Response of global quality of life to high-dose palliative radiotherapy for non-small-cell lung cancer

Integrated Palliative Care and Oncologic Care in Non-Small-Cell Lung Cancer

OPINION STATEMENT

Palliative care integrated into standard medical oncologic care will transform the way we approach and practice oncologic care. Integration of appropriate components of palliative care into oncologic treatment using a pathway-based approach will be described in this review. Care pathways build on disease status (early, locally advanced, advanced) as well as patient and family needs. This allows for an individualized approach to care and is the best means for proactive screening, assessment, and intervention, to ensure that all palliative care needs are met throughout the continuum of care. Components of palliative care that will be discussed include assessment of physical symptoms, psychosocial distress, and spiritual distress. Specific components of these should be integrated based on disease trajectory, as well as clinical assessment. Palliative care should also include family and caregiver education, training, and support, from diagnosis through survivorship and end of life. Effective integration of palliative care interventions have the potential to impact quality of life and longevity for patients, as well as improve caregiver outcomes.

Quality of life measurement in cancer patients receiving palliative radiotherapy for symptomatic lung cancer: a literature review

Approximately 27% of North American cancer deaths are attributable to cancer of the lung. Many lung cancers are found at an advanced stage, rendering the tumours inoperable and the patients palliative. Common symptoms associated with palliative lung cancer include cough, hemoptysis, and dyspnea, all of which can significantly debilitate and diminish quality of life (QOL). In studies of the effects of cancer therapies, the frequent evaluative endpoints are survival and local control; however, it is imperative that clinical trials with palliative patients also have a QOL focus when a cure is unattainable. We conducted a literature review to investigate the use of QOL instrument tools in trials studying QOL or symptom palliation of primary lung cancer or lung metastases through the use of radiotherapy. We identified forty-three studies: nineteen used a QOL tool, and twenty-four examined symptom palliation without the use of a QOL instrument. The European Organization for Research and Treatment of Cancer (eortc) QLQ-C30 survey was the most commonly used QOL questionnaire (in thirteen of twenty trials). Of those thirteen studies, eight also incorporated the lung-specific QOL survey eortc QLQ-LC13 (or the eortc QLQ-LC17). A second lung-specific survey, the Functional Assessment of Cancer Therapy-Lung (fact-L) was used in only two of the twenty trials. In total, only ten of forty-three trials (23%) used a lung-specific QOL tool, suggesting that QOL was of low priority as an endpoint and that measures created for lung cancer patients are underused. We encourage investigators in future trials to include specific QOL instruments such as the eortc QLQ-LC13 or the fact-L for studies in palliative thoracic radiotherapy because those instruments provide a measure of QOL specific to patients with lung cancer or lung metastases.

A Review and Meta-Analysis of Utility Values for Lung Cancer

Background. Published utility estimates for lung cancer are plentiful and vary greatly. The reason for this variability is unclear, but may result from differences in the methods used to elicit each utility. Purpose. To identify a set of pooled lung cancer utility estimates reflective of the available literature and determine which methodological factors significantly influence the value of lung cancer utility. Data Sources. Searches of PubMed, the NHS Economic Evaluation Database, and the Cost Effectiveness Analysis Registry from the Center for the Evaluation of Value and Risk in Health. Study Selection. English-language studies were included if they presented at least one previously unpublished lung cancer utility value, noted the elicitation technique and utility value provider. Data Extraction and Analysis. Two trained readers independently reviewed each article and extracted information for analysis. A hierarchical linear model (HLM) was used to perform a meta-regression with cancer stage, lower bound of scale, upper bound of scale, respondent, elicitation method, and lung cancer subtype as explanatory variables. Data Synthesis. Twenty-three articles containing 223 unique utility values were included. Lung cancer stage and subtype, the upper bound label of the utility scale, and respondent identity were significant predictors of utility (P < 0.05), while the lower bound label of utility scale was not. The HLM provided a set of pooled utility values for metastatic (0.57), mixed or nonspecified stage (0.77), and nonmetastatic lung cancer (0.87 )—for the case of standard gamble as method, patients as respondents, non-small-cell lung cancer and scale labeled death to perfect health. Conclusion. Methodological factors significantly affect lung cancer utilities; therefore, analysts should avoid direct comparisons of lung cancer utility values elicited with dissimilar methods.

A phase I trial of high-dose palliative radiotherapy plus concurrent weekly Vinorelbine and Cisplatin in patients with locally advanced and metastatic NSCLC

The role of concurrent chemoradiotherapy (CRT) in patients with non-small-cell lung cancer (NSCLC) unsuitable for radical therapy but who require locoregional treatment has not been defined. The aims of this phase I trial were thus to develop a novel regimen of weekly chemotherapy concurrent with high-dose palliative RT (40 Gy/20 fractions) and assess its tolerability, objective and symptomatic response rates. Eligible patients had stage I–IIIB NSCLC unsuitable for radical RT or limited stage IV disease, ECOG PS⩽1 and required locoregional therapy. Treatment was RT (40 Gy/20 fractions/5 per week) and weekly Vinorelbine plus Cisplatin escalated in six planned dose levels (DLs). At 4 weeks post-RT, patients received two cycles of Cisplatin 80 mg m⁻² day 1+Vinorelbine 25 mg m⁻² days 1, 8, 15. Dose-limiting toxicities (DLTs) were defined in the CRT phase. Disease-related symptoms were assessed by the Lung Cancer Symptom Scale. In all, 24 patients accrued, stage IIIB (n=12) and IV disease (n=10). The highest administered dose was at DL 4, Vinorelbine 30 mg m⁻²+Cisplatin 20 mg m⁻² with DLTs of grade 4 neutropenia in two of three patients. No grade 3 or 4 nonhaematological toxicities were observed. The overall radiological response rate was 65% (n=23: complete response 4% and partial response 61%) and infield FDG-PET responses were seen in 89% (n=18). There was an improvement or stabilisation of symptoms and quality of life. Dose level 3, Vinorelbine 25 mg m⁻²+Cisplatin 20 mg m⁻², is recommended for further assessment. This regimen was tolerable and produced meaningful responses for patients for whom locoregional control is required, but who are unsuitable for radical CRT.

Supportive Care in Lung Cancer

Lung cancer often is associated with significant morbidity, which has a detrimental effect on quality of life. Supportive care plays a central role in the multimodal treatment of lung cancer. Palliation of symptoms often improves quality of life and compliance with therapy. New developments in supportive care, reviewed here, include management of symptoms of the disease, such as respiratory problems, pain, and cachexia, as well as effects of treatment, including chemotherapy-induced nausea and vomiting, neutropenia, anemia, and mucositis. In the past few years, significant advances have been made in this field; however, palliation of the symptoms of lung cancer remains an area of active investigation.

Estimating the benefit and cost of radiotherapy for lung cancer

Purpose: To estimate the benefit and cost of using radiotherapy (RT) in the initial management of lung cancer in the general population.

Methods: We identified indications for RT in the initial management of small cell and non–small cell lung cancer through a review of the literature. The proportion of patients with each specific indication for treatment was determined using epidemiological observations from cancer registry data and from the literature. We estimated the benefit gained from RT use for each indication in the model using values published in the literature. We estimated the cost of RT for each indication using published Canadian data. The total benefit and cost was calculated for all indications combined. Results are reported in 2001 Canadian dollars.

Results: The mean benefit was 7 months of survival for each lung cancer patient treated with curative intent and 3 months of symptom control for each patient treated with palliative intent. The average cost was $9,881 per life year gained and $13,938 per year of symptom control gained. Sensitivity analysis revealed values between $7,905 and $19,762 per year of survival gain and between $10,368 and $27,875 per year of symptom control gained.

Conclusions: Using RT in the initial management of lung cancer can provide considerable gains in survival and symptom control. The cost of RT for the initial management of lung cancer is inexpensive compared with a common cut off of $50,000 per life year gained.

The cost-effectiveness and cost-utility of high-dose palliative radiotherapy for advanced non-small-cell lung cancer

PURPOSE

To compute cost-effectiveness/cost-utility (CE/CU) ratios, from the treatment clinic and societal perspectives, for high-dose palliative radiotherapy treatment (RT) for advanced non-small-cell lung cancer (NSCLC) against best supportive care (BSC) as comparator, and thereby demonstrate a method for computing CE/CU ratios when randomized clinical trial (RCT) data cannot be generated.

METHODS AND MATERIALS

Unit cost estimates based on an earlier reported 1989-90 analysis of treatment costs at the Vancouver Island Cancer Centre, Victoria, British Columbia, Canada, are updated to 1997-1998 and then used to compute the incremental cost of an average dose of high-dose palliative RT. The incremental number of life days and quality-adjusted life days (QALDs) attributable to treatment are from earlier reported regression analyses of the survival and quality-of-life data from patients who enrolled prospectively in a lung cancer management cost-effectiveness study at the clinic over a 2-year period from 1990 to 1992.

RESULTS

The baseline CE and CU ratios are $9245 Cdn per life year (LY) and $12,836 per quality-adjusted life year (QALY), respectively, from the clinic perspective; and $12,253/LY and $17,012/QALY, respectively, from the societal perspective. Multivariate sensitivity analysis for the CE ratio produces a range of $5513-28,270/LY from the clinic perspective, and $7307-37,465/LY from the societal perspective. Similar calculations for the CU ratio produce a range of $7205-37, 134/QALY from the clinic perspective, and $9550-49,213/QALY from the societal perspective.

CONCLUSION

The cost effectiveness and cost utility of high-dose palliative RT for advanced NSCLC compares favorably with the cost effectiveness of other forms of treatment for NSCLC, of treatments of other forms of cancer, and of many other commonly used medical interventions; and lies within the US $50, 000/QALY benchmark often cited for cost-effective care.