Systematic review of caregiver responses for patient health-related quality of life in adult cancer care

Benefits, Harms, and Stakeholder Perspectives Regarding Opioid Therapy for Pain in Individuals With Metastatic Cancer: Protocol for a Descriptive Cohort Study

BACKGROUND

Opioids are a key component of pain management among patients with metastatic cancer pain. However, the evidence base available to guide opioid-related decision-making in individuals with advanced cancer is limited. Patients with advanced cancer or cancer that is unlikely to be cured frequently experience pain. Opioids are a key component of pain management among patients with metastatic cancer pain. Many individuals with advanced cancer are now living long enough to experience opioid-related harm. Emerging evidence from chronic noncancer pain literature suggests that longer-term opioid therapy may have limited benefits for pain and function, and opioid-related harms are also a major concern. However, whether these benefits and harms of opioids apply to patients with cancer-related pain is unknown.

OBJECTIVE

This manuscript outlines the protocol for the "Opioid Therapy for Pain in Individuals With Metastatic Cancer: The Benefits, Harms, and Stakeholder Perspectives (BEST) Study." The study aims to better understand opioid decision-making in patients with advanced cancer, along with opioid benefits and harms, through prospective examination of patients' pain experiences and opioid side effects and understanding the decision-making by patients, care partners, and clinicians.

METHODS

This is a multicenter, prospective cohort study that aims to enroll 630 patients with advanced cancer, 20 care partners, and 20 clinicians (670 total participants). Patient participants must have an advanced solid cancer diagnosis, defined by the American Cancer Society as cancer that is unlikely to be cured. We will recruit patient participants within 12 weeks after diagnosis so that we can understand opioid benefits, harms, and perspectives on opioid decision-making throughout the course of their advanced cancer (up to 2 years). We will also specifically elicit information regarding long-term opioid use (ie, opioids for ≥90 consecutive days) and exclude patients on long-term opioid therapy before an advanced cancer diagnosis. Lived-experience perspectives related to opioid use in those with advanced cancer will be captured by qualitative interviews with a subset of patients, clinicians, and care partners. Our data collection will be grounded in a behavioral decision research approach that will allow us to develop future interventions to inform opioid-related decision-making for patients with metastatic cancer.

RESULTS

Data collection began in October 2022 and is anticipated to end by November 2024.

CONCLUSIONS

Upon successful execution of our study protocol, we anticipate the development of a comprehensive evidence base on opioid therapy in individuals with advanced cancer guided by the behavioral decision research framework. The information gained from this study will be used to guide interventions to facilitate opioid decisions among patients, clinicians, and care partners. Given the limited evidence base about opioid therapy in people with cancer, we envision this study will have significant real-world implications for cancer-related pain management and opioid-related clinical decision-making.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/54953.

Minimal Clinically Important Difference of Scales Reported in Stroke Trials: A Review

There is a growing awareness of the significance of using minimum clinically important differences (MCIDs) in stroke research. An MCID is the smallest change in an outcome measure that is considered clinically meaningful. This review is the first to provide a comprehensive summary of various scales and patient-reported outcome measures (PROMs) used in stroke research and their MCID values reported in the literature, including a concise overview of the concept of and methods for determining MCIDs in stroke research. Despite the controversies and limitations surrounding the estimation of MCIDs, their importance in modern clinical trials cannot be overstated. Anchor-based and distribution-based methods are recommended for estimating MCIDs, with patient self-evaluation being a crucial component in capturing the patient's perspective on their health. A combination of methods can provide a more comprehensive understanding of the clinical relevance of treatment effects, and incorporating the patient's perspective can enhance the care of stroke patients.

Cancer symptoms: do patients, family caregivers and professionals agree?

OBJECTIVES

To assess the level of agreement among patients, their family caregivers and health professionals regarding the symptoms presented by patients with cancer.

METHODS

This is a cross-sectional study carried out in patients with cancer admitted to a hospital in Brazil from December 2019 to July 2020. One family caregiver for each patient was included in the study. In addition, nurses and physicians involved in patient care were included. Patients, family caregivers and health professionals responded to the Palliative Outcome Scale (POS).

RESULTS

Sixty-one patients with their family caregivers, 18 nurses and 8 physicians were included. Physicians reported a lower mean POS score than patients (p=0.008). In general, physicians and nurses underestimated the anxiety of the patient and the anxiety of the family caregivers and how much the patient feels that his or her life is worthwhile. Intraclass correlation coefficient showed moderate and good levels of agreement between patients' and family caregivers' responses (0.61). Agreement between patient and nurse (0.02) and physician (0.21) responses was poor.

CONCLUSIONS

The level of agreement between patients and healthcare professionals was very poor regarding patients' symptoms. However, the caregiver's perception of the patient's symptoms can be a reliable source of information.

Measuring the reliability of proxy respondents in behavioural assessments: an open question

BACKGROUND

In behavioural assessment, information can be gathered from internally referenced self-reports or from proxy informants.

AIMS

This study aimed to fine-tune a brief but reliable method for evaluating the proxy accuracy in cases where responses obtained from adult and older adults' patient cannot be considered reliable.

METHODS

We generated a set of items reflecting both overt and covert behaviours related to the basic instrumental activities of daily living. The psychometric properties of the content, factorial, and criterium validity of these items were then checked. The Proxy Reliability Questionnaire-ProRe was created. We tested the frequency of "I don't know" responses as a measure of proxy reliability in a sample of healthy older adults and their proxies, and in a second sample of proxy respondents who answered questions about their parents.

RESULTS

As expected, response precision was lower for items characterizing covert behaviours; items about covert compared to overt behaviours generated more "I don't know" answers. Proxies provided less "I don't know" responses when evaluating the parent, they claimed they knew better. Moreover, we tried to validate our approach using response confidence. Encouragingly, these results also showed differences in the expected direction in confidence between overt and covert behaviours.

CONCLUSIONS

The present study encourages clinicians/researchers to how well the proxy the patient know each other, the tendency of proxies to exhibit, for example, response bias when responding to questions about patients' covert behaviours, and more importantly, the reliability of informants in providing a clinical assessment of neurocognitive diseases associated with aging.

Risk factors associated with the comprehensive needs of cancer caregivers in China

BACKGROUND

Cancer incidence and mortality rates have been rising in developing countries, especially in Asia. Cancer caregivers face unique challenges which put them at risk for burden, poor quality of life, and burnout. The purpose of this study was to investigate the comprehensive needs and associated factors of cancer caregivers, and explore the correlation with cancer patients.

METHODS

In Mainland China, 200 cancer patient-caregiver dyads were chosen and interviewed for a cross-sectional questionnaire survey by convenient sampling method. Cancer caregivers' comprehensive needs were assessed with Comprehensive Needs Assessment Tool in cancer for Caregivers(CNAT-C), including seven domains (health and psychological problems, family and social support, healthcare staffs, information, religious/spiritual support, hospital facilities and services, and practical support). The comprehensive needs assessment tool in cancer for patients (CNAT) was used to assess patients' comprehensive needs. The sociodemographic survey was completed by both cancer patients and caregivers. The mean differences in domain scores for different groups of characteristics were compared by one-way ANOVA or non-parametric analyses, and those factors that had significant differences were selected for the multivariate regression analysis to determine the final influencing factors. The correlation between cancer patients' and caregivers' needs was evaluated by Spearman's correlation analysis.

RESULTS

The cancer caregivers' need for healthcare staff (82.60±19.56) was the highest among the seven domains, followed by the need for information (72.17±14.61) and the need for hospital facilities and services (56.44±18.22). The lowest score was the need for religious/spiritual support (28.33±16.05). Caregivers who were younger, highly educated, with high household income, and less than 1 year since diagnosis had higher scores of CNAT-C. Also sociodemographic characteristics were associated with each domain of cancer caregivers' need. Correlations between patients' and caregivers' comprehensive needs were low to moderate (0.013~0.469).

CONCLUSION

Cancer caregivers experience high levels of comprehensive needs, which are closely related to their sociological characteristics. The tailored interventions and mobilization of social and health care support may thus provide multiple levels of benefit across cancer trajectories. The patient-caregiver dyad should be regarded as a unit for treatment in cancer care.

Feasibility, use and benefits of patient-reported outcome measures in palliative care units: a multicentre observational study

BACKGROUND

Research has shown that routinely assessed, patient-reported outcome measures (PROMs) have positive effects in patients with advanced oncologic diseases. However, the transferability of these results to specialist palliative care is uncertain because patients are more impaired and staff doubt the feasibility and benefits. The aim of this study is to evaluate the feasibility of patient self-assessment of PROMs, their use by staff and the benefits in palliative care wards.

METHOD

A multicentre observational study was conducted in the context of the implementation of the Integrated Patient Outcome Scale (IPOS) in three specialist palliative care wards at university hospitals in Germany. All admitted patients who screened positive regarding their ability to complete questionnaires were asked to participate and complete the IPOS on paper weekly, with assistance if necessary. Feasibility of questionnaire completion (e.g. proportion of patients able to complete them), use (e.g. involvement of different professional groups) and benefit (e.g. unexpected information in IPOS as rated by treating physicians) were assessed. Staff members' opinion was obtained in a written, anonymous evaluation survey, patients' opinion in a short written evaluation.

RESULTS

A total of 557 patients were screened for eligibility, 235 were assessed as able to complete the IPOS (42.2%) and 137 participated in the study (24.6%). A majority needed support in completing the IPOS; 40 staff members and 73 patients completed the evaluation. Unexpected information was marked by physicians in 95 of the 137 patient questionnaires (69.3%). The staff differed in their opinions on the question of whether this also improved treatment. A majority of 32 staff members (80.0%) were in favour of continuing the use of IPOS (4 against continuation, 4 no answer); 43 (58.9%) patients rated their overall experience of IPOS use as 'positive', 29 (39.7%) as 'neutral' and 1 (1.4%) as 'negative'.

CONCLUSIONS

While most staff wished to continue using IPOS, it was a challenge to integrate the effort to support the completion of IPOS into daily practice. Digital implementation was not successful, despite various attempts. To explore the effects on care and patient outcomes, multicentre cluster-randomised trials could be employed.

TRIAL REGISTRATION

German Clinical Trials Register DRKS-ID: DRKS00016681 (24/04/2019).

The potential impact of proxy reports for symptom experience and care quality and experience in advanced cancer

OBJECTIVES

As the US tests models of care for the seriously ill, patient perceptions of the quality of care are important. Proxies are often needed for this group. We sought to understand the potential impact of proxy reports for the assessment of care quality and experience in cancer.

METHODS

Secondary data analysis of a deidentified prospective study that included surveys of perceived care quality, including symptom management, from patients with advanced cancer receiving chemotherapy and their caregivers. Surveys were administered at diagnosis (time 1) and treatment (time 2), with top-box scoring used for analysis. Overall concordance was assessed using metrics including Gwet's AC1. The proportion of the highest scores by respondent type within 2 subgroups were examined: (1) symptom burden and (2) practice setting.

RESULTS

Data from 83 dyads were analyzed. Proxies and patients frequently reported the highest scores for quality (time 1: proxies: 77% and patients: 80%). At time 1, 14% of proxies and 10% of patients reported an unmet need for symptom palliation. Most patients reporting an unmet need gave the top score for quality (75%), but fewer proxies did so (45%). Proxy and patient reports were similar within practice settings. Concordance was at least moderate (nearly all outcomes >0.5 and some >0.8) by Gwet's AC1.

SIGNIFICANCE OF RESULTS

Findings of at least moderate concordance and similar experience outcomes within subgroups suggest the use of proxies may not change estimates substantially. However, consideration should be taken when evaluating symptom management, particularly if such evaluations inform assessment of provider performance.

Symptom Agreement Between Patients and Their Peer Caregivers in Prison

Peer caregivers are incarcerated people who provide adjunct, nonclinical support to other incarcerated people. We described patient-caregiver symptom agreement in prison and correlates of symptom agreement to explore peer caregivers' ability to understand their patients' experience. We found dyads were aligned closely (N = 52; k = .86; αbinary = .86), though patients and peer caregivers often reported no symptoms during the assessment period. Peer caregivers were capable of matching their patients' self-reported symptoms beyond chance alone, though few correlates of patient-caregiver symptom agreement in prison emerged. The role of reverence and social homophily are discussed as potential drivers of symptom agreement. Future examination of caregiver burden or measures that account for both patient and caregiver characteristics are encouraged.

Patient reported outcomes in oncology: changing perspectives-a systematic review

In public health context, oncology is associated with severe negative impact on patients and on their relatives’ quality of life. Over the last decades, survival has remained at 50% worldwide for some tumor locations. Patient reported outcomes (PROs) assessment and, the corresponding use in clinical practice, help establishing patient individualized profiling involving caregivers. The purpose of this systematic review was to examine critical success factors for PROs assessment in daily clinical oncology practice. Additionally, we investigated how PROs collection can change oncology perspectives for patients and caregivers. According to PRISMA guidelines, 83 studies were included in this systematic review, whether related with implementation in daily clinical practice or associated with its use in oncology. PROs assessment gathers multi-professional teams, biomedical and clinical expertise, patients, families and caregivers. Institutional involvement, first line for caregiver’s adherence, team continuous formation, encompassing training and support, design of clear workflows, continuous monitoring, and data analysis are crucial for implementation. PROs measures are decisive in oncology. Several items were improved, including caregiver–patient–physician communication, patient risk groups identification, unmet problems and needs detection, disease course and treatment tracking, prognostic markers, cost-effectiveness measurement and comfort/support provision for both patients and caregivers. Routine assessment and implementation of PROs in clinical practice are a major challenge and a paradigm transformation for future.

The use of proxies and proxy-reported measures: a report of the international society for quality of life research (ISOQOL) proxy task force

AIMS

Proxy reports are often used when patients are unable to self-report. It is unclear how proxy measures are currently in use in adult health care and research settings. We aimed to describe how proxy reports are used in these settings, including the use of measures developed specifically for proxy reporting in adult health populations.

METHODS

We systematically searched Medline, PsycINFO, PsycTESTS, CINAHL and EMBASE from database inception to February 2018. Search terms included a combination of terms for quality of life and health outcomes, proxy-reporters, and health condition terms. The data extracted included clinical context, the name of the proxy measure(s) used and other descriptive data. We determined whether the measures were developed specifically for proxy use or were existing measures adapted for proxy use.

RESULTS

The database search identified 17,677 possible articles, from which 14,098 abstracts were reviewed. Of these, 11,763 were excluded and 2335 articles were reviewed in full, with 880 included for data extraction. The most common clinical settings were dementia (30%), geriatrics (15%) and cancer (13%). A majority of articles (51%) were paired studies with proxy and patient responses for the same person on the same measure. Most paired studies (77%) were concordance studies comparing patient and proxy responses on these measures.

DISCUSSION

Most published research using proxies has focused on proxy-patient concordance. Relatively few measures used in research with proxies were specifically developed for proxy use. Future work is needed to examine the performance of measures specifically developed for proxies.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO No. CRD42018103179.

How is quality of life defined and assessed in published research?

PURPOSE

To ensure clarity in communication in the field of quality of life research, and meaningful use of 'quality of life' as a research outcome, requires two things: awareness that there is a range of conceptualisations and definitions of 'quality of life', and for any particular study, consistency between the way the term is defined and operationalised in that setting. We aimed to identify how frequently research articles described (HR)QOL as a construct of interest, how frequently they referred to "patient-reported outcome (measures)", which patient-reported outcome measures were used, and how (HR)QOL was defined.

METHODS

We reviewed all Quality of Life Research articles published in 2017 and recorded whether they described health-related quality of life or quality of life as constructs of interest, and/or mentioned the term(s) patient-reported outcome (measures). We recorded definitions of (HR)QOL stated and questionnaires used. We classified articles according to constructs assessed and instruments used, and examined whether articles citing the same definition used the same questionnaires.

RESULTS

We reviewed 300 articles; 65% stated that (HR)QOL was a construct of interest, 27% mentioned patient-reported outcome (measures), and 20% mentioned neither. Fifty-one articles provided definitions of (HR)QOL, citing 66 sources, with 11 definitions cited more than once. PROMIS, SF, EQ-5D, and EORTC instruments were the most commonly used. The only definition and questionnaire consistently used together were the WHO definitions/instruments.

CONCLUSION

These results demonstrate considerable heterogeneity in the definition and operationalisation of (HR)QOL, between and within studies. This limits meaningful interpretation of (HR)QOL scores and complicates literature searches. Investigators should define constructs and select instruments aligned with their definitions.

Assessing the proxy response bias of EQ-5D-3 L in general population: a study based on a large-scale representative household health survey using propensity score matching

Background

Proxy respondent-someone who assists the intended respondent or responds on their behalf-are widely applied in the measurement of health-related quality of life (HRQL). However, proxies may not provide the same responses as the intended respondents, which may bias the findings.

Objectives

To determine whether the use of proxies is related to socio-demographic characteristics of the intended respondent, and to assess the possible proxy response bias of Chinese version of EQ-5D-3 L in general population.

Methods

A cross-sectional study based on a provincially representative sample from 2013 National Health Service Survey (NHSS) in Shaanxi, China was performed. HRQL was measured by Chinese version of EQ-5D-3 L. Propensity score matching (PSM) was used to get matched pairs of self-reports and proxy-reports. Before and after PSM, univariate logistic and linear models including the indicator of proxy response as the only independent variable, were employed to assess the possible proxy response bias of the dimensional and overall health status of EQ-5D-3 L respectively.

Results

19.9% of the responses involved a proxy. Before PSM, the proxy-report group was younger in age and reported less unhealthy lifestyle, lower prevalence of disease, and less hospitalization than the self-report group. After PSM, it showed that the proxy-report group was statistically more likely to report health problem on each dimension of EQ-5D-3 L, with odds ratios larger than one comparing with self-report group. The means of EQ-5D-3 L index and EQ VAS of proxy-report group were 0.022 and 0.834 lower than self-report group.

Conclusions

Significantly negative proxy response bias was found in Chinese EQ-5D-3 L in general population, and the magnitude of the bias was larger in physical dimensions than psychological dimensions after using PSM to control confounders.

Comparison of Patient and Proxy Assessment of Patient-Centeredness in the Care of Coronary Heart Disease: A Cross Sectional Survey Using the PACIC-S11.1

INTRODUCTION

When making medical care more patient-centered, surveys on patients' and their relatives' experiences can be helpful in identifying opportunities for improvement. In cases where the targeted patients are unable to express their own perspective, for example, due to them being too young or suffering from severe impairments, proxies can serve as substitutes. Proxies are frequently used in care planning and consent. Nevertheless, it is unclear whether patients' assessments of how patient-centered their medical care is are similar to those of their proxies. This study aims to assess the level of consistency between patients' and their proxies' assessments using an adapted version of the Patient Assessment of Chronic Illness Care (PACIC) short form questionnaire.

METHODS

In a cross-sectional study, patients with coronary heart disease were recruited at cardiologists' offices, rehabilitation clinics and hospitals. Participants were surveyed with regard to the perceived level of patient-centeredness during their care using an adapted version of the German PACIC short form (PACIC-S11.1). Correlations in the assessments made by each patient and their respective proxy were analyzed. On the level of the patients group and the relatives group differences between mean ratings for each item were compared using paired t-tests.

RESULTS

In total, 74 pairs of patients and proxies submitted the completed questionnaire. On the level of the individual patient/proxy pairs, no correlation, or significant but low correlation, was found between the ratings. On the group level, patients' and their proxies' item ratings were similar in the interpretation of averages, but still demonstrated statistically significant differences. Overall, patients rated their care as more patient-centered than their proxies did.

CONCLUSION

The study shows that, on the individual level, proxies' ratings do not necessarily reflect the patients' assessment of PCC. On the group level, the assessments of relatives regarding PCC are similar to those of the patients.

TRIAL REGISTRATION

German clinical trials register (Deutsches Register Klinischer Studien, DRKS) Registration Number: DRKS00012434 (URL: https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00012434).

Concordance of Patient and Caregiver Reports on the Quality of Colorectal Cancer Care

PURPOSE

We aimed to better understand how similarly patients with colorectal cancer and caregivers view care quality and to assess factors that may influence concordance.

MATERIALS AND METHODS

We conducted a secondary analysis of paired patient and caregiver quality ratings of colorectal cancer care in three specific domains: surgery, chemotherapy overall, and chemotherapy nursing. Agreement was assessed with difference scores, concordance with Gwet second-order agreement statistics (AC2), and variation in agreement with stratified analyses. We examined whether the care experiences of patients and caregivers were associated with top-box (most-positive) ratings and examined variations in concordance on the basis of the presence of a top-box score.

RESULTS

Four hundred seventeen patient-caregiver dyads completed the surveys. Quality-of-care ratings were positively skewed, with most dyads indicating top-box ratings. Patient and caregiver care experiences were highly associated with top-box ratings. Overall patient-caregiver concordance was very high for all three care domains (surgery: AC2, 0.87 [95% CI, 0.83 to 0.90]; chemotherapy overall: AC2, 0.84 [95% CI, 0.79 to 0.88]; chemotherapy nursing: AC2, 0.91 [95% CI, 0.87 to 0.94]). Stratified analyses of patient and caregiver characteristics did not identify any patterns that consistently affected concordance. The concordance statistic significantly decreased for all three outcomes (P < .001), however, when the patient or caregiver assessed quality as anything other than top box.

CONCLUSION

Caregiver and patient reports on care quality were highly concordant for top-box care and did not vary with patient or caregiver factors. Additional exploration is needed to identify reasons for increased variability when the quality scores were less than a top-box response.

A brief, patient- and proxy-reported outcome measure in advanced illness: Validity, reliability and responsiveness of the Integrated Palliative care Outcome Scale (IPOS)

BACKGROUND

Few measures capture the complex symptoms and concerns of those receiving palliative care.

AIM

To validate the Integrated Palliative care Outcome Scale, a measure underpinned by extensive psychometric development, by evaluating its validity, reliability and responsiveness to change.

DESIGN

Concurrent, cross-cultural validation study of the Integrated Palliative care Outcome Scale - both (1) patient self-report and (2) staff proxy-report versions. We tested construct validity (factor analysis, known-group comparisons, and correlational analysis), reliability (internal consistency, agreement, and test-retest reliability), and responsiveness (through longitudinal evaluation of change).

SETTING/PARTICIPANTS

In all, 376 adults receiving palliative care, and 161 clinicians, from a range of settings in the United Kingdom and Germany.

RESULTS

We confirm a three-factor structure (Physical Symptoms, Emotional Symptoms and Communication/Practical Issues). Integrated Palliative care Outcome Scale shows strong ability to distinguish between clinically relevant groups; total Integrated Palliative care Outcome Scale and Integrated Palliative care Outcome Scale subscale scores were higher - reflecting more problems - in those patients with 'unstable' or 'deteriorating' versus 'stable' Phase of Illness (F = 15.1, p < 0.001). Good convergent and discriminant validity to hypothesised items and subscales of the Edmonton Symptom Assessment System and Functional Assessment of Cancer Therapy-General is demonstrated. The Integrated Palliative care Outcome Scale shows good internal consistency (α = 0.77) and acceptable to good test-retest reliability (60% of items k_w > 0.60). Longitudinal validity in form of responsiveness to change is good.

CONCLUSION

The Integrated Palliative care Outcome Scale is a valid and reliable outcome measure, both in patient self-report and staff proxy-report versions. It can assess and monitor symptoms and concerns in advanced illness, determine the impact of healthcare interventions, and demonstrate quality of care. This represents a major step forward internationally for palliative care outcome measurement.

Moving from clinician-defined to patient-reported outcome measures for survivors of high-grade glioma

BACKGROUND

Persons with high-grade glioma face both neurological and cancer-related symptoms from the tumor itself and its treatment affecting their daily lives. Survival alone is not an adequate outcome, the quality of the survivorship experience needs to be regarded with equal importance. Patient-reported outcome (PRO) measures can be used to evaluate treatment effects and symptom management interventions.

PURPOSE

The aim of this review was to identify the use, challenges, and potential of PRO measures in survivors of high-grade glioma.

METHODS

A narrative expert opinion review was performed on the subject. In addition to our own experiences we searched PubMed, Cumulative Index to Nursing and Allied Health Literature, the Cochrane Library, and PsycINFO for brain tumor-specific PRO measures used in the population of adult patients with high-grade glioma, both original articles and reviews were included.

RESULTS

There are several PRO measures that have been validated for patients with primary brain tumors including high-grade glioma. PRO measures are used both in clinical trials to evaluate the effect of treatment on health-related quality of life, and in daily clinical practice for holistic needs assessment and symptom management. Common PRO measures used for patients with high-grade glioma are European Organization for Research and Treatment of Cancer general instrument for patients with cancer together with brain tumor module, Functional Assessment of Cancer Therapy-Brain, and MD Anderson Symptom Inventory for Brain Tumor. Neurologic and cognitive disorders often occur in patients with high-grade glioma, which affects patients' ability to self-report over time, making it more challenging in this population. PRO as a primary outcome seems underutilized.

CONCLUSION

For clinical research, PRO measures need to be used together with other clinical outcome measures rather than replacing traditional outcome measures. Moving to more use of PRO measures in survivorship care has potential to improve patient-caregiver-healthcare team communication, symptom management, and quality of care. Implementing PROs in survivorship care should also involve caregivers and a response based on the results.

Geriatric Oncology, Spirituality, and Palliative Care

Cancer is a major cause of morbidity and mortality for older individuals. Palliative care is essential to improve the outcome of cancer treatment in terms of quality of life and treatment satisfaction. This review examines the influence of spirituality on aging in general and on the management of older cancer patients. A spiritual perspective has been associated with successful aging, and with better tolerance of physical and emotional stress, including the ability to cope with serious diseases and with isolation. It has also been associated with decreased risk of suicide and depression. Gerotranscendence, the more urgent search for meaning by older than younger individuals, confirms the importance of spirituality in this phase of life. Spirituality has also improved the quality of life and reduced the risk of disease and death for the patient's caregiver. Addressing patient and caregiver spirituality may render the palliative care of cancer more effective and may also aid in detection and management of spiritual pain, which may prevent healing at the end of life.

Patient-Reported Outcomes with Chimeric Antigen Receptor T Cell Therapy: Challenges and Opportunities

Patient-reported outcomes (PROs) are an important tool to assess the impact of a new therapy on symptom burden and health-related quality of life (HRQoL). Chimeric antigen receptor T (CAR-T) cell therapies have been approved for use in relapsed or refractory leukemia and lymphoma based on promising efficacy in clinical trials. However, data are lacking on patient-reported toxicity and impact on HRQoL. This review provides an overview of the incorporation of PROs in CAR-T cell therapy and the specific challenges in this context. The first step is to demonstrate feasibility of PRO monitoring in the acute phase after CAR-T cell infusion. Apart from core PRO domains like physical functioning, disease-related symptoms, and symptomatic adverse effects, important measures to consider are cognitive functioning and financial toxicity. Because there are no validated PRO instruments in the setting of CAR-T cell therapy, universally validated measures like Patient-Reported Outcomes Measurement Information System (PROMIS) could be considered, which is also recommended in the setting of hematopoietic stem cell transplantation. Given the timeline of toxicities with CAR-T cell therapy, PRO instruments should be administered at baseline and at least weekly in the first 30 days. Subsequently, frequent monitoring of PROs in the first year might be helpful in identifying short- and intermediate-term toxicities, functional limitations, and neuropsychiatric effects. The major potential challenge in acute phase would be missing data when patients develop severe cytokine release syndrome or neurotoxicity. Designing a strategy for handling missing data is crucial. The long-term safety of CAR-T cell therapy is not well characterized because of short follow-up in most studies reported thus far. PROs should be measured at least yearly after the first year to identify potential late effects like cognitive deficit or autoimmune manifestations. Collaboration between institutions performing cellular therapy and engagement with patients, clinicians, and statisticians with expertise in PROs are crucial for setting a comprehensive agenda on integration of PROs with CAR-T cell therapy.

The Association of Proxy Care Engagement with Proxy Reports of Patient Experience and Quality of Life

OBJECTIVE

To assess the association of proxy-specific covariates with proxy-reported patient cancer care experience, quality rating, and quality of life.

DATA SOURCES/STUDY SETTING

Secondary analysis of data from the Cancer Care Outcomes Research and Surveillance (CanCORS) study.

STUDY DESIGN

Cross-sectional observational study. The respondents were proxies for patients with incident colorectal or lung cancer.

DATA COLLECTION/EXTRACTION METHODS

Analyses used linear regression models and adjusted for patient sociodemographic and clinical characteristics. Outcomes included patients' experiences with medical care, nursing care, and care coordination, overall quality ratings, and physical and mental health, all scored on 0-100 scales (0 = worst, 100 = best). Independent variables included the proxy's relationship with the patient and engagement in patient care.

PRINCIPAL FINDINGS

Of 1,011 proxies, most were the patient's spouse (50 percent) or child (36 percent). Although most proxies (66 percent) always attended medical visits, 3 percent reported never attending. After adjustment, on average children reported worse experiences and poorer quality care than spouses (4-9 points lower across outcomes). Proxies who never attended medical visits reported significantly worse medical care (-11 points, 95 percent CI = -18 to -3) and care coordination (-13 points, 95 percent CI = -20 to -6).

CONCLUSIONS

Collecting data on proxy engagement in care is warranted if proxy responses are used.

Proxy and patient reports of health-related quality of life in a national cancer survey

Background

Proxy respondents are frequently used in surveys, including those assessing health-related quality of life (HRQOL). In cancer, most research involving proxies has been undertaken with paired proxy-patient populations, where proxy responses are compared to patient responses for the same individual. In these populations, proxy-patient differences are small and suggest proxy underestimation of patient HRQOL. In practice, however, proxy responses will only be used when patient responses are not available. The difference between proxy and patient reports of patient HRQOL where patients are not able to report for themselves in cancer is not known. The objective of this study was to evaluate the difference between patient and proxy reports of patient HRQOL in a large national cancer survey, and determine if this difference could be mitigated by adjusting for clinical and sociodemographic information about patients.

Methods

Data were from the Cancer Care Outcomes Research and Surveillance (CanCORS) study. Patients or their proxies were recruited within 3–6 months of diagnosis with lung or colorectal cancer. HRQOL was measured using the SF-12 mental and physical composite scales. Differences of ½ SD (=5 points) were considered clinically significant. The primary independent variable was proxy status. Linear regression models were used to adjust for patient sociodemographic and clinical covariates, including cancer stage, patient age and education, and patient co-morbidities.

Results

Of 6471 respondents, 1011 (16%) were proxies. Before adjustment, average proxy-reported scores were lower for both physical (−6.7 points, 95% CI -7.4 to −5.9) and mental (−6 points, 95% CI -6.7 to −5.2) health. Proxy-reported scores remained lower after adjustment (physical: −5.8 points, −6.6 to −5; mental: −5.8 points, −6.6 to 5). Proxy-patient score differences remained clinically and statistically significant, even after adjustment for sociodemographic and clinical variables.

Conclusions

Proxy-reported outcome scores for both physical and mental health were clinically and significantly lower than patient-reported scores for these outcomes. The size of the proxy-patient score differences was not affected by the health domain, and adjustment for sociodemographic and clinical variables had minimal impact.

The clinical value of Coop/Wonca charts in assessment of HRQoL in a large cohort of relapsing-remitting multiple sclerosis patients: Results of a multicenter study

BACKGROUND

Multiple sclerosis (MS) is a chronic neurological disease impacting patients' health-related quality of life (HRQoL). Since MS specific HRQoL questionnaire are often time consuming; thus, simple, feasible and ease administering instruments are needed to assess MS HRQoL in clinical practice and clinical trials. Hence, aim of our study was to investigated the HRQoL in a large cohort of MS patients using the Coop/Wonca charts.

METHODS

This was multicenter, independent, non-sponsored, observational study, including patients from 40 Italian MS centers. Inclusion criteria were Expanded Disability Status Scale score between 1.0 and 5.5; stable disease at enrolment. HRQoL was assessed, using six Coop/Wonca charts for physical fitness, feelings, daily activities, social activities, changes in health, health condition, and the Composites Scores of Multiple Sclerosis Quality of Life-54 (MSQoL-54), physical health composite summary (PHCS) and the mental health composite summary (MHCS).

RESULTS

Out of 648, 593 relapsing-remitting MS patients, 415 (70%) women, mean age years, 417 (70%) were finally enrolled. We found a inter-rater agreement of 0.8, ranging from 0.64 to 0.91, as expressed by the alpha coefficient. Intra-rater agreement was 0.82, ranging from 0.78 to 0.96. Coop/Wonca charts were scored with a Likert method from one to five (corresponding to best and worst HRQoL respectively). According to this scoring, study population was stratified into three categories (score 1-2 corresponding to better HRQoL; score 3 corresponding to neutral profile; score 4-5 corresponding to worse HRQoL). Coop/Wonca charts resulted significantly correlated with PHCS and with MHCS.