Health-related quality of life in cancer immunotherapy: a systematic perspective, using causal loop diagrams

Using system dynamics modeling approach to strengthen health systems to combat cancer: a systematic literature review

AIM

Dynamic cancer control is a current health system priority, yet methods for achieving it are lacking. This study aims to review the application of system dynamics modeling (SDM) on cancer control and evaluate the research quality.

METHODS

Articles were searched in PubMed, Web of Science, and Scopus from the inception of the study to 15 November 2023. Inclusion criteria were English original studies focusing on cancer control with SDM methodology, including prevention, early detection, diagnosis and treatment, and palliative care. Exclusion criteria were non-original research, and studies lacking SDM focus. Analysis involved categorization of studies and extraction of relevant data to answer the research question, ensuring a comprehensive synthesis of the field. Quality assessment was used to evaluate the SDM for cancer control.

RESULTS

Sixteen studies were included in this systematic review predominantly from the United States (7, 43.75%), with a focus on breast cancer research (5, 31.25%). Studies were categorized by WHO cancer control modules, and some studies may contribute to multiple modules. The results showed that included studies comprised two focused on prevention (1.25%), ten on early detection (62.50%), six on diagnosis and treatment (37.50%), with none addressing palliative care. Seven studies presented a complete SDM process, among which nine developed causal loop diagrams for conceptual models, ten utilized stock-flow charts to develop computational models, and thirteen conducted simulations.

LIMITATIONS

This review's macrofocus on SDM in cancer control missed detailed methodological analysis. The limited number of studies and lack of stage-specific intervention comparisons limit comprehensiveness. Detailed analysis of SDM construction was also not conducted, potentially overlooking nuances in cancer control strategies.

CONCLUSION

SDM in cancer control is underutilized, focusing mainly on early detection and treatment. Inconsistencies suggest a need for standardized SDM approaches. Future research should expand SDM's application and integrate it into cancer control strategies.

Immuno-related cardio-vascular adverse events associated with immuno-oncological treatments: an under-estimated threat for cancer patients

Immunotherapy represents an emergent and heterogeneous group of anticancer treatments harnessing the human immune-surveillance system, including immune-checkpoint inhibitor monoclonal antibodies (mAbs), Chimeric Antigen Receptor T Cells (CAR-T) therapy, cancer vaccines and lymphocyte activation gene-3 (LAG-3) therapy. While remarkably effective against several malignancies, these therapies, often in combination with other cancer treatments, have showed unforeseen toxicity, including cardiovascular complications. The occurrence of immuno-mediated adverse (irAEs) events has been progressively reported in the last 10 years. These irAEs present an extended range of severity, from self-limiting to life-threatening conditions. Although recent guidelines in CardioOncology have provided important evidence in managing cancer treatments, they often encompass general approaches. However, a specific focus is required due to the particular etiology, unique risk factors, and associated side effects of immunotherapy. This review aims to deepen the understanding of the prevalence and nature of cardiovascular issues in patients undergoing immunotherapy, offering insights into strategies for risk stratification and management.

Effects of Immunotherapy on Quality-of-Life Outcomes in Patients with Gastroesophageal Cancers: A Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Immune checkpoint inhibitors (ICIs) have revolutionized cancer care, with increasing data demonstrating improved survival outcomes using ICIs among patients with advanced gastroesophageal cancer (GEC). ICIs are also associated with a lower incidence of grade ≥ 3 adverse events (AEs) compared to chemotherapy, suggesting that ICIs may have favorable effects on health-related quality of life (HRQoL). This meta-analysis sought to evaluate the effects of ICIs on the HRQoL of patients with advanced GEC.

METHODS

We conducted an online bibliographic search on Medline via PubMed using MeSH-based terms to retrieve randomized controlled trials (RCTs) that evaluated the effects of ICIs on HRQoL in patients with advanced GEC (we searched for all studies between 2018 and 2021). We included RCTs that incorporated ICIs as part of the intervention arm either as monotherapy (first or second line) or as a combination therapy (first-line) with another ICI or chemotherapy. We combined the HRQoL measures into a meta-analysis using standard random effects models, from which estimates of the average mean difference (MD) were obtained with 95% confidence intervals. We assessed the heterogeneity of the study outcomes using the Q and I2 statistics.

RESULTS

We identified 11 phase 3 RCTs that met the inclusion criteria, with a mean enrollment of 820 patients. Eight RCTs used an ICI plus chemotherapy combination in the intervention arm, three had ICIs as monotherapy, and one had doublet ICI therapy in the intervention arm. All RCTs used chemotherapy for the control arm. Collectively, the trials reported 37 HRQoL measures using five different HRQoL tools. The pooled analysis favored the intervention over the control arm in terms of the Functional Assessment of Cancer Therapy-Esophageal (FACT-E) scores [MD 2.7 (95% CI 0.1 to 5.3), p < 0.041]. In a subgroup analysis of eight RCTs comparing combination therapy with ICIs plus chemotherapy versus chemotherapy alone, the effect estimates favored the ICI arm regarding the FACT-E [MD 2.7 (95% CI 0.1 to 5.3), p < 0.041] and the EORTC QLQ-OES18 pain scale [MD -2.2 (95% CI -4.3 to -0.2), p < 0.030]. Likewise, the effect estimates favored the ICI monotherapy arm over the chemotherapy arm regarding the QLQ-STO22 hair loss subscale [MD -23.2 (95% CI -29.7 to -16.7), p < 0.001], QLQ-STO22 dysphagia subscale [MD 6.7 (95% CI 1.7 to 11.7), p = 0.009], EQ-5D pain scale [MD 6.9 (95% CI 2.9 to 10.9), p < 0.001], and QLQ-OES18 saliva subscale [MD 5.8 (95% CI 0.1 to 11.6), p = 0.046].

CONCLUSIONS

In this meta-analysis, we found that the inclusion of ICIs as a first-line treatment for advanced GEC yielded better HRQoL outcomes than chemotherapy alone. Further research on the impact of ICIs on HRQoL is needed, with increasing evidence that ICIs improve the survival outcomes in patients with advanced GEC.

Health-related quality of life and its influencing factors among lung cancer patients receiving immune checkpoint inhibitors: A cross-sectional study

PURPOSE

The aim of this study was to examine the level of health-related quality of life (HRQOL) of lung cancer patients receiving immune checkpoint inhibitors (ICIs) and analyze its influencing factors.

METHOD

A cross-sectional study was conducted. From April 2022 to March 2023, 560 lung cancer patients receiving ICIs at three medical bases in Guangzhou, China were recruited using a convenient sampling method. A general information questionnaire, the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30), the Social Support Rating Scale (SSRS) and the Medical Coping Modes Questionnaire (MCMQ) were used for collecting data on sociodemographic and clinical characteristics, HRQOL, social support and medical coping mode. A descriptive analysis was conducted to describe HRQOL. Multiple regression analysis was applied to determine the factors influencing HRQOL.

RESULTS

For lung cancer patients receiving ICIs, the mean score of HRQOL was 59.21 ± 19.86. Multivariate analysis indicated that acceptance-resignation coping mode (β = -0.37, P < 0.01), Eastern Cooperative Oncology Group (ECOG) score (β = -0.35, P < 0.01), combination of chemotherapy and/or bevacizumab (β = -0.14, P < 0.01), and subjective support (β = 0.07, P = 0.04) all contributed to 42.7% of the variance in HRQOL of the patients receiving ICIs.

CONCLUSIONS

It is imperative to address and resolve the HRQOL issue for lung cancer patients receiving ICIs. The findings suggest nurse practitioners should be aware of a variety of factors that influence HRQOL and provide tailored inventions to patients as early as possible to help them achieve better HRQOL.

Strengthening a Weak Link: Transparency of Causal Loop Diagrams, Current State and Recommendation

Transparency is a critical aspect of systems science. While transparency of quantitative models has been assessed, transparency of their qualitative structures has been less scrutinized. We assess the transparency of causal loop diagrams (CLDs), a key qualitative visualization tool in system dynamics. We evaluate System Dynamics Review (SDR) publications and a sample of most-cited comparable articles in other journals. We assess the inclusion of a plain language methods statement, overall discernibility of the methods, and identification of causal link sources. Reviewing 72 articles (SDR: 36; other journals: 36), only 44%, 38%, and 25% fully satisfy each criterion, respectively. SDR articles are characterized by higher transparency in the clarity of CLD development method and communication of causal link sources, yet the potential for enhancement is evident. We provide specific recommendations to increase the transparency of CLDs. Transparent reporting benefits original research authors, future expansion of CLDs, and the systems science community.

Associations between treatments, comorbidities and multidimensional aspects of quality of life among patients with advanced cancer in the Netherlands-a 2017-2020 multicentre cross-sectional study

OBJECTIVE

To investigate associations between quality of life (QoL) and 1) immunotherapy and other cancer treatments received three months before QoL measurements, and 2) the comorbidities at the time of completion or in the year prior to QoL measurements, among patients with advanced cancer.

METHODS

A cross-sectional study is conducted on patients with advanced cancer in the Netherlands. The data come from the baseline wave of the 2017-2020 eQuiPe study. Participants were surveyed via questionnaires (including EORTC QLQ-C30). Using multivariable linear and logistic regression models, we explored statistical associations between QoL components and immunotherapy and other cancer treatments as well as pre-existing comorbidities while adjusting for age, sex, socio-economic status.

RESULTS

Of 1088 participants with median age 67 years, 51% were men. Immunotherapy was not associated with global QoL but was associated with reduced appetite loss (odds ratio (OR) = 0.6, 95%CI = [0.3,0.9]). Reduced global QoL was associated with chemotherapy (adjusted mean difference (β) = - 4.7, 95% CI [- 8.5,- 0.8]), back pain (β = - 7.4, 95% CI [- 11.0,- 3.8]), depression (β = - 13.8, 95% CI [- 21.5,- 6.2]), thyroid diseases (β = - 8.9, 95% CI [- 14.0,- 3.8]) and diabetes (β = - 4.5, 95% CI [- 8.9,- 0.5]). Chemotherapy was associated with lower physical (OR = 2.4, 95% CI [1.5,3.9]) and role (OR = 1.8, 95% CI [1.2,2.7]) functioning, and higher pain (OR = 1.9, 95% CI [1.3,2.9]) and fatigue (OR = 1.6, 95% CI [1.1,2.4]).

CONCLUSION

Our study identified associations between specific cancer treatments, lower QoL and more symptoms. Monitoring symptoms may improve QoL of patients with advanced cancer. Producing more evidence from real life data would help physicians in better identifying patients who require additional supportive care.

Investigating the Quality of Life for Cancer Patients and Estimating the Cost of Immunotherapy in Selected Cases

The aim of this study is to assess the quality of life of patients receiving immune checkpoint inhibitors (ICI) by evaluating their physical and psychological well-being as well as their social and spiritual functioning. The 36-item Short Form Health Survey (SF-36) and quality of life core 30 (QLQ-C30) questionnaires were used to measure the quality of life of people receiving checkpoint inhibitors. An attempt was also made to make a rough estimate of the cost of checkpoint inhibitors in selected cases. The present study was conducted at the Oncology Day Hospital of the General University Hospital of Patras and the sample consisted of 100 subjects. The results of the two questionnaires show that the subjective evaluation of the patient's quality of life is satisfactory and functional since most of the respondents evaluate their quality of life as good to very good. Regarding the duration of immunotherapy, their health status seems to have improved, as 49% of respondents report having no pain, while the QLQ-C30 shows that 93% of patients have no problems with personal hygiene. Important determinants related to the limitation of work and daily activities were influenced by patients' age and marital status. Finally, age, monthly income, and education level seem to exert a general influence on a person's physical condition.