Understanding Patient Experience in Biliary Tract Cancer: A Qualitative Patient Interview Study

Durvalumab plus gemcitabine and cisplatin in advanced biliary tract cancer (TOPAZ-1): patient-reported outcomes from a randomised, double-blind, placebo-controlled, phase 3 trial

BACKGROUND

In the ongoing, randomised, double-blind phase 3 TOPAZ-1 study, durvalumab, a PD-L1 inhibitor, plus gemcitabine and cisplatin was associated with significant improvements in overall survival compared with placebo, gemcitabine, and cisplatin in people with advanced biliary tract cancer at the pre-planned intermin analysis. In this paper, we present patient-reported outcomes from TOPAZ-1.

METHODS

In TOPAZ-1 (NCT03875235), participants aged 18 years or older with previously untreated, unresectable, locally advanced, or metastatic biliary tract cancer with an Eastern Cooperative Oncology Group performance status of 0 or 1 and one or more measurable lesions per Response Evaluation Criteria in Solid Tumors (RECIST; version 1.1) were randomly assigned (1:1) to the durvalumab group or the placebo group using a computer-generated randomisation scheme. Participants received 1500 mg durvalumab or matched placebo intravenously every 3 weeks (on day 1 of the cycle) for up to eight cycles in combination with 1000 mg/m2 gemcitabine and 25 mg/m2 cisplatin intravenously on days 1 and 8 every 3 weeks for up to eight cycles. Thereafter, participants received either durvalumab (1500 mg) or placebo monotherapy intravenously every 4 weeks until disease progression or other discontinuation criteria were met. Randomisation was stratified by disease status (initially unresectable vs recurrent) and primary tumour location (intrahepatic cholangiocarcinoma vs extrahepatic cholangiocarcinoma vs gallbladder cancer). Patient-reported outcomes were assessed as a secondary outcome in all participants who completed the European Organisation for Research and Treatment of Cancer's 30-item Quality of Life of Cancer Patients questionnaire (QLQ-C30) and the 21-item Cholangiocarcinoma and Gallbladder Cancer Quality of Life Module (QLQ-BIL21). We calculated time to deterioration-ie, time from randomisation to an absolute decrease of at least 10 points in a patient-reported outcome that was confirmed at a subsequent visit or the date of death (by any cause) in the absence of deterioration-and adjusted mean change from baseline in patient-reported outcomes.

FINDINGS

Between April 16, 2019, and Dec 11, 2020, 685 participants were enrolled and randomly assigned, 341 to the durvalumab group and 344 to the placebo group. Overall, 345 (50%) of participants were male and 340 (50%) were female. Data for the QLQ-C30 were available for 318 participants in the durvalumab group and 328 in the placebo group (median follow-up 9·9 months [IQR 6·7 to 14·1]). Data for the QLQ-BIL21 were available for 305 participants in the durvalumab group and 322 in the placebo group (median follow-up 10·2 months [IQR 6·7 to 14·3]). The proportions of participants in both groups who completed questionnaires were high and baseline scores were mostly similar across treatment groups. For global health status or quality of life, functioning, and symptoms, we noted no difference in time to deterioration or adjusted mean changes from baseline were observed between groups. Median time to deterioration of global health status or quality of life was 7·4 months (95% CI 5·6 to 8·9) in the durvalumab group and 6·7 months (5·6 to 7·9) in the placebo group (hazard ratio 0·87 [95% CI 0·69 to 1·12]). The adjusted mean change from baseline was 1·23 (95% CI -0·71 to 3·16) in the durvalumab group and 0·35 (-1·63 to 2·32) in the placebo group.

INTERPRETATION

The addition of durvalumab to gemcitabine and cisplatin did not have a detrimental effect on patient-reported outcomes. These results suggest that durvalumab, gemcitabine, and cisplatin is a tolerable treatment regimen in patients with advanced biliary tract cancer.

FUNDING

AstraZeneca.

Mapping the experiences of people with advanced cancer across multiple cancer types-a scoping review

BACKGROUND

Through the introduction of tumor agnostic therapies, people with metastatic cancer and their treating physicians are facing new treatment choices that have differing side effect and efficacy profiles from conventional chemotherapy.

OBJECTIVE

The present study undertakes a scoping review of research into the experiences of people with advanced or metastatic cancer across various solid tumor types with the goal of developing a tumor-agnostic conceptual model.

DESIGN

Automated queries on three internet search engines were performed to identify qualitative interview studies that focused on people with metastatic cancer. No limits were imposed for dates nor location of studies.

RESULTS

Of the 173 hits generated from the searches, 25 peer-reviewed papers were selected for the review with dates that ranged from 2007 to 2022. All papers originated from the USA, Europe, Australia, or Japan. Three major themes emerged that formed the basis for the tumor-agnostic conceptual model: symptoms, loss of autonomy, and adaptation/coping.

CONCLUSIONS

The explication of the interplay between the physical and emotional symptoms experienced by those with advanced and metastatic cancer using a multi-tumor approach provides the potential to make generalizations about the needs of this population. An opportunity exists to potentially address these needs through matching patient needs and preferences with the characteristics of novel therapeutics.

IMPLICATIONS FOR CANCER SURVIVORS

In the era of tumor agnostic therapies, the elicitation of patient preferences across the spectrum of anatomical origins has the potential to enhance shared decision making in the setting of metastatic disease.

Productivity loss outcomes and costs among patients with cholangiocarcinoma in the United States: an economic evaluation

BACKGROUND

Cholangiocarcinoma (CCA) is associated with poor prognosis. Healthcare-related management likely presents a substantial economic burden associated with time away from work in patients with CCA.

OBJECTIVES

To assess productivity loss, associated indirect costs, and all-cause healthcare resource utilization and costs owing to workplace absenteeism, short-term disability, and long-term disability in CCA patients with work absence and disability benefits eligibility in the United States.

METHODS

US retrospective claims data from Merative MarketScan Commercial and Health and Productivity Management Databases. Eligible patients were adults with ≥1 non-diagnostic medical claim for CCA in the index period (1 January 2011-31 December 2019) and had ≥6 months of continuous medical and pharmacy benefit enrolment before and ≥1 month of follow-up and full-time employee work absence and disability benefits eligibility after the index date. Outcomes were assessed in patients with CCA, intrahepatic CCA (iCCA), and extrahepatic CCA (eCCA) in absenteeism, short-term disability, and long-term disability cohorts (measured per patient per month [PPPM] for a month of 21 workdays), with costs standardized to 2019 USD.

RESULTS

One thousand and sixty-five patients with CCA were included (iCCA: n = 624 [58.6%]; eCCA: n = 380 [35.7%]). The mean age was 51.9-53.9 years across cohorts. In patients with iCCA and eCCA, respectively, the number of mean all-cause days absent PPPM for illness was 6.0 and 4.3, and 12.9 and 6.6% had ≥1 CCA-related short-term disability claim. Median indirect costs PPPM owing to absenteeism, short-term disability, and long-term disability, respectively, in patients with iCCA were $622, $635, and $690, and $304, $589, and $465 in patients with eCCA. Patients with iCCA vs. eCCA had higher inpatient, outpatient medical, outpatient pharmacy, and all-cause healthcare costs PPPM.

CONCLUSIONS

Patients with CCA had high productivity losses, indirect costs, and medical costs. Outpatient services costs contributed greatly to the higher healthcare expenditure observed in patients with iCCA vs. eCCA.

Natural Language Processing for Automated Classification of Qualitative Data From Interviews of Patients With Cancer

OBJECTIVES

This study sought to explore the use of novel natural language processing (NLP) methods for classifying unstructured, qualitative textual data from interviews of patients with cancer to identify patient-reported symptoms and impacts on quality of life.

METHODS

We tested the ability of 4 NLP models to accurately classify text from interview transcripts as "symptom," "quality of life impact," and "other." Interview data sets from patients with hepatocellular carcinoma (HCC) (n = 25), biliary tract cancer (BTC) (n = 23), and gastric cancer (n = 24) were used. Models were cross-validated with transcript subsets designated for training, validation, and testing. Multiclass classification performance of the 4 models was evaluated at paragraph and sentence level using the HCC testing data set and analyzed by the one-versus-rest technique quantified by the receiver operating characteristic area under the curve (ROC AUC) score.

RESULTS

NLP models accurately classified multiclass text from patient interviews. The Bidirectional Encoder Representations from Transformers model generally outperformed all other models at paragraph and sentence level. The highest predictive performance of the Bidirectional Encoder Representations from Transformers model was observed using the HCC data set to train and BTC data set to test (mean ROC AUC, 0.940 [SD 0.028]), with similarly high predictive performance using balanced and imbalanced training data sets from BTC and gastric cancer populations.

CONCLUSIONS

NLP models were accurate in predicting multiclass classification of text from interviews of patients with cancer, with most surpassing 0.9 ROC AUC at paragraph level. NLP may be a useful tool for scaling up processing of patient interviews in clinical studies and, thus, could serve to facilitate patient input into drug development and improving patient care.

Emerging Systemic Therapies in Advanced Unresectable Biliary Tract Cancer: Review and Canadian Perspective

Biliary tract cancer (BTC) is a group of rare and aggressive malignancies with a dismal prognosis. There is currently a significant lack in effective treatment options for BTC, with gemcitabine-cisplatin remaining the first-line standard of care treatment for over a decade. A wave of investigational therapies, including new chemotherapy combinations, immunotherapy, and biomarker-driven targeted therapy have demonstrated promising results in BTC, and there is hope for many of these therapies to be incorporated into the Canadian treatment landscape in the near future. This review discusses the emerging therapies under investigation for BTC and provides a perspective on how they may fit into Canadian practice, with a focus on the barriers to treatment access.

Quality of Life and Symptom Management in Advanced Biliary Tract Cancers

Simple Summary

Patients with advanced BTC have poor prognosis and frequently experience symptoms that adversely impact their quality of life. In this review, we explore the potential complications of advanced BTC and its treatments. We also review the possible strategies and interventions available to manage these adverse events.

Abstract

Biliary tract carcinomas (BTCs) account for less than 1% of all cancers but are increasing in incidence. Prognosis is poor for BTC patients, with 5-year survival rates of less than 10%. While chemotherapy has been the mainstay treatment for patients with advanced BTC, immunotherapy and targeted therapies are being evaluated in numerous clinical trials and rapidly incorporated into clinical practice. As patients with BTC have reduced health-related quality of life (HRQoL) due to both tumor- and treatment-related symptoms, it is important for clinicians to recognize and manage these symptoms early. This review will highlight the anticipated complications from BTC and its systemic treatment, as well as their effects on HRQoL.