Defining and analysing symptom palliation in cancer clinical trials: a deceptively difficult exercise

Comparison between 1-week and 2-week palliative radiotherapy courses for superior vena cava syndrome

PURPOSE

The aim of this study was to evaluate the effectiveness of palliative radiation therapy (RT) for superior vena cava (SVC) syndrome from lung cancer and to compare the 2-week and 1-week schedules.

MATERIALS AND METHODS

A retrospective study was conducted on lung cancer patients with palliative RT for SVC syndrome. Patients received 30 Gy in 10 fractions (2-week group) or 20 Gy in 5 fractions (1-week group) between July 2012 and June 2022. Treatment outcomes were evaluated at 1 to 2 months after RT. The tumor response and recanalization were evaluated based on the computed tomography (CT).

RESULTS

Of the 39 patients, 24 received a 2-week course RT and 15 received a 1-week course of RT. The most common SVC-associated symptoms were edema (51.3%) and dyspnea (43.6%). There were no significant differences in performance status, histology, and grade of SVC. Symptom relief in symptomatic patients was comparable (85.7% in the 2-week group vs. 91.6% in the 1-week group; p = 0.581). There were no significant differences between the 2-week and 1-week groups in recanalization rates (62.5% vs. 60.0%; p = 0.876), tumor responses (75% vs. 60.0%; p = 0.876), and 6-month overall survival rates (29.2% vs. 36.4%; p = 0.726). In each of the two groups, one patient was consulted for re-irradiation. The median survival were 3.7 months for the 2-week group and 4.4 months for the 1-week group.

CONCLUSION

In patients with SVC syndrome, the palliative effect of a 1-week course was equivalent to that of a 2-week course. Given the poor prognosis, a 1-week course may be an option.

Feasibility of perioperative remote monitoring of patient-generated health data in complex surgical oncology

BACKGROUND

The feasibility of remote perioperative telemonitoring of patient-generated physiologic health data and patient-reported outcomes in a high risk complex general and urologic oncology surgery population is evaluated.

METHODS

Complex general surgical/urologic oncology patients wore a pedometer, completed ePROs (electronic patient-reported outcome surveys) and record their vitals (weight, pulse, pulse oximetry, blood pressure, and temperature) via a telehealth app platform. Feasibility (% adherence) was assessed as the primary outcome measure.

RESULTS

Twenty-one patients with a median age 58 (32-82) years were included. The readmission rate was 33% and the incidence of ≥Grade 3a morbidity was 24%. Adherence to vital sign and ePRO measurements was 95% before surgery, 91% at discharge, and 82%, 68%, and 64% at postdischarge d2, 7, 14, and 30, respectively. There was significant worsening of mobility, self-care and usual daily activity at postdischarge d2 compared to preoperative baseline (p < 0.05). Median daily preoperative steps taken by patients with <Grade 3a versus ≥Grade 3a postoperative morbidity was 6062 versus 4166 (p < 0.05). Of those interviewed, 87% (13/15) viewed vital sign devices as helpful in recovery.

CONCLUSIONS

Telemonitoring is feasible in a general surgical and urologic oncology setting. Future studies will ascertain optimal patient selection, duration, and extent of perioperative monitoring.

Patient-Reported Outcomes Assessing the Impact of Palliative Radiotherapy on Quality of Life and Symptom Burden in Head and Neck Cancer Patients: A Systematic Review

Incurable head and neck cancer has a poor prognosis and impairs a patient's health-related quality of life. Palliative radiotherapy may improve or stabilize health-related quality of life and symptoms, best measured by patient-reported outcomes. There is no systematic analysis if palliative radiotherapy for head and neck cancer improves or stabilizes health-related quality of life or symptoms as validly measured by patient-reported outcomes. Therefore, the primary objective of this systematic review (PROSPERO-ID: CRD42020166434) was to assess the effect of palliative radiotherapy for head and neck cancer on patient-reported outcomes. The secondary objective was to assess the rate and quality of use of patient-reported outcomes in relevant studies claiming a "palliative effect" of radiotherapy. The databases MEDLINE/PubMed, EMBASE, Cochrane CENTRAL, "ClinicalTrials.gov" were searched. Concerning the primary objective, four studies were eligible to assess the effectiveness of palliative radiotherapy as measured by patient-reported outcomes. A narrative synthesis suggests a favorable impact of palliative radiotherapy on health-related quality of life and symptom burden. The risk of bias, however, is considerable and the overall quality of evidence low. Concerning the secondary objective, over 90% of studies claiming a "palliative effect" of palliative radiotherapy did either not use patient-reported outcomes or did so by limited quality. In conclusion, implementation of patient-reported outcomes in studies assessing palliative radiotherapy for head and neck cancer should be fostered. Palliative radiotherapy remains an option for head and neck cancer patients, although more studies focusing on patient-reported outcomes are needed.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/prospero/, identifier CRD42020166434.

Portomesenteric Venous Stenting for Palliation of Ascites and Variceal Bleeding Caused by Prehepatic Portal Hypertension

BACKGROUND

The purpose of this study was to evaluate percutaneous transhepatic portal vein stenting (PVS) for palliation of refractory ascites and/or variceal bleeding caused by extrahepatic portomesenteric venous stenosis in patients with pancreaticobiliary cancer.

MATERIALS AND METHODS

A single-institution, retrospective review of patients who underwent PVS between January 2007 and July 2015 was performed. A total of 38 patients were identified, of whom 28 met the inclusion criterion of PVS performed primarily for refractory ascites or variceal bleeding. In addition to technical success and overall survival, clinical success was measured by fraction of remaining life palliated. The palliative effect of PVS was also quantified by measuring changes in liver and ascites volumes after the procedure.

RESULTS

Technical success was 93% (26/28). Stent deployment involved more than one portomesenteric vessel in most patients (20/26). The cumulative probability of symptom recurrence at 6, 12, 18, and 24 months was 12%, 16%, 26%, and 40%, respectively. There was a significant difference (p < .001) in the probability of symptom recurrence, recurrence of abdominal ascites, and increase in liver volume between patients whose stents remained patent and those whose stents demonstrated partial or complete occlusion. The mean fraction of remaining life palliated was 87%. All but two patients were found to have improvement in clinical symptoms for the majority of their lives after the procedure. There were no major or minor complications.

CONCLUSION

As a low-risk procedure with a high clinical success rate, PVS can play a substantial role in improving quality of life in patients with portomesenteric stenoses.

IMPLICATIONS FOR PRACTICE

Portomesenteric venous stenosis is a challenging complication of pancreaticobiliary malignancy. Portomesenteric stenoses can lead to esophageal, gastric, and mesenteric variceal bleeding, as well as abdominal ascites. The purpose of this study was to evaluate the safety and efficacy of portal vein stenting (PVS) in patients with cancer who have symptomatic portal hypertension caused by portomesenteric venous compression. As a low-risk procedure with a high clinical success rate, PVS can play a substantial role in improving quality of life in patients with portomesenteric stenoses.

Safety and palliative efficacy of single-dose 8-Gy reirradiation for painful local failure in patients with stage IV non-small cell lung cancer previously treated with radical chemoradiation therapy

PURPOSE

To investigate the safety and efficacy of single-dose 8-Gy palliative chest reirradiation (CRI) in metastatic non-small cell lung cancer (M-NSCLC) patients with painful thoracic failures (TF) within the previous radiation portal.

PATIENTS AND METHODS

We retrospectively analyzed the clinical data of 78 M-NSCLC patients who received single-dose 8-Gy CRI for painful TF after concurrent chemoradiation therapy to a total radiation dose of 52 to 66 Gy between 2007 and 2012. Primary endpoints included significant pain relief (SPR) defined as a ≥2 point decrement in the Visual Analogue Scale for Pain inventory (VAS-P), time to pain relief, and duration of pain control. Secondary objectives were survival and prognostic factors.

RESULTS

Treatment was well tolerated, with only 5.1% grade 3 pneumonitis and 1.3% grade 2 esophagitis. Pre-CRI median and post-CRI minimum VAS-P were 7 and 3 (P<.001), respectively. SPR was noted in 67 (85.9%) patients, and only 3 (3.9%) scored progressive pain. Median time to lowest VAS-P and duration of pain control were 27 days and 6.1 months, respectively. Median overall survival (OS) was 7.7 months, and the 1-year OS rate was 26.5%. On multivariate analyses, lower Eastern Cooperative Oncology group score (1-2; P<.001), absence of anemia (P=.001), and fewer metastatic sites (1-2; P<.001) were found to be associated with longer OS.

CONCLUSIONS

Single-dose 8-Gy CRI provides safe, effective, and durable pain palliation for TF in radically irradiated M-NSCLC patients. Because of its convenience, lower cost, and higher comfort, the present protocol can be considered an appropriate option for patients with limited life spans.

Quality-of-life evaluation for advanced non-small-cell lung cancer: a comparison between vinorelbine plus gemcitabine followed by docetaxel versus paclitaxel plus carboplatin regimens in a randomized trial: Japan Multinational Trial Organization LC00-03 (BRI LC03-01)

Background

A randomized trial of vinorelbine plus gemcitabine followed by docetaxel (VGD) versus paclitaxel plus carboplatin (PC) in patients with advanced non-small-cell lung cancer showed no difference in overall survival (median survival time: 13.6 versus 14.1 months) between the two treatment groups. We report here the results of quality-of-life (QOL) study initiated in the mid-course of this randomized trial.

Methods

The patients themselves assessed the Functional Assessment of Cancer Therapy (FACT)-Lung (FACT-L), FACT-Taxane and the Functional Assessment of Chronic Illness Therapy - Spirituality (FACIT-Sp) QOL instruments at baseline and 6, 12 and 18 weeks after the treatment. The primary endpoint was a comparison of total QOL score for each assessment instrument between the two groups.

Results

Sixty-eight patients from the trial (VGD, 34; PC, 34) who submitted baseline questionnaires and at least one questionnaire over the course of treatment were eligible. Longitudinal analysis showed a significant difference in slope of the FACT-Taxane score (p = 0.004) between treatment regimens over time, but no difference was found in FACT-L score (p = 0.311) and FACIT-Sp score (p = 0.466) between the two groups.

Conclusions

The significant difference in slope of FACT-Taxane score favored the VGD regimen. These data should be considered in treatment decision-making for patients with advanced non-small-cell lung cancer.

Trial registration

NCT00242983.

Effect of celecoxib on survival in patients with advanced non-small cell lung cancer: a double blind randomised clinical phase III trial (CYCLUS study) by the Swedish Lung Cancer Study Group

BACKGROUND

Increased expression of cyclooxygenase-2 (COX-2) is common in non-small cell lung cancer (NSCLC) and has been associated with poor prognosis. Experimental and clinical phase II trials have indicated that the addition of the COX-2 inhibitor celecoxib to palliative chemotherapy might increase survival time in patients with advanced NSCLC.

METHODS

We performed a double-blind, placebo-controlled multicentre phase III trial at 13 centres in Sweden. Three hundred and nineteen patients with advanced NSCLC stage IIIB-IV and performance status 0-2 were randomised to receive celecoxib 400mg b.i.d. or placebo in addition to palliative chemotherapy. The primary objective was to compare overall survival. Other end-points were quality of life, progression-free survival, toxicity, cardiovascular events and biological markers. The trial is registered with ClinicalTrials.gov, No. NCT00300729.

FINDINGS

Three hundred and sixteen patients were included in the analysis, 158 in each treatment group. Median survival time was 8.5 months. There was no survival difference between the treatment arms. Small but not statistically significant differences in global quality of life and pain were seen favouring the celecoxib group. No increased incidence of cardiovascular events was observed in the celecoxib group.

INTERPRETATION

This study failed to demonstrate a survival benefit of the addition of celecoxib to palliative chemotherapy.

Impact of home mechanical ventilation on health-related quality of life in patients with chronic alveolar hypoventilation: a prospective study

BACKGROUND

Nocturnal ventilatory support by nasal positive pressure ventilation (NPPV) is an established treatment method in patients with chronic alveolar hypoventilation (CAH). The knowledge about its long-term effects on health-related quality of life (HRQL) is limited.

METHODS

In a prospective, longitudinal, single-strand study, patients with CAH caused by non-COPD conditions, consecutively recruited among referral patients in three Swedish university hospital pulmonary departments, were examined at baseline and after 9 months (n = 35) and 8 years (n = 11) on NPPV treatment. Both volume pre-set and pressure pre-set ventilators were used. Patients completed a battery of condition-specific and generic HRQL questionnaires at baseline and follow-up. Spirometry and blood gases were measured. Compliance with treatment, side effects and patient satisfaction were evaluated.

RESULTS

After 9 months of NPPV, improvements were seen primarily not only in sleep-related domains, but also in emotional behaviour, ambulation and sleep/rest functioning as measured with the Sickness Impact Profile (SIP). Improvements in sleep-related symptoms were related to effectiveness in ventilation, evaluated by morning PaCO(2), and remained by 8 years. Mental well-being was stable over time, while emotional distress improved by 8 years. Satisfaction with treatment was high in spite of frequent side effects.

CONCLUSION

NPPV improves HRQL, particularly in condition-specific areas. Improvements are related to effectiveness in ventilation. Side effects are common, but compliance is good and patient satisfaction is high.

Split-course palliative radiotherapy for advanced non-small cell lung cancer

PURPOSE

Palliative chest radiotherapy (RT) for lung malignancies is effective in relieving serious chest symptoms from tumor bleeding or mass effect on major airways, vessels, and nerves. Albeit an important subject, there is a lack of consensus for an optimal palliative RT regimen. We report the outcomes of a split-course palliative chest RT, a frequently used schema at our institution.

METHODS AND MATERIALS

Records of 140 patients treated between 1995 and 2006 were reviewed. Treatment was prescribed to an initial 25 Gy in 10 fractions through anterior-posterior/posterior-anterior beam arrangements. After a 2-week rest period, patients were selected to receive an additional 10 Gy (anterior-posterior/posterior-anterior) followed by off-cord beams to a final dose of 50 to 62.5 Gy. Symptom relief and toxicity during RT and after completion of RT were assessed from clinician notes and patient-reported symptom inventory forms. Second, the impact on survival was assessed.

RESULTS

Symptomatic relief was observed in 52 to 84% of patients with durable palliation in 58%. There were no grade 3 to 5 toxicities. Grades 1 and 2 esophagitis and pneumonitis were observed in 34 and 8% patients, respectively. Median survival was 5 months.

CONCLUSIONS

A majority of patients experienced symptomatic improvement. The built-in 2-week break allowed for selection of patients for high-dose palliative radiation and balanced treatment benefits with potential side effects. Cancer survival was not adversely affected by treatments in this population with mostly advanced disease. This regimen is a viable option for patients who cannot tolerate a protracted, uninterrupted course of treatment.

Patient-reported outcomes after cytotoxic chemotherapy in metastatic castration-resistant prostate cancer: a systematic review

BACKGROUND

In the clinical setting of metastatic castration-resistant prostate cancer the aim of treatment is palliation. Palliation can refer to symptom management or non-curative treatments. Patient-reported outcome is any outcome based on data provided by patients. The aim of this paper is to perform a systematic review of clinical trials including a patient-reported outcome assessment in patients treated with cytotoxic chemotherapy, and to compare their results by traditional medical and patient-reported outcomes assessment.

METHODS

In November 2009 a literature search for published studies was undertaken. Selected phase-3 studies were primarily evaluated on the quality of patient-reported outcomes reporting and assessment methodology.

FINDINGS

Health-related quality of life assessment was the most common endpoint, pain control the second one. Results of patient-reported and traditional endpoints analysis are resumed, as well as methodology assessment and quality of patient-reported outcomes reporting. Frequently, methodologic limitations affect patient-reported outcomes assessment in clinical trials, either data analysis, particularly not reporting individual scores of health-related quality of life questionnaires, statistical corrections, limited efforts to avoid missing data, or lacking report of duration of palliative response.

CONCLUSIONS

Results of trials can differ if different outcomes, medical or patient-reported, are considered in the analysis. Cytotoxic chemotherapy of metastatic castration-resistant prostate cancer is a challenging issue. A survival benefit is reported only for docetaxel, but this treatment is not always feasible. In all patients, initiation of chemotherapy should be based on patient's preferences within discussion of individual risk and benefit, particularly in patients with extensive asymptomatic and symptomatic metastases.

Irinotecan Plus Carboplatin Versus Oral Etoposide Plus Carboplatin in Extensive Small-Cell Lung Cancer: A Randomized Phase III Trial

Purpose

A Japanese randomized trial showed superior survival for patients with extensive-disease (ED) small-cell lung cancer (SCLC) receiving irinotecan plus cisplatin compared with etoposide plus cisplatin. The present trial evaluated the efficacy of irinotecan plus carboplatin (IC) compared with oral etoposide plus carboplatin (EC).

Patients and Methods

Patients with ED SCLC were randomly assigned to receive either IC, which consisted of carboplatin (area under the curve = 4; Chatelut formula) and irinotecan (175 mg/m2) intravenously both on day 1, or EC, which consisted of carboplatin as in IC and etoposide (120 mg/m2/d) orally on days 1 through 5. Courses were repeated every 3 weeks with four cycles planned. Doses were reduced by one third in patients with a WHO performance status (PS) of 3 to 4 and/or age older than 70 years. Primary end point was overall survival (OS). Secondary end points were quality of life (QOL) and complete response (CR) rate.

Results

Of 220 randomly assigned patients, 209 were eligible for analysis (IC, n = 105; EC, n = 104). Thirty-five percent were older than 70 years, and 47% had a PS of 2 to 4. The groups were well balanced with respect to prognostic factors. OS was inferior in the EC group (hazard ratio = 1.41; 95% CI, 1.06 to 1.87; P = .02). Median survival time was 8.5 months for IC compared with 7.1 months for EC. One-year survival rate was 34% for IC and 24% for EC. CR was seen in 18 IC patients compared with seven EC patients (P = .02). There were no statistically significant differences in hematologic grade 3 or 4 toxicity. Grade 3 or 4 diarrhea was more common in the IC group. QOL differences were small, with a trend toward prolonged palliation with the IC regimen.

Conclusion

IC prolongs survival in ED SCLC with slightly better scores for QOL.

NCIC Clinical Trials Group experience of employing patient-reported outcomes in clinical trials: an illustrative study in a palliative setting

In this article we briefly review the experience of the National Cancer Institute of Canada (NCIC) Clinical Trials Group (CTG) with respect to the assessment of patient reported outcomes in clinical trials, and illustrate issues important to assessing symptom palliation in clinical trials of cancer therapy. We highlight a standard approach taken by the NCIC CTG, and illustrate how this approach may be applied to the complex problem of symptom control analysis in patients with locally advanced NSCLC. We further illustrate how variations in this analysis yield different apparent rates of palliation. Apparent rates of palliation critically depended on the outcome measures used: single symptom response across patients (5-32%, depending on the symptom of interest), symptom response in specific symptomatic patients (37-100%), symptom control (45-82%), index symptom response (60%), proportion of patients experiencing improvement in all symptoms (21%), or health-related quality of life (HRQoL) improvement (23%, global). Rates also varied substantively depending on which cohort of patients was considered relevant to each analysis (i.e., was included in the respective denominator). Substantive discordance in patients' apparent palliation was seen when HRQoL data were compared with symptom diary data. Appropriate and valid descriptions of palliative outcomes in clinical trials are complex undertakings. We conclude that several measures are required for a textured clinical description of outcome, and recommend reporting palliation according to individual symptom response rates and HRQoL response rates, in order to address each construct of palliation success.

Active symptom control with or without chemotherapy in the treatment of patients with malignant pleural mesothelioma (MS01): a multicentre randomised trial

BACKGROUND

Malignant pleural mesothelioma is almost always fatal, and few treatment options are available. Although active symptom control (ASC) has been recommended for the management of this disease, no consensus exists for the role of chemotherapy. We investigated whether the addition of chemotherapy to ASC improved survival and quality of life.

METHODS

409 patients with malignant pleural mesothelioma, from 76 centres in the UK and two in Australia, were randomly assigned to ASC alone (treatment could include steroids, analgesic drugs, bronchodilators, palliative radiotherapy [n=136]); to ASC plus MVP (four cycles of mitomycin 6 mg/m2, vinblastine 6 mg/m2, and cisplatin 50 mg/m2 every 3 weeks [n=137]); or to ASC plus vinorelbine (one injection of vinorelbine 30 mg/m2 every week for 12 weeks [n=136]). Randomisation was done by minimisation, with stratification for WHO performance status, histology, and centre. Follow-up was every 3 weeks to 21 weeks after randomisation, and every 8 weeks thereafter. Because of slow accrual, the two chemotherapy groups were combined and compared with ASC alone for the primary outcome of overall survival. Analysis was by intention to treat. This study is registered, number ISRCTN54469112.

FINDINGS

At the time of analysis, 393 (96%) patients had died (ASC 132 [97%], ASC plus MVP 132 [96%], ASC plus vinorelbine 129 [95%]). Compared with ASC alone, we noted a small, non-significant survival benefit for ASC plus chemotherapy (hazard ratio [HR] 0.89 [95% CI 0.72-1.10]; p=0.29). Median survival was 7.6 months in the ASC alone group and 8.5 months in the ASC plus chemotherapy group. Exploratory analyses suggested a survival advantage for ASC plus vinorelbine compared with ASC alone (HR 0.80 [0.63-1.02]; p=0.08), with a median survival of 9.5 months. There was no evidence of a survival benefit with ASC plus MVP (HR 0.99 [0.78-1.27]; p=0.95). We observed no between-group differences in four predefined quality-of-life subscales (physical functioning, pain, dyspnoea, and global health status) at any of the assessments in the first 6 months.

INTERPRETATION

The addition of chemotherapy to ASC offers no significant benefits in terms of overall survival or quality of life. However, exploratory analyses suggested that vinorelbine merits further investigation.

Quality of life and/or symptom control in randomized clinical trials for patients with advanced cancer

BACKGROUND

Measures reflecting quality of life (QoL) or symptom control should be included as major endpoints in most phase III trials for patients with advanced cancer. Here we review the use of such endpoints.

METHODS

We evaluated methodological aspects relating to QoL or symptom control in randomized controlled trials (RCTs) that included >or=150 patients, published from 1994 to 2004, using a 10-point checklist.

RESULTS

Of 112 RCTs that met our criteria, few were rated as high quality: 22% defined QoL or symptom control as a primary endpoint; 19% established an a priori hypothesis relevant to palliation and 21% defined minimal differences in QoL or symptom scores that were clinically meaningful. Most trials (81%) analyzed differences between mean or median scores across groups and only 21% defined the proportion of individual patients who met criteria for palliative response. Only 15% of the studies met more than 5/10 criteria from our checklist. There was improvement over time in methodology and reporting.

CONCLUSIONS

Current standards for analyzing QoL and symptom control in RCTs are poor. Definition of a palliative endpoint, with an a priori hypothesis, is essential; defining the proportion of patients with palliative response is preferred. The proposed checklist could raise standards of reporting in future RCTs.

Assessing Coughing and Wheezing in Lung Cancer: A Pilot Study

PURPOSE/OBJECTIVES

To establish reliability and validity of two self-report questionnaires, the Lung Cancer Cough Questionnaire and the Lung Cancer Wheezing Questionnaire.

DESIGN

Prospective, exploratory pilot study.

SETTING

Clinical oncology settings in the southern United States.

SAMPLE

31 adult women with lung cancer.

METHODS

Content validity of both questionnaires was assessed through a comprehensive literature review and an expert judge panel. Concurrent validity was established by Spearman rank correlation coefficients and Wil-coxon Rank Sum tests with items from other valid tools. Test-retest reliability was assessed by percent agreement, kappa, paired t tests, and correlations. Internal consistency was determined by Cronbach's alpha.

MAIN RESEARCH VARIABLES

Cough, wheeze.

FINDINGS

Cronbach's alpha showed excellent internal consistency and percent agreement, and kappa showed similarity of item responses across test-retest administrations. Nonsignificant paired t tests indicated similar mean scores, and significant test-retest correlations supported test-retest reliability.

CONCLUSIONS

Preliminary testing indicates good reliability and validity for both questionnaires. Both instruments can identify people with problems of coughing and wheezing and have the potential for monitoring these symptoms over time and determining effectiveness of interventions.

IMPLICATIONS FOR NURSING

Assessment of coughing and wheezing is an important component of monitoring respiratory symptoms of lung cancer. Both of these symptoms can be amenable to interventions. Further research is needed to confirm psychometrics and sensitivity of these tools.

The Analysis, Interpretation, and Presentation of Quality of Life Data

All too often in clinical trials the assessment of quality of life is seen as a bolt-on study. Consequently insufficient consideration is often given to its design, collection, analysis and presentation, and its impact on the trial results and on clinical practice is minimal. In many trials quality of life is a key endpoint, and it is vital that quality of life expertise is involved as soon as possible in the design. Setting a priori quality of life hypotheses will focus the decisions regarding which questionnaire to use, when to administer it, the sample size required, and the primary analyses. Nevertheless quality of life data are complex, and require much skill in determining how to deal with multi-dimensional and longitudinal data, much of which is often missing. There are no agreed standard ways of analysing and presenting quality of life data, but there are guidelines, which if followed, will add transparency to the way results have been calculated. Understanding the impact of treatments on their quality of life is vital to patients, and it is up to us, as statisticians and trialists, to present the data as clearly as we can.

Palliative chemotherapy beyond three courses conveys no survival or consistent quality-of-life benefits in advanced non-small-cell lung cancer

This randomised multicentre trial was conducted to establish the optimal duration of palliative chemotherapy in advanced non-small-cell lung cancer (NSCLC). We compared a policy of three vs six courses of new-generation platinum-based combination chemotherapy with regard to effects on quality of life (QoL) and survival. Patients with stage IIIB or IV NSCLC and WHO performance status (PS) 0–2 were randomised to receive three (C3) or six (C6) courses of carboplatin (area under the curve (AUC) 4, Chatelut's formula, equivalent to Calvert's AUC 5) on day 1 and vinorelbine 25 mg m⁻² on days 1 and 8 of a 3-week cycle. Key end points were QoL at 18 weeks, measured with EORTC Quality of Life Questionnaire (QLQ)-C30 and QLQ-LC13, and overall survival. Secondary end points were progression-free survival and need of palliative radiotherapy. Two hundred and ninety-seven patients were randomised (C3 150, C6 147). Their median age was 65 years, 30% had PS 2 and 76% stage IV disease. Seventy-eight and 54% of C3 and C6 patients, respectively, completed all scheduled chemotherapy courses. Compliance with QoL questionnaires was 88%. There were no significant group differences in global QoL, pain or fatigue up to 26 weeks. The dyspnoea palliation rate was lower in the C3 arm at 18 and 26 weeks (P<0.05), but this finding was inconsistent across different methods of analysis. Median survival in the C3 group was 28 vs 32 weeks in the C6 group (P=0.75, HR 1.04, 95% CI 0.82–1.31). One- and 2-year survival rates were 25 and 9% vs 25 and 5% in the C3 and C6 arm, respectively. Median progression-free survival was 16 and 21 weeks in the C3 and C6 groups, respectively (P=0.21, HR 0.86, 95% CI 0.68–1.08). In conclusion, palliative chemotherapy with carboplatin and vinorelbine beyond three courses conveys no survival or consistent QoL benefits in advanced NSCLC.

Phase III Study of Docetaxel Compared With Vinorelbine in Elderly Patients With Advanced Non–Small-Cell Lung Cancer: Results of the West Japan Thoracic Oncology Group Trial (WJTOG 9904)

Purpose

Docetaxel has shown activity in elderly patients with advanced non–small-cell lung cancer (NSCLC). This randomized phase III trial evaluated the efficacy and safety of docetaxel versus vinorelbine (the current standard treatment) in elderly patients.

Patients and Methods

Chemotherapy-naïve patients age 70 years or older with stage IIIB/IV NSCLC and performance status 2 or lower were eligible. Patients randomly received docetaxel 60 mg/m2 (day 1) or vinorelbine 25 mg/m2 (days 1 and 8) every 21 days for four cycles. The primary end point was overall survival. Overall disease-related symptom improvement was assessed using an eight-item questionnaire.

Results

In total, 182 patients were enrolled. Median age was 76 years (range, 70 years to 86 years). There was no statistical difference in median overall survival with docetaxel versus vinorelbine (14.3 months v 9.9 months; hazard ratio, 0.780; 95% CI, 0.561 to 1.085; P = .138). There was a significant difference in median progression-free survival (5.5 months v 3.1 months; P < .001). Response rates were also significantly improved with docetaxel versus vinorelbine (22.7% v 9.9%; P = .019). The most common grade 3 to 4 toxicities were neutropenia (82.9% for docetaxel; 69.2% for vinorelbine; P = .031) and leukopenia (58.0% for docetaxel; 51.7% for vinorelbine). Other toxicities were mild and generally well tolerated. Docetaxel improved overall disease-related symptoms over vinorelbine (odds ratio, 1.86; 95% CI, 1.09 to 3.20).

Conclusion

Docetaxel improved progression-free survival, response rate, and disease-related symptoms versus vinorelbine. Overall survival was not statistically significantly improved at this time. Docetaxel monotherapy may be considered as an option in the standard treatment of elderly patients with advanced NSCLC.

Ethics of palliative surgery in patients with cancer

BACKGROUND

Surgery is an important palliative method for patients with advanced malignant disease. In addition to concerns related to clinical decision making, various moral challenges are encountered in palliative surgery. Some of these relate to the patients and their illness, others to the surgeons, their attitudes, skills and knowledge base.

METHOD AND RESULTS

Pertinent moral challenges are addressed and analysed with respect to prevailing perspectives in normative ethics. The vulnerability of patients with non-curable cancer calls for moral awareness. Demands regarding sensibility and precaution in this clinical setting represent substantial challenges with regard to the 'duty to help', benevolence, respect of autonomy and proper patient information. Moreover, variations in definition of palliative surgery as well as limited scientific evidence with respect to efficacy, effectiveness and efficiency pose methodological and moral problems. Therefore, a definition of palliative surgery that addresses these issues is provided.

CONCLUSION

Both surgical skill and much moral sensibility are required to improve palliative care in surgical oncology. This should be taken into account not only in clinical practice but also in education and research.

Quality of life in patients with advanced gastric cancer treated with second-line chemotherapy

OBJECTIVE

Despite many trials of systemic chemotherapy in advanced gastric cancer, treatment after failure with first-line chemotherapy remains controversial. We prospectively assessed quality of life (QL) in gastric cancer patients treated with second-line chemotherapy.

METHODS

Forty-three patients who received second-line chemotherapy for advanced gastric cancer completed the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 and hospital anxiety and depression scale (HADS) at baseline and at regular intervals during and after chemotherapy.

RESULTS

Compliance with QL questionnaire completion decreased to 72% after third cycle of treatment. In general, clinically meaningful improvements compared with baseline (change QLQ-C30 scores > or =10) were seen in a number of domains and items, including global health/QL, emotional function, cognitive function and all of the symptom scales and single items but appetite. There was no difference in QL between responders and non-responders (P = 0.473). At baseline, 27 (63%) patients were suspected to have anxiety or depressive disorder (HADS score > or =11), and this incidence decreased after chemotherapy (14.7 vs 9.5; P < 0.001).

CONCLUSION

Improvements from baseline in QL measures and HADS scores were demonstrated in patients with advanced gastric cancer, treated with second-line chemotherapy.

Results of the Dutch National study of the palliative effect of irradiation using two different treatment schemes for non-small-cell lung cancer

PURPOSE

A national multicenter randomized study compared the efficacy of 2 x 8 Gy versus our standard 10 x 3 Gy in patients with inoperable stage IIIA/B (with an Eastern Cooperative Oncology Group score of 3 to 4 and/or substantial weight loss) and stage IV non-small-cell lung cancer.

PATIENTS AND METHODS

Between January 1999 and June 2002, 297 patients were eligible and randomized to receive either 10 x 3 Gy or 2 x 8 Gy by external-beam irradiation. The primary end point was a patient-assessed score of treatment effect on seven thoracic symptoms using an adapted Rotterdam Symptom Checklist. Study sample size was determined based on an average total symptom score difference of more than one point over the initial 39 weeks post-treatment. The time course of symptom scores were also evaluated, and other secondary end points were toxicity and survival.

RESULTS

Both treatment arms were equally effective, as the average total symptom score over the initial 39 weeks did not differ. However, the pattern in time of these scores differed significantly (P < .001). Palliation in the 10 x 3-Gy arm was more prolonged (until week 22) with less worsening symptoms than in 2 x 8-Gy. Survival in the 10 x 3-Gy arm was significantly (P = .03) better than in the 2 x 8-Gy arm with 1-year survival of 19.6% (95%CI, 14.1% to 27.3%) v 10.9% (95%CI, 6.9% to 17.3%).

CONCLUSION

The 10 x 3-Gy radiotherapy schedule is preferred over the 2 x 8-Gy schedule for palliative treatment, as it improves survival and results in a longer duration of the palliative response.

A prospective, randomised study to compare two palliative radiotherapy schedules for non-small-cell lung cancer (NSCLC)

A prospective randomised study compared two palliative radiotherapy schedules for inoperable symptomatic non-small-cell lung cancer (NSCLC). After stratification, 100 patients were randomly assigned to 20 Gy/5 fractions (fr)/5 days (arm A) or 16 Gy/2 fr/day 1 and 8 (arm B). There were 90 men and 10 women aged 47–81 years (mean 66), performance status 1–4 (median 2). The major clinical characteristics and incidence and degree of initial disease-related symptoms were similar in both groups. Treatment effects were assessed using patient's chart, doctor's scoring of symptomatic change and chest X-ray. Study end points included degree and duration of symptomatic relief, treatment side effects, objective response rates and overall survival. A total of 55 patients were assigned to arm A and 45 to arm B. In all, 98 patients received assigned treatment, whereas two patients died before its termination. Treatment tolerance was good and did not differ between study arms. No significant differences between study arms were observed in the degree of relief of all analysed symptoms. Overall survival time differed significantly in favour of arm B (median 8.0 vs 5.3 months; P=0.016). Both irradiation schedules provided comparable, effective palliation of tumour-related symptoms. The improved overall survival and treatment convenience of 2-fraction schedule suggest its usefulness in the routine management of symptomatic inoperable NSCLC.

Evaluation of safety and efficacy of gefitinib ('iressa', zd1839) as monotherapy in a series of Chinese patients with advanced non-small-cell lung cancer: experience from a compassionate-use programme

BACKGROUND

The gefitinib compassionate-use programme has enabled >39,000 patients worldwide to receive gefitinib ('Iressa', ZD1839) treatment. This paper reports the outcome of gefitinib treatment in Chinese patients who enrolled into the 'Iressa' Expanded Access Programme (EAP) at the Peking Union Medical College Hospital.

METHODS

Thirty-one patients with advanced or metastatic non-small-cell lung cancer (NSCLC) that had progressed after prior systemic chemotherapy were eligible to receive oral gefitinib 250 mg/day as part of the EAP. Treatment was continued until disease progression or unacceptable toxicity occurred. The impact of treatment on disease-related symptoms and quality of life (QoL) was evaluated with the Chinese versions of European Organization for Research and Treatment of Cancer Quality of Life Questionnaires (EORTC QLQ-C30 and QLQ-LC13).

RESULTS

Gefitinib was well tolerated. Adverse events (AEs) were generally mild (grade 1 and 2) and reversible. The most frequent AEs were acneform rash and diarrhoea. Only one patient withdrew from the study due to a drug-related AE. The objective tumour response rate was 35.5% (95% confidence interval [CI]: 18.6-52.3); median progression-free survival was 5.5 months (95% CI, 1.6 to 9.4); median overall survival was 11.5 months (95% CI, 5.6 to 17.3). The QoL response rates for five functioning scales and global QoL varied from 56-88%. The main symptom response rates varied from 44-84%. QoL and symptom response were correlated with objective tumour response.

CONCLUSION

Gefitinib demonstrated safety and efficacy as monotherapy in this series of Chinese patients with advanced NSCLC and was also associated with remarkable symptom relief and improvement in QoL. Although clinical trials are needed to confirm these positive findings, the data suggest that treatment with gefitinib may be beneficial for some Chinese patients who do not respond to chemotherapy and have poor prognosis.

Quality of cancer care

Quality of cancer care is difficult to define and to evaluate. Here we consider three components represented by the questions: (i) Is the right question treatment being given? (ii) Is it being done well? and (iii) Is the patient being treated as well as the disease? Determining the right treatment requires a hierarchy of evidence from clinical trials, and high quality clinical trials to determine and supplement that evidence. Evidence-based guidelines are then useful in increasing compliance with evidence-based treatment. Quality of delivery of treatment is dependent on volume of practice: patients with rare or complex diseases should be referred to cancer centres. Treatment of the whole patient requires attention to communication, and to the management of symptoms such as pain and fatigue. Cancer care must be of high quality and delivered with compassion.

Assessment of quality of life and symptom improvement in lung cancer clinical trials

The majority of lung cancers are diagnosed at advanced stages when treatment options are limited and mainly palliative. In advanced lung cancer, quality-of-life (QOL) issues have become an integral part of making decisions about various treatment options. Recent clinical trials in patients with lung cancer have assessed symptom improvement and QOL as important endpoints. There are several valid and reliable QOL assessment instruments that specifically evaluate symptoms of lung cancer. These questionnaires evaluate a variety of factors related to emotional, physical, and social well-being. Several key factors, including age, gender, comorbidities, and quality of supportive care may affect symptoms and QOL in patients with lung cancer. Overall, QOL is important for patients with advanced lung cancer; therefore, symptom and QOL assessments are becoming vital in evaluating the efficacy of emerging cancer treatments.

Palliative therapy for lung cancer

Attention to palliation is imperative in the management of patients with lung cancer, given the burden of symptoms and the incurable nature of the illness in a large proportion of patients. Focus on symptom control and enhancing quality of life can and should coexist with active treatment of the cancer process and attempts at prolongation of life. This article reviews some of the methodological issues in assessing palliation, and presents the evidence for the role of various therapeutic modalities in palliation of thoracic symptoms, including external beam radiotherapy, brachytherapy, chemotherapy, photodynamic therapy, and vascular stents. Palliation of metastatic disease, particularly bone and brain metastases, is also reviewed.

Hypofractionated external beam radiotherapy as retreatment for symptomatic non–small-cell lung carcinoma: an effective treatment?

PURPOSE

To evaluate prospectively the efficacy, toxicity, and duration of the palliative effect of retreatment with external beam radiotherapy in symptomatic patients with recurrent non-small-cell lung cancer.

METHODS AND MATERIALS

Twenty-eight symptomatic patients with local recurrence of non-small-cell lung cancer underwent repeated treatment after previous radiotherapy (equivalent dose, 46-60 Gy). Reirradiation consisted of two fractions of 8 Gy on Days 1 and 8 with two opposed beams using 6-18-MV photon beams at the site of pulmonary recurrence. The physician scored symptom resolution.

RESULTS

Relief of hemoptysis and superior vena cava syndrome could be obtained in all assessable cases (100%). Treatment was less effective for coughing (67%) and dyspnea (35%). The overall median duration of this palliative effect was 4 months. Palliation in almost all patients lasted more than one-half of their remaining life span. The Karnofsky performance score improved in 45% of assessable cases. One patient had Grade 2 esophagitis. Complications consisted of tumor-related fatal hemoptysis in 5 patients (17%) and 1 death from bronchoesophageal fistula (4%).

CONCLUSION

External beam hypofractionated reirradiation can be effective as a palliative treatment for local complaints in non-small-cell lung cancer. The complication rate of reirradiation was acceptably low.

Palliative treatment for advanced non-small cell lung cancer

It should go without saying that all patients with advanced NSCLC are entitled to the treatment and care described in this article. It is probably also true that in many countries where these patients are often elderly and socially disadvantaged, they may have very variable access to this treatment and care. There is reasonable research evidence that both chemotherapy and palliative radiotherapy are modestly effective in controlling symptoms and prolonging life for some patients, but with significant risks of unpleasant and sometimes life-threatening toxicity. For this large and important group of patients, however, there are a large number of unanswered questions about the best regimens to use, how best to select patients so that they get the greatest benefit, how to mitigate side effects, and how best to integrate all the available treatment options. There have been significantly more trials in chemotherapy, but we must not overlook the need for research into palliative radiotherapy and other supportive care measures. There is still plenty of scope for intelligent and coordinated research.

BTS randomised feasibility study of active symptom control with or without chemotherapy in malignant pleural mesothelioma: ISRCTN 54469112

BACKGROUND

The incidence of mesothelioma is rising rapidly in the UK. There is no generally accepted standard treatment. The BTS recommends active symptom control (ASC). It is not known whether chemotherapy in addition prolongs survival or provides worthwhile palliation with acceptable toxicity. Palliation as recorded by patients has been fully reported for only two regimens: mitomycin, vinblastine, and cisplatin (MVP), and vinorelbine (N). The BTS and collaborators planned to conduct a phase III randomised trial comparing ASC only, ASC+MVP, and ASC+N in 840 patients with survival as the primary outcome measure. The aim of the present study was to assess the acceptability of the trial design to patients and the suitability of two standard quality of life (QL) questionnaires for mesothelioma.

METHODS

Collaborating centres registered all new patients with mesothelioma. Those eligible and giving informed consent completed EORTC QLQ-C30+LC13 and FACT-L QL questionnaires and were randomised between all three or any two of (1) ASC only, (2) ASC+4 cycles of MVP, and (3) ASC+12 weekly doses of N.

RESULTS

During 1 year, 242 patients were registered of whom 109 (45%) were randomised (55% of the 197 eligible patients). Fifty two patients from 20 centres were randomised to an option including ASC only. This translates into a rate of 312 per year from 60 centres interested in collaborating in the phase III trial. The EORTC QL questionnaire was superior to FACT-L in terms of completeness of data and patient preference. Clinically relevant palliation was achieved with ASC.

CONCLUSION

The planned phase III trial is feasible.

Symptom control

Symptom control has become increasingly recognized as an important goal in patient care. In this article, advances in symptom assessment, and various definitions of symptom improvement are reviewed. Theoretical concepts underlying symptom control and clinically significant change are presented, as well as the role of symptom control as an endpoint in clinical trials. Symptom control is then surveyed in two broad categories for selected symptoms. The first area is therapy related symptoms, secondary to chemotherapy, radiation, hormonal therapy, and surgery. Symptoms reviewed include chemotherapy related mucositis, emesis, fatigue; hot flashes; and radiation related dermatitis, xerostomia, and mucositis. The second area is palliative oncologic approaches to disease-related symptoms. Results in palliative chemotherapy, palliative radiation therapy, cancer pain, and lack of appetite are summarized. Areas requiring further research are noted. Findings are presented in both a clinical and research context to help guide the reader with interpreting symptom control studies.

A prospective evaluation of palliative outcomes for surgery of advanced malignancies

BACKGROUND

We prospectively evaluated the effectiveness of major surgery in treating symptoms of advanced malignancies.

METHODS

Fifty-nine patients were evaluated for major symptoms of intent to treat and were followed up until death or last clinical evaluation. Surgeons identified planned operations before surgery as either curative or palliative and estimated patient survival time. An independent observer assessed symptom relief. A palliative surgery outcome score was determined for each symptomatic patient.

RESULTS

Surgeons identified 22 operations (37%) as palliative intent and 37 (63%) as curative intent. The median overall survival time was 14.9 months and did not differ between curative and palliative operations. Surgical morbidity was high but did not differ between palliative (41%) and curative (44%) operations. Thirty-three patients (56%) were symptomatic before surgery, and major symptom resolution was achieved after surgery in 26 (79%) of 33. Good to excellent palliation, defined as a palliative surgery outcome score >70, was achieved in 64% of symptomatic patients.

CONCLUSIONS

Most symptomatic patients with advanced malignancies undergoing major operations attained good to excellent symptom relief. Outcome measurements other than survival are feasible and can better define the role of surgery in multimodality palliative care. A new outcome measure to evaluate major palliative operations is proposed.

Symptom prevalence, distress, and change over time in adults receiving treatment for lung cancer

Adequate management of symptoms in adults with lung cancer is an important focus for clinical interventions. Knowledge of symptom prevalence and distress can be used to develop empirically based interventions that can potentially reduce distressing symptoms and improve quality of life. The purposes of this study were to describe which symptoms are most distressing, describe the prevalence of symptoms in adults receiving treatment for lung cancer, identify how symptoms change over time, and identify patient-related and clinical characteristics related to symptom distress. Data were available from 117 patients. Fatigue and pain were the most distressing symptoms for each group and at each time. Significant differences in distressing symptoms among the treatment groups were noted for nausea, fatigue, bowel pattern, and concentration at entry into the study and difficulty with appetite at 6 months. Many of the individual symptoms demonstrated a decrease in distress from 0 to 3 months and then an increase in distress levels from 3 to 6 months. Many of the individual symptoms were associated with demographic covariates and treatment group values but no consistent pattern emerged over time except for baseline symptom distress. Symptom distress at entry to the study was a strong predictor of nine distressing symptoms at 3 months and seven distressing symptoms at 6 months. Questionnaires such as the SDS may be useful as screening instruments to target those who need more intensive interventions.

Randomized phase III trial of single versus fractionated thoracic radiation in the palliation of patients with lung cancer (NCIC CTG SC.15)

PURPOSE

This multi-institutional Phase III randomized study compared 10 Gy single-fraction radiotherapy (RT) with 20 Gy in five fractions in the palliation of thoracic symptoms from lung cancer.

METHODS AND MATERIALS

The primary end point was palliation of thoracic symptoms at 1 month after RT, evaluated by a patient-completed daily diary card. Secondary end points included quality of life, toxicity, and survival.

RESULTS

Most (69%) of 230 patients randomized had locally advanced disease unsuitable for curative treatment. The treatment arms were well balanced with respect to the known prognostic factors. At 1 month after RT, no difference was found in symptom control between the two arms, as judged by the daily diary scores. The changes in the scores on the Lung Cancer Symptom Scale indicated that the fractionated RT (five fractions) group had greater improvement in symptoms related to lung cancer (p = 0.009), pain (p = 0.0008), ability to carry out normal activities (p = 0.037), and better global quality of life (p = 0.039). The European Organization for Research and Treatment of Cancer QLQ-C30 scores showed that patients receiving five fractions had a greater improvement in scores with respect to pain (p = 0.04). No significant difference was found in treatment-related toxicity. Patients who received five fractions survived on average 2 months longer (p = 0.0305) than patients who received one fraction.

CONCLUSION

Although the two treatment strategies provided a similar degree of palliation of thoracic symptoms, the difference in survival between the two study arms was of a clinically relevant magnitude.

Decision making in palliative surgery

BACKGROUND

Palliative surgery for advanced cancer patients involves complex decision making. Surgeons with a cancer-focused practice were surveyed to determine the extent to which palliative surgery was currently practiced, to identify ethical dilemmas and barriers they faced in performing palliative surgery, and to evaluate their treatment choices in four different clinical scenarios.

STUDY DESIGN

A 110-item survey was devised after extensive review of the palliative care and palliative surgery literature to evaluate current practices and attitudes regarding palliative surgery. Case vignettes were devised to evaluate dinical factors influencing surgeons' selection of treatment for symptomatic patients with advanced malignancy.

RESULTS

Survey response rate was 24% (419 of 1,740). Respondents reported 74% of their surgery caseload as cancer related, and 21% of these as palliative. On a scale of 1 (uncommon problem) to 7 (common problem), surgeons reported that the most common ethical dilemmas in palliative surgery were providing patients with honest information without destroying hope (5.6 +/- 1.4) (mean +/- standard deviation), and preserving patient choice (5.0 +/- 1.7). Bound on error of the average frequency estimate for ethical dilemmas, based on response rate, was 0.08. On a scale of 1 (not a barrier) to 7 (a severe barrier), surgeons rated the most severe barriers to optimum use of palliative surgery as limitations of managed care (4.1 +/- 2.0) and referral to surgery by other specialists (3.9 +/- 1.8). Bound on error of the estimate for average severity of barriers, based on response rate, was 0.09. They rated the least severe barriers to palliative surgery as surgeon avoidance of dying patients (3.0 +/- 1.8) and surgery department reluctance to perform palliative surgery (2.6 +/- 1.6). Analysis of surgeons' treatment selection in case vignettes indicated that patient age, aggressiveness of tumor biology, local extent of disease, and severity of patient symptoms were all variables of influence for treatment selection in patients with advanced malignancies.

CONCLUSIONS

Palliative surgery involves numerous ethical dilemmas, the most prominent being providing honest information to patients without destroying hope, and complex treatment decision making. We have identified variables of major influence to surgeons in the palliative treatment selection for patients with advanced, solid malignancies. Validation of these variables as meaningful will require future studies focusing on patient outcomes.

Comparison of survival, palliation, and quality of life with three chemotherapy regimens in metastatic colorectal cancer: a multicentre randomised trial

BACKGROUND

This randomised trial compared three chemotherapy regimens in the first-line treatment of advanced colorectal cancer, in terms of their effect on overall and progression-free survival; other endpoints included toxicity, symptom palliation, and quality of life.

METHODS

905 patients were randomly assigned the de Gramont regimen (n=303; folinic acid 200 mg/m(2), fluorouracil bolus 400 mg/m(2), and infusion 600 mg/m(2) on days 1 and 2, repeated every 14 days), the Lokich regimen (n=301; protracted venous infusion of fluorouracil 300 mg/m(2) daily), or raltitrexed (n=301; 3 mg/m(2) intravenously every 21 days). Analyses were by intention to treat.

FINDINGS

Median follow-up of survivors was 67 weeks. For the de Gramont, Lokich, and raltitrexed groups, respectively, median survival was 294, 302, and 266 days. The hazard ratios for overall survival were 0.88 (95% CI 0.70-1.12, p=0.17) for de Gramont versus Lokich, and 0.99 (0.79-1.25, p=0.94) for de Gramont versus raltitrexed. An increase in treatment-related deaths was seen on raltitrexed (de Gramont one, Lokich two, raltitrexed 18) due to combined gastrointestinal and haematological toxicity. Patients' assessment of quality of life showed that raltitrexed was inferior to the fluorouracil-based regimens, especially in terms of palliation and functioning.

INTERPRETATION

The deGramont and Lokich regimens were similar in terms of survival, quality of life, and response rates. The Lokich regimen was associated with more central line complications and hand-foot syndrome. Raltitrexed showed similar response rates and overall survival to the de Gramont regimen and was easier to administer, but resulted in greater toxicity and inferior quality of life.

Multicenter randomized controlled trial of the management of unresectable malignant mesothelioma proposed by the British Thoracic Society and the British Medical Research Council

Malignant mesothelioma is almost invariably fatal. The incidence of the disease is rising rapidly in many countries, and there is no generally accepted standard treatment for patients with unresectable disease. According to current British Thoracic Society (BTS) guidelines, patients should be treated with active symptom control (ASC), involving (1) regular follow-up in a specialist clinic; (2) structured assessments of physical, psychological and social problems with appropriate action; (3) rapid involvement of additional specialists; and (4) parallel nursing support. Although many nonrandomized studies have reported tumor responses to anticancer chemotherapy, few have studied palliation and it is not known whether chemotherapy prolongs survival or provides clinically worthwhile palliation with acceptable toxicity when given in addition to ASC. We therefore plan to conduct a multicenter randomized controlled trial comparing (1) ASC alone, (2) ASC plus mitomycin vinblastine and cisplatin (MVP), and (3) ASC plus vinorelbine (N; Navelbine, Pierre Fabre Oncology, Winchester, UK). We chose these chemotherapy regimens because they have been shown in nonrandomized studies to provide good symptom control as recorded by patients. The outcome measures are overall survival, palliation of symptoms, performance status, analgesic usage, toxicity, quality of life, tumor response, and recurrence/progression-free survival. In a preliminary feasibility study, we are assessing the acceptability of the trial design to patients and the suitability of two standard quality-of-life instruments in mesothelioma. Data will help us to decide the final details of the large multicenter trial.

Activity of single-agent gemcitabine as second-line treatment after previous chemotherapy or radiotherapy in advanced non-small-cell lung cancer

The aim of the study was to evaluate activity, toxicity and health-related quality of life (HRQL) with gemcitabine as second-line treatment after previous chemo- or radiotherapy in non-small-cell lung cancer (NSCLC). Patients with previously treated NSCLC were treated with gemcitabine (1000 mg/m(2)) on days 1, 8 and 15 in a 28-day cycle. Eighty patients were included; median age was 57 years (range 38-77). Prior treatment consisted of platinum-containing chemotherapy in 29 patients and high-dose thoracic radiotherapy in 51 patients. Median number of cycles was three (range 1-6). Granulocytopenia CTC grade 3 and 4 occurred in 9% and thrombocytopenia CTC grade 3 and 4 in 9% of cycles. Non-haematological toxicity was mild. Tumour response was achieved in 13% of the patients (95% CI 7-20), median survival time was 26 weeks and 1-year survival was 22%. Tumour response to second-line gemcitabine could not be predicted from response to first-line therapy, first-line treatment modality or treatment interval. In a subset of 35 patients HRQL was assessed with the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 and QLQ-LC13 questionnaires and showed improvement or control of symptoms and functioning in approximately 30% of patients. We conclude that gemcitabine in second-line treatment has modest anti-tumour activity, is well tolerated, and may control tumour-related symptoms and improve HRQL in a significant minority of patients.

Prospective study on quality of life before and after radical radiotherapy in non-small-cell lung cancer

PURPOSE

The purpose of this study was to investigate changes in respiratory symptoms and quality of life (QoL) in patients with non-small-cell lung cancer (NSCLC) receiving radical radiotherapy (60 Gy). Additionally, the association between the level of symptom relief and objective tumor response, as well as with radiation-induced pulmonary changes, was investigated.

PATIENTS AND METHODS

One hundred sixty-four patients were entered onto this prospective study. The European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ)-C30 and EORTC QLQ-LC13 were used to investigate changes in QOL: Assessments were performed before radiotherapy and 2 weeks, 6 weeks, 3 months, 6 months, and 12 months after the completion of radiotherapy.

RESULTS

The QoL response rates were excellent for hemoptysis (83%); good for chest pain (68%), arm/shoulder pain (63%), and appetite loss (60%); and poor for dyspnea (37%), cough (31%), and fatigue (28%). The QoL response rates for the five functioning scales of the QLQ-C30 varied from 35% for physical and role functioning to 55% for social and cognitive functioning. The response rate for global QoL was 36%. A significant association was found between tumor response and palliation of chest pain, arm/shoulder pain, and physical functioning. During radiotherapy, a significant increase for most general symptoms and a deterioration in functioning and QoL were noted.

CONCLUSION

This study is the first to describe palliation and changes in QoL in radically irradiated patients with NSCLC. Radical radiotherapy offers palliation of respiratory symptoms and improved QoL in a substantial proportion of patients with NSCLC who have relatively good prognostic features. Although tumor reduction is associated with palliation of respiratory symptoms, it cannot serve as a surrogate for palliation.

External irradiation versus external irradiation plus endobronchial brachytherapy in inoperable non-small cell lung cancer: a prospective randomized study

PURPOSE

No randomized studies are available on the additional value of endobronchial brachytherapy (EBB) to external irradiation (XRT) regarding palliation of respiratory symptoms (RS). A prospective randomized study was initiated to test the hypothesis that the addition of EBB to XRT provides higher levels of palliation of dyspnea and other RS and improvement of quality of life (QoL) in patients with non-small cell lung cancer (NSCLC) with endobronchial tumour.

MATERIALS AND METHODS

Patients with previously untreated NSCLC, stages I-IIIb, WHO-performance status of 0-3 and with biopsy proven endobronchial tumour in the proximal airways were eligible. EBB consisted of two fractions of 7.5 Gy at 1 cm on day 1 and 8. XRT started at day 2. The XRT dose was 30 Gy (2 weeks) or 60 Gy (6 weeks). The EORTC QLQ-C30 and QLQ-LC13 were assessed before treatment and 2 weeks, 6 weeks, 3, 6 and 12 months after treatment. Re-expansion of collapsed lung was tested by the inspiratory vital capacity (IVC) and CT scan of the chest.

RESULTS

Ninety-five patients were randomized between arm 1 (XRT alone) (n=48) or arm 2 (XRT+EBB) (n=47). The arms were well balanced regarding pre-treatment characteristics and QoL scores. The compliance for QoL-assessment was >90% at all times. No significant difference between the trial arms was observed with respect to response of dyspnea. However, a beneficial effect of EBB was noted concerning the mean scores of dyspnea over time (P=0.02), which lasted for 3 months. This benefit was only observed among patients with an obstructing tumour of the main bronchus. A higher rate of re-expansion of collapsed lung was observed in arm 2 (57%) compared to arm 1 (35%) (P=0.01). The inspiratory vital capacity (IVC) assessed 2 weeks after radiotherapy improved with 493 cm(3) in arm 2 and decreased 50 cm(3) in arm 1 (P=0.03). No difference was noted regarding the incidence of massive haemoptysis (13 vs. 15%).

CONCLUSION

The addition of EBB to XRT in NSCLC is safe and provides higher rates of re-expansion of collapsed lung resulting in a transient lower levels of dyspnea. This beneficial effect was only observed among patients with obstructing tumours in the main bronchus.

Important issues in planning and conducting multi-centre randomised trials in cancer and publishing their results

The principles and practical issues involved in planning and conducting multi-centre randomised trials in cancer and in publishing their results are reviewed for the benefit of those conducting trials or planning to do so. There is increasing public awareness of the importance of randomised trials and this needs to be nurtured. Questions addressed by trials must be clinically worthwhile, and trials must be planned and conducted to provide reliable results that will convince the clinical community and influence future clinical practice to patients' benefit. Trial protocols must justify the trial and give clear and unambiguous instructions to collaborating centres. Only data necessary for answering the trial questions should be collected, and the reliability of data should be checked. All trials should be published in peer-reviewed journals, and ways should be considered of communicating their results to patients, their families and the public. Wide consultation and independent review are needed to achieve these aims.

Clinical and quality of life outcomes in the first United Kingdom randomized trial of endobronchial brachytherapy (intraluminal radiotherapy) vs. external beam radiotherapy in the palliative treatment of inoperable non-small cell lung cancer

BACKGROUND AND PURPOSE

A randomized controlled trial was designed to evaluate the clinical and quality of life (QL) outcomes of patients receiving endobronchial brachytherapy (EBT) or external beam radiotherapy (XRT) as a primary palliative treatment in advanced lung cancer.

MATERIALS AND METHODS

Ninety-nine patients presenting de novo with lung cancer were randomized to receive EBT or XRT. Eleven key symptoms or clinical signs were assessed by clinicians and patient ratings using self-assessment questionnaires were obtained at the same time. The primary endpoints were a comparison of EBT and XRT for symptom relief and acute and late side-effects (palliation) and their effect on patients' functional status and patient-rated QL outcomes. A secondary objective was a comparison of clinician assessments with patient self-reported symptoms.

RESULTS

Both treatments produced good levels of symptom relief. They were better for XRT at the expense of more acute morbidity. Late side-effects were similar. The functional status of patients was well maintained and changed similarly with time in both groups. XRT gave a better duration of palliation. Twenty-eight percent of XRT patients required EBT (at a median time of 304 days) whereas 51% of EBT patients subsequently had XRT (at a median of 125 days). There was a significant modest gain in median survival with initial XRT (287 vs. 250 days). When clinician and patient assessments were compared, doctors were found to underestimate the severity of breathlessness, anorexia, tiredness and nausea.

CONCLUSIONS

Fractionated XRT is preferred to EBT as an initial treatment in better performance patients because it provides better overall and more sustained palliation with fewer retreatments and a modest gain in survival time. QL assessment is required in the evaluation of palliative treatments because clinicians frequently underestimate the incidence and severity of key symptoms.

Treatment and outcomes for elderly patients with small cell lung cancer

It is estimated that approximately half of the 500 000 people diagnosed with lung cancer worldwide every year are aged >70 years. Thus, this disease represents a major problem in the elderly and one that will indeed increase as the median age of the population increases. For small cell lung cancer (SCLC), which accounts for approximately 20% of cases of lung cancer, the primary treatment is chemotherapy and in the majority of cases the primary aim is to control the disease which generally would have spread beyond the lungs at the time of presentation. A small number of 'standard' chemotherapy regimens (combined with radiotherapy for patients with limited disease) have been shown to improve survival and quality of life and are widely used. Much of the work investigating the relationship between age and treatment outcomes has been based on clinical trial data and may itself be inherently biased due to trial eligibility criteria excluding elderly patients. However, there is no good evidence that elderly patients fare worse with treatment than their younger counterparts in terms of response rates and survival. Nevertheless with increasing age comes increasing concomitant illnesses which may account for the widely observed increases in drug toxicity, and this may be the primary consideration in selecting the treatment option. Thus for many elderly patients, carboplatin/ etoposide may be the treatment of choice because it is perhaps the least toxic of the standard regimens. Whatever regimen is chosen, the key to treatment effectiveness seems to be to deliver the first 3 or 4 cycles without delay or dosage reduction. Although palliation of symptoms remains a major goal in the treatment of all patients with SCLC there is a dearth of data on whether elderly patients are equally well palliated as their younger counterparts. There is no good evidence that age per se should be a factor in deciding whether patients should receive standard treatment rather than a more gentle approach, and more elderly patients should be included in clinical trials. The key areas where more information is required regarding the treatment and outcomes of elderly patients with SCLC are the assessment of palliation, and comprehensive reviews of all patients diagnosed with the disease, not just those included in trials.

Gemcitabine plus best supportive care (BSC) vs BSC in inoperable non-small cell lung cancer--a randomized trial with quality of life as the primary outcome. UK NSCLC Gemcitabine Group. Non-Small Cell Lung Cancer

Three hundred patients with symptomatic, locally advanced or metastatic NSCLC not requiring immediate radiotherapy were enrolled into this randomized multicentre trial comparing gemcitabine + BSC vs BSC alone. Patients allocated gemcitabine received 1000 mg/m2 on days 1, 8 and 15 of a 28-day cycle, for a maximum of six cycles. The main aim of this trial was to compare patient assessment of a predefined subset of commonly reported symptoms (SS14) from the EORTC QLQ-C30 and LC13 scales. The primary end-points were defined as (1) the percentage change in mean SS14 score between baseline and 2 months and (2) the proportion of patients with a marked (> or = 25%) improvement in SS14 score between baseline and 2 months sustained for > or =4 weeks. The secondary objectives were to compare treatments with respect to overall survival, and multidimensional QL parameters. The treatment groups were balanced with regard to age, gender, Karnofsky performance status (KPS) and disease stage (40% had metastatic disease). The percentage change in mean SS14 score from baseline to 2 months was a 10% decrease (i.e. improvement) for gemcitabine plus BSC and a 1% increase (i.e. deterioration) for BSC alone (P = 0.113, two-sample t-test). A sustained (> or = 4 weeks) improvement (> or =25%) on SS14 was recorded in a significantly higher proportion of gemcitabine + BSC patients (22%) than in BSC alone patients (9%) (P = 0.0014, Pearson's chi-squared test). The QLQ-C30 and L13 subscales showed greater improvement in the gemcitabine plus BSC arm (in 11 domains) than in the BSC arm (one symptom item). There was greater deterioration in the BSC alone arm (six domains/items) than in the gemcitabine + BSC arm (three QL domains). Tumour response occurred in 19% (95% CI 13-27) of gemcitabine patients. There was no difference in overall survival: median 5.7 months (95% CI 4.6-7.6) for gemcitabine + BSC patients and 5.9 months (95% CI 5.0-7.9) (log-rank, P = 0.84) for BSC patients, and 1 -year survival was 25% for gemcitabine + BSC and 22% for BSC. Overall, 74 (49%) gemcitabine + BSC patients and 119 (79%) BSC patients received palliative radiotherapy. The median time to radiotherapy was 29 weeks for gemcitabine + BSC patients and 3.8 weeks for BSC. Patients treated with gemcitabine + BSC reported better QL and reduced disease-related symptoms compared with those receiving BSC alone. These improvements in patient-assessed QL were significant in magnitude and were sustained.