Past and Current Practice of Patient-Reported Outcome Measurement in Randomized Cancer Clinical Trials: A Systematic Review

Validation of the cancer-specific utility measure EORTC QLU-C10D using evidence from four lung cancer trials covering six country value sets

The Quality of Life (QoL) Utility measure, QLU-C10D, is derived of the European Organisation for Research and Treatment of Cancer (EORTC) QoL Questionnaire, QLQ-C30. Based on the cancer-specific nature, the QLU-C10D is expected to be sensitive and responsive in lung cancer patients.This retrospective analysis used data from four international lung cancer multi-center trials (NCT00656136, NCT00949650, NCT01085136, NCT01523587). Clinical validity was assessed in comparison to a generic standard utility instrument, the EuroQoL Group´s EQ-5D-3L. Utilities of six country value sets (Australia, Canada, Italy, the Netherlands, Poland, UK) were calculated at baseline and end of treatment for both measures. Country value set pairs of both measures (k) were compared in terms of Relative Efficiency (RE) and difference in Effect Sizes (dES) in 1) sensitivity to detect differences between performance status groups and 2) responsiveness to changes at each trial sample. Analysis of the four trials (N1 = 496, N2 = 290, N3 = 202, N4 = 770) with the six country value sets of each utility measure showed ad 1) Sensitivity indices favored the QLU-C10D (k = 18, p ≤ 0.019; RE > 1.10; dES > 0.03), and ad 2) Responsiveness indices of changes within clinically known groups (k = 78), largely favored QLU-C10D (k = 74, p ≤ .024; RE > 1.01; dES > 0.02), in comparison with the generic utility instrument. In summary, 96% of the comparative indices favored the QLU-C10D. In summary, this study confirms the clinical validity of the QLU-C10D in lung cancer patients. The QLU-C10D produced homogenous results across six country value sets and detected differences/changes in alignment with clinical expectations. In most comparisons the QLU-C10D was more sensitive or responsive compared to the EQ-5D-3L.

Electronic Patient Reported Outcome Measures and quality of life in cancer (E-PROMISE): systematic review of the evidence and meta-analysis

OBJECTIVE

The objective of this systematic review and meta-analysis (SRMA) was to evaluate the impact of electronic patient-reported outcomes (ePROs) on health-related quality of life (HRQoL) in patients with cancer.

DESIGN

We performed SRMA of randomised controlled trials (RCTs) comparing ePRO interventions with usual care in patients with cancer. The primary outcome was HRQoL. We used a random effects model a priori due to the anticipated clinical heterogeneity. Subgroup analyses and meta-regressions were performed to explore sources of heterogeneity. After assessing the risk of bias using risk-of-bias tool (RoB V.2), we rated the evidence certainty using the Grading of Recommendations, Assessment, Development and Evaluations framework.

ELIGIBILITY CRITERIA

We included studies meeting the following criteria: (1) RCTs; (2) patients diagnosed with any type of cancer, undergoing or having completed treatment; (3) comparing ePROs with usual care without ePRO interventions; (4) assessing the effect on HRQoL.

INFORMATION SOURCES

We systematically searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials up to April 2024.

RESULTS

We screened 7706 records to include 36 RCTs with 9608 patients. ePRO interventions showed a standardised mean difference (SMD) of 0.35; 95% CI 0.18 to 0.51 compared with usual care. Patients receiving ongoing therapy had an SMD of 0.39 (95% CI 0.21 to 0.58), while those who had completed therapy had an SMD of 0.12 (95% CI 0.01 to 0.22), with a significant subgroup difference (p=0.01). No statistically significant differences were observed across the method of ePRO assessment, cancer site, metastasis status, therapy status, average age or duration of ePRO use. The results remained consistent with Bayesian and other sensitivity analyses.

CONCLUSIONS

ePRO interventions improve HRQoL more than usual care in patients with cancer, with greater effect in those currently undergoing therapy. This improvement is independent of cancer type, duration of ePRO use or patient age. Future research should address sources of heterogeneity, explore long-term impacts and develop strategies to increase patient engagement and adherence to ePRO systems.

PROSPERO REGISTRATION NUMBER

CRD42024531708.

Validation of the Cancer-Specific Preference-Based Measure EORTC QLU-C10D against the Generic Instruments EQ-5D-5L and SF-6Dv2 in a Prospectively Collected Sample of Patients with Cancer in Austria and France

BACKGROUND

The Quality of Life Utility - Core 10 Dimensions (QLU-C10D) is a disease-specific preference-based measure (PBM) designed to obtain health state utility values from patients with cancer. Previously, satisfactory psychometric properties were established from retrospective trial analyses using clinical anchors. This study aimed to validate the QLU-C10D against two generic PBMs in a prospective sample of Austrian and French patients with cancer using patient-reported anchors.

METHODS

Patients completed the European Organisation of Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire - Core 30 (QLQ-C30), EQ-5D-5L and Short Form 36 (SF-36) at study baseline (any time during anti-cancer treatment) plus a follow-up assessment 3-6 months later. Sociodemographic and clinical characteristics were assessed. QLU-C10D and SF-6Dv2 utilities were calculated from QLQ-C30 and SF-36 data, respectively. German, French and UK value sets were applied for all three PBMs. Floor and ceiling effects were assessed. Known-group validity (independent t-test) and responsiveness (paired t-tests) were assessed respectively by ability to detect health status differences and changes over time according to patient-rated overall quality of life/health perception assessed by the QLQ-C30 Global Health Status scale, the EQ-5D-5L VAS and the SF-36 General Health scale.

RESULTS

A total of 465 patients were included in the analysis. QLU-C10D index scores (intra-class correlation) and domains (Pearson) were correlated with EQ-5D-5L and Short-Form Six Dimensions (SF-6Dv2) conceptual counterparts. Correlation coefficients for the index scores of QLU-C10D and the generic PBMs ranged from 0.63 to 0.81. The QLU-C10D detected statistically significant differences between groups at baseline in 100% of tests performed (n = 27). For changes over time, QLU-C10D detected expected effects in 68% of cases (n = 29). In comparison with the generic PBMs, QLU-C10D detected differences and changes with a higher statistical efficiency in 76% of cases (77 of 102).

CONCLUSIONS

The QLU-C10D is a fit-for-purpose ready-to-use PBM to estimate health state utilities of patients with cancer. This study adds to evidence that QLU-C10D has appropriate psychometric properties and appears to have higher statistical efficiency than generic PBMs in cancer.

Exploring what constitutes "a good day" for individuals living with advanced cancer: a qualitative interview study

PURPOSE

More people are living longer with stage IV cancer due to advances in cancer treatments. However, individuals living with advanced cancer must navigate unique day-to-day challenges and experiences that may be incompletely understood by their health care team. This study aims to better understand the activities, decisions, and experiences that characterize a "good day" versus a "bad day" for individuals living with advanced cancer.

METHODS

Twenty participants with stage IV cancer completed semi-structured interviews which involved rating the quality of their day as well as characterizing their experiences and activities during the day. Participants were also asked to describe a theoretical "very good day" versus a "very bad day" for them personally, as well as advice they would give to another patient with advanced cancer about how to make a day better. Thematic analysis was used to analyze interview transcripts and identify common themes across participants.

RESULTS

Interviews revealed that "good days" were associated with feeling like oneself before cancer, bringing oneself to engage in activities that bring wellness and joy, feeling connected to others, feeling accomplished, and practicing positive thought patterns. On the other hand, loss of control, uncertainty/unpredictability, disruptive physical symptoms, negative experiences with health care, and inability to reach one's goals were common on "bad days."

CONCLUSIONS

This qualitative study highlighted common themes in what defines good and bad days living with stage IV cancer. Understanding individual values and priorities may help care teams support people with advanced cancer to optimize their quality of life and functioning and navigate treatment decisions.

A multicenter prospective observational study for health assessment questionnaires EQ-5D-5L and G8 in unresectable advanced pancreatic cancer treated with first-line gemcitabine plus nab-paclitaxel therapy

BACKGROUND

In chemotherapy for unresectable advanced pancreatic cancer (UPC), the clinical utility of pre-treatment health assessment questionnaires, EuroQoL 5-Dimension 5-Level (EQ-5D-5L) and G8, is unknown. This study aimed to fill this gap.

METHODS

This multicenter, prospective, observational study investigated the association of EQ-5D-5L and G8 with the clinical outcomes of first-line gemcitabine plus nab-paclitaxel (GnP) for UPC. Differences in survival were analyzed using the log-rank test, and multivariate analyses were performed using the Cox proportional hazards model.

RESULTS

Between April 2022 and September 2023, 60 patients were enrolled, and their data were analyzed. When patients were classified into two groups using the median EQ-5D-5L utility value (0.824), progression-free survival (PFS) and overall survival (OS) were significantly longer in patients with high EQ-5D-5L utility values than in those with low utility values (median PFS 7.0 vs. 4.7 months, P < 0.01; median OS 12 vs. 8.0 months, P = 0.023). Such differences were not observed in the EQ-5D-5L Visual Analog Scale or G8 scores. There was no association between the occurrence of severe adverse events and EQ-5D-5L or G8 scores. Multivariate analyses showed that high EQ-5D-5L utility value (≥ 0.824), high albumin (≥ 3.8 g/dl), and low carcinoembryonic antigen (CEA) (< 5.4 ng/mL) were preferable independent efficacy predictors for PFS and also independent prognostic factors for OS.

CONCLUSION

Pre-treatment EQ-5D-5L utility value, along with albumin and CEA, was an independent efficacy predictor and prognostic factor in patients with UPC treated with first-line GnP. Their usefulness should be validated in future studies.

Prognostic value of baseline EORTC QLQ-C30 scores for overall survival across 46 clinical trials covering 17 cancer types: a validation study

Background

A pooled data analysis by Quinten et al. (2009) found three European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30) health-related quality of life (HRQoL) scales to be prognostic for survival: physical functioning, pain and appetite loss. This study aims to replicate these findings in an independent data set comprising a broader cancer population.

Methods

Data were obtained from 46 clinical trials across three cancer research networks conducted between 1996 and 2013 that assessed HRQoL using the EORTC QLQ-C30. A stratified Cox proportional hazards model was employed to assess the prognostic significance of baseline QLQ-C30 scale scores on overall survival, adjusting for socio-demographic and clinical variables. Stepwise model selection was done at 5% significance level. Model stability and prognostic accuracy were evaluated via bootstrapping and the C index respectively.

Findings

Data from 16,210 patients reporting HRQoL at baseline, spanning 17 cancer types, was used. The stratified multivariable model confirmed that better physical functioning (hazard ratio [HR], 0.94; 95% confidence interval [CI], 0.93-0.96), lower pain (HR, 1.02; 95% CI, 1.01-1.03), and appetite loss (HR, 1.04; 95% CI, 1.03-1.05) were significantly associated with survival. Additionally, global health status/QoL, dyspnoea, emotional and cognitive functioning were found to be prognostic for survival. This final model, encompassing sociodemographic, clinical, and HRQoL variables, achieved a corrected C index of 0.74, marking a 48% enhancement in discriminatory ability. Bootstrap evaluation indicated no major instability issues.

Interpretation

These results support previous findings that baseline physical functioning, pain, and appetite loss scores, along with four other scales from the EORTC QLQ-C30, predict survival in cancer patients.

Funding

EORTC Quality of Life Group.

Clinical trials involving rare gynaecological cancers

Clinical trials that investigate therapies for rare gynaecological cancers (RGC) are essential to provide evidence-based data towards new effective and safe treatments, however, they present unique challenges. The main objective of this narrative review is to summarize completed phase III clinical trials investigating therapies for RGC and to discuss the outcomes of these trials. PRISMA guidelines were used to report the steps of the review. We searched the WHO's International Clinical Trials Registry Platform, clinicaltrials.gov and PubMed/Medline for publications reporting results from clinical trials on RGC including at least one medication. From 31 identified phase III clinical trials, 13 were still ongoing, four were terminated and just eight (25.8 %) had posted results and/or publications. The latter completed trials were mostly multi-center and located in at least two continents, participants were mainly adults, and the recruitment period varied from about 2.5 to 10.5 years. Allocation was randomized with parallel assignment in 7 out of 8 trials, while only one trial had double masking. The most common primary outcome measure was progression-free survival (PFS), followed by overall survival (OS). Patient-reported outcomes were secondary outcome measures in four completed trials, assessing quality of life by various questionnaires. Most of the trials did not meet their primary endpoints. By highlighting the scarcity of clinical trials on RGC, our findings further emphasize the need for designing, conducting and sustaining phase III clinical trials to investigate innovative therapies for these conditions and report meaningful outcome measures.

The Psychometric Properties of the EQ-HWB and EQ-HWB-S in Patients With Breast Cancer: A Comparative Analysis With EQ-5D-5L, FACT-8D, and SWEMWBS

OBJECTIVES

The EQ Health and Wellbeing (EQ-HWB) is a new generic measure that captures constructs beyond health-related quality of life, with a 25-item long form and a shorter 9-item version (EQ-HWB-S). This study aimed to assess the psychometric performance of both versions in breast cancer, which is the most prevalent cancer worldwide, and compare them with other instruments.

METHODS

A longitudinal survey in Indonesia (2023-2024) with 300 female patients used the EQ-HWB, 5-level EQ-5D (EQ-5D-5L), Functional Assessment of Cancer Therapy - General (from which Functional Assessment of Cancer Therapy Eight Dimension [FACT-8D] was derived), and Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS, from which the Short WEMWBS was derived). Distributional characteristics, convergent validity, known-group validity (Student's t test or analysis of variance), test-retest reliability, and responsiveness were assessed.

RESULTS

All patients reported problems in at least 1 EQ-HWB item. The EQ-HWB-S index (11%) had a lower ceiling than the EQ-5D-5L (35%) and the Short WEMWBS (15.3%), but not the FACT-8D (5%). EQ-HWB-S index values correlated strongly with EQ-5D-5L (r = 0.73) and FACT-8D index values (r = 0.70), whereas EQ-HWB level sum scores correlated strongly with Functional Assessment of Cancer Therapy - General (r = 0.69) and moderately with WEMWBS (r = 0.49). The EQ-HWB and EQ-HWB-S discriminated across known groups comparably with the EQ-5D-5L and FACT-8D with large effect sizes according to EuroQol visual analog scale groups, number of symptoms, and general health and exhibited excellent instrument-level test-retest reliability (intraclass correlations, 0.79-0.83) and acceptable responsiveness (standardized response means, |0.24| to |0.97|).

CONCLUSIONS

This study represents one of the first validations of the EQ-HWB and EQ-HWB-S in any clinical population. Both instrument versions demonstrate robust psychometric performance. The EQ-HWB-S can be recommended to inform resource allocation decisions of breast cancer treatments.

Cancer-specific utility instrument for health economic evaluations: A synopsis of the EORTC QLU-C10D user manual and current validity evidence

The European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Utility - Core 10 Dimensions (QLU-C10D) adds a preference-based scoring algorithm to the EORTC measurement portfolio. It is built on the most widely used health-related quality of life (HRQoL) measure in oncology, the EORTC Quality of Life Questionnaire - Core 30 (QLQ-C30), allowing for the calculation of both HRQoL profiles and health utilities. This is an important advancement for integrating cancer-specific values into health economic evaluations and decision making, offering greater content validity and statistical power than some generic measures. This article presents an outline of the EORTC QLU-C10D User Manual to inform health-technology bodies, academic researchers, and industry, on the why and how of using this instrument for utility measurement. It covers basic concepts, proper use of the tool, including administration and scoring. Further, we summarise the presently published valuation studies, country-specific value sets, and body of evidence about psychometric properties. Current methodological questions are discussed, including mapping between utility measures and adaptions of generic measures for use in cancer populations. Taking into account empirical studies on psychometric properties, like content and construct validity, and comparisons with generic measures, we argue that the QLU-C10D is a reliable and valid instrument for cancer populations. Without imposing additional patient and administrative burden it has the potential to support health economic decisions in cancer by providing high-quality cancer-specific utility scores, to complement the more detailed HRQoL information from the QLQ-C30.

Exploring "good days" with advanced cancer: A pilot daily diary study

BACKGROUND

People with Stage IV cancer face physical and emotional challenges impacting quality of life. Conventional quality of life measures do not capture daily fluctuations in patient well-being.

AIM

This pilot study used daily diaries to explore the concept of a "good day" living with advanced cancer and to identify activities associated with "good days" as well as associations between daily "goodness" and conventional quality of life measures.

DESIGN

Twenty participants with Stage IV cancer completed daily diaries on a mobile app over a 14-day period. Participants rated each day's "goodness" and documented daily activities. Statistical analyses examined associations between daily "goodness" ratings, activities, and baseline quality of life measures from the Patient-Reported Outcomes Measurement Information System (PROMIS).

SETTING/PARTICIPANTS

Participants were recruited from oncology clinics and online research registries. Inclusion criteria included age over 18 years old, having Stage IV cancer, and owning a smartphone.

RESULTS

Analysis of 178 completed surveys from 18 participants revealed overall average "goodness" ratings exhibited more within-person than between-person variability. Average goodness was positively related to the PROMIS domain of Ability to Participate in Social Roles/Activities and negatively related to PROMIS domains of Anxiety and Depression. Participants reported better days when they engaged in leisure activities and worse days when they spent time managing physical symptoms.

CONCLUSIONS

This study highlights the importance of understanding day-to-day quality of life in individuals with advanced cancer. Further research is needed to assess quality of life longitudinally and to develop personalized supportive and palliative care interventions in this population.

Norwegian and Swedish value sets for the EORTC QLU-C10D utility instrument

PURPOSE

This study aimed to develop utility weights for the European Organization for Research and Treatment of Cancer (EORTC) QLU-C10D, a cancer-specific utility instrument, tailored to the Norwegian and Swedish populations. The utility weights are intended for use in the specific welfare contexts of Norway and Sweden to support more precise healthcare decision-making in cancer treatment and care.

METHODS

This cross-sectional study included 1019 Norwegian and 1048 Swedish participants representative in age and gender of the two general populations. Participants completed a discrete choice experiment involving 960 choice sets, each consisting of two EORTC QLU-C10D health states described by the instrument's domains and the duration of each state. Utility weights were calculated using generalized estimation equation models, and non-monotonic levels were merged to ensure consistent valuation.

RESULTS

In the Norwegian participants, the largest utility decrements were seen for the domain of physical functioning (decrement of - 0.263 for highest level "very much"), followed by pain (decrement - 0.205 for level "very much") and role functioning (- 0.139). Among the cancer-specific domains, nausea had the largest utility decrement (- 0.124). In the Swedish participants, the largest utility decrements were also observed for physical functioning (- 0.207 for the response "very much"), followed by pain (- 0.139), role functioning (- 0.133), and nausea (- 0.119). Emotional functioning also exhibited a sizable utility decrement (- 0.115).

CONCLUSION

This study provides the first set of utility weights for the EORTC QLU-C10D specific to Norway and Sweden, reflecting the unique health preferences of these populations. The generated utility decrements can inform cost-utility analyses and optimize resource allocation in cancer care within the Norwegian and Swedish healthcare systems.

The EORTC QLU-C10D distinguished better between cancer patients and the general population than PROPr and EQ-5D-5L in a cross-sectional study

OBJECTIVES

Health state utility (HSU) instruments for calculating quality-adjusted life years, such as the European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Utility - Core 10 Dimensions (QLU-C10D), derived from the EORTC QLQ-30 questionnaire, the Patient-Reported Outcome Measurement Information System (PROMIS) preference score (PROPr), and the EuroQoL-5-Dimensions-5-Levels (EQ-5D-5L), yield different HSU values due to different modeling and different underlying descriptive scales. For example the QLU-C10D includes cancer-relevant dimensions such as nausea. This study aimed to investigate how these differences in descriptive scales contribute to differences in HSU scores by comparing scores of cancer patients receiving chemotherapy to those of the general population.

STUDY DESIGN AND SETTING

EORTC QLU-C10D, PROPr, and EQ-5D-5L scores were obtained for a convenience sample of 484 outpatients of the Department of Oncology, Charité - Universitätsmedizin Berlin, Germany. Convergent and known group's validity were assessed using Pearson's correlation and intraclass correlation coefficients (ICC). We assessed each descriptive dimension score's discriminatory power and compared them to those of the general population (n > 1000) using effect size (ES; Cohen's d) and area under the curve (AUC).

RESULTS

The mean scores of QLU-C10D (0.64; 95% CI 0.62-0.67), PROPr (0.38; 95% CI 0.36-0.40), and EQ-5D-5L (0.72; 95% CI 0.70-0.75) differed significantly, irrespective of sociodemographic factors, condition, or treatment. Conceptually similar descriptive scores as obtained from the HSU instruments showed varying degrees of discrimination in terms of ES and AUC between patients and the general population. The QLU-C10D and its dimensions showed the largest ES and AUC.

CONCLUSION

The QLU-C10D and its domains distinguished best between health states of the two populations, compared to the PROPr and EQ-5D-5L. As the EORTC Core Quality of Life Questionnaire (QLQ-C30) is widely used in clinical practice, its data are available for economic evaluation.

PLAIN LANGUAGE SUMMARY

The assessment of dimensions of health-related quality of life (HRQoL), such as physical functioning or depression, is important to cancer patients and physicians for treatment and side effect monitoring. Descriptive HRQoL is measured by patient-reported outcomes measures (PROM). The European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 questionnaire and the Patient-Reported Outcome Measurement Information System (PROMIS) are the most common PROM in the clinical HRQoL assessment. In recent years, multidimensional preference-based HRQoL measures were developed using these PROM as dimensions. These preference-based measures, also referred to as health state utility (HSU) scores, are needed for economic evaluations of treatments. The QLQ-C30's corresponding HSU score is the Quality of Life Utility measure-Core 10 Dimensions (QLU-C10D), and PROMIS' HSU score is the PROMIS preference score (PROPr). Both new HSU scores are frequently compared to the well-established EuroQoL-5-dimensions-5-levels (EQ-5D-5L). They all conceptualize HSU differently, as they assess different dimensions of HRQoL und use different models. Both the QLU-C10D and the PROPr have thus shown systematic differences to the EQ-5D-5L but these were largely consistent across the subgroups. Convergent and known groups validity can therefore be considered established. However, as HSU is a multidimensional construct, it remains unclear how differences in its dimensions, for example, its descriptive scales, contribute to differences in HSU scores. This is of importance as it is the descriptive scales that measure clinical HRQoL. We investigated this question by assessing each dimension's ability to distinguish between a sample of 484 cancer patients and the German general population. We could show that the ability to distinguish depended on the domain: for example, for depression, the QLU-C10D and EQ-5D-5L distinguished clearer, while for physical function, PROMIS did. Overall, the QLU-C10D and its dimensions distinguish best between cancer patients and general population.

Valuation of the EORTC Quality of Life Utility Core 10 Dimensions (QLU-C10D) in a Multi-ethnic Asian Setting: How Does Having Cancer Matter?

OBJECTIVES

The aim of the study was to develop and compare utility value sets for the EORTC QLU-C10D, a cancer-specific utility instrument based on the EORTC QLQ-C30, using the preferences of the general public and cancer patients in Singapore, and to assess their measurement properties.

METHODS

A total of 600 individuals from the general public were recruited using a multi-stage random sampling, along with 626 cancer patients with clinically confirmed diagnoses from outpatient clinics of the largest tertiary cancer hospital. Each participant valued 16 pairs of EORTC QLU-C10D health states using a discrete choice experiment (DCE). Conditional logit models were used to analyze the DCE responses of the general public and cancer patients separately. Utility values were assessed for known-group validity and responsiveness in the cancer patients by comparing mean values across subgroups of patients and calculating standardized response means using longitudinal EORTC QLQ-C30 data, respectively.

RESULTS

Physical functioning and pain had the most impact on utility for both cancer patients and general public groups. Worst health state utility values were -0.821 and -0.463 for the general public and cancer patients, respectively. Cancer patients' values were lower for mild-to-moderate health states but higher for moderately-to-highly impaired states compared with the general public's values. Both value sets discriminated between patients with differing characteristics and responded equally well to improved health status, but the cancer patients' value set was slightly more responsive to deteriorated health.

CONCLUSIONS

EORTC QLU-C10D value sets based on the preferences of the Singaporean general public and cancer patients exhibited differences in values but similar psychometric properties.

The EORTC QLU-C10D is a valid cancer-specific preference-based measure for cost-utility and health technology assessment in the Netherlands

BACKGROUND

Cost-utility analysis typically relies on preference-based measures (PBMs). While generic PBMs are widely used, disease-specific PBMs can capture aspects relevant for certain patient populations. Here the EORTC QLU-C10D, a cancer-specific PBM based on the QLQ-C30, is validated using Dutch trial data with the EQ-5D-3L as a generic comparator measure.

METHODS

We retrospectively analysed data from four Dutch randomised controlled trials (RCTs) comprising the EORTC QLQ-C30 and the EQ-5D-3L. Respective Dutch value sets were applied. Correlations between the instruments were calculated for domains and index scores. Bland-Altman plots and intra-class correlations (ICC) displayed agreement between the measures. Independent and paired t-tests, effect sizes and relative validity indices were used to determine the instruments' performance in detecting clinically known-group differences and health changes over time.

RESULTS

We analysed data from 602 cancer patients from four different trials. In overall, the EORTC QLU-C10D showed good relative validity with the EQ-5D-3L as a comparator (correlations of index scores r = 0.53-0.75, ICCs 0.686-0.808, conceptually similar domains showed higher correlations than dissimilar domains). Most importantly, it detected 63% of expected clinical group differences and 50% of changes over time in patients undergoing treatment. Both instruments showed poor performance in survivors. Detection rate and measurement efficiency were clearly higher for the QLU-C10D than for the EQ-5D-3L.

CONCLUSIONS

The Dutch EORTC QLU-C10D showed good comparative validity in patients undergoing treatment. Our results underline the benefit that can be achieved by using a cancer-specific PBM for generating health utilities for cancer patients from a measurement perspective.

Chinese utility weights for the EORTC cancer-specific utility instrument QLU-C10D

OBJECTIVE

The aim of this study is to provide Chinese utility weights for the European Organization for Research and Treatment of Cancer Quality of Life Utility Measure-Core 10 Dimensions (EORTC QLU-C10D) which is a preference-based cancer-specific utility instrument derived from the EORTC QLQ-C30.

METHODS

We conducted an online survey of the general population in China, with quota sampling for age and gender. Each respondent was asked to complete a discrete choice experimental survey consisting of 16 randomly selected choice sets. The conditional logit model and mixed logit model were used to analyze respondents' preferences, and the goodness of fit of the model was tested.

RESULTS

A total of 2003 respondents were included in the analysis. Utility decrements within dimensions were typically monotonic. Monotonic inconsistency issues in the Fatigue, Sleep, and Nausea dimensions were normalized by monotonicity correction. Physical functioning, Pain, and Role functioning were associated with the greatest utility weights, with the smallest decrements being in Bowel problems and Emotional functioning. The utility value for the worst health state was 0.083, i.e. slightly higher than being dead.

CONCLUSIONS

This study provides the first China-specific set of value for the QLU-C10D based on societal preferences of the Chinese adult general population. The value set can be used as a cancer-specific scoring system for economic evaluations of new oncology therapies and technologies in China.

Valuing quality of life for economic evaluations in cancer: navigating multiple methods

INTRODUCTION

Utility values offer a quantitative means to evaluate the impact of novel cancer treatments on patients' quality of life (QoL). However, the multiple methods available for valuing QoL present challenges in selecting the most appropriate method across different contexts.

AREAS COVERED

This review provides cancer clinicians and researchers with an overview of methods to value QoL for economic evaluations, including standalone and derived preference-based measures (PBMs) and direct preference elicitation methods. Recent developments are described, including the comparative performance of cancer-specific PBMs versus generic PBMs, measurement of outcomes beyond health-related QoL, and increased use of discrete choice experiments to elicit preferences. Recommendations and considerations are provided to guide the choice of method for cancer research.

EXPERT OPINION

We foresee continued adoption of the QLU-C10D and FACT-8D in cancer clinical trials given the extensive use of the EORTC QLQ-C30 and FACT-G in cancer research. While these cancer-specific PBMs offer the convenience of eliciting utility values without needing a standalone PBM, researchers should consider potential limitations if they intend to substitute them for generic PBMs. As the field advances, there is a greater need for consensus on the approach to selection and integration of various methods in cancer clinical trials.

Machine learning models including patient-reported outcome data in oncology: a systematic literature review and analysis of their reporting quality

PURPOSE

To critically examine the current state of machine learning (ML) models including patient-reported outcome measure (PROM) scores in cancer research, by investigating the reporting quality of currently available studies and proposing areas of improvement for future use of ML in the field.

METHODS

PubMed and Web of Science were systematically searched for publications of studies on patients with cancer applying ML models with PROM scores as either predictors or outcomes. The reporting quality of applied ML models was assessed utilizing an adapted version of the MI-CLAIM (Minimum Information about CLinical Artificial Intelligence Modelling) checklist. The key variables of the checklist are study design, data preparation, model development, optimization, performance, and examination. Reproducibility and transparency complement the reporting quality criteria.

RESULTS

The literature search yielded 1634 hits, of which 52 (3.2%) were eligible. Thirty-six (69.2%) publications included PROM scores as a predictor and 32 (61.5%) as an outcome. Results of the reporting quality appraisal indicate a potential for improvement, especially in the areas of model examination. According to the standards of the MI-CLAIM checklist, the reporting quality of ML models in included studies proved to be low. Only nine (17.3%) publications present a discussion about the clinical applicability of the developed model and reproducibility and only three (5.8%) provide a code to reproduce the model and the results.

CONCLUSION

The herein performed critical examination of the status quo of the application of ML models including PROM scores in published oncological studies allowed the identification of areas of improvement for reporting and future use of ML in the field.

The Cancer-Specific Health Economic Measure QLU-C10D is Valid and Responsive for Assessing Health Utility in Patients with Thyroid Cancer

Background: Health economic appraisals often rely on the assessment of health utilities using preference-based measures (PBM). The cancer-specific PBM, European Organisation for Research and Treatment of Cancer Quality of Life Utility - Core 10 Dimensions (EORTC QLU-C10D), was developed recently, and now needs to be validated in various clinical populations. Methods: In a multicenter, multinational prospective cohort study, we longitudinally collected EORTC QLQ-C30 and EQ-5D-5L data from patients with thyroid cancer. We applied seven country-specific value sets to the QLQ-C30 data to derive country-specific utility values and used the EQ-5D-5L as a comparator PBM. Criterion validity was assessed by correlating index scores and Bland-Altman plots. Construct validity was investigated by correlating domain scores. Known-group comparisons and responsiveness were assessed using external clinical criteria. Results: A total of 181 patients with thyroid cancer from nine countries (three continents) provided analyzable data. Patients were included if they had differentiated, medullary, or anaplastic thyroid cancer. Mean utility values of both instruments were generally lower compared to general population norms. No floor or ceiling effects were present for the QLU-C10D. The intra-class correlation for EQ-5D-5L and QLU-C10D index values ranged from 0.761 to 0.901 across the measurement timepoints, supporting criterion validity. Spearman's correlation coefficients ranged from 0.289 to 0.716 for theoretically corresponding domain pairs. The QLU-C10D detected differences in 9 of 15 known-group comparisons, supporting sensitivity. Clinically important changes were detected by all QLU-C10D country specific value sets, supporting responsiveness. Further, the QLU-C10D had higher statistical efficiency than the EQ-5D-5L in 74.7% of comparisons. Conclusions: The QLU-C10D is a valid PBM for health economic evaluations in thyroid cancer studies. We recommend its use to estimate health utilities in economic evaluations of thyroid cancer therapies.

A comparison of measurement properties between EORTC QLU-C10D and FACT-8D in patients with hematological malignances

OBJECTIVE

To perform a comparison of the measurement properties of two cancer-specific Multi-Attribute Utility Instruments (MAUIs), EORTC QLU-C10D and FACT-8D, in Chinese patients with hematologic malignancies (HM).

METHODS

We conducted a longitudinal study on patients with HM in China, using QLU-C10D and FACT-8D at baseline and follow-up (3-4 months from baseline). We assessed: (i) convergent validity using Spearman's rank correlation test (r) with EQ-5D-5L; (ii) clinical-groups validity by differentiating cancer stages, overall health assessment (OHA), Eastern Cancer Oncology Group (ECOG) performance status, and mental health status. We also examined clinical validity with effect size (ES) and relative efficiency (RE); (iii) responsiveness to changes in patient self-perception using receiver operating characteristics (ROC) curves and area under the curves (AUC); and (iv) agreement using intraclass correlation coefficients (ICC) and visualized with Bland-Altman plot.

RESULTS

Among the 308 patients with HM at baseline, 131 completed the follow-up survey. Agreement between the two measures was high (ICC = 0.76). Both measures were highly correlated with EQ-5D-5 L and significantly differentiated (p < 0.001) among groups categorized by cancer stage, OHA performance status, and mental health. ESs for QLU-C10D were numerically higher for cancer stage, OHA, and performance status (ES = 0.53-1.49), whereas ES was higher for FACT-8D and mental health status (ES = 1.35). Responsiveness was higher for QLU-C10D (AUC = 0.84) compared to FACT-8D (AUC = 0.78).

CONCLUSION

Both QLU-C10D and FACT-8D are valid cancer-specific MAUIs for evaluating patients with HM. However, scholars should consider their slight differences in focus when choosing between the two measures.

Decitabine in older patients with AML: quality of life results of the EORTC-GIMEMA-GMDS-SG randomized phase 3 trial

ABSTRACT

We hypothesized that fit older patients with acute myeloid leukemia (AML) treated with decitabine (DEC) would report better health-related quality of life (HRQoL) outcomes than those receiving intensive chemotherapy (IC). We conducted a phase 3 randomized trial to compare DEC (10-day schedule) with IC (3+7) in older fit patients with AML. HRQoL was a secondary end point, and it was assessed with the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30) in conjunction with its elderly module (EORTC QLQ-ELD14). The following scales were a priori selected for defining the primary end point: physical and role functioning, fatigue, pain, and burden of illness. HRQoL was assessed at baseline, at regeneration from cycle 2, and at 6 and 12 months after randomization, and also before allogeneic hematopoietic stem cell transplantation (allo-HSCT) and 100 days after transplantation. Overall, 606 patients underwent randomization. At 2 months, the risk of HRQoL deterioration was lower in the DEC arm than in the 3+7 arm; 76% (95% confidence interval [CI], 69-82) vs 88% (95% CI, 82-93); odds ratio, 0.43 (95% CI, 0.24-0.76; P = .003). No statistically significant HRQoL differences were observed between treatment arms at the long-term evaluation combining assessments at 6 and 12 months. HRQoL deteriorations between baseline and after allo-HSCT were observed in both arms. However, these deteriorations were not clinically meaningful in patients randomized to DEC, whereas this was the case for those in the 3+7 arm, in 4 of 5 primary HRQoL scales. Our HRQoL findings suggest that lower-intensity treatment with DEC may be preferable to current standard IC (3+7) in fit older patients with AML. This trial was registered at www.clinicaltrials.gov as #NCT02172872.

The EORTC QLU-C10D: the Hong Kong valuation study

OBJECTIVE

The EORTC QLU-C10D is a new preference-based measure derived from the EORTC QLQ-C30. Country-specific value sets are required to support the cost-utility analysis of cancer-related interventions. This study aimed to generate an EORTC QLU-C10 value set for Hong Kong (HK).

METHODS

A HK online panel was quota-sampled to achieve an adult general population sample representative by sex and age. Participants were invited to complete an online discrete choice experiment survey. Each participant was asked to complete 16 choice-pairs, randomly assigned from a total of 960 choice-pairs, each comprising two QLU-C10D health states and a duration attribute. Conditional and mixed logistic regression analyses were used to analyse the data.

RESULTS

The analysis included data from 1041 respondents who had successfully completed the online survey. The distribution of sex did not differ from that of the general population, but a significant difference was found among age groups. A weighting analysis for non-representative variable (age) was used. Utility decrements were generally monotonic, with the largest decrements for physical functioning (- 0.308), role functioning (- 0.165), and pain (- 0.161). The mean QLU-C10D utility score of the participants was 0.804 (median = 0.838, worst to best = - 0.169 to 1). The value of the worst health state was - 0.223, which was sufficiently lower than 0 (being dead).

CONCLUSIONS

This study established HK utility weights for the QLU-C10D, which can facilitate cost-utility analyses across cancer-related health programmes and technologies.

Japanese value set for the EORTC QLU-C10D: A multi-attribute utility instrument based on the EORTC QLQ-C30 cancer-specific quality-of-life questionnaire

PURPOSE

This study aimed to develop a Japanese value set for the EORTC QLU-C10D, a multi-attribute utility measure derived from the cancer-specific health-related quality-of-life (HRQL) questionnaire, the EORTC QLQ-C30. The QLU-C10D contains ten HRQL dimensions: physical, role, social and emotional functioning, pain, fatigue, sleep, appetite, nausea, and bowel problems.

METHODS

Quota sampling of a Japanese online panel was used to achieve representativeness of the Japanese general population by sex and age (≥ 18 years). The valuation method was an online discrete choice experiment. Each participant considered 16 choice pairs, randomly assigned from 960 choice pairs. Each pair included two QLU-C10D health states and life expectancy. Data were analyzed using conditional logistic regression, parameterized to fit the quality-adjusted life-year framework. Preference weights were calculated as the ratio of each dimension-level coefficient to the coefficient for life expectancy.

RESULTS

A total of 2809 eligible panel members consented, 2662/2809 (95%) completed at least one choice pair, and 2435/2662 (91%) completed all choice pairs. Within dimensions, preference weights were generally monotonic. Physical functioning, role functioning, and pain were associated with the largest utility weights. Intermediate utility weights were associated with social functioning and nausea; the remaining symptoms and emotional functioning were associated with smaller utility decrements. The value of the worst health state was - 0.221, lower than that seen in most other existing QLU-C10D country-specific value sets.

CONCLUSIONS

The Japan-specific QLU-C10D value set is suitable for evaluating the cost and utility of oncology treatments for Japanese health technology assessment and decision-making.

Leveraging patient experience data to guide medicines development, regulation, access decisions and clinical care in the EU

Patient experience data (PED), provided by patients/their carers without interpretation by clinicians, directly capture what matters more to patients on their medical condition, treatment and impact of healthcare. PED can be collected through different methodologies and these need to be robust and validated for its intended use. Medicine regulators are increasingly encouraging stakeholders to generate, collect and submit PED to support both scientific advice in development programs and regulatory decisions on the approval and use of these medicines. This article reviews the existing definitions and types of PED and demonstrate the potential for use in different settings of medicines' life cycle, focusing on Patient-Reported Outcomes (PRO) and Patient Preferences (PP). Furthermore, it addresses some challenges and opportunities, alluding to important regulatory guidance that has been published, methodological aspects and digitalization, highlighting the lack of guidance as a key hurdle to achieve more systematic inclusion of PED in regulatory submissions. In addition, the article discusses opportunities at European and global level that could be implemented to leverage PED use. New digital tools that allow patients to collect PED in real time could also contribute to these advances, but it is equally important not to overlook the challenges they entail. The numerous and relevant initiatives being developed by various stakeholders in this field, including regulators, show their confidence in PED's value and create an ideal moment to address challenges and consolidate PED use across medicines' life cycle.

Missingness mechanisms and generalizability of patient reported outcome measures in colorectal cancer survivors - assessing the reasonableness of the "missing completely at random" assumption

BACKGROUND

Patient-Reported Outcome Measures (PROM) provide important information, however, missing PROM data threaten the interpretability and generalizability of findings by introducing potential bias. This study aims to provide insight into missingness mechanisms and inform future researchers on generalizability and possible methodological solutions to overcome missing PROM data problems during data collection and statistical analyses.

METHODS

We identified 10,236 colorectal cancer survivors (CRCs) above 18y, diagnosed between 2014 and 2018 through the Danish Clinical Registries. We invited a random 20% (2,097) to participate in a national survey in May 2023. We distributed reminder e-mails at day 10 and day 20, and compared Initial Responders (response day 0-9), Subsequent Responders (response day 10-28) and Non-responders (no response after 28 days) in demographic and cancer-related characteristics and PROM-scores using linear regression.

RESULTS

Of the 2,097 CRCs, 1,188 responded (57%). Of these, 142 (7%) were excluded leaving 1,955 eligible CRCs. 628 (32%) were categorized as initial responders, 418 (21%) as subsequent responders, and 909 (47%) as non-responders. Differences in demographic and cancer-related characteristics between the three groups were minor and PROM-scores only marginally differed between initial and subsequent responders.

CONCLUSION

In this study of long-term colorectal cancer survivors, we showed that initial responders, subsequent responders, and non-responders exhibit comparable demographic and cancer-related characteristics. Among respondents, Patient-Reported Outcome Measures were also similar, indicating generalizability. Assuming Patient-Reported Outcome Measures of subsequent responders represent answers by the non-responders (would they be available), it may be reasonable to judge the missingness mechanism as Missing Completely At Random.

General population normative values for the EORTC QLQ-C30 by age, sex, and health condition for the French general population

BACKGROUND

General population normative values for the widely used health-related quality of life (HRQoL) measure EORTC QLQ-C30 support the interpretation of trial results and HRQoL of patients in clinical practice. Here, we provide sex-, age- and health condition-specific normative values for the EORTC QLQ-C30 in the French general population.

METHODS

French general population data was collected in an international EORTC project. Online panels with quota samples were used to recruit sex and age groups. Number and type of comorbidities were assessed. Descriptive statistics were used to calculate general population values for each QLQ-C30 scale, separately for sex, age, and presence of one- and more chronic health conditions. A multivariate linear regression model has been developed to allow estimating the effect of sex, age, and the presence for one- and more chronic health conditions on EORTC QLQ-C30 scores. Data was weighted according to United Nation statistics adjusting for the proportion of sex and age groups.

RESULTS

In total, 1001 French respondents were included in our analyses. The weighted mean age was 47.9 years, 514 (51.3%) participants were women, and 497 (52.2%) participants reported at least one health condition. Men reported statistically significant better scores for Emotional Functioning (+9.6 points, p = 0.006) and Fatigue (-7.8 point; p = 0.04); women reported better profiles for Role Functioning (+8.7 points; p = 0.008) and Financial Difficulty (-7.8 points, p = 0.011). According to the regression model, the sex effect was statistically significant in eight scales; the effect of increasing age had a statistically significant effect on seven of the 15 EORTC QLQ-C30 scales. The sex- and age effect varied in its direction across the various scales. The presence of health conditions showed a strong negative effect on all scales.

CONCLUSION

This is the first publication of detailed French normative values for the EORTC QLQ-C30. It aims to support the interpretation of HRQoL profiles in French cancer populations. The strong impact of health conditions on QLQ-C30 scores highlights the importance of considering the impact of comorbidities in cancer patients when interpreting HRQoL data.

Toward a more patient-centered drug development process in clinical trials for patients with myelodysplastic syndromes/neoplasms (MDS): Practical considerations from the International Consortium for MDS (icMDS)

Notable treatment advances have been made in recent years for patients with myelodysplastic syndromes/neoplasms (MDS), and several new drugs are under development. For example, the emerging availability of oral MDS therapies holds the promise of improving patients' health-related quality of life (HRQoL). Within this rapidly evolving landscape, the inclusion of HRQoL and other patient-reported outcomes (PROs) is critical to inform the benefit/risk assessment of new therapies or to assess whether patients live longer and better, for what will likely remain a largely incurable disease. We provide practical considerations to support investigators in generating high-quality PRO data in future MDS trials. We first describe several challenges that are to be thoughtfully considered when designing an MDS-focused clinical trial with a PRO endpoint. We then discuss aspects related to the design of the study, including PRO assessment strategies. We also discuss statistical approaches illustrating the potential value of time-to-event analyses and their implications within the estimand framework. Finally, based on a literature review of MDS randomized controlled trials with a PRO endpoint, we note the PRO items that deserve special attention when reporting future MDS trial results. We hope these practical considerations will facilitate the generation of rigorous PRO data that can robustly inform MDS patient care and support treatment decision-making for this patient population.

Danish value sets for the EORTC QLU-C10D utility instrument

PURPOSE

In this study, we developed Danish utility weights for the European Organisation for Research and Treatment of Cancer (EORTC) QLU-C10D, a cancer-specific utility instrument based on the EORTC QLQ-C30.

METHODS

Following a standardized methodology, 1001 adult participants from the Danish general population were quota-sampled and completed a cross-sectional web-based survey and discrete choice experiment (DCE). In the DCE, participants considered 16 choice sets constructed from the key 10 dimensions of the QLU-C10D and chose their preferred health state for each one. Utility weights were calculated using conditional logistic regression with correction for non-monotonicity.

RESULTS

The sample (n = 1001) was representative of the Danish general population with regard to age and gender. The domains with the largest utility decrements, i.e., the domains with the biggest impact on health utility, were physical functioning (- 0.224), pain (- 0.160), and role functioning (- 0.136). The smallest utility decrements were observed for the domains lack of appetite (- 0.024), sleep disorders (- 0.057), and fatigue (- 0.064). Non-monotonicity of severity levels was observed for the domains sleep disturbances, lack of appetite, and bowel problems. Deviations from monotonicity were not statistically significant.

CONCLUSION

The EORTC QLU-C10D is a relatively new multi-attribute utility instrument and is a promising cancer-specific health technology assessment candidate measure. The country-specific Danish utility weights from this study can be used for cost-utility analyses in Danish patients and for comparison with other country-specific utility data.

Establishing Meaningful Change Thresholds in Patient-Reported Outcomes Among Patients With Anaplastic Lymphoma Kinase-Positive Non-Small Cell Lung Cancer in ALTA-1L Trial

OBJECTIVES

An earlier study from the ALTA-1L trial of patients with anaplastic lymphoma kinase-positive non-small cell lung cancer demonstrated that brigatinib produces superior health-related quality of life (QoL) outcomes over crizotinib. This study aimed to derive meaningful change thresholds (MCTs) for European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ)-C30 and EORTC QLQ-LC13 to refine the earlier results.

METHODS

Patients from the ALTA-1L trial were administered the EORTC QLQ-C30 and EORTC QLQ-LC13 questionnaires. Responses were analyzed using anchor-based analysis, graphical analysis, distribution-based analysis, longitudinal responder analysis, and time to deterioration.

RESULTS

The patient-reported outcome population comprised 262 patients who completed the EORTC QLQ-C30 at baseline and at least 1 follow-up timepoint. Both anchors (QLQ-C30 items for overall health and QoL) had correlations >0.40 or < -0.40 with all functioning domains, fatigue, pain, appetite loss, and all dyspnea scores. Within-group analysis for most scales found the derived MCT was consistent with a cutoff of 10 points for classifying individual-patient change, except for 3-item dyspnea. The probability of improvement/remaining stable was significantly greater in the brigatinib group over crizotinib for the EORTC QLQ-C30 emotional functioning, appetite loss, and constipation domains.

CONCLUSIONS

This study derived MCTs for EORTC QLQ-C30 and QLQ-LC13 domains that may be applied in future studies and again demonstrated the superiority of brigatinib over crizotinib in health-related QoL outcomes in patients with non-small cell lung cancer.

Equipercentile equating of scores from common patient-reported outcome measures of physical function in patients with cancer

OBJECTIVE

To provide equipercentile equating of physical function (PF) scores from frequently used patient-reported outcome measures (PROMs) in cancer patients to facilitate data pooling and comparisons.

STUDY DESIGN AND SETTING

Adult cancer patients from five European countries completed the European Organization for Research and Treatment of Cancer (EORTC) computer adaptive test (CAT) Core, EORTC Quality of Life Questionnaire Version 3.0 (QLQ-C30), Functional Assessment of Cancer Therapy - General (FACT-G), 36-item Short Form Health Survey (SF-36), and the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function 20a short form. The R package "equate" was used to establish conversion tables of PF scores on those measures with a bivariate rank correlation of at least 0.75.

RESULTS

In total, 953 patients with cancer (mean age 58.9 years, 54.7% men) participated. Bivariate rank correlations between PF scores from the EORTC CAT Core, EORTC QLQ-C30, SF-36, and PROMIS were all above 0.85, but below 0.69 for the FACT-G. Conversion tables were established for all measures but the FACT-G. These tables indicate which score from one PROM best matches the score from another PROM and provide standard errors of converted scores.

CONCLUSION

Our analysis indicates that linking of PF scores from both EORTC measures (CAT and QLQ-C30) with PROMIS and SF-36 is possible, whereas the physical domain of the FACT-G seems to be different. The established conversion tables may be used for comparing results or pooling data from clinical studies using different PROMs.

Understanding health-related quality of life measures used in early-stage non-small cell lung cancer clinical trials: A review

Health-related quality of life (HRQoL) is an important consideration in cancer clinical research, which can be substantially influenced by cancer treatment procedures and medications. The treatment landscape for early-stage (stage I-III) non-small cell lung cancer (NSCLC) is rapidly evolving. In this light, it is important to evaluate the most suitable instruments for HRQoL assessment and timing. Given there is often a requirement for patients with early-stage disease to receive long-term treatment to reduce the risk of disease recurrence after surgery, maintenance or improvement in HRQoL is an important goal of both neoadjuvant and adjuvant treatments. Key challenges with assessing HRQoL relate to the suitability of existing instruments to measure relevant treatment-related adverse effects, consistency in HRQoL assessment approach between similar studies, gaps in data collection and reporting, and interpretation of longitudinal data. Frequent assessments during and after treatment are warranted to capture the true impact of treatment and disease progression on HRQoL, and changes in the relative importance of these factors over time. There is scope for improving existing HRQoL approaches, including ease of use and integration of digital tools to facilitate analysis and interpretation, to enhance the experience of both patients and healthcare professionals. In this narrative review, we discuss key considerations for HRQoL assessment and evaluate the tools currently available to measure HRQoL in NSCLC, many of which were designed with advanced disease in mind. We focus on the key challenges of measuring HRQoL for the specific needs of patients with early-stage disease, and consider future perspectives, to determine the most appropriate HRQoL instruments and analysis methods to use in early-stage NSCLC clinical trials.1.

Assessing the Content Validity of Preference-Based Measures in Cancer

OBJECTIVES

This study assessed the content validity of generic and condition-specific preference-based measures (PBMs) with patients treated for cancer, evaluated against 10 Consensus-Based Standards for the Selection of Health Measurement Instruments criteria for good content validity, to best inform measurement strategies regarding the use of PBMs in oncology development programs and real-world applications.

METHODS

Individual, semistructured interviews were conducted with patients who received drug treatment for cancer in the United Kingdom (n = 47) and the United States (n = 49). During the interview, patients completed 3 generic PBMs (EQ-5D-5L, EuroQol Health and Wellbeing measure-Short Form, Château Santé Base) and 2 condition-specific PBMs (Quality of Life Utility-Core 10 Dimension, Functional Assessment of Cancer Therapy Eight Dimension [FACT-8D]). Interviews were conducted via teleconference, audio recorded, and transcribed verbatim. Transcripts were coded using thematic and content analysis methods.

RESULTS

Condition-specific measures were evaluated as having better relevancy than generic PBMs. Overall, the FACT-8D was evaluated as holding the best content validity in terms of relevancy, and the EuroQol Health and Wellbeing measure-Short Form received the most favorable evaluation of relevancy for generic PBMs. All measures demonstrated comparable comprehensiveness, with all suggested by patients to be missing concepts. The EQ-5D-5L was evaluated best in terms of comprehensibility. This was followed by the Quality of Life Utility-Core 10 Dimension and FACT-8D; both received similar evaluations.

CONCLUSIONS

All measures were generally seen by patients as adequate in capturing appropriate aspects of health-related quality of life for measuring cancer outcomes, although together condition-specific measures were evaluated as having better relevancy than generic PBMs. Further health-related quality of life instrument development is encouraged, particularly with regard to the longer-term detrimental impacts of cancer and treatment side effects. Other developments could include new cancer-specific tools inclusive of conventional health items, treatment impacts, and psychological items.

The Assessment of Patient-Reported Outcomes for the Authorisation of Medicines in Europe: A Review of European Public Assessment Reports from 2017 to 2022

OBJECTIVES

Health regulators have progressively increased their attention and focus on patient-reported outcomes (PROs), driven by the diffusion of a patient-centred approach to the drug development process. This study investigates the consideration of PROs and their measures (PROMs) in the authorisation of medicines in Europe.

METHODS

All medicines for human use authorised or refused by the European Medicines Agency (EMA) in the period 2017-2022 were identified, and corresponding European Public Assessment Reports (EPARs) were downloaded for review. Medicine and PROs/PROM characteristics were systematically recorded. A multivariate logistic regression was performed to identify variables associated with the use of patient-reported evidence in EPARs.

RESULTS

Overall, 497 EPARs of authorised medicines and 19 EPARs of refused medicines were analysed; of these, 240 (48.3%) and 10 (52.6%), respectively, reported any use of PROs/PROMs (p = 0.710). For authorised medicines, the likelihood of using PROs/PROMs was negatively affected by generic (OR = 0.01, p < 0.001) and biosimilar status (OR = 0.46, p = 0.013) and positively affected by orphan status (OR = 1.41, p = 0.177). The use of PROMs (50.6% in 2017 vs 47.9% in 2022) did not show a clear pattern over the 6-year period considered (p = 0.758) and was particularly uncommon in some therapeutic areas (e.g., 15.2% in infectious diseases). A total of 816 dyads of PROs/PROMs were identified. On average each EPAR considered 1.6 (range: 0-14) instruments. Patient-reported outcomes were typically secondary (53.3%) and exploratory endpoints (18.8%); in one-third of cases (32.5%), they assessed generic quality of life. Among the PROMs, 227 (27.8%) targeted general population; EQ-5D (11.0%), SF-36/SF-12 (5.9%) and EORTC QLQ-C30 (5.6%) were the instruments most frequently used.

CONCLUSIONS

This study suggests PROs/PROMs are considered in less than half of total medicine assessments and even more rarely in some disease areas. The adoption of PROs is key in EMA strategy to 2025 and would be facilitated by consensus development on their measures and optimisation of data collection.

The impact of clinical and translational research on the quality of life during the metastatic colorectal cancer patient journey

The journey of metastatic colorectal cancer patients is complex and challenging, requiring coordination and collaboration between multiple healthcare providers. Understanding patients' needs, fears, feelings, concerns, and behaviors is essential for providing individualized patient-centered care. In recent years, mCRC patients have experienced improvements in clinical outcomes, from 16 months of overall survival to 32 months, thanks to research. However, there is still room for improvement, and integrating clinical and translational research into routine practice can help patients benefit from treatments and techniques that would not be an option. In the Journey of mCRC patients, living well with cancer and quality of life becomes a priority given the outcomes of the disease. Patient reported outcomes (PRO) and Patient Reported Outcome Measures (PROMs) are becoming therefore new estimands in Oncology. Patient advocates represent important figures in this process by prioritizing issues and research questions; evaluating research designs and the performance of the research; the analysis and interpretation of data; and how results are disseminated. Multidisciplinary Tumor Boards and shared decision-making is essential for designing treatment strategies for individual patients. Quality of Life is often prioritized only when it comes to refractory advanced disease and end-of-life care, but it has to be integrated from the beginning, as the emotional impact of diagnosis leads to a vulnerable situation where patients' needs and preferences can be easily overseen. First-line treatment will be chosen among more treatment options than subsequent lines, with longer progression-free survival and a bigger impact on the outcomes. Practicing patient-centered care and optimizing first-line treatment for colorectal cancer patients requires a comprehensive understanding of patient experience and treatment outcomes, which can guide clinical practice and inform regulatory decisions for the benefit of patients.

Information about missing patient-reported outcome data in breast cancer trials is frequently not documented: a scoping review

OBJECTIVES

This review addresses the common problem of missing patient-reported outcome (PRO) data in clinical trials by assessing the current practice of their statistical handling as reported in publications of randomized controlled trials (RCTs) in patients with breast cancer.

STUDY DESIGN AND SETTING

We searched PubMed to identify RCTs evaluating biomedical treatments in breast cancer patients with at least one PRO endpoint published between January 2019 and February 2022. Two reviewers independently assessed the eligibility of the publications for this scoping review and extracted prespecified information on missing PRO data and related statistical practices.

RESULTS

Of 1,598 publications identified, 118 trials met the inclusion criteria. Eighty-eight (74.6%) trials reported the extent of missing data, with 11 (9.3%) not containing any missing PRO data. Twenty-one (19.6%) trials explicitly stated the statistical approach for handling missing data, with a preference for single imputation over multiple imputation approaches (57.2%/19.0%). Only six (5.6%) trials reported a sensitivity analysis to examine the extent to the results being affected by changes in assumptions made about missing PRO data.

CONCLUSION

International efforts to raise awareness of the importance of accurately reporting state-of-the-art handling of missing PRO data are not yet fully reflected in the current literature of breast cancer RCTs.

Defining Priorities in Value-Based Cancer Care: Insights From the Alliance for Clinical Trials in Oncology National Cooperative Group Survey

PURPOSE

We determine how stakeholders prioritize the importance of oncologic outcomes, patient-reported outcomes (PROs), and cancer-related health care costs.

METHODS

A survey was distributed to the National Clinical Trials Network Alliance for Clinical Trials in Oncology cooperative group membership from May 14 to June 30, 2022. Respondents were asked to rate (5-point Likert scale) and rank (1-9) evidence-based value domains: overall survival, treatment toxicities/complications, quality of life (QOL), financial toxicity, access to care, compliance with evidence-based care, health system performance, scientific discovery and innovation, and cost to the health care system.

RESULTS

A total of 514 members responded, including researchers (24.7%), nurses (19.5%), medical oncologists (17.9%), administrators (9.3%), surgical and radiation oncologists (9.1%), patient advocates (3.1%), and nonphysician providers (16.4%). Participants represented various practice settings including National Cancer Institute-designated cancer centers (29.8%), university-affiliated academic cancer centers (21%), hospital-owned oncology practices (21.8%), and others (27.4%). There was agreement in how respondents prioritized value domains (W = 0.39, P < .001). Respondents ranked patient QOL (mean rank: 2.6 ± 1.9) as most important above all other metrics including survival (mean rank: 3.5 ± 0.3) and access to care (mean rank: 3.5 ± 2.1; P < .001). Members engaged in direct patient care also ranked access to care of higher importance than nonclinicians (P = .026). Cost to the health care system (mean rank: 7.5 ± 2.1) and health system performance (mean rank: 7 ± 2) were ranked as least important (P < .001). Inclusion of PROs into therapeutic assessment (59.3%) was the most frequently selected priority of future cooperative group initiatives.

CONCLUSION

Oncology community stakeholders deemed patient-centered value domains as most important and considered patient QOL the highest priority. Inclusion of PROs into clinical trials was endorsed as an important component of therapeutic assessment. These findings can be taken into consideration when creating a value framework for inclusion in cancer clinical trials.

Content comparison of the EORTC CAT Core, SF-36, FACT-G, and PROMIS role and social functioning measures based on the International Classification of Functioning, Disability and Health

OBJECTIVES

In line with the World Health Organizations' health definition, patient-reported outcome (PRO) measures frequently cover aspects of social health. Our study aimed to evaluate the role functioning (RF) and social functioning (SF) contents assessed by PRO measures commonly used in cancer patients.

METHODS

We analysed the item content of the SF and RF domains of the EORTC CAT Core, the EORTC QLQ-C30, the SF-36, and the FACT-G as well as the PROMIS item bank covering the Ability to Participate in Social Roles and Activities. Following an established methodology we linked item content to the International Classification of Functioning, Disability and Health (ICF) framework.

RESULTS

The content of 85 items was assigned to three ICF components ('Activities and Participation', 'Body Functions', and 'Environmental Factors'). The EORTC CAT Core RF items were mostly related to the first-level ICF categories 'Domestic life' and 'Community, social and civic life', while its SF item bank focused on 'Interpersonal interactions and relationships'. These three categories were also covered by the PROMIS social participation item bank. The FACT-G Social/Family scale focused on environmental factors ('Support and Relationships' and 'Attitudes') while the SF-36 Role-physical/emotional scales had a stronger focus on 'General tasks and demands' and 'Major life areas'.

CONCLUSIONS

Our results highlight conceptual overlap and differences among PRO measures for the assessment of social health in cancer. This information may help to select the most appropriate measure for a specific setting or study purpose and to better understand the possibilities of linking scores across different PRO measures.

Clinical outcome assessment trends in clinical trials-Contrasting oncology and non-oncology trials

BACKGROUND

Clinical outcome assessments (COAs) are key to patient-centered evaluation of novel interventions and supportive care. COAs are particularly informative in oncology where a focus on how patients feel and function is paramount, but their incorporation in trial outcomes have lagged that of traditional survival and tumor responses. To understand the trends of COA use in oncology and the impact of landmark efforts to promote COA use, we computationally surveyed oncology clinical trials in ClinicalTrials.gov comparing them to the rest of the clinical research landscape.

METHODS

Oncology trials were identified using medical subject heading neoplasm terms. Trials were searched for COA instrument names obtained from PROQOLID. Regression analyses assessed chronological and design-related trends.

RESULTS

Eighteen percent of oncology interventional trials initiated 1985-2020 (N = 35,415) reported using one or more of 655 COA instruments. Eighty-four percent of the COA-using trials utilized patient-reported outcomes, with other COA categories used in 4-27% of these trials. Likelihood of COA use increased with progressing trial phase (OR = 1.30, p < 0.001), randomization (OR = 2.32, p < 0.001), use of data monitoring committees (OR = 1.26, p < 0.001), study of non-FDA-regulated interventions (OR = 1.23, p = 0.001), and in supportive care versus treatment-focused trials (OR = 2.94, p < 0.001). Twenty-six percent of non-oncology trials initiated 1985-2020 (N = 244,440) reported COA use; they had similar COA-use predictive factors as oncology trials. COA use increased linearly over time (R = 0.98, p < 0.001), with significant increases following several individual regulatory events.

CONCLUSION

While COA use across clinical research has increased over time, there remains a need to further promote COA use particularly in early phase and treatment-focused oncology trials.

Minimally important differences for interpreting EORTC QLQ-C30 change scores over time: A synthesis across 21 clinical trials involving nine different cancer types

INTRODUCTION

Early guidelines for minimally important differences (MIDs) for the EORTC QLQ-C30 proposed ≥10 points change as clinically meaningful for all scales. Increasing evidence that MIDs can vary by scale, direction of change, cancer type and estimation method has raised doubt about a single global standard. This paper identifies MID patterns for interpreting group-level change in EORTC QLQ-C30 scores across nine cancer types.

METHODS

Data were obtained from 21 published EORTC Phase III trials that enroled 13,015 patients across nine cancer types (brain, colorectal, advanced breast, head/neck, lung, mesothelioma, melanoma, ovarian, and prostate). Anchor-based MIDs for within-group change and between-group differences in change over time were obtained via mean change method and linear regression, respectively. Separate MIDs were estimated for improvements and deteriorations. Distribution-based estimates were derived and compared with anchor-based MIDs.

RESULTS

Anchor-based MIDs mostly ranged from 5 to 10 points. Differences in MIDs for improvement vs deterioration, for both within-group and between-group, were mostly within a 2-points range. Larger differences between within-group and between-group MIDs were observed for several scales in ovarian, lung and head/neck cancer. Most anchor-based MIDs ranged between 0.3 SD and 0.5 SD distribution-based estimates.

CONCLUSIONS

Our results reinforce recent claims that no single MID can be applied to all EORTC QLQ-C30 scales and disease settings. MIDs varied by scale, improvement/deterioration, within/between comparisons and by cancer type. Researchers applying commonly used rules of thumb must be aware of the risk of dismissing changes that are clinically meaningful or underpowering analyses when smaller MIDs apply.

A Review of Labeling Based on Patient-Reported Outcome Endpoints for New Oncology Drugs Approved by the European Medicines Agency (2017-2021)

OBJECTIVE

A review of new oncology indications approved by the European Medicines Agency (EMA) for 2012-2016 showed that 33% of new drugs had labeling based on patient-reported outcomes (PROs). We reviewed labeling text based on PRO endpoints for new oncology indications approved during 2017-2021.

METHODS

New oncology drugs approved by EMA to treat indications of cancers during 2017-2021 were identified from the EMA website. PRO-related language reported in EMA summaries of product characteristics (SmPCs) were summarized and compared with similar findings reported for oncology indications approved during 2012-2016.

RESULTS

Review documents by the EMA during 2017-2021 were available for 49 new oncology drugs for 70 cancer indications. Submissions for 52 (74.3%) of the 70 indications included PRO data for EMA review. Of all submissions, 14 (20.0%) approvals contained PRO-related language in the SmPC. Broad concepts such as health-related quality of life were most common and found in 8 of 14 (57.1%) PRO-related labels.

CONCLUSION

PRO-related language appeared in SmPCs for 20% of all indications of new oncology drugs approved by EMA during 2017-2021 compared with approximately 33% of EMA approvals during 2012-2016. PRO-related labeling during the same periods showed a greater decline (from 47% to 27%) for indications of new oncology drugs that also included PRO data. One possible reason for this decline may be the increase in open-label studies from 62% between 2012 and 2016 to approximately 79% between 2017 and 2021.

Cost-Effectiveness of Robot-Assisted Radical Cystectomy vs Open Radical Cystectomy for Patients With Bladder Cancer

Importance

The value to payers of robot-assisted radical cystectomy with intracorporeal urinary diversion (iRARC) when compared with open radical cystectomy (ORC) for patients with bladder cancer is unclear.

Objectives

To compare the cost-effectiveness of iRARC with that of ORC.

Design, Setting, and Participants

This economic evaluation used individual patient data from a randomized clinical trial at 9 surgical centers in the United Kingdom. Patients with nonmetastatic bladder cancer were recruited from March 20, 2017, to January 29, 2020. The analysis used a health service perspective and a 90-day time horizon, with supplementary analyses exploring patient benefits up to 1 year. Deterministic and probabilistic sensitivity analyses were undertaken. Data were analyzed from January 13, 2022, to March 10, 2023.

Interventions

Patients were randomized to receive either iRARC (n = 169) or ORC (n = 169).

Main Outcomes and Measures

Costs of surgery were calculated using surgery timings and equipment costs, with other hospital data based on counts of activity. Quality-adjusted life-years were calculated from European Quality of Life 5-Dimension 5-Level instrument responses. Prespecified subgroup analyses were undertaken based on patient characteristics and type of diversion.

Results

A total of 305 patients with available outcome data were included in the analysis, with a mean (SD) age of 68.3 (8.1) years, and of whom 241 (79.0%) were men. Robot-assisted radical cystectomy was associated with statistically significant reductions in admissions to intensive therapy (6.35% [95% CI, 0.42%-12.28%]), and readmissions to hospital (14.56% [95% CI, 5.00%-24.11%]), but increases in theater time (31.35 [95% CI, 13.67-49.02] minutes). The additional cost of iRARC per patient was £1124 (95% CI, -£576 to £2824 [US $1622 (95% CI, -$831 to $4075)]) with an associated gain in quality-adjusted life-years of 0.01124 (95% CI, 0.00391-0.01857). The incremental cost-effectiveness ratio was £100 008 (US $144 312) per quality-adjusted life-year gained. Robot-assisted radical cystectomy had a much higher probability of being cost-effective for subgroups defined by age, tumor stage, and performance status.

Conclusions and Relevance

In this economic evaluation of surgery for patients with bladder cancer, iRARC reduced short-term morbidity and some associated costs. While the resulting cost-effectiveness ratio was in excess of thresholds used by many publicly funded health systems, patient subgroups were identified for which iRARC had a high probability of being cost-effective.

Trial Registration

ClinicalTrials.gov Identifier: NCT03049410.

International Society for Quality of Life Research commentary on the US Food and Drug Administration draft guidance for industry on core patient-reported outcomes in cancer clinical trials

In June 2021, the US Food and Drug Administration (FDA) released a draft guidance for industry on core patient-reported outcomes (PROs) and related considerations for instrument selection and trial design in registrational cancer clinical trials, building on prior communications about the use of PROs to assess efficacy and tolerability in oncology drug development. The International Society for Quality of Life Research (ISOQOL) Standards and Best Practices Committee led an initiative to draft a commentary about the guidance, focusing on its positive aspects and areas that would benefit from additional clarification and consideration. For comprehensiveness, the authors reviewed existing public comments on the draft guidance, and the commentary underwent a thorough review process through three ISOQOL Special Interest Groups (Psychometrics, Clinical Practice, and Regulatory and Health Technology Assessment Engagement) followed by the ISOQOL Board. The goal of this commentary is to situate this new and relevant guidance document within the context of recent regulatory efforts on PROs and highlight areas in which further work may ultimately benefit the field.

The European Organisation for Research and Treatment of Cancer Quality of Life Utility-Core 10 Dimensions: Development and Investigation of General Population Utility Norms for Canada, France, Germany, Italy, Poland, and the United Kingdom

OBJECTIVES

The European Organisation for Research and Treatment of Cancer Quality of Life Utility-Core 10 Dimensions (EORTC QLU-C10D) is a cancer-specific preference-based measure, providing health utilities for use in economic evaluations derived from the widely used health-related quality of life measure, EORTC QLQ-C30. Several EORTC QLU-C10D country-specific value sets are available. This article aimed to provide EORTC QLU-C10D general population utility norms for Canada, France, Germany, Italy, Poland, and the United Kingdom, to aid interpretability of obtained utilities in these countries.

METHODS

Data were collected in aforementioned countries via a quota-sampled, cross-sectional online survey (n = 100/age-sex group; N = approximately 1000/country). Participants were asked to complete the EORTC QLQ-C30 and provide sociodemographic data. Country-specific utility norms were calculated using the respective country tariff on the country's EORTC QLQ-C30 data after weighting to achieve population representativeness for age and sex. Norm values are provided as means (SDs) by country, age, and sex groups. Tukey's multiple comparison test investigated mean differences among countries. The impact of country, age, and sex on utility values was investigated with a multiple linear regression model.

RESULTS

Country-specific mean utilities range from 0.724 (United Kingdom) to 0.843 (Italy). Country-, sex-, and age-specific mean utilities range from 0.664 for 30- to 39-year-old male Canadians to 0.899 for > 70-year-old male Italians. Utilities were lower in females in 4 of 6 countries, and the impact of age differed among countries. Independent of the impact of age and sex, between-country differences were found (P ≤ .05).

CONCLUSION

Results showed a varying impact of age and sex on EORTC QLU-C10D utilities and significant between-country differences. Using national utility norms and utility decrements is recommended.

A Review of Patient-Reported Outcome Considerations in Oncologic Drugs Advisory Committee Meetings (2016-2021)

PURPOSE

The purpose of this project was to gain insight into the role of patient-reported outcome (PRO) data in US Food and Drug Administration (FDA) Oncologic Drugs Advisory Committee (ODAC) reviews and recommendations by documenting PRO-related considerations that appear in transcripts of ODAC meetings over a 6-year period (2016-2021).

METHODS

ODAC meeting transcripts were reviewed for any mention of PRO-related concepts. Meetings that reviewed biosimilars and meetings that discussed conceptual matters were excluded. For each identified transcript, the meeting date, brand and generic names of the drug, and indication were collected from the meeting minutes. Comments by ODAC members, FDA reviewers, and study sponsors on PRO data were captured during the review. Qualitative review of transcripts included both reading and searching for key terms, including PROs, quality of life, and health-related quality of life. Discussion of PRO-related topics was captured verbatim, organized thematically, and analyzed by two independent reviewers.

RESULTS

Twenty-seven transcripts of reviews were identified for 2016-2021. Topics related to PROs were included in 12 of those 27 reviews. The ODAC was satisfied with PROs included in 2 of those 12 reviews. Reasons for dissatisfaction in 10 of the 12 reviews included key concepts not assessed (5/12), missing data (5/12), and disagreement with sponsors' interpretation (3/12). The ODAC also expressed dissatisfaction with the lack of PRO data in 6 of 15 reviews that did not include PROs.

CONCLUSION

Less than half of ODAC reviews in 2016-2021 included PROs, and reviewers expressed frustration at the lack of PRO data. Even when included, evidence on the basis of PROs was rarely deemed adequate for benefit-risk assessments.

Role of Patient-Reported Outcomes in Clinical Trials in Metastatic Colorectal Cancer: A Scoping Review

PURPOSE

To perform a scoping review on the use of Patient-Reported Outcome Measures (PROMs) in randomized trials on systemic therapy in patients with metastatic colorectal cancer (mCRC) between 2010 and 2021.

METHODS

First, a search on clinicaltrials.gov was performed, looking for randomized trials in mCRC. The use of PROMs was analyzed quantitatively. Subsequently, we assessed the completeness of PROM reporting based on the CONSORT PRO extension in publications related to the selected trials acquired using Embase and PubMed.

RESULTS

A total of 46/176 trials were registered on clinicaltrials.gov used PROMs. All these trials used validated PROM instruments. The EORTC QLQ-C30 was most frequently used (37 times), followed by the EQ-5D (21 times) and the EORTC QLQ-CR29 (six times). A total of 56/176 registered trials were published. In 35% (n = 20), the results of the PROMs were available. Overall, 7/20 (35%) trials documented all items of the CONSORT PRO extension and quality of reporting according to the CONSORT PRO extension was higher than in the period 2004-2012. In 3/20 (15%) of the published trials, the results of PROMs were not discussed nor included in the positioning of the new treatment compared to the reference treatment.

CONCLUSION

When PROMs are used, the quality of reporting on patient-reported outcomes is improving, but this must continue in order to optimize the translation of trial results to individual patient values.

Patient-reported outcome measures for physical function in cancer patients: content comparison of the EORTC CAT Core, EORTC QLQ-C30, SF-36, FACT-G, and PROMIS measures using the International Classification of Functioning, Disability and Health

BACKGROUND

Patient-reported physical function (PF) is a key endpoint in cancer clinical trials. Using complex statistical methods, common metrics have been developed to compare scores from different patient-reported outcome (PRO) measures, but such methods do not account for possible differences in questionnaire content. Therefore, the aim of our study was a content comparison of frequently used PRO measures for PF in cancer patients.

METHODS

Relying on the framework of the International Classification of Functioning, Disability and Health (ICF) we categorized the item content of the physical domains of the following measures: EORTC CAT Core, EORTC QLQ-C30, SF-36, PROMIS Cancer Item Bank for Physical Function, PROMIS Short Form for Physical Function 20a, and the FACT-G. Item content was linked to ICF categories by two independent reviewers.

RESULTS

The 118 items investigated were assigned to 3 components ('d - Activities and Participation', 'b - Body Functions', and 'e - Environmental Factors') and 11 first-level ICF categories. All PF items of the EORTC measures but one were assigned to the first-level ICF categories 'd4 - Mobility' and 'd5 - Self-care', all within the component 'd - Activities and Participation'. The SF-36 additionally included item content related to 'd9 - Community, social and civic life' and the PROMIS Short Form for Physical Function 20a also included content related to 'd6 - domestic life'. The PROMIS Cancer Item Bank (v1.1) covered, in addition, two first-level categories within the component 'b - Body Functions'. The FACT-G Physical Well-being scale was found to be the most diverse scale with item content partly not covered by the ICF framework.

DISCUSSION

Our results provide information about conceptual differences between common PRO measures for the assessment of PF in cancer patients. Our results complement quantitative information on psychometric characteristics of these measures and provide a better understanding of the possibilities of establishing common metrics.

Improved social functioning and role functioning in rheumatic patients using a non-verbal communication tool: Results from a randomized, double-blind, controlled pilot-study

Introduction

Pain is a leading symptom in patients with rheumatic diseases, limiting not only physical functioning but also social well-being. This study studied the practicability of colored wristbands as non-verbal communication tools and the effects of these tools on social and role functioning in rheumatic patients.

Methods

This prospective, double-blind, randomized controlled pilot study recruited 110 patients. Practicability of colored silicon wristbands as non-verbal communication tools was assessed by questionnaires. The control group received written information on the rheumatic diseases and their management in general. Social functioning and role functioning were assessed using two subscales from the EORTC QLQ-C30.

Results

A significant overall improvement of social functioning (p = 0.005) and role functioning (p = 0.001) with medium to large effect size were reported by patients both in the intervention and the control group. Post hoc analyses revealed a significant change in the mean social functioning (p = 0.007) and role functioning scores with medium effect size, while no such effect was found in the control group for neither variable (p = 0.006 and p = 0.06-0.21, respectively). 42.9% of the patients will continue to use a non-verbal communication tool in the future. Practicability of the wristbands was limited by small size of the wristbands in 17.6% and uncomfortable wearing of the wristbands and skin irritation each in 4.4% of the patients.

Discussion

This study shows first promising results for the use of a non-verbal communication tool in about 50.0% of the patients with rheumatic diseases, to improve their social functioning and role functioning.

Clinician and Patient Reporting of Symptomatic Adverse Events in Cancer Clinical Trials: Using CTCAE and PRO-CTCAE® to Provide Two Distinct and Complementary Perspectives

Inclusion of the patient perspective in the reporting of symptomatic adverse events provides different and complementary information to clinician reporting using the Common Terminology Criteria for Adverse Events (CTCAE). The National Cancer Institute's Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE^®) is designed for patients to self-report their symptomatic adverse events in a manner that complements CTCAE reporting. Using CTCAE and PRO-CTCAE together offers the potential to refine our understanding of the prevalence and trajectory of lower grade AEs that can lead to elective discontinuation of therapy and diminished quality of life. This review addresses the development of PRO-CTCAE with an emphasis on the differences between PRO-CTCAE scores and CTCAE severity grades. This distinction is important when evaluating, grading and reporting toxicity and tolerability in cancer clinical trials.

Patient reported outcomes based on EQ-5D-5L questionnaires in head and neck cancer patients: a real-world study

OBJECTIVE

Health economic comparisons of various therapies are often based on health-related quality of life (HRQOL) using EQ-5D questionnaires within the framework of clinical trials. This real-world study prospectively evaluates the patient reported outcomes (PROs)-based HRQOL of head-and-neck (H&N) cancer patients undergoing modern radiotherapy (RT) to reflect PRO trajectories.

METHODS

All H&N cancer patients treated in our clinic between July 2019 and December 2020 who completed the self-reported validated EQ-5D-5L questionnaire (health state index (HI) and Visual Analog Scale (VAS)) at baseline, end of radiotherapy, and at each respective follow up (FU) were included. Descriptive analysis of clinical and sociodemographic data, the frequency and level of each dimension was conducted. To assess the significance of therapy-induced HRQOL changes within and between the group, a distribution-based approach was used.

RESULTS

Altogether, 366 participants completed a total of 565 questionnaires. For the whole cohort, HI at baseline was 0.804 (±0.208), 0.830 (±0.162) at RT completion, 0.812 (±0.205) at the first follow-up, and 0.769 (±0.224) at the second follow-up. The respective VAS values were 62.06 (±23,94), 66.73 (±82.20), 63.30 (±22.74), and 65.48 (±23.39). Females showed significantly lower HI values compared to males, but only at baseline (p = 0.034). Significantly lower HI values were also seen in patients with definitive RT as compared to adjuvant RT at baseline (p = 0.023), the second follow-up (p = 0.047), and the third follow-up (p = 0.010). As compared to outpatients, inpatients had significantly lower HI values at RT completion (p = 0.017), the second follow-up (p = 0.007), and the third follow-up (p = 0.031). Subgroup analyses by age (< 65 vs. ≥65) and smoking status (smokers vs. non-smokers) showed no difference at any time point.

CONCLUSION

PROs demonstrated detectability of time- and intra-/inter-group therapy-induced HRQOL changes. A further detailed exploration of EQ-5D-5L responsiveness for H&N cancer patients is required.

Listening to the Patient Voice Adds Value to Cancer Clinical Trials

Randomized clinical trials are critical for evaluating the safety and efficacy of interventions in oncology and informing regulatory decisions, practice guidelines, and health policy. Patient-reported outcomes (PROs) are increasingly used in randomized trials to reflect the impact of receiving cancer therapies from the patient perspective and can inform evaluations of interventions by providing evidence that cannot be obtained or deduced from clinicians' reports or from other biomedical measures. This commentary focuses on how PROs add value to clinical trials by representing the patient voice. We employed 2 previously published descriptive frameworks (addressing how PROs are used in clinical trials and how PROs have an impact, respectively) and selected 9 clinical trial publications that illustrate the value of PROs according to the framework categories. These include 3 trials where PROs were a primary trial endpoint, 3 trials where PROs as secondary endpoints supported the primary endpoint, and 3 trials where PROs as secondary endpoints contrast the primary endpoint findings in clinically important ways. The 9 examples illustrate that PROs add valuable data to the care and treatment context by informing future patients about how they may feel and function on different treatments and by providing clinicians with evidence to support changes to clinical practice and shared decision making. Beyond the patient and clinician, PROs can enable administrators to consider the cost-effectiveness of implementing new interventions and contribute vital information to policy makers, health technology assessors, and regulators. These examples provide a strong case for the wider implementation of PROs in cancer trials.

Common Patient-Reported Outcomes Within the Food and Drug Administration Voice of the Patient Reports

OBJECTIVES

Proponents of disease-specific patient-reported outcome measurements (PROMs) often argue disease-agnostic measures do not adequately capture their patient population's experience. Patient-Reported Outcomes Measurement Information System (PROMIS) provides a disease-agnostic domain set that may adequately cover many diseases. This study seeks to investigate whether PROMIS's quality of life domain coverage can span patient-reported outcomes (PROs) elicited from patients across unrelated diseases.

METHODS

The Food and Drug Administration Voice of the Patient reports were an initiative to elevate patient voices regarding their condition and associated treatments. Two reviewers extracted patient-reported health-related (quality of life) domains from the reports and categorized them into PROMIS domains or non-PROMIS domains. Domain coverage was summarized for each report. Any extracted PROs not covered by PROMIS domains were placed in an "other" category and analyzed for common themes.

RESULTS

Across 26 reports, PROMIS covered 216 of 374 (70%) of the reports' PRO domains. The heritable bleeding disorders report had the highest coverage (82%). Human immunodeficiency virus had the lowest coverage (50%). The most common PROMIS domain, "ability to participate in social roles," appeared in 25 reports (96%). The most common domains not included in PROMIS were stigma, sensitivities, and sensory deficits as evident in 19 (73%), 18 (69%), and 18 reports (69%), respectively. If the top 3 unincluded domains were amended into PROMIS, the total domain coverage would increase to 84%.

CONCLUSIONS

PRO domains elicited in the Food and Drug Administration Voice of the Patient reports were widely captured by PROMIS, suggesting domains patients experience contain enough overlap to be recorded by appropriate PROMIS domains. PROMIS could increase its coverage by adding domains.