title: What Factors are Associated With Quality Of Life, Pain Interference, Anxiety, and Depression in Patients With Metastatic Bone Disease?
abstract: BACKGROUND
  It would be helpful for the decision-making process of patients with metastatic bone disease to understand which patients are at risk for worse quality of life (QOL), pain, anxiety, and depression. Normative data, and where these stand compared with general population scores, can be useful to compare and interpret results of similar patients or patient groups, but to our knowledge, there are no such robust data.
  
  
  OBJECTIVE
  We wished (1) to assess what factors are independently associated with QOL, pain interference, anxiety, and depression in patients with metastatic bone disease, and (2) to compare these outcomes with general US population values.
  
  
  METHODS
  Between November 2011 and February 2015, 859 patients with metastatic bone disease presented to our orthopaedic oncology clinic; 202 (24%) were included as they completed the EuroQOL-5 Dimension (EQ-5DTM), PROMIS®Pain Interference, PROMIS®Anxiety, and PROMIS®Depression questionnaires as part of a quality improvement program. We did not record reasons for not responding and found no differences between survey respondents and nonrespondents in terms of age (63 versus 64 years; p = 0.916), gender (51% men versus 47% men; p = 0.228), and race (91% white versus 88% white; p = 0.306), but survey responders were more likely to be married or living with a partner (72%, versus 62%; p = 0.001). We assessed risk factors for QOL, pain interference, anxiety, and depression using multivariable linear regression analysis. We used the one-sample signed rank test to assess whether scores differed from US population averages drawn from earlier large epidemiologic studies.
  
  
  RESULTS
  Younger age (β regression coefficient [β], < 0.01; 95% CI, 0.00-0.01; p = 0.041), smoking (β, -0.12; 95% CI, -0.22 to -0.01; p = 0.026), pathologic fracture (β, -0.10; 95% CI, -0.18 to -0.02; p = 0.012), and being unemployed (β, -0.09; 95% CI, -0.17 to -0.02; p = 0.017) were associated with worse QOL. Current smoking status was associated with more pain interference (β, 6.0; 95% CI, 1.6-11; p = 0.008). Poor-prognosis cancers (β, 3.8; 95% CI, 0.37-7.2; p = 0.030), and pathologic fracture (β, 6.3; 95% CI, 2.5-7.2; p = 0.001) were associated with more anxiety. Being single (β, 5.9; 95% CI, 0.83-11; p = 0.023), and pathologic fracture (β, 4.4; 95% CI, 0.8-8.0; p = 0.017) were associated with depression. QOL scores (0.68 versus 0.85; p < 0.001), pain interference scores (65 versus 50; p < 0.001), and anxiety scores (53 versus 50; p = 0.011) were worse for patients with bone metastases compared with general US population values, whereas depression scores were comparable (48 versus 50; p = 0.171).
  
  
  CONCLUSIONS
  Impending pathologic fractures should be treated promptly to prevent deterioration in QOL, anxiety, and depression. Our normative data can be used to compare and interpret results of similar patients or patient groups. Future studies could focus on specific cancers metastasizing to the bone, to further understand which patients are at risk for worse patient-reported outcomes.
  
  
  METHODS
  Level III, prognostic study.
authors.affiliation: Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
authors.forename: Q M J
authors.initials: QM
authors.lastname: van der Vliet
authors.affiliation: Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA. nunorui.pp@gmail.com.|Massachusetts General Hospital, Room 3.946, Yawkey Building, 55 Fruit Street, Boston, MA, 02114, USA. nunorui.pp@gmail.com.
authors.forename: N R
authors.identifier: http://orcid.org/0000-0003-3813-2212
authors.initials: NR
authors.lastname: Paulino Pereira
authors.affiliation: Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
authors.forename: S J
authors.initials: SJ
authors.lastname: Janssen
authors.affiliation: Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
authors.forename: F J
authors.initials: FJ
authors.lastname: Hornicek
authors.affiliation: Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
authors.forename: M L
authors.initials: ML
authors.lastname: Ferrone
authors.affiliation: Department of Orthopaedic Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
authors.forename: J A M
authors.initials: JA
authors.lastname: Bramer
authors.affiliation: Department of Orthopaedic Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
authors.forename: C N
authors.initials: CN
authors.lastname: van Dijk
authors.affiliation: Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
authors.forename: J H
authors.initials: JH
authors.lastname: Schwab
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001007:Anxiety / Q000150:complications / Q000523:psychology*; D001859:Bone Neoplasms / Q000150:complications / Q000523:psychology* / Q000556:secondary*; D000072716:Cancer Pain / Q000150:complications / Q000523:psychology*; D003863:Depression / Q000150:complications / Q000523:psychology*; D004185:Disability Evaluation; D005260:Female; D006304:Health Status; D006801:Humans; D008297:Male; D008875:Middle Aged; D010147:Pain Measurement; D011788:Quality of Life / Q000523:psychology*; D012307:Risk Factors; D011795:Surveys and Questionnaires