Cancer patients' acceptability of incorporating an epidemiology questionnaire within a clinical trial

BACKGROUND/AIMS

Understanding the influence or impact of epidemiological factors on cancer outcomes in clinical trials can broaden our knowledge of disease, trial populations and therapeutic effects thus leading to improved patient care. However, there is a lack of data on cancer patients' compliance with an epidemiology questionnaire in the context of a clinical trial.

PATIENTS AND METHODS

Cancer patients were provided with a hypothetical scenario and surveyed regarding their willingness and preferences to complete an epidemiology questionnaire if incorporated into a cancer therapy trial. Patient compliance with completing a voluntary epidemiology questionnaire and trial coordinators perceptions therein were separately determined in the NCIC Clinical Trials Group HN.6 clinical trial, an ongoing randomized phase III trial comparing two first-line treatment regimens in patients with locoregionally advanced head and neck cancer.

RESULTS

Of 617 cancer patients from community, academic and tertiary cancer centres, the majority were willing to complete an epidemiology questionnaire either unconditionally (45%), or provided it did not inconvenience them (31%); 4% would refuse. Patients preferred shorter questionnaires of 30-50 questions requiring 10-20 min to complete, administered over 1-3 sessions. Patients were less willing, but still compliant, to answer questions relating to sexual history (71%) and annual household income (66%) relative to other questions (>90%). Eighteen percent thought that the questionnaire should be mandatory, with 31% believing that they may benefit personally from such research. In the HN.6 trial, compliance averaged 94.8% per question.

CONCLUSIONS

Cancer patients are very willing to complete epidemiology questions in clinical trials.

Factors influencing a specific pathologic diagnosis of non-small-cell lung carcinoma

INTRODUCTION

Historically, a non-small-cell lung carcinoma diagnosis, without pathologic subclassification, provided sufficient information to guide therapy. Evidence now demonstrates that pathologic subtype classification is central in selecting optimal treatment. This review aimed to identify factors associated with a specific pathologic diagnosis.

METHODS

All nonoperative cases of non-small-cell lung carcinoma (NSCLC) referred to the medical oncology divisions of the Ottawa Hospital Cancer Centre (2008) and Princess Margaret Hospital, Toronto (2007-2010) were identified. The charts were reviewed for demographics, diagnostic methods, and final diagnosis. Logistic regression was performed to identify variables associated with a specific diagnosis.

RESULTS

Of 739 patient records analyzed, 377 (51%) were men, 299 (40%) were aged over 70 years, and 510 (69%) had an Eastern Cooperative Oncology Group performance status of 0-2. Three hundred and eighty five (52%) of patients were diagnosed in a tertiary academic center. The lung primary was sampled in 503 (68%) of patients. Computed tomography-guided biopsy (n = 370, 50%) and bronchoscopy (n = 179, 24%) were the most common techniques. Four hundred and seventy seven (65%) of biopsies were cytologic specimens alone, and immunohistochemistry was performed in 337 (46%) of cases. The most common diagnoses were adenocarcinoma (n = 338, 46%), NSCLC not otherwise specified (n = 254, 34%), and squamous cell carcinoma (n = 115, 16%). Overall, 456 (62%) of patients received a specific pathologic diagnosis. Factors significantly associated with attaining a specific pathologic diagnosis were diagnosis outside an academic center (adjusted odds ratios [OR] 2.1 [95% CI, 1.41-3.14]; P = .0003), histologic laboratory samples (adjusted OR 1.58 [95% CI, 1.003-2.49]; P = .049), and immunohistochemical testing (adjusted OR 1.82 [95% CI, 1.25-2.70], P = .0021).

CONCLUSIONS

A significant minority of patients with NSCLC do not receive a specific pathologic diagnosis. In an era of individualized medicine, this may potentially impact optimal clinical management.

Cancer patients’ and physicians’ preferences for decision making regarding pharmacogenomic testing (PGT)

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Background: Pharmacogenomics is increasingly utilized in oncology; however, there is little knowledge concerning cancer patients’ or oncologists’ attitudes toward PGT decision-making in clinical practice. Methods: A broad cross-section of cancer patients were interviewed regarding their attitudes toward PGT using hypothetical time, efficacy and toxicity trade-off and willingness-to-pay scenarios (N=278) and/or quantitative choice-based conjoint analysis surveys (N=264); 64 cancer specialists/physicians in training were surveyed similarly. Results: Of patients participating in the trade-off scenario phase of study, >94% accepted chemotherapy, and of these, >98% wanted PGT that identifies a subset of patients either benefiting from chemotheraphy or who were at risk of severe toxicity. Patients were willing to pay between CAD $1,000-$1,900 for PGT and accept wait times for results of 2-3 weeks. Similar findings were observed in the conjoint phase of the study, with preferences for PGT starting to decline when the out-of-pocket costs reached CAD $500-$1,500, wait time for results exceeded 14 days, and when the prevalence of the genetic variant fell below 25%. Adjuvant patients’ acceptance of PGT was most influenced by cost (decision weight [DW]=41%) and prevalence of the genetic variant associated with lack of benefit from chemo (DW=26%). Metastatic patients were most influenced by cost (DW=49%) and wait times (DW=31%). More patients reported difficulty understanding conjoint surveys (14%) than trade-off scenarios (7%; p=0.01). 81% of patients wanted to be involved in decision-making regarding PGT; while 30% of physicians felt it should be a physician-only decision (p=0.006). However, 21% of patients and 5% of physicians admitted to not understanding PGT, while just 14% of physicians rated themselves as very knowledgeable regarding PGT. Conclusions: Cancer patients overwhelmingly accept and want to be involved in decision-making regarding PGT, to a greater extent than what physicians prefer. However, communication of PGT information was a potential barrier, as a considerable minority lacked the necessary knowledge to facilitate informed decision-making. Improved patient and physician education is necessary.

Cancer patient acceptance, understanding, and willingness to pay for pharmacogenetic testing (PGT)

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Background: PGT offers the potential to improve cancer therapy through the use of specialized tests that can predict the level of efficacy and/or toxicity of specific treatments in an individual. However, there is currently little knowledge concerning cancer patient attitudes towards such testing in the clinical setting. Methods: We interviewed a broad cross-section of 278 cancer patients (20% lung, 19% breast, 20% colorectal, 40% other) using hypothetical time, efficacy, toxicity and willingness-to-pay trade-off PGT scenarios. Results: 153 potentially curable patients and 125 incurable patients received a separate series of trade-off scenarios. For curative patients, 70% accepted chemo that had a 5% absolute improvement in cure rate and <5% of severe toxicity. Of these, 99% wanted PGT where the test identifies a subset of patients benefiting from chemo; the same individuals were willing to pay a median $2,000 (range: $0-25,000) for PGT and would accept a median wait time for PGT results of 21 days (0-90). Patient preferences were insensitive to variation of fractions of individuals carrying the genetics associated with lack of benefit. In the incurable scenario, 90% of patients accepted palliative chemo with an 80% response rate and a severe side effect rate of 5%. Of these, 98% wanted PGT, where there test identifies individuals at highest risk of severe toxicity; the same individuals were willing to pay a median $1,000 ($0-15,000) for PGT, and would accept PGT turnaround times of 14 days (1-90). Patient preferences were insensitive to variation of fractions of individuals carrying the genetics associated with severe toxicity. The majority of patients (76% adjuvant; 87% metastatic) wanted to be involved in decision making regarding PGT; however, one in five patients (20% adjuvant; 22% metastatic) admitted that they lacked a basic understanding of what PGT means and its clinical implications. Conclusions: Among cancer patients willing to undergo chemo, almost all wanted PGT and were willing to pay for it, waiting several weeks for results. While patients had a strong desire to be involved in decision making for PGT, a considerable proportion lacked the necessary knowledge to make informed choices.