Objective: To compare the health-related quality of life (HRQL) of acromegalics with healthy individuals and to investigate factors predictive of HRQL.

Design: Observational study with a comparison group. Patients from an endocrinology referral center attended from 2014 to 2017 were selected. The HRQL was evaluated using the Short Form Health Survey 36 (SF-36) and the Acromegaly Quality of Life Questionnaire (AcroQol).

Main Outcome Measures: Acromegalic patients have lower HRQL than healthy individuals, and psychiatric disorders are associated with a reduction in the HRQL of these patients. Socioeconomic factors can also impact quality of life.

Results: A 71 acromegalic patients and 76 healthy individuals were studied. Patient scores were much lower and ranged from 25% to 50% of the values from the comparison group. Patients' scores were comparable to the healthy Brazilian geriatric population, with a mean age of 28 years older. The median of the AcroQol inventory result was 53.4 (28.4-68.1) and the only clinical variable associated with low scores in this inventory was the presence of psychiatric disorders even after adjusted for sex (p= 0.021).

Conclusion: Acromegalic patients have HRQL more compromised than the healthy population and psychiatric aspects have a factor of worsening of HRQL. Mental health monitoring should be implemented in neuroendocrinology services, in favor of improving HRQL.

Acromegaly manifests itself with physical deformities and multiple systemic complications, being more common between 35 and 50 years of age [1-5]. Individuals with acromegaly have a reduced life expectancy at 5 years compared to healthy people [5,6]. The HRQL of acromegalic patients was lower than that of the healthy population, mainly due to decreased work activity, chronic pain, psychological and psychiatric disorders, sexual problems, and discomfort with self-image [7-18]. These aspects are commonly associated with changes in growth hormone (GH) [19]. The orofacial alterations caused by acromegaly, such as prognathism and macroglossia, compromise socialization and self-esteem [9-18]. Thus, changes in self-image were associated with high scores for anxiety and depression, low self-esteem, poor HRQL scores, and emotional apathy for acromegalic patients [20]. Even if treated, these patients present alterations, which suggest that the effect of GH excess on the central nervous system can be long-lasting and even irreversible. As such, this study aims to describe the quality of life (QoL) of patients with acromegaly, to compare them to healthy individuals (comparative group) and to investigate the predictors of patients' HRQL.

This is an Observational study with a comparison group performed at a reference centre in Endocrinology and Diabetes in Brazil from 2014 to 2017. To evaluate the impact of acromegaly on the HRQL of affected patients, it was used a generic (Medical Outcomes Study-36 Item Short Form Health Survey- SF-36) and specific questionnaire (Acromegaly Quality of Life Questionnaire -AcroQol). The present study was approved by the local Research Ethics Committee, under the number CAAE: 56840516.4.0000.5544. All research participants signed the Informed Consent Form. The Statistical Package for the Social Sciences (SPSS, Armonk, NY, USA), version 21.0 IBM® was used to analyse and tabulate the data. The categorical variables were expressed by absolute and relative frequency, the continuous variables by mean and standard deviation, and the scores by median and interquartile range. The acromegalic group was divided according to the median AcroQol scores (median = 53), to investigate the factors associated with HRQL Student's t-tests, Mann Whitney, Pearson Chi-Square tests and Fisher exact test were used to compare the groups. After the initial analysis, the variables that showed a p-value < 0.20 between the groups divided according to the median AcroQol scores, were adjusted in the logistic regression (psychiatric disturbs and sex). P-values ? 0.05 were considered statiscally significant.

The sample consisted of 71 acromegalic patients and 76 healthy individuals. The groups were similar (Table 1).

Table 1: Sociodemographic characteristics of 147 subjects studied.

Figure 1: Quality of life in the groups: mediano f scores of SF-36 (Mann-Whitney Test).

Figure 1 compares the acromegalic scores with the comparison group. The median of the patient's SF-36 scales ranged from 25% to 50% of the comparison group scores (healthy). The median of the inventory result, AcroQol, was 53.4 (28.4-68.1). Values of p < 0.001.

The clinical characteristics of patients are described in Table 2.

Table 2: Clinical characteristics in 71 acromegalic patients.

This study showed that acromegalic patients have lower HRQL than healthy individuals, and that psychiatric disorders are associated with a reduction in the HRQL of these patients. Socioeconomic factors can also impact quality of life. Although the mean age of the sample was comprised of adults, the median SF-36 scores of the patients, when compared to the results of the Brazilian healthy population, were also lower, being similar to the data of the elderly age group i.e., above 75 years (healthy Brazilian population almost 28 years older), as illustrated below Figure 1. Therefore, it can be concluded that acromegaly has an impact on HRQL as well as on functional capacity, thus compromising and aging the health scores (Figure 3).

Figure 3: SF-36 scores of patients in the sample compared to the normative study of the Brazilian population (over 75 years).

Acromegalic patients present more psychological complaints compared to other dimensions of health [21,22]. The reduction of HRQL is predominantly driven by psychopathology rather than other biochemical factors in acromegalic patients. In the present study, the only clinical factor associated with HRQL reduction was the presence of psychiatric issues, which corroborates findings from the literature. The present study presented important differences between the control group and patients, regarding emotional aspects and mental health (SF-36 domains), in order to reiterate that acromegalic patients present more psychic suffering than the general population. Regarding emotional aspects, the patients had a median score that was 67% lower than the comparison group. The median mental health of the patients was almost 32% lower than the median of the comparative group. The mean AcroQol scores in the patient sample were lower in relation to national and international studies, which may suggest interference with sociodemographic aspects [23,24].

In addition to the scientific implications, the clinical application of this research is the finding that important predictors of decreased HRQL are the psychiatric aspects, which are essentially modifiable predictors. Thus, mental health monitoring should be implemented in neuroendocrinology services, in favour of improving HRQL.

Acknowledgements

None

Declaration of Interest Statement

There is no conflict of interest. This survey did not receive any specific grants from any public, non-profit, or commercial funding agencies.

1. Abreu A, Tovar AP, Castellanos R, Valenzuela A, Giraldo CMG, Pinedo, et al. Challenges in the diagnosis and management of acromegaly: a focus on comorbidities. Pituitary. 2016; 19: 448-457.
2. Adelman DT, Liebert KJP, Nachtigall LB, Lamerson M, Bakker B. Acromegaly: the disease, its impact on patients, and managing the burden of long-term treatment. Int J General Med. 2013; 6: 31-38.
3. McCabe J, Ayuk J, Sherlock M. Treatment factors that influence mortality in acromegaly. Neuroendocrinol. 2016; 103: 66-74.
4. Pivonello R, Auriemma RS, Grasso LFS, Pivonello C, Simeoli C, Patalano R, et al. Complications of acromegaly: cardiovascular, respiratory and metabolic comorbidities. Pituitary. 2017; 20: 46-62.
5. Burton T, Nestour EL, Neary M, Ludlam WH. Incidence and prevalence of acromegaly in a large US health plan database. Pituitary. 2016; 19: 262-267.
6. Varandhan L, Reulen R C, Brown M, Clayton RN. The role of cumulative growth hormone exposure in determining mortality and morbidity in acromegaly: a single centre study. Pituitary. 2016; 19: 251-261.
7. Shlomo AB, Sheppard MC, Stephens JM, Pulgar S, Melmed S. Clinical, quality of life, and economic value of acromegaly disease control. Pituitary. 2011; 14: 284-294.
8. Geraedts VJ, Andela CD, Stalla GK, Pereira AM, Furth WR, Sievers C, et al. Predictors of quality of life in acromegaly: No consensus on biochemical parameters. Frontiers Endocrinol. 2017; 8: 40.
9. Guitelman M, Abreu A, Monteros ALE, Mercado M. Patient-focussed outcomes in acromegaly. Pituitary. 2014; 17: 18-23.
10. Sievers C, Dimopoulou C, Pfister H, Lieb R, Steffin B, Roemmler J, et al. Prevalence of mental disorders in acromegaly: a cross-sectional study in 81 acromegalic patients. Clinical Endocrinol. 2009; 71: 691-701.
11. Webb SM, Badia X. Quality of life in Acromegaly. Neuroendocrinol. 2016; 103: 106-11.
12. Geraedts VJ, Dimopoulou C, Auer M, Schopohl J, Stalla GK, Sievers C, et al. Health outcomes in Acromegaly: Depression and anxiety are promising targets for improving reduced quality of life. Frontiers Endocrinol. 2014; 5: 229.
13. Sievers C, Ising M, Pfister H, Dimopoulou C, Schneider HJ, Roemmler J, et al. Personality in patients with pituitary adenomas is characterized by increased anxiety-related traits: Comparison of 70 acromegalic patients with patients with non-functioning pituitary adenomas and age- and gender-matched controls. European J Endocrinol. 2009; 160: 367-373.
14. Szczesniak D, Przyby?owska AJ, Rymaszewska J. The quality of life and psychological, social and cognitive functioning of patients with acromegaly. Advances Clin Experimental Med. 2015; 24: 167-172.
15. Llanes LL, Redondo BLF, Alvarez CTG, Trujillo MM, Machado AA, Rodriguez JH, et al. Sexualidad de personas con acromegalia y sindrome de Cushing; experiencias y aspectos psicosociales relacionados. Revista Cubana de Endocrinologia. 2017; 28.
16. Matta MP, Couture E, Cazals L, Vezzosi D, Bennet A, Caron P, et al. Impaired quality of life of patients with acromegaly: control of GH/IGF-I excess improves psychological subscale appearance. European J Endocrinol. 2008; 158: 305-310.
17. Pereira AM, Tiemensma J, Romijn JA, Biermasz NR. Cognitive impairment and psychopathology in patients with pituitary diseases. Netherlands J Med. 2012; 70: 255-60.
18. Vilar L, Vilar CF, Lyra R, Lyra R, Naves LA. Acromegaly: clinical features at diagnosis. Pituitary. 2017; 20: 22-32.
19. Carrion JL, Rodriguez JFM, Atutxa AM, Moreno AS, Moreno EV, Vela ET, et al. Evidence of cognitive and neurophysiological impairment in patients with untreated naive acromegaly. J Cli Endocrinol Metabolism. 2010; 95: 4367-4379.
20. Crespo I, Valassi E, Webb SM. Update on quality of life in patients with acromegaly. Pituitary. 2017; 20.
21. Laguardia J, Campos MR, Travassos C, Najar AL, Anjos LA, Vasconcellos MM, et al. Dados normativos brasileiros do questionario Short Form-36 versao 2. Revista Brasileira de Epidemiologia. 2013; 16: 889-897.
22. Siegel S, Werf CS, Schott JS, Nolte K, Karges W, Andermahr IK, et al. Diagnostic delay is associated with psychosocial impairment in acromegaly. Pituitary. 2013; 16: 507-514.
23. Christofides EA. Clinical importance of achieving biochemical control with medical therapy in adult patients with acromegaly. Patient preference adherence. 2016; 10: 1217-1225.
24. Roerink SHPP, Wagenmakers MAEM, Wessels JF, Sterenborg RBTM, Smit JW, Hermus ARMM, et al. Persistent self-consciousness about facial appearance, measured with the Derriford appearance scale 59, in patients after long-term biochemical remission of acromegaly. Pituitary. 2015; 18: 366-375.