Patient reported outcomes in oncology: changing perspectives-a systematic review

Rationale and design of an exercise intervention for patients with cancer cachexia: protocol for a one-year follow-up prospective study (2CAPA)

BACKGROUND

The prevalence of cancer with cachexia is rising sharply. More than 80% of digestive cancer patients are affected by cancer cachexia. Cachexia leads to weight loss, and reduces quality of life, cancer treatment response and survival. Exercise could counteract the deleterious effects of cachexia. The 2CAPA study aims to assess the effectiveness of a 12-week exercise program on various symptoms associated with cancer cachexia, including food intake, body composition, physical fitness, physical activity levels, Health-Related QoL (HRQoL) and fatigue. Additionally, it seeks to examine compliance with the exercise program, identify barriers to regular exercise and determine how compliance influences physical and psychological effects. Furthermore, we will determine the maintenance of physical activity levels and the effects post-program for one year follow-up on cachexia-related symptoms.

METHODS

This study will include 31 cancer patients with cachexia. Participants will receive a supervised exercise program lasting 12-weeks with two sessions per week combining endurance and resistance training. Our outcomes include food intake, anthropometric parameters, physical performances, and physical activity levels, HRQoL, and fatigue, at baseline, at the end of the 12-week exercise program, and at 3-, 6- and 12- months post-intervention. Outcomes will be compared between cancer patients with cachexia and a control group of 31 non-cachectic patients.

CONCLUSION

This study is the first prospective, monocenter, real-life investigation designed to assess the efficacy of a supervised 12-week exercise program on physical and psychological cachexia-related symptoms at the end of the program and then during a one-year follow-up. Moreover, our study will identify compliance and barriers to regular exercise for patients with cachexia. Our results will contribute to the management of cachexia-associated with cancer and provide recommendations to ensure that the program achieves the greatest possible effects and the greatest possible compliance.

ETHICS AND DISSEMINATION

This study was reviewed and approved by Ethics Committee of Rennes (N°2023-039). The findings will be disseminated to the scientific and medical community via publications in peer-reviewed journals and conference presentations.

TRIAL REGISTRATION NUMBER

NCT06323733, 21/03/2024.

Patient-reported outcomes from DESTINY-Breast04: trastuzumab deruxtecan versus physician's choice of chemotherapy in patients with HER2-low mBC

BACKGROUND

The phase 3 DESTINY-Breast04 trial demonstrated superior efficacy and acceptable safety with trastuzumab deruxtecan (T-DXd) vs physician's choice of chemotherapy in previously treated patients with human epidermal growth factor receptor 2 (HER2)-low metastatic breast cancer (mBC). We report the patient-reported outcomes (PROs), focusing on the hormone receptor-positive cohort.

PATIENTS AND METHODS

Patients were randomized 2:1 to T-DXd (5.4 mg/kg intravenously every 3 weeks) or physician's choice of chemotherapy and prospectively assessed for PRO measures. Change from baseline and time to definitive deterioration (TDD) were calculated from the EORTC QLQ-C30 and QLQ-BR45 and the EQ-5D-5L questionnaires.

RESULTS

Baseline global health status/quality of life (GHS/QoL) scores were similar between groups (T-DXd, 331 patients; physician's choice, 163 patients); there were no clinically meaningful changes while on either treatment (median duration: T-DXd, 8.2 months; physician's choice, 3.5 months). Median TDD for GHS/QoL was delayed with T-DXd vs physician's choice (11.4 vs 7.5 months, respectively; hazard ratio, 0.69; 95% CI, 0.52-0.92). Median TDD for all prespecified PROs, including pain, favored T-DXd. In an additional analysis, the median TDD was shorter for nausea and vomiting with T-DXd vs the physician's choice.

CONCLUSIONS

Trastuzumab deruxtecan maintained GHS/QoL scores despite a longer treatment course compared with standard chemotherapy and delayed definitive deterioration across all prespecified PROs vs the physician's choice. Appropriate management of adverse events and use of preventive measures (ie, antiemetic prophylaxis) may further support patient health-related quality of life. These findings reinforce the benefit of T-DXd as an option for patients with HER2-low mBC. ClinicalTrials.gov: NCT03734029.

Developing a novel predictive model for identifying risk factors associated with being lost to follow-up among high-risk patients for recurrence following radical resection of hepatocellular carcinoma: the first report

BACKGROUND

Follow-up is essential especially for patients who are at a high risk of recurrence after radical resection of hepatocellular carcinoma (HCC). The aim of this study was to develop a predictive model aimed at identifying the risk factors associated with being lost to follow-up (LTFU) in high-risk patients for recurrence following radical resection of HCC.

METHODS

The retrospective study was conducted at our institution between October 2018 to May 2023. The patients who underwent radical liver resection for HCC and had high-risk factors for recurrence were categorized into an LTFU group and a control group. Multivariate logistic regression analysis was utilized to determine risk factors and construct a nomogram predictive model.

RESULTS

A total of 352 patients were included and subsequently classified into two distinct groups: the LTFU group (n = 123, 34.94%) and the control group (n = 229, 65.06%). Logistic regression analysis was then conducted to explore the potential associations between various factors and the occurrence of LTFU. The findings identified several independent risk factors for LTFU, including smoking (odds ratio, OR = 1.823, 95% confidence interval, CI 1.086-3.060, p = 0.023); residing more than 200 km away from the hospital (OR = 1.857, 95% CI 1.105-3.121, p = 0.019); having an unstable profession (OR = 1.918, 95% CI 1.112-3.311, p = 0.019); and lacking medical insurance (OR = 5.921, 95% CI 1.747-20.071, p = 0.004); the presence of liver cirrhosis (OR = 2.161, 95% CI 1.153-4.048, p = 0.016); an operation time less than 240 min (OR = 2.138, 95% CI 1.240-3.688, p = 0.006); and the absence of postoperative adjuvant therapy (OR = 2.641, 95% CI 1.504-4.637, p = 0.001). Based on these seven significant factors, a main effects model was established, designated as the Wei-LTFU model, which achieved an area under the curve value of 0.744 (95% CI 0.691-0.798) in predicting the likelihood of LTFU.

CONCLUSION

A main effects model, namely the Wei-LTFU model, incorporating the seven significant factors was formulated to predict the likelihood of LTFU occurrence, ultimately aiming to assist healthcare workers in developing effective strategies to improve follow-up outcomes for patients.

Evaluating the Impact of Minimally Invasive Surgery on Long-Term Quality of Life in Foregut Cancer Patients

INTRODUCTION

Compared to open surgery (OS), minimally invasive surgery (MIS) for foregut cancer improves perioperative outcomes. However, the impact of MIS on long-term quality of life (QOL) is unknown. We compare the long-term QOL of patients who underwent MIS and OS for foregut cancer.

METHODS

Surgically managed esophageal and gastric cancer patients were surveyed globally via online support groups. Physical (P-QOL) and mental (M-QOL) well-being were determined using the Short Form-12 questionnaire and compared based on the surgical approach (MIS vs OS). We defined "long-term" as greater than 3 months from surgery.

RESULTS

Out of 100 respondents with esophageal and gastric cancer, 64 survivors underwent surgical management greater than 3 months before the survey. They were 56.6 ± 9.9 years, 46.0% female, and 95.2% White, with a median survival of 33.0 (14.0-63.0) months. The most common diagnosis was esophageal adenocarcinoma (69.8%). Surgical procedures included esophagectomy (56.5%), esophagogastrectomy (29.0%), and gastrectomy (14.5%), of which 45.2% were OS and 48.4% were MIS. The cohort overall exhibited lower P-QOL (40.7 ± 10.4) and M-QOL (44.6 ± 15.2) compared to the general population (50.0 ± 10.0; p < 0.050). There was no difference in age, sex, race, education, income, diagnosis, and adjuvant therapy between OS and MIS cohorts (all p > 0.050). Long-term P-QOL (38.5 ± 11.6 OS vs. 42.8 ± 9.5 MIS, p = 0.123) and M-QOL (44.7 ± 15.3 OS vs. 44.9 ± 14.9 MIS, p = 0.901) was similar between patients who underwent OS and MIS for foregut cancer.

CONCLUSION

MIS is not associated with higher long-term QOL in patients who have undergone surgery for foregut malignancy.

Patient-reported outcome based symptom management is a better option for early postoperative recovery after breast cancer surgery: a parallel controlled randomized clinical trial

BACKGROUND

We aimed to assess the efficacy and feasibility of applying patient-reported outcome (PRO) based symptom management in the early postoperative period after breast cancer surgery.

MATERIALS AND METHODS

Before surgery, patients diagnosed with breast cancer who met the inclusion criteria were randomly assigned in a 1:1 ratio to receive either postoperative PRO-based symptom management or usual care. All patients completed the MD Anderson Symptom Inventory-Chinese version (MDASI-C) via the electronic PRO system preoperatively, on a daily basis postoperatively, and twice weekly after discharge, for a duration up to 2 weeks. In the PRO-based care group, in addition to receiving usual care, patients whose symptoms reported by completing MDASI-C with a score of ≥4 will be managed symptomatically by the attending surgeon. Patients in the usual care group received routine care and their MDASI-C scores were unknown to their attending surgeon. The primary outcome was the MDASI-C score of patients at the time of discharge. Analyses were conducted in accordance with the established protocol.

RESULTS

Of the 134 participants, 67 were randomly assigned to each group. At discharge, the total score of MDASI-C scale was significantly higher in the usual care group comapred to the PRO-based care group (median [interquartile range], 22 [19] vs. 35 [36]; P = 0.002). The score of FACT-B scale (adjusted mean difference, 0.39; 95% confidence interval, 0.11-1.06; P = 0.009) was significantly lower in the usual care group than in the PRO-based care group during the 14 days after surgery. In the PRO-based care group, 87.2% of patients found the PRO-based symptom management approach helpful in their early postoperative recovery.

CONCLUSION

The implementation of a PRO-based symptom management system within 2 weeks after breast cancer surgery effectively alleviates symptom burden and improves quality of life compared to usual care.

Proactive assessment of patient reported outcomes in ovarian cancer studies: a systematic review and call for action in future studies

OBJECTIVE

This systematic review aims to evaluate the proactive or real-time assessment of patient reported outcomes in studies involving patients with ovarian cancer undergoing systemic therapy.

METHODS

PubMed, Embase, and Cochrane databases were searched (from database inception until February 2022), and prospective ovarian cancer studies (experimental or observational) that incorporated patient reported outcomes, including quality of life, were included. The primary objective was to assess the ratio of studies incorporating real-time use of patient reported outcomes among those studies performing patient reported outcomes. A secondary objective was to describe the patient reported outcome reporting. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) 2020 checklist was followed. Descriptive statistics were used.

RESULTS

3071 articles were screened, with 117 included in the final analysis. Studies were published between 1990 and 2022, and consisted of 35 735 patients (median 140 patients per study; interquartile range 58-415). Median time from patient enrollment initiation to study publication was 7 years (range 1-15). Most studies were experimental/clinical trials (n=93, 79%) followed by observational (n=23, 20%). Therapeutic strategies were assessed in 98% (91/93) of experimental studies, most frequently chemotherapy (n=53, 58%), followed by antiangiogenics or poly-ADP ribose polymerase (PARP) inhibitors (n=8, 9%, each). Patient reported outcomes were the primary endpoint in 7.5% (7/93) and 83% (19/23) of experimental and observational studies, respectively. The ratio of real-time patient reported outcomes assessment/evaluation was 0.9% (1/117).

CONCLUSIONS

Completion of patient reported outcome questionnaires involves time and effort for patients with ovarian cancer. Responses to these questionnaires were only assessed in real time in <1% of analyzed studies. Efforts should be made to incorporate proactive assessment of patient reported outcomes to optimize patient care and safety.

An Overview of Patient-reported Outcomes for Men with Prostate Cancer: Results from the PIONEER Consortium

Background and objective

Patient-reported outcome measures (PROMs) are increasingly being used to capture the patients' perspective of their functional status and quality of life (QoL). Big data can help us better understand patient-reported outcomes (PROs). Using prospectively collected data from the Prostate Cancer Diagnosis and Treatment Enhancement Through the Power of Big Data in Europe (PIONEER) consortium, we aimed to describe the functional status and QoL in men with prostate cancer (PCa) treated with active surveillance (AS), radical prostatectomy (RP), and radiotherapy (RT), and to demonstrate the applicability of PROM data on a large scale and at a European level.

Methods

We identified data sources that collected QoL data using the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30, EORTC QLQ-PR25, or Expanded Prostate Cancer Index Composite (EPIC)-26/50 questionnaires. Aggregated summary scores for urinary, bowel, and sexual dysfunction, global health status, and QoL were shared for each data source.

Key findings and limitations

We identified eight data sources originating from various settings: routine hospital data, embedded research PRO collection, survey data collected by a patient organization, multi-institutional prospective cohort study, and registry data. PRO data were available for 709 men on AS, 20 508 on RP, and 3417 on RT, with a median time between diagnosis and PROM assessment ranging from 1 to 8.7 yr. Most men were diagnosed with Gleason ≤7 disease, and T1 or T2 PCa. We observed that sexual dysfunction was the most affected PRO and found large differences between data sources.

Conclusions and clinical implications

Our results support the feasibility of PRO assessment using big data in Europe. Implementation of PROMs in clinical practice and the use of standardized methods could improve value-based health care provision.

Patient summary

In this study, we combined several data sources that reported urinary, bowel, and sexual dysfunction, global health status, and quality of life. We identified eight data sources and show that sexual function is the most affected domain after treatment.

Professional-patient discrepancies in assessing lung cancer radiotherapy symptoms: An international multicentre study

BACKGROUND AND PURPOSE

We investigate discrepancies in the assessment of treatment-related symptoms in lung cancer between healthcare professionals and patients, and factors contributing to these discrepancies.

MATERIALS AND METHODS

Data from 515 participants in the REQUITE study were analysed. Five symptoms (cough, dyspnoea, bronchopulmonary haemorrhage, chest wall pain, dysphagia) were evaluated both before and after radiotherapy. Agreement between healthcare professionals and people with lung cancer was quantified using Gwet's-AC2 coefficient. The influence of clinical variables, comorbidities, and quality-of-life outcomes on agreement was examined through stratified analyses.

RESULTS

We found varying levels of agreement between healthcare professionals and people with lung cancer. Bronchopulmonary haemorrhage and dysphagia exhibited very good agreement (meanAC2 > 0.81), while cough and chest wall pain showed substantial agreement (meanAC2 = 0.64 and 0.76, respectively). Dyspnoea had the lowest agreement (meanAC2 = 0.59), with prior chemotherapy significantly reducing agreement levels. Chronic obstructive pulmonary disease (COPD) and early cancer stages also contributed to discrepancies in dyspnoea assessments. Regarding quality-of-life, the most relevant factor was fatigue, which reduced agreement in the assessment of dyspnoea (AC2 = 0.55 vs 0.70), dysphagia (AC2 = 0.48 vs 0.69), cough (AC2 = 0.58 vs 0.82), and chest wall pain (AC2 = 0.77 vs 0.91).

CONCLUSIONS

Our findings indicate strong alignment between healthcare professionals' and people with lung cancer evaluations of observable treatment-related symptoms, but less consistency for subjective symptoms such as dyspnoea. Factors such as prior chemotherapy, COPD, and cancer stage should be considered when interpreting symptom assessments. Furthermore, our study underscores the importance of integrating quality-of-life considerations, particularly fatigue, into symptom evaluations to mitigate potential biases in symptom perception.

The evolving value assessment of cancer therapies: Results from a modified Delphi study

The move toward early detection and treatment of cancer presents challenges for value assessment using traditional endpoints. Current cancer management rarely considers the full economic and societal benefits of therapies. Our study used a modified Delphi process to develop principles for defining and assessing value of cancer therapies that aligns with the current trajectory of oncology research and reflects broader notions of value. 24 experts participated in consensus-building activities across 5 months (16 took part in structured interactions, including a survey, plenary sessions, interviews, and off-line discussions, while 8 participated in interviews). Discussion focused on: 1) which oncology-relevant endpoints should be used for assessing treatments for early-stage cancer and access decisions for early-stage treatments, and 2) the importance of additional value components and how these can be integrated in value assessments. The expert group reached consensus on 4 principles in relation to the first area (consider oncology-relevant endpoints other than overall survival; build evidence for endpoints that provide earlier indication of efficacy; develop evidence for the next generation of predictive measures; use managed entry agreements supported by ongoing evidence collection to address decision-maker evidence needs) and 3 principles in relation to the second (routinely use patient reported outcomes in value assessments; assess broad economic impact of new medicines; consider other value aspects of relevance to patients and society).

Determining doses for backfill cohorts based on patient-reported outcome

BACKGROUND

Incorporating backfill cohorts in phase I oncology trials is a recently developed strategy for dose optimization. However, the efficacy assessment window is long in general, causing a lag in identifying ineffective doses and more patients being backfilled to those doses. There is necessity to investigate how to use patient-reported outcomes (PRO) to determine doses for backfill cohorts.

METHODS

We propose a unified Bayesian design framework, called 'Backfill-QoL', to utilize patient-reported quality of life (QoL) data into phase I oncology trials with backfill cohorts, including methods for trial monitoring, algorithm for dose-finding, and criteria for dose selection. Simulation studies and sensitivity analyses are conducted to evaluate the proposed Backfill-QoL design.

RESULTS

The simulation studies demonstrate that the Backfill-QoL design is more efficient than traditional dose-expansion strategy, and fewer patients would be allocated to doses with unacceptable QoL profiles. A user-friendly Windows desktop application is developed and freely available for implementing the proposed design.

CONCLUSIONS

The Backfill-QoL design enables continuous monitoring of safety, efficacy and QoL outcomes, and the recommended phase II dose (RP2D) can be identified in a more patient-centered perspective.

Understanding factors impacting patient-reported outcome measures integration in routine clinical practice: an umbrella review

PURPOSE

Patient-report outcome measures (PROMs) have gained widespread support as a mechanism to improve healthcare quality. We aimed to map out key enablers and barriers influencing PROMs implementation strategies in routine clinical practice.

METHODS

An umbrella review was conducted to identify reviews exploring enablers and barriers related to the integration of PROMs in routine clinical practice from January 2000 to June 2023. Information on key enablers and barriers was extracted and summarised thematically according to the Theoretical Domains Framework.

RESULTS

34 reviews met our criteria for inclusion. Identified reviews highlighted barriers such as limited PROMs awareness among clinicians and patients, perceived low value by clinicians and patients, PROMs that were too complex or difficult for patients to complete, poor usability of PROMs systems, delayed feedback of PROMs data, clinician concerns related to use of PROMs as a performance management tool, patient concerns regarding privacy and security, and resource constraints. Enablers encompassed phased implementation, professional training, stakeholder engagement prior to implementation, clear strategies and goals, 'change champions' to support PROMs implementation, systems to respond to issues raised by PROMs, and integration into patient pathways. No consensus favoured paper or electronic PROMs, yet offering both options to mitigate digital literacy bias and integrating PROMs into electronic health records emerged as important facilitators.

CONCLUSIONS

The sustainable implementation of PROMs is a complex process that requires multicomponent organisational strategies covering training and guidance, necessary time and resources, roles and responsibilities, and consultation with patients and clinicians.

Letter to the editor regarding "Induction chemotherapy regimes in first-line treatment for locoregionally advanced nasopharyngeal carcinoma: A network meta-analysis and cost-effectiveness analysis

The research paper offers a detailed analysis of induction chemotherapy regimens for locoregionally advanced nasopharyngeal carcinoma (LA-NPC), assessing their effectiveness and cost-effectiveness. It presents important data on disease-free survival and overall survival outcomes. However, this letter suggests several improvements. It advocates for the inclusion of patient-centered outcomes such as quality of life and functional status to better gauge treatment impacts on daily living. Additionally, it calls for a more thorough investigation into long-term adverse effects and the role of biomarkers in tailoring treatments. It also recommends a comparative analysis of cost-effectiveness across various healthcare systems and the creation of practical guidelines for regimen selection. These proposed changes aim to enhance the study's practical relevance and clinical applicability.

Bayesian joint modeling of multivariate longitudinal and survival outcomes using Gaussian copulas

There is an increasing interest in the use of joint models for the analysis of longitudinal and survival data. While random effects models have been extensively studied, these models can be hard to implement and the fixed effect regression parameters must be interpreted conditional on the random effects. Copulas provide a useful alternative framework for joint modeling. One advantage of using copulas is that practitioners can directly specify marginal models for the outcomes of interest. We develop a joint model using a Gaussian copula to characterize the association between multivariate longitudinal and survival outcomes. Rather than using an unstructured correlation matrix in the copula model to characterize dependence structure as is common, we propose a novel decomposition that allows practitioners to impose structure (e.g., auto-regressive) which provides efficiency gains in small to moderate sample sizes and reduces computational complexity. We develop a Markov chain Monte Carlo model fitting procedure for estimation. We illustrate the method's value using a simulation study and present a real data analysis of longitudinal quality of life and disease-free survival data from an International Breast Cancer Study Group trial.

Feasibility of Weekly Integrated Palliative Care Outcome Scale (IPOS) Within a Stepped Care Model

CONTEXT

Patients with advanced cancer may experience symptoms and concerns that are inadequately identified by the healthcare team, leading to calls for patient-reported symptom monitoring.

OBJECTIVES

Assess the feasibility of administering weekly patient-reported online Integrated Palliative care Outcome Scale (IPOS) questionnaires within the context of a stepped care model in the outpatient care setting.

METHODS

Analysis of intervention group data in a randomized controlled trial to assess the effectiveness of a stepped care model of palliative care for patients with advanced cancer. Patients in the intervention group were invited to complete the IPOS weekly for 16 weeks through a remotely-administered online questionnaire. At the end of the 16-week period, patients were invited to complete a feedback survey. Multivariable logistic regression was used to assess factors associated with more versus less than 70% completion of weekly questionnaires.

RESULTS

Among 111 patients who survived more than 16 weeks, the mean number of questionnaires completed was 9.2/16 (58%). A total of 53 out of the 111 patients (48%) completed more than 70% of the questionnaires. Higher education level was found to be associated with higher completion of the questionnaires. A total of 79 out of 111 (71%) patients responded to the feedback survey, of which 67 (85%) felt comfortable with completing the online questionnaire and 11 (14%) felt it was troublesome to complete it on a weekly basis.

CONCLUSION

In our study, there was suboptimal completion of patient-reported IPOS questionnaire. Further research is needed to improve the uptake of patient-reported outcomes in real-world clinical settings.

Stereotactic Magnetic Resonance-Guided Daily Adaptive Radiation Therapy for Localized Prostate Cancer: Acute and Late Patient-Reported Toxicity Outcomes

Purpose

To report acute and late bowel, urinary, and sexual dysfunction patient-reported outcome measures, among patients with localized prostate cancer who underwent stereotactic magnetic resonance-guided daily adaptive radiation therapy (SMART).

Methods and Materials

All patients who completed a baseline 12-item Patient-Reported Outcomes Version of the Common Terminology Criteria for Adverse Events questionnaire, before undergoing SMART with 36.25 Gy in 5 fractions, were subsequently followed up with the same graded questionnaire at set time points. Latest prostate-specific antigen levels were recorded. The percentage of patients who reported no change from their baseline adverse event (AE) or reported a new ≥ "frequent or almost constant" or "severe grade or higher" AE grade during follow-up was calculated. The maximum 12-item Patient-Reported Outcomes Version of the Common Terminology Criteria for Adverse Events grade for each item was recorded for each patient. The percentage of toxicity levels for each separate AE item at set time points was calculated.

Results

The total number of patients was 69 with a median follow-up of 27 months. Median age of the cohort was 73 years (range, 54-85 years). The median pretreatment prostate-specific antigen level, T stage, and Gleason score were 7.5 mmol/L (range, 4.5-32 mmol/L), T2b (range, T2-T3b), and 7 (3 + 4; range, 6-9), respectively. No patient had biochemical failure during follow-up. Regarding bowel symptoms, >80% of men reported no change from baseline toxicity during follow-up. New ≥ frequent or almost constant diarrhea was reported in 9% of patients. "Almost constant" diarrhea peaked at 1 month but was absent at >33 months. Regarding urinary symptoms, increased urinary urgency was the most common complaint (39%). Twenty percent of men reported new ≥ frequent or almost constant urinary urgency incidence peaking at 1 month but absent at >33 months. New "severe" sexual dysfunction was seen in 26% of patients and was persistent at >33 months.

Conclusions

Our study is one the largest patient-reported outcomes study after prostate SMART. It shows acceptable levels of toxicity even up to 2 years after treatment.

A randomized controlled trial of shared decision-making treatment planning process to enhance shared decision-making in patients with MBC

PURPOSE

Opportunities exist for patients with metastatic breast cancer (MBC) to engage in shared decision-making (SDM). Presenting patient-reported data, including patient treatment preferences, to oncologists before or during a treatment plan decision may improve patient engagement in treatment decisions.

METHODS

This randomized controlled trial evaluated the standard-of-care treatment planning process vs. a novel treatment planning process focused on SDM, which included oncologist review of patient-reported treatment preferences, prior to or during treatment decisions among women with MBC. The primary outcome was patient perception of shared decision-making. Secondary outcomes included patient activation, treatment satisfaction, physician perception of treatment decision-making, and use of treatment plans.

RESULTS

Among the 109 evaluable patients from December 2018 to June 2022, 28% were Black and 12% lived in a highly disadvantaged neighborhood. Although not reaching statistical significance, patients in the intervention arm perceived SDM more often than patients in the control arm (63% vs. 59%; Cramer's V = 0.05; OR 1.19; 95% CI 0.55-2.57). Among patients in the intervention arm, 31% were at the highest level of patient activation compared to 19% of those in the control arm (V = 0.18). In 82% of decisions, the oncologist agreed that the patient-reported data helped them engage in SDM. In 45% of decision, they reported changing management due to patient-reported data.

CONCLUSIONS

Oncologist engagement in the treatment planning process, with oncologist review of patient-reported data, is a promising approach to improve patient participation in treatment decisions which should be tested in larger studies.

TRIAL REGISTRATION

NCT03806738.

Symptom impact and health-related quality of life (HRQoL) assessment by cancer stage: a narrative literature review

BACKGROUND

Cancer stage at diagnosis is an important prognostic indicator for patient outcomes, with detection at later stages associated with increased mortality and morbidity. The impact of cancer stage on patient-reported outcomes is poorly understood. This research aimed to understand symptom burden and health related quality of life (HRQoL) impact by cancer stage for ten cancer types: 1) ovarian, 2) lung, 3) pancreatic, 4) esophageal, 5) stomach, 6) head and neck, 7) colorectal, 8) anal, 9) cervical, and 10) liver and bile duct.

METHODS

Ten narrative literature reviews were performed to identify and collate published literature on patient burden at different stages of disease progression. Literature searches were conducted using an AI-assisted platform to identify relevant articles published in the last five (2017-2022) or ten years (2012-2022) where articles were limited. Conference abstracts were searched for the last two years (2020-2022). The geographic scope was limited to the United States, Canada, Europe, and global studies, and only journal articles written in English were included.

RESULTS

A total of 26 studies with results stratified by cancer stage at diagnosis (and before treatment) were selected for the cancer types of lung, pancreatic, esophageal, stomach, head and neck, colorectal, anal, and cervical cancers. Two cancer types, ovarian cancer, and liver and bile duct cancer did not return any search results with outcomes stratified by disease stage. A general trend was observed for worse patient-reported outcomes in patients with cancer diagnosed at an advanced stage of disease compared with diagnosis at an earlier stage. Advanced disease stage was associated with greater symptom impact including general physical impairments such as pain, fatigue, and interference with functioning, as well as disease/region-specific symptom burden. Poorer HRQoL was also associated with advanced disease with commonly reported symptoms including anxiety and depression.

CONCLUSIONS

Overall, the general trend for greater symptom burden and poorer HRQoL seen in late stage versus early-stage disease across the included cancer types supports the importance for early diagnosis and treatment to improve patient survival and decrease negative impacts on disease burden and HRQoL.

Health Status in Heart Failure and Cancer: Analysis of the Medicare Health Outcomes Survey 2016-2020

BACKGROUND

People with heart failure (HF) and cancer experience impaired physical and mental health status. However, health-related quality of life (HRQOL) has not been directly compared between these conditions in a contemporary population of older people.

OBJECTIVES

The authors sought to compare HRQOL in people with HF vs those with lung, colorectal, breast, and prostate cancers.

METHODS

The authors performed a pooled analysis of Medicare Health Outcomes Survey data from 2016 to 2020 in participants ≥65 years of age with a self-reported history of HF or active treatment for lung, colon, breast, or prostate cancer. They used the Veterans RAND-12 physical component score (PCS) and mental component score (MCS), which range from 0-100 with a mean score of 50 (based on the U.S. general population) and an SD of 10. The authors used pairwise Student's t-tests to evaluate for differences in PCS and MCS between groups.

RESULTS

Among participants with HF (n = 71,025; 54% female, 16% Black), mean PCS was 29.5 and mean MCS 47.9. Mean PCS was lower in people with HF compared with lung (31.2; n = 4,165), colorectal (35.6; n = 4,270), breast (37.7; n = 14,542), and prostate (39.6; n = 17,670) cancer (all P < 0.001). Participants with HF had a significantly lower mean MCS than those with lung (31.2), colon (50.0), breast (52.0), and prostate (53.0) cancer (all P < 0.001).

CONCLUSIONS

People with HF experience worse HRQOL than those with cancer actively receiving treatment. The pervasiveness of low HRQOL in HF underscores the need to implement evidence-based interventions that target physical and mental health status and scale multidisciplinary clinics.

Evaluating the sensitivity of EQ-5D-5L in patients with brain metastases: a secondary analysis of NRG CC001

BACKGROUND

EuroQoL EQ-5D-5L is a commonly used measure of health-related quality of life in clinical trials given the use of its index score as a measure of health utilities. It is unclear whether EQ-5D-5L is sensitive to changes in neurocognitive function and progression that occur following brain radiation. This study sought to evaluate the sensitivity of EQ-5D-5L in reflecting these changes.

METHODS

A secondary analysis of NRG Oncology CC001 was performed. Mean EQ-5D-5L index and visual analog scale (VAS) score changes from baseline between groups of patients stratified by neurocognitive function and intracranial progression status were assessed. MD Anderson Symptom Inventory for brain tumor (MDASI-BT) symptom and interference items were also analyzed between groups.

RESULTS

EQ-5D-5L mean index and VAS score changes between patients who had cognitive failure and those who had preserved cognition showed no statistically significant differences at any timepoint. In contrast, VAS changes at 4 months (1.61 vs -5.13, P = .05) and 6 months (8.17 vs -0.14, P = .04) were significantly improved in the patients who survived without intracranial progression. MDASI-BT cognitive factor scores were improved in the cohort of patients with preserved neurocognitive function at 2 months (1.68 vs 2.08, P = .05) and 4 months (1.35 vs 1.83, P = .04). MDASI-BT symptom interference was significantly associated with intracranial progression at 4 months, but not with neurocognitive status.

CONCLUSION

EQ-5D-5L index and VAS scores were not sensitive to neurocognitive changes that patients experienced, but VAS scores were sensitive to progression. This study challenges the routine use of EQ-5D as a quality of life metric in brain metastases clinical trials that are focused on preventing neurocognitive dysfunction.

TRIAL REGISTRATION

NCT# 02360215.

Implementing paper-based patient-reported outcome collection within outpatient integrative health and medicine

OBJECTIVE

To investigate the feasibility of pre- and post-encounter patient-reported outcome (PRO) measure collection within an outpatient integrative health and medicine (IHM) clinic and to characterize factors associated with successful completion.

METHODS

We conducted a retrospective review of 27,464 outpatient IHM encounters including 9,520 chiropractic; 8,237 acupuncture; 5,847 massage; 2,345 IHM consultation; and 1,515 osteopathic manipulation treatment encounters at four clinics offering IHM over 18 months. Patients were asked to complete paper questionnaires rating pain, anxiety, and stress from 0-10 immediately pre- and post-encounter. Generalized linear mixed effect regression models were used to examine the relationship between demographic, clinical, and operational covariates and completing (1) pre-encounter and (2) paired (i.e., pre and post) PROs.

RESULTS

Patients (N = 5587, mean age 49 years, 74% white, 77% female) generally presented for musculoskeletal conditions (81.7%), with a chief complaint of pain (55.1%). 21,852 (79.6%) encounters were among patients who completed pre-encounter PROs; 11,709/21,852 (53.6%) completed subsequent post-encounter PROs. Odds of PRO completion were more impacted by provider, operational, and clinical-level factors than patient factors. Covariates associated with increased odds of pre-encounter PRO completion included being female, having additional IHM encounters, and having a pain or anxiety complaint. Covariates associated with increased odds of paired PRO completion included being aged 31-40 vs. 51-60 years and having additional IHM encounters.

CONCLUSION

Implementing a paper-based PRO collection system in outpatient IHM is feasible; however, collecting post-encounter PROs was challenging. Future endeavors should leverage the electronic health record and patient portals to optimize PRO collection and engage patients and clinical providers.

Using natural language processing to analyze unstructured patient-reported outcomes data derived from electronic health records for cancer populations: a systematic review

INTRODUCTION

Patient-reported outcomes (PROs; symptoms, functional status, quality-of-life) expressed in the 'free-text' or 'unstructured' format within clinical notes from electronic health records (EHRs) offer valuable insights beyond biological and clinical data for medical decision-making. However, a comprehensive assessment of utilizing natural language processing (NLP) coupled with machine learning (ML) methods to analyze unstructured PROs and their clinical implementation for individuals affected by cancer remains lacking.

AREAS COVERED

This study aimed to systematically review published studies that used NLP techniques to extract and analyze PROs in clinical narratives from EHRs for cancer populations. We examined the types of NLP (with and without ML) techniques and platforms for data processing, analysis, and clinical applications.

EXPERT OPINION

Utilizing NLP methods offers a valuable approach for processing and analyzing unstructured PROs among cancer patients and survivors. These techniques encompass a broad range of applications, such as extracting or recognizing PROs, categorizing, characterizing, or grouping PROs, predicting or stratifying risk for unfavorable clinical results, and evaluating connections between PROs and adverse clinical outcomes. The employment of NLP techniques is advantageous in converting substantial volumes of unstructured PRO data within EHRs into practical clinical utilities for individuals with cancer.

Interventions for Concerning Patient-Reported Outcomes in Routine Cancer Care: A Systematic Review

IMPORTANCE

Collecting patient-reported outcomes (PROs) in routine cancer care improves patient-clinician communication, decision making, and overall patient satisfaction. Recommendations exist regarding standardized ways to collect, store, and interpret PRO data. However, evidence on incorporating PROs into cancer process of care, especially the type of HIs that are warranted after observing a concerning PRO and the effectiveness of these HIs are lacking.

OBJECTIVE

This study summarizes HIs triggered after PRO completion and their effectiveness in improving patient outcomes for adults being treated for cancer types that are resource intensive and associated with high symptom burden [i.e., gastrointestinal (GI), lung, and head and neck cancer (HNC)]. Secondary outcomes included factors associated with poor implementation of PROs.

EVIDENCE REVIEW

A literature search of peer-reviewed publications on MEDLINE, CINAHL Plus, APA PsycInfo, Scopus, and Cochrane was conducted following PRISMA guidelines from 1 January 2012, to 31 July 2022. Trial and real-world studies describing HIs after PRO completion for adult patients being treated for GI, lung, and HNC were included. Sixteen studies involving 144,496 patients were included. The Joanna Briggs Institute critical appraisal checklist was used to assess risk of bias.

FINDINGS

Of the 16 included studies, 5 included patients with HNC. Commonly used PRO measurement tools were the PRO-CTCAE and ESAS. Only three studies reported specific HIs delivered in response to concerning PROs and measured their effectiveness on patient outcomes. In all three studies, these HIs significantly improved cancer-related care. The most common HIs undertaken in response to concerning PROs were referrals to other specialists/allied healthcare professionals, medication changes, or self-management advice. Provider-related barriers to PRO measurement and delivery included the overwhelming number of alerts, the time required to address each PRO and the unclear role of healthcare providers in response to these alerts. Patient-related barriers included lower digital literacy and socioeconomic status, older age, rural living, and patients suffering from GI and HNC.

CONCLUSIONS AND RELEVANCE

This review highlights that PRO-triggered HIs are heterogenous and can improve patient quality of life. Further studies are necessary to determine the types of interventions with the greatest impact on patient care and outcomes.

Canakinumab Versus Placebo in Combination With First-Line Pembrolizumab Plus Chemotherapy for Advanced Non-Small-Cell Lung Cancer: Results From the CANOPY-1 Trial

PURPOSE

The addition of checkpoint inhibitors to first-line treatment has prolonged survival of patients with non-small-cell lung cancer (NSCLC), but prognosis remains poor, with new treatment options needed. Canakinumab, a human, monoclonal anti-interleukin (IL)-1β antibody, has potential to enhance the activity of PD-L1 inhibitors and chemotherapy (CT) by inhibiting protumor inflammation.

METHODS

CANOPY-1 was a phase III, randomized, double-blind study comparing canakinumab (200 mg subcutaneously once every 3 weeks) versus placebo, both combined with pembrolizumab (200 mg intravenously once every 3 weeks) and platinum-based doublet CT, as first-line treatment for advanced/metastatic NSCLC without EGFR or ALK mutations. The primary end points were progression-free survival (PFS) and overall survival (OS). The secondary endpoints included overall response rate, safety, and patient-reported outcomes.

RESULTS

Overall, 643 patients were randomly assigned to canakinumab (n = 320) or placebo (n = 323). With a median study follow-up of 6.5 months, the median PFS was 6.8 months with canakinumab versus 6.8 months with placebo (hazard ratio [HR], 0.85; 95% CI, 0.67 to 1.09; P = .102). With a median study follow-up of 21.2 months, the median OS was 20.8 months with canakinumab versus 20.2 months with placebo (HR, 0.87; 95% CI, 0.70 to 1.10; P = .123). No unexpected safety signals were observed for canakinumab combination. Infection rates were comparable between treatment and control arms. A higher frequency of neutropenia and ALT increase (grade ≤2) were reported in the treatment arm. Higher baseline C-reactive protein and IL-6 levels were associated with shorter PFS and OS. Patients treated with canakinumab had clinically meaningful delays in deterioration of lung cancer symptoms, including chest pain and coughing per LC13 and dyspnea per LC13 and C30.

CONCLUSION

The addition of canakinumab to first-line pembrolizumab and CT did not prolong PFS or OS in patients with NSCLC.

Remote Symptom Monitoring to Enhance the Delivery of Palliative Cancer Care in Low-Resource Settings: Emerging Approaches from Africa

This paper brings together researchers, clinicians, technology developers and digital innovators to outline current applications of remote symptom monitoring being developed for palliative cancer care delivery in Africa. We outline three remote symptom monitoring approaches from three countries, highlighting their models of delivery and intended outcomes, and draw on their experiences of implementation to guide further developments and evaluations of this approach for palliative cancer care in the region. Through highlighting these experiences and priority areas for future research, we hope to steer efforts to develop and optimise remote symptom monitoring for palliative cancer care in Africa.

End-of-Life Care Education as Blended Learning Approach for General Practitioners: a Scoping Review

General practitioners (GPs) are critical in providing primary palliative care in the community. Apprehensions about managing a dying person at home, difficulties in goals of care discussion, limited resources and lack of palliative care education often hinder end-of-life care provision in the community. This review focused on the end-of-life care training programs accessed by GPs and sought to understand if the training programs' content and mode of delivery aligned with their preferred needs. MEDLINE, EMBASE, CINAHL, and PsycINFO were searched to identify articles published in English between 01 January 1990 and 30 September 2022. Additionally, searches were conducted using SCOPUS, the Web of Science, and the Cochrane database using free texts. The reviewers screened the titles, abstracts, and full text to identify eligible studies and extracted textual data to analyse and generate themes. Out of 5532 citations initially accessed, 17 studies were included in the review. Six themes were generated: knowledge translation, skill development, a change in attitude, self-efficacy, satisfaction, and patient outcomes. The GPs' end-of-life care knowledge, skills, attitude, self-efficacy, and patient outcomes were better when their training had a combination of small-group interactive workshops, trigger case-based reflective learning, mentor-facilitated experiential learning, web-based modules, and peer learning. The synthesis of review findings supports blended learning as a training approach for general the practitioners' end-of-life care education as it facilitates learning and patient outcomes.

Patient-Reported Outcomes in Clinical Trials: From an Endpoint to an Intervention in Cancer Care

Underreporting of patient symptoms by clinicians is a common and well-documented phenomenon that has led to integrating patient-reported outcomes (PROs) as endpoints into clinical trials. While PROs are often used to measure disease symptoms, cancer therapy toxicities, and quality of life, they can also assess patients' general experiences and preferences. With the increasing use of electronic medical records and the digital health revolution in oncology, conversion from paper to electronic PROs (ePROs) has also facilitated the integration of PROs into routine care. Evidence from clinical trials is rapidly emerging to support ePROs as a care delivery innovation, given the potential for ePROs to improve patient outcomes through timely evaluation and response to patient needs. Meanwhile, work is ongoing to understand and address ePRO use and challenges to equitable integration, including technical and language barriers for patients, clinicians, and health systems. Nonetheless, the health system and regulatory bodies continue to develop stipulations to promote the use of ePROs. Herein, we review the evolution of PROs from an endpoint to an intervention in prospective clinical trials in oncology.

Understanding the impact of radiotherapy related insufficiency fractures and exploring satisfaction with two existing patient reported outcome measures: A qualitative interview study

Introduction

Radiotherapy related insufficiency fractures (RRIFs) occur in approximately 10-15% of cancer survivors who underwent pelvic radiotherapy. Little research has been conducted to explore the impact of RRIFs on quality of life (QOL). Patient reported outcome measures (PROMs) are often used in oncology to measure side effects and QOL. The study aims to understand the influence of RRIF on QOL and to discover whether available PROMs address their needs.

Materials and methods

Twenty-five patients randomly selected from a Tertiary Oncology Centre bone health clinic database of patients referred with RRIFs were approached. Interested patients were sent two existing PROMs and a patient information sheet. Eleven patients agreed to take part in a semi-structured interview to explore their experiences and their opinion on the existing PROMs. Telephone interviews were conducted. Interviews were audio recorded, transcribed, and analysed using thematic analysis.

Results

Four themes were identified: 1) Route to diagnosis, 2) management of RRIFs and 3) resilience all had an impact on 4) QOL. Additionally, participants discussed PROMs and how they might be integrated into clinical practice. The data highlights the wide ranging QOL impacts experienced and highlights potential areas for improvement in terms of diagnosis and management pathways.

Discussion

The impact of RRIFs on QOL is considerable. Participants highlighted key areas for improvement including the provision of more information, more access to support and improved management pathways. Participants also highlighted the potential benefits of PROMs but suggested existing measures could be improved.

Circulating biomarkers in perioperative management of cancer patients

Owing to the advances in surgical technology, most solid tumours can be controlled by surgical excision. The priority should be tumour control, while some routine perioperative management might influence cancer progression in an unnoticed way. Moreover, it is increasingly recognized that effective perioperative management should include techniques to improve postoperative outcomes. These influences are elucidated by the different functions of circulating biomarkers in cancer patients. Here, circulating biomarkers with two types of clinical functions were reviewed: (i) circulating biomarkers for cancer progression monitoring, for instance, those related to cancer cell malignancy, tumour microenvironment formation, and early metastasis, and (ii) circulating biomarkers with relevance to postoperative outcomes, including systemic inflammation, immunosuppression, cognitive dysfunction, and pain management. This review aimed to provide new perspectives for the perioperative management of patients with cancer and highlight the potential clinical translation value of circulating biomarkers in improving outcomes.

Patient-reported outcomes in CD30-directed CAR-T cells against relapsed/refractory CD30+ lymphomas

Chimeric antigen receptor (CAR)-T cells targeting CD30 have demonstrated high response rates with durable remissions observed in a subset of patients with relapsed/refractory CD30+ hematologic malignancies, particularly classical Hodgkin lymphoma. This therapy has low rates of toxicity including cytokine release syndrome with no neurotoxicity observed in our phase 2 study. We collected patient-reported outcomes (PROs) on patients treated with CD30 directed CAR-T cells to evaluate the impact of this therapy on their symptom experience. We collected PROs including PROMIS (Patient-Reported Outcomes Measurement Information System) Global Health and Physical Function questionnaires and selected symptom questions from the NCI PRO-CTCAE in patients enrolled on our clinical trial of CD30-directed CAR-T cells at procurement, at time of CAR-T cell infusion, and at various time points post treatment. We compared PROMIS scores and overall symptom burden between pre-procurement, time of infusion, and at 4 weeks post infusion. At least one PRO measurement during the study period was found in 23 out of the 28 enrolled patients. Patient overall symptom burden, global health and mental health, and physical function were at or above baseline levels at 4 weeks post CAR-T cell infusion. In addition, PROMIS scores for patients who participated in the clinical trial were similar to the average healthy population. CD30 CAR-T cell therapy has a favorable toxicity profile with patient physical function and symptom burden recovering to at least their baseline pretreatment health by 1 month post infusion. Trial registration number: NCT02690545.

Oncology nursing on the move: a contemporary issue on Chinese oncology nursing in cancer care

Cancers have become the primary cause of death among Chinese residents, seriously affecting their health and life. Oncology nursing is a specialized nursing practice focusing on cancer education, prevention, screening, early detection, and palliative and hospice care. China has made tremendous progress in developing oncology nursing. However, to ensure more individuals can get cancer care, the country's healthcare system still confronts several problems in oncology nursing that need to be addressed to ensure that more individuals can receive cancer care. This article reviews the current development of oncology nursing in China, especially in pain symptom control, palliative care, end-of-life care, education and training. The challenges faced in oncology nursing in China and the suggestions for developing oncology nursing in China are also discussed and proposed in this review. The growth of research on oncology nursing by Chinese nursing scholars and concerned policymakers is anticipated to ultimately improve oncology nursing and the quality of life of patients with cancer in China.

The Effects of Patient-Reported Outcome Screening on the Survival of People with Cancer: A Systematic Review and Meta-Analysis

This study examined the effects of the routine assessment of patient-reported outcomes (PROs) on the overall survival of adult patients with cancer. We included clinical trials and observational studies with a control group that compared PRO monitoring interventions in cancer clinical practice to usual care. The Cochrane risk-of-bias tools were used. In total, six studies were included in the systematic review: two randomized trials, one population-based retrospectively matched cohort study, two pre−post with historical control studies and one non-randomized controlled trial. Half were multicenter, two were conducted in Europe, three were conducted in the USA and was conducted in Canada. Two studies considered any type of cancer, two were restricted to lung cancer and two were restricted to advanced forms of cancer. PRO screening was electronic in four of the six studies. The meta-analysis included all six studies (intervention = 130.094; control = 129.903). The pooled mortality outcome at 1 year was RR = 0.77 (95%CI 0.76−0.78) as determined by the common effect model and RR = 0.82 (95%CI 0.60−1.12; p = 0.16) as determined by the random-effects model. Heterogeneity was statistically significant (I2 = 73%; p < 0.01). The overall risk of bias was rated as moderate in five studies and serious in one study. This meta-analysis seemed to indicate the survival benefits of PRO screening. As routine PRO monitoring is often challenging, more robust evidence regarding the effects of PROs on mortality would support systematic applications.