Determining issues of importance for patients with prostate cancer: Results of a web-based study in 2,128 patients with prostate cancer for the development of a quality of life (QL) instrument, the prostate cancer symptom scale (PCSS)

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Background: Identifying key issues for patients with malignancy is central to assessing QL and patient reported outcomes. This aids in evaluating the effectiveness of treatment programs for those with the disease. The immediate aim of this study was to determine content validity using a large patient panel for the PCSS, a QL measure for patients with prostate cancer. The PCSS also uses an inexpensive hand-held pocket PC to enhance feasibility. The PCSS concept is based on the LCSS (a validated lung cancer instrument). Methods: We used the established patient base of the web-based NexCura patient information resource to survey registered patients with prostate cancer. Demographic stratifications included stage of disease, prior radical prostatectomy, and current treatment (none, hormonal, non-hormonal). 2,128 patients completed the anonymous web-conducted survey, performed over a 3-day period. Patients were asked to rank 18 issues on a 5-point scale assessing the importance of each item. Issues included general, prostate-specific, psychosocial and summative items. Results: The 10 highest (and 2 lowest) ranked items are seen in the table ; results are described by the percent of patients choosing the top category (very important) and the top 2 rating categories of importance. Ratings by disease subsets (such as NED or metastatic disease; hormonal or non-hormonal treatment) were quite similar to results found for the whole group, as listed in the table . Conclusions: These results represent the largest survey of patient concerns in prostate cancer and support using computer-assisted survey technology to assess such information in all malignancies to obtain patient input rapidly from large patient samples. Strong support for content validity for the PCSS was obtained.

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No significant financial relationships to disclose.

Comparing two methods of meta-analysis in clinical research - individual patient data-based (IPD) and literature-based abstracted data (AD) methods: Analyzing five oncology issues involving more than 10,000 patients in randomized clinical trials (RCTs)

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Background: Meta-analyses are one of the highest recommendations levels in Evidence-Based Medicine (EBM). Recently, meta-analyses have increased using either IPD or AD methods. Controversy exists regarding reliability, applicability and feasibility of the different methods to draw conclusions from conflicting RCTs and to estimate magnitude of benefit of different treatments. Methods: As seen in the table , we selected 5 major issues in 3 malignancies subjected to IPD meta-analysis, and then conducted AD meta-analyses from publications of the individual studies, using published methods (Bria, Cancer Treat Rev 2006). We required that >90% of patient numbers for both IPD and AD analyses be available. Event-based relative risk ratios (RRs) with 95% confidence intervals (CI) were derived. Fixed- and random-effect models, and absolute benefits (AB) were calculated. Correlations between IPD Hazard Ratios (HRs) and AD-RRs were estimated using a linear regression model according to Pearson (r) and R2 coefficients (parametric) and Spearman (Rho) coefficient (non- parametric). Results: Results are below. A strong linear correlation exists between IPD-HRs and AD-RRs (r=0.994, R2=0.989; p<0.001; Rho=1.00). Conclusions: The strong correlation supports using high quality meta-analyses with either method to resolve major issues. Differences exist between the methods: IDP is well-suited for sensitivity analyses and for hypothesis generation involving issues not originally anticipated; AD is a practical method allowing EBM to be applied rapidly to major issues in oncology in a timely fashion.

No significant financial relationships to disclose.

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Is symptom improvement in patients with small cell lung cancer (SCLC) associated with clinical response? An analysis using the Patient Symptom Assessment Lung Cancer (PSALC) scale in a randomized trial comparing oral topotecan (OT) with best supportive care (BSC)

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Background: SCLC is a highly symptomatic disease with poor survival in prior treated patients. To evaluate the role of chemotherapy, a recent multicenter trial randomized 141 patients with prior treatment to receive either OT + BSC or BSC only. This was the first trial to use a BSC control group in SCLC while evaluating survival, response and symptoms. Survival data were reported (O'Brien et al JCO 2006; median survival of 25.9 weeks on OT + BSC vs 13.9 weeks on BSC, p = 0.01). 51% on OT had “disease control” (partial response [PR] + stable disease [SD]); no patient on BSC was reported to have a major response, although response was not an endpoint for this group. Trials have shown that those with progressive disease have the most symptom worsening, as occurred in this trial. The objective of this analysis is to determine if patients with PR report greater symptom relief than those with SD, in that SD can reflect a more indolent course in some patients while PR is due to treatment effect only. Methods: We used the investigators evaluation of response (PR or SD) and analyzed these groups by the patients’ scoring of their symptoms using the PSALC instrument which evaluates 9 SCLC symptoms, in the 71 patients on the OT + BSC arm. Results: Patients with lower ECOG PS at baseline reported more severe symptoms (higher PSALC score). Mean changes in PSALC score from baseline are shown in the Table and demonstrate an association between tumor response and decrease in symptoms. Conclusions: Patients who achieved a major response on OT treatment reported significantly better symptom control than those whose best response was SD. This indicates that in addition to a survival benefit, treatment with this chemotherapy can aid in symptom control. While the small number of patients limits the strength of the conclusions, this trial represents the largest BSC controlled study in SCLC.

No significant financial relationships to disclose.

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Is it cost-effective to add erlotinib to gemcitabine in advanced pancreatic cancer?

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Background: Single agent gemcitabine has been considered the standard of care in advanced pancreatic cancer since 1996. A recent 569 patient randomized trial comparing gemcitabine alone with gemcitabine + erlotinib as first line therapy found a small but statistically significant difference in survival (6.0 vs 6.4 months, respectively, p = .028). The impact on survival may be small, but with nearly 33,000 new cases of pancreatic cancer per year, the impact on health care costs with the use of the combined regimen may be large. Using the known survival data and costs, we analyzed the incremental cost-effectiveness of adding erlotinib. Methods: Costs for a six month course of gemcitabine were developed using Medicare reimbursement from the January, 2006 CMS Drug Payment Table and Physician Fee Schedule assuming no change in infusion reimbursement. Since erlotinib is not approved as a Medicare Part B drug, costs were developed from wholesale and retail sources. Drug dosing and schedules were based on the clinical trial protocol leading to approval. Incremental cost effectiveness of adding erlotinib was calculated. Results: Six month course of gemcitabine alone costs $23,493. The addition of erlotinib increases cost by $12,156 wholesale or $16,613 retail. Given an increase of 0.4 months in median survival over gemcitabine alone, the addition of erlotinib costs $364,680 per year of life gained (YLG) wholesale and $498,379/YLG retail. Sensitivity analyses were conducted assuming shorter therapy of 4 and 5 months. In order to be cost effective even at the $100,000/YLG level, six months of erlotinib would have to be reduced to 20% of the current retail cost (lowered to $18.52 per tablet.) Conclusions: Adding erlotinib to gemcitabine does not approach cost effectiveness at even the highest year per life gained parameters. Such impacts on health care costs, especially for very small gains, become more pressing as all health care costs continue to increase.

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A prospective evaluation of the attitudes of patients, physicians and nurses using a computer-assisted quality of life instrument (LCSS-QL) in a multicenter clinical trial in non-small cell lung cancer (NSCLC)

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Background: The LCSS has been computerized (LCSS-QL) for inexpensive hand-held devices (pocket-pc) to enhance feasibility, provide immediate results, and automatically record data. Correlation coefficient between paper form and electronic version is excellent (r=0.93). This analysis determines the acceptability and value of LCSS-QL assessed by patients and health care professionals. Methods: NSCLC patients utilized LCSS-QL in a clinical trial and also completed a form evaluating their experiences after their first and third treatment cycles. All received docetaxel and platinum. Eleven physicians and nurses administered LCSS-QL and completed an evaluation form. The evaluation included: time required, satisfaction with the process, value of assessment, impact on communication, resource utilization. Results: The evaluation form was completed by 126 patients (cycle 1) and 94 (75%) completing cycle 3. Baseline characteristics: Stage III/IV 29/71%; median KPS 80%; 56% male; median age 69 yrs. Results are in the table : All physicians considered their time per patient was not lengthened and 80% felt that QL evaluation could save time. 67% of nurses felt the instrument could save time, while 83% felt that their time with patients was lengthened. Utilization: 67% of professionals reported QL evaluation would identify earlier patients not benefiting from chemo; 91% were more aware of pain issues. Conclusions: Patients and health-care professionals found using a validated QL instrument in a computerized form via a hand-held device was easy, added value and satisfaction while enhancing communication and awareness of PRO issues. This electronic format added no physician time. These results indicate that this QL evaluation method should be used more frequently in clinical trials and patient management. Supported in part by a grant from Sanofi-Aventis Canada, Laval, QC.

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Examining the cost and cost-effectiveness of adding bevacizumab to carboplatin and paclitaxel in advanced non-small cell lung cancer

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Background: Two-drug platinum-containing regimens are considered the standard of care in advanced non-small cell lung cancer. A recent randomized trial (ECOG 4599) compared carboplatin + paclitaxel (PC) with PC + bevacizumab (PCB). PCB was found to result in a modest improvement in survival (12.5 months vs 10.2 months with PC, p = .007). This finding was exceptional in showing a survival benefit with the addition of a molecularly targeted agent to chemotherapy in a largely unselected population, and doing so in this most common cause of malignant death in the US. Additionally, new therapies can have a major impact on health care costs. Using the known survival data and costs, we analyzed the cost-effectiveness of the addition of bevacizumab to this chemotherapy regimen. Methods: Medicare reimbursement (cost) of the two regimens was developed using the CMS Drug Payment Table and Physician Fee Schedule for January, 2005. Incremental cost effectiveness was calculated. Results: Carboplatin and paclitaxel regimen costs $14,073 for 6 cycles (the number of cycles planned in the clinical trial.) The addition of bevacizumab increases cost by $66,270 to $80,343. Given an increase of 2.3 months in median overall survival over chemotherapy alone, the addition of bevacizumab to chemotherapy costs $345,762 per year of life gained. Conclusions: Adding bevacizumab to chemotherapy is not cost effective even at the $100,000 per Year of Life Gained (YLG) threshold. To be cost effective at the $100,000/YLG level, bevacizumab reimbursement would have to be reduced to $14.70/10 mg. ($1,764/cycle) or 26% of 2005 Medicare reimbursement of $57.08/10 mg. ($6,849/cycle). Prior analyses have examined the impact of chemotherapy on survival and cost-effectiveness. Several factors beneficially influence survival in NSCLC, as shown in meta-analyses, including: chemotherapy vs supportive care, two-agents vs one, and the choice of which platinum agent to use. While all of these may increase costs, some are cost-effective, while others are not. The addition of bevacizumab is the most costly and least cost-effective of any of these interventions.

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Combined data from two phase III trials of the NK1 antagonist aprepitant plus a 5HT 3 antagonist and a corticosteroid for prevention of chemotherapy-induced nausea and vomiting: effect of gender on treatment response

GOALS OF WORK

Prevention of chemotherapy-induced nausea and vomiting (CINV) with standard antiemetics has been more difficult to achieve in female patients. Data from two phase III trials of the NK1 antagonist aprepitant were assessed for potential effect of gender on treatment response.

PATIENTS AND METHODS

1,044 patients receiving cisplatin (> or = 70 mg/m2) were randomly assigned to control regimen [ondansetron (O) 32 mg i.v. and dexamethasone (D) 20 mg p.o. on day 1; D 8 mg twice daily on days 2-4] or aprepitant (A) regimen (A 125 mg p.o. plus O 32 mg and D 12 mg on day 1; A 80 mg and D 8 mg once daily on days 2-3; and D 8 mg on day 4). The primary endpoint was overall complete response (no emesis and no rescue therapy over days 1-5). Data were analyzed by a modified intent-to-treat approach. Between-treatment comparisons for each gender were made using logistic regression.

MAIN RESULTS

Women comprised 42 and 43% of the aprepitant and control groups, respectively. In the control group, 41% of women had overall complete response compared with 53% of men. In the aprepitant group, 66% of women had overall complete response compared with 69% of men.

CONCLUSION

The addition of aprepitant may negate the adverse prognostic effect of female gender on the prevention of CINV in patients receiving highly emetogenic chemotherapy.

A comparison of visual analogue and numerical rating scale formats for the Lung Cancer Symptom Scale (LCSS): does format affect patient ratings of symptoms and quality of life?

PROBLEM AND PURPOSE

The Lung Cancer Symptom Scale (LCSS), a site-specific health-related quality of life measure for patients with lung cancer, was originally developed using a Visual Analogue Scale (VAS) format. However, the VAS format is not readily compatible with data management and software programs using scanning. The primary aim of this study was to evaluate the convergence of ratings obtained with a Numerical Rating Scale (NRS), with an 11-pt response category format, to those obtained with a VAS format. The intent was to determine the degree of agreement between two formats to generalize the existing psychometric properties for the original measure to the new presentation.

DESIGN/SETTING

This methodological study evaluated the feasibility, reliability, and validity of a NRS format for the LCSS. The study was conducted at two cancer centers in New York City. PATIENTS/PROCEDURES: Sixty-eight patients with non-small cell lung cancer (NSCLC) completed both versions of the LCSS along with demographic and feasibility questions on a single occasion. The VAS form was administered first, followed by the NRS form to prevent bias. The intraclass correlation coefficient (ICC), Lin's concordance correlation coefficient (CCC), and Bland-Altman plots were used to evaluate agreement and to characterize bias.

RESULTS

Cronbach's alpha for the NRS format total score was 0.89 for the 68 patients with NSCLC. Agreement was excellent, with both the ICC and CCC > or = 0.90 for the two summary scores (total score and average symptom burden index) for the LCSS. Only five of the nine individual items showed this level of strict agreement. An agreement criterion of > or = 0.80 (representing excellent) was observed for seven of the nine individual items (all but appetite loss and hemoptysis). Mean differences tended to be slightly lower for the VAS format compared to the NRS format (more so for the appetite and hemoptysis items), with evidence of scale shift for the same two items. The summary measures showed good concordance as measured by the ICC and CCC, but did display mean differences (VAS - NRS) of -2.7 and -3.1, respectively.

CONCLUSIONS

Overall, the NRS format for the LCSS suitable for scanning has good feasibility, reliability (internal consistency), and convergent validity. The complete set of concordance evaluation measures supports the reproducibility of VAS scores by NRS scores, particularly for the two summary scores.

Multi-Institutional Phase I/II Trial of Oral Bexarotene in Combination With Cisplatin and Vinorelbine in Previously Untreated Patients With Advanced Non–Small-Cell Lung Cancer

PURPOSE: Bexarotene (Targretin; Ligand Pharmaceuticals, Inc, San Diego, CA) is a retinoid-X-receptor (RXR)-selective retinoid with preclinical antitumor activity in squamous cell cancers. In this phase I/II trial, we combined bexarotene with cisplatin and vinorelbine in the treatment of patients with non–small-cell lung cancer (NSCLC).

PATIENTS AND METHODS: Forty-three patients who had stage IIIB NSCLC with pleural effusion or stage IV NSCLC and had received no prior therapy received bexarotene in combination with cisplatin (100 mg/m2) and vinorelbine (alternating doses of 30 mg/m2 and 15 mg/m2). In the phase I portion, the daily dose of bexarotene was escalated in cohorts of three patients from 150 mg/m2 to 600 mg/m2, beginning 1 week before the start of the cisplatin-vinorelbine regimen. Once the maximum-tolerated dose (MTD) of bexarotene was determined, the study entered the phase II portion. Response rate was the primary end point; median survival time and 1-year survival rate were secondary end points.

RESULTS: In the phase I portion, the daily MTD of bexarotene was determined to be 400 mg/m2. Eight of 43 patients exhibited major responses. Seven (25%) of the 28 patients in the phase II portion responded to treatment. The median survival time in the phase II portion was 14 months; nine (32%) of the 28 patients were still alive at a minimum follow-up of 2 years. One-year and projected 3-year survival rates were 61% and 30%, respectively. The most common grade 3 and 4 adverse events were hyperlipemia, leukopenia, nausea, vomiting, pneumonia, dyspnea, anemia, and asthenia. Grade 3 and 4 laboratory abnormalities with incidences greater than 5% were decreased hemoglobin levels and WBC, absolute neutrophil, and absolute lymphocyte counts and increased prothrombin time and creatinine and amylase levels. Of the two cases of pancreatitis, one required hospitalization and both were associated with increased triglyceride levels. There was one death secondary to renal insufficiency unrelated to bexarotene treatment.

CONCLUSION: In patients with advanced NSCLC, bexarotene with cisplatin and vinorelbine yielded acceptable phase II response rates (25%) and was associated with better-than-expected survival (14-month median survival time; 61% 1-year, 32% 2-year, and 30% projected 3-year survival rates). The regimen should be studied in larger clinical trials.

Efficacy of intravenous granisetron to control nausea and vomiting during multiple cycles of cisplatin-based chemotherapy

The safety and efficacy of granisetron (10 micrograms/kg and 40 micrograms/kg) were evaluated during a second (n = 393) and third (n = 200) cycle of chemotherapy in this multicenter, double-blind, randomized, parallel-group study. Granisetron was administered as a single intravenous dose before the start of cisplatin chemotherapy (> or = 60 mg/m2). Total control (no vomiting, no retching, no nausea, and no use of antiemetic rescue medication) after the first 24 hr following chemotherapy was achieved in 40% and 49% of patients in Cycles 2 and 3, respectively, for the 10 micrograms/kg group, and in 42% and 38% of patients in Cycles 2 and 3, respectively, for the 40 micrograms/kg group. Both dose levels of granisetron were well tolerated. The results demonstrate comparable efficacy between the 10 micrograms/kg and 40 micrograms/kg doses of granisetron in preventing nausea and vomiting during repeat cycles of high-dose cisplatin-based chemotherapy. The results of this study show that granisetron 10 micrograms/kg is safe and well tolerated, and remains effective with repeat cycle use.