Development of a Novel Hematological Malignancy Specific Patient-Reported Outcome Measure (HM-PRO): Content Validity

Guidelines for the Use and Reporting of Patient-Reported Outcomes in Multiple Myeloma Clinical Trials

In the era of personalized medicine there is an increasing need for the assessment of patient-reported outcomes (PROs) to become a standard of patient care. Patient-reported outcome measures (PROM) are important in assessing significant and meaningful changes as a result of an intervention based on a patient's own perspective. It is well established that active multiple myeloma (MM) can be characterized by a high burden of disease and treatment-related symptoms, with considerable worsening of quality of life (QoL). In general, and over the past decade, the focus has shifted to obtaining the most durable remissions with the best QoL as primary goals for MM treatment. Patients place considerable value on their QoL and communicating about QoL data prior to treatment decisions allows them to make informed treatment choices. Consequently, optimization of QoL of patients with MM is an important therapeutic goal and the incorporation of PROs into clinical trials has the potential of improving treatment outcomes. In this regard, guidance for the use and reporting of PROMs in MM in clinical trials is warranted. Under the auspices of the European Hematology Association, evidence-based guidelines for the use and reporting of PROs in patients with MM have been developed according to the EHA's core Guidelines Development Methodology. This document provides general considerations for the choice of PROMs in MM clinical trials as well as a series of recommendations covering a selection of PROMs in MM clinical trials; the mode of administration; timing of assessments; strategies to minimize missing data; sample size calculation; reporting of results; and interpretation of results.

Measuring chronic myeloid leukaemia TKI-related toxic effects in the real world: a systematic review and critical assessment of content validity of patient-reported outcome measures

Insight into real-world treatment-related toxic effects reported by patients has the potential to improve care, benchmark trials, and fill knowledge gaps, especially in patients with chronic myeloid leukaemia, which is treated in the majority of patients continually with tyrosine-kinase inhibitors (TKIs). The aim of our systematic review was to investigate the content validity of instruments that elicit TKI-related toxic effects reported by patients with chronic myeloid leukaemia in the real world. We searched PubMed and Embase from Jan 1, 2017 to Oct 21, 2022. Studies on instruments used in or developed for patients with chronic myeloid leukaemia that assess a patient's symptoms were eligible. Content validity was assessed according to the Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN): none of the six identified instruments were rated as sufficient. Five instruments (European Organisation for Research and Treatment of Cancer Core Quality of Life Questionnaire for chronic myeloid leukaemia with 24 items [EORTC QLQ-CML24], EORTC symptom set, Functional Assessment of Cancer Therapy-Leukaemia [FACT-LEU], haematological malignancies patient-reported outcomes [HM-PRO], and MD Anderson Symptom Inventory for chronic myeloid leukaemia [MDASI-CML]) were rated as inconsistent due to not being evaluated by professionals post-development, having very few patients with chronic myeloid leukaemia involved, or missing key symptoms. Moderate-quality to very low-quality evidence underpinned these ratings. The two EORTC instruments were the only ones not to miss key toxic effects (eg, muscle cramps). However, their relevance was rated as inconsistent: the QLQ-CML24 includes questions on health-related quality-of-life, whereas the symptom set includes items sourced from solid cancer treatments. This Review shows the need for an instrument with sufficient content validity to measure toxic effects from TKI treatment in patients with chronic myeloid leukaemia. Until then, stakeholders can make an informed choice from currently used instruments with our assessment.

Advances in the management of myeloma: an update

Myeloma is an aggressive B-cell malignancy resulting from an uncontrolled production of plasma cells in the bone marrow. A multitude of drugs and combinations of drugs are now approved for use to treat this complex disease and nurses require knowledge and skills in recognising and managing new side effects associated with these treatments. This article presents an overview of some of the newer and recently approved drugs and the important side effects that have been associated with them. Clinical nurse specialists and advanced nurse practitioners are at the forefront of patients' treatment journeys and play a central role in supporting patients and families to manage side effects. Through this support, patients can continue the treatments for as long as possible with the aim of maintaining a good quality of life.

Assessment tools for patient-reported outcomes in multiple myeloma

BACKGROUND

Patients with multiple myeloma experience severe symptom burden. Patient participation in self-reporting is essential as medical staff's assessment of patient symptom severity is often lower than patient self-reporting. This article reviews patient-reported outcome (PRO) assessment tools and their application in the field of multiple myeloma.

RESULTS

The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30) is the universal patient-reported outcome assessment tool most frequently used to evaluate the life quality in people with multiple myeloma. Among the specific patient-reported outcome assessment tools, the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Multiple Myeloma Module (EORTC QLQ-MY20), the Functional Assessment of Cancer Therapy-Multiple Myeloma (FACT-MM), and the M.D. Anderson Symptom Inventory-Multiple Myeloma Module (MDASI-MM) are the most widely used, with some scholars using the EORTC QLQ-MY20 as a calibration correlate for scale development. Most current assessment instruments were developed using classical measurement theory methods; future researchers could combine classic theory tests and item response theory to create scientific assessment instruments. In addition, researchers select the appropriate assessment tool based on the purpose of the study. They can translate high-quality assessment tools into different languages and consider applying them more often to assessing multiple myeloma patients. Finally, most existing PROs focus on measuring life quality and symptoms in people with multiple myeloma, with less research on outcomes such as adherence and satisfaction, thus failing to comprehensively evaluate the patient treatment and disease management.

CONCLUSIONS

Research has shown that the field of PROs in multiple myeloma is in an exploratory phase. There is still a need to enrich the content of PROs and develop more high-quality PRO scales for multiple myeloma based on the strengths and weaknesses of existing tools. With the successful advancement of information technology, PROs for people with multiple myeloma could be integrated with electronic information systems, allowing patients to report their health status in real time and doctors to track their condition and adjust their treatment, thereby improving patient outcomes.

Systematic Review of the Effect of a One-Day Versus Seven-Day Recall Duration on Patient Reported Outcome Measures (PROMs)

BACKGROUND

There is ongoing uncertainty around the most suitable recall period for patient-reported outcome measures (PROMs).

METHOD

This systematic review integrates quantitative and qualitative literature across health, economics, and psychology to explore the effect of a one-day (or '24-h') versus seven-day (or 'one week') recall period. The following databases were searched from database inception to 30 November 2021: MEDLINE, EMBASE, PsycINFO, Web of Science, EconLit, CINAHL Complete, Cochrane Library, and Sociological Abstracts. Studies were included that compared a one-day (or '24-h') versus seven-day (or weekly) recall period condition on patient-reported scores for PROM and Health-Related Quality-of-Life (HRQoL) instrument scores in adult populations (aged 18 and above) or combined paediatric and adult populations with a majority of respondents aged over 18 years. Studies were excluded if they assessed health behaviours only, used ecological momentary assessment to derive an index of daily recall, or incorporated clinician reports of patient symptoms. We extracted results relevant to six domains with generic health relevance: physical functioning, pain, cognition, psychosocial wellbeing, sleep-related symptoms and aggregated disease-specific signs and symptoms. Quantitative studies compared weekly recall scores with the mean or maximum score over the last seven days or with the same-day recall score.

RESULTS

Overall, across the 24 quantitative studies identified, 158 unique results were identified. Symptoms tended to be reported as more severe and HRQoL lower when assessed with a weekly recall than a one-day recall. A narrative synthesis of 33 qualitative studies integrated patient perspectives on the suitability of a one-day versus seven-day recall period for assessing health state or quality of life. Participants had mixed preferences, some noted the accuracy of recall for the one-day period but others preferred the seven-day recall for conditions characterised by high symptom variability, or where PROMs concepts required integration of infrequent experiences or functioning over time.

CONCLUSION

This review identified a clear trend toward higher symptom scores and worse quality of life being reported for a seven-day compared to a one-day recall. The review also identified anomalies in this pattern for some wellbeing items and a need for further research on positively framed items. A better understanding of the impact of using different recall periods within PROMs and HRQoL instruments will help contextualise future comparisons between instruments. Questionnaires ask patients about their health over different time periods (e.g., "what were your symptoms like over the last week?" versus "what were your symptoms like today?"). Studies find that people may report their symptoms as more severe when they are asked to think about their symptoms over the last week compared to the last day. Understanding how different time periods influence patient responses will allow researchers to compare and develop new questionnaires and may help clinicians to choose the best questionnaire to understand their patient's condition. We conducted a systematic literature review on studies which had looked at the impact of using different recall periods on patient responses. We found 24 studies that compared patient scores from questionnaires asking their health "over the last day" compared to "over the last week". Overall, symptoms tended to be reported as more severe and health as poorer when they were reported over the last week compared to the last day on average. We also found 33 studies that asked patients to describe which recall period they preferred. Patients had mixed preferences with more preferring a seven-day recall where symptoms and health impacts varied a lot.

Understanding Quality of Life in Patients With Acute Leukemia, a Global Survey

Purpose

The Acute Leukemia Advocates Network (ALAN) sought to determine which factors are most associated with poor quality of life (QoL) in patients with acute leukemia and to determine key issues and unmet needs through administration of an online survey distributed worldwide via partner patient organizations.

Methods

ALAN developed a questionnaire informed by literature review and based extensively on the hematological malignancy-specific patient-reported outcomes (HM-PRO) measure to assess the impact of acute leukemia on QoL and its relationships with patients' demographics, disease state, disease impact, and support from health care professionals. Univariate and multivariable statistical analysis was used to investigate relationships between HM-PRO scores and the other factors.

Results

Of 552 respondents from 42 countries, 332 had acute myeloid leukemia, 139 had acute lymphoblastic leukemia, and 81 had acute promyelocytic leukemia (survey data collected in 2019). Younger age, female gender, and lower income were all significantly negatively associated with QoL. Weak or moderate correlations were observed between overall support, management, and impact of treatment and diagnosis of acute leukemia. Feeling isolated and having reduced ability to carry out physical or enjoyable activities were the most important individual factors, while the best predictors for QoL impact were age, gender, and income (model r²=0.16, complete case n=449).

Conclusions

Findings indicated key factors, particularly age, gender, and socioeconomic state, that clinicians responsible for the care of patients with acute leukemia should be aware of when designing support strategies. The importance of social functioning in relation to patient QoL also should be included in considerations.

Targeting health-related quality of life in patients with myelodysplastic syndromes - Current knowledge and lessons to be learned

Using a range of health-related quality of life (HRQoL) instruments, most - but not all - studies of myelodysplastic syndromes (MDS) have reported that lower hemoglobin levels and red blood cell transfusion dependency are associated with worse HRQoL. In addition, some MDS treatments may significantly improve HRQoL, particularly among those patients who respond to therapy; however, the majority of these studies were underpowered for this secondary endpoint. Furthermore, decreased HRQoL has been associated with worse survival outcomes, and HRQoL scores can be used to refine classical prognostic systems. Despite the subjective nature of HRQoL, the importance and validity of measuring it in trials and clinical practice are increasingly being recognized, but properly validated MDS-specific instruments are required. We describe what is currently known about HRQoL in patients with MDS, and the limitations of measuring HRQoL, and we provide some recommendations to improve the measurement of this outcome in future trials.

Reliability of a Novel Hematological Malignancy Specific Patient-Reported Outcome Measure: HM-PRO

BACKGROUND

Patients' experience of symptoms often goes undetected during consultation in an outpatient clinic, and the use of a patient-reported outcome measure (PRO) in such a setting could be useful to aid treatment decision-making. A new PRO measure, the HM-PRO (Hematological Malignancy Specific Patient-Reported Outcome Measure) has been recently developed to evaluate hematological malignancy (HM) patients' health-related quality of life (HRQoL) and their symptom experience in daily clinical practice as well as in research. The objectives of the study were to assess: the internal consistency of the scores for Part A (impact) and its four domains (physical behavior; social well-being; emotional behavior; and eating and drinking habits) and Part B (signs and symptoms); and the test-retest reliability of the individual items of the newly developed hematological malignancy specific composite measure, the HM-PRO.

METHODS

This was a prospective longitudinal observational study where 150 patients with different HMs and different stage of disease (male n = 98 (65.3%); mean age 64.9 ± 14.4 years, range 17.9-89.2 years; mean time since diagnosis 3.7 ± 4.9 years, range 0.04-25.8 years) completed the HM-PRO at baseline (assessment 1 at t1) and after 7 days (assessment 2 at t2). Data analysis was performed using IBMSPSS 23 statistical software.

RESULTS

The Cronbach's alpha estimates of the HM-PRO for both assessment points (t1 and t2) were above 0.9 for Part A, and above 0.8 for Part B, showing strong stability of the measurement. The level of agreement for the reproducibility between the two assessments, using intra-class correlation coefficients (ICC), was very strong with Part A: ICC = 0.93 (95% CI = 0.90-0.95), and Part B: ICC = 0.91 (0.88-0.93). The ICC for the four domains of Part A ranged from 0.85-0.91. The ICC was greater than 0.8 for overall score of Part A and Part B for all the 10 diagnoses, confirming strong reliability.

CONCLUSION

This study clearly indicates that the HM-PRO possesses strong test-retest reliability for both Part A and Part B. The Cronbach's alpha confirmed acceptable internal consistency. The extensive reliability testing described in this study supports the generic nature of the HM-PRO for use in hematological malignancies in both routine clinical practice, to aid treatment decisions, as well as in research.

Hematological Malignancy Specific Patient-Reported Outcome Measure (HM-PRO): Construct Validity Study

BACKGROUND

Validity is the ability of an instrument to measure what it claims to measure. It means the degree to which the empirical evidence supports the trustworthiness of interpretations based on the calculated scores. The hematological malignancy (HM) specific patient reported outcome measure (HM-PRO), is a newly developed instrument for use in daily clinical practice as well as in research. This study, provides the evidence for construct validity of the HM-PRO, specifically focusing on the convergent and divergent validity compared to the other established instruments used in hematology.

METHODS

This validation study adopted a prospective cross-sectional design where a heterogeneous group of patients diagnosed with different HMs and different disease state were recruited. A total of 905 patients were recruited from seven secondary care hospitals in the UK and online through five patient organizations. Patients were asked to complete the HM-PRO and other cancer specific PRO's, FACT-G and EORTC QLQ C-30. Data analysis was performed using IBM SPSS 23 statistical software.

RESULTS

A total of 486 males (53.7%) and 419 females (46.3%), with a mean age of 64.3 (± 12.4) years and mean time since diagnosis of 4.6 ( ± 5.2) were recruited. The total score of Part A of the HM-PRO highly correlated with the five functional scales of the EORTC QLQ-C30 (Physical = -0.71, Role = -0.72, Emotional = -0.64, Cognitive = -0.58, Social = -0.74-p < 0.001). With respect to correlation with FACT-G, the total score of Part A of the HM-PRO highly correlated with Physical (-0.74), Emotional (-0.57), Functional (-0.66) domains and overall score of FACT-G (-0.74). Similarly, the total score of Part B of the HM-PRO highly correlated with three symptoms scales of EORTC QLQ-C30 (Fatigue scale = -0.74, Nausea and Vomiting = -0.52, Pain = -0.59-p < 0.001) and individual symptom items (Dyspnea = 0.51, Insomnia= 0.43, Appetite loss = 0.54-p < 0.001).

CONCLUSION

The construct validity evidence presented in this research is a testimony to the HM-PRO's ability to measure HRQoL issues which it intends to measure. This is of utmost importance when a PRO is used in routine clinical practice so that the interpretation of the scores or response to an individual item is understood by the clinicians/nurses as intended by the patients.