The functional assessment of cancer therapy–BRM (FACT–BRM): A new tool for the assessment of quality of life in patients treated with biologic response modifiers

Effectiveness of Adjuvant Pembrolizumab vs High-Dose Interferon or Ipilimumab for Quality-of-Life Outcomes in Patients With Resected Melanoma: A Secondary Analysis of the SWOG S1404 Randomized Clinical Trial

Importance

A key issue for the adjuvant treatment of patients with melanoma is the assessment of the effect of treatment on relapse, survival, and quality of life (QOL).

Objective

To compare QOL in patients with resected melanoma at high risk for relapse who were treated with adjuvant pembrolizumab vs standard of care with either ipilimumab or high-dose interferon α 2b (HDI).

Design, Setting, and Participants

The S1404 phase 3 randomized clinical trial was conducted by the SWOG Cancer Research Network at 211 community/academic sites in the US, Canada, and Ireland. Patients were enrolled from December 2015 to October 2017. Data analysis for this QOL substudy was completed in March 2022. Overall, 832 patients were evaluable for the primary QOL end point.

Interventions

Patients were randomized (1:1) to treatment with adjuvant pembrolizumab vs standard of care with ipilimumab/HDI.

Main Outcomes and Measures

Quality of life was assessed for patients at baseline and cycles 1, 3, 5, 7, and 9 after randomization using the Functional Assessment of Cancer Therapy (FACT) Biological Response Modifiers (FACT-BRM), FACT-General, Functional Assessment of Chronic Illness Therapy-Diarrhea, and European QOL 5-Dimension 3-Level scales. The primary end point was the comparison by arm of cycle 3 FACT-BRM trial outcome index (TOI) scores using linear regression. Linear-mixed models were used to evaluate QOL scores over time. Regression analyses included adjustments for the baseline score, disease stage, and programmed cell death ligand 1 status. A clinically meaningful difference of 5 points was targeted.

Results

Among 1303 eligible patients (median [range] age, 56.7 [18.3-86.0] years; 524 women [40.2%]; 779 men [59.8%]; 10 Asian [0.8%], 7 Black [0.5%], 44 Hispanic [3.4%], and 1243 White [95.4%] individuals), 1188 (91.1%) had baseline FACT-BRM TOI scores, and 832 were evaluable at cycle 3 (ipilimumab/HDI = 267 [32.1%]; pembrolizumab = 565 [67.9%]). Evaluable patients were predominantly younger than 65 years (623 [74.9%]) and male (779 [58.9%]). Estimates of FACT-BRM TOI cycle 3 compliance did not differ by arm (ipilimumab/HDI, 96.0% vs pembrolizumab, 98.3%; P = .25). The adjusted cycle 3 FACT-BRM TOI score was 9.6 points (95% CI, 7.9-11.3; P < .001) higher (better QOL) for pembrolizumab compared with ipilimumab/HDI, exceeding the prespecified clinically meaningful difference. In linear-mixed models, differences by arm exceeded 5 points in favor of pembrolizumab through cycle 7. In post hoc analyses, FACT-BRM TOI scores favored the pembrolizumab arm compared with the subset of patients receiving ipilimumab (difference, 6.0 points; 95% CI, 4.1-7.8; P < .001) or HDI (difference, 17.0 points; 95% CI, 14.6-19.4; P < .001).

Conclusions and Relevance

This secondary analysis of a phase 3 randomized clinical trial found that adjuvant pembrolizumab improved QOL vs treatment with adjuvant ipilimumab or HDI in patients with high-risk resected melanoma.

Trial Registration

ClinicalTrials.gov identifier: NCT02506153.

Patient-reported tolerability of adjuvant ipilimumab (3 or 10 mg/kg) versus high-dose interferon alfa-2b for resected high-risk stage III-IV melanoma in phase III trial E1609

PURPOSE

Trial E1609 demonstrated superior overall survival with ipilimumab 3 mg/kg (ipi3) compared to high-dose interferon (HDI) for patients with resected high-risk melanoma. To inform treatment tolerability, we compared health-related quality of life (HRQoL), gastrointestinal (GI), and treatment-specific physical and cognitive/emotional symptoms. We also compared treatment-specific concerns between all arms.

METHODS

We assessed HRQoL using the Functional Assessment of Cancer Therapy-General, physical and cognitive/emotional concerns using the FACT-Biologic Response Modifier subscale, and GI symptoms with the Functional Assessment of Chronic Illness Therapy-Diarrhea subscale pre-treatment and every 3 months. The primary outcome was the difference in HRQoL at 3 months between ipi3/ipi10 vs. HDI.

RESULTS

549 patients (n = 158 ipi3; n = 191 ipi10; n = 200 HDI) were analyzed. 3-month completion was 58.7%. Compared to HDI, ipilimumab patients reported better HRQoL (ipi3 = 87.5 ± 14.6 vs. HDI = 74.7 ± 15.4, p < .001; ipi10 = 84.9 ± 16.5 vs. HDI, p < .001) and fewer physical (ipi3 = 22.3 ± 4.6 vs. HDI = 17.1 ± 5.4, p < .001; ipi10 = 21.8 ± 5.0 vs. HDI p < .001) and cognitive/emotional (ipi3 = 18.6 ± 4.4 vs. HDI = 15.0 ± 5.3, p < .001; ipi10 = 17.7 ± 4.8 vs. HDI p < .001) concerns, but worse GI symptoms (ipi3 = 40.8 ± 5.0 vs. HDI = 42.2 ± 2.9, p = .011; ipi10 = 39.5 ± 7.0 vs. HDI, p < .001). Fewer ipilimumab patients reported worsening treatment-specific concerns (e.g., 52% of ipi3 and 58% of ipi10 reported worsening fatigue vs. 82% HDI, p's < .001).

CONCLUSION

PROs demonstrated less toxicity of ipi3 compared to HDI and ipi10. Priorities for symptom management among patients receiving ipilimumab include GI toxicities, fatigue, weakness, appetite loss, arthralgia, and depression.

TRIAL REGISTRATION

NCT01274338, January 11, 2011 (first posted date) https://clinicaltrials.gov/ct2/show/NCT01274338?term=NCT01274338&draw=2&rank=1 .

Clinical Responses of Oncolytic Coxsackievirus A21 (V937) in Patients With Unresectable Melanoma

PURPOSE

We evaluated the activity of intratumoral Coxsackievirus A21 (V937) in 57 patients with unresectable stage IIIC or IV melanoma.

PATIENTS AND METHODS

In this multicenter, open-label, phase II study, patients received up to a total V937 dose of 3 × 10⁸ TCID₅₀ (50% tissue culture infectious dose) in a maximum 4.0-mL volume by intratumoral injection. Ten sets of V937 injections were administered between days 1 and 127 (NCT01227551). Patients who had stable disease or were responding could continue treatment in an extension study (NCT01636882). Response and progression status were based on contrast-enhanced computed tomography, magnetic resonance imaging, or caliper measurement and were categorized using immune-related Response Evaluation Criteria in Solid Tumors (irRECIST). Other evaluations included monitoring of adverse events and serum levels of V937 and anti-V937 antibody titers. The primary efficacy end point was 6-month progression-free survival (PFS) rate per irRECIST.

RESULTS

The primary efficacy end point, 6-month PFS rate per irRECIST, was 38.6% (95% CI, 26.0 to 52.4). Durable response rate (partial or complete response for ≥ 6 months) was 21.1% per irRECIST. Best overall response rate (complete plus partial response) was 38.6% (unconfirmed) and 28.1% (confirmed) per irRECIST. Regression of melanoma was observed in noninjected lesions. Based on Kaplan-Meier estimation, 12-month PFS was 32.9% (95% CI, 19.5 to 46.9) per irRECIST and 12-month overall survival was 75.4% (95% CI, 62.1 to 84.7). No treatment-related grade ≥ 3 adverse events occurred. Viral RNA was detected in serum within 30 minutes of administration. Neutralizing antibody titers increased to > 1:16 in all patients after day 22, without effect on clinical or immunologic response.

CONCLUSION

V937 was well tolerated and warrants further investigation for treatment of patients with unresectable melanoma. Studies of combination approaches with V937 and immune checkpoint inhibitors are ongoing.

Adoptive transfer of zoledronate-expanded autologous Vγ9Vδ2 T-cells in patients with treatment-refractory non-small-cell lung cancer: a multicenter, open-label, single-arm, phase 2 study

BACKGROUND

Not all non-small cell lung cancer (NSCLC) patients possess drug-targetable driver mutations, and response rates to immune checkpoint blockade therapies also remain unsatisfactory. Therefore, more effective treatments are still needed. Here, we report the results of a phase 2 clinical trial of adoptive cell therapy using zoledronate-expanded autologous Vγ9Vδ2 T-cells for treatment-refractory NSCLC.

METHODS

NSCLC patients who had undergone at least two regimens of standard chemotherapy for unresectable disease or had had at least one treatment including chemotherapy or radiation for recurrent disease after surgery were enrolled in this open-label, single-arm, multicenter, phase 2 study. After preliminary testing of Vγ9Vδ2 T-cell proliferation, autologous peripheral blood mononuclear cells were cultured with zoledronate and IL-2 to expand the Vγ9Vδ2 T-cells. Cultured cells (>1×10⁹) were intravenously administered every 2 weeks for six injections. The primary endpoint of this study was progression-free survival (PFS), and secondary endpoints included overall survival (OS), best objective response rate (ORR), disease control rate (DCR), safety and immunomonitoring. Clinical efficacy was defined as median PFS significantly >4 months.

RESULTS

Twenty-five patients (20 adenocarcinoma, 4 squamous cell carcinoma and 1 large cell carcinoma) were enrolled. Autologous Vγ9Vδ2 T-cell therapy was administered to all 25 patients, of which 16 completed the foreseen course of 6 injections of cultured cells. Median PFS was 95.0 days (95% CI 73.0 to 132.0 days); median OS was 418.0 days (179.0-479.0 days), and best overall responses were 1 partial response, 16 stable disease (SD) and 8 progressive disease. ORR and DCR were 4.0% (0.1%-20.4%) and 68.0% (46.5%-85.1%), respectively. Severe adverse events developed in nine patients, mostly associated with disease progression. In one patient, pneumonitis and inflammatory responses resulted from Vγ9Vδ2 T-cell infusions, together with the disappearance of a massive tumor.

CONCLUSIONS

Although autologous Vγ9Vδ2 T-cell therapy was well tolerated and may have an acceptable DCR, this trial did not meet its primary efficacy endpoint.

TRIAL REGISTRATION NUMBER

UMIN000006128.

Adoptive immunotherapy for gastric cancer using zoledronate-activated killer cells: A prospective observational study

For several years, adoptive immunotherapy (AIT) has been performed using autologous zoledronate-activated killer (ZAK) cells to develop a novel modality for cancer treatment. In the current study, data from 50 patients with incurable gastric cancer were analyzed. Patients were treated with AIT using intravenous ZAK cells every 3-4 weeks in combination with chemotherapy of the physician’s choice. The possible clinical benefits were subsequently examined. The median overall survival (OS) time of all patients was 7.5 months. In patients that received 5 or more rounds of treatment, the OS was 13.5 months. Additionally, the OS times of 1st, 2nd or later line chemotherapy with ZAK cell AIT were 27.3 months and 13.3 months, respectively. No objective response was observed and the disease control rate was 67.9%. No severe adverse event was recorded. Functional Assessment of Cancer Therapy-Biologic Response Modifier analysis revealed possible improvement of quality of life after ZAK cell AIT. Univariate analysis revealed a significant positive association between longer survival times and baseline lymphocyte percentages in white blood cell counts (P<0.001), serum albumin (P=0.001), C-reactive protein (P=0.006), carbohydrate antigen (CA)19-9 (P=0.010), neutrophil-lymphocyte ratio (P<0.001) and Glasgow prognostic score (GPS). Only the GPS value (P=0.024) was a significant survival marker when analyzed using the multivariate Cox proportional hazards model. Although the results cannot provide a definitive conclusion, the current suggested that ZAK cell AIT in combination with chemotherapy is safe, feasible and may be a promising treatment option for patients with incurable gastric cancer. The GPS value at baseline may be a potential biomarker for chemo-immunotherapy.

Imatinib Intolerance Is Associated With Blastic Phase Development in Philadelphia Chromosome-Positive Chronic Myeloid Leukemia

BACKGROUND

Over the past years, the survival of patients with Philadelphia-positive chronic myeloid leukemia (CML Ph(+)) has increased as a result of therapy with tyrosin kinase inhibitors (TKIs). Intolerance to TKIs has been described in approximately 20% of patients receiving treatment. We studied the incidence of imatinib intolerance in patients with CML Ph(+) and their outcome in our CML reference site, as there is no information about the evolution of patients intolerant to TKIs.

PATIENTS AND METHODS

A group of 86 patients with CML Ph(+) receiving imatinib monotherapy who abandoned treatment were the basis for this study. We present the trends of their disease evolution.

RESULTS

The median of age at diagnosis was 42 years. Within a year, 19 (22%) of 86 patients developed imatinib intolerance, all of them with grade III or IV disease that required imatinib dose reduction or discontinuation. Of these patients, 16 (84%) of 19 developed transformation to blastic phase. The cumulative incidences of blastic phase development were 47% in the nonintolerant group and 84% in the intolerant group. There was a relative risk for those with imatinib intolerance to develop blastic phase of 1.78 (95% confidence interval, 1.28 to 2.42) (P < .05).

CONCLUSION

Most imatinib-intolerant patients develop blastic phase transformation, with a poor survival of 3 to 6 months; no effective rescue treatment is available. Future research should to determine whether the origin of this evolution is really due to the intolerance itself or whether it is due to a more aggressive form of the disease, perhaps related to genetic transformation.

Durable response rate as an endpoint in cancer immunotherapy: insights from oncolytic virus clinical trials

Background

Traditional response criteria may be insufficient to characterize full clinical benefits of anticancer immunotherapies. Consequently, endpoints such as durable response rate (DRR; a continuous response [complete or partial objective response] beginning within 12 months of treatment and lasting ≥6 months) have been employed. There has not, however, been validation that DRR correlates with other more traditional endpoints of clinical benefit such as overall survival.

Methods

We evaluated whether DRR was associated with clinically meaningful measures of benefit (eg, overall survival [OS], quality of life [QoL], or treatment-free interval [TFI]) in a phase 3 clinical trial of an oncolytic virus for melanoma treatment. To evaluate the association between DRR and OS and to mitigate lead time bias, landmark analyses were used. QoL was evaluated using the FACT-BRM questionnaire (comprising the FACT-BRM Physical, Social/Family, Emotional, and Functional well-being domains, the Additional Concerns, Physical and Mental treatment-specific subscales, and the Trial Outcome Index [TOI]). TFI was defined as time from the last study therapy dose to first subsequent therapy dose (including any systemic anticancer therapy for melanoma after study therapy discontinuation).

Results

Four hundred thirty-six patients were included in the intent-to-treat population. Achieving DR was associated with a statistically significant improvement in OS in a landmark analysis at 9 months (HR = 0.07; P = 0.0003), 12 months (HR = 0.05, P < 0.0001), and 18 months (HR = 0.11; P = 0.0002) that persisted after adjusting for disease stage and line of therapy. Achieving a DR was associated with a longer median TFI (HR = 0.33; P = 0.0007) and a higher TOI improvement rate (58.1% versus 30.0%; P = 0.025).

Conclusions

Achieving a DR was associated with clinical benefits such as improved OS and QoL and prolonged TFI, thus supporting the usefulness of DR as a meaningful immunotherapy clinical trial endpoint.

Trial registration

ClinicalTrials.gov identifier, NCT00769704 (https://clinicaltrials.gov/ct2/show/NCT00769704) October 7, 2008

Electronic supplementary material

The online version of this article (doi:10.1186/s40425-017-0276-8) contains supplementary material, which is available to authorized users.

Lentinula edodes mycelia extract plus adjuvant chemotherapy for breast cancer patients: Results of a randomized study on host quality of life and immune function improvement

Anthracycline-based chemotherapies for breast cancer are known to adversely affect patients' quality of life (QOL) and immune function. For that reason, adjuvants that improve those impairments are required. A randomized double-blind study was conducted to evaluate the effectiveness of Lentinula edodes mycelia extract (LEM), which is an oral biological response modifier (BRM) medicine for cancer patients as such an adjuvant. A total of 47 breast cancer patients who were scheduled to receive postoperative adjuvant anthracycline-based chemotherapy, i.e., 5-fluorouracil (5-FU) + cyclophosphamide + epirubicin (FEC regimen), 5-FU + cyclophosphamide + doxorubicin/pirarubicin (FAC regimen), cyclophosphamide + doxorubicin/pirarubicin (AC regimen) and cyclophosphamide + epirubicin (EC regimen), were entered in the study. The patients were randomly divided into either an LEM or a placebo tablet group; the tablets were orally ingested daily over 2 courses of each therapy. In the placebo group, the total scores for QOL were lower on day 8 of the second course of chemotherapy compared with the baseline scores, whereas in the LEM group the scores had not decreased. In the placebo group, the QOL functional well-being score was lower on day 8 after both the first and second courses of chemotherapy compared with the baseline score, but it had not decreased in the LEM group. Evaluation of immunological parameters indicated that an increase in the proportion of regulatory T cells to peripheral blood CD4⁺ cells tended to be inhibited in the LEM group compared with the placebo group. Oral LEM that was coadministered with anthracycline-based chemotherapies was useful for maintaining patients' QOL and immune function. Thus, LEM appears to be a useful oral adjuvant for patients receiving anthracycline-based chemotherapy.

De-escalation of tyrosine kinase inhibitor dose in patients with chronic myeloid leukaemia with stable major molecular response (DESTINY): an interim analysis of a non-randomised, phase 2 trial

BACKGROUND

Discontinuation of tyrosine kinase inhibitor (TKI) therapy is feasible for some patients with chronic myeloid leukaemia with deep molecular responses; however, patients with stable major molecular response (MMR), but not MR4, have not been studied, nor has the effect of treatment de-escalation rather than outright cessation. We aimed to examine the effects of treatment de-escalation as a prelude to complete cessation, not only in patients with MR4 or greater, but also in those with MMR but not MR4.

METHODS

We did this interim analysis of a non-randomised, phase 2 trial at 20 hospitals in the UK. We recruited patients (aged ≥18 years) with chronic myeloid leukaemia in first chronic phase who had received TKI for 3 years or more and were either in stable MR4 (BCR-ABL1:ABL1 ratio <0·01%; MR4 cohort) or in stable MMR (BCR-ABL1:ABL1 ratio consistently <0·1%) but not MR4 (MMR cohort) for 12 months or longer. Participants received half their standard TKI dose (imatinib 200 mg daily, dasatinib 50 mg daily, or nilotinib 200 mg twice daily) for 12 months. Molecular recurrence was defined as loss of MMR (BCR-ABL1:ABL1 ratio >0·1%) on two consecutive samples. The primary endpoint of this interim analysis was the proportion of patients who lost MMR on de-escalation and regained MMR on TKI resumption. Analyses were by intention to treat. This study is registered with ClinicalTrials.gov, number NCT01804985.

FINDINGS

Between Dec 16, 2013 and April 10, 2015, we enrolled 174 patients into the MMR cohort (n=49) or the MR4 cohort (n=125). During the 12 months of half-dose therapy, 12 patients (7%) had molecular recurrence, all of whom regained MMR within 4 months of full-dose TKI resumption (median time to recovery 77 days). Recurrence was significantly lower in the MR4 cohort (three [2%; 90% CI 0·2-4·8] of 121 evaluable patients) than in the MMR cohort (nine [19%; 90% CI 9·5-28·0] of 48 evaluable patients; hazard ratio 0·12, 90% CI 0·04-0·37; p=0·0007), but was unrelated to previous TKI or TKI therapy duration. Adverse events (eg, lethargy, diarrhoea, rash, and nausea) improved during the first 3 months of de-escalation, though not thereafter. 16 serious adverse events were reported, including one fatality due to worsening pre-existing peripheral arterial occlusive disease in a patient who had received only imatinib.

INTERPRETATION

TKI de-escalation is safe for most patients with excellent responses to TKI therapy, and is associated with improvement in symptoms. These findings show that lower TKI doses might maintain responses in these patients, implying that such patients could be unnecessarily overtreated. Studies of more ambitious de-escalation are warranted.

FUNDING

Newcastle University and Bloodwise.

Efficacy and safety of talimogene laherparepvec versus granulocyte-macrophage colony-stimulating factor in patients with stage IIIB/C and IVM1a melanoma: subanalysis of the Phase III OPTiM trial

OBJECTIVES

Talimogene laherparepvec is the first oncolytic immunotherapy to receive approval in Europe, the USA and Australia. In the randomized, open-label Phase III OPTiM trial (NCT00769704), talimogene laherparepvec significantly improved durable response rate (DRR) versus granulocyte-macrophage colony-stimulating factor (GM-CSF) in 436 patients with unresectable stage IIIB-IVM1c melanoma. The median overall survival (OS) was longer versus GM-CSF in patients with earlier-stage melanoma (IIIB-IVM1a). Here, we report a detailed subgroup analysis of the OPTiM study in patients with IIIB-IVM1a disease.

PATIENTS AND METHODS

The patients were randomized (2:1 ratio) to intralesional talimogene laherparepvec or subcutaneous GM-CSF and were evaluated for DRR, overall response rate (ORR), OS, safety, benefit-risk and numbers needed to treat. Descriptive statistics were used for subgroup comparisons.

RESULTS

Among 249 evaluated patients with stage IIIB-IVM1a melanoma, DRR was higher with talimogene laherparepvec compared with GM-CSF (25.2% versus 1.2%; P<0.0001). ORR was also higher in the talimogene laherparepvec arm (40.5% versus 2.3%; P<0.0001), and 27 patients in the talimogene laherparepvec arm had a complete response, compared with none in GM-CSF-treated patients. The incidence rates of exposure-adjusted adverse events (AE) and serious AEs were similar with both treatments.

CONCLUSION

The subgroup of patients with stage IIIB, IIIC and IVM1a melanoma (57.1% of the OPTiM intent-to-treat population) derived greater benefit in DRR and ORR from talimogene laherparepvec compared with GM-CSF. Talimogene laherparepvec was well tolerated.

Randomised phase III study of S-1 alone versus S-1 plus lentinan for unresectable or recurrent gastric cancer (JFMC36-0701)

BACKGROUND

Lentinan (LNT) is a purified β-1, 3-glucan that augments immune responses. The present study was conducted to assess the efficacy of LNT in combination with S-1 as a first-line treatment for unresectable or recurrent gastric cancer.

PATIENTS AND METHODS

Eligible patients were randomly assigned to receive S-1 alone or S-1 plus LNT. The primary end-point was overall survival (OS). Secondary end-points were time-to-treatment failure (TTF), overall response rate (ORR), safety, quality of life (QOL), and biomarker. The percentages of LNT-binding monocytes in peripheral blood prior to treatment were analysed for the biomarker assessment.

RESULTS

One hundred and fifty-four and 155 patients were randomly assigned to receive S-1 alone or S-1 plus LNT, respectively. The median OS was 13.8 and 9.9 months (P = 0.208), the median TTF was 4.3 and 2.6 months (P < 0.001), the ORR was 22.3% and 18.7% for the S-1 and S-1 plus LNT groups, respectively. The incidences of haematologic and non-haematologic adverse events were similar, and no significant changes in QOL scores were observed during the treatment in both groups. In a subpopulation of patients with LNT-binding monocytes ≥2%, patients who received more than two cycles of chemotherapy showed a longer survival time in the S-1 plus LNT group.

CONCLUSIONS

OS did not improve and TTF was significantly worse in the S-1 plus LNT group as compared with the S-1-only group. This study showed no efficacy of LNT when combined with S-1 treatment in patients with unresectable or recurrent gastric cancer.

CLINICAL TRIAL REGISTRATION ID NUMBER

UMIN 000000574.

WITHDRAWN: Immunotherapy for advanced renal cell cancer

This review is being updated and replaced following the publication of a new protocol (Unverzagt S, Moldenhauer I, Coppin C, Greco F, Seliger B. Immunotherapy for metastatic renal cell carcinoma [Protocol]. Cochrane Database of Systematic Reviews 2015, Issue 4. Art. No.: CD011673. DOI: 10.1002/14651858.CD011673). It will remain withdrawn when the new review is published.

The editorial group responsible for this previously published document have withdrawn it from publication.

Cytokine and vaccine therapy of kidney cancer

In this paper, results from current randomized and other relevant studies on cytokine and vaccine therapy of kidney cancer in the adjuvant setting and in metastatic disease are reviewed. Improvement of medical therapy of kidney cancer is required since the relative 5-year survival of kidney cancer is only 62%. In the adjuvant setting, cytokine monotherapy (interferon [IFN]-alpha or interleukin [IL]-2) is not effective in improving progression-free or overall survival. Recently, an autologous kidney cancer cell vaccine has been shown to reduce the risk of tumor progression following radical nephrectomy for organ-confined or locally advanced kidney cancer in a randomized Phase III study. There were only a few vaccine-related side effects. Presently, this is the only promising approach for the adjuvant treatment of kidney cancer following nephrectomy. In metastatic kidney cancer patients with the tumor-bearing kidney in situ, a combination of radical nephrectomy plus IFN-alpha is more effective than IFN-alpha alone. In metastatic kidney cancer without the option of operative removal of the primary tumor and/or metastases, cytokines such as IFN-alpha, IL-2 and IL-12 and their combinations result in response rates of 10-30%, but the 5-year overall survival is less than 10%. Furthermore, the ideal dose, administration and combination of different agents are yet to be defined. Vaccine therapy of metastatic kidney cancer has been investigated only in Phase I and II studies with limited clinical benefit. Based on the current literature there is a clear need for new approaches in metastatic kidney cancer.

Quality of Life in Patients with Advanced Cancer Using the Functional Assessment of Cancer Therapy-General Assessment Tool: A Literature Review

Quality of life (QOL) has become an increasingly meaningful endpoint in advanced cancer research. Clinicians assess QOL to help them select appropriate treatment options and regimens. The present review aims to compare QOL scores of the Functional Assessment of Cancer Therapy-General Assessment Tool (FACT-G) in relation to clinical and socio-demographic features in patients with advanced cancer. A literature search in MEDLINE and EMBASE was conducted; a total of 33 studies encompassing 39 study arms were identified that reported FACT-G scores. Four statistically significant parameters were identified with respect to FACT-G scores: education, national per capita healthcare expenditures, admittance status and previous radiation therapy. A greater percentage of patients completing higher education programs were correlated to significantly better emotional well-being and global QOL. Cohorts from countries with higher national per capita healthcare expenditures had better physical well-being, social/family well-being and improved relationships with their doctors. Patient samples comprised of purely outpatients had better levels of emotional well-being and global QOL when compared to samples with a mix of outpatients and inpatients. A greater percentage of patients previously receiving radiation therapy were correlated to a better relationship with doctor score. Although limitations of the present review exist, differences in QOL scores based on socio-demographic and clinical factors are observed; certain correlations described in the present work have been described previously in the literature while others have not. Future work aimed at either determining confounding parameters or cause and effect relationships is recommended.

Critical appraisal of nilotinib in frontline treatment of chronic myeloid leukemia

The development of imatinib has revolutionized the treatment of chronic myeloid leukemia. Follow-up analysis of IRIS trial participants continues to demonstrate durable responses for imatinib at 400 mg/day. However, 10%-15% of patients with chronic myeloid leukemia will become imatinib-resistant or intolerant of adverse events. Phase II studies have shown that most of these patients will respond to second-generation tyrosine kinase inhibitors, such as nilotinib, dasatinib, and bosutinib. Both nilotinib and dasatinib have recently demonstrated clinical efficacy as frontline therapy in Phase III studies. In the ENESTnd trial, nilotinib 600-800 mg/day produced significantly higher major molecular rates and complete cytogenetic response rates in comparison with imatinib at 12 months. Recently, 18-month follow-up analysis of this trial continues to demonstrate superiority for nilotinib. It is unknown whether this will ultimately translate into improved long-term outcomes, such as event-free survival or overall survival. Nilotinib continues to be generally well tolerated and tends to produce less Grade 3/4 toxicity in frontline therapy when compared with its use following imatinib failure. With three tyrosine kinase inhibitors for potential frontline therapy and an active drug discovery pipeline, treatment for chronic myeloid leukemia is still subject to change with time as clinical algorithms continue to evolve.

Beyond traditional outcomes: improving quality of life in patients with renal cell carcinoma

The introduction of molecular targeted therapies for patients with metastatic renal cell carcinoma has provided treatment options that are more efficacious and better tolerated than cytokine therapy, the previous standard of care. These advances have led to renewed efforts to define the health-related quality of life (HRQOL) impact of disease status stabilization or improvement versus that of treatment-associated adverse events. The distinct classes of targeted agents have unique AE profiles related to their specific targets; therefore, treatment considerations should include the patient's pretreatment HRQOL along with the known HRQOL effects of each drug. With more second- and third-line treatment options available for patients with metastatic renal cell carcinoma, HRQOL outcomes in earlier lines of therapy may guide treatment decisions for subsequent therapy, as poor HRQOL at therapy onset predicts poor survival. Both general and disease-specific instruments are used in clinical trials to reveal the impact of treatment on patient-reported outcomes. In this article, the common instruments used to assess HRQOL and the HRQOL outcomes observed in pivotal trials of targeted therapies are reviewed. Current data indicate that first-line therapy with sunitinib and first-line therapy in poor-prognosis patients with temsirolimus provide improved HRQOL compared with interferon-α. First- and second-line therapy with pazopanib and second-line therapy with everolimus and sorafenib maintained HRQOL levels similar to placebo, indicating that these agents do not worsen HRQOL. The HRQOL effects of bevacizumab plus IFN-α have not been reported. As new agents enter clinical investigation, HRQOL data can help determine their overall role in treatment.

Patient-reported outcomes in support of oncology product labeling claims: regulatory context and challenges

The US FDA has advocated the patient-reported outcome (PRO) draft guidance as the main vehicle for evaluating PRO-based labeling claims for oncology drugs. In addition, FDA-affiliated researchers have identified factors inhibiting acceptance of health-related quality of life (HRQoL)-based claims for oncology product labels. The views of the FDA on PRO claims are extensive and prescriptive. By contrast, the European Medicines Agency (EMA) has conducted authorizations without an explicitly defined approach for evaluating HRQoL data. A reflective paper released in 2005 offered only broad recommendations on HRQoL labeling claims. The different approaches between the two regulatory agencies partly stem from underlying, divergent organizational characteristics. Moreover, general issues inherent in PRO research in oncology trials including trial design, missing data, multiplicity of end points and inconsistent findings of HRQoL data are discussed.

Intolerance to tyrosine kinase inhibitors in chronic myeloid leukemia: Definitions and clinical implications

Tyrosine kinase inhibitor (TKI) treatment targeting breakpoint cluster region-Abelson murine leukemia virus, the cause of chronic myeloid leukemia (CML), has revolutionized therapy for patients with this disease. The majority of patients with CML maintain favorable responses with long-term imatinib therapy; however, the availability of the second-generation TKIs nilotinib and dasatinib limits the need for patients intolerant to imatinib to continue with therapy. Unfortunately, there is currently no standard definition of intolerance to imatinib. Common Toxicity Criteria for grading adverse events, designed to identify acute toxicities, are often used to determine intolerance. However, because CML therapies are long-term, patient quality of life may provide a better measure of true intolerance. Several general methods of quantifying patient quality of life are in use for patients with CML, and a CML-specific variant of the M. D. Anderson Symptom Inventory is in development. An appropriate and consistent definition of intolerance will provide clinicians with an algorithm for managing their patients with severe or chronic adverse events during treatment with imatinib. As more long-term data become available for newer TKIs, the definition of intolerance in the context of CML treatment will continue to evolve to maximize the likelihood of durable responses and superior quality of life for patients.

A structured review and guide through studies on health-related quality of life in kidney cancer, hepatocellular carcinoma, and leukemia

Aim of this paper is to review and describe Health-Related Quality of Life (HRQoL) measures applied in kidney cancer, hepatocellular carcinoma, and leukemia patients under drug therapy. A comprehensive search in PubMed was conducted to identify studies assessing quality of life (QoL) in these indications. In total 32 studies, including four studies through reference list checking and 21 different HRQoL instruments, were identified. Six generic, five disease-specific, and 10 domain-specific instruments were identified. In conclusion no overall standards in HRQoL measurement could be observed in the respective indications.

Quality of life in patients with metastatic renal cell carcinoma: the importance of patient-reported outcomes

Renal cell carcinoma is the most common form of kidney cancer worldwide, and is associated with poor survival. Approximately a third of patients diagnosed with renal cell carcinoma present with metastatic disease and a further third experience recurrence following treatment for localized disease. Until recently, the cytokines interferon-alpha and interleukin-2 were the only effective treatments available for metastatic renal cell carcinoma and were associated with a modest increase in survival in a limited subset of patients. The prognosis for metastatic renal cell carcinoma has dramatically improved with the development of novel targeted agents including the oral tyrosine kinase inhibitors, sunitinib and sorafenib. However, renal cell carcinoma and the therapies used to treat patients with renal cell carcinoma are associated with a range of symptoms and treatment-related adverse events which contribute to the burden of disease. Common adverse events associated with targeted agents include fatigue, gastrointestinal and skin-associated toxicities. These adverse events, while mostly mild and manageable, affect the patients' health-related quality of life. As this review of the available quality of life data shows, assessment of the impact of the disease and its treatment on health-related quality of life may influence the choice of treatment and highlights the importance of incorporating patient-reported outcomes in clinical trials.

Employment and quality of survivorship among women with cancer: domains not captured by quality of life instruments

BACKGROUND

Many quality of life instruments assess the amount of paid work in combination with role function at home in the same items and do not specifically assess social support in the workplace. The goal of this study was to obtain women's views on the relationship between employment and health-related quality of life.

METHODS

A focus group and questionnaire study was conducted among 73 women with gynecologic cancer who were employed at diagnosis and 25 people who provided them with psychosocial support.

RESULTS

The women held a variety of blue collar and white collar jobs at diagnosis. Employment provided a strong sense of accomplishment and a welcome distraction during treatment. The employment experience was described as distinct from role function at home. No one equated working more hours with better quality of life. Social support at work could be poor at the same time that support from family and friends grew stronger.

CONCLUSIONS

The contribution to their quality of life that cancer survivors feel they receive from employment may not be linearly related to the quantity of their role function in the workplace. Employment-related items could be useful as an adjunct to standard quality of life measures.

Reliability across studies from the functional assessment of cancer therapy-general (FACT-G) and its subscales: a reliability generalization

PURPOSE

The aim of this study was to conduct a reliability generalization of the Functional Assessment of Cancer Therapy-General (FACT-G) and its subscales to examine variation in score reliability across all published studies.

METHODS

We reviewed 344 publications based on predetermined criteria. About 78 published studies reported Cronbach's Alpha reliability coefficients from their study in which data were collected. Sample size based weights were applied, and studies were coded on several scale and demographic characteristics. Using independent samples t tests, we examined associations between study characteristics and internal consistency variability.

RESULTS

Average FACT-G score reliability was .88 (subscales ranged between .71-.83). Three variables produced small, statistically significant (P < or = .05) eta squared effects (ranging between .06-.21) due to different sources of variation in the FACT-G and subscales: ethnicity, cancer type, and study type-all of which appeared to be related to disproportionate representation of studies with the majority including Caucasian samples, mixed cancer samples, and validation type studies.

CONCLUSIONS

The FACT-G and its subscales demonstrated acceptable reliability evidence across observed studies, without substantial variability due to scale or demographic characteristics.

Heterologous prime-boost immunotherapy of melanoma patients with Influenza virosomes, and recombinant Vaccinia virus encoding 5 melanoma epitopes and 3 co-stimulatory molecules. A multi-centre phase I/II open labeled clinical trial

To the exception of early stages of disease, the morbidity and mortality of melanoma is considerable, with no acknowledged therapeutic options beyond surgery. Immunotherapy of melanoma has achieved some success, but further refinements are urgently needed in order to realize its potential. This paper describes a multi-centre phase I/II open labeled, controlled clinical trial investigating 2 innovative immunotherapeutic reagents. Two successive groups of 20 resected AJCC stages IIb-IV melanoma patients will be treated, first with melanoma epitopes included into Influenza virosomes (group 1), and second with a heterologous prime-boost protocol priming with a recombinant Vaccinia virus, and boosting with Influenza virosomes (group 2). Five melanoma epitopes from three different melanoma differentiation antigens were included into Influenza virosomes, that cross-stimulate CD4+ T cells and are endowed with high adjuvant capacity in the generation of CTL. The same five melanoma epitopes, two co-stimulatory molecules CD80 and CD86, and the CD40 ligand, a marker known to play a crucial role in CTL generation and memory maintenance were encoded in a recombinant Vaccinia virus. GM-CSF will be administered as a supporting cytokine. Both Influenza virosomes and octo-recombinant Vaccinia virus are innovative and original constructs assessed for the first time in human. Immunotherapy foresees 12 weekly immunizations for each group. Toxicity and adverse events will be monitored clinically. Immunological efficacy will be assessed dynamically by ex-vivo multimer analysis, Elispot, and quantitative real-time PCR for up to 3 months following completion of immunotherapy schedule. Disease free survival will be assessed by 4-monthly serial clinic visits, including physical and FDG-PET examinations, for a follow-up time of 2 years. Quality of life will be assessed with a dedicated FACT-BRM 4 questionnaire.

Symptom burden among patients with renal cell carcinoma (RCC): content for a symptom index

BACKGROUND

Renal cell carcinoma (RCC) has multiple symptoms stemming from disease and treatments. There are few validated scales for evaluating RCC symptoms.

METHODS

A national cross-sectional study of adult RCC patients was conducted from October to December 2003 to define patient-reported RCC symptomology. Participants were asked open-ended questions regarding their signs and symptoms and completed an 86-item pilot questionnaire of physical and psychological symptoms. Patients were asked to rate the relevancy and clarity of each pilot question using a 5-point Likert scale. Subsequent open-ended caregiver interviews and a provider panel relevance ranking contributed additional information.

RESULTS

The average age of the participants (n = 31) was 55 years; 55% of patients were male, 74% had attended college, and 97% were Caucasian. The five most frequent symptoms among localized-stage patients (n = 14) were irritability (79%), pain (71%), fatigue (71%), worry (71%), and sleep disturbance (64%). Among metastatic patients (n = 17), the five most frequent symptoms were fatigue (82%), weakness (65%), worry (65%), shortness of breath (53%), and irritability (53%). More than 50% of localized and metastatic-stage patients reported pain, weakness, fatigue, sleep disturbance, urinary frequency, worry, and mood disorders as being moderately to highly relevant.

CONCLUSION

A brief, self-administered RCC Symptom Index was created that captures the relevant signs and symptoms of both localized and metastatic patients. Pending additional content validation, the Index can be used to assess the signs and symptoms of RCC and the clinical benefit resulting from RCC treatment.

Evaluating linguistic equivalence of patient-reported outcomes in a cancer clinical trial

BACKGROUND

In order to make meaningful cross-cultural or cross-linguistic comparisons of health-related quality of life (HRQL) or to pool international research data, it is essential to create unbiased measures that can detect clinically important differences. When HRQL scores differ between cultural/linguistic groups, it is important to determine whether this reflects real group differences, or is the result of systematic measurement variability.

PURPOSE

To investigate the linguistic measurement equivalence of a cancer-specific HRQL questionnaire, and to conduct a sensitivity analysis of treatment differences in HRQL in a clinical trial.

METHODS

Patients with newly diagnosed chronic myelogenous leukemia (n = 1049) completed serial HRQL assessments in an international Phase III trial. Two types of differential item functioning (uniform and non-uniform) were evaluated using item response theory and classical test theory approaches. A sensitivity analysis was conducted to compare HRQL between treatment arms using items without evidence of differential functioning.

RESULTS

Among 27 items, nine (33%) did not exhibit any evidence of differential functioning in both linguistic comparisons (English versus French, English versus German). Although 18 items functioned differently, there was no evidence of systematic bias. In a sensitivity analysis, adjustment for differential functioning affected the magnitude, but not the direction or interpretation of clinical trial treatment arm differences.

LIMITATIONS

Sufficient sample sizes were available for only three of the eight language groups. Identification of differential functioning in two-thirds of the items suggests that current psychometric methods may be too sensitive.

CONCLUSIONS

Enhanced methodologies are needed to differentiate trivial from substantive differential item functioning. Systematic variability in HRQL across different groups can be evaluated for its effect upon clinical trial results; a practice recommended when data are pooled across cultural or linguistic groups to make conclusions about treatment effects.

A brief symptom index for advanced renal cell carcinoma

Background

Our objective was to test a brief, symptom index for advanced renal cell carcinoma, a disease affecting over 38,000 Americans each year and often diagnosed in late stages.

Methods

We conducted secondary data analyses on patient-reported outcomes of 209 metastatic renal cell carcinoma patients participating in a Phase III clinical trial. Patient-reported outcomes, obtained from the FACT-Biological Response Modifier (FACT-BRM) scale, were available at baseline, 2, and 8 weeks. We analyzed data from eight FACT-BRM items previously identified by clinical experts to represent the most important symptoms of advanced renal cell carcinoma. Items comprising this index assess nausea, pain, appetite, perceived sickness, fatigue and weakness, with higher scores indicating fewer symptoms. We determined reliability and validity of the index and estimated a minimally important difference.

Results

The index had excellent internal reliability at all three time points (alphas ≥ 0.83). Baseline scores were able to discriminate patients across Karnofsky performance status, number of metastatic sites, and risk group categories (ps < .01). Mean index scores declined over time likely indicative of the toxic nature of the administered treatments. Distribution- and anchor-based methods converged on a minimally important difference estimate of 2 to 3 points.

Conclusion

The 8-item index of patient-reported symptoms of renal cell carcinoma appears to be a psychometrically sound measure. It is a brief, reliable, and valid measure that can easily be adapted for use in clinical trials and observational studies.

Using multiple anchor- and distribution-based estimates to evaluate clinically meaningful change on the Functional Assessment of Cancer Therapy-Biologic Response Modifiers (FACT-BRM) instrument

OBJECTIVE

The interpretation of health-related quality of life (HRQL) data from clinical trials can be enhanced by understanding the degree of change in HRQL scores that is considered meaningful. Our objectives were to combine distribution-based and two anchor-based approaches to identify minimally important differences (MIDs) for the 27-item Trial Outcome Index (TOI), the seven-item Social Well-Being (SWB) subscale, and the six-item Emotional Well-being (EWB) subscale from the Functional Assessment of Cancer Therapy-Biological Response Modifiers (FACT-BRM) instrument.

METHODS

Distribution-based MIDs were based on the standard error of measurement. Anchor-based approaches utilized patient-reported global rating of change (GRC) and change in physician-reported performance status rating (PSR). Correlations and weighted kappa statistics were used to assess association and agreement between the two anchors. FACT-BRM changes were evaluated for three time periods: baseline to month 1, month 2 to month 3, and month 5 to month 6.

RESULTS

Association between GRC and change in PSR was poor. Correlation between the anchors and HRQL change scores was largest at month 1 and decreased through month 6. Combining results from all approaches, the MIDs identified were 5-8 points for the TOI, 2 points for the SWB subscale, and 2-3 points for the EWB subscale.

CONCLUSIONS

We combined patient-reported estimates, physician-reported estimates, and distribution-based estimates to derive MIDs for HRQL outcomes from the FACT-BRM. These results will enable interpretation of treatment group effects in a clinical trial setting, and they can be used to estimate sample size or power when designing future studies.

Immunotherapy for advanced renal cell cancer

BACKGROUND

The course of advanced renal cell carcinoma is extremely variable, ranging from spontaneous remission to disease progression refractory to chemotherapy. Immunotherapy has held promise of improved outcomes based on uncontrolled studies and randomized controlled trials generally limited by small size and low power.

OBJECTIVES

To evaluate immunotherapy for advanced renal cell carcinoma by comparing: (1) high dose interleukin-2 to other options and (2) interferon-alfa to other options. The primary outcome of interest was overall survival at one year, with remission as the main secondary outcome of interest.

SEARCH STRATEGY

A systematic search of the CENTRAL, MEDLINE, and EMBASE databases was conducted for the period 1966 through end of December 2003. Handsearches were made of the proceedings of the periodic meetings of the American Urologic Association, the American Society of Clinical Oncology, ECCO - the European Cancer Conference, and the European Society of Medical Oncology for the period 1995 to June 2004.

SELECTION CRITERIA

Randomized controlled trials that selected (or stratified) patients with advanced renal cell carcinoma, utilized an immunotherapeutic agent in at least one study arm, and reported remission or survival by allocation. Fifty-three identified studies involving 6117 patients were eligible and all but one reported remission; 32 of these studies reported the one-year survival outcome.

DATA COLLECTION AND ANALYSIS

Two reviewers independently abstracted each article by following a prospectively designed protocol. Dichotomous outcomes for treatment remission (partial plus complete) and for deaths at one year were used for the main comparisons. Survival hazard ratios were also used for studies of interferon-alfa versus controls, and for two randomized studies of the value of initial nephrectomy prior to interferon-alfa in fit patients with metastases detected at the time of diagnosis.

MAIN RESULTS

Combined data for a variety of immunotherapies gave an overall chance of partial or complete remission of only 12.9% (99 study arms), compared to 2.5% in 10 non-immunotherapy control arms, and 4.3% in two placebo arms. Twenty-eight percent of these remissions were designated as complete (data from 45 studies). Median survival averaged 13.3 months (range by arm, 6 to 27+ months). The difference in remission rate between arms was poorly correlated with the difference in median survival so that remission rate is not a good surrogate or intermediate outcome for survival for advanced renal cancer. We were unable to identify any published randomized study of high-dose interleukin-2 versus a non-immunotherapy control, or of high-dose interleukin-2 versus interferon-alfa reporting survival. It has been established that reduced dose interleukin-2 given by intravenous bolus or by subcutaneous injection provides equivalent survival to high dose interleukin-2 with less toxicity. Results from four studies (644 patients) indicate that interferon-alfa is superior to controls (OR for death at one year = 0.56, 95% confidence interval 0.40 to 0.77). Using the method of Parmar 1998, the pooled overall hazard ratio for death was 0.74 (95% confidence interval 0.63 to 0.88). The weighted average median improvement in survival was 3.8 months. T he optimal dose and duration of interferon-alfa remains to be elucidated. The addition of a variety of enhancers, including lower dose intravenous or subcutaneous interleukin-2, has failed to improve survival compared to interferon-alfa alone. Two recent randomized studies have examined the role of initial nephrectomy prior to interferon-alfa therapy in highly selected fit patients with metastases at diagnosis and minimal symptoms: despite minimal improvement in the chance of remission, both studies of up-front nephrectomy improved median survival by 4.8 months over interferon-alfa alone. Recent studies have been examining anti-angiogenesis agents. A landmark study of bevacizumab, an anti-vascular endothelial growth factor antibody, was associated with significant prolongation of the time to progression of disease when given at high dose compared to low-dose or placebo therapy though frequency of remissions or survival were not improved.

AUTHORS' CONCLUSIONS

interferon-alfa provides a modest survival benefit compared to other commonly used treatments and should be considered for the control arm of future studies of systemic agents. In fit patients with metastases at diagnosis and minimal symptoms, nephrectomy followed by interferon-alfa gives the best survival strategy for fully validated therapies. The need for more effective specific therapy for this condition is apparent.

The Functional Assessment of Chronic Illness Therapy (FACIT) Measurement System: properties, applications, and interpretation

The Functional Assessment of Chronic Illness Therapy (FACIT) Measurement System is a collection of health-related quality of life (HRQOL) questionnaires targeted to the management of chronic illness. The measurement system, under development since 1987, began with the creation of a generic CORE questionnaire called the Functional Assessment of Cancer Therapy-General (FACT-G). The FACT-G (now in Version 4) is a 27-item compilation of general questions divided into four primary QOL domains: Physical Well-Being, Social/Family Well-Being, Emotional Well-Being, and Functional Well-Being. It is appropriate for use with patients with any form of cancer, and extensions of it have been used and validated in other chronic illness condition (e.g., HIV/AIDS; multiple sclerosis; Parkinson's disease; rheumatoid arthritis), and in the general population. The FACIT Measurement System now includes over 400 questions, some of which have been translated into more than 45 languages. Assessment of any one patient is tailored so that the most-relevant questions are asked and administration time for any one assessment is usually less than 15 minutes. This is accomplished both by the use of specific subscales for relevant domains of HRQOL, or computerized adaptive testing (CAT) of selected symptoms and functional areas. FACIT questionnaires can be administered by self-report (paper or computer) or interview (face-to-face or telephone). Available scoring, normative data and information on meaningful change now allow one to interpret results in the context of a growing literature base.

Quality of life on imatinib

Imatinib (Gleevec), a highly effective specific tyrosine kinase inhibitor, demonstrates a better side effect profile than interferon-alpha (IFN), which impairs patients' quality of life (QoL). This phase III international study evaluated QoL outcomes in 1,106 newly diagnosed patients with chronic-phase chronic myeloid leukemia (CML) who were randomized to receive either imatinib 400 mg daily or IFN up to 5 MU/m(2)/d with cytarabine (Ara-C) 20 mg/m(2)/d added for 10 days every month (IFN + LDAC). Crossover to the other treatment arm was permitted due to a lack of efficacy or treatment intolerance. QoL was assessed with the Functional Assessment of Cancer Therapy-Biologic Response Modifiers (FACT-BRM) at baseline, monthly for 6 months and then at months 9, 12, and 18. The Trial Outcome Index (TOI; a composite endpoint of physical/functional/treatment-specific subscales) was the primary endpoint. Secondary endpoints measured were social/family well-being (SFWB) and emotional well-being (EWB). QoL was analyzed for the first 18 months of treatment using mixed effects growth curve models. The primary analyses were intention-to-treat (ITT); secondary analyses incorporated crossover as a time-dependent covariate. A total of 1,049 patients completed at least one QoL assessment. Two hundred sixty-one patients (50%) crossed over from IFN to imatinib and 11 (2%) crossed over from imatinib to IFN. There was a significant decline in TOI scores for the IFN treatment arm compared with preservation of baseline TOI scores in the imatinib arm (P <.001, ITT). Mean social/family and EWB scores were 22.8 and 19.5, respectively, for imatinib and 21.6 and 17.6, respectively, for IFN (P <.001, ITT). After crossing over from IFN to imatinib, patients experienced a significant (P <.001) increase in TOI scores. Imatinib offers clear QoL advantages over IFN as first-line treatment of chronic-phase CML. In addition, patients who crossed over to imatinib reported higher QoL than those who remained on IFN. Semin Hematol 40(suppl 2):31-36.