJ, Howell SJ, Lissett CA, Rahim A, Smethurst LE, Shalet SM 1999 Influence on quality of life in GH deficient adults and their effect on response to treatment. Clin Endocrinol (Oxf) 51:565–573[CrossRef][Medline]

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This Article Abstract Full Text (PDF) Submit a related Letter to the Editor Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Copyright Permission Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Rowles, S. V. Articles by Trainer, P. J. Search for Related Content PubMed PubMed Citation Articles by Rowles, S. V. Articles by Trainer, P. J. Pubmed/NCBI databases Substance via MeSH Related Collections Neuroendocrinology and Pituitary Endocrine Oncology