Functional Living Index – Cancer (FLIC)

Abstract

The Functional Living Index Cancer (FLIC) is a widely recognized and utilized patient-reported outcome measure designed specifically for assessing the Quality of Life (QoL) in cancer patients. Developed by Schipper and colleagues in 1984, the FLIC aims to capture the multi-dimensional impact of cancer and its associated treatments on a patient’s daily functioning and well-being. It is a brief, self-administered instrument that provides a quantitative assessment across various domains, including physical health, psychological state, social interaction, and overall satisfaction with life, making it a crucial tool in clinical oncology research and practice.

Keywords

Functional Living Index Cancer, FLIC, Quality of Life, HRQoL, Oncology, Cancer Patients, Functional Status, Psychometrics.

Authors

Schipper, H., Clinch, J., McMurray, A., Levitt, M.

Purpose

The primary purpose of the Functional Living Index Cancer (FLIC) is to provide a reliable and sensitive measure of health-related Quality of Life (HRQoL) in adult patients undergoing treatment for cancer. It was developed to capture changes in functional status and well-being over time, which are often subtle yet clinically significant, allowing researchers and clinicians to better evaluate the risks and benefits associated with specific therapeutic interventions.

The FLIC is intended for use in clinical trials and routine clinical settings where the impact of the disease and treatment extends beyond mere survival rates. By assessing subjective patient experience across multiple domains, it helps provide a holistic view of the patient’s condition, complementing traditional objective medical measures.

Construct

The FLIC measures the psychological construct of Health-Related Quality of Life (HRQoL) as experienced by cancer patients. This construct is generally conceptualized as encompassing five major domains, though subscales may vary slightly in implementation:

• Physical Well-being/Functional Status: Measures physical symptoms (e.g., pain, nausea) and the ability to perform daily and household tasks.
• Psychological Well-being: Assesses emotional states such as anxiety, depression, and fear of the future.
• Social Interaction and Support: Measures the willingness and ability to maintain social relationships with friends and family.
• Work/Leisure Satisfaction: Evaluates satisfaction with personal productivity and recreational activities.
• Attitude/Coping: Reflects the patient’s confidence in treatment and their ability to cope with stress and illness.

Validity

The FLIC has demonstrated robust evidence of validation since its introduction. Early studies, including the original development paper by Schipper et al. (1984), focused on establishing content and construct validity in diverse oncology populations.

Subsequent psychometric analyses, such as those conducted by Morrow et al. (1992) and Kuenstner et al. (2002), confirmed its discriminatory power and its ability to differentiate between groups of patients with varying disease severity. Furthermore, comparative studies have shown that the FLIC exhibits convergent validity with other established HRQoL measures, such as the EORTC QLQ-C30 and the SF-36, confirming that it measures similar underlying aspects of functional status and well-being.

Reliability

The internal consistency and test-retest reliability of the FLIC have been generally reported as acceptable to good in various studies involving different types of cancer. The scale typically yields high Cronbach’s alpha values, indicating strong inter-relatedness among the items within its domains and suggesting that the measure consistently captures the intended underlying construct of HRQoL. High reliability ensures that the scores obtained are stable and reproducible, essential for monitoring patient progress during longitudinal treatment studies.

Factor Analysis

Initial factor analyses of the FLIC suggested a multi-dimensional structure, supporting the theoretical foundation that HRQoL is not a single construct but a combination of several domains. While the structure can vary slightly depending on the patient population studied, analyses often extract factors corresponding closely to the intended domains: physical function, psychological state, and social interaction. These findings confirm the scale’s ability to provide domain-specific scores rather than just a single global score, offering nuanced insight into the patient experience.

Instrument

Test Type: Patient-Reported Outcome (PRO) Measure / Health-Related Quality of Life (HRQoL) Scale

Format: 22 items, typically using a 7-point Likert scale format, with anchors ranging from extreme negative to extreme positive states, depending on the item phrasing.

Language Available: English (Original); translations into other major languages often exist for international clinical trials, though not explicitly listed in the source material.

Population Group: Clinical / Oncology Patients

Age Group: Adult

Population Details: Patients diagnosed with various forms of cancer, often those undergoing active treatment (chemotherapy, radiation, etc.).

Test Methodology: Self-administered questionnaire. Scoring involves summing item responses, with specific items being reversed to ensure higher scores consistently reflect better Quality of Life.

Keywords

Psychometrics, Clinical Oncology, Likert scale, Outcome Measurement, Symptom Burden, Validation, Functional Assessment.

Authors

Author ORCID Identifier: Not specified in source material.

Affiliation Email addresses: Not specified in source material.

Correspondence Address: Not specified in source material.

Permissions & Fee and Test Year

Test Year: 1984 (Original Development)

Permissions and Fees: The FLIC is often used freely in academic and non-commercial research settings, though formal permission from the original developers or copyright holders (if applicable) should always be sought for commercial or large-scale use. The original PDF of a compilation that includes this instrument can be downloaded here: www.a4ebm.org/sites/default/files/Measuring%20Health.pdf

Reference’s

• Schipper, H., Clinch, J., McMurray, A., Levitt, M. (1984). Measuring the quality of life of cancer patients: the Functional Living Index- Cancer: development and validation. J Clin Oncol, 2(5):472–483.
• Schipper, H., Levitt, M. (1985). Measuring quality of life: risks and benefits. Cancer Treat Rep, 69(10):1115–1123.
• Morrow, G.R., Lindke, J., Black, P. (1992). Measurement of quality of life in patients: psychometric analyses of the Functional Living Index-Cancer (FLIC). Qual Life Res, 1:287–296.
• Kuenstner, S., Langelotz, C., Budach, V., Possinger, K., Krause, B., Sezer, O. (2002). The comparability of quality of life scores: a multitrait multimethod analysis of the EORTC QLQ-C30, SF-36 and FLIC questionnaires. European Journal of Cancer, 38, 339-348.
• Cheung, Y.B., Khoo, K.S., Wong, Z.W., et al. (2003) Quick-FLIC: a short questionnaire for assessing quality of life of cancer patients. Acta Oncol 42: 36–42
• McDowell, Ian. (2006). Measuring Health: A Guide to Rating Scales and Questionnaires, Third Edition. OXFORD UNIVERSITY PRESS

Items of the Functional Living Index Cancer (FLIC)

IMPORTANT: The following scale items must be preserved in their original language and must not be changed in any way.

1. How well do you appear today?
Poor Extremely 1 2 3 4 5 6 7 Well Extremely

2. Rate your confidence in your prescribed course of treatment.
No Confidence 1 2 3 4 5 6 7 Very Confident

3. How much of your pain or discomfort over the past 2 weeks was related to your cancer?
None 1 2 3 4 5 6 7 All

4. Rate how willing you were to see and spend time with friends, in the past 2 weeks.
Unwilling 1 2 3 4 5 6 7 Very Willing

5. Rate the degree to which you are frightened of the future.
Constantly Terrified 1 2 3 4 5 6 7 Not Afraid

6. How much nausea have you had in the past 2 weeks?
None 1 2 3 4 5 6 7 A Great Deal

7. Rate how willing you were to see and spend time with those closest to you, in the past 2 weeks.
Unwilling 1 2 3 4 5 6 7 Very willing

8. How much of your usual household tasks are you able to complete?
All 1 2 3 4 5 6 7 None

9. Rate the degree to which your cancer has imposed a hardship on you (personally) in the past 2 weeks.
Tremendous Hardship 1 2 3 4 5 6 7 No Hardship

10. How much is pain or discomfort interfering with your daily activities?
Not At All 1 2 3 4 5 6 7 A Great Deal

11. Rate in your opinion, how disruptive your cancer has been to those closest to you in the past 2 weeks.
Totally Disruptive 1 2 3 4 5 6 7 No Disruption

12. How uncomfortable do you feel today?
Not At All 1 2 3 4 5 6 7 Very Uncomfortable

13. Rate your satisfaction with your work and your jobs around the house in the past month.
Very Dissatisfied 1 2 3 4 5 6 7 Very Satisfied

14. Rate how often you feel discouraged about your life.
Always 1 2 3 4 5 6 7 Never

15. Rate the degree to which your cancer has imposed a hardship on those closest to you in the past 2 weeks.
No Hardship 1 2 3 4 5 6 7 Tremendous Hardship

16. Do you feel well enough to make a meal or do minor household repairs today?
Very Able 1 2 3 4 5 6 7 Not Able

17. How well do you feel today?
Extremely Poor 1 2 3 4 5 6 7 Extremely Well

18. Has nausea affected your daily functioning?
Not At All 1 2 3 4 5 6 7 A Great Deal

19. Rate your ability to maintain your usual recreation or leisure activities.
Able 1 2 3 4 5 6 7 Unable

20. How much time do you spend thinking about your illness?
Constantly 1 2 3 4 5 6 7 Never

21. How well are you coping with your everyday stress?
Not well 1 2 3 4 5 6 7 Very Well

22. Most people experience some feelings of depression at times. Rate how often you feel these feelings.
Never 1 2 3 4 5 6 7 Continually

Scores for questions 3, 6, 8, 10, 12, 15, 16, 18, 19, and 22 are reversed for summation.