Patient-reported outcomes assessment in cancer trials: taking stock, moving forward

A Collection of Components to Design Clinical Dashboards Incorporating Patient-Reported Outcome Measures: Qualitative Study

BACKGROUND

A clinical dashboard is a data-driven clinical decision support tool visualizing multiple key performance indicators in a single report while minimizing time and effort for data gathering. Studies have shown that including patient-reported outcome measures (PROMs) in clinical dashboards supports the clinician's understanding of how treatments impact patients' health status, helps identify changes in health-related quality of life at an early stage, and strengthens patient-physician communication.

OBJECTIVE

This study aims to determine design components for clinical dashboards incorporating PROMs to inform software producers and users (ie, physicians).

METHODS

We conducted interviews with software producers and users to test preselected design components. Furthermore, the interviews allowed us to derive additional components that are not outlined in existing literature. Finally, we used inductive and deductive coding to derive a guide on which design components need to be considered when building a clinical dashboard incorporating PROMs.

RESULTS

A total of 25 design components were identified, of which 16 were already surfaced during the literature search. Furthermore, 9 additional components were derived inductively during our interviews. The design components are clustered in a generic dashboard, PROM-related, adjacent information, and requirements for adoption components. Both software producers and users agreed on the primary purpose of a clinical dashboard incorporating PROMs to enhance patient communication in outpatient settings. Dashboard benefits include enhanced data visualization and improved workflow efficiency, while interoperability and data collection were named as adoption challenges. Consistency in dashboard design components is preferred across different episodes of care, with adaptations only for disease-specific PROMs.

CONCLUSIONS

Clinical dashboards have the potential to facilitate informed treatment decisions if certain design components are followed. This study establishes a comprehensive framework of design components to guide the development of effective clinical dashboards incorporating PROMs in health care practice.

Yoga Therapy as an Intervention to Improve Patient-Reported Outcomes Among Adults After Treatment for Cancer: Preliminary Findings From a Trial Using Single-Subject Experimental Design

BACKGROUND

Cancer is a chronic condition associated with a substantial symptom burden, which can impair recovery after treatment. Investigating interventions with potential to improve self-reported disease and/or treatment effects-known as patient-reported outcomes (PROs)-is paramount to inform cancer care. The objective of this study was to evaluate the effects of a yoga therapy (YT) intervention on key PROs (ie, cancer-related fatigue, anxiety, cognitive function, depression, stress, quality of life [QoL]) among adults after treatment for cancer.

METHODS

Data from 20 adults (Mage = 55.74 years, 85% female; Mtime since diagnosis = 2.83 years) who had completed treatment for cancer were analyzed for this study. In this single-subject exploratory experimental study, the YT intervention comprised a 1:1 YT session (ie, 1 participant with 1 yoga therapist) followed by 6 weekly small (ie, 2-3 participants) group YT sessions. Group sessions were facilitated by the same yoga therapist who delivered participants' 1:1 session to ensure an in-depth personalized approach. PROs were assessed before (ie, pre-intervention) and after the 1:1 YT session (ie, during the intervention), as well as after the last group YT session (ie, post-intervention). Hierarchical linear modeling was used to analyze the data.

RESULTS

Participants showed improvements in cancer-related fatigue, state anxiety, trait anxiety, perceived cognitive impairments, impacts of perceived cognitive impairments on QoL, and 1 dimension of QoL (ie, functional wellbeing) over time. Notably, cancer-related fatigue and state anxiety increased immediately after the 1:1 session, but showed greater improvements over time afterward (ie, during the intervention phase). No changes were observed for the remaining PROs.

CONCLUSION

Although results require confirmation in future trials, this study highlights the importance of continuing to investigate YT as an intervention to enhance important PROs (ie, cancer-related fatigue and state anxiety) after treatment for cancer. More research is needed to identify additional beneficial effects and factors that influence participants' responses to 1:1 and group YT (ie, moderators and mediators).

REGISTRATION NUMBER

ISRCTN64763228.

DATE OF REGISTRATION

December 12, 2021. This trial was registered retrospectively.

URL OF TRIAL REGISTRY RECORD

https://www.isrctn.com/ISRCTN64763228.

PUBLISHED PROTOCOL

Brunet, J., Wurz, A., Hussien, J., Pitman, A., Conte, E., Ennis, J. K., . . . & Seely, D. (2022). Exploring the Effects of Yoga Therapy on Heart Rate Variability and Patient-Reported Outcomes After Cancer Treatment: A Study Protocol. Integrative Cancer Therapies, 21, 15347354221075576.

Integrative Oncology Care of Symptoms of Anxiety and Depression in Adults With Cancer: Society for Integrative Oncology-ASCO Guideline

PURPOSE

To provide evidence-based recommendations to health care providers on integrative approaches to managing anxiety and depression symptoms in adults living with cancer.

METHODS

The Society for Integrative Oncology and ASCO convened an expert panel of integrative oncology, medical oncology, radiation oncology, surgical oncology, palliative oncology, social sciences, mind-body medicine, nursing, methodology, and patient advocacy representatives. The literature search included systematic reviews, meta-analyses, and randomized controlled trials published from 1990 through 2023. Outcomes of interest included anxiety or depression symptoms as measured by validated psychometric tools, and adverse events. Expert panel members used this evidence and informal consensus with the Guidelines into Decision Support methodology to develop evidence-based guideline recommendations.

RESULTS

The literature search identified 110 relevant studies (30 systematic reviews and 80 randomized controlled trials) to inform the evidence base for this guideline.

RECOMMENDATIONS

Recommendations were made for mindfulness-based interventions (MBIs), yoga, relaxation, music therapy, reflexology, and aromatherapy (using inhalation) for treating symptoms of anxiety during active treatment; and MBIs, yoga, acupuncture, tai chi and/or qigong, and reflexology for treating anxiety symptoms after cancer treatment. For depression symptoms, MBIs, yoga, music therapy, relaxation, and reflexology were recommended during treatment, and MBIs, yoga, and tai chi and/or qigong were recommended post-treatment.

DISCUSSION

Issues of patient-health care provider communication, health disparities, comorbid medical conditions, cost implications, guideline implementation, provider training and credentialing, and quality assurance of natural health products are discussed. While several approaches such as MBIs and yoga appear effective, limitations of the evidence base including assessment of risk of bias, nonstandardization of therapies, lack of diversity in study samples, and lack of active control conditions as well as future research directions are discussed.Additional information is available at www.asco.org/survivorship-guidelines.

The Association of Resilience with Way of Coping, Psychological Well-Being and Quality of Life in Parents of Children with Cancer

Evidence shows that resilience is crucial to maintain psychological well-being and quality of life in the face of stress and adversity. However, the relationships between resilience and psychological well-being and factors associated with quality of life in Hong Kong Chinese parents of children with cancer are underexplored. This study aimed to examine the interrelationships among resilience, ways of coping, psychological well-being, and quality of life among Chinese parents of children with cancer, and identify factors associated with their quality of life. A cross-sectional study was conducted with 119 Chinese parents of children with cancer at the Hong Kong Children's Hospital between January 2020 and March 2022. Parents' resilience level, ways of coping, depressive symptoms, state anxiety scores, perceived social support, and quality of life were assessed. Participating parents (n = 119) included 98 mothers (82.4%) and 11 parents were from single-parent families (9.2%). Almost half (47.9%) of the parents were potentially at risk for depression. The results showed that participants from single-parent families reported statistically significantly lower levels of resilience (p < 0.001), more depressive symptoms (p < 0.001), and poorer quality of life (p < 0.001) than those who lived with their partners (married). In addition, parents who adopted problem-focused coping strategies reported statistically significantly higher levels of resilience (p < 0.001), fewer depressive symptoms (p < 0.001), and better quality of life (p < 0.001) than those who adopted emotion-focused coping strategies. A multiple regression analysis revealed that resilience (p < 0.001) was associated with quality of life among parents of children with cancer. This study provides further support that resilience is an important factor associated with quality of life in parents of children with cancer. Assessing resilience in parents is an important prerequisite for designing appropriate interventions to increase their resilience and enhance their quality of life.

Prediction of morning fatigue severity in outpatients receiving chemotherapy: less may still be more

INTRODUCTION

Fatigue is the most common and debilitating symptom experienced by cancer patients undergoing chemotherapy (CTX). Prediction of symptom severity can assist clinicians to identify high-risk patients and provide education to decrease symptom severity. The purpose of this study was to predict the severity of morning fatigue in the week following the administration of CTX.

METHODS

Outpatients (n = 1217) completed questionnaires 1 week prior to and 1 week following administration of CTX. Morning fatigue was measured using the Lee Fatigue Scale (LFS). Separate prediction models for morning fatigue severity were created using 157 demographic, clinical, symptom, and psychosocial adjustment characteristics and either morning fatigue scores or individual fatigue item scores. Prediction models were created using two regression and five machine learning approaches.

RESULTS

Elastic net models provided the best fit across all models. For the EN model using individual LFS item scores, two of the 13 individual LFS items (i.e., "worn out," "exhausted") were the strongest predictors.

CONCLUSIONS

This study is the first to use machine learning techniques to accurately predict the severity of morning fatigue from prior to through the week following the administration of CTX using total and individual item scores from the Lee Fatigue Scale (LFS). Our findings suggest that the language used to assess clinical fatigue in oncology patients is important and that two simple questions may be used to predict morning fatigue severity.

Exploring differences in symptomatic adverse events assessment between nurses and physicians in the clinical trial setting

A cross-sectional study was performed at Hebei Medical University Fourth Affiliated Hospital from April to July 2020 to explore the difference and consistency between nurses and physicians in terms of symptomatic adverse event (AE) assessment. The Common Terminology Criteria for Adverse Events (CTCAE) was utilized by nurses and physicians to assess patients' symptomatic AEs. Patients self-reported their AEs utilizing the Patient-Reported Outcomes Version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE). Four nurses and three physicians were enrolled to assess patients' symptomatic AEs. Given the same AEs, nurses tended to detect more AEs than physicians, and the differences were statistically significant (P < 0.001). The toxicity grade reported by nurses and physicians showed no difference for all AEs, except for fatigue (χ² = 5.083, P = 0.024). The agreement between nurses and patients was highest compared to the agreement between nurses versus physicians and physicians versus patients. The differences in symptomatic AE assessment can lead to different symptom management. Thus, it is important to establish a collaborative approach between nurses and physicians to ensure continuity in care delivery.

Relationship between nurses' psychological capital and satisfaction of elderly cancer patients during the COVID-19 pandemic

INTRODUCTION

As a special vulnerable group, the physical and mental health of elderly cancer patients has attracted much attention. However, few studies have focused on the impact of nurses' mental state on the mental health of elderly cancer patients during the COVID-19 pandemic. In response to this literature gap, this study aims to explore the impact of nurses' psychological capital on the satisfaction of elderly cancer patients. The job demands-resources model (JD-R) is used to further investigate how work engagement and job resources of nurses affect this relationship.

METHODS

The questionnaire survey was used to collect data, participants included 230 elderly cancer patients and their nurses from a tertiary first-class cancer hospital in China. Partial least squares structural equation modeling (PLS-SEM) was conducted with SmartPLS 3.3.9.

RESULTS

Nurses' psychological capital has a significant positive impact on the satisfaction of elderly cancer patients during the COVID-19 pandemic. Nurses' work engagement is an important mechanism for their psychological capital to affect the satisfaction of elderly cancer patients. In addition, nurses' job resources positively moderate the relationship between their psychological capital and work engagement. The positive relationship between psychological capital and work engagement of nurses is stronger when they have abundant job resources.

DISCUSSION

These findings suggest that healthcare organizations should take the psychological capital of medical staff as an important means to improve their competitive advantage. It can improve the quality of medical services to obtain good performance by effectively developing and managing the psychological capital of medical staff. In addition, healthcare organizations should recognize the importance of providing adequate job resources for medical staff.

Relationship between nurses’ psychological capital and satisfaction of elderly cancer patients during the COVID-19 pandemic

Introduction

As a special vulnerable group, the physical and mental health of elderly cancer patients has attracted much attention. However, few studies have focused on the impact of nurses’ mental state on the mental health of elderly cancer patients during the COVID-19 pandemic. In response to this literature gap, this study aims to explore the impact of nurses’ psychological capital on the satisfaction of elderly cancer patients. The job demands-resources model (JD-R) is used to further investigate how work engagement and job resources of nurses affect this relationship.

Methods

The questionnaire survey was used to collect data, participants included 230 elderly cancer patients and their nurses from a tertiary first-class cancer hospital in China. Partial least squares structural equation modeling (PLS-SEM) was conducted with SmartPLS 3.3.9.

Results

Nurses’ psychological capital has a significant positive impact on the satisfaction of elderly cancer patients during the COVID-19 pandemic. Nurses’ work engagement is an important mechanism for their psychological capital to affect the satisfaction of elderly cancer patients. In addition, nurses’ job resources positively moderate the relationship between their psychological capital and work engagement. The positive relationship between psychological capital and work engagement of nurses is stronger when they have abundant job resources.

Discussion

These findings suggest that healthcare organizations should take the psychological capital of medical staff as an important means to improve their competitive advantage. It can improve the quality of medical services to obtain good performance by effectively developing and managing the psychological capital of medical staff. In addition, healthcare organizations should recognize the importance of providing adequate job resources for medical staff.

Efficacy of a 4-Week Nurse-Led Exercise Rehabilitation Program in Improving the Quality of Life in Women Receiving a Post-Mastectomy Reconstruction Using the Motiva ErgonomixTM Round SilkSurface

We assessed the efficacy of a 4-week nurse-led exercise rehabilitation (ER) program in improving the quality of life (QOL) of breast cancer survivors (BCS) receiving an implant-based breast reconstruction. The eligible patients were equally randomized to either of both groups: the intervention group (n = 30; a 4-week nurse-led ER program) and the control group (n = 30; a 4-week physical therapist-supervised one). Both after a 4-week ER program and at baseline, the patients were evaluated for the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30) and Fatigue Severity Scale (FSS) scores. There was a significantly higher degree of increase in global health status/QOL scores, physical functioning scores, role functioning scores, and emotional functioning scores at 4 weeks from baseline in the intervention group as compared with the control group (p = 0.001). However, there was a significantly higher degree of decrease in fatigue scores, nausea/vomiting scores, pain scores, dyspnea scores, and FSS scores in the intervention group as compared with the control group (p = 0.001). In conclusion, our results indicate that a 4-week nurse-led ER program might be effective in the QOL in BCS receiving a post-mastectomy implant-based reconstruction using the Motiva Ergonomix^TM Round SilkSurface.

Systematic self-reporting of patients’ symptoms: improving oncologic care and patients’ satisfaction

Background:

In recent years, there has been a growing interest to enhance patients’ symptom management during routine cancer care using patient-reported outcome measures. The goal of this study is to analyse patients’ responses to the Edmonton Symptom Assessment System (ESAS) to determine whether patient-reported outcomes could help characterise those patients with the highest supportive care needs and symptom burden in order to help provide targeted support for patients.

Methods:

In this study, we analysed ESAS questionnaire responses completed by patients as part of their routine care and considered part of patients’ standard of care. Statistical analyses were performed using the IBM SPSS Statistics version 26.0. Descriptive statistics are used to summarise patient demographics, disease characteristics and patient-reported symptom severity and prevalence.

Results:

The overall mean age is 65.2 ± 12.8 years comprising 43.8% male and 56.2% female patients. The five common primary disease sites are breast (26.2%), haematology (21.1%), gastrointestinal (15.3%), genitourinary (12.7%) and lung (12.0%) cancers. The mean severity for each symptom is all mild (score: 1–3). The three most common reported symptoms causing distress are tiredness, poor overall wellbeing and anxiety, and the least reported symptom is nausea.

Conclusions:

Systematic self-reporting of patients’ symptoms is important to improve symptom management, timely facilitation of appropriate intervention, patient experience, and patient and family satisfaction. The awareness of disease site, gender and age-related symptom variations should help in the design and provision of appropriate symptom-directed, tumour-specific and patient-focused interventions to meet patients’ immediate needs.

Assessment of Patient Reported Outcomes (PROs) in Outpatients Taking Oral Anticancer Drugs Included in the Real-Life Oncoral Program

Simple Summary

Patients receiving oral anticancer agents (OAAs) have a substantial symptom burden. Given the trend toward patient-centered care, the use of patient-reported outcomes (PROs) seems appropriate to secure medication management, and to improve clinical decision-making. The aim of this study was to assess symptoms potentially related to adverse events experienced by cancer outpatients treated by OAAs using PROs. In total, 407 questionnaires were completed by 63 patients, in which 2333 symptoms were reported. Almost three-quarters (74.6%) reported at least one high-level symptom. The symptoms most commonly experienced were fatigue, various psychological disorders and general pain. This initiative is the first step in the implementation of symptom assessment by PROs in patients treated by OAAs. The results highlight the need for close coordination between community and hospital health professionals, and the integration of patient self-reporting systems in oncologic clinical practice.

Abstract

Background In previous studies, patient-reported outcomes (PROs) have been shown to improve survival in cancer patients. The aim of the present study was to assess symptoms potentially related to adverse events experienced by cancer outpatients treated by oral anticancer agents (OAAs) using PROs. Methods Between September 2018 and May 2019, outpatients starting OAAs were included in a 12-week follow-up to assess 15 symptoms listed in the National Cancer Institute PRO Common Terminology Criteria for Adverse Events, using a 5-point scale of severity or frequency. Patients were requested to alert a referral nurse or pharmacist when they self-assessed high-level (level 3 or 4) symptoms. Results 407 questionnaires were completed by 63 patients in which 2333 symptoms were reported. Almost three-quarters (74.6%) reported at least one high-level symptom. The symptoms that were most commonly experienced were fatigue (>9 in 10 patients; 13.2% of symptoms declared), various psychological disorders (>9 in 10 patients; 28.6% of symptoms declared) and general pain (>8 in 10 patients; 9.4% of symptoms declared). Conclusion PROs are appropriate to detect potential adverse events in cancer outpatients treated by OAAs. This study is the first step for integrating the patient’s perspective in a digital e-health device in routine oncology care.

Patient, family and provider views of measurement-based care in an early-psychosis intervention programme

Background

Measurement-based care (MBC) in mental health improves patient outcomes and is a component of many national guidelines for mental healthcare delivery. Nevertheless, MBC is not routinely integrated into clinical practice. Several known reasons for the lack of integration exist but one lesser explored variable is the subjective perspectives of providers and patients about MBC. Such perspectives are critical to understand facilitators and barriers to improve the integration of MBC into routine clinical practice.

Aims

This study aimed to uncover the perspectives of various stakeholders towards MBC within a single treatment centre.

Method

Researchers conducted qualitative semi-structured interviews with patients (n = 15), family members (n = 7), case managers (n = 8) and psychiatrists (n = 6) engaged in an early-psychosis intervention programme. Data were analysed using thematic analysis, informed by critical realist theory.

Results

Analysis converged on several themes. These include (a) implicit negative assumptions; (b) relevance and utility to practice; (c) equity versus flexibility; and (d) shared decision-making. Providers assumed patients’ perspectives of MBC were negative. Patients’ perspectives of MBC were actually favourable, particularly if MBC was used as an instrument to engage patients in shared decision-making and communication rather than as a dogmatic and rigid clinical decision tool.

Conclusions

This qualitative study presents the views of various stakeholders towards MBC, providing an in-depth examination of the barriers and facilitators to MBC through qualitative investigation. The findings from this study should be used to address the challenges organisations have experienced in implementing MBC.

Perspectives and Emotional Experiences of Patients With Chronic Myeloid Leukemia During ENESTPath Clinical Trial and Treatment-Free Remission: Rationale and Protocol of the Italian Substudy

Achievement of deep molecular response following treatment with a tyrosine kinase inhibitor (TKI) allows for treatment-free remission (TFR) in many patients with chronic myeloid leukemia (CML). Successful TFR is defined as the achievement of a sustained molecular response after cessation of ongoing TKI therapy. The phase 3 ENESTPath study was designed to determine the required optimal duration of consolidation treatment with the second-generation TKI, nilotinib 300 mg twice-daily, to remain in successful TFR without relapse after entering TFR for 12 months. The purpose of this Italian 'patient's voice CML' substudy was to evaluate patients' psycho-emotional characteristics and quality of life through their experiences of stopping treatment with nilotinib and entering TFR. The purpose of the present contribution is to early present the study protocol of an ongoing study to the scientific community, in order to describe the study rationale and to extensively present the study methodology. Patients aged ≥18 years with a confirmed diagnosis of Philadelphia chromosome positive BCR-ABL1+ CML in chronic phase and treated with front-line imatinib for a minimum of 24 months from the enrollment were eligible. Patients consenting to participate the substudy will have quality of life questionnaires and in-depth qualitative interviews conducted. The substudy will include both qualitative and quantitative design aspects to evaluate the psychological outcomes as assessed via patients' emotional experience during and after stopping nilotinib therapy. Randomization is hypothesized to be a timepoint of higher psychological alert or distress when compared to consolidation and additionally any improvement in health-related quality of life (HRQoL) due to nilotinib treatment is expected across the timepoints (from consolidation, to randomization, and TFR). An association is also expected between dysfunctional coping strategies, such as detachments and certain personality traits, and psychological distress and HRQoL impairments. Better HRQoL outcomes are expected in TFR compared to the end of consolidation. This substudy is designed for in-depth assessment of all potential psycho-emotional variables and aims to determine the need for personalized patient care and counselling, and also guide clinicians to consider the psychological well-being of patients who are considering treatment termination. NCT number: NCT01743989, EudraCT number: 2012-005124-15.

Patient-reported outcomes following neoadjuvant endocrine therapy, external beam radiation, and adjuvant continuous/intermittent endocrine therapy for locally advanced prostate cancer: A randomized phase III trial

Background

We evaluated patient‐reported outcomes (PRO) during neoadjuvant androgen deprivation therapy (ADT) plus external beam radiation therapy (EBRT) followed by either adjuvant continuous ADT (CADT) or intermittent ADT (IADT) for patients with locally advanced prostate cancer (Pca).

Methods

A multicenter, randomized phase III trial enrolled 303 patients with locally advanced Pca. The patients were treated with 6 months (M) of ADT followed by 72 Gy of EBRT, and were randomly assigned to CADT or IADT after 14 M. The PROs were evaluated at sic points: baseline, 6 M, 8 M, 14 M, 20 M, and 38 M using FACT‐P questionnaires and EPIC urinary, bowel, and sexual bother subscales.

Results

The FACT‐P total scores were significantly better (p < 0.05) in IADT versus CADT at 20 M (121.6 vs.115.4) and at 38 M (119.9 vs. 115.2). The physical well‐being scores (PWB) were significantly better (p < 0.05) in IADT versus CADT at 38 M (25.4 vs. 24.0). The functional scores were significantly better in IADT than those in CADT at 14 M (20.2 vs18.7, p < 0.05) and at 20 M (21.0 vs.18.9, p < 0.05).

Conclusion

The PRO was significantly favorable in IADT on FACT‐P total score at 20 M and 38 M, PWB and functional scores at 38 M.

COSMIN reporting guideline for studies on measurement properties of patient-reported outcome measures

PURPOSE

To develop a set of consensus and empirically based reporting recommendations for primary studies of the measurement properties of patient-reported outcome measures (PROMs).

METHODS

This study included four phases: 1. Conducting an extensive literature review of recommendations for reporting of studies testing measurement properties of PROMs; 2. Preparing for the Delphi study by identifying experts; 3. Conducting three Delphi rounds aiming for consensus on the item list of recommendations found in phase 1; 4. Developing the COSMIN reporting guideline and user manual.

RESULTS

The literature review resulted in 93 reporting items, included in the first Delphi round. A total of 84 individuals (from 12 countries) agreed to participate in the Delphi study, with 47, 30 and 25 responding in rounds one, two and three, respectively. After three rounds, we achieved consensus on a set of 71 items separated into a set of 35 "common" items (relevant to all studies on measurement properties) and 41 "specific" items (exclusively relevant to one of the nine measurement properties).

CONCLUSION

Consensus was achieved on a set of 71 items for inclusion in a reporting guideline for studies on measurement properties of PROMs. These items will guide researchers on the necessary information to include in their reports of investigations of measurement properties of PROMs. This guideline will likely improve the completeness of reporting of these important studies.

Factors predicting missing instruments in three cancer randomized clinical trials

PURPOSE

Missing patient-reported outcome (PRO) data can seriously threaten the validity of randomized clinical trials (RCTs). Identifying which factors predict missing instruments may help researchers develop strategies to prevent it from happening. This study examined the association of factors with time to the first missing instrument after randomization in three cooperative group RCTs.

METHODS

We performed descriptive analyses and Cox proportional hazards regressions for three RCTs selected from the Canadian Cancer Trials Group: MA17 (breast cancer), PR7 (prostate cancer), and LY12 (non-Hodgkin's lymphoma). The outcome was the time from randomization to the first missing instrument. Variables for 15 factors were used as covariates based on availability and previously-reported putative associations with missing PRO data.

RESULTS

Nine percent of 1352 subjects on MA17, 37% of 923 subjects on PR7, and 59% of 477 subjects on LY12 had a missing instrument. Twenty-five percent of subjects on MA17 had first missing instrument within 4.6 years. The median time to first missing instrument was: not observed for MA17, 7.3 years for PR7, 0.12 years for LY12. Cox regression revealed statistically significant independent associations with outcome for only five factors: baseline age (PR7) and level of well-being (LY12), and centre level of activity (LY12), presence of post-graduate residency training program (MA17, PR7), and centre geographic location (PR7, LY12).

CONCLUSION

Many factors reported to have association with missing instruments do not seem to predict time to the first missing instrument after randomization in RCTs. Context is important in understanding the few that may.

Patient reported outcomes interfering with daily activities in prostate cancer patients receiving antineoplastic treatment

BACKGROUND

Patient-reported outcome (PRO) can give information to caregivers and doctors about adverse effects and give real-world data on symptom burden for patients during treatment. We here report PROs from patients with metastatic castration resistant prostate cancer (mCRPC) receiving oncological treatment. Our findings are compared with adverse events from published findings in relevant registration studies and we discuss possible applications by looking at the level of interference with usual or daily activities.

MATERIAL AND METHODS

An electronic PRO-Common Terminology Criteria for Adverse Events (ePRO-CTCAE) questionnaire, with 41 items corresponding to 22 symptoms/adverse events associated with the treatment regimens commonly used for mCRPC, were collected from 54 patients with mCRPC receiving medical oncological treatment. Eleven symptoms attributing interference with usual or daily living were selected and stratified by antineoplastic treatment administered. The responses were pooled and compared with data from relevant registration studies for docetaxel, cabazitaxel, radium-223 and abiraterone.

RESULTS

168 questionnaires were completed, and among responses from patients receiving docetaxel, 89% of responses shows that fatigue interfered with their usual or daily activities to some degree and 22% to a high or very high degree. In the registration study for docetaxel fatigue is reported with 53% for all grades and 5% for grade 3 or above. For cabazitaxel, radium-223 and abiraterone the percentage of responses with interference of daily activities from fatigue range from 58% to 82%. Between four and six of the eleven chosen PRO-CTCAE symptoms are not reported in the registration studies as common side effects.

CONCLUSION

PRO may help inform caregivers about symptoms not previously reported, interfering with usual or daily activities but also point to the use of this information to inform new patients. This may help clinicians and patients decide a treatment plan with an acceptable benefit-to-harm ratio.

Health-related quality of life outcomes among breast cancer survivors

BACKGROUND

Data from a nationwide sample of US breast cancer survivors were used to examine associations between patient characteristics (breast cancer clinical features, prognostic factors, and treatments) and health-related quality of life (HRQOL). Associations between postdiagnosis HRQOL and mortality were then evaluated.

METHODS

The authors identified female breast cancer survivors (n = 2453) from the Sister Study or Two Sister Study who were at least 1 year from breast cancer diagnosis and who had responded to a survivorship survey in 2012. HRQOL was assessed with the Patient-Reported Outcomes Measurement Information System (PROMIS) Global 10 measures. Multivariable linear regression was used to assess predictors associated with HRQOL. Cox regression was used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between HRQOL and all-cause mortality.

RESULTS

HRQOL, assessed an average of 4.9 years after the cancer diagnosis (standard deviation of 1.9 years), was negatively associated with a higher cancer stage at diagnosis; a higher comorbidity score at the survey; experience of surgical complications; dissatisfaction with breast surgery; and experience of any recent recurrence, metastasis, or secondary malignancy. Since the completion of the survey, there were 85 deaths (3.5%) during a mean follow-up of 4 years (standard deviation of 0.5 years). In multivariate models, decreases in PROMIS physical T scores and mental T scores were associated with increased mortality (HR for physical T scores, 1.08; 95% CI, 1.05-1.11; HR for mental T scores, 1.03; 95% CI, 1.01-1.06).

CONCLUSIONS

Prognostic and cancer treatment-related factors affect HRQOL in breast cancer survivors and may inform targeted survivorship care. PROMIS global health measures may offer additional insights into patients' well-being and mortality risk.

LAY SUMMARY

Findings from a study suggest that prognostic and cancer treatment-related factors affect health-related quality of life (HRQOL) in breast cancer survivors and that poor HRQOL may increase the mortality risk. The evaluation of HRQOL is important because it may hold potential as a tool for optimizing survivorship care.

The Impact of AC and AC-T Chemotherapy's Toxicities on Quality of Life Among Women with Breast Cancer in Ethiopia: A Prospective Patient-Reported Outcomes Study

PURPOSE

The study aimed to evaluate the quality of life patterns and the effects of AC and AC-T chemotherapy's toxicities on QoL among Ethiopian women with breast cancer.

METHODS

QoL was measured at baseline and at every end of two cycles, for the median of 8 cycles among 146 breast cancer women on AC and AC-T chemotherapy, using EORTC QLQ-C30 and BR23 instruments. The effect of QoL score, socio-demographic, and clinical variables at baseline were adjusted for the effect of chemotherapy's toxicities on QoL.

RESULTS

Overall QoL, all functional scales (except cognitive functioning, body image, future perspectives, and sexual functioning) and symptom scales (except dyspnea, insomnia, pain score, arm, and breast symptoms) of EORTC QLQ-C30 and BR23 deteriorated significantly both clinically and statistically, in particular, during the first two cycles of chemotherapy. After the end of cycle 2 or 4, except for cognitive, social functioning, and financial difficulties of the patients, almost all other QoL dimensions were improved towards pretreatment score by the end of cycle 8. In addition to age, educational status, and tumor stage, the Global Health Status (-10.55≤B≤-7.71, P≤0.013), and the functional scales (-25.320≤B≤-6.351, P≤0.033) of EORTC QLQ-C30 and BR23 were significantly affected at least by one of the AC and AC-T chemotherapy's toxicity such as grade≥2 fatigue, dysgeusia, constipation, dry mouth, vomiting, oral mucositis, skin hyperpigmentation and/or peripheral neuropathy than their lower grade. Grade≥2 fatigue, dysgeusia, oral mucositis, constipation, peripheral neuropathy, anemia arthralgia/myalgia, dry mouth, diarrhea, constipation, and/or skin hyperpigmentation were positively predicted for the deterioration of symptoms scale of EORTC QLQ-C30 and BR23 (4.819≤B≤26.451, P≤0.043).

CONCLUSION

Quality of life among Ethiopian breast cancer patients on AC and AC-T regimens significantly deteriorated particularly during the first two cycles of chemotherapy. In addition to the age, tumor stage and educational status of the patients, grade≥2 fatigue, dysgeusia, constipation, oral mucositis, dry mouth, peripheral neuropathy, and skin hyperpigmentation due to AC and AC-T chemotherapy were frequently associated with deterioration of different scales/items QoL. Hence, devising different strategies to improve the deteriorated QoL due to chemotherapy's toxicities particularly during the first two cycles has paramount importance.

Patient outcomes, patient experiences and process indicators associated with the routine use of patient-reported outcome measures (PROMs) in cancer care: a systematic review

Purpose

In current cancer care, there is a growing debate about the value of using patient-reported outcome measures (PROMs) in daily clinical follow-up. A systematic review of the literature was conducted to assess the evidence of the effectiveness of the routine use of PROMs in daily cancer care in terms of patient outcomes, patient experiences and process indicators and to identify the effect of giving feedback about PROM findings to patients and/or health care professionals (HCPs).

Methods

A systematic search was performed. Studies were eligible for inclusion when they (1) used a PROM as an intervention, with or without feedback to patients and/or HCPs, compared with not using a PROM, and (2) used a PROM as an intervention with feedback to patients and/or HCPs, compared with using a PROM without giving feedback to patients and/or HCPs.

Results

After screening of 8341 references, 22 original studies met the inclusion criteria. Most studies found a positive effect on survival, symptoms, HRQoL and patient satisfaction. In general, using feedback to patient and/or HCPs about the PROM results led to better symptom control, HRQoL, patient satisfaction and patient-doctor communication. The majority of included studies had insufficient power to detect significant differences in the outcomes assessed.

Conclusion

This review shows that predominantly positive findings were found in the use of a PROM in daily cancer care. Additionally, more positive effects were seen when feedback is provided to patient and/or health care professionals, and it is thus highly recommended that this is always done.

Using the Healthy Days Measure to Assess Factors Associated with Poor Health-Related Quality of Life for Patients with Metastatic Breast, Lung, or Colorectal Cancer Enrolled in a Medicare Advantage Health Plan

This study investigated factors associated with patient-reported health-related quality of life (HRQoL) using the Centers for Disease Control and Prevention's Healthy Days tool for patients with Medicare Advantage undergoing treatment for metastatic breast, lung, and colorectal cancer. In 2015, a total of 6390 patients were mailed surveys regarding factors that may influence their HRQoL, including cancer-related symptoms. HRQoL was measured as the number of physically and mentally unhealthy days experienced in the past 30 days and summed for the total number of unhealthy days. Frequent unhealthy days was defined as ≥14 total unhealthy days in the prior month. Of 1567 respondents, the mean number of total unhealthy days (standard deviation) was 14.0 (11.9) with 46.2% experiencing frequent unhealthy days. On average, patients reported 10.5 (10.5) physically and 6.7 (9.4) mentally unhealthy days. Cancer-related symptoms, particularly pain and fatigue, were significantly associated with increased unhealthy days. In adjusted models, patients with pain had 83% more unhealthy days than patients without pain; patients with fatigue had 104% more unhealthy days than patients without fatigue. Diarrhea/constipation and shortness of breath also were associated with more unhealthy days. Cancer-related symptoms, most notably pain and fatigue, were associated with worse HRQoL for patients with metastatic cancer. Interventions aimed at ameliorating symptoms may improve quality of life for patients undergoing cancer treatment.

Cancer Care Treatment Outcome Ontology: A Novel Computable Ontology for Profiling Treatment Outcomes in Patients With Solid Tumors

PURPOSE

There is as yet no computer-processable resource to describe treatment end points in cancer, hindering our ability to systematically capture and share outcomes data to inform better patient care. To address these unmet needs, we have built an ontology, the Cancer Care Treatment Outcome Ontology (CCTOO), to organize high-level concepts of treatment end points with structured knowledge representation to facilitate standardized sharing of real-world data.

METHODS

End points from oncology trials in ClinicalTrials.gov were extracted, queried using the keyword cancer, and followed by an expert appraisal. Synonyms and relevant terms were imported from the National Cancer Institute Thesaurus and Common Terminology Criteria for Adverse Events. Logical relationships among concepts were manually represented by production rules. The applicability of 1,847 rules was tested in an index case.

RESULTS

After removing duplicated terms from 54,705 trial entries, an ontology holding 1,133 terms was built. CCTOO organized concepts into four domains (cancer treatment, health services, physical, and psychosocial health-related concepts), 13 subgroups (including efficacy, safety, and quality of life), and two (taxonomic and evaluative) concept hierarchies. This ontology has a comprehensive term coverage in the cancer trial literature: at least one term was mentioned in 98% of MEDLINE abstracts of phase I to III trials, whereas concepts about efficacy were mentioned in 7,208 (79%) phase I, 15,051 (92%) phase II, and 3,884 (86%) phase III trials. The event sequence of the index case was readily convertible to a comprehensive profile incorporating response, treatment toxicity, and survival by applying the set of production rules curated in the CCTOO.

CONCLUSION

CCTOO categorizes high-level treatment end points used in oncology and provides a mechanism for profiling individual patient data by outcomes to facilitate translational analysis.

Exploring the implementation of patient-reported outcome measures in cancer care: need for more real-world evidence results in the peer reviewed literature

BACKGROUND

To explore the existing evidence of the real-world implementation of patient-reported outcomes (PROs) in oncology clinical practice and address two aims: (1) summarize available evidence of PRO use in clinical practice using a framework based on the International Society for Quality of Life Research (ISOQOL) PRO Implementation Guide; and (2) describe reports of real-world, standardized PRO administration in oncology conducted outside of scope of a research study.

METHODS

A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol was developed to guide the systematic literature review (SLR) that was conducted in MEDLINE and Embase databases. A two step search strategy was implemented including two searches based on previously completed reviews. Studies published from 2006 to 2017 were synthesized using a framework based on the ISOQOL PRO Implementation Guide.

RESULTS

After screening 4427 abstracts, 36 studies met the eligibility criteria. Most elements of the ISOQOL PRO Implementation Guide were followed. Two notable exceptions were found: 1) providing PRO score interpretation guidelines (39% of studies); and 2) providing patient-management guidance for addressing issues identified by PROs (25% of studies). Of the 22 studies with an intervention component, 19 (86%) reported intervention effects on study outcomes. The European Organisation for Research and Treatment of Cancer Quality-of-Life Questionnaire-Core 30 (EORTC QLQ-C30) was the most commonly used PRO (n = 10, 28%); use of 38 other PRO measures was also reported. Only three studies (8%) reported real-world PRO implementation.

CONCLUSION

Reports of real-world PRO implementation are limited. Reports from studies conducted in clinical settings suggest gaps in information on PRO score interpretation and the use of PRO results to inform patient management. Before the promise of practice-based PRO assessment in oncology can be truly realized, investigators need to advance the state-of-the-art of real-time PRO score interpretation as well as developing guidance on how to use PRO insights to drive clinically-meaningful patient-management strategies.

Implementing Measurement-Based Care in Behavioral Health: A Review

IMPORTANCE

Measurement-based care (MBC) is the systematic evaluation of patient symptoms before or during an encounter to inform behavioral health treatment. Despite MBC's demonstrated ability to enhance usual care by expediting improvements and rapidly detecting patients whose health would otherwise deteriorate, it is underused, with typically less than 20% of behavioral health practitioners integrating it into their practice. This narrative review addresses definitional issues, offers a concrete and evaluable operationalization of MBC fidelity, and summarizes the evidence base and utility of MBC. It also synthesizes the extant literature's characterization of barriers to and strategies for supporting MBC implementation, sustainment, and scale-up.

OBSERVATIONS

Barriers to implementing MBC occur at multiple levels: patient (eg, concerns about confidentiality breach), practitioner (eg, beliefs that measures are no better than clinical judgment), organization (eg, no resources for training), and system (eg, competing requirements). Implementation science-the study of methods to integrate evidence-based practices such as MBC into routine care-offers strategies to address barriers. These strategies include using measurement feedback systems, leveraging local champions, forming learning collaboratives, training leadership, improving expert consultation with clinical staff, and generating incentives.

CONCLUSIONS AND RELEVANCE

This narrative review, informed by implementation science, offers a 10-point research agenda to improve the integration of MBC into clinical practice: (1) harmonize terminology and specify MBC's core components; (2) develop criterion standard methods for monitoring fidelity and reporting quality of implementation; (3) develop algorithms for MBC to guide psychotherapy; (4) test putative mechanisms of change, particularly for psychotherapy; (5) develop brief and psychometrically strong measures for use in combination; (6) assess the critical timing of administration needed to optimize patient outcomes; (7) streamline measurement feedback systems to include only key ingredients and enhance electronic health record interoperability; (8) identify discrete strategies to support implementation; (9) make evidence-based policy decisions; and (10) align reimbursement structures.

Retracted: Using the Healthy Days Measure to Assess Factors Associated with Poor Health-Related Quality of Life for Patients with Metastatic Breast, Lung, or Colorectal Cancer Enrolled in a Medicare Advantage Health Plan

The article entitled, "Using the Healthy Days Measure to Assess Factors Associated with Poor Health-Related Quality of Life for Patients with Metastatic Breast, Lung, or Colorectal Cancer Enrolled in a Medicare Advantage Health Plan," by Casebeer AW et al, which published online ahead of print in Population Health Management [doi: 10.1089/pop.2018.0024], is being retracted by the authors so that they can remove references to the 8-item Morisky Medication Adherence Scale (MMAS-8) and republish the article without such references. Dr. Casebeer's team obtained a license to use the MMAS-8 scale from Dr. Morisky prior to conducting the study. Nevertheless, after publication of a separate article in the Journal of Patient-Reported Outcomes that also cited the MMAS-8, as the lead author, Dr. Casebeer was contacted by Dr. Morisky who requested that a number of changes be made to the article. Dr. Casebeer and her team have no desire to engage in a dispute with Dr. Morisky and therefore proactively contacted the Editor of Population Health Management and requested that the scale be removed from her published paper. After assessing all of the provided information, the Editor agreed to the authors' request. It is important to note that the retraction of Dr. Casebeer's article is not the result of any misconduct on her part or that of her team. The retraction serves to remove the published version of the article that contains the MMAS-8 scale and a revised version that does not contain the tool or any references to it will be published. The elimination of the scale does not alter the results or conclusions of the study. Population Health Management is committed to upholding the highest standards of peer review and the community it serves.

Protocol for a Delphi consensus exercise to identify a core set of criteria for selecting health related outcome measures (HROM) to be used in primary health care

BACKGROUND

Promoting the collection and use of health related outcome measures (HROM) in daily practice has long been a goal for improving and assessing the effectiveness of care provided to patients. However, there has been a lack of consensus on what criteria to use to select outcomes or instruments, particularly in the context of primary health care settings where patients present with multiple concurrent health conditions and interventions are whole-health and person-focused. The purpose of this proposed study is to undertake a formal consensus exercise to establish criteria for selecting HROM (including patient-reported (PRO or PROM), observer-reported (ObsR)), clinician-reported (ClinRO) and performance related outcomes (PerfO) for use in shared decision-making, or in assessing, screening or monitoring health status in primary health care settings.

METHODS

A Delphi consensus online survey will be developed. Criteria for the Delphi panel participants to consider were selected from a targeted literature search. These initial criteria (n = 35) were grouped into four categories within which items will be presented in the Delphi survey, with the option to suggest additional items. Panel members invited to participate will include primary health care practitioners and administrators, policy-makers, researchers, and experts in HROM development; patients will be excluded. Standard Delphi methodology will be employed with an expectation of at least 3 rounds to achieve consensus (75% agreement). As the final list of criteria for selecting HROM emerges, panel members will be asked to provide opinions about potential weighting of items. The Delphi survey was approved by the Ethics Committee in the Faculty of Health Sciences at McMaster University.

DISCUSSION

Previous literature establishing criteria for selecting HROM were developed with a focus on patient reported outcomes, psychological/ behavioural outcomes or outcomes for minimum core outcome sets in clinical trials. Although helpful, these criteria may not be applicable and feasible for application in a primary health care context where patients with multi-morbidity and complex interventions are typical and the constraints of providing health services differ from those in research studies. The findings from this Delphi consensus study will address a gap for establishing consensus on criteria for selecting HROM for use across primary health care settings.

Health-Related Quality of Life among Women Breast Cancer Patients in Eastern China

Objectives

Breast cancer is one of the major cancers in Chinese women. European Organization for Research and Treatment of Cancer Quality of Life Questionnaires (EORTC QLQ-C30 and QLQ-BR23) are now the most common and well developed instruments assessing the health-related quality of life (HRQOL) of breast cancer patients internationally, whereas there are relatively few Chinese studies. This study has two aims: to investigate the HRQOL and explore which dimensions of HRQOL play more important roles in breast cancer patients' overall quality of life in China and to explore the latent factor structure and the potential complementary relationship between these two EORTC questionnaires.

Methods

This cross-sectional and descriptive study was performed from October 2014 to February 2015 in Qingdao Municipal Hospital, China. A total of 621 women breast cancer patients were enrolled. EOTRC QLQ-C30 and QLQ-BR23 were used to evaluate the HRQOL of the participants. The nonparametric test, multiple linear regression, and exploratory factor analysis (EFA) were the main statistical methods we used.

Results

608 participants completed the questionnaires with a response rate of 97.9%. The mean age of the participants was 48.0 years (SD=9.6). About 33% were illiterate or only finished primary school education. Almost half participants (47.4%) only adopted chemotherapy. HRQOL was significantly different with regard to patients' social-demographic and clinical characteristics. Age, residence, educational level, employment status, and TNM stage were five significant predictors for global health status. Pain, dyspnea, sexual enjoyment, and systemic therapy side-effect were main subscales which had a significant impact on the global health status for patients in different TNM stage. The EFA result suggested that QLQ-C30 and QLQ-BR23 were complementary questionnaires.

Conclusions

The EORTC QLQ-C30 and QLQ-BR23 questionnaires provide complementary information regarding breast cancer patients' HRQOL, and depending on the different cancer staging functional/symptom scales which significantly contributed to the overall HRQOL differed.

Adventure-based training to promote physical activity and reduce fatigue among childhood cancer survivors: A randomized controlled trial

BACKGROUND

Cancer-related fatigue is one of the most distressing symptoms reported by childhood cancer survivors. Despite the body of evidence that regular physical activity helps alleviate cancer-related fatigue, insufficient participation in physical activity is frequently observed among childhood cancer survivors.

OBJECTIVES

This study examined the effectiveness of an adventure-based training programme in promoting physical activity, reducing fatigue, and enhancing self-efficacy and quality of life among Hong Kong Chinese childhood cancer survivors.

DESIGN

A prospective randomised controlled trial.

SETTINGS

A paediatric oncology outpatient clinic, a non-governmental organisation, and a non-profit voluntary organisation.

PARTICIPANTS

Hong Kong Chinese childhood cancer survivors aged 9-16 years who reported symptoms of fatigue and had not engaged in regular physical exercise in the past 6 months.

METHODS

The experimental group underwent a 4-day adventure-based training programme. The control group received a placebo intervention. The primary outcome was fatigue at 12 months. Secondary outcomes were physical activity levels, self-efficacy and quality of life at 12 months. Data collection was conducted at baseline, and 6 and 12 months after the intervention began. We performed intention-to-treat analyses.

RESULTS

From 6 January, 2014 to 8 June, 2015, we randomly assigned 222 eligible childhood cancer survivors to either an experimental (n = 117) or a control group (n = 105). The experimental group showed statistically significantly lower levels of cancer-related fatigue (P < 0.001), higher levels of self-efficacy (P < 0.001) and physical activity (P < 0.001), and better quality of life (P < 0.01) than the control group at 12 months.

CONCLUSIONS

This study provides evidence that adventure-based training is effective in promoting physical activity, reducing cancer-related fatigue, and enhancing self-efficacy and quality of life among Hong Kong Chinese childhood cancer survivors. These results may help inform parents and healthcare professionals that regular physical activity is crucial for the physical and psychological wellbeing and quality of life of childhood cancer survivors.

Oncology Nurses' Attitudes Toward the Edmonton Symptom Assessment System: Results From a Large Cancer Care Ontario Study

PURPOSE/OBJECTIVES

To examine oncology nurses' attitudes toward and reported use of the Edmonton Symptom Assessment System (ESAS) and to determine whether the length of work experience and presence of oncology certification are associated with their attitudes and reported usage.
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DESIGN

Exploratory, mixed-methods study employing a questionnaire approach.
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SETTING

14 regional cancer centers (RCCs) in Ontario, Canada.
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SAMPLE

Oncology nurses who took part in a larger province-wide study that surveyed 960 interdisciplinary providers in oncology care settings at all of Ontario's 14 RCCs.
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METHODS

Oncology nurses' attitudes and use of ESAS were measured using a 21-item investigator-developed questionnaire. Descriptive statistics and Kendall's tau-b or tau-c test were used for data analyses. Qualitative responses were analyzed using content analysis.
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MAIN RESEARCH VARIABLES

Attitudes toward and self-reported use of standardized symptom screening and ESAS.
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FINDINGS

More than half of the participants agreed that ESAS improves symptom screening, most said they would encourage their patients to complete ESAS, and most felt that managing symptoms is within their scope of practice and clinical responsibilities. Qualitative comments provided additional information elucidating the quantitative responses. Statistical analyses revealed that oncology nurses who have 10 years or less of work experience were more likely to agree that the use of standardized, valid instruments to screen for and assess symptoms should be considered best practice, ESAS improves symptom screening, and ESAS enables them to better manage patients' symptoms. No statistically significant difference was found between oncology-certified RNs and noncertified RNs on attitudes or reported use of ESAS.
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CONCLUSIONS

Implementing a population-based symptom screening approach is a major undertaking. The current study found that oncology nurses recognize the value of standardized screening, as demonstrated by their attitudes toward ESAS.
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IMPLICATIONS FOR NURSING

Oncology nurses are integral to providing high-quality person-centered care. Using standardized approaches that enable patients to self-report symptoms and understanding barriers and enablers to optimal use of patient-reported outcome tools can improve the quality of patient care.

Relationship between phase I study duration and symptom burden

PURPOSE

Phase I clinical trials are critical to development of cancer therapeutics. Adverse events (AEs) and symptom burden contribute to early treatment withdrawal, and it is often difficult to ascertain whether these events are disease- or treatment-related. Regardless, early withdrawal may delay determination of the effectiveness of potential new therapies. We sought to characterize the reasons for early treatment termination to identify potential modifiable events.

METHODS

A retrospective chart review was conducted on solid tumor patients enrolled in institutional phase I clinical trials from 2003 to 2013 through the Case Comprehensive Cancer Center.

RESULTS

Two hundred fifty-five patients were included in the analysis. The mean duration on study was 78.4 days (SD 63.4 days), and 23% of the patients were on study ≤ 30 days. Patients experienced an average of 25.1 AEs, of which 46.9% were non-laboratory. Constitutional symptoms (29.3%), gastrointestinal symptoms (24%), and pain (12.8%) were the most common non-laboratory AEs. Disease progression (57.6%) was the most common reason for study discontinuation, followed by adverse events (16.5%). Approximately 13% of the patients discontinued treatment for other reasons, of which 41.7% were identified as related to symptom burden on further review. Increased rates of AEs negatively correlated with duration on study (r = - 0.331; p < 0.01).

CONCLUSIONS

AEs may lead to early termination of trial participation and confound clinical assessment of investigational treatments. Designing interventions to reduce AE burden may extend duration on trial, affect the recommended phase II dose, and benefit the quality of life of participants on phase I trials.

Patient reported outcomes in orthopaedics

Patient reported outcome measures (PROMs) are key tools when performing clinical research and PROM data are increasingly used to inform clinical decision-making, patient-centered care, health policy and more recently, reimbursement decisions. PROMs must possess particular properties before they are used. Thus purpose of this paper is to give an overview of PROMs, their definition, how their evidence can be assessed, how they should be reported in clinical research, how to choose PROMs, the types of PROMs available in orthopaedics, where these measures can be found, PROMs in orthopaedic clinical practice and what are some key next steps in this field. If PROMs are used in accordance with the guidance in this article, I believe we will gain considerable insight into PROMs in orthopaedics and will advance this field in a way that can contribute to science, improve patient care and save considerable resources. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:2098-2108, 2017.

Feasibility Assessment of Patient Reporting of Symptomatic Adverse Events in Multicenter Cancer Clinical Trials

IMPORTANCE

In cancer clinical trials, symptomatic adverse events (AEs), such as nausea, are reported by investigators rather than by patients. There is increasing interest to collect symptomatic AE data via patient-reported outcome (PRO) questionnaires, but it is unclear whether it is feasible to implement this approach in multicenter trials.

OBJECTIVE

To examine whether patients are willing and able to report their symptomatic AEs in multicenter trials.

DESIGN, SETTING, AND PARTICIPANTS

A total of 361 consecutive patients enrolled in any 1 of 9 US multicenter cancer treatment trials were invited to self-report 13 common symptomatic AEs using a PRO adaptation of the National Cancer Institute's Common Terminology Criteria for Adverse Events (CTCAE) via tablet computers at 5 successive clinic visits. Patient adherence was tracked with reasons for missed self-reports. Agreement with clinician AE reports was analyzed with weighted κ statistics. Patient and investigator perspectives were elicited by survey. The study was conducted from March 15, 2007, to August 11, 2011. Data analysis was performed from August 9, 2013, to March 21, 2014.

RESULTS

Of the 361 patients invited to participate, 285 individuals enrolled, with a median age of 57 years (range, 24-88), 202 (74.3%) female, 241 (85.5%) white, 73 (26.8%) with a high school education or less, and 176 (64.7%) who reported regular internet use (denominators varied owing to missing data). Across all patients and trials, there were 1280 visits during which patients had an opportunity to self-report (ie, patients were alive and enrolled in a treatment trial at the time of the visit). Self-reports were completed at 1202 visits (93.9% overall adherence). Adherence was highest at baseline and declined over time (visit 1, 100%; visit 2, 96%; visit 3, 95%; visit 4, 91%; and visit 5, 85%). Reasons for missing PROs included institutional errors in 27 of 48 (56.3%) of the cases (eg, staff forgetting to bring computers to patients at visits), patients feeling "too ill" in 8 (16.7%), patient refusal in 8 (16.7%), and internet connectivity problems in 5 (10.4%). Patient-investigator CTCAE agreement was moderate or worse for most symptoms (most κ < 0.05), with investigators reporting fewer AEs than patients across symptoms. Most patients believed that the system was easy to use (234 [93.2%]) and useful (230 [93.1%]), and investigators thought that the patient-reported AEs were useful (133 [94.3%]) and accurate (119 [83.2%]).

CONCLUSIONS AND RELEVANCE

Participants in multicenter cancer trials are willing and able to report their own symptomatic AEs at most clinic visits and report more AEs than investigators. This approach may improve the precision of AE reporting in cancer trials.

Capturing and Incorporating Patient-Reported Outcomes into Clinical Trials: Practical Considerations for Clinicians

Patient centeredness as the focus of healthcare delivery requires the incorporation of patient-reported outcomes into clinical trials. Clearly defining measurable outcomes as well as selecting the most appropriate validated collection tool to use is imperative for success. Creating and validating one's own instrument is also possible, albeit more cumbersome. Meticulous data collection to avoid missing data is key, as is limiting the number of data collection points to prevent survey fatigue and using electronic systems to facilitate data gathering and analysis. Working in a multidisciplinary team that includes statisticians with expertise in patient reported outcomes is essential to navigate the complexities of statistical analysis of these variables. Use of available and emerging technologies for data collection and analysis as well as data sharing will greatly facilitate the process of incorporating patient-reported outcomes into trials and routine clinical practice.

Series: Pragmatic trials and real world evidence: Paper 6. Outcome measures in the real world

Results from pragmatic trials should reflect the comparative treatment effects encountered in patients in real-life clinical practice to guide treatment decisions. Therefore, pragmatic trials should focus on outcomes that are relevant to patients, clinical practice, and treatment choices. This sixth article in the series (see Box) discusses different types of outcomes and their suitability for pragmatic trials, design choices for measuring these outcomes, and their implications and challenges. Measuring outcomes in pragmatic trials should not interfere with real-world clinical practice to ensure generalizability of trial results, and routinely collected outcomes should be prioritized. Typical outcomes include mortality, morbidity, functional status, well-being, and resource use. Surrogate endpoints are typically avoided as primary outcome. It is important to measure outcomes over a relevant time horizon and obtain valid and precise results. As pragmatic trials are often open label, a less subjective outcome can reduce bias. Methods that decrease bias or enhance precision of the results, such as standardization and blinding of outcome assessment, should be considered when a high risk of bias or high variability is expected. The selection of outcomes in pragmatic trials should be relevant for decision making and feasible in terms of executing the trial in the context of interest. Therefore, this should be discussed with all stakeholders as early as feasible to ensure the relevance of study results for decision making in clinical practice and the ability to perform the study.

United States Population-Based Estimates of Patient-Reported Outcomes Measurement Information System Symptom and Functional Status Reference Values for Individuals With Cancer

Purpose To estimate cancer population-based reference values in the United States for eight PROMIS (Patient-Reported Outcomes Measurement Information System) domains by age and stage of disease. Patients and Methods For the Measuring Your Health (MY-Health) study, persons newly diagnosed with cancer (prostate, colorectal, non-small-cell lung, non-Hodgkin lymphoma, breast, uterine, or cervical) from 2010 to 2012 (N = 5,284) were recruited through the National Cancer Institute's SEER Program. Participants were mailed surveys 6 to 13 months after diagnosis. Raking by race/ethnicity, age, and stage generated weighted average PROMIS scores for pain interference, fatigue, anxiety, depression, sleep disturbance, physical function, ability to participate in social roles, and cognitive function. PROMIS measures are standardized to a T-score metric, with a score of 50 representing the general US population mean. Clinically meaningful differences were defined as a 3-point difference in scores. Results Several reference values (means) for patients with cancer were worse than the general United States population norms of 50. These include pain interference (52.4), fatigue (52.2), and physical function (44.1). Reference values were highest (ie, showed greatest symptom burden) in lung cancer (pain interference, 55.5; fatigue, 57.3; depression, 51.4) and cervical cancer (anxiety, 53.2; sleep disturbance, 53.4). Reference values for patients age 65 to 84 years reported lower sleep disturbance, anxiety, and depression, and better cognitive function than younger patients. Cancer reference values were poorer among those with advanced disease compared with patients with limited or no evidence of disease, specifically physical function (41.1 v 46.6, respectively), fatigue (55.8 v 50.2, respectively), and pain interference (55.2 v 50.9, respectively). Conclusion In a large, population-based sample of patients with recently diagnosed cancer, we observed symptom severity and functional deficits by age, stage, and cancer type consistent with the expected impact of cancer diagnosis and treatment. These United States cancer reference values can help facilitate interpretation of the PROMIS domain scores in research studies or in clinical applications that measure and evaluate the symptom and functional burden patients with cancer experience after initial treatment.

The DSM5/RDoC debate on the future of mental health research: implication for studies on human stress and presentation of the signature bank

In 2008, the National Institute of Mental Health (NIMH) announced that in the next few decades, it will be essential to study the various biological, psychological and social "signatures" of mental disorders. Along with this new "signature" approach to mental health disorders, modifications of DSM were introduced. One major modification consisted of incorporating a dimensional approach to mental disorders, which involved analyzing, using a transnosological approach, various factors that are commonly observed across different types of mental disorders. Although this new methodology led to interesting discussions of the DSM5 working groups, it has not been incorporated in the last version of the DSM5. Consequently, the NIMH launched the "Research Domain Criteria" (RDoC) framework in order to provide new ways of classifying mental illnesses based on dimensions of observable behavioral and neurobiological measures. The NIMH emphasizes that it is important to consider the benefits of dimensional measures from the perspective of psychopathology and environmental influences, and it is also important to build these dimensions on neurobiological data. The goal of this paper is to present the perspectives of DSM5 and RDoC to the science of mental health disorders and the impact of this debate on the future of human stress research. The second goal is to present the "Signature Bank" developed by the Institut Universitaire en Santé Mentale de Montréal (IUSMM) that has been developed in line with a dimensional and transnosological approach to mental illness.

'Trial Exegesis': Methods for Synthesizing Clinical and Patient Reported Outcome (PRO) Data in Trials to Inform Clinical Practice. A Systematic Review

Purpose

The CONSORT extension for patient reported outcomes (PROs) aims to improve reporting, but guidance on the optimal integration with clinical data is lacking. This study examines in detail the reporting of PROs and clinical data from randomized controlled trials (RCTs) in gastro-intestinal cancer to inform design and reporting of combined PRO and clinical data from trials to improve the ‘take home’ message for clinicians to use in practice.

Materials and Methods

The case study was undertaken in gastro-intestinal cancer trials. Well-conducted RCTs reporting PROs with validated instruments were identified and categorized into those combining PRO and clinical data in a single paper, or those separating data into linked primary and supplemental papers. Qualitative methods were developed to examine reporting of the critical interpretation of the trial results (trial exegesis) in the papers in relation of the PRO and clinical outcomes and applied to each publication category. Results were used to inform recommendations for practice.

Results

From 1917 screened abstracts, 49 high quality RCTs were identified reported in 36 combined and 15 linked primary and supplemental papers. In-depth analysis of manuscript text identified three categories for understanding trial exegesis: where authors reported a “detailed”, “general”, or absent PRO rationale and integrated interpretation of clinical and PRO results. A total of 11 (30%) and 6 (16%) combined papers reported “detailed” PRO rationale and integrated interpretation of results although only 2 (14%) and 1 (7%) primary papers achieved the same standard respectively. Supplemental papers provide better information with 11 (73%) and 3 (20%) achieving “detailed” rationale and integrated interpretation of results. Supplemental papers, however, were published a median of 20 months after the primary RCT data in lower impact factor journals (median 16.8 versus 5.2).

Conclusion

It is recommended that single papers, with detailed PRO rationale and integrated PRO and clinical data are published to optimize trial exegesis. Further work to examine whether this improves the use of PRO data to inform practice is needed.

Willingness of Patients with Breast Cancer in the Adjuvant and Metastatic Setting to Use Electronic Surveys (ePRO) Depends on Sociodemographic Factors, Health-related Quality of Life, Disease Status and Computer Skills

Introduction: Because of the often unfavorable prognosis, particularly for patients with metastases, health-related quality of life is extremely important for breast cancer patients. In recent years, data on patient-relevant endpoints is being increasingly collected electronically; however, knowledge on the acceptance and practicability of, and barriers to, this form of data collection remains limited. Material and Methods: A questionnaire was completed by 96 patients to determine to what extent existing computer skills, disease status, health-related quality of life and sociodemographic factors affect patients' potential willingness to use electronics methods of data collection (ePRO). Results: 52 of 96 (55 %) patients reported a priori that they could envisage using ePRO. Patients who a priori preferred a paper-based survey (pPRO) tended to be older (ePRO 53 years vs. pPRO 62 years; p = 0.0014) and typically had lower levels of education (p = 0.0002), were in poorer health (p = 0.0327) and had fewer computer skills (p = 0.0003). Conclusion: Barriers to the prospective use of ePRO were identified in older patients and patients with a lower quality of life. Given the appropriate conditions with regard to age, education and current health status, opportunities to participate should be provided to encourage patients' willingness to take part and ensure the validity of survey results. Focusing on ease of use of ePRO applications and making applications more patient-oriented and straightforward appears to be the way forward.

Graphical displays of patient-reported outcomes (PRO) for use in clinical practice: What makes a pro picture worth a thousand words?

Patient-reported outcomes (PROs) report patients' assessments of the impact of a health condition and its treatment, and can promote patient-centered care.

OBJECTIVES

To address the effectiveness of graphic display of PRO data in clinical practice by reviewing existing literature, and current recommendations, regarding graphic presentations of PROs.

METHODS

We performed an integrated literature review to identify themes and emerging principles guiding effective graphic display of PRO data. The findings were placed in the context of the literature informing graphical presentation of other clinical data.

RESULTS

Although a large body of literature informs graphical presentation of clinical data, only nine empirical studies addressed presentation of PROs. Four major themes emerged: many patients and most clinicians can accurately interpret some PRO graphs; interpretation accuracy, personal preference, and perceived level of understanding are sometimes discordant; patient age and education may predict PRO graph comprehension; patients tend to prefer simpler graphs than do clinicians.

CONCLUSIONS

Little empirical research specifically addresses graphic representation of PRO data. A single format may not work optimally for both clinicians and patients.

PRACTICE IMPLICATIONS

Patients and clinicians may or may not comprehend PRO data when graphically presented. Further research to determine best practices for presenting PROs optimally is needed.

Feasibility of an interactive electronic self-report tool for oral cancer therapy in an outpatient setting

BACKGROUND

The introduction of oral anti-cancer agents provides a convenient administration route for chronic cancer treatment to outpatients. Health information technology through web-based applications or other electronic tools can offer a platform to improve treatment compliance, symptom management, and patient-provider communication.

PURPOSE

The purposes of this study were to test the feasibility and clinical utility of an electronic self-report device (RemeCoach) for patients or their caregivers and to register and prospectively evaluate the quality of data generated.

PATIENTS AND METHODS

Patients using Teysuno® (S-1) for advanced gastrointestinal carcinoma used a pre-programmed device in order to register compliance to treatment and six clinical parameters. Real-time data were collected onto a central platform, which processed the data by an algorithm. This algorithm stratified the data into different grades based on the Common Terminology Criteria for Adverse Events (CTCAE v4.0).

RESULTS

From December 2013 to March 2014, 11 patients (5 men, 6 women) were enrolled. Compliance to the device was high, six patients (55 %) registered timely intake of medication (demonstrating >95 % treatment compliance). Agreement between patients' and clinicians' reported toxicity was substantial for nausea, but discrepant for fatigue, hand-foot syndrome, and mucositis.

CONCLUSION

The use of an interactive self-report tool is feasible, reliable, and acceptable to outpatients. The RemeCoach and the algorithm devised will be further developed as an interactive patient-reported outcome (PRO) system, to improve early detection of side effects in an outpatient setting. Further studies are needed to confirm these data and to explore the relationship between optimal patient support and efficacy of treatment.

Systematic collection of patient reported outcome research data: A checklist for clinical research professionals

Understanding the human experience is no longer an outcome explored strictly by social and behavioral researchers. Increasingly, biomedical researchers are also including patient reported outcomes (PROs) in their clinical research studies not only due to calls for increased patient engagement in research but also healthcare. Collecting PROs in clinical research studies offers a lens into the patient's unique perspective providing important information to industry sponsors and the FDA. Approximately 30% of trials include PROs as primary or secondary endpoints and a quarter of FDA new drug, device and biologic applications include PRO data to support labeling claims. In this paper PRO, represents any information obtained directly from the patient or their proxy, without interpretation by another individual to ascertain their health, evaluate symptoms or conditions and extends the reference of PRO, as defined by the FDA, to include other sources such as patient diaries. Consumers and clinicians consistently report that PRO data are valued, and can aide when deciding between treatment options; therefore an integral part of clinical research. However, little guidance exists for clinical research professionals (CRPs) responsible for collecting PRO data on the best practices to ensure quality data collection so that an accurate assessment of the patient's view is collected. Therefore the purpose of this work was to develop and validate a checklist to guide quality collection of PRO data. The checklist synthesizes best practices from published literature and expert opinions addressing practical and methodological challenges CRPs often encounter when collecting PRO data in research settings.

An Internet-Based Means of Monitoring Quality of Life in Post-Prostate Radiation Treatment: A Prospective Cohort Study

Background

Widespread integration of the Internet has resulted in an increase in the feasibility of using Web-based technologies as a means of communicating with patients. It may be possible to develop secure and standardized systems that facilitate Internet-based patient-reported outcomes which could be used to improve patient care.

Objective

This study investigates patient interest in participating in an online post-treatment disease outcomes and quality of life monitoring program developed specifically for patients who have received radiation treatment for prostate cancer at a regional oncology center.

Methods

Patients treated for prostate cancer between 2007 and 2011 (N=1113) at the British Columbia Cancer Agency, Centre for the Southern Interior were invited by mail to participate in a standardized questionnaire related to their post-treatment health. Overall participation rates were calculated. In addition, demographics, access to broadband Internet services, and treatment modalities were compared between participants and nonparticipants.

Results

Of the 1030 eligible invitees, 358 (358/1030, 34.7%) completed the online questionnaire. Participation rates were higher in individuals younger than age 60 when compared to those age 60 or older (42% vs 31%) and also for those living in urban areas compared with rural (37% vs 29%) and in those who received brachytherapy versus external beam radiotherapy (EBRT) (41% vs 31%). Better participation rates were seen in individuals who had access to Internet connectivity based on the different types of broadband services (DSL 35% for those with DSL connectivity vs 29% for those without DSL connectivity; cable 35% vs 32%; wireless 38% vs 26%). After adjusting for age, the model indicates that lack of access to wireless broadband connectivity, living in a rural area, and receiving EBRT were significant predictors of lower participation.

Conclusions

This study demonstrates that participation rates vary in patient populations within the interior region of British Columbia, especially with older patients, those in rural areas, and those with limited access to quality Internet services.

Design and feasibility of integrating personalized PRO dashboards into prostate cancer care

OBJECTIVE

Patient-reported outcomes (PROs) are a valued source of health information, but prior work focuses largely on data capture without guidance on visual displays that promote effective PRO use in patient-centered care. We engaged patients, providers, and design experts in human-centered design of "PRO dashboards" that illustrate trends in health-related quality of life (HRQOL) reported by patients following prostate cancer treatment.

MATERIALS AND METHODS

We designed and assessed the feasibility of integrating dashboards into care in 3 steps: (1) capture PRO needs of patients and providers through focus groups and interviews; (2) iteratively build and refine a prototype dashboard; and (3) pilot test dashboards with patients and their provider during follow-up care.

RESULTS

Focus groups (n = 60 patients) prioritized needs for dashboards that compared longitudinal trends in patients' HRQOL with "men like me." Of the candidate dashboard designs, 50 patients and 50 providers rated pictographs less helpful than bar charts, line graphs, or tables (P < .001) and preferred bar charts and line graphs most. Given these needs and the design recommendations from our Patient Advisory Board (n = 7) and design experts (n = 7), we built and refined a prototype that charts patients' HRQOL compared with age- and treatment-matched patients in personalized dashboards. Pilot testing dashboard use (n = 12 patients) improved compliance with quality indicators for prostate cancer care (P < .01).

CONCLUSION

PRO dashboards are a promising approach for integrating patient-generated data into prostate cancer care. Informed by human-centered design principles, this work establishes guidance on dashboard content, tailoring, and clinical use that patients and providers find meaningful.

Quality of life research in endometrial cancer: what is needed to advance progress in this disease site? Methodological considerations from the Gynecologic Cancer InterGroup Symptom Benefit Working Group brainstorming session, Leiden 2012

BACKGROUND

Quality of life (QoL) in endometrial cancer (EC) is understudied. Incorporation of QoL questionnaires and patient-reported outcomes in clinical trials has been inconsistent, and the tools and interpretation of these measures are unfamiliar to most practitioners. In 2012, the Gynecologic Cancer InterGroup Symptom Benefit Working Group convened for a brainstorming collaborative session to address deficiencies and work toward improving the quality and quantity of QoL research in women with EC.

METHODS

Through literature review and international expert contributions, we compiled a comprehensive appraisal of current generic and disease site-specific QoL assessment tools, strengths and weaknesses of these measures, assessment of sexual health, statistical considerations, and an exploration of the unique array of histopathologic and clinical factors that may influence QoL outcomes in women with EC.

RESULTS

This collaborative composition is the first publication specific to EC that addresses methodology in QoL research and the components necessary to achieve high quality QoL data in clinical trials. Future recommendations regarding (1) the incorporation of patient-reported outcomes in all clinical trials in EC, (2) definition of an a priori hypothesis, (3) utilization of validated tools and consideration of new tools corresponding to new therapies or specific symptoms, (4) publication within the same time frame as clinical outcome data, and (5) attempt to correct for disease site-specific potential confounders are presented.

CONCLUSIONS

Improved understanding of methodology in QoL research and an increased undertaking of EC-specific QoL research in clinical trials are imperative if we are to improve outcomes in women with EC.