Determining the relationship between toxicity and quality of life in an ovarian cancer chemotherapy clinical trial

Trace elements and metal nanoparticles: mechanistic approaches to mitigating chemotherapy-induced toxicity-a review of literature evidence

Anticancer chemotherapy (ACT) remains a cornerstone in cancer treatment, despite significant advances in pharmacology over recent decades. However, its associated side effect toxicity continues to pose a major concern for both oncology clinicians and patients, significantly impacting treatment protocols and patient quality of life. Current clinical strategies to mitigate ACT-induced toxicity have proven largely unsatisfactory, leaving a critical unmet need to block toxicity mechanisms without diminishing ACT's therapeutic efficacy. This review aims to document the molecular mechanisms underlying ACT toxicity and highlight research efforts exploring the protective effects of trace elements (TEs) and their nanoparticles (NPs) against these mechanisms. Our literature review reveals that the primary driver of ACT toxicity is redox imbalance, which triggers oxidative inflammation, apoptosis, endoplasmic reticulum stress, mitochondrial dysfunction, autophagy, and dysregulation of signaling pathways such as PI3K/mTOR/Akt. Studies suggest that TEs, including zinc, selenium, boron, manganese, and molybdenum, and their NPs, can potentially counteract ACT-induced toxicity by inhibiting oxidative stress-mediated pathways, including NF-κB/TLR4/MAPK/NLRP3, STAT-3/NLRP3, Bcl-2/Bid/p53/caspases, and LC3/Beclin-1/CHOP/ATG6, while also upregulating protective signaling pathways like Sirt1/PPAR-γ/PGC-1α/FOXO-3 and Nrf2/HO-1/ARE. However, evidence regarding the roles of lncRNA and the Wnt/β-catenin pathway in ACT toxicity remains inconsistent, and the impact of TEs and NPs on ACT efficacy is not fully understood. Further research is needed to confirm the protective effects of TEs and their NPs against ACT toxicity in cancer patients. In summary, TEs and their NPs present a promising avenue as adjuvant agents for preventing non-target organ toxicity induced by ACT.

Impacts of systemic treatments on health-related quality of life for patients with metastatic colorectal cancer: a systematic review and network meta-analysis

OBJECTIVE

There is limited evidence of comparative results among different treatments regarding impacts of Health-Related Quality of Life (HRQoL) for patients with metastatic colorectal cancer (mCRC). We aimed to compare efficacy of systemic treatments on HRQoL among patients with mCRC.

METHODS

We collected randomized controlled trials (RCTs) reported in English up until July 2023, from databases including PubMed, Embase, Cochrane Library, ClinicalTrials.gov, and prominent conference databases, for this Bayesian network meta-analysis. Phase 2 or 3 trials that evaluated at least two therapeutic regimens were included. Primary outcomes were short-term and long-term mean changes in EORTC QLQ-C30 global health status/quality of life (GHS/QoL) scores. Secondary outcome was mean change in EQ-5D health utility scores. Mean differences (MDs) with 95% confidence intervals (CIs) were used as effect size. Subgroup analysis was performed based on whether patients received systemic treatments before. We conducted various sensitivity analyses, including differentiating between chemotherapy types, and analyzed patient cohorts with non-specified gene expression levels as well as those with target KRAS expression statuses. The current systematic review protocol was registered on PROSPERO (CRD42023453315 and CRD42023420498).

RESULTS

Immunotherapy and targeted therapy significantly improved HRQoL over chemotherapy, with MDs of 9.27 (95% CI: 3.96 to 14.6) and 4.04 (95% CI: 0.11 to 7.94), respectively. Monotherapy significantly outperformed both combination therapy (MD 5.71, 95%CI 0.78 to 10.63) and no active treatment (MD 3.7, 95%CI 1.41 to 6.01) regarding GHS/QoL in the short-term. Combining targeted therapy with chemotherapy did not improve HRQoL. Focusing on HRQoL, cetuximab excelled when gene expression baselines were unspecified. Subgroup and sensitivity analyses upheld these robust findings, unaffected by model or patient baseline characteristics. Evidence from clinical trials without specific gene level data suggested that monotherapies, especially targeted therapies such as cetuximab, demonstrated superiority in HRQoL. For KRAS wild-type patients, no significant HRQoL differences emerged between chemotherapy, targeted therapy, or their combination..

CONCLUSIONS

Targeted therapies and immunotherapy demonstrate superior HRQoL benefits, monotherapy such as cetuximab is associated with significant improvements as compared to combination therapy. However, tailoring these results to individual gene expression profiles requires more evidence.

A comprehensive review on Ellagic acid in breast cancer treatment: From cellular effects to molecular mechanisms of action

Globally, breast cancer (BC) is the leading cause of cancer-related deaths in women. Hence, developing a therapeutic plan to overcome the disease is crucial. Numerous factors such as endogenous hormones and environmental factors may play a role in the pathophysiology of BC. Regarding the multi-modality treatment of BC, natural compounds like ellagic acid (EA) received has received increased interest in antitumor efficacy with lower adverse effects. Based on the results of this comprehensive review, EA has multiple effects on BC cells including (1) suppresses the growth of BC cells by arresting the cell cycle in the G0/G1 phase, (2) suppresses migration, invasion, and metastatic, (3) stimulates apoptosis in MCF-7 cells via TGF-β/Smad3 signaling axis, (4) inhibits CDK6 that is important in cell cycle regulation, (5) binds to ACTN4 and induces its degradation via the ubiquitin-proteasome pathway, inducing decreased cell motility and invasion in BC cells, (6) inhibits the PI3K/AKT pathway, and (7) inhibits angiogenesis-associated activities including proliferation (reduces VEGFR-2 tyrosine kinase activity). In conclusion, EA exhibits anticancer activity through various molecular mechanisms that influence key cellular processes like apoptosis, cell cycle, angiogenesis, and metastasis in BC. However, further researches are essential to fully elucidate its molecular targets and implications for clinical applications.

Ellagic acid modulates cisplatin toxicity in DMH induced colorectal cancer: Studies on membrane alterations

Systemic toxicity due to chemotherapy contributes to poor prognosis in patients receiving chemotherapy. The present study, therefore, explores the role of Ellagic acid, a phytochemical, in modulating cisplatin (CP) toxicity in dimethylhydrazine-induced colorectal cancer. Colons excised from DMH administered animals showed abnormal crypts and bulges over the mucosal surface. SEM revealed significant alterations and dysplastic lesions in DMH administered mice. Animals receiving combined treatment showed improvement in colonic epithelium with lesser irregularities. DMH and CP administration disturbed the membrane dynamics and integrity as observed with the fluorescent probes DPH and pyrene. However, EA co-supplementation with CP proved to be beneficial in normalizing the altered membrane. Ellagic acid co-supplementation along with CP; therefore, showed great promise and helped restore the membrane alterations in the colon caused due to CP-induced toxicity and DMH insult. These observations could pave way towards developing a combination therapy targeting colon carcinogenesis in future.

Change in cancer-related fatigue over time predict health-related quality of life in ovarian cancer patients

OBJECTIVE

There is limited research examining how change in cancer-related fatigue (CRF) over time predicts change in health-related quality of life (HRQOL), and no studies have examined this relationship in ovarian cancer patients, specifically. The purpose of this study was to explore the prevalence and trajectory of CRF over time and examine how change in CRF over time predicts change in HRQOL in ovarian cancer patients.

METHODS

Ovarian cancer patients (N = 202) were recruited from Princess Margaret Cancer Centre in Toronto, Canada. Consenting participants completed measures at baseline (beginning of study) and again three months later. Data were analyzed using a longitudinal multilevel mixed model design.

RESULTS

Four groups of CRF trajectories emerged. Fifty-four percent reported CRF as always present, 16% reported CRF subsided, 21% reported CRF developed, and 9% reported CRF as never present. As CRF developed, functional and physical wellbeing decreased. As CRF subsided, functional, physical, and emotional wellbeing improved. CRF trajectory was not associated with change in social wellbeing over time.

CONCLUSIONS

Our findings suggest CRF negatively impacts all domains of HRQOL except for social wellbeing in ovarian cancer patients. Among patients who reported that CRF improved over time, all HRQOL domains impacted by CRF showed recovery to normal endorsement rates. Among patients who reported development of CRF, impacted HRQOL domains significantly declined over time. Implications from this research indicate that fatigue management should be prioritized during and after cancer treatment to ensure optimal physical, functional, and emotional wellbeing.

Effects of a Home-based Exercise Program on Anxiety and Mood Disturbances in Older Adults with Cancer Receiving Chemotherapy

BACKGROUND/OBJECTIVE

Exercise interventions improve anxiety and mood disturbances in patients with cancer. However, studies are limited in older adults with cancer. We assessed the effects of exercise on anxiety, mood, and social and emotional well-being in older patients with cancer during their first 6 weeks of chemotherapy.

DESIGN

Exploratory secondary analysis of a randomized controlled trial (RCT).

SETTING

Community oncology practices.

PARTICIPANTS

Older patients (aged 60 years or older) undergoing chemotherapy (N = 252).

INTERVENTION

Patients were randomized to Exercise for Cancer Patients (EXCAP) or usual care (control) for the first 6 weeks of chemotherapy. EXCAP is a home-based, low- to moderate-intensity progressive walking and resistance training program.

MEASUREMENTS

Analysis of covariance, with study arm as the factor, baseline value as the covariate, and study arm × baseline interaction, was used to evaluate arm effects on postintervention anxiety (State Trait Anxiety Inventory [STAI]), mood (Profile of Mood States [POMS]), and social and emotional well-being (Functional Assessment of Cancer Therapy-General subscales) after 6 weeks.

RESULTS

Median age was 67 years; 77% had breast cancer. Statistically significant group differences were observed in the STAI score (P = .001), POMS score (P = .022), social well-being (P = .002), and emotional well-being (P = .048). For each outcome, EXCAP patients with worse baseline scores had larger improvements at 6 weeks; these improvements were clinically significant for STAI score and social well-being.

CONCLUSIONS

Among older cancer patients receiving chemotherapy, a 6-week structured exercise program improved anxiety and mood, especially among those participants with worse baseline symptoms. Additional RCTs are needed to confirm these findings and evaluate the appropriate exercise prescription for managing anxiety, mood, and well-being in this patient population. J Am Geriatr Soc 67:1005-1011, 2019.

Observational Prospective Study to Determine the Evolution of the Symptomatic Profile of Metastatic Non-Small Cell Lung Cancer (NSCLC) Patients and Its Relation to the Control of the Disease

OBJECTIVE

To evaluate the evolution of disease-related symptoms and its relationship with the control of the disease in first-line treatment in patients with metastatic non-small cell lung cancer (NSCLC).

METHODS

This was an observational, prospective, national and multicentre study with two visits in which the following were collected: (1) baseline visit: sociodemographic and clinical variables (2) visit after completing the 4-6 chemotherapy cycles: criteria for ending treatment, control of the disease and clinical variables. Ad hoc questionnaires were collected to assess the frequency of symptoms (evaluated by the patient), and quality-of-life questionnaires to assess the intensity of symptoms (using the Lung Cancer Symptom Scale, LCSS), and interference in the patient's daily life, assessed by the patient and by the investigator.

RESULTS

A total of 155 patients were included. Patients predominantly described tiredness (24.1%) and pain (23.9%) as the symptoms that appeared "frequently or continuously". A statistically significant decrease in scores for symptoms of cough (15.4 points), dyspnoea (8.5 points), pain (9.5 points) and discomfort related to their illness (9 points) was observed between visits. Patients who achieved a complete or partial response showed a statistically significant reduction in the cough, dyspnoea, pain and disconfort frequency. Regarding the intensity, cough was the only symptom that showed  a statistically significant decrease for both the patient and the investigator. Tiredness/asthenia and pain were the symptoms with the greatest interference in daily life at baseline according to the patient; however, according to the investigator, they were mood and quality/quantity of sleep, although none of them were significant. But changes in the score of the interference questionnaire between visits were not statistically significantly related to the control of the disease. However, average score according to both investigator and patients showed a significant correlation with ECOG status.

CONCLUSION

The first-line treatment of NSCLC is correlated with an improvement in the symptomatic evolution of advanced NSCLC patients.

FUNDING

Roche.

Oncologic orphan drugs approved in the EU - do clinical trial data correspond with real-world effectiveness?

BACKGROUND

Evaluation of evidence for efficacy of orphan medicinal products (OMPs) for rare malignancies may be hampered by the use of tumor measurements instead of clinical endpoints. This may cause efficacy data to not always match effectiveness in the real-world. We investigated whether an efficacy-effectiveness gap exists for oncologic OMPs and aimed to identify which factors contribute to it. Also, the magnitude of the clinical efficacy of oncologic OMPs was evaluated.

METHODS

We included all oncologic OMPs authorized in the European Union from 2000 to 2017. Pivotal studies were evaluated by means of the European Society for Medical Oncology - Magnitude of Clinical Benefit Scale (ESMO-MCBS). To estimate real-world effectiveness, a literature search was performed to identify post-marketing studies, of which data on overall survival (OS) were extracted. OS of the new OMP was compared with OS data of standard of care. An OS gain of ≥3 months compared to pre-marketing data was considered clinically relevant.

RESULTS

Twenty OMPs were included, of which 5 were authorized based on OS as a primary endpoint. 10 OMPs had post-marketing data available, of which 40% did not show a clinically relevant OS gain in the real world. All OMPs that were studied with OS as primary endpoint in the pivotal study had a clinically relevant OS gain in the real world. Furthermore, all OMPs that had a high ESMO-MCBS score and post-marketing data available, resulted in a clinically relevant OS gain in the real world.

CONCLUSIONS

Although the sample size is small, our results indicate an efficacy-effectiveness gap for oncologic OMPs exists. Significant changes in PFS do not always lead to an increased OS. The use of PFS may be justified, but validation of surrogate endpoints is needed.

Frailty in geriatric head and neck cancer: A contemporary review

OBJECTIVE

To provide a summary of the current frailty literature relating to head and neck cancer.

DATA SOURCES

Ovid MEDLINE, PubMed, Google Scholar.

METHODS

A comprehensive review of the literature was performed from 2000 to 2017 using key words frailty, elderly, geriatric, surgery, otolaryngology, head and neck cancer.

RESULTS

The aging population has led to an increased diagnosis of head and neck cancer in elderly patients. The prevalence of comorbidities, disabilities, geriatric syndromes and social issues can make treatment planning and management in this population challenging. Chronological age alone may not be the optimal approach to guiding treatment decisions, as there is marked heterogeneity amongst this age group. Individualization of treatment can be achieved by assessing for the presence of frailty, which has growing evidence as an important marker of health status in geriatric oncology. Frailty is a complex geriatric syndrome characterized by a state of increased vulnerability to stressors and is associated with morbidity, mortality, and treatment toxicity. Screening for frailty may provide an efficient method to identify those who would benefit from further assessment or pretreatment optimization, and to provide prognostic information to assist clinicians and patients in formulating the most ideal treatment plan for the elderly individual with head and neck cancer.

CONCLUSIONS

Frailty has emerged as an important concept in geriatric oncology, with wide significance in head and neck cancer. Incorporating frailty assessments into clinical practice may provide otolaryngologists pertinent information regarding health status and outcomes leading to optimal care of the elderly cancer patient. Laryngoscope, 128:E416-E424, 2018.

Immune-related adverse events associated with PD-1 and PD-L1 inhibitors for nonsmall cell lung cancer: Protocol for a systematic review and meta-analysis

INTRODUCTION

Nonsmall cell lung cancer accounts for approximately 80% of all lung cancers, and approximately 75% of cases are diagnosed in the middle and late stages of disease. Unfortunately, limited treatment does not improve the prognosis of advanced disease. Monoclonal antibodies targeting programmed cell death protein-1 (PD-1) and programmed death-ligand 1 (PD-L1) represent a new treatment paradigm for nonsmall cell lung cancer. Nevertheless, the immune-related adverse events (irAEs) associated with PD-1 and PD-L1 inhibitors are unique, and early recognition and treatment of these events are essential.

METHODS AND ANALYSIS

A systematic literature search will be performed using the EMBASE, MEDLINE, and Cochrane databases to identify relevant articles published in any language. Randomized clinical trials, case series, and case reports of PD-1 and PD-L1 inhibitors in the treatment of nonsmall cell lung cancer will be included. All meta-analyses will be performed using RevMan software. The quality of the studies will be evaluated using the guidelines listed in the Cochrane Handbook. If the necessary data are available, then subgroup analyses will be performed for high-, median-, and low-dose cohorts. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statements will be followed until the findings of the systematic review and meta-analysis are reported.

CONCLUSIONS

This will be the first systematic review and meta-analysis to describe previously reported irAEs related to PD-1 and PD-L1 inhibitors in the treatment of nonsmall cell lung cancer.

Effect of Red Ginseng on Genotoxicity and Health-Related Quality of Life after Adjuvant Chemotherapy in Patients with Epithelial Ovarian Cancer: A Randomized, Double Blind, Placebo-Controlled Trial

We evaluated the effect of red ginseng on toxicity, health-related quality of life (HRQL) and survival after adjuvant chemotherapy in patients with epithelial ovarian cancer (EOC). A total of 30 patients with EOC were randomly assigned to placebo (n = 15) and red ginseng groups (n = 15). All patients took placebo or red ginseng (3000 mg/day) for three months. Then, we compared changes of genotoxicity, HRQL and survival between the two groups. As a result, red ginseng reduced micronuclei yield in comparison with placebo despite no difference of binucleated cells index. Although red ginseng increased serum levels of alanine aminotransferase and aspartate aminotransferase significantly, they were within the normal value. Moreover, there were no differences in adverse events between placebo and red ginseng groups. In terms of HRQL, red ginseng was associated with improved emotional functioning and decreased symptoms of fatigue, nausea and vomiting, and dyspnea, reduced anxiety and interference affecting life and improved daytime somnolence. However, there was no effect of red ginseng on prognosis of EOC. Conclusively, red ginseng may be safe and effective to reduce genotoxicity and improve HRQL despite no benefit of survival in patients with EOC who received chemotherapy.

Exploration of the ASCO and ESMO Value Frameworks for Antineoplastic Drugs

Purpose:

In 2015, both ASCO and the European Society for Medical Oncology (ESMO) proposed frameworks to quantify the benefit of antineoplastic drugs in the face of rising costs. We applied these frameworks to drugs approved by the US Food and Drug Administration over the past 12 years and examined relationships between costs and benefits.

Methods:

We searched FDA.gov for drugs that received initial approval for solid tumors from 2004 to 2015 and calculated the ASCO Net Health Benefit version 2016 (NHB16) and 2015 (NHB15) and the ESMO Magnitude of Clinical Benefit Scale scores for each drug. We calculated descriptive statistics and explored correlations and associations among benefit scores, cost, and independent variables.

Results:

We identified 55 drug approvals supported by phase II (18.2%) and III (81.8%) trials, with primary outcomes of overall survival (36.4%), progression-free survival (43.6%), or response rate (20.0%). No significant association was found between NHB16 and year of approval ( P = .81), organ system ( P = .20), or trial comparator arm ( P = .17), but trials with progression-free survival outcomes were associated with higher scores ( P = .007). Both NHB15 and Magnitude of Clinical Benefit Scale scores were approximately normally distributed, but only a moderate correlation existed between them ( r = 0.40, P = .006). No correlation between benefit score and cost (NHB16, r = 0.19; ESMO, r = −0.07) was found. Before 2010, two (15.3%) of 13 approved drugs exceeded $500/NHB point × month compared with 10 (25.0%) of 40 drugs subsequently approved.

Conclusion:

Our analysis of the ASCO and ESMO value frameworks illuminates the heterogeneous benefit of new medications and highlights challenges in constructing a unified concept of drug value. Drug benefit does not correlate with cost, and the number of high cost/benefit outliers has increased.

Safety and Tolerability of PD-1/PD-L1 Inhibitors Compared with Chemotherapy in Patients with Advanced Cancer: A Meta-Analysis

BACKGROUND

Compared with chemotherapy, significant improvement in survival outcomes with the programmed death receptor-1 (PD-1) inhibitors nivolumab and pembrolizumab and the programmed death-ligand 1 (PD-L1) inhibitor atezolizumab has been shown in several types of advanced solid tumors. We conducted a systematic review and meta-analysis to compare safety and tolerability between PD-1/PD-L1 inhibitors and chemotherapy.

METHODS

PubMed and American Society of Clinical Oncology (ASCO) databases were searched 1966 to September 2016. Eligible studies included randomized controlled trials (RCTs) comparing single-agent U.S. Food and Drug Administration-approved PD-1/PD-L1 inhibitors (nivolumab, pembrolizumab, or atezolizumab) with chemotherapy in cancer patients reporting any all-grade (1-4) or high-grade (3-4) adverse events (AEs), all- or high-grade treatment-related symptoms, hematologic toxicities and immune-related AEs, treatment discontinuation due to toxicities, or treatment-related deaths. The summary incidence, relative risk, and 95% confidence intervals were calculated.

RESULTS

A total of 3,450 patients from 7 RCTs were included in the meta-analysis: 4 nivolumab, 2 pembrolizumab, and 1 atezolizumab trials. The underlying malignancies included were non-small cell lung cancer (4 trials) and melanoma (3 trials). Compared with chemotherapy, the PD-1/PD-L1 inhibitors had a significantly lower risk of all- and high-grade fatigue, sensory neuropathy, diarrhea and hematologic toxicities, all-grade anorexia, nausea, and constipation, any all- and high-grade AEs, and treatment discontinuation. There was an increased risk of all-grade rash, pruritus, colitis, aminotransferase elevations, hypothyroidism, and hyperthyroidism, and all- and high-grade pneumonitis with PD1/PD-L1 inhibitors.

CONCLUSION

2017;22:470-479 IMPLICATIONS FOR PRACTICE: We conducted a systematic review and meta-analysis to compare summary toxicity endpoints and clinically relevant adverse events between programmed death receptor-1 (PD-1)/programmed death-ligand 1 (PD-L1) inhibitors and chemotherapy. PD1/PD-L1 inhibitors were associated with a lower risk of treatment-related symptoms (fatigue, anorexia, nausea, diarrhea, constipation, and sensory neuropathy) but a higher risk of immune-related adverse events (AEs). Summary toxicity endpoints favor PD1/PD-L1 inhibitors (any all- and high-grade AEs and treatment discontinuation). PD1/PD-L1 inhibitors are overall better tolerated than chemotherapy. In addition to efficacy data from trials, our findings provide useful information for clinicians for well-balanced discussions with their patients on the risks and benefits of treatment options for advanced cancer.

Biological and predictive role of ERCC1 polymorphisms in cancer

Excision repair cross-complementation group 1 (ERCC1) is a key component in DNA repair mechanisms and may influence the tumor DNA-targeting effect of the chemotherapeutic agent oxaliplatin. Germline ERCC1 polymorphisms may alter the protein expression and published data on their predictive and prognostic value have so far been contradictory. In the present article we review available evidence on the clinical role and utility of ERCC1 polymorphisms and, in the absence of a 'perfect' trial, what we call the 'sliding doors' trial, we present the data of ERCC1 genotyping in our local patient population. We found a useful predictive value for oxaliplatin-induced risk of anemia.

Salvage treatment with irinotecan/cisplatin versus pemetrexed/cisplatin in patients with non-small cell lung cancer pre-treated with a non-platinum-based regimen in the first-line setting: a randomized phase II study of the Hellenic Oncology Research Group (HORG)

BACKGROUND

Platinum-based chemotherapy is the standard front-line treatment for patients with advanced non-small cell lung cancer (NSCLC). However, non-platinum combinations of third-generation chemotherapeutic agents are considered an alternative therapeutic option for patients who cannot tolerate the toxic effects of platinum compounds. In this study, the efficacy and toxicity of the combination of irinotecan plus cisplatin (IC) was compared to pemetrexed plus cisplatin (PC) regimen, in platinum-naïve patients with advanced NSCLC, who had been previously treated with the combination of a taxane plus gemcitabine.

PATIENTS AND METHODS

A total of 124 patients with locally advanced or metastatic NSCLC were randomly assigned to either irinotecan 110 mg/m² on day 1 and 100 mg/m² on day 8 plus cisplatin 80 mg/m² on day 8 every 3 weeks (IC arm) or pemetrexed 500 mg/m² plus cisplatin 80 mg/m² on day 1 every 3 weeks (PC arm). The primary endpoint of the study was the overall response rate (ORR).

RESULTS

The ORR and median progression-free survival (PFS) in the IC arm were 18 % and 3.3 months, respectively, while in the PC arm were 19 % and 4.2 months (p = ns). Median overall survival (OS) was significantly higher in patients with PC (6.9 vs. 10.9; p = 0.013). PC regimen had a better toxicity profile compared to IC, with a statistically significant lower incidence of grade 3/4 neutropenia (3 vs. 31 %; p = 0.0001) and diarrhea (1.6 vs. 14.7 %, p = 0.018).

CONCLUSIONS

In patients with advanced NSCLC pretreated with docetaxel/gemcitabine, the combination of pemetrexed/cisplatin is associated with increased OS and is better tolerated than the combination of irinotecan/cisplatin and should be considered as a valid therapeutic option for platinum-naive, previously treated patients. CLINICALTRIALS.

GOV IDENTIFIER

NCT00614965.

Determining chemotherapy tolerance in older patients with cancer

Older adults with cancer constitute a heterogeneous group of patients who pose unique challenges for oncology care. One major concern is how to identify patients who are at a higher risk for chemotherapy intolerance, because a standard oncology workup may not always be able to distinguish an older individual's level of risk for treatment-related complications. Geriatric oncologists incorporate tools used in the field of geriatrics, and have developed the Comprehensive Geriatric Assessment to enhance the standard oncology workup. This assessment pinpoints problems with daily activities, comorbidities, medications, nutritional status, cognitive function, psychological state, and social support systems, all of which are risk factors for treatment vulnerability in older adults with cancer. Additional tools that also serve to predict chemotherapy toxicity in older patients with cancer are now available to identify patients at higher risk for morbidity and mortality. Together, these instruments complement the standard oncology workup by providing a global assessment, thereby guiding therapeutic interventions that may improve a patient's quality of life and clinical outcomes.

Chemotherapy-induced peripheral neuropathy and its association with quality of life: a systematic review

BACKGROUND

The objective of this study was to systematically review all available literature concerning chemotherapy-induced peripheral neuropathy (CIPN) and quality of life (QOL) among cancer patients.

METHODS

A computerized search of the literature was performed in December 2013. Articles were included if they investigated CIPN and QOL among cancer patients. Twenty-five articles were selected and were subjected to a 13-item quality checklist independently by two investigators.

RESULTS

The methodological quality of the majority of the selected studies was adequate to high. The included studies differed tremendously with respect to study design (19 prospective studies, 5 cross-sectional, 1 both cross-sectional and prospective), patient population (lung, colorectal, ovarian, endometrial, cervical or breast cancer, lymphoma, acute lymphoblastic leukemia, or a mixed population), number of included patients (ranging from 14 to 1643), and ways to assess CIPN (objectively, subjectively, or both). Of the 25 included studies, 11 assessed the association of CIPN on patients' QOL. While three of these studies did not find an association between CIPN and QOL, the others concluded that more CIPN was associated with a lower QOL.

IMPLICATIONS FOR CANCER SURVIVORS

Although the included studies in this systematic review were very diverse, which impedes drawing firm conclusions on this topic, CIPN is likely to have a negative association with QOL. The variety of the studied patient populations and chemotherapeutic agents in the existing studies calls for further studies on this topic. These studies are preferably prospective in nature, include a large number of patients, and assess QOL and CIPN with validated questionnaires.

Comparing the retrospective reports of fatigue using the Fatigue Symptom Index with daily diary ratings in women receiving chemotherapy for gynecologic cancer

CONTEXT

Fatigue, one of the most common side effects of chemotherapy, is typically assessed via retrospective recall (e.g., over the past week). It is unknown how such retrospective recall of fatigue correlates with daily ratings among people receiving chemotherapy.

OBJECTIVES

The current study compared fatigue recorded in daily diaries with retrospective ratings using the Fatigue Symptom Inventory (FSI) in patients receiving chemotherapy for gynecologic cancer.

METHODS

During the week before and the week after their first infusion of chemotherapy, patients completed daily diaries at 10 AM, 2, and 6 PM and the FSI at the end of each week.

RESULTS

FSI and diary ratings of peak, lowest, and average fatigue were significantly correlated (P < 0.001). When peak, end, average, and variance diary ratings were regressed separately on the average FSI item, each was significant pre-chemotherapy (P < 0.01) and post-chemotherapy (P < 0.05). However, when entered into a stepwise regression model, only the average fatigue diary rating was retained, explaining 52% of the variance pre-chemotherapy and 54% of the variance post-chemotherapy average FSI item (P < 0.001).

CONCLUSION

The FSI keyed to the past week accurately reflects daily ratings of fatigue among patients receiving chemotherapy. This study has important implications, as completing retrospective ratings of fatigue may be less burdensome for cancer patients than daily assessments.

[The importance of individual beliefs about cancer treatments for therapeutic decisions]

Interest for representations about cancer treatments and their side effects is increasing because their central role has been proved in how patients cope with illness and symptoms and how they react emotionally. Through a synthesis of the literature, this paper has two objectives: firstly, to clarify the current state of knowledge in this field, and secondly to point out the manner that bringing out these individual representations during oncological consultations contributes to preventing difficulties and treatment discontinuation and facilitates medical decision processing.

Lagged relationships among sleep disturbance, fatigue, and depressed mood during chemotherapy

OBJECTIVE

Recent research suggests that sleep disturbance, fatigue, and depressed mood form a symptom cluster in patients treated with chemotherapy. To date, however, no studies have examined lagged relationships among these symptoms during chemotherapy, a time when symptom variability is high. The aim of the current study was to examine lagged changes among daily symptoms during platinum-based chemotherapy.

METHOD

Participants were 78 women with gynecologic cancer (mean age 63 years, SD = 11; 91% Caucasian, 97% non-Hispanic). Sleep disturbance was assessed via wrist actigraphy, whereas fatigue and depressed mood were assessed via daily diary in the week after participants' first chemotherapy infusion. Latent change score models (LCS) were used to examine lagged relationships between symptom pairs.

RESULTS

High levels of sleep disturbance (i.e., minutes awake at night) were associated with earlier subsequent peaks in fatigue, and high levels of fatigue were associated with higher subsequent levels of depressed mood.

CONCLUSIONS

These findings suggest that sleep disturbance, fatigue, and depressed mood occur in a cascade pattern during chemotherapy, in which increases in sleep disturbance contribute to fatigue, which, in turn, contributes to depressed mood. Interventions targeting symptoms early in the cascade, such as sleep disturbance, may provide benefits across multiple downstream symptoms.

Monitoring physical and psychosocial symptom trajectories in ovarian cancer patients receiving chemotherapy

BACKGROUND

Diagnosis and treatment of ovarian cancer (OC) entail severe symptom burden and a significant loss of quality of life (QOL). Somatic and psychological impairments may persist well beyond active therapy. Although essential for optimal symptom management as well as for the interpretation of treatment outcomes, knowledge on the course of QOL-related issues is scarce. This study aimed at assessing the course of depressive symptoms, anxiety, fatigue and QOL in patients with OC over the course of chemotherapy until early after-care.

METHODS

23 patients were assessed longitudinally (eight time points) with regard to symptom burden (depression, anxiety, fatigue, and QOL) by means of patient-reported outcome instruments (HADS, MFI-20, EORTC QLQ-C30/-OV28) and clinician ratings (HAMA/D) at each chemotherapy cycle and at the first two aftercare visits.

RESULTS

Statistically significant decrease over time was found for depressive symptoms and anxiety as well as for all fatigue scales. With regard to QOL, results indicated significant increase for 11 of 15 QOL scales, best for Social (effect size = 1.95; p < 0.001), Emotional (e.s. = 1.62; p < 0.001) and Physical Functioning (e.s. = 1.47; p < 0.001). Abdominal Symptoms (e.s. = 1.01; p = 0.009) decreased, Attitudes towards Disease and Treatment (e.s. = 1.80; p < 0.001) improved significantly over time. Analysis of Sexual Functioning was not possible due to a high percentage of missing responses (61.9%).

CONCLUSIONS

The present study underlines the importance of longitudinal assessment of QOL in order to facilitate the identification of symptom burden in OC patients. We found that patients show high levels of fatigue, anxiety and depressive symptoms and severely impaired QOL post-surgery (i.e. at start of chemotherapy) but condition improves considerably throughout chemotherapy reaching nearly general population symptoms levels until aftercare.

Adjuvant chemotherapy for endometrial cancer after hysterectomy

BACKGROUND

Endometrial adenocarcinoma (womb cancer) is a malignant growth of the lining (endometrium) of the womb (uterus). It is distinct from sarcomas (tumours of the uterine muscle). Survival depends the risk of microscopic metastases after surgery. Adjuvant (postoperative) chemotherapy improves survival from some other adenocarcinomas, and there is evidence that endometrial cancer is sensitive to cytotoxic therapy. This systematic review examines the effect of chemotherapy on survival after hysterectomy for endometrial cancer.

OBJECTIVES

To assess efficacy of adjuvant (postoperative) chemotherapy for endometrial cancer.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2010, Issue 3), MEDLINE and EMBASE up to August 2010, registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing adjuvant chemotherapy with any other adjuvant treatment or no other treatment.

DATA COLLECTION AND ANALYSIS

We used a random-effects meta-analysis to assess hazard ratios (HR) for overall and progression-free survival and risk ratios (RR) to compare death rates and site of initial relapse.

MAIN RESULTS

Five RCTs compared no additional treatment with additional chemotherapy after hysterectomy and radiotherapy. Four trials compared platinum based combination chemotherapy directly with radiotherapy. Indiscriminate pooling of survival data from 2197 women shows a significant overall survival advantage from adjuvant chemotherapy (RR (95% CI) = 0.88 (0.79 to 0.99)). Sensitivity analysis focused on trials of modern platinum based chemotherapy regimens and found the relative risk of death to be 0.85 ((0.76 to 0.96); number needed to treat for an additional beneficial outcome (NNT) = 25; absolute risk reduction = 4% (1% to 8%)). The HR for overall survival is 0.74 (0.64 to 0.89), significantly favouring the addition of postoperative platinum based chemotherapy. The HR for progression-free survival is 0.75 (0.64 to 0.89). This means that chemotherapy reduces the risk of being dead at any censorship by a quarter. Chemotherapy reduces the risk of developing the first recurrence outside the pelvis (RR = 0.79 (0.68 to 0.92), 5% absolute risk reduction; NNT = 20). The analysis of pelvic recurrence rates is underpowered but the trend suggests that chemotherapy may be less effective than radiotherapy in a direct comparison (RR = 1.28 (0.97 to 1.68)) but it may have added value when used with radiotherapy (RR = 0.48 (0.20 to 1.18)).

AUTHORS' CONCLUSIONS

Postoperative platinum based chemotherapy is associated with a small benefit in progression-free survival and overall survival irrespective of radiotherapy treatment. It reduces the risk of developing a metastasis, could be an alternative to radiotherapy and has added value when used with radiotherapy.

Assessing health-related quality of life in gynecologic oncology: a systematic review of questionnaires and their ability to detect clinically important differences and change

OBJECTIVES

Researchers wishing to assess the health-related quality of life (HRQoL) of women with gynecologic cancers have a range of questionnaires to choose from. In general, disease-, treatment-, or symptom-specific questionnaires are assumed to be better able to identify between-group differences (sensitivity) and changes over time (responsiveness) than are cancer-specific or generic questionnaires. However, little work has tested this assumption in oncology. We set out to (a) identify all multidimensional HRQoL questionnaires used in studies with women with gynecologic cancer and (b) evaluate their track records in identifying minimal clinically important differences (MCIDs), with a view to making recommendations.

METHODS

We searched MEDLINE using the term quality of life and each gynecologic cancer type, as well as the names of identified questionnaires. We used 10% of the scale range as the threshold for an MCID.

RESULTS

We identified 1 generic (SF-36/SF-12), 3 cancer-specific (European Organisation for the Research and Treatment of Cancer Quality of Life Questionnaire [EORTC QLQ] C30, Functional Assessment of Cancer Therapy-General [FACT-G], and short-form Cancer Rehabilitation Evaluation System [CARES-SF]), and 1 disease-specific (QOL-Ovarian Cancer Patient Version) HRQoL questionnaires and 5 disease-specific (QLQ-OV28, FACT-O for ovarian, QLQ-CX24, FACT-Cx for cervical and FACT-V for vulvar), 1 treatment-specific (FACT and Gynecologic Oncology Group-Ntx for neurotoxicity), and 2 symptom-specific (FACT-Anemia and Functional Assessment of Chronic Illness and Therapy [FACIT]-Fatigue) modules. Twenty-seven articles reported results from 26 studies in which an MCID had been identified. The FACIT's anemia and fatigue subscales were more sensitive, and the neurotoxicity subscale more sensitive and responsive than the FACT-G on at least 1 comparison. However, we found no evidence for superior performance by the FACT-G compared with the SF-36 or EORTC and FACIT disease-specific modules versus the QLQ-C30 and FACT-G. There was also little evidence to favor EORTC versus FACIT questionnaires or vice versa.

CONCLUSIONS

The evidence we reviewed offered little support for the hypothesis that disease-, symptom-, or treatment-specific instruments are more sensitive and responsive than cancer-specific or generic questionnaires. However, conclusions were limited by the small number of head-to-head comparisons available. We summarize the clinical contexts in which each instrument identified an MCID to inform choice of questionnaire(s), sample size calculations, and interpretation of results in future studies.

Toxicity and quality of life outcomes in ovarian cancer patients participating in randomized controlled trials

MAIN PURPOSE

The objective of this study was to determine the relationship between clinician-graded symptoms based on the common toxicity criteria (CTC) and patient-reported quality of life (QoL). We hypothesized that toxicity symptoms that are objective or observable would have a higher correlation with QoL than subjective data.

MATERIAL AND METHODS

A retrospective analyses of data from three closed randomized chemotherapy trials was performed. A total of 2,110 patients with ovarian cancer (stage IIB-IV) who had complete toxicity and QoL data at cycles 3 and 6 were included. Toxicities were graded according to the National Cancer Institute Common Toxicity Criteria. Quality of life was assessed every other cycle by using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30).

MAIN RESULTS

Correlations between CTC grading and the QLQ-C30 functioning scales were weak (<0.30); correlation coefficients between CTC ratings and the QLQ-C30 symptom scales including nausea, vomiting, constipation, pain, and dyspnea ranged from 0.32 to 0.49 except for constipation (0.55). On a symptom level exact agreement between clinician and patient reporting ranged from 54.2% (pain) to 80.8% (emesis/vomiting). When symptom grading differed, patients reported greater severity for pain, constipation, and dyspnea, whereas clinicians graded emesis/vomiting and nausea as more severe than the grading by patients.

CONCLUSION

Patient experience is not routinely captured by CTC toxicity scales. Therefore, clinicians should not entirely rely on the CTC grading but consider patient-reported outcomes as well.

Added value of health-related quality of life measurement in cancer clinical trials: the experience of the NCIC CTG

Health-related quality-of-life (HRQoL) data are often included in Phase III clinical trials. We evaluate and classify the value added to Phase III trials by HRQoL outcomes, through a review of the National Cancer Institute of Canada Clinical Trials Group clinical trials experience within various cancer patient populations. HRQoL may add value in a variety of ways, including the provision of data that may contrast with or may support the primary study outcome; or that assess a unique perspective or subgroup, not addressed by the primary outcome. Thus, HRQoL data may change the study's interpretation. Even in situations where HRQoL measurement does not alter the clinical interpretation of a trial, important methodologic advances can be made. A classification of the added value of HRQoL information is provided, which may assist in choosing trials for which measurement of HRQoL outcomes will be beneficial.

Unanticipated toxicities from anticancer therapies: survivors' perspectives

CONTEXT

Improved therapies in oncology have resulted in increased survival across numerous malignancies, shifting attention to other aspects of the cancer experience. In particular, the impact of treatment-related toxicities has gained considerable attention, due to their physical and psychosocial effects, and possible impact on clinical outcome. These untoward events have not been examined from the survivors' perspective.

OBJECTIVE

To identify and describe treatment-related toxicities having a negative effect on quality of life from the perspective of cancer survivors.

DESIGN

Quantitative study using written questionnaires and content analysis.

SETTING

Cancer survivors' workshop across the United States.

PARTICIPANTS

A total of 379 participants from six survivor groups: breast (n = 250), ovarian (n =27), lung (n = 23), colorectal (n = 15), genitourinary (n = 23), and other cancers (n = 45).

OUTCOME MEASURES

Survivors' perceptions on treatment-related dermatologic, gastrointestinal, and constitutional toxicities.

RESULTS

Survivors reported an increased concern regarding dermatologic toxicities, including irritated and dry skin, after receiving their cancer treatment. These events had a negative effect on their lives. Although gastrointestinal and constitutional toxicities also had a negative effect, the concern over their development was unchanged prior to and after treatments.

CONCLUSION

The impact of dermatologic toxicities is unanticipated prior to cancer treatments. Since these events have a negative effect on survivors' lives, pretreatment counseling and effective interventions are vital in order to maximize quality of life and minimize unnecessary treatment interruptions or discontinuations.

Health-related quality of life in patients with advanced colorectal cancer treated with cetuximab: overall and KRAS-specific results of the NCIC CTG and AGITG CO.17 Trial

PURPOSE

National Cancer Institute of Canada Clinical Trials Group CO.17 demonstrated the antiepidermal growth factor receptor (anti-EGFR) monoclonal antibody cetuximab improves overall and progression-free survival in patients with advanced, chemotherapy-refractory colorectal cancer (CRC), particularly in patients with wild-type KRAS tumors. This article reports the health-related quality-of-life (HRQL) outcomes from CO.17.

PATIENTS AND METHODS

Patients (N = 572) with pretreated EGFR-detectable advanced CRC were randomly assigned to cetuximab and best supportive care (BSC) or to BSC alone. HRQL primary end points assessed by the EORTC QLQ-C30 were physical function (PF) and global health status (GHS); mean changes from baseline to 8 and 16 weeks were assessed. Post hoc analysis by KRAS mutation status was performed.

RESULTS

Questionnaire compliance was 94% at baseline, but it declined differentially (67% v 47% for cetuximab v BSC at 16 weeks). PF change scores were -3.9 for cetuximab and -8.6 for BSC (P = .046) at 8 weeks and were -5.9 and -12.5 for cetuximab and BSC, respectively, (P = .027) at 16 weeks. GHS change scores were -0.5 and -7.1 (P = .008) at 8 weeks and were -3.6 and -15.2 (P = .008) at 16 weeks for cetuximab and BSC, respectively. In patients who had tumors with wild-type KRAS status, cetuximab resulted in less PF deterioration at 8 weeks (-0.7 v -7.2; P = .11) and 16 weeks (-3.4 v -13.8; P = .008) compared with BSC. Patients with wild-type status who received cetuximab experienced improved GHS at 8 weeks, whereas patients who received BSC alone deteriorated (3.2 v -7.7; P = .002). Cetuximab preserved GHS at 16 weeks (-0.2 v -18.1; P < .001). No significant differences were noted between study arms for patients with mutated KRAS tumors.

CONCLUSION

Cetuximab offers important HRQL and survival benefits for pretreated patients with advanced, wild-type KRAS CRC.

Quality-of-life issues in the management of epithelial ovarian cancer

The importance of quality-of-life (QOL) measurements in cancer management is being increasingly appreciated. This is especially important in patients with advanced cancers. Over 80% of women with epithelial ovarian cancer (EOC) will present with disease outside the ovary as there are no accurate screening tests, and symptoms usually do not develop until EOC has spread. Standard treatment includes debulking surgery followed by chemotherapy to which most women will have a complete response but only a minority of women with advanced disease will be cured. Fortunately, advances in surgical and chemotherapeutic management have improved overall survival with 45% of women of all stages living 5 years or longer. EOC may in many cases be considered a "chronic cancer," which highlights the importance of QOL in management decisions. QOL may be affected by the disease itself as well as by surgical and chemotherapeutic treatments. Future studies of the care and treatment of EOC patients should include well-designed QOL evaluations.

Follow-up after breast cancer

Should be evidence based, flexible, and tailored to patients’ lifelong needs

Lessons learned in the assessment of health-related quality of life: selected examples from the National Cancer Institute of Canada Clinical Trials Group

In this article, we provide a brief historical review of the development of patient-reported outcome measurement, analysis, and reporting in clinical trials of the National Cancer Institute of Canada Clinical Trials Group (NCIC CTG). In doing so, we examine selected lessons learned in furthering the quality of these data and their application to clinical practice. We conclude that sequential institution of key policies within the NCIC CTG and the development of a collective philosophy within the group has enabled the routine incorporation of health-related quality of life into clinical trial protocols according to robust scientific principles; that collection of quality data is possible in a variety of circumstances (although not universally so); that patient-reported data on subjective experiences is likely to be more reliable and valid than conventional toxicity information; and that simple analyses that report group trends as well as individual patient response rates are preferred.

The prognostic effects of performance status and quality of life scores on progression-free survival and overall survival in advanced ovarian cancer

OBJECTIVE

Performance status (PS) is an important prognostic factor in advanced ovarian cancer. The purpose of this study was to evaluate the prognostic significance of PS and quality of life (QoL) assessment on progression-free survival (PFS) and overall survival (OS) in patients with advanced ovarian cancer.

METHODS

We studied Canadian patients participating in an intergroup study in ovarian cancer (NCIC-OV10), which randomized patients to receive either standard chemotherapy using cisplatin/cyclophosphamide or cisplatin/paclitaxel chemotherapy. QoL was assessed using the EORTC quality of life questionnaire (QLQ-C30+3). The effects of multiple variables including the relevant clinical variables, PS and QoL scores were analyzed by Cox stepwise regression at baseline and again 3 months after completion of chemotherapy.

RESULTS

At baseline and at 3 months after chemotherapy, there were 151 and 93 patients respectively who completed the QLQ-C30+3 questionnaires. Baseline PS, global QoL score and treatment were independent predictors for both PFS and OS. Baseline cognitive functioning score was also an additional independent predictor for OS. At 3 months after completion of chemotherapy global QoL score, PS and grade were significant independent predictors of OS; however, only physical functioning score, emotional functioning score and tumor grade predicted for PFS.

CONCLUSIONS

Performance status and global quality of life scores at baseline are prognostic factors in advanced ovarian cancer for both PFS and OS. Higher baseline cognitive functioning scores were also associated with improved survival. Global QoL scores at 3 following completion of chemotherapy proved to be of prognostic significance for OS but not PFS.

Symptom Clusters and Quality of Life in Survivors of Ovarian Cancer

Ovarian cancer has nonspecific symptoms, and no screening tool is available for early diagnosis; therefore, only 19% of ovarian cancers are found at an early stage. Given the late diagnosis, women with ovarian cancer often have a prolonged course of treatment and significant morbidity that lasts into survivorship. However, distressing symptoms and their effects on quality of life have been relatively understudied, particularly in survivors of the disease. The purpose of this study was to describe a symptom cluster and its relationship to quality of life in women with ovarian cancer who were recruited from an online cancer support group. Descriptive statistics and hierarchical regression techniques were used to analyze the data obtained from a larger study testing the psychometric properties of a quality-of-life instrument. Most participants had stage III ovarian cancer, and nearly all (97%) had undergone treatment before the study. A symptom cluster composed of depression and fatigue was identified using work by Kim and colleagues [Symptom clusters: concept analysis and clinical implications for cancer nursing. Cancer Nurs. 2005;28(4):270-282]. The symptom cluster explained 41% (P = .000) of the variance in quality of life. These results suggest that fatigue and depression are significant problems for survivors of ovarian cancer.

Symptom improvement in lung cancer patients treated with erlotinib: quality of life analysis of the National Cancer Institute of Canada Clinical Trials Group Study BR.21

PURPOSE

This report describes the quality of life (QOL) findings of a randomized placebo controlled study of erlotinib, an epidermal growth factor receptor inhibitor, in patients with non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

This double-blind phase III trial randomly assigned 731 patients with NSCLC who had progressed after prior chemotherapy to erlotinib 150 mg daily or placebo, with survival as the primary study outcome. QOL was assessed by European Organisation for Research and Treatment of Cancer QLQ-C30 and the lung cancer module QLQ-LC13. The primary end points for QOL analysis were time to deterioration of three common lung cancer symptoms: cough, dyspnea, and pain.

RESULTS

Survival was significantly longer (hazard ratio, 0.70; P < .0001) in the erlotinib arm. Compliance with QOL was 87% at baseline and more than 70% during treatment. Patients receiving erlotinib had significantly longer median time to deterioration for all three symptoms (4.9 v 3.7 months for cough [P = .04]; 4.7 v 2.9 months for dyspnea [P = .04], and 2.8 v 1.9 months for pain [P = .03]). QOL response analyses showed that 44%, 34%, and 42% of patients receiving erlotinib had improvement in these three symptoms, respectively. This was accompanied by a significant improvement in the physical function (31% erlotinib v 19% placebo, P = .01), and global QOL (35% v 26%, P < .0001). Patients with complete or partial response were more likely to have improvement in the QOL response than patients with stable or progressive disease (P < .01).

CONCLUSION

Erlotinib not only improves survival in previously treated patients with NSCLC, but also improves tumor-related symptoms and important aspects of QOL.

Longitudinal assessment of quality of life and lifestyle in newly diagnosed ovarian cancer patients: the roles of surgery and chemotherapy

OBJECTIVES

To prospectively evaluate quality of life (QoL), use of complementary and alternative medicine (CAM), and diet/exercise changes in ovarian cancer patients during the first 6 months following diagnosis.

METHODS

Patients with newly diagnosed ovarian cancer were enrolled pre- or post-operatively and surveyed at 3 and 6 months. The Functional Assessment of Cancer Therapy (FACT-G), Medical Outcomes Survey (SF-36), and CAM/diet/exercise questionnaires were used. Independent samples t test and repeated measures ANOVA were used.

RESULTS

Forty-two patients underwent surgical debulking and staging prior to chemotherapy. Patients completing the initial surveys post-operatively had significantly lower physical FACT-G and SF-36 physical scores compared to patients completing the surveys pre-operatively. In patients completing the baseline survey pre-operatively, there was a decrease in physical scores at 3 months (after surgery and during chemotherapy). There was no change observed at 3 months relative to baseline when patients completed the baseline survey post-operatively. Increases in physical and functional well-being were seen at 6 months relative to 3 months. There were no changes in emotional or social scores over time. CAM use increased over time; main reasons were to improve QoL and relieve symptoms. Alterations in diet and exercise were not seen.

CONCLUSIONS

These data highlight the need to conduct assessments before and after surgery to identify effects due to surgery and/or chemotherapy. Patients may be using CAM during chemotherapy to deal with symptoms and compensate for decreased QoL. Intervention trials should be implemented to increase QoL following surgery and during adjuvant chemotherapy.

The Relationship Between Meaning of Illness, Social Support, Coping Strategies, and Quality of Life for Lung Cancer Patients and Their Family Members

This article explores the relationship between meaning of illness, perceived social support resources, coping strategies used, and quality of life (QOL) by patients with lung cancer and their family members. The study was cross-sectional using interview data from 85 patients and associated family members. Regression results showed that total QOL in patients with lung cancer is predicted most by meaning of illness, specifically, the illness being perceived as manageable. QOL in family members is predicted most by meaning of illness, specifically, less adverse impact. Interestingly, the overall meaning of illness, coping strategies used, and social support were similar in the 2 groups. The results of the study emphasize the importance of acknowledging the circumstances of people's lives, both patients surviving lung cancer and their family members, which contribute to QOL.

SCOTROC 2B: feasibility of carboplatin followed by docetaxel or docetaxel-irinotecan as first-line therapy for ovarian cancer

The feasibility of combination irinotecan, carboplatin and docetaxel chemotherapy as first-line treatment for advanced epithelial ovarian carcinoma was assessed. One hundred patients were randomised to receive four 3-weekly cycles of carboplatin (area under the curve (AUC) 7) followed by four 3-weekly cycles of docetaxel 100 mg m(-2) (arm A, n=51) or docetaxel 60 mg m(-2) with irinotecan 200 mg m(-2) (arm B, n=49). Neither arm met the formal feasibility criterion of an eight-cycle treatment completion rate that was statistically greater than 60% (arm A 71% (90% confidence interval (CI) 58-81%; P=0.079; arm B 67% (90% CI 55-78%; P=0.184)). Median-dose intensities were >85% of planned dose for all agents. In arms A and B, 15.6 and 12.2% of patients, respectively, withdrew owing to treatment-related toxicity. Grade 3-4 sensory neurotoxicity was more common in arm A (1.9 vs 0%) and grade 3-4 diarrhoea was more common in arm B (0.6 vs 3.5%). Of patients with radiologically evaluable disease at baseline, 50 and 48% responded to therapy in arms A and B, respectively; at median 17.1 months' follow-up, median progression-free survival was 17.1 and 15.9 months, respectively. Although both arms just failed to meet the formal statistical feasibility criteria, the observed completion rates of around 70% were reasonable. The addition of irinotecan to first-line carboplatin and docetaxel chemotherapy was generally well tolerated although associated with increased gastrointestinal toxicity. Further exploratory studies of topoisomerase-I inhibitors in this setting may be warranted.

Residual neurotoxicity in ovarian cancer patients in clinical remission after first-line chemotherapy with carboplatin and paclitaxel: the Multicenter Italian Trial in Ovarian cancer (MITO-4) retrospective study

BACKGROUND

Carboplatin/paclitaxel is the chemotherapy of choice for advanced ovarian cancer, both in first line and in platinum-sensitive recurrence. Although a significant proportion of patients have some neurotoxicity during treatment, the long-term outcome of chemotherapy-induced neuropathy has been scantly studied. We retrospectively assessed the prevalence of residual neuropathy in a cohort of patients in clinical remission after first-line carboplatin/paclitaxel for advanced ovarian cancer.

METHODS

120 patients have been included in this study (101 participating in a multicentre phase III trial evaluating the efficacy of consolidation treatment with topotecan, and 19 treated at the National Cancer Institute of Naples after the end of the trial). All patients received carboplatin (AUC 5) plus paclitaxel (175 mg/m2) every 3 weeks for 6 cycles, completing treatment between 1998 and 2003. Data were collected between May and September 2004. Residual sensory and motor neurotoxicity were coded according to the National Cancer Institute--Common Toxicity Criteria.

RESULTS

55 patients (46%) did not experience any grade of neurological toxicity during chemotherapy and of these none had signs of neuropathy during follow-up. The other 65 patients (54%) had chemotherapy-induced neurotoxicity during treatment and follow-up data are available for 60 of them. Fourteen out of 60 patients (23%) referred residual neuropathy at the most recent follow-up visit, after a median follow up of 18 months (range, 7-58 months): 12 patients had grade 1 and 2 patients grade 2 peripheral sensory neuropathy; 3 patients also had grade 1 motor neuropathy. The remaining 46/60 patients (77%) had no residual neuropathy at the moment of interview: recovery from neurotoxicity had occurred in the first 2 months after the end of chemotherapy in 22 (37%), between 2 and 6 months in 15 (25%), or after more than 6 months in 9 patients (15%). Considering all 120 treated patients, there was a 15% probability of persistent neurological toxicity 6 months after the end of chemotherapy.

CONCLUSION

A significant proportion of patients with advanced ovarian cancer treated with first-line carboplatin/paclitaxel suffer long-term residual neuropathy. This issue should be carefully taken into account before considering re-treatment with the same agents in sensitive recurrent disease.

The impact of treatment for gynecological cancer on health-related quality of life (HRQoL): a systematic review

Gynecologic cancers are major sources of mortality and morbidity. Although many review articles have reported on the impact of these diseases on health-related quality of life (HRQoL), none have reviewed the evidence in specific relation to the effect of treatment on HRQoL. Consequently, we systematically searched 4 electronic databases and hand-searched relevant reference lists and bibliographies to identify literature on this subject. Only 47 studies used a validated questionnaire to measure HRQoL. Although a meta-analysis was not possible, we found HRQoL rarely included as a treatment outcome, and when included assessment was often methodologically flawed. Seldom were pretreatment and posttreatment data collected or treatment regimes documented. Except for a few studies, analysis of HRQoL was conducted on small samples, excluding the cancer site and stage. Consequently, no definitive conclusions could be drawn and therefore we conclude with recommendations for the future reporting of HRQoL in gynecologic oncology studies.

Acceptance of adjuvant therapy and quality of life issues

The acceptance of adjuvant treatment for early breast cancer (EBC) is dependent on the information that women are given about: available options, likely therapeutic gains, side effect profiles, convenience of treatment as well as their prior knowledge, experience and expectations. Acceptability in terms of adherence to treatment is then dependent on the actual burden experienced and the impact this has on quality of life (QoL). Studies show that >40% women do not adhere to tamoxifen because of side effects affecting QoL. The burden of adjuvant therapy may be underestimated by clinicians; thus, when options are discussed, treatments may appear more favourable and acceptable than they really are. The aim of the newer aromatase inhibitors (AIs) is to enhance efficacy without the associated unacceptable side effects. Interim results from the QoL sub-protocols of three trials, ATAC, IES and MA-17, provide useful indications of acceptability and the impact that AIs have on QoL. Data from patient self-report questionnaires and preference studies are needed to inform treatment recommendations and to aid the development of ameliorative interventions needed to accompany the most efficacious therapies.

Quality of life assessment during adjuvant and salvage chemotherapy for advance stage epithelial ovarian cancer

OBJECTIVES

This report assessed the quality of life of ovarian cancer patients undergoing adjuvant and salvage chemotherapy treatment.

METHODS

All epithelial ovarian cancer patients requiring chemotherapy to manage their disease were recruited from university based gynecologic oncology clinics. Quality of life was measured using the FACT-O (Functional Assessment of Cancer Therapy-Ovarian module version 4) questionnaire. Descriptive statistics and two-way analysis of variance were used to compare the effect on the mean quality of life scores with respect to the indications of chemotherapy and best radiologic response. Any P value of less than 0.10 was considered worthy of interest.

RESULTS

Ninety-three patients participated. In the adjuvant setting, there was a trend towards better quality of life with better response to therapy. In patients with a first recurrence, complete response to therapy clearly had a beneficial effect on overall quality of life compared to stable or partial response. There was no significant quality of life difference between those with partial response versus stable disease in a first recurrent setting. In patients with more than one recurrence, no large change in overall quality of life was observed across the range of tumor responses.

CONCLUSION

Chemotherapy is beneficial to improve quality of life of ovarian cancer patients. Differential effect of tumor response status on quality of life at different treatment phases requires further investigations.

Magnifying endoscopic observation of the gastric mucosa, particularly in patients with atrophic gastritis

The gastric mucosal surface was observed using the magnifying fibergastroscope (FGS-ML), and the fine gastric mucosal patterns, which were even smaller than one unit of gastric area, were examined at a magnification of about 30. For simplicification, we classified these patterns by magnifying endoscopy in the following ways; FP, FIP, FSP, SP and MP, modifying Yoshii's classification under the dissecting microscope. The FIP, which was found to have round and long elliptical gastric pits, is a new addition to our endoscopic classification. The relationship between the FIP and the intermediate zone was evaluated by superficial and histological studies of surgical and biopsy specimens. The width of the band of FIP seems to be related to the severity of atrophic gastritis. Also, the transformation of FP to FIP was assessed by comparing specimens taken from the resected and residual parts of the stomach, respectively. Moreover, it appears that severe gastritis occurs in the gastric mucosa which shows a FIP. Therefore, we consider that the FIP indicates the position of the atrophic border.