Survival benefit needed to undergo chemotherapy: Patient and physician preferences

Differences between physician and patient preferences for cancer treatments: a systematic review

BACKGROUND

Shared decision-making is useful to facilitate cancer treatment decisions. However, it is difficult to make treatment decisions when physician and patient preferences are different. This review aimed to summarize and compare the preferences for cancer treatments between physicians and patients.

METHODS

A systematic literature search was conducted on PubMed, Embase, PsycINFO, CINAHL and Scopus. Studies elicited and compared preferences for cancer treatments between physicians and patients were included. Information about the study design and preference measuring attributes or questions were extracted. The available relative rank of every attribute in discrete choice experiment (DCE) studies and answers to preference measuring questions in non-DCE studies were summarized followed by a narrative synthesis to reflect the preference differences.

RESULTS

Of 12,959 studies identified, 8290 were included in the title and abstract screening and 48 were included in the full text screening. Included 37 studies measured the preferences from six treatment-related aspects: health benefit, adverse effects, treatment process, cost, impact on quality of life, and provider qualification. The trade-off between health benefit and adverse effects was the main focus of the included studies. DCE studies showed patients gave a higher rank on health benefit and treatment process, while physicians gave a higher rank on adverse effects. Non-DCE studies suggested that patients were willing to take a higher risk of adverse effects or lower health benefit than physicians when accepting a treatment.

CONCLUSIONS

Physicians and patients had important preference differences for cancer treatment. More sufficient communication is needed in cancer treatment decision-making.

Ki 67: a Promising Prognostic Marker in Early Breast Cancer-a Review Article

Ki67 index is considered to be a reliable indicator of the proliferative activity of breast cancer. Additionally, the Ki67 proliferative marker may play a role in assessing response to systemic therapeutic strategies and can act as a prognostic biomarker. But its limited reproducibility which stems from a lack of standardization of procedures, inter-observer variability, and preanalytical and analytical variabilities all have hampered the use of the Ki67 index in clinical practice. Currently, clinical trials have been evaluating Ki67 as a predictive marker for needing adjuvant chemotherapy in luminal early breast cancer patients receiving neoadjuvant endocrine therapy. But the inconsistencies existing in the estimation of the Ki67 index limit the utility of Ki67 in standard clinical practice. The purpose of this review is to evaluate the benefits and drawbacks of utilizing Ki-67 in early-stage breast cancer to prognosticate the disease and predict the risk of recurrence.

Patient perspectives on testing for clonal hematopoiesis of indeterminate potential

Clonal hematopoiesis of indeterminate potential (CHIP), an emerging biomarker for personalized risk-directed interventions, is increased in cancer survivors. However, little is known about patient preferences for CHIP testing. We surveyed participants in a prospective cohort study of young women with breast cancer (BC). The emailed survey included an introduction to CHIP and a vignette eliciting participants' preferences for CHIP testing, considering sequentially: population-based 10-year risk of BC recurrence, hematologic malignancy, and heart disease; increased CHIP-associated risks; current CHIP management; dedicated CHIP clinic; and hypothetical CHIP treatment. Preference changes were evaluated using the McNemar test. The survey response rate was 82.2% (528/642). Median age at time of survey was 46 years and median time from diagnosis was 108 months. Only 5.9% had prior knowledge of CHIP. After vignette presentation, most survivors (87.1%) recommended CHIP testing for the vignette patient. Presented next with CHIP-independent, population-based risks, 11.1% shifted their preference from testing to not testing. After receiving information about CHIP-associated risks, an additional 10.1% shifted their preference to testing. Preference for testing increased if vignette patient was offered a CHIP clinic or hypothetical CHIP treatment, with 7.2% and 14.1% switching preferences toward testing, respectively. Finally, 75.8% of participants desired CHIP testing for themselves. Among participants, 28.2% reported that learning about CHIP caused at least moderate anxiety. Most young survivors favored CHIP testing, with preferences influenced by risk presentation and potential management strategies. Our findings highlight the importance of risk communication and psychosocial support when considering biomarkers for future risk in cancer survivors. This trial has been registered at www.clinicaltrials.gov as #NCT01468246.

Addressing the problem of overtreatment in breast cancer

INTRODUCTION

As breast cancer treatment options have multiplied and biologic diversity within breast cancer has been recognized, the use of the same treatment strategies for patients with early-stage and favorable disease, and for those with biologically aggressive disease, has been questioned. In addition, as patient-reported outcome measures have called attention to the morbidity of many common treatments, and as the cost of breast cancer care has continued to increase, reduction in the overtreatment of breast cancer has assumed increasing importance.

AREAS COVERED

Here we review selected aspects of surgery, radiation oncology, and medical oncology for which scientific evidence supports de-escalation for invasive carcinoma and ductal carcinoma in situ, and assess strategies to address overtreatment.

EXPERT OPINION

The problems of breast cancer overtreatment we face today are based on improved understanding of the biology of breast cancer and abandonment of the 'one-size-fits-all' approach. As breast cancer care becomes increasingly complex, and as our knowledge base continues to increase exponentially, these problems will only be magnified in the future. To continue progress, the move must be made from advocating the maximum-tolerated treatment to advocating the minimum-effective one.

Physicians’ Perception of the Evidence in Relation to Primary Endpoints of Clinical Trials on Breast Cancer

<b><i>Objective:</i></b> To investigate physicians’ perception of the evidence of clinical trials on breast cancer. <b><i>Methods:</i></b> A survey was conducted by the Chinese Society of Breast Surgeons. We investigated the physicians’ perception of meaningful endpoints, appropriate follow-up duration, and clinically acceptable benefit through online questionnaires. <b><i>Results:</i></b> Among 278 validated questionnaires, the majority of the questions had no consistent answer. For local treatment, 30.6, 28.8, and 28.4% of participants regarded locoregional recurrence (LRR), disease-free survival (DFS), and overall survival (OS) as the most meaningful endpoint, respectively, 47.5% believed that 5-year follow-up can alter clinical practice, and 34.5% thought it should be &#x3e;10 years. In the adjuvant setting, 45.7, 38.5, and 12.9% regarded DFS, OS, and LRR as the most meaningful endpoint, respectively, 52.5% thought that 10-year follow-up was solid, while 37.4% thought that 5-year follow-up was enough. In the advanced setting, 49.6, 24.1, and 23.7% considered progression-free survival, quality of life, and OS the most meaningful endpoint, respectively, and 39.6 and 28.8% considered that a follow-up of 1 year and 3 years, respectively, was meaningful. Similarly, the clinically acceptable absolute difference was inconsistent. <b><i>Conclusion:</i></b> Most Chinese oncologists advocated that surrogate endpoints could be used in certain circumstances, though OS was the most reliable one in breast cancer studies. Doctors’ perceptions of follow-up time and magnitude of benefit vary widely, reflecting the fact that there are many unanswered questions about supporting the use of new cancer treatments; a common understanding needs to be reached, such as a very consensual surrogate endpoint and a meaningful sufficiently large therapeutic benefit.

Clinical Benefit in the Treatment of Patients with Early Breast Cancer

Adjuvant treatment for early breast cancer involves multiple modalities with distinct toxicities and varying relative contributions to the improvement of long-term outcomes. In many situations the expected benefits of treatment may be modest and thus debated, and even in higher risk scenarios, when treatment is clearly indicated, several options are available with varying schedules and toxicities. Regulatory and professional society guidelines defining clinical benefit are available to guide decision-making, but do not capture clinical meaningfulness. There is wide variation among patients regarding the expected improvement in outcomes sufficient to make adjuvant chemotherapy or endocrine therapy worthwhile. While many consider small improvements in outcomes meaningful, some need greater benefit, and a small minority prefer to avoid adjuvant therapies at any rate. Shared decision making has a central role in bridging between clinical evidence, multiple treatment alternatives and patient preferences in the adjuvant treatment of early breast cancer. It is associated with increased patient involvement and responsibility, satisfaction, quality of life and in some instances increase the likelihood of accepting adjuvant treatment. A current understanding of evidence and clinical guidelines, combined with the skills to elicit and appreciate individual patient preferences, is necessary to determine an optimal treatment approach for every individual with breast cancer.

Association between perceived benefits and receipt of radiotherapy among older breast cancer patients

While radiotherapy can be safely omitted in many older women with early-stage breast cancer after lumpectomy, approximately two-thirds of eligible women still undergo this treatment. We surveyed 63 older women with stage I (T1N0M0), estrogen-receptor-positive breast cancer who underwent lumpectomy, and were considering/receiving radiotherapy. Participants perceived that radiotherapy would reduce their 10-year risk of local recurrence by an average of 18.7%, which is significantly higher than the 8% risk reduction reported in literature. Multivariate analyses demonstrated that participants who reported a large perceived benefit were significantly more likely to undergo radiotherapy treatment (odds ratio 10.34; 95% confidence interval: 1.66-66.35).

Differences in perception of breast cancer treatment between patients, physicians, and nurses and unmet information needs in Japan

Purpose

Discrepancies exist between healthcare provider and patient perceptions surrounding breast cancer treatment. Significant treatment changes in the last 10 years have made re-evaluation of these perceptions necessary.

Methods

Physicians and nurses involved in breast cancer treatment, and patients who had received breast cancer chemotherapy (past 5 years), were questioned using an Internet survey. Participants ranked physical concerns (treatment side effects), psychological concerns, priorities for treatment selection, and side effects to be avoided during treatment. Patients were asked about desired treatment information/information sources. Rankings were calculated using the mean value of scores. Spearman’s rank correlation was used to determine the concordance of rankings among groups.

Results

Survey respondents included 207 patients, 185 physicians, and 150 nurses. Patients and nurses similarly ranked distressing physical concerns; physician rankings differed. Quality of life (QoL) and treatment response ranked high with physicians and patients when considering future treatment; nurses prioritized QoL. All three groups generally agreed on ranking of psychological concerns experienced during chemotherapy, explanation of treatment options, and how treatment decisions were made, although more patients thought treatment decisions should be made independently. Healthcare providers reported providing explanations of treatment side effects and information on physical/psychological support options while patients felt both were lacking. Concordance was calculated as 0.47 (patient–physician), 0.83 (patient–nurse), and 0.76 (physician–nurse). Patients desired additional information, preferring healthcare providers as the source.

Conclusions

Specific areas for improvement in breast cancer patient care were identified; programs should be implemented to address unmet needs and improve treatment in these areas.

Electronic supplementary material

The online version of this article (10.1007/s00520-019-05029-z) contains supplementary material, which is available to authorized users.

Patient preferences for adjuvant radiotherapy in early breast cancer are strongly influenced by treatment received through random assignment

OBJECTIVE

TARGIT-A randomised women with early breast cancer to receive external beam radiotherapy (EBRT) or intraoperative radiotherapy (TARGIT-IORT). This study aimed to identify what extra risk of recurrence patients would accept for perceived benefits and risks of different radiotherapy treatments.

METHODS

Patient preferences were determined by self-rated trade-off questionnaires in two studies: Stage (1) 209 TARGIT-A participants (TARGIT-IORTn = 108, EBRTn = 101); Stage (2) 123 non-trial patients yet to receive radiotherapy (pre-treatment group), with 85 also surveyed post-radiotherapy. Patients traded-off risks of local recurrence in preference selection between TARGIT-IORT and EBRT.

RESULTS

TARGIT-IORT patients were more accepting of IORT than EBRT patients with 60% accepting the highest increased risk presented (4%-6%) compared to 12% of EBRT patients, and 2% not accepting IORT at all compared to 43% of EBRT patients. Pre-treatment patients were more accepting of IORT than post-treatment patients with 23% accepting the highest increased risk presented compared to 15% of post-treatment patients, and 15% not accepting IORT at all compared to 41% of pre-treatment patients.

CONCLUSIONS

Breast cancer patients yet to receive radiotherapy accept a higher recurrence risk than the actual risk found in TARGIT-A. Measured patient preferences are highly influenced by experience of treatment received. This finding challenges the validity of post-treatment preference studies.

Treatment satisfaction in women receiving palbociclib combination therapies for advanced/metastatic breast cancer

Aim: To understand treatment satisfaction in patients with advanced or metastatic breast cancer receiving palbociclib plus an aromatase inhibitor or palbociclib plus fulvestrant in a real-world setting. Patients & methods: We performed an observational, cross-sectional, web-based survey of 604 patients with self-reported hormone receptor-positive (HR+)/HER2-negative (HER2-) ABC/mBC in six countries. Results: Overall, more than 96% of patients reported the benefits of their palbociclib combination therapy met or exceeded their expectations. Patient expectations and satisfaction with therapy did not differ between patients on palbociclib plus letrozole and palbociclib plus fulvestrant, or between patients with visceral and nonvisceral metastases. Conclusion: The patients on palbociclib combination therapy reported high satisfaction scores across multiple countries.

Double-Blind Phase III Trial of Adjuvant Chemotherapy With and Without Bevacizumab in Patients With Lymph Node-Positive and High-Risk Lymph Node-Negative Breast Cancer (E5103)

Purpose Bevacizumab improves progression-free survival but not overall survival in patients with metastatic breast cancer. E5103 tested the effect of bevacizumab in the adjuvant setting in patients with human epidermal growth factor receptor 2-negative disease. Patients and Methods Patients were assigned 1:2:2 to receive placebo with doxorubicin and cyclophosphamide (AC) followed by weekly paclitaxel (arm A), bevacizumab only during AC and paclitaxel (arm B), or bevacizumab during AC and paclitaxel followed by bevacizumab monotherapy for 10 cycles (arm C). Random assignment was stratified and bevacizumab dose adjusted for choice of AC schedule. Radiation and hormonal therapy were administered concurrently with bevacizumab in arm C. The primary end point was invasive disease-free survival (IDFS). Results Four thousand nine hundred ninety-four patients were enrolled. Median age was 52 years; 64% of patients were estrogen receptor positive, 27% were lymph node negative, and 78% received dose-dense AC. Chemotherapy-associated adverse events including myelosuppression and neuropathy were similar across all arms. Grade ≥ 3 hypertension was more common in bevacizumab-treated patients, but thrombosis, proteinuria, and hemorrhage were not. The cumulative incidence of clinical congestive heart failure at 15 months was 1.0%, 1.9%, and 3.0% in arms A, B, and C, respectively. Bevacizumab exposure was less than anticipated, with approximately 24% of patients in arm B and approximately 55% of patients in arm C discontinuing bevacizumab before completing planned therapy. Five-year IDFS was 77% (95% CI, 71% to 81%) in arm A, 76% (95% CI, 72% to 80%) in arm B, and 80% (95% CI, 77% to 83%) in arm C. Conclusion Incorporation of bevacizumab into sequential anthracycline- and taxane-containing adjuvant therapy does not improve IDFS or overall survival in patients with high-risk human epidermal growth factor receptor 2-negative breast cancer. Longer duration bevacizumab therapy is unlikely to be feasible given the high rate of early discontinuation.

The outweigh of toxicity versus risk of recurrence for adjuvant interferon therapy: a survey in German melanoma patients and their treating physicians

After more than two decades with interferon alfa-2a and 2b (IFN) as the only approved drugs in the adjuvant setting for melanoma, new treatment approaches like immune checkpoint inhibitors and BRAF-MEK inhibitors improve the progression free survival (PFS) and also the overall survival (OS). We compared physicians' preferences ("utilities") for health states associated with IFN therapy to their patients' preferences. Utilities describe a preference for a specific health state on a scale of 0 (as bad as death) to 1.0 (perfect health).

SETTING

We assessed utilities for health states associated with adjuvant IFN using the standard gamble technique in 108 physicians and 130 melanoma patients. Four IFN toxicity scenarios and three outcome scenarios were given to the participants. Both groups were asked for the 5-year disease free survival (DFS) they would need to accept the described IFN-related side effects.

RESULTS

In both groups, utilities for melanoma relapse were significantly lower than for IFN side effects, showing that toxicity was more acceptable than relapse. Physicians indicated higher utilities for each scenario and needed lower 5-year DFS both in case of mild-to-moderate and severe side effects. Patients were willing to tolerate mild-to-moderate and severe toxicity for a 50% and 75% chance of 5-year DFS, while physicians only required a chance of 40% and 50%, respectively.

CONCLUSION

Both physicians and patients rated melanoma recurrence much lower than even severe IFN side effects. In direct comparison, physicians rated cancer-related scenarios more positively and accepted IFN toxicity for an even lower treatment benefit.

A review of systemic anticancer therapy in disease palliation

BACKGROUND

Systemic anticancer therapy (SACT) is a collective term to describe the growing number of differing therapies used in malignancy to achieve palliation. Improving symptoms, quality of life (QOL) and where possible quantity of life are the goals of these treatments.

SOURCES OF DATA

A comprehensive literature review was undertaken using Medline, Embase and the Cochrane database.

AREAS OF AGREEMENT

The use of palliative SACT can lead to increases in symptom control, QOL and survival. The breadth of treatable cancers has increased along with the number of therapeutic options.

AREAS OF CONTROVERSY

The increasing use of SACT in the last weeks of life and the lack of consistency about the terms Supportive Care/Best Supportive Care in the trial setting.

GROWING POINTS

Integration between oncology and other palliative services leads to better outcomes.

AREAS TIMELY FOR DEVELOPING RESEARCH

Improved prognostication tools to elucidate which patients will benefit from SACT.

Societal preferences for adjuvant melanoma health states: UK and Australia

BACKGROUND

No studies have measured preference-based utility weights for specific toxicities and outcomes associated with approved and investigational adjuvant treatments for patients with resected high-risk melanoma.

METHODS

A cross-sectional study was conducted in the United Kingdom and Australia to obtain utilities for 14 adjuvant melanoma health states. One-on-one interviews were conducted using standard gamble; utility weights range from 0.0, dead, to 1.0, full health. Supplemental risk questions also were asked.

RESULTS

Among 155 participants (52% male; mean age, 46 years) "adjuvant treatment no toxicities" (0.89) was most preferred, followed by "induction treatment" (0.88), and "no treatment" (0.86). Participants least preferred "cancer recurrence" (0.62); the utility for "cancer recurrence and 10-year survival with treatment" was 0.70. Disutilities for grade 2 toxicities ranged from -0.06 for fatigue to -0.13 for hypophysitis. The mean maximum acceptable risk of a life-threatening event ranged from 30% for a 6% increase in the chance of remaining cancer free over 3 years to 40% for an 18% increase; Australian respondents were willing to take higher risks.

CONCLUSION

Reproducible health utilities for adjuvant melanoma health states were obtained from the general population in two countries. These utilities can be incorporated into treatment-specific cost-effectiveness evaluations.