**5. Definition of quality of life and importance of QoL measuring**

QoL can be defined in many ways. As a general term it is used to indicate the well-being of people and societies. A person's environment, physical and mental health, education, recrea‐ tion, social well-being, freedom, human rights and happiness are also significant factors.

The World Health Organization (WHO) defines QoL as individuals' perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards, and concerns [11].

number of valid and reliable instruments available for use in research investigations, which are the culmination of years of research with various populations, and reflect the target

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HRQoL-measurement instruments validated for use in cancer patients have two basic categories. Questionnaires specifically designed for the disease explore the repercussions of the most typical symptoms and side-effects and are appropriate for comparing different treatment modalities or changes in patients. The general instruments are applicable to any population and are better suited to studies that seek to ascertain the disease's repercussion on HRQoL, taking the general population as reference [16]. Among the former, the most used in Europe for MM patients are the European Organization for Research and Treatment of Cancer Core Cancer Quality Life Questionnaire (EORTC QLQ-C30) and its MM-specific module (EORTC-QLQ-MY24/MY20). Among the latter, the Medical Outcomes Survey Short-Form

There are also symptom-specific instruments, assessing the patient's reflections directly

For example, the Functional Assessment of Chronic Illness Therapy (FACIT) system which is an established, comprehensive set of health-related quality-of-life measures includes a 27-item general measure, the Functional Assessment of Cancer Therapy (FACT-G), which can be combined with disease or treatment-specific subscales. The FACT-G captures four domains of health-related quality of life: physical, social, emotional and functional well-being. The supplemental subscales measure additional concerns of a specific disease or treatment. For example, the multiple myeloma subscale (FACT-MM) includes MM-relevant items There are also symptom-specific measures, such as FACT-An for patients with anemia or fatigue, FACT-Bone Pain: for patients with bone pain and treatment-specific measures assessing the QoL changing due to treatment such as FACT&GOG-Ntx: for patients with neurotoxicity [17].

In the case of MM, disease severity and type of treatment (high-dose chemotherapy and ASCT, the use of novel agents such as bortezomib, thalidomide or lenalidomide) have a clear influence on the patient's subjective perception of the disease. Their effects on HRQoL are also modu‐ lated by personality traits, personal resources and the availability and perception of social and

Clinical applications of HRQoL tools may include prognostication, monitoring response to treatment, prioritizing problems or facilitating communication. The use of HRQoL instruments in clinical practice has also been shown to independently improve HRQoL in general oncology patients [18]. Some authors who have demonstrated reduced HRQoL in myeloma have concluded that HRQoL assessment should become a normal part of clinical care [19, 20].

Besides the typical primary parameters of clinical trials for measuring the treatment effect, such as tumor volume and time to progression, recognition of HRQoL is also an important

populations' perceptions of their health status and HRQoL [15].

General Health Survey (SF-36) is the most widely used.

concerning pain, fatigue, neuropathy and nausea.

**7. Importance of quality of life issues**

family support.

As illness and its treatment affect the psychological, social, and economic well-being, as well as the biological integrity of individuals, any definition should be all encompassing while allowing individual components to be delineated. This allows the impact of different disease states or interventions on overall or specific aspects of QoL to be determined.

QoL is measured in a variety of contexts. Aside from healthcare, it is also used in international development and political science. This results in diverse definitions being given to the term. Factors that are considered are both qualitative and quantitative. Many local, national and international organizations conduct surveys and psychological tests to determine an individ‐ ual or society's life quality for different purposes.

A major rule for physicians is the principle of "nil nocere". While making an effort to reach better and better disease control for cancer patients, we often neglect the repercussions of the patient in regards to "being ill", to the consequences of the treatment, and to the disease per se. The main purpose for all clinicians is therefore to improve the quality of the patient's life and to avoid iatrogenic harm. It is not enough to make implicit, subjective judgments about QoL when treating a patient. Making explicit, objective assessments about QoL using validated tools and instruments is needed. Formal assessment of QoL is now a mandatory requirement in most clinical trials.
