Patient-Centered Outcome Measures in Lung Cancer Trials

The impact of frailty on health outcomes in older adults with lung cancer: A systematic review

BACKGROUND

Frailty is prevalent in older adults with lung cancer, however the impact of frailty in this population is not well understood. The aim of this review was to evaluate the outcomes that are measured in frail older adults with lung cancer, and to determine the associations between frailty and these outcomes.

METHODS

A systematic online search of PubMed, EMBASE, and Cochrane databases was conducted to identify all English-language studies between January 2015 and May 2022 prospectively evaluating frailty and outcomes in older adults (median age > 65 years) with lung cancer. Studies were excluded if frailty was defined by a single domain assessment or not clearly defined. Quality was assessed using the Newcastle-Ottawa Scale.

RESULTS

Of 1891 studies screened, 16 met inclusion criteria. The median number of patients was 96 (range 26-494) and the mean age was 76.6 years. Eight different frailty assessments were used, and frailty definitions varied widely. The most frequently assessed outcomes were overall survival (n = 13,81%), treatment-related toxicity (n = 8,50%), hospitalisation (n = 5,31%), and treatment completion/discontinuation (n = 4,25%). Quality of life (n = 3,19%), function (n = 1,6%), frailty trajectory (n = 1,6%), and emergency visits (n = 1,6%) were infrequently assessed. Frailty had a strong and consistent association with mortality (Hazard Ratio range: 3.5-11.91). It was also associated with treatment-related toxicity and treatment selection. The remaining outcomes were not statistically significant.

CONCLUSION

These data support frailty as an important predictor of mortality in older adults with lung cancer, however further research is warranted to determine the association between frailty and other meaningful endpoints for this vulnerable population.

Health-related quality of life in stage III-IV melanoma treated with targeted therapy or immunotherapy: A systematic review on the adequacy of reporting and clinical issues in phase III randomized controlled trials

Cutaneous melanoma represents around over 90% of all melanoma. With more effective treatments able to extend patients' survival, health-related quality of life (HRQOL) is increasingly becoming an important endpoint in cancer clinical trials. They are often secondary outcomes measured in phase III randomized controlled trials and their implementation, collection, analysis, and reporting can be challenging methodologically. For these reasons, an increasing number of international recommendations introduced the standards regarding the conduct of HRQOL. In this systematic review, we appraise the adequacy of HRQOL reporting in phase III randomized controlled trials of stage III-IV cutaneous melanoma and the clinical issues of immunotherapy and small-molecular-targeted therapy on HRQOL. Our search strategy totally got 55 articles, and only 13 studies met all inclusion criteria. Findings suggest that most treatments did not yield significant improvements in HRQOL but kept baseline levels, accompanied by prolonged survival and acceptable toxicity. Except for some existing limitations, reporting of HRQOL has made encouraging progress during the period covered by our search, but some aspects still need further optimization.

Study objectives in clinical trials in older patients with solid malignancies: do we measure what matters?

PURPOSE

We set out to determine study objectives of clinical trials which included older patients with the four most common malignancies, to assess the extent to which the inclusion of patient-related outcomes (PROs) has changed over the last fifteen years.

METHOD

A search of the National Institutes of Health clinical trial registry was performed to identify currently recruiting or completed phase II or III clinical trials started between 2005 and 2020, which addressed chemotherapy or immunotherapy in patients aged > 65 years with the four most common solid malignancies. Trial characteristics and study objectives were extracted from the registry website.

RESULTS

Compared to disease- and treatment-related outcomes, PROs were the least measured outcomes. Of the 1,663 trials, PROs were addressed in only 21% of all trials, in which quality of life as primary objective was found in less than 1% of all trials. Compared to all trials, trials exclusively for older patients addressed more often PROs (respectively, 30% vs 21%, p < 0.001). Over the last fifteen years, there was an incremental trend in the reporting of PROs from 17 to 24% of all trials (p = 0.007).

CONCLUSION

Despite a slight incremental trend over the past 15 years, PROs appear to be underrepresented in clinical trials which include patients with a solid malignancy. In order to provide physicians and older patients with cancer realistic information about the impact of chemo- or immunotherapy on quality of life or functioning, researchers should strongly consider including PROs in their future clinical trials.

Providing Medical Information to Older Adults in a Web-Based Environment: Systematic Review

Background

Cancer is a disease that predominantly affects older adults, and several organizations recommend the completion of a geriatric assessment to help with cancer treatment decision-making. Owing to a shortage of geriatric teams and the vast number of older adults diagnosed with cancer each year, a web-based geriatric assessment may improve access to geriatric assessment for older adults. We systematically reviewed the literature to obtain the latest evidence for the design of our web-based geriatric assessment tool Comprehensive Health Assessment for My Plan.

Objective

This review aimed to probe the following questions: what is the impact of providing health test results to older adults in a web-based environment without the presence of a health care provider for patient-centered outcomes, including satisfaction, perceived harm, empowerment, quality of life, and health care use (eg, hospitalization, physician visits, emergency room visits, and costs), and what recommendations do older adults and developers have for designing future apps or websites for older adults?

Methods

This systematic review was guided by the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analysis) statement. Studies were limited to publications in English that examined a web-based tool that provided test results to older adults (aged ≥65 years) without the presence of a health care provider. A health sciences librarian performed the search on November 29, 2019, on the following electronic databases: MEDLINE, Embase, CINAHL, PsycINFO, and the Cochrane Library. The quality of the included studies was assessed using the Mixed Methods Appraisal Tool Version 2018. The findings are summarized narratively and in tabular format.

Results

A total of 26,898 titles and abstracts were screened by 2 independent reviewers, of which 94 studies were selected for a full-text review, and 9 studies were included in this review. There were only 2 randomized controlled trials of high quality that explored the effects of receiving health care results on the web via eHealth tools for older adults or provided evidence-based recommendations for designing such tools. Older adults were generally satisfied with receiving screening results via eHealth tools, and several studies suggested that receiving health screening results electronically improved participants’ quality of life. However, user interfaces that were not designed with older adults in mind and older adults’ lack of confidence in navigating eHealth tools proved challenging to eHealth uptake and use. All 9 studies included in this systematic review made recommendations on how to design eHealth tools that are intuitive and useful for older adults.

Conclusions

eHealth tools should incorporate specific elements to ensure usability for older adults. However, more research is required to fully elucidate the impact of receiving screening and results via eHealth tools without the presence of a health care provider for patient-centered outcomes in this target population.

Health-Related Quality of Life Data in Cancer Clinical Trials for Drug Registration: The Value Beyond Reimbursement

PURPOSE

A review of the literature was performed to evaluate how quality of life measures are collected, analyzed, and reported in cancer clinical trials intended to support drug registration.Health-related quality of life (HRQoL) data points are one of the patient-reported outcome (PRO) assessments used in clinical trials to evaluate the effects of treatments from the patient perspective. The use of PROs has gained focus in cancer clinical trials as more options become available for greater longevity of patients on treatment. Standardization of PRO data is evolving and involves unique challenges when used for assessing biologic and chemotherapeutic agents for the treatment of cancer.

METHODS

In this study, a review of literature published between 2009 and 2019 was conducted using PubMed, COCHRANE Library, and Medline. The research focus was on the current guidance, implementation, and reporting as well as highlighting the issues, and recommendations for the inclusion of HRQoL end points in cancer clinical trials intended for use in drug registration.

RESULTS

Although there exist many levels of guidance for HRQoL measures in cancer drug trials, challenges to operational implementation, the current inconsistent adherence to reporting standards, and the lack of consensus and understanding of analyses limit the value and potential of the resulting data collected.

CONCLUSION

The results of HRQoL data collected from cancer clinical trials can be difficult to interpret and apply to inform clinical decision making. Increased reporting and access to these data can provide opportunities for potential applications to improve translatability of HRQoL data collected in clinical trials into practice.

Chemotherapy and healthcare utilisation near the end of life in patients with cancer

The quality of medical care delivered to patients with cancer near the end of life is a significant issue. Previous studies have defined several areas suggestive of aggressive cancer treatment as potentially representing poor quality care. The primary objective of current analysis was to examine chemotherapy and healthcare utilisation in the last 3 months of life among patients with cancer that received palliative chemotherapy. Patients were selected from the hospital administration database of the Diakonessenhuis Utrecht, the Netherlands. Data were extracted from the medical files. A total of 604 patients were included for analysis (median age: 64 years). For 300 patients (50%) chemotherapy was given in the last 3 months (CT+). For 76% (n = 229) of CT+ patients unplanned hospital admissions were made in these last 3 months, compared to 44% (n = 133) of CT- patients (p < .001). Visits to the emergency room in last 3 months were made by 67% (n = 202) of CT+ patients compared to 43% (n = 132) of CT- patients (p < .001). Healthcare consumption was significantly higher in patients who received chemotherapy in the last 3 months of life. Being able to inform our patients about these aspects of treatment can help to optimise both the quality of life and the quality of dying in patients with cancer.

Multidisciplinary decision-making regarding chemotherapy for lung cancer patients-An age-based comparison

Optimising decision-making in elderly patients is becoming increasingly urgent. We analysed treatment decisions and course of therapy for patients with lung cancer in different age categories: <65, 65-75, and 75 years and older. About 349 patients with lung cancer (median age 67.8 years), discussed at the multidisciplinary team meeting in the Diakonessenhuis Utrecht, the Netherlands, were reviewed. Multidisciplinary decision-making and subsequent clinical course were extracted from medical files. We found that 39% of eligible patients older than 75 years of age started treatment with chemotherapy compared to 80% of the younger patients (<65 and 65-75). When patients did receive chemotherapy, primary and secondary treatment adaptations were effectuated in 58%: for patients aged <65 in 49%, for patients aged 65-75 and >75 years in 66%. For 44% of all patients treated with chemotherapy, unplanned hospital admissions were required: in 42% for the patients <65, in 52% for those aged 65-75 and in 27% for >75 years. The decision-making process and course of treatment for lung cancer vary per age category. In particular, patients between 65 and 75 years of age might be more frail than initially thought. Age and frailty are important characteristics that need more attention.

Lung Cancer in the Oldest Old: A Nation-Wide Study in The Netherlands

INTRODUCTION

An important step in improving research and care for the oldest patients with lung cancer is analyzing current data regarding diagnostic work-up, treatment choices, and survival.

METHODS

We analyzed data on lung cancer from the Netherlands Cancer Registry (NCR-IKNL) regarding diagnostic work-up, treatment, and survival in different age categories; the oldest old (≥85 years of age) versus those aged 71-84 (elderly) and those aged ≤70 years (younger patients).

RESULTS

47,951 patients were included in the 2010-2014 NCR database. 2196 (5%) patients were aged ≥85 years. Histological diagnosis was obtained significantly less often in the oldest old (38%, p < 0.001), and less standard treatment regimen was given (8%, p < 0.001) compared to elderly and younger patients. 67% of the oldest old received best supportive care only versus 38% of the elderly and 20% of the younger patients (p < 0.001). For the oldest old receiving standard treatment, survival rates were similar in comparison with the elderly patients. In the oldest old, no survival differences were found when comparing standard or adjusted regimens for stage I and IV NSCLC; for stage III, oldest old receiving standard treatment had longer survival. No oldest old patients with stage II received standard treatment.

CONCLUSION

Clinicians make limited use of diagnostics and invasive treatment in the oldest old; however, selected oldest old patients experienced similar survival rates as the elderly when receiving some form of anticancer therapy (standard or adjusted). More research is needed to further develop individualized treatment algorithms.