Patient preferences for treatments to delay bone metastases

Discrete-Choice Experiment to Understand the Preferences of Patients with Hormone-Sensitive Prostate Cancer in the USA, Canada, and the UK

BACKGROUND

Treatment options for patients with metastatic hormone-sensitive prostate cancer (mHSPC) have broadened, and treatment decisions can have a long-lasting impact on patients' quality of life. Data on patient preferences can improve therapeutic decision-making by helping physicians suggest treatments that align with patients' values and needs.

OBJECTIVE

This study aims to quantify patient preferences for attributes of chemohormonal therapies among patients with mHSPC in the USA, Canada, and the UK.

METHODS

A discrete-choice experiment survey instrument was developed and administered to patients with high- and very-high-risk localized prostate cancer and mHSPC. Patients chose between baseline androgen-deprivation therapy (ADT) alone and experimentally designed, hypothetical treatment alternatives representing chemohormonal therapies. Choices were analyzed using logit models to derive the relative importance of attributes for each country and to evaluate differences and similarities among patients across countries.

RESULTS

A total of 550 respondents completed the survey (USA, 200; Canada, 200; UK, 150); the mean age of respondents was 64.3 years. Treatment choices revealed that patients were most concerned with treatment efficacy. However, treatment-related convenience factors, such as route of drug administration and frequency of monitoring visits, were as important as some treatment-related side effects, such as skin rash, nausea, and fatigue. Patient preferences across countries were similar, although patients in Canada appeared to be more affected by concomitant steroid use.

CONCLUSION

Patients with mHSPC believe the use of ADT alone is insufficient when more effective treatments are available. Efficacy is the most significant driver of patient choices. Treatment-related convenience factors can be as important as safety concerns for patients.

Patient and General Population Preferences Regarding the Benefits and Harms of Treatment for Metastatic Prostate Cancer: A Discrete Choice Experiment

Background

Patient preferences for treatment outcomes are important to guide decision-making in clinical practice, but little is known about the preferences of patients with metastatic hormone-sensitive prostate cancer (mHSPC).

Objective

To evaluate patient preferences regarding the attributed benefits and harms of systemic treatments for mHSPC and preference heterogeneity between individuals and specific subgroups.

Design setting and participants

We conducted an online discrete choice experiment (DCE) preference survey among 77 patients with metastatic prostate cancer (mPC) and 311 men from the general population in Switzerland between November 2021 and August 2022.

Outcome measurements and statistical analysis

We evaluated preferences and preference heterogeneity related to survival benefits and treatment-related adverse effects using mixed multinomial logit models and estimated the maximum survival time participants were willing to trade to avert specific adverse effects. We further assessed characteristics associated with different preference patterns via subgroup and latent class analyses.

Results and limitations

Patients with mPC showed an overall stronger preference for survival benefits in comparison to men from the general population (p = 0.004), with substantial preference heterogeneity between individuals within the two samples (both p < 0.001). There was no evidence of differences in preferences for men aged 45-65 yr versus ≥65 yr, patients with mPC in different disease stages or with different adverse effect experiences, or general population participants with and without experiences with cancer. Latent class analyses suggested the presence of two groups strongly preferring either survival or the absence of adverse effects, with no specific characteristic clearly associated with belonging to either group. Potential biases due to participant selection, cognitive burden, and hypothetical choice scenarios may limit the study results.

Conclusions

Given the relevant heterogeneity in participant preferences regarding the benefits and harms of treatment for mHSPC, patient preferences should be explicitly discussed during decision-making in clinical practice and reflected in clinical practice guidelines and regulatory assessment regarding treatment for mHSPC.

Patient summary

We examined the preferences (values and perceptions) of patients and men from the general population regarding the benefits and harms of treatment for metastatic prostate cancer. There were large differences between men in how they balanced the expected survival benefits and potential adverse effects. While some men strongly valued survival, others more strongly valued the absence of adverse effects. Therefore, it is important to discuss patient preferences in clinical practice.

Patient Preferences in Targeted Pharmacotherapy for Cancers: A Systematic Review of Discrete Choice Experiments

BACKGROUND

Targeted pharmacotherapy has been increasingly applied in cancer treatment due to its breakthroughs. However, the unmet needs of cancer patients are still significant, highlighting the urgency to investigate patient preferences. It is unclear how patients deliberate their choices between different aspects of targeted therapy, including cost, efficacy, and adverse events. Since discrete choice experiments (DCEs) have been widely applied to patient preference elicitation, we reviewed DCEs on targeted therapy for different cancers. We also synthesized evidence on the factors influencing patients' choices and their willingness-to-pay (WTP) for survival when treated by targeted therapy.

METHODS

We searched databases, including PubMed, EMBASE and MEDLINE, up to August 16, 2022, supplemented by a reference screening. The attributes from the selected studies were categorized into three groups: outcomes, costs, and process. We also calculated the relative importance of attributes and WTP for survival whenever possible. The purpose, respondents, explanation, findings, significance (PREFS) checklist was used to evaluate the quality of the included DCE studies.

RESULTS

The review identified 34 eligible studies from 13 countries covering 14 cancers, such as breast, ovarian, kidney, prostate, and skin cancers. It also reveals a rising trend of DCEs on this topic, as most studies were published after 2018. We found that patients placed higher weights on the outcome (e.g., overall survival) and cost attributes than on process attributes. On average, patients were willing to pay $561 (95% confidence interval [CI]: $415-$758) and $716 (95% CI $524-$958) out-of-pocket for a 1-month increase in progression-free survival and overall survival, respectively. PREFS scores of the 34 studies ranged from 2 to 4, with a mean of 3.38 (SD: 0.65), suggesting a reasonable quality based on the checklist. However, most studies (n = 32, 94%) did not assess the impact of non-responses on the results.

CONCLUSIONS

This is the first systematic review focusing on patient preferences for targeted cancer therapy. We showcased novel approaches for evidence synthesis of DCE results, especially the attribute relative importance and WTP. The results may inform stakeholders about patient preferences toward targeted therapy and their WTP estimates. More studies with improved study design and quality are warranted to generate more robust evidence to assist decision making.

Behavioral Theories That Have Influenced the Way Health State Preferences Are Elicited and Interpreted: A Bibliometric Mapping Analysis of the Time Trade-Off Method With VOSviewer Visualization

Aim

The aim of this paper is to develop an understanding of how behavioral theories have influenced the way preferences for health-related quality of life are elicited and interpreted. We focus on the Time Trade-off (TTO) method given it represents the quality-adjusted life-year (QALY) concept-that survival in less-than-full health can be deemed equivalent to a shorter survival in full health. To our knowledge this is the first review using a combination of systematic scoping review, bibliometrics and VOSviewer visualization to map the development of ideas in health economics.

Methods

A priori, we selected three behavioral theories to explore within our review, referred to here as Expected Utility Theory, Non-Expected Utility Theory and Probabilistic Choice Theory. A fourth topic, Order Effects, is defined broadly to encompass behavioral theories around timing/sequence of events. For the main search, Scopus was used to identify literature that had (a) elicited TTO values and/or (b) contributed to the way TTO values were elicited and interpreted, from inception to July 2021. Papers that focused on the latter category were given the label "behavioral" and underwent additional analyses. A two stage-screening was applied to assess eligibility. Co-citation, co-authorship and co-occurrence of keywords was used to chart the development of TTO over time.

Results

A total of 1,727 records were retrieved from Scopus and were supplemented by an additional 188 papers. There were 856 applied and 280 behavioral papers included in the final corpus, with the behavioral set split equally into four sets of 70 papers to chart the development of keywords over time: (1) 1972-1999; (2) 2000-2010, (3) 2010-2015 and (4) 2015-2021.

Discussion

The keyword analysis suggested that whilst some ideas transition quickly from economic theory to the TTO literature, such as the impact of Order Effects, others take longer to be assimilated, for example Non-Expected Utility models or failure of constant discounting. It is therefore important that researchers within health economics work more closely with those in mainstream economics and keep abreast of the wider economics and behavioral sciences to expedite the uptake of new and relevant ideas.

A Systematic Review of Patients' Values, Preferences, and Expectations for the Treatment of Metastatic Prostate Cancer

CONTEXT

Advances in systemic agents have increased overall survival for men diagnosed with metastatic prostate cancer. Additional cytoreductive prostate treatments and metastasis-directed therapies are under evaluation. These confer toxicity but may offer incremental survival benefits. Thus, an understanding of patients' values and treatment preferences is important for counselling, decision-making, and guideline development.

OBJECTIVE

To perform a systematic review of patients' values, preferences, and expectations regarding treatment of metastatic prostate cancer.

EVIDENCE ACQUISITION

The MEDLINE, Embase, and CINAHL databases were systematically searched for qualitative and preference elucidation studies reporting on patients' preferences for treatment of metastatic prostate cancer. Certainty of evidence was assessed using Grading of Recommendation, Assessment, Development and Evaluation (GRADE) or GRADE Confidence in the Evidence from Reviews of Qualitative Research (CERQual). The protocol was registered on PROSPERO as CRD42020201420.

EVIDENCE SYNTHESIS

A total of 1491 participants from 15 studies met the prespecified eligibility for inclusion. The study designs included were discrete choice experiments (n = 5), mixed methods (n = 3), and qualitative methods (n = 7). Disease states reported per study were: metastatic castration-resistant prostate cancer in nine studies (60.0%), metastatic hormone-sensitive prostate cancer in two studies (13.3%), and a mixed cohort in four studies (26.6%). In quantitative preference elicitation studies, patients consistently valued treatment effectiveness and delay in time to symptoms as the two top-ranked treatment attributes (low or very low certainty). Patients were willing to trade off treatment-related toxicity for potential oncological benefits (low certainty). In qualitative studies, thematic analysis revealed cancer progression and/or survival, pain, and fatigue as key components in treatment decisions (low or very low certainty). Patients continue to value oncological benefits in making decisions on treatments under qualitative assessment.

CONCLUSIONS

There is limited understanding of how patients make treatment and trade-off decisions following a diagnosis of metastatic prostate cancer. For appropriate investment in emerging cytoreductive local tumour and metastasis-directed therapies, we should seek to better understand how this cohort weighs the oncological benefits against the risks.

PATIENT SUMMARY

We looked at how men with advanced (metastatic) prostate cancer make treatment decisions. We found that little is known about patients' preferences for current and proposed new treatments. Further studies are required to understand how patients make decisions to help guide the integration of new treatments into the standard of care.

A Systematic Review of Discrete Choice Experiments in Oncology Treatments

BACKGROUND

As the number and type of cancer treatments available rises and patients live with the consequences of their disease and treatments for longer, understanding preferences for cancer care can help inform decisions about optimal treatment development, access, and care provision. Discrete choice experiments (DCEs) are commonly used as a tool to elicit stakeholder preferences; however, their implementation in oncology may be challenging if burdensome trade-offs (e.g. length of life versus quality of life) are involved and/or target populations are small.

OBJECTIVES

The aim of this review was to characterise DCEs relating to cancer treatments that were conducted between 1990 and March 2020.

DATA SOURCES

EMBASE, MEDLINE, and the Cochrane Database of Systematic Reviews were searched for relevant studies.

STUDY ELIGIBILITY CRITERIA

Studies were included if they implemented a DCE and reported outcomes of interest (i.e. quantitative outputs on participants' preferences for cancer treatments), but were excluded if they were not focused on pharmacological, radiological or surgical treatments (e.g. cancer screening or counselling services), were non-English, or were a secondary analysis of an included study.

ANALYSIS METHODS

Analysis followed a narrative synthesis, and quantitative data were summarised using descriptive statistics, including rankings of attribute importance.

RESULT

Seventy-nine studies were included in the review. The number of published DCEs relating to oncology grew over the review period. Studies were conducted in a range of indications (n = 19), most commonly breast (n =10, 13%) and prostate (n = 9, 11%) cancer, and most studies elicited preferences of patients (n = 59, 75%). Across reviewed studies, survival attributes were commonly ranked as most important, with overall survival (OS) and progression-free survival (PFS) ranked most important in 58% and 28% of models, respectively. Preferences varied between stakeholder groups, with patients and clinicians placing greater importance on survival outcomes, and general population samples valuing health-related quality of life (HRQoL). Despite the emphasis of guidelines on the importance of using qualitative research to inform attribute selection and DCE designs, reporting on instrument development was mixed.

LIMITATIONS

No formal assessment of bias was conducted, with the scope of the paper instead providing a descriptive characterisation. The review only included DCEs relating to cancer treatments, and no insight is provided into other health technologies such as cancer screening. Only DCEs were included.

CONCLUSIONS AND IMPLICATIONS

Although there was variation in attribute importance between responder types, survival attributes were consistently ranked as important by both patients and clinicians. Observed challenges included the risk of attribute dominance for survival outcomes, limited sample sizes in some indications, and a lack of reporting about instrument development processes.

PROTOCOL REGISTRATION

PROSPERO 2020 CRD42020184232.

Unmet needs in non-metastatic castration-resistant prostate cancer from the Japanese patient perspective: a discrete choice experiment

OBJECTIVES

With novel antiandrogen treatments of varying clinical benefits and risks becoming available, this study investigates how patients with castration-resistant prostate cancer (CRPC) value differences in treatment characteristics.

DESIGN

Cross-sectional observational study.

SETTING

A discrete choice experiment was conducted. Patients chose between two hypothetical non-metastatic CRPC (nmCRPC) treatments defined by six attributes: risk of fatigue, falls or fracture, cognitive impairment, hypertension, rashes as side effects to treatment and extension of time until cancer-related pain occurs.

PARTICIPANTS

A total of 137 adult male patients with CRPC with no prior experience with chemotherapy and with Eastern Cooperative Oncology Group status 0-1 were recruited. Patients were excluded if they participated in an investigational programme outside of routine clinical practice, had a clinically relevant medical or psychiatric condition, or diagnosis of visceral/other metastases not related to the prostate, or were otherwise deemed ineligible by the referring physician.

PRIMARY OUTCOME MEASURES

Relative preference weights and relative importance of the attributes was estimated by hierarchical Bayesian logistic regression.

RESULTS

Among the treatment attributes, 'risk of cognitive impairment as a side effect of treatment' was the most important attribute (relative importance (RI) (95% CI): 27.47% (24.80% to 30.14%)), followed by 'extension of time until cancer-related pain occurs' (RI (95% CI): 17.87% (15.49% to 20.25%)) and the 'risk of falls or fracture' (RI (95% CI): 15.99% (14.73% to 17.25%)). The 'risk of hypertension as a side effect of treatment' (RI (95% CI): 13.77% (12.73% to 14.81%)) had similar RI as 'risk of rashes as a side effect of treatment' (RI (95% CI): 13.17% (12.15% to 14.19%)), followed by the 'risk of fatigue as a side effect of treatment' (RI (95% CI): 11.74% (10.75% to 12.73%)).

CONCLUSIONS

Patients consider the risk of cognitive impairment as a side effect of treatment as the most important attribute in nmCRPC, followed by the extension of time until cancer-related pain occurs, and the risk of falls and fracture. These features should be considered in treatment decision making for nmCRPC in Japan.

Patients' preferences for delaying metastatic castration-resistant prostate cancer: Combining health state and treatment valuation

PURPOSE

Men with castration-resistant prostate cancer (CRPC) experience disease progression at different rates. The purpose of this study was to quantify the strength of patient preferences for delaying prostate cancer progression utilizing a discrete choice experiment (DCE) and valuing 3 health states in the continuum of CRPC.

PATIENTS AND METHODS

Men with CRPC, recruited from US patient panels, completed a cross-sectional web-based survey. The survey consisted of vignette-based time trade-off and a DCE designed to quantify patients' willingness to pay to delay metastatic CRPC. Three health states were presented: (1) living with non-metastatic castration-resistant prostate cancer (nmCRPC) (2) living with metastatic CRPC (mCRPC) before chemotherapy, and (3) living with mCRPC either on or after chemotherapy. The DCE consisted of 15 hypothetical choices with attributes characterizing CRPC (pain, fatigue, out of pocket cost, dosing, and time until cancer metastasizes). Patients' willingness to pay for changes in each attribute were derived.

RESULTS

A total of 176 patients with CRPC were surveyed (mean age: 64.2 years; 74% nmCRPC). Patients valued the nmCRPC health state (0.865) significantly higher than mCRPC before chemotherapy (0.743) or mCRPC on or after chemotherapy (0.476), both P < 0.001. In the DCE, patient treatment valuation was most affected by increasing the number of months until cancer metastasized; patients were willing to pay an additional $682 per month to delay time to metastases from 6 to 24 months (95% Confidence Interval: $387-$977) and additional $1,041 per month to delay time to metastasis to 48 months (95% Confidence Interval: $591-$1,490).

CONCLUSIONS

The results of this study demonstrated men with CRPC place significant value on delaying metastases. This study represents the first time 2 stated preference methods, time trade-off and DCE, were used together to understand patients' preferences and valuation of health states in CRPC.

Patient Preference for Antiepileptic Drugs Treatment in China: Evidence From the Discrete Choice Experiment

Objective: Explore Chinese patients' risk-benefit preferences and willingness-to-pay (WTP) for antiepileptic drugs (AEDs) treatment through the discrete choice experiment (DCE).

Method: Six attributes including the efficacy of AEDs, adverse reactions (digestive system, neuropsychic systems, and the effects on the fetus), dosing frequency and drug costs (to estimate patient WTP) were included in the DCE questionnaire based on results collected from literature reviews, expert consultation, and patient survey. The alternative-specific conditional logit model was used to analyze patient preference and WTP for each attribute and its level and to assess the sociodemographic impact and clinical characteristics.

Results: A total of 151 valid questionnaires were collected. The result shows that five out of the six attributes are significant, except the dosing frequency. Among the six attributes, the efficacy of AEDs (10.0; 95% CI 8.9–11.1) is mostly concerned by patients, followed by the effects of AEDs on the fetus (8.9; 95% CI 7.7–10.1), duration of side effects in the neuropsychic system (4.9; 95% CI 3.7–6.0) and adverse reactions of the digestive system (3.2; 95% CI 1.5–4.2). The patients surveyed are willing to spend ¥ 1,246 (95% CI, ¥ 632- ¥ 1,861) per month to ensure 100% seizure control, and ¥ 1,112 (95% CI, ¥ 586–¥ 1,658) to reduce the risk of the drug affecting the fetus to 3%. Besides, it was found that personal characteristics including the intention for conception and AEDs treatment regimens have statistical significance.

Conclusion: Improving the drug's efficacy and reducing its side effects are predominant considerations for patients with epilepsy in China, especially for those who are concerned about the seizure control and the drug effect on the fetus. This finding is useful to physicians and can encourage shared decision-making between the patients and their doctors in the clinic.

Patient and caregiver benefit-risk preferences for nonmetastatic castration-resistant prostate cancer treatment

Background

Recently approved second‐generation androgen receptor inhibitors (SGARIs) for non‐metastatic castration‐resistant prostate cancer (nmCRPC) have similar efficacy but differ in safety profiles. We used a discrete choice experiment (DCE) to examine how nmCRPC patients and caregivers perceive the benefits versus risks of these new treatments.

Methods

An online DCE survey with 14 treatment choice questions was administered to nmCRPC patients and caregivers. Each choice question compared two hypothetical medication profiles varying in terms of 5 safety attributes (risk or severity of adverse events [AEs]: fatigue, skin rash, cognitive problems, serious fall, and serious fracture) and two efficacy attributes (duration of overall survival [OS] and time to pain progression). Random parameters logit models were used to estimate each attribute's relative importance. We also estimated the amounts of OS that respondents were willing to forego for a reduction in AEs.

Results

In total, 143 nmCRPC patients and 149 caregivers viewed the AEs in following order of importance (most to least): serious fracture, serious fall, cognitive problems, fatigue, and skin rash. On average, patients were willing to trade 5.8 and 4.0 months of OS to reduce the risk of serious fracture and fall, respectively, from 3% to 0%; caregivers were willing to trade 6.6 and 5.4 months of OS.

Conclusions

nmCRPC patients and caregivers preferred treatments with lower AE burdens and were willing to forego OS to reduce the risk and severity of AEs. Our results highlight the importance of carefully balancing risks and benefits when selecting treatments in this relatively asymptomatic population.

Physician preferences for non-metastatic castration-resistant prostate cancer treatment

BACKGROUND

Recent approvals of second-generation androgen receptor inhibitors (SGARIs) have changed the treatment landscape for non-metastatic castration-resistant prostate cancer (nmCRPC). These SGARIs have similar efficacy but differ in safety profiles. We used a discrete choice experiment to explore how United States physicians make treatment decisions between adverse events (AEs) and survival gains in nmCRPC, a largely asymptomatic disease.

METHODS

Treating physicians (n = 149) participated in an online survey that included 14 treatment choice questions, each comparing 2 hypothetical treatment profiles, which varied in terms of 5 safety and 2 efficacy attributes. We described safety attributes (fatigue, skin rash, cognitive problems, falls, and fractures) in terms of severity and frequency, and efficacy attributes (overall survival [OS] and time to pain progression) in terms of duration of effect. We used a random parameters logit model to estimate preference weights and importance scores for each attribute. We also estimated the amount of survival gain physicians were willing to trade for a reduction in specific AEs between treatment options.

RESULTS

Physicians placed more importance on survival than on time to pain progression, and viewed a reduction in cognitive problems from severe to none, a reduction in risk of a serious fracture from 8% to none, and a reduction in fatigue from severe to none as the most important safety attributes. Physicians were willing to forego 9.1 and 6.6 months of OS, respectively, to reduce cognitive problems and fatigue from severe to mild-to-moderate. To reduce the risk of a serious fracture from 8 to 5% and 5% to none, physicians were willing to trade 3.9 and 5.3 months of OS, respectively.

CONCLUSIONS

Physicians were willing to trade substantial amounts of survival to avoid AEs between hypothetical treatments. These results emphasize the importance of carefully balancing therapies' benefits and risks to ultimately optimize the overall quality of nmCRPC patients' survival. Nonetheless, it is noted that the results from the study sample of 149 physicans may not be representative of the viewpoints of all nmCRPC-treating physicians.

Discrete Choice Experiments in Health Economics: Past, Present and Future

OBJECTIVES

Discrete choice experiments (DCEs) are increasingly advocated as a way to quantify preferences for health. However, increasing support does not necessarily result in increasing quality. Although specific reviews have been conducted in certain contexts, there exists no recent description of the general state of the science of health-related DCEs. The aim of this paper was to update prior reviews (1990-2012), to identify all health-related DCEs and to provide a description of trends, current practice and future challenges.

METHODS

A systematic literature review was conducted to identify health-related empirical DCEs published between 2013 and 2017. The search strategy and data extraction replicated prior reviews to allow the reporting of trends, although additional extraction fields were incorporated.

RESULTS

Of the 7877 abstracts generated, 301 studies met the inclusion criteria and underwent data extraction. In general, the total number of DCEs per year continued to increase, with broader areas of application and increased geographic scope. Studies reported using more sophisticated designs (e.g. D-efficient) with associated software (e.g. Ngene). The trend towards using more sophisticated econometric models also continued. However, many studies presented sophisticated methods with insufficient detail. Qualitative research methods continued to be a popular approach for identifying attributes and levels.

CONCLUSIONS

The use of empirical DCEs in health economics continues to grow. However, inadequate reporting of methodological details inhibits quality assessment. This may reduce decision-makers' confidence in results and their ability to act on the findings. How and when to integrate health-related DCE outcomes into decision-making remains an important area for future research.

Patient driven care in the management of prostate cancer: analysis of the United States military healthcare system

Background

Patient preferences are assumed to impact healthcare resource utilization, especially treatment options. There is limited data exploring this phenomenon. We sought to identify factors associated with patients transferring care for prostatectomy, from military to civilian facilities, and the receipt of minimally invasive radical prostatectomy (MIRP).

Methods

Retrospective review of 2006-2010 TRICARE data identified men diagnosed with prostate cancer (ICD-9 185) receiving open radical prostatectomy (ORP; ICD-9: 60.5) or MIRP (ICD-9 60.5 + 54.21/17.42). Patients diagnosed at military facilities but underwent surgery at civilian facilities were defined as “transferring care”. Logistic regression models identified predictors of transferring care for patients diagnosed at military facilities. A secondary analysis identified the predictors of MIRP receipt at civilian facilities.

Results

Of 1420 patients, 247 (17.4%) transferred care. These patients were more likely to undergo MIRP (OR = 7.83, p < 0.01), and get diagnosed at low-volume military facilities (OR = 6.10, p < 0.01). Our secondary analysis demonstrated that transferring care was strongly associated with undergoing MIRP (OR = 1.51, p = 0.04).

Conclusions

Patient preferences induced a demand for greater utilization of MIRP and civilian facilities. Further work exploring factors driving these preferences and interventions tailoring them, based on evidence and cost considerations, is required.

Patients' Preferences for the Treatment of Metastatic Castrate-resistant Prostate Cancer: A Discrete Choice Experiment

PURPOSE

Patient treatment preferences are increasingly being used to inform health care decision making. This discrete choice experiment assessed how men perceive the risks and benefits of hypothetical treatment options for metastatic castrate-resistant prostate cancer (mCRPC).

METHODS

Treatment attributes for inclusion were identified through a review of the literature and product labels. Expert interviews confirmed clinical appropriateness and patient relevance of the attributes, which included effectiveness (delay in months before chemotherapy), steroid use, possible drug interactions (additional hospital visits for monitoring), fogginess (effects on cognition and memory), fatigue (extreme tiredness), food restrictions, and bone pain. Following a pilot, the final discrete choice experiment included 18 choice sets presenting treatments for mCRPC and was completed by men with mCRPC in France, Germany, and the United Kingdom. Data were analyzed using a conditional logit model, with odds ratios (ORs) used to indicate preference for attributes, and tradeoff measures (TOM) were estimated using the ratio of coefficients.

FINDINGS

Within each attribute category and with all other factors being equal, participants (N = 285) indicated a strong preference for treatments that fully control bone pain (OR = 12.069 [95% CI, 10.555-13.800]) and for treatments that delay chemotherapy (OR, 1.727 [95% CI, 1.548-1.927]). They also preferred treatments that were associated with the lowest risk of fogginess (OR, 2.115 [95% CI, 1.849-2.420]), a lower risk of fatigue (OR, 1.365 [95% CI 1.219-1.528]), and fewer additional hospital visits (OR, 1.245 [95% CI 1.111-1.397]) than the respective reference categories. Participants preferred to use steroids under advice from a physician (OR, 1.275 [95% CI 1.132-1.437]). Food restrictions related to taking medication were not a significant concern for participants. TOM results indicated that large tradeoffs in effectiveness, fogginess, and fatigue are required for patients to prefer a treatment with uncontrolled bone pain that is very difficult to live with.

IMPLICATIONS

Men with mCRPC consider a wide range of factors when making decisions regarding their treatment. They showed a strong preference for treatment associated with better control of bone pain. They also placed value on treatments that could delay the need for chemotherapy, and they preferred to avoid side effects such as cognition and memory loss, and extreme tiredness. TOMs highlighted the importance of symptom control, even compared with potential side effects. An understanding of the degree to which patients value the attributes associated with various treatment options will assist clinicians and health care professionals when making decisions regarding the management of men with mCRPC.

Patient, Caregiver, and Nurse Preferences for Treatments for Bone Metastases from Solid Tumors

BACKGROUND

Bone-targeted agents (BTAs) used for the prevention of skeletal-related events (SREs) associated with metastatic bone disease possess different attributes that factor into treatment decisions.

OBJECTIVE

The aim of this study was to evaluate preferences of patients, caregivers, and nurses for features of BTAs used to prevent SREs in patients with a self-reported physician diagnosis of bone metastasis from solid tumors.

METHODS

Patients (n = 187), primary caregivers (n = 197), or nurses (n = 196) completed a web-enabled discrete-choice experiment (10-question survey) in which they chose between pairs of hypothetical profiles of BTAs. Each profile was defined by six key treatment attributes, including efficacy and safety (two each) and route/frequency of administration and cost (one each). The relative importance of treatment attributes and levels was estimated.

RESULTS

The most important treatment attribute for patients and nurses was out-of-pocket cost, and for caregivers, treatment-related risk of renal impairment. Risk of renal impairment was the second most important attribute for patients and nurses, while time until first SRE was the third most important attribute for all respondents. For nurses, risk of osteonecrosis of the jaw was least important, and for patients and caregivers, mode of administration was least important.

LIMITATIONS

Respondents considered hypothetical medications; therefore, their decisions may not have the same consequences as actual decisions.

CONCLUSIONS

The perspectives of patients, caregivers, and nurses are integral when making treatment decisions about BTAs to prevent SREs associated with solid tumors. Identifying the relative importance of attributes of BTAs will aid in the proper selection of therapy in this setting, which may improve patient outcomes.

Longitudinal patterns of bone-targeted agent use among patients with solid tumors and bone metastases in the United States

Purpose

This study examined real-world long-term use of guideline-recommended bone targeted agents (BTA) among patients with metastatic solid tumors.

Methods

Adults with a solid tumor diagnosis followed by a bone metastasis diagnosis in 2012–2014 were identified from electronic medical records in the Oncology Services Comprehensive Electronic Records (OSCER) database. Patients initiated zoledronic acid (ZA) or denosumab on or after the bone metastasis diagnosis and were followed through last clinic visit by 30 June 2015. We describe time to BTA initiation, compliance (≥12 administrations in a year), switching, and non-persistence (switch or ≥90 day gap in therapy), by agent and follow-up period.

Results

The majority of the 14,881 study patients (50% female, 65% age ≥65 years) had breast (33%), prostate (26%), or lung (26%) tumors. Half of all patients initiated on each agent, with denosumab initiations exceeding ZA initiations in 2014. Most (91% denosumab, 93% ZA) initiations occurred within 3 months of bone metastasis diagnosis. At 1, 2, and 3 years post-initiation, denosumab patients were less likely to switch agents (4, 3, and 1% versus 14, 12, and 11%) and more likely to be compliant (50, 37, and 31% versus 41, 26, and 6%). Median time to non-persistence was 25.9 months for denosumab and 17.2 months for ZA, p < 0.0001.

Conclusions

This is the first study reporting long-term treatment patterns for the two primary BTAs used in the USA. The greater compliance and longer persistence observed among denosumab patients may improve treatment effectiveness achieved in the real-world setting.

Electronic supplementary material

The online version of this article (doi:10.1007/s00520-017-3583-1) contains supplementary material, which is available to authorized users.

Patient preferences for treatment of castration-resistant prostate cancer in Japan: a discrete-choice experiment

Background

Up to a fifth of patients diagnosed with prostate cancer (PC) will develop castration-resistant prostate cancer (CRPC), which has been associated with a poor prognosis. The aim of this study was to consider the patient perspective as part of the overall treatment decision-making process for CRPC, given that an alignment between patient preference and prescribing has been shown to benefit patient outcomes. This study examines preferences of patients with CRPC in Japan for treatment features associated with treatments like RA-223, abiraterone, and docetaxel and to examine the extent to which treatment preferences may vary between symptomatic and asymptomatic patients.

Methods

A two-phase research approach was implemented. In Phase 1, N = 8 patients with CRPC were recruited from a single hospital to complete a qualitative interview to provide feedback on the draft survey. In Phase 2, N = 134 patients with CRPC were recruited from five hospitals to complete a paper survey. The survey included 6 treatment choice questions, each asking patients to choose between two hypothetical treatments for their CRPC. Each treatment alternative was defined by the following attributes: length of overall survival (OS), time to a symptomatic skeletal event (SSE), method of administration, reduction in the risk of bone pain, treatment-associated risk of fatigue and lost work days. A hierarchical Bayesian logistic regression was used to estimate relative preference weights for each attribute level and mean relative importance.

Results

A total of N = 133 patients with CRPC completed the survey and were included in the final analysis. Patients had a mean age of 75.4 years (SD = 7.4) and had been diagnosed with PC a mean of 6.5 years prior (SD = 4.4). Over the attribute levels shown, fatigue (relative importance [RI] = 24.9 %, 95 % CI: 24.7 %, 25.1 %) was the most important attribute, followed by reduction in the risk of bone pain (RI = 23.2 %, 95 % CI: 23.0 %, 23.5 %), and OS (RI = 19.2 %, 95 % CI: 19.0 %, 19.4 %). Although symptomatic patients placed significantly more importance on delaying an SSE (p < .05), no other preference differences were observed.

Conclusions

CRPC patients were more concerned about reduced quality of life from side effects of treatment rather than extension of survival, which may have implications for shared decision-making between patients and physicians.

Patient Benefit-Risk Tradeoffs for Radioactive Iodine-Refractory Differentiated Thyroid Cancer Treatments

Background. The aims of this study were to assess patients' preferences to wait or start systemic treatment and understand how patients would make tradeoffs between certain severe adverse events (AEs) and additional months of progression-free survival (PFS). Materials and Methods. Adults in France, Germany, and Spain with a diagnosis of DTC and who have had at least one RAI treatment completed a direct-elicitation question and a discrete-choice experiment (DCE) online. The direct-elicitation question asked respondents whether they would opt out of treatment when their tumor is RAI-R. In the DCE, respondents chose between 12 pairs of hypothetical RAI-R DTC treatment profiles. Profiles were defined by magnitudes of efficacy (PFS) and safety (severe hand-foot skin reaction [HFSR], severe proteinuria, and severe hypertension). A main-effects random-parameters logit model was estimated. Results. 134 patients completed the survey. Most patients (86.6%) opted for treatment rather than “wait and see” decision. Patients placed a greater weight on the risk of severe hypertension than the risk of proteinuria and HFSR. Conclusions. DTC patients showed preference toward treatment for RAI-R DTC over watchful waiting. Patients' concerns about the risk of severe hypertension appeared to have had a greater effect on patients' choice than severe proteinuria or HFSR.

The Role of Patients' Age on Their Preferences for Choosing Additional Blood Pressure-Lowering Drugs: A Discrete Choice Experiment in Patients with Diabetes

Objectives

To assess whether patients’ willingness to add a blood pressure-lowering drug and the importance they attach to specific treatment characteristics differ among age groups in patients with type 2 diabetes.

Materials and Methods

Patients being prescribed at least an oral glucose-lowering and a blood pressure-lowering drug completed a questionnaire including a discrete choice experiment. This experiment contained choice sets with hypothetical blood pressure-lowering drugs and a no additional drug alternative, which differed in their characteristics (i.e. effects and intake moments). Differences in willingness to add a drug were compared between patients <75 years (non-aged) and ≥75 years (aged) using Pearson χ²-tests. Multinomial logit models were used to assess and compare the importance attached to the characteristics.

Results

Of the 161 patients who completed the questionnaire, 151 (72%) could be included in the analyses (mean age 68 years; 42% female). Aged patients were less willing to add a drug than non-aged patients (67% versus 84% respectively; P = 0.017). In both age groups, the effect on blood pressure was most important for choosing a drug, followed by the risk of adverse drug events and the risk of death. The effect on limitations due to stroke was only significant in the non-aged group. The effect on blood pressure was slightly more important in the non-aged than the aged group (P = 0.043).

Conclusions

Aged patients appear less willing to add a preventive drug than non-aged patients. The importance attached to various treatment characteristics does not seem to differ much among age groups.