Perspectives of patients with advanced or metastatic non-small cell lung cancer on symptoms, impacts on daily activities, and thresholds for meaningful change: a qualitative research study

Introduction

Advanced or metastatic non-small cell lung cancer (NSCLC) is associated with significant symptom burden. It is important to understand the impact of these disease-and treatment-related symptoms on patients' daily lives and explore from a patient perspective what constitutes a meaningful change in NSCLC symptoms.

Methods

Patient experience of advanced or metastatic NSCLC was explored in this prospective, non-interventional qualitative research study recruiting patients from the United States (US). Interviews were conducted to explore the most important symptoms, daily life impacts, and patients' perspectives of what constitutes meaningful change when considering their current symptoms versus 6-12 months prior, based on the Patient Global Impression of Severity (PGI-S) and Patient Global Impression of Change (PGI-C) items.

Results

Between February and April 2022, 19 US-based patients with Stage IV NSCLC were recruited; 95% were female, 63% were White, 79% had been diagnosed >1 year prior, and 63% were receiving targeted therapy. Over half the patients indicated their most important symptoms were fatigue, shortness of breath, and cough. Patient differentiation between whether symptoms were disease- or treatment-related lacked concordance, and often patients were unable to distinguish the two. The most frequently mentioned impacts of these symptoms on patients' daily lives were difficulty walking, sleep disturbance, anxiety/depression, impact on relationships, and difficulty doing daily tasks. Most patients considered a one-point change on the PGI-S or PGI-C to be meaningful based on rating their symptom severity at the time of the interview compared with 6-12 months before the interview.

Conclusion

Based on their own symptom experience, patients with advanced or metastatic NSCLC indicated a one-point threshold for meaningful change, whether improvement or worsening. This suggests a one-point change on the PGI-S or PGI-C may be a potential anchor for patient-reported outcome (PRO) endpoints used in clinical trials. It is important to use PRO instruments that capture the symptoms and impacts identified as most important to patients. These findings highlight the importance of using qualitative methods to assess disease-related symptoms, treatment-related side effects, and the impacts on daily life for patients with advanced or metastatic NSCLC, underscoring how qualitative assessments can complement quantitative PRO instruments for evaluating clinical trials.

Development of the Cold Agglutinin Disease Symptoms and Impact Questionnaire (CAD-SIQ)

OBJECTIVES

Cold agglutinin disease (CAD) is a rare autoimmune hemolytic anemia. This study aimed to identify disease-related symptoms and impacts important to patients with CAD, and to develop a novel CAD-specific patient-reported outcome measure.

METHODS

Adults with CAD were randomly selected from a United States patient panel to participate in concept elicitation (CE) interviews to identify important symptoms and impacts or cognitive debriefing (CD) interviews to assess the comprehension and relevance of the draft item set.

RESULTS

Overall, 37 adults were included (mean [range] age 67.2 [35-87] years). In CE interviews (n = 16), the most frequently reported CAD-related symptoms were reactions to cold environments and fatigue (both 93.8%). CAD had negative impacts on enjoyable activities (81.3%) and daily activities (75.0%). Following CE, standard survey methodological principles were used to develop a draft item pool of 14 concepts. Items were refined through three iterative rounds of CD interviews (n = 21), yielding 11 final items: fatigue; cold sensitivity; dyspnea; wearing extra clothing; limited physical, social, and enjoyable activities; difficulty with usual activities; mood; frustration; and anxiety/stress.

CONCLUSIONS

The novel 11-item CAD-Symptoms and Impact Questionnaire provides a measure of the symptoms and impacts of CAD that are important to patients.

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.

Sources of Information for Learning and Decision-Making in Men With Localized Prostate Cancer

Information seeking is essential for effective patient-centered decision-making. However, prostate cancer patients report a gap between information needed and information received. The importance of different information sources for treatment decision remains unclear. Thus, using the Comprehensive Model of Health Information (CMIS) framework, we assessed the antecedent factors, information carrier factors, and information-seeking activities in localized prostate cancer patients. Data were collected via semistructured one-on-one, interviews and structured survey. Men with localized prostate cancer were recruited from two urban health-care centers. Following the interview, participants completed a survey about sources that were helpful in learning about prostate cancer treatment and decision-making. The interviews were audio-recorded, transcribed, and subjected to a thematic analysis using NVivo 10. Fifty localized prostate cancer survivors completed the interviews and surveys. Important antecedent factors that were observed were age, marital status, uncertainty, anxiety, caregiver burden, and out-of-pocket expenses. We identified complexity, magnitude, and reliability as information carrier characteristics. Preferred sources for information were health providers, medical websites, and pamphlets from the doctor’s office. These sources were also perceived as most helpful for decision-making. Urologists, urological oncologists, and radiation/radiation oncologists were important sources of information and helpful in decision-making. Prostate cancer patients obtained information from multiple sources. Most prostate cancer patients make patient-centered choices by incorporating personal factors and medical information. By considering factors that influence patients’ treatment decisions, health-care providers can enhance the patient-centeredness of care. Multiple strategies and interventions are necessary for disseminating valid, reliable, and unbiased information to prostate cancer patients to facilitate informed decisions.

Patient interviews in interprofessional and intercultural contexts (PinKo) - project report on interdisciplinary competence development in students of medicine, pharmacy, and community interpreting

Background: Hospitals and other medical institutions must prepare for a further increase in patients who are either immigrants or Germans with a migration background. In spite of the unquestionable educational and socio-political relevance of this topic, most German universities do not offer a comprehensive curriculum aimed at increasing intercultural awareness and putting it into practice in the training of students in medicine and pharmacy. Against this background, this article presents the innovative teaching project "Die Triade", which was jointly implemented by the Departments of Medicine, Pharmacy and Translation Studies at the University of Mainz. Aim: The aim is to give an overview of the development, realisation, implementation and consolidation of the course "Patient interviews in interprofessional and intercultural contexts" (PinKo), which was designed in the project "Die Triade". Project description: A two-day course was developed, starting with a block session for all participating students to teach the basics of interprofessional and intercultural competence development. On the second practical training day, students learn and practice triadic conversation in different language groups using scripted roles. While the trainee doctors and pharmacists represent their respective professions in the prepared conversational situations, the interpreting students take on the roles of interpreters and patients. The event is jointly supervised by lecturers from the participating professions and language groups. Results: In the 2016 summer semester and the following winter semester, the course was organised for a total of 112 students. The event as a whole was evaluated by means of a questionnaire by the students of the participating departments (Medicine (M) N=8, Pharmacy (P) N=60; Translation (T) N=44). Overall, the event was rated as good (1=very good, 6=insufficient) ((M) 1.67/2.00; (P) 2.29/3.33; (T) 1.50/1.86). The course tended to be rated lower by pharmacy students; this also applies to the rating of the development of interprofessional competences ((M) 1.33/2.00, (P) 2.00/2.93, (T) 1.82/2.25). Discussion: The course is suitable for the acquisition of interprofessional as well as intercultural competences. However, in order to improve the course in a participant-centred way, train larger numbers of participants and include additional healthcare occupations such as nursing or assistant medical professions, adaptations of the concept would be necessary. In this context, the digitalisation of the learning content appears to be particularly useful for ensuring that the course can be adapted to heterogeneous groups of participants and to optimise in-person times for further opportunities for practice.

The unmet needs of patients with sarcoma

OBJECTIVE

Sarcoma is a rare cancer that imposes a significant burden on the lives of patients. Many survivors have long-term disability as a result of treatment and the disease. Patients often experience functional issues, poorer mental health, reduced quality of life, and interpersonal issues. There is a need to explore the unmet needs of sarcoma patients as it is unclear how these issues are being addressed. The aim of this study was to explore the unmet needs of patients who have been diagnosed with sarcoma.

METHODS

The participants were individuals previously diagnosed with a sarcoma (n = 22). Participants completed a semi-structured interview about their unmet needs relating to sarcoma. The transcripts were analyzed using thematic analysis.

RESULTS

Five overarching themes were identified: daily living, financial needs, lack of information, need for a community, and navigating the healthcare system. Participants reported a range of practical needs, including transport, limited understanding of their treatments, and financial issues. Participants also described a need to connect with people who had gone through similar experiences.

CONCLUSIONS

Sarcoma patients have fundamental needs that affect their capacity to live their life in the best possible way. Health services need to better facilitate sarcoma patients at each stage of their experience by providing individualized referrals, support, and coordination. Support interventions are needed to help patients adjust to sarcoma and to improve their quality of life as an outpatient. Connecting patients with sarcoma support groups may provide them with more relevant and intimate support.

Elicitation of disease concepts in patients with diabetic foot ulcers: a qualitative study

OBJECTIVE

To identify in-depth information directly from patients with diabetic foot ulcers (DFU) on DFU symptoms, impacts on functioning and effects on health-related quality of life (HRQoL).

METHOD

Semi-structured, qualitative concept elicitation interviews were conducted with patients with DFUs (Wagner grade 1 or 2) until saturation was reached. Qualitative analysis (using MAXQDA, VERBI GmbH, Germany) of interview transcripts was conducted to identify concepts relevant to patients with DFUs, based on the frequency of mentions, and elucidate themes regarding impacts on HRQoL.

RESULTS

Of the 18 participants, most were male (n=14; 78%) and 10 (56%) presented with a Wagner grade of 1. Frequently reported symptoms were pain/discomfort (n=15; 83%), weeping/discharge (n=10; 56%), bleeding (n=10; 56%) and swelling (n=8; 44%). Overall, patients reported more impacts than symptoms-wound care/treatment burden (n=14; 78%), limitations on exercise/physical activity (n=13; 72%), mobility limitations (n=12; 67%), and offloading (n=12; 67%) were the most frequently mentioned. Based on findings from the patient interviews, a draft conceptual model was developed outlining interrelationships between DFU symptoms, impacts, and HRQoL from the patient perspective.

CONCLUSION

Qualitative interviews captured the breadth of disease-related concepts of direct importance to patients. The draft conceptual model developed from the analysis can help identify measures or instruments for use in assessing patient-reported symptoms or HRQoL in clinical practice and may have wider research applicability, including evaluation of treatment benefits in patients with DFUs.

Exploring patient preferences for involvement in medication management in hospitals

AIM

The aim of this study was to identify patient preferences for involvement in medication management during hospitalization.

DESIGN

A qualitative descriptive study.

METHODS

This is a study of 20 inpatients in two medical and two surgical wards at an academic health science centre in Melbourne, Australia. Semi-structured interviews were recorded and analysed using content analysis.

FINDINGS

Three themes were identified: (a) 'understanding the medication' established large variation in participants' understanding of their pre-admission medication and current medication; (b) 'ownership of medication administration' showed that few patients had considered an alternative to their current regimen; only some were interested in taking more control; and (c) 'supporting discharge from hospital' showed that most patients desired written medication instructions to be explained by a health professional. Family involvement was important for many.

CONCLUSION

There was significant diversity of opinion from participants about their involvement in medication management in hospital. Patient preferences for inclusion need to be identified on admission where appropriate. Education about roles and responsibilities of medication management is required for health professionals, patients and families to increase inclusion and engagement across the health continuum and support transition to discharge.

IMPACT STATEMENT

Little is known about patient preferences for participation in medication administration and hospital discharge planning. Individual patient understanding of and interest in participation in medication administration varies. In accordance with individual patient preferences, patients need to be included more effectively and consistently in their own medication management when in hospital.

The Voices of Young Women with Breast Cancer: Providing Support and Information for Improved Fertility Preservation Discussions

Purpose: Fertility is a concern for young women with breast cancer. We explore patient experiences with fertility discussions at diagnosis to identify barriers and preferences to patient-centered delivery of care. Methods: A qualitative study was conducted on consecutive, female breast cancer survivors, 39 years of age or younger at diagnosis and within 2 years of diagnosis, who attended routine outpatient follow-up at a large academic teaching center. Interviews lasted 30 minutes and were transcribed verbatim. Thematic analysis was conducted to explore experiences around fertility discussions. Strength of the theme was determined by examining the frequency of a response. Data collection and analysis continued until theoretical saturation was reached. Results: Analysis comprised 50 women with a median age of 34.5 years (range 25-39 years). Thirty-nine women (78%) had completed university education. Thirty-three women (66%) recalled having fertility preservation discussions at diagnosis. The most common themes identified include the following: (i) the requirement for more patient support, (ii) improving information, (iii) integration of patient values, (iv) creating options for patients, (v) financial limitations, and (vi) the need to look beyond the immediate impact. Conclusions: In this contemporary cohort of young adult breast cancer survivors, fertility discussion experiences at diagnosis remain suboptimal. Improved information and a focus on individual patient desires can improve experiences.

Patient involvement is essential in identifying drug-related problems

AIMS

The aim of this study is to evaluate how critical patient involvement is in pharmacist-led clinical medication reviews and in identifying the most significant clinical drug-related problems (DRPs).

METHODS

Pharmacist-led clinical medication reviews were conducted with 161 consenting patients aged ≥75 years with at least seven prescribed medicines, living independently at home in Finland. A pharmacist, a nurse and a physician evaluated the clinical significance of the DRPs identified during the patient interview at an interprofessional case conference. It was evaluated whether the most significant clinical DRPs could also have been identified through reviewing the medication list only or the medication list and certain patient details.

RESULTS

Altogether, the 111 most significant clinical DRPs were evaluated. Only 6% could have been identified through reviewing the medication list only, and 16% through reviewing the medication list and certain patient details. Hence, 84% of the most significant clinical DRPs could only have been identified with patient involvement. The most common DRPs were: poor therapy control (25%); nonoptimal drug (22%); intentional nonadherence (12%); and additional drug needed (11%). patient involvement was critical when identifying DRPs related to additional drug needed, unintentional nonadherence, use of over-the-counter medicines or dietary supplements, or contradictions in counselling.

CONCLUSION

Patient involvement is essential when identifying clinical DRPs. Indeed, poor therapy control, nonoptimal drug use, intentional or unintentional nonadherence might otherwise be missed.

A Description of Patient and Provider Experience and Clinical Outcomes After Heart Failure Shared Medical Appointment

Background:

Shared medical appointments (SMAs) are clinical visits in which several patients meet with 1 or more providers at the same time.

Objective:

To describe the outcomes of an interdisciplinary SMA for veterans recently discharged for heart failure (HF).

Methods:

A retrospective chart review for patients’ readmission rates, survival, medication adherence, and medication-related problems. For qualitative outcomes, we performed semistructured interviews on 12 patients who had undergone HF SMAs and their respective caregivers focusing on care satisfaction, HF knowledge, disease self-care, medication reconciliation, and peer support.

Results:

The cohort comprised 70 patients—49% had left ventricular function <40% and 50% were prescribed >10 medications. Medication-related problems occurred in 60% of patients. Interviews revealed overall satisfaction with HF-SMA, but patients felt overwhelmed with HF instructions, perceived lack of peer support and self-efficacy, and feelings of hopelessness related to HF.

Conclusion:

Shared medical appointments are well-perceived. Medication problems and need for medication management are prevalent along with patient’s lack of self-efficacy in HF care. Multiple HF-SMA visits may be needed to reinforce concepts, reduce confusion, and garner peer support.

Understanding the Patient Experience with Carcinoid Syndrome: Exit Interviews from a Randomized, Placebo-controlled Study of Telotristat Ethyl

PURPOSE

Telotristat ethyl, an oral tryptophan hydroxylase inhibitor, is intended to treat carcinoid syndrome by reducing serotonin production. Telotristat ethyl was evaluated in TELESTAR, a Phase III study for patients who had carcinoid syndrome with at least 4 bowel movements (BMs) per day and who were receiving somatostatin analogue therapy. This interview substudy was conducted to provide insight into the patient experience in TELESTAR and to help understand whether reductions in BM frequency (the primary end point) and other symptoms were clinically meaningful.

METHODS

Participating sites were asked to invite (before randomization) all eligible patients to telephone interviews scheduled at the end of the double-blind treatment period. Patients and interviewers were blinded to treatment.

FINDINGS

All 35 interviewed participants reported diarrhea and/or excessive BMs at baseline. Patients reported that these symptoms negatively affected emotional, social, physical, and occupational well-being. Prespecified criteria for treatment response (achieving ≥30% reduction in BM frequency for at least 50% of the days) were met by 8 of 26 patients taking telotristat ethyl and 1 of 9 patients taking placebo. All 8 patients taking telotristat ethyl described clinically meaningful reductions in BM frequency and were very satisfied with the ability of the study drug to control their carcinoid syndrome symptoms. Overall, reports of being very satisfied were observed in 12 patients taking telotristat ethyl and 0 taking placebo.

IMPLICATIONS

Patient interviews revealed that TELESTAR patients, at baseline, were significantly affected by their high BM frequency. Patient reports of their clinical trial experience supported the significance of the primary end point and clinical responder analysis in TELESTAR, helping identify and understand clinically meaningful change produced by telotristat ethyl.

A longitudinal, qualitative study exploring sustained adherence to a hand exercise programme for rheumatoid arthritis evaluated in the SARAH trial

PURPOSE

This study explores the experience of participants taking part in a hand exercise programme for people with rheumatoid arthritis with a focus on adherence. The exercise programme was tested in a randomised controlled trial. This parallel qualitative study will inform future implementation into clinical practice.

METHOD

Twenty-seven semi-structured interviews from 14 participants were undertaken at two time points (4 and 12 months after randomisation). We collected data of participants' experiences over time. This was guided by an interview schedule. Interview data were analysed using interpretative phenomenological analysis which is informed by phenomenological and hermeneutic theory. We recruited participants from National Health Service rheumatology and therapy departments.

RESULTS

At 4 months, 11/14 participants reported continuing with the exercises. By 12 months, 7/13 participants still reported exercising. The ability to establish a routine determined whether participants adhered to the exercise programme. This was sometimes influenced by practical issues. We also identified facilitators and barriers to regular exercise in the themes of the following: the therapeutic encounter, perceived benefit of exercises, attitude of mind, confidence, and unpredictability.

CONCLUSIONS

Establishing a routine was an important step towards participants being able to exercise independently. Therapists provided participants with skills to continue to exercise while dealing with changes in symptoms and schedules. Potential barriers to long-term exercise adherence need to be taken into account and addressed for successful implementation of this programme. Implications for Rehabilitation Behavioural change components such as the use of an exercise planner (stating intentions of where, when and how), daily diary sheets, and joint goal setting enhance adherence to a hand exercise programme for RA by helping to establish routines. Exercise routines need to be flexible enough to fit in with life and symptom changes whilst delivering a sufficient dosage. Therapists facilitate this process by using behavioural components alongside more commonly used aspects of care (assessment, education, advice, and encouragement) to enable people with RA to become independent exercisers.