Using patient-reported health status to improve prognostic assessment in patients with acute myeloid leukemia: current challenges and future applications

Patient-reported outcome measures for advanced cancer in China: A systematic review of cross-cultural adaptation and psychometric properties

BACKGROUND

The number of patients with advanced cancer in China is rapidly increasing. As services and policy evolve, it is essential to improve the quality of care by measuring outcomes of importance to patients and families by identifying patient-reported outcome measures (PROMs) for use with advanced cancer patients in China, and critically appraising their cross-cultural adaptation process and measurement properties.

METHODS

A systematic review was conducted in accordance with COnsensus-based Standards for the selection of health status Measurement INstruments (COSMIN), with quality assessment using the Guidelines for the Process of Cross-Cultural Adaptation of Self-Report Measures and COSMIN quality criteria for measurement properties. MEDLINE, EMBASE, PsycINFO, CINAHL, CNKI and WanFang were systematically searched from inception to May 2019, updated to August 2022. Supplemental searches were conducted in grey literature databases, Google scholar and hand-searching of reference lists.

RESULTS

From 10793 articles, 437 were selected for full-text review based on titles and abstracts. A total of 46 studies reporting 39 PROMs were retained. No articles were rated as "good quality" in more than four of the six stages of cross-cultural adaptation. At least half of the required information on psychometric properties was missing for each measure. Based on COSMIN, none identified PROMs were valid across all properties nor appropriate to use.

CONCLUSION

There is currently no contextually appropriate and psychometrically sound PROMs for advanced cancer patients in China. The psychometric literature suggest that adaptation of existing measures is the potential solution.

POLICY SUMMARY

Developing outcome measures for advanced cancer patients in China is invaluable to improve audit, clinical services and assess the quality of care, for research purposes and secure funding. Future research in measures' development, refinement and cross-cultural adaptation in this field is urgently needed.

Treatment options for older unfit patients with acute myeloid leukemia

Older acute myeloid leukemia patients usually experience a bleak outcome, especially those in the unfit group. For this unfit category, intensive chemotherapy and allogeneic stem cell transplantation are usually accompanied by higher early mortality, which results from higher risk genetic profiles and worse psychological and physiological conditions. The significant improvement in genetic technology recently has driven the appearance of several mutation-targeted therapies, such as FLT3, Bcl-2, IDH and Hedgehog pathway inhibitors and an anti-CD33 antibody-drug conjugate, which have changed enormously the therapeutic landscape of acute myeloid leukemia. This review describes the treatment dilemma of the unfit group and discusses the objective clinical data of each targeted drug and mechanisms of resistance, with a focus on combination strategies with fewer toxicities and abrogation of drug resistance.

Patient-Reported Outcomes as Independent Prognostic Factors for Survival in Oncology: Systematic Review and Meta-Analysis

OBJECTIVES

Assessment of patient-reported outcomes (PROs) in oncology is of critical importance because it provides unique information that may also predict clinical outcomes.

METHODS

We conducted a systematic review of prognostic factor studies to examine the prognostic value of PROs for survival in cancer. A systematic literature search was performed in PubMed for studies published between 2013 and 2018. We considered any study, regardless of the research design, that included at least 1 PRO domain in the final multivariable prognostic model. The protocol (EPIPHANY) was published and registered in the International Prospective Register of Systematic Reviews (CRD42018099160).

RESULTS

Eligibility criteria selected 138 studies including 158 127 patients, of which 43 studies were randomized, controlled trials. Overall, 120 (87%) studies reported at least 1 PRO to be statistically significantly prognostic for overall survival. Lung (n = 41, 29.7%) and genitourinary (n = 27, 19.6%) cancers were most commonly investigated. The prognostic value of PROs was investigated in secondary data analyses in 101 (73.2%) studies. The EORTC QLQ-C30 questionnaire was the most frequently used measure, and its physical functioning scale (range 0-100) the most frequent independent prognostic PRO, with a pooled hazard ratio estimate of 0.88 per 10-point increase (95% CI 0.84-0.92).

CONCLUSIONS

There is convincing evidence that PROs provide independent prognostic information for overall survival across cancer populations and disease stages. Further research is needed to translate current evidence-based data into prognostic tools to aid in clinical decision making.

Symptoms and anxiety predict declining health-related quality of life in multiple myeloma: A prospective, multi-centre longitudinal study

BACKGROUND

Patients with multiple myeloma, an incurable haematological cancer, often receive palliative care only late in their trajectory. Criteria for early referral are lacking.

AIM

To identify which patients might benefit from early integration, by identifying trajectories of health-related quality of life and the determinants for declining or poor Health related quality of life .

DESIGN

Prospective, longitudinal cohort study.

PARTICIPANTS

Multiple myeloma patients at all stages (newly diagnosed, first-line or second-line treatment, early or later treatment-free interval, refractory disease) from in- and outpatient units at 14 hospitals in England were recruited. In addition to clinical information and standardised Health related quality of life and psychological aspects, the Myeloma Patient Outcome Scale (MyPOS) measured palliative care concerns.

RESULTS

A total of 238 patients were recruited, on average 3.5 years ( SD: 3.4) post-diagnosis. Latent mixture growth models identified four Health related quality of life trajectories. Classes 3 and 4 represent trajectories of stable poor Health related quality of life or declining Health related quality of life over an 8-month period. The strongest predictors of poor outcome at the end of follow-up were general symptom level (odds ratio (OR): 1.3, 95% CI: 1.0-1.6, p = 0.028), presence of clinically relevant anxiety (OR: 1.2, 95% confidence interval (CI): 1.0-1.4, p = 0.019), and presence of pain (OR: 1.02, 95% CI: 1.0-1.1, p = 0.018), all being more predictive than demographic or clinical characteristics.

CONCLUSION

General symptom level, pain and presence of anxiety predict declining Health related quality of life in multiple myeloma. Identification of patients with palliative care needs should focus on assessing patient-reported symptoms and psychosocial well-being for identifying those at risk of deterioration.

[The usage of comprehensive geriatric assessment in elderly patients with acute myeloid leukemia: a multicenter, prospective study]

Objective: To evaluate the feasibility and potential value of comprehensive geriatric assessment (CGA) in elderly (≥60 years) patients with newly diagnosed acute myeloid leukemia (AML) in China. Methods: The CGA results of 83 newly diagnosed AML (non-APL) patients from 16 hospitals in Beijing and Tianjin between March 2016 and December 2017 were prospectively collected and analyzed. The clinical data, treatment and follow-up information were also collected. Results: Of 83 newly diagnosed elderly AML patients, 81 patients (97.6%) completed all designated CGA assessment. The median number of impaired scales of the CGA assessment in the studied population was 2(0-6). Sixteen patients (19.3%) showed no impairments according to the geriatric assessment scales implem ented by this study. The distributions of impaired scales were as follows: impairment in ADL, 55.4%; IADL impairment, 42.2%; MNA-SF impairment, 48.2%; cognitive impairment, 15.7%; GDS impairment, 31.7%; HCT-CI impairment, 19.5%, respectively. In patients with "good" ECOG (n=46), the proportion of impairment for each CGA scale ranged from 6.5% to 37.0% and 32 patients (68.9%) had at least one impaired CGA scale. Survival analysis showed that the number of impaired scales of the CGA was significantly correlated with median overall survival (P=0.050). Conclusions: CGA was a tool with feasibility for the comprehensive evaluation in elderly AML patients in China. Combined with age and ECOG, CGA may be more comprehensive in assessing patients' physical condition.

A preliminary investigation examining patient reported outcome measures for low back pain and utilisation amongst chiropractors in Australia: facilitators and barriers to clinical implementation

Background

The current utilisation of patient reported outcome measures (PROMs) for low back pain (LBP) within the Australian Chiropractic profession is unknown. The aims of this study were to determine the current utilisation of LBP PROMs amongst Chiropractors in Australia and to identify the potential barriers and facilitators of using PROMs for LBP in Chiropractic practice.

Methods

A cross sectional online survey was distributed to Chiropractors in Australia who were members of the Chiropractic Association of Australia (CAA) and Chiropractic Australia (CA) between June-August 2016. Three thousand fourteen CAA members and 930 CA members were invited to participate totaling 3944 potential participants.

Results

The findings from this survey provides baseline data for the prevalence of LBP PROMs within the Australian Chiropractic profession. A total of 558 participants completed the survey reflecting a response rate of 14.1%. 72.5% of respondents used LBP PROMs in clinical practice. PROMs were categorised into pain, function and health. At initial patient consultations the most commonly used pain PROMs were the pain diagram, Visual Analogue Scale and Numeric Rating Scale. Most commonly used functional LBP PROMs were the Oswestry Disability Index, Functional Rating Index and Roland Morris Questionnaire. The Health Status Questionnaire (HSQ) was the most commonly used health LBP PROM followed by RAND Health Questionnaires.

Conclusion

Most of the survey respondents use PROMs in clinical practice. The most common barrier chiropractors identified that prevent LBP PROM utilisation was the lack of operational definition surrounding PROMs, as well as how to use them and the perception that they are time consuming. Facilitatory factors to implement PROMs included using simple administration systems, utilising electronic forms and consistent implementation. This research indicates that there is a potential need to further educate the Chiropractic profession regarding PROMs.

Longitudinal patterns of cancer patient reported outcomes in end of life care predict survival

PURPOSE

Patients with advanced cancer typically demonstrate sharp deterioration in physical function and psychological status during the last months of life. This study evaluates the relationship between survival in patients with advanced cancer and longitudinal assessment of anxiety, depression, fatigue, pain interference, and/or physical function using the US National Institute of Health Patient Reported Outcomes Information System.

METHODS

Mixed-effects models were used to evaluate patient-reported outcome trajectories over time among patients with advanced loco-regional or metastatic cancer receiving care in a hospital-based palliative care clinic. Cox regression analysis was used to assess the statistical significance of differences in the probability of survival associated with patient-reported outcome scores.

RESULTS

A total of 472 patients completed 1992 assessments during the 18-month study period. Longitudinal scores for fatigue, pain interference, and physical function demonstrated statistically significant non-linear trajectories. Scores for depression, fatigue, pain interference, and physical function were highly statistically significant predictors of survival (p < 0.01). Clinically meaningful differences in the probability of survival were demonstrated between patients with scores at the 25th vs. 75th percentiles, with absolute differences in survival at 6 and 12 months after assessment from 10 to 18 percentage points.

CONCLUSIONS

Patient-reported outcomes can be used to reliably estimate where patients are along the trajectory of deteriorating health status leading toward the end of life, and for identifying patients with declining symptoms in need of referral to palliative care or more aggressive symptom management.

The Prognostic Value of Patient-Reported Outcome Data in Patients With Colorectal Hepatic Metastases Who Underwent Surgery

INTRODUCTION

Patient-reported outcomes (PROs) are critical to evaluate clinically effective treatments and evidence suggests that PROs might predict survival. The prognostic value of PROs in patients with isolated liver metastases from colorectal cancer (CRC) who undergo surgery is unclear. In this study we investigated whether baseline PROs are prognostic in this patient group.

PATIENTS AND METHODS

From April 2004 to May 2007, consecutive patients who underwent curative resection of CRC liver metastases completed the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (QLQ)-C30 and QLQ-LMC21 questionnaires before surgery. Patients were followed until death or data were censored on April 9, 2012. Cox proportional hazards models were used to assess the effect of PROs on survival controlling for predefined clinical covariates. Models were simplified using a backwards stepwise approach and model utility appraised using the Harrell C and Somers D statistics and bootstrap methods.

RESULTS

Two hundred thirty-two patients underwent liver resection and 101 (43.5%) survived 5 years. Multivariate analysis controlling for relevant clinical covariates showed that a 10-point improvement in baseline global quality of life scores was associated with a 54% improvement in survival (hazard ratio [HR], 0.46; 95% confidence interval [CI], 0.33-0.63; P < .001), and a clinically significant weight loss was associated with 75% worse survival (HR, 1.75; 95% CI, 1.20-2.55; P = .004). Smaller effects were noted for worsening abdominal pain, taste problems, and fatigue (30%-38% poorer survival). Results of bootstrap resampling suggested that global health and weight loss most reliably predicted survival.

CONCLUSION

Results of this study demonstrated that patients who reported worse baseline global quality of life and increased weight loss before liver resection for CRC liver metastases had significantly poorer survival. These findings if externally validated might be used to inform patients, and could also influence treatment planning and advise follow-up strategies and supportive care.