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Comparing EQ-5D-3L and EQ-5D-5L performance in common cancers: suggestions for instrument choosing

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To compare the performance of three-level EuroQol five-dimensions (EQ-5D-3L) and five-level EuroQol five-dimensions (EQ-5D-5L) among common cancer patients in urban China.


A hospital-based cross-sectional survey was conducted in three provinces from 2016 to 2018 in urban China. Patients with breast cancer, colorectal cancer, or lung cancer were recruited to complete the EQ-5D-3L and EQ-5D-5L questionnaires. Response distribution, discriminatory power (indicator: Shannon index [H′] and Shannon evenness index [J′]), ceiling effect (the proportion of full health state), convergent validity, and health-related quality of life (HRQoL) were compared between the two instruments.


A total of 1802 cancer patients (breast cancer: 601, colorectal cancer: 601, lung cancer: 600) were included, with the mean age of 55.6 years. The average inconsistency rate was 4.4%. Compared with EQ-5D-3L (average: H′ = 1.100, J′ = 0.696), an improved discriminatory power was observed in EQ-5D-5L (H′ = 1.473, J′ = 0.932), especially contributing to anxiety/depression dimensions. The ceiling effect was diminished in EQ-5D-5L (26.5%) in comparison with EQ-5D-3L (34.5%) (p < 0.001), mainly reflected in the pain/discomfort and anxiety/depression dimensions. The overall utility score was 0.790 (95% CI 0.778–0.801) for EQ-5D-3L and 0.803 (0.790–0.816) for EQ-5D-5L (p < 0.001). A similar pattern was also observed in the detailed cancer-specific analysis.


With greater discriminatory power, convergent validity and lower ceiling, EQ-5D-5L may be preferable to EQ-5D-3L for the assessment of HRQoL among cancer patients. However, higher utility scores derived form EQ-5D-5L may also lead to lower QALY gains than those of 3L potentially in cost-utility studies and underestimation in the burden of disease.

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Health-related quality of life


Quality-adjusted life years


EuroQol five-dimensions


Three-level EuroQol five-dimensions


Five-level EuroQol five-dimensions

95% CI:

95% Confidence interval


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This study was supported by the National Natural Science Foundation of China (81773521, 81402740) and the State Key Projects Specialized on Infectious Diseases (2017ZX10201201-008-002). We thank local health administrative institutes in Guangdong Province, Hunan Province, and Inner Mongolia Autonomous Region for the implementation of the survey, and all cancer patients signed the informed consent. We also appreciate all the dedicated supervisors and interviewers.

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Correspondence to Min Dai, Wanqing Chen or Ju-Fang Shi.

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Zhu, J., Yan, XX., Liu, CC. et al. Comparing EQ-5D-3L and EQ-5D-5L performance in common cancers: suggestions for instrument choosing. Qual Life Res 30, 841–854 (2021).

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