Quality-of-life assessment in cancer clinical trials: a status report

Impact of Oocyte Extract Supplement on Quality of Life after Hepatectomy for Liver Tumours: A Prospective, Multicentre, Double-Blind Randomized Clinical Trial

BACKGROUND

Previous studies on oocyte extract supplementation showed benefits in patients with liver tumours. In this trial, we hypothesized that the oocyte extract supplement impacted the QoL after hepatectomy for hepatocellular carcinoma and intrahepatic cholangiocarcinoma.

METHODS

This was a multicentre, double-blind, randomized clinical trial designed to assess the QoL of patients receiving a supplement of oocyte extract or placebo postoperatively. QoL was assessed using the Short Form-36 questionnaire in participants randomly assigned to treatment (Synchrolevels) or placebo. All study personnel and participants were masked to treatment assignment. The endpoint was the change in the QoL score.

RESULTS

Between June 2018 and September 2022, 66 of 128 expected patients were considered as per interim analysis, of which 33 were assigned to the treatment and 33 to the placebo group. Baseline and clinicopathological characteristics were similar between the two groups. In the treatment group, the health, mental and psychological status improved for many of the items considered, reaching statistical significance, while in the placebo group, those items either did not change or were impaired in comparison with the corresponding baseline.

CONCLUSIONS

Supplementation with oocyte extract modifies QoL after liver surgery by enhancing functional recovery. Further in-depth studies are required to confirm this evidence.

Surgical Resection Is Superior to TACE in the Treatment of HCC in a Well Selected Cohort of BCLC-B Elderly Patients-A Retrospective Observational Study

Hepatocellular carcinoma (HCC) usually develops in cirrhotic liver, with high recurrence rates. However, considering its increasing detection in non-cirrhotic liver, the choice of treatment assumes particular relevance. This study aimed to investigate outcomes of patients among BCLC stages and enrolled for surgical resection (SR) according to a more complex evaluation, to establish its safety and efficacy. A total of 186 selected HCC patients (median age 73.2 yrs), submitted to SR between January 2005 and January 2021, were retrospectively analyzed. Of which, 166 were staged 0, A, B according to the BCLC system, while 20 with a single large tumor (>5 cm) were classified as stage AB. No perioperative mortality was recorded; complications occurred in 48 (25.80%) patients, and all but two were Clavien−Dindo grade I−II. Median follow-up was 9.2 years. Subsequently, 162 recurrent patients (87,1%) were selected for new treatments. Comparable overall survival rates (OS) were observed at 1, 3, 5, and 10 years in 0, A, B and AB stages (p = 0.2). Eventually, the BCLC-B group was matched to 40 BCLC-B patients treated (2015-2021) with TACE. Significant differences in baseline characteristics (p <0.0001) and in OS were observed at 1 and 3 years (p <0.0001); a significant difference was also observed in oncological outcomes, in terms of the absence, residual, or relapse of disease (p <0.05). Surgery might be a valid treatment in HCC for patients affected by chronic liver disease in a condition of compensation, up to BCLC-B stage. Surgical indication for liver resection in case of HCC should be extensively revised.

Outcome selection and role of patient reported outcomes in contemporary cardiovascular trials: systematic review

OBJECTIVES

To systematically assess the type of outcomes selected and the prevalence of patient reported outcomes in contemporary cardiovascular trials and to quantify any misuse or underuse of patient reported outcomes using a specially developed tool that would allow estimation of the relevance of such outcomes to clinical decision making.

DESIGN

Systematic review.

DATA SOURCES

Medline and Embase.

STUDY SELECTION

Randomised controlled trials of the treatment for or prevention of cardiovascular disease published in 10 leading general medical and cardiology journals from January 2005 to December 2008.

RESULTS

Primary outcomes were patient important (death, morbidity, or patient reported outcomes) in only 93 of 413 trials (23%, SE 2%), whereas another 92 (22%, SE 2%) combined these outcomes with other less important ones into a composite. Sixty five trials (16%; SE 2%) used at least one instrument to measure patient reported outcomes, mostly in trials where such information would have been important or crucial for clinical decision making (52 trials). Patient reported outcomes were judged to be of little incremental value to a large number of, mostly explanatory, cardiovascular trials (152 trials). However, many trials in which patient reported outcomes would have been important or crucial for clinical decision making did not report such outcomes (122 of 174 trials, 70%). These included several trials that primarily aimed to improve symptoms or functional status, trials that tested interventions with a considerable potential for causing harm (mainly bleeding) that were not meaningfully measured, and trials with composite outcomes that were dominated by outcomes of questionable importance to patients.

CONCLUSIONS

Despite a continued rise in the reporting of patient reported outcomes with no evidence for their misuse in more recent cardiovascular trials, they seem to be still underused once their relevance to clinical decision making has been taken into account. This was largely explained by inappropriate use of composite outcomes and inadequate measurement of harms.

Towards the Implementation of Quality of Life Monitoring in Daily Clinical Routine: Methodological Issues and Clinical Implication

Quality of life (QOL) has become a widely used outcome parameter in the evaluation of treatment modalities in clinical oncology research. By now, many of the practical problems associated with measuring QOL in clinical practice can be overcome by the use of computer-based assessment methods. QOL assessment in oncology is dominated by two measurement systems, the FACT scales and the EORTC QLQ-C30 with its modules. The amount of human resources required to implement routine data collection has been reduced significantly by advanced computer technology allowing data collection in busy clinical practice. Monitoring of QOL can contribute to oncologic care by facilitating detection of physical and psychological problems and tracking the course of disease and treatment over time. Furthermore, the integration of screening for psychosocial problems into QOL monitoring contributes to the identification of patients who are in need of psychooncologic interventions. Computer-based QOL monitoring does not replace the direct physician-patient communication but enables to identify specific impairments and symptoms including psychological problems. Beyond clinical practice, QOL data can be used for research purposes and may help health care planners to determine those patient services that should be maintained or ones that should be developed.

Economic evaluation and health-related quality of life

Health-related quality of life (HRQL) is concerned with the opportunities that a person's health status affords, the constraints that it places upon the person and the value that a person places on his or her health status. The rationale for measuring HRQL falls into three categories: discrimination, evaluation, and prediction. Measures have to meet generally accepted psychometric criteria such as acceptability, reliability/reproducibility, responsiveness, validity, interpretability, and usefulness. HRQL instruments have been designed for self-administration or administration by interviews and some have been adapted to multiple cultural/linguistic needs. For adolescents and young adults with cancer several instruments are available. Overall HRQL is compromised, to varying degrees, in such survivors by comparison with peers in the general population; and the burden of morbidity is greatest after brain and bone tumors. As there is a burden of treatment-related morbidity and as the number of survivors within the health care system is growing, the economic dimension of care and cure has to be taken into consideration. Economic evaluation affords a comparison of the costs and consequences (effects) of relevant therapeutic alternatives. The future research activities with respect to HRQL have to consider these new dimensions of care.

The role of health-related quality of life in early discontinuation of chemotherapy for breast cancer

To examine the role of health-related quality of life (HRQOL) in early treatment discontinuation among women enrolled in a breast cancer clinical trial. A total of 464 women were enrolled in the Eastern Cooperative Oncology Group randomized controlled trial of adjuvant regimens comparing six cycles of cytoxan, adriamycin and 5-flurouricil (5-FU) with a 16-week regimen (weekly therapy with cytoxan, adriamycin, vincristine, methotrexate, and 5-FU) among women with lymph node positive breast cancer. One hundred sixty-four women participated in the HrQL substudy using the Breast Chemotherapy Questionnaire, which was designed to measure HRQOL in women receiving chemotherapy. Changes in global HRQOL score were examined over time as a predictor of early treatment discontinuation using generalized estimation equations (GEE) modeling and Cox proportional hazards regression. We considered early treatment discontinuation as a longitudinal binary variable determined at each time point HRQOL was measured. The results of multivariate GEE model fitting indicated that declines in HRQOL (p=0.04), older age (p=0.02), higher degree of nausea (p=0.02), higher degree of neurosensory toxicity (0.03) and lower degrees of hair loss (p=0.004) were correlated with early treatment discontinuation. We then fitted a proportional hazard regression model for time to early discontinuation with HRQOL score as a time-dependent covariate. The results were identical. Declines in HRQOL during therapy predicted early treatment discontinuation even after accounting for age and chemotherapy-related side effects. In the age of ever more aggressive treatments for breast cancer, women's perception of the impact of these treatments on their lives will become more important.

Health-related quality of life measurement in symptom management trials

There is increasing support for the incorporation of patient-reported outcomes (PROs) into clinical trials in cancer. While the need for inclusion of measures of target symptoms in symptom management trials is clear, arguments can also be made for measurement of a broader range of symptoms, for evaluation of symptom burden, and for evaluation of health-related quality of life (HRQOL) in these trials. What is key to their inclusion is a priori selection of instruments, provision of a theoretic basis for inclusion of instruments, and a clearly described plan of analysis. The federal Food and Drug Administration (FDA) has provided guidance regarding the use of PROs (symptom and HRQOL measures) to support treatment benefit claims in product labeling. Moving forward, research is needed to address methodological issues raised by the FDA and to increase understanding of relationships among symptoms, symptom clusters, HRQOL, and other outcome measures.

A combination of distribution- and anchor-based approaches determined minimally important differences (MIDs) for four endpoints in a breast cancer scale

OBJECTIVE

To determine distribution- and anchor-based minimal important difference (MID) estimates for four scores from the Functional Assessment of Cancer Therapy-Breast (FACT-B): the breast cancer subscale (BCS), Trial Outcome Index (TOI), FACT-G (the general version), and FACT-B.

STUDY DESIGN AND SETTING

We used data from a Phase III clinical trial in metastatic breast cancer (ECOG study 1193; n=739) and a prospective observational study of pain in metastatic breast cancer (n=129). One third and one half of the standard deviation and 1 standard error of measurement were used as distribution-based criteria. Clinical indicators used to determine anchor-based differences included ECOG performance status, current pain, and response to treatment.

RESULTS

FACT-B scores were responsive to performance status and pain anchors, but not to treatment response. By combining the results of distribution- and anchor-based methods, MID estimates were obtained: BCS=2-3 points, TOI=5-6 points, FACT-G=5-6 points, and FACT-B=7-8 points.

CONCLUSION

Distribution- and anchor-based estimates of the MID do show convergence. These estimates can be used in combination with other measures of efficacy to determine meaningful benefit and provide a basis for sample size estimation in clinical trials.

Critical review of current treatment strategies for advanced hormone insensitive breast cancer

Breast cancer is the most common cancer diagnosis in American women. Over the past several decades, there has been a steady increase in the incidence of this disease. Fortunately, the death rates in the last decade has showed a decrease. Patients with breast cancer now have more treatment options and a better chance of long term survival than ever before. Patients with metastatic disease are considered candidates for chemotherapy if they are symptomatic, have rapidly progressing or bulky disease, or if they are inappropriate candidates for hormonal therapy either because of negative hormonal receptor status or progression of disease on hormonal therapies. Patients are often treated with a chemotherapy regimen until progression of disease, or prohibitive toxicity, at which time the therapy is changed to a second or a third line therapy. This manuscript will provide a review of the current treatment strategies for advanced hormone insensitive breast cancer.

Is outcomes research on cancer ready for prime time?

Contemporary treatment of patients with cancer has been challenged by the same influences that have stimulated broad interest among stakeholders in assessing the outcomes or "results" of medical care. These interrelated external forces include growing awareness of practice variations, increased recognition of the patient's central role in decision making, acknowledgment that treatment decisions for situations where cure is not possible require explicit metrics to assess trade-offs between length and quality of life, strong interest in cost containment, and broad public concern that efforts to rationalize spending may have led to decreases in quality of care. Clinical and health services researchers interested in cancer diagnosis and treatment have striven to address these issues and have been in the forefront of efforts to develop and use valid measures of health-related quality of life. However, the current challenges to the field of outcomes research are equally applicable to those applying its tools and methods to the study of cancer: lack of standardization of outcomes measures, limited evidence that assessing outcomes of care is followed by improved outcomes in practice, and development of a research infrastructure that links the products of outcomes research with informed, shared decision making in routine practice. The purpose of this article is to provide a brief overview of lessons learned from the first decade of outcomes research sponsored by the Agency for Healthcare Research and Quality that will inform suggested directions for future directions for cancer outcomes research.

Patient participation in medical decision-making: a French study in adjuvant radio-chemotherapy for early breast cancer

BACKGROUND

Shared decision-making is increasingly advocated as an ideal model. However, very few studies have tested the feasibility of giving patients the opportunity to participate in the choice of treatment.

PATIENTS AND METHODS

Women, with non-metastatic breast cancer, eligible for non-intensified adjuvant chemotherapy attending our hospital were proposed two administrations of chemotherapy and radiotherapy: a sequential and a concomitant one. Two patient-questionnaires were used to elicit motivations for their choice and their degree of comfort with the process of decision-making and one questionnaire to test physicians' ability to predict patients' choice.

RESULTS

Participation rate in the study was 75.3% (n = 64). Majority (64%) of patients chose the concomitant treatment. Multivariate analysis revealed that patients with a lower level of education, who discussed the choice with social circle, and who most feared side-effects were more likely to choose the sequential treatment. Physicians were able to predict patients' choice in 66% of cases. 89% of patients declared that they were fully satisfied with having participated in the choice of treatment and 79% supported shared decision-making.

CONCLUSIONS

Results are in favour of promoting active participation of cancer-patients in medical decision-making. The adequate degree of such participation remains however to be elicited and tested for therapeutic choices implying more difficult trade-offs between quantity and quality of life.

A quantitative approach to the distress caused by symptoms in patients treated with radical radiotherapy

A computerised self-assessment instrument was used to capture data on the distress caused by symptoms in 110 patients treated with radical radiotherapy. Patients selected symptoms from a list of 34 problems and then quantified the distress associated with each problem using a linear Analogue self assessment (LASA)-type scale. The test instrument was feasible: 90% of assessments were completed in under 14 min. There was a significant increase in tiredness and significant decrease in anxiety and worries about the family, during treatment. Menopausal symptoms and post-surgical problems were important causes of distress in the patients with breast cancer. When the area under the curve method was used to quantify distress in the patients with breast cancer, difficulty concentrating, pain and sleep disturbances emerged as significantly troublesome problems. Computerised self-assessment may have a useful role in quantifying the distress caused by treatment with radiotherapy.

Long-range effect of clinical trial interventions on quality of life

Phase III randomized clinical trials have been designed primarily to answer questions of clinical efficacy. Although the primary outcome for most clinical trials is improved survival or disease free survival, recent studies have also compared the efficacy of treatments with no anticipated effects on survival but with different toxicities or rehabilitation outcomes. By identifying treatments with less morbidity, clinical trials have contributed to improving the quality of life of patients with cancer. This paper will highlight several clinical trials that have produced outcomes with quality-of-life implications, including limb-salvage therapy in patients with bone tumors, conservation surgery for patients with breast cancer, and conservation treatment for patients with bladder and laryngeal cancers. Although quality of life has rarely been measured explicitly in these trials, the demonstration that more conservative treatments are equally efficacious permits the discussion of these less radical treatments with patients. However, conservation treatment does affect quality of life, in that combined modality treatment is usually more complex and may not lead to improvement in quality of life in all patients. In the future, we can expect the explicit incorporation of patient-rated quality-of-life assessments in Phase III clinical trials, especially when maintenance of or improvement in quality of life is a specific objective of the trial.

Quality of life as an outcome variable in oncology and surgery

The major objective of all health interventions is to improve the quality of life. Assessment of the results of treatment for cancer has traditionally included tumour response, treatment toxicity, patient's physical performance status and length of survival. More recently, attempts have been made to incorporate quality of life assessment in oncology research and practice. The audit of surgical treatment includes the evaluation of process and outcome. Although prominence has often been given to the relatively readily identified negative features of operative mortality and complications, both positive and negative effects need to be assessed. Elective surgery may be intended to reduce the risk of future disease-specific mortality but it may be extremely difficult to establish whether this objective has been achieved. We therefore need to recognize that the main and legitimate aims of elective surgery are to relieve disability, discomfort and disfigurement. These are quality of life issues. Minimally invasive surgery and day surgery are examples of current practice where quality of life assessment is important in the thorough evaluation of their role. In this review the available methods of assessment of quality of life are examined and a case is made for their routine inclusion in the evaluation of treatment in oncology and surgery.