Patient reported endpoints for measuring clinical benefit in (high grade glioma) primary brain tumor patients

Neurological Health: Not Merely the Absence of Disease: Current Wellbeing Instruments Across the Spectrum of Neurology

OBJECTIVE

Well-being and quality of life can vary independently of disease. Instruments measuring well-being and quality of life are commonly used in neurology, but there has been little investigation into the extent in which they accurately measure wellbeing/quality of life or if they merely reflect a diseased state of an individual.

DESIGN

Systematic searches, thematic analysis and narrative synthesis were undertaken. Individual items from instruments represented in ≥ 5 publications were categorised independently, without prior training, by five neurologists and one well-being researcher, as relating to 'disease-effect' or 'Well-being' with a study-created instrument. Items were additionally categorised into well-being domains.

DATA SOURCES

MEDLINE, EMBASE, EMCARE and PsycINFO from 1990 to 2020 were performed, across the 13 most prevalent neurological diseases.

RESULTS

301 unique instruments were identified. Multiple sclerosis had most unique instruments at 92. SF-36 was used most, in 66 studies. 22 instruments appeared in ≥ 5 publications: 19/22 'well-being' outcome instruments predominantly measured disease effect (Fleiss kappa = .60). Only 1/22 instruments was categorised unanimously as relating to well-being. Instruments predominantly measured mental, physical and activity domains, over social or spiritual.

CONCLUSIONS

Most neurological well-being or quality-of-life instruments predominantly measure disease effect, rather than disease-independent well-being. Instruments differed widely in well-being domains examined.

The burden of a brain tumor: guiding patient centric care in neuro-oncology

PURPOSE

Brain tumor patients report an overwhelming sense of uncertainty when navigating the course of their terminal disease. Historically, organizational experts and/or treating physicians have established neuro-oncology programs. However, given the disease burden and incurable nature of current medical treatments, patient-centric care should be prioritized alongside institutional and academic objectives. Integrating patient perspectives into interdisciplinary programmatic development can improve comprehensive care and empower patients to advocate for their own quality healthcare needs.

METHODS

Data was derived from four focus groups with adult brain tumor patients (N = 15; M_age = 46 years, 53% female). A trained moderator led each 90-min group and posed semi-structured questions regarding patients' care needs throughout their neuro-oncological disease trajectory. Emphasis was placed on quality of life and psychological distress reduction for both patients and their loved ones. Common themes were identified via thematic content analysis using NVivo software. A high inter-rater reliability (M_kappa = 0.92, range= 0.85-0.93) was achieved.

RESULTS

Six distinct themes emerged, where the frequency of each theme ranged from 12.5 to 23.3%. Specifically, patients discussed relational concerns, navigation of interdisciplinary care, neurobehavioral impacts, emotional responses to stressors, existential concerns, and caregiver support. A discussion of themes follows.

CONCLUSIONS

It is imperative that we include the patient perspective in the development of neuro-oncology programs; considering the quality of survival in addition to quantity. Neuro-oncology quality care themes identified were relational concerns, navigating interdisciplinary care, neurobehavioral impact, emotional response to stressors, existential concerns, and caregiver support. A paramount concentration for comprehensive neuro-oncology programs must include patients' quality needs.

Outcomes from the use of computerized neurocognitive testing in a recurrent glioblastoma clinical trial

Assessment of neurocognitive function (NCF) is important in brain tumor clinical trials, however there are varying methodologies available. We used the Cogstate computerized NCF testing battery and the mini-mental state examination (MMSE) to prospectively assess cognition in adult patients with recurrent glioblastoma (GBM) enrolled in the CABARET randomized phase II clinical trial of bevacizumab versus bevacizumab plus carboplatin chemotherapy. We determined completion rates; compared NCF results between trial arms; and assessed baseline NCF as a predictor of survival outcome. 93 of 103 eligible patients completed baseline Cogstate NCF testing. Completion rates were between 60 and 100% across each timepoint, and 38% at disease progression. There was no evidence of difference between arms in time to deterioration in NCF using either test. Prior to disease progression, deterioration on the Cogstate tests was substantially more common (90%) than deterioration on the MMSE (37%), and decline in the Cogstate composite score within the first 8 weeks was associated with shorter overall survival. This testing methodology may be useful when determining net clinical benefit for therapies in patients with recurrent GBM.

Functional Outcomes and Health-Related Quality of Life Following Glioma Surgery

Functional outcome following glioma surgery is defined as how the patient functions or feels. Functional outcome is a coprimary end point of surgery in patients with diffuse glioma, together with oncological outcome. In this review, we structure the functional outcome measurements following glioma surgery as reported in the last 5 yr. We review various perspectives on functional outcome of glioma surgery with available measures, and offer suggestions for their use. From the recent neurosurgical literature, 160 publications were retrieved fulfilling the selection criteria. In these publications, neurological outcomes were reported most often, followed by activities of daily living, seizure outcomes, neurocognitive outcomes, and health-related quality of life or well-being. In more than a quarter of these publications functional outcome was not reported. A minimum essential consensus set of functional outcome measurements would benefit comparison across neurosurgical reports. The consensus set should be based on a combination of clinician- and patient-reported outcomes, assessed at a predefined time before and after surgery. The selected measurements should have psychometric properties supporting the intended use including validity-related evidence, reliability, and sensitivity to detect meaningful change with minimal burden to ensure compliance. We circulate a short survey as a start towards reporting guidelines. Many questions remain to better understand, report, and improve functional outcome following glioma surgery.

The Impact of the Timing of Health-Related Quality of Life Assessments on the Actual Results in Glioma Patients: A Randomized Prospective Study

Background: The aim of this study was to explore the impact of the timing of Health-Related Quality of Life (HRQoL) measurements in clinical care on the obtained HRQoL scores in glioma patients, and the association with feelings of anxiety or depression. Methods: Patients completed the European Organisation for Research and Treatment of Cancer (EORTC)’s Quality of Life Questionnaires (QLQ-C30 and QLQ-BN20), and the Hospital Anxiety and Depression Scale (HADS) twice. All patients completed the first measurement on the day of the Magnetic Resonance Imaging (MRI) scan (t = 0), but the second measurement (t = 1) depended on randomization; Group 1 (n = 49) completed the questionnaires before and Group 2 (n = 51) after the consultation with the physician. Results: median HRQoL scale scores on t0/t1 and change scores were comparable between the two groups. Between 8–58% of patients changed to a clinically relevant extent (i.e., ≥10 points) on the evaluated HRQoL scales in about one-week time, in both directions, with only 3% of patients remaining stable in all scales. Patients with a stable role functioning had a lower HADS anxiety change score. The HADS depression score was not associated with a change in HRQoL. Conclusions: Measuring HRQoL before or after the consultation did not impact HRQoL scores on a group level. However, most patients reported a clinically relevant difference in at least one HRQoL scale between the two time points. These findings highlight the importance of standardized moments of HRQoL assessments, or patient-reported outcomes in general, during treatment and follow-up in clinical trials.

Identifying symptom recurrences in primary brain tumor patients using the MDASI-BT and qualitative interviews

Background

Identifying symptoms experienced throughout the disease trajectory is pivotal to understanding management of patient symptoms. Patient interviews to solicit input from those who have experienced these symptoms is one method to capture this perspective to validate symptoms included in patient reported outcomes (PRO) measures.

Methods

A thematic approach was used to identify themes within qualitative interviews. The MD Anderson Symptom Inventory- Brain Tumor (MDASI-BT) was completed by glioma patients. Descriptive statistics was used for analysis of the MDASI-BT.

Results

Thematic saturation was reached with 23 participants, with a median age of 53 (23–62), on treatment (57%) and diagnosed with a glioblastoma (48%). Patients endorsed 20 out of the 22 MDASI-BT symptoms (symptoms not reported: dry mouth, shortness of breath) during the interviews and with completion of the instrument (seizures and vomiting were not endorsed). Fatigue (55%), seizures (50%), and pain (50%) were common symptoms described by the sample. During treatment, more symptoms were identified with fatigue, hair loss, and nausea more problematic. Aside from itching and swelling (endorsed by 2 patients each), all other symptoms not included in the MDASI-BT instrument were endorsed by only one patient.

Conclusions

Completion of the MDASI-BT, found patients reported on average 6.8 symptoms with 14% of reported symptoms (mean = 3) rated as moderate to severe. The findings demonstrate how applicable the MDASI-BT is in capturing significant symptoms experienced and how important it is to utilize throughout ones’ care to manage symptoms effectively.

Electronic supplementary material

The online version of this article (10.1186/s41687-019-0143-0) contains supplementary material, which is available to authorized users.

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.

Quality-adjusted life years in glioma patients: a systematic review on currently available data and the lack of evidence-based utilities

BACKGROUND

Cost-effectiveness studies gain importance in the context of rising health care expenses and treatment options. Especially in the neuro-oncological context, surgical therapy may increase overall survival, but restrain the patient by postoperative disability. Quality-adjusted life years, express treatment effects and are based on health utilities. In our study, we analyze the current evidence on health economic evaluations in glioma patients.

MATERIAL AND METHODS

We performed a systematic database search including Medline and Cochrane Library. Studies were critically appraised for statistical analyzes including glioma patients, health economic modeling and detailed health outcome. Study evidence was classified according to levels of evidence for therapeutic studies from the Centre for Evidence-Based Medicine (Oxford).

RESULTS

37 studies (1995-2018) were identified, 29 matched our inclusion criteria. Studies addressed surgical cost-efficiency and/or the standard treatment, postoperative chemotherapy (n = 6) and 5-ALA (n = 3). Only 16 studies used QALY as the outcome measure, most used overall survival or life years gained (LYG). Utilities were either based on one single study (Garside et al. in Health Technol Assess 11:iii-iv, ix-221) or derived from visual analogue scale (VAS). None assessed quality of life values for specific health statuses or utilities. Incremental cost-effectiveness ratios varied from 8325€ per QALY (5-ALA) to 518,342€ per LYG (tumor treating fields).

CONCLUSIONS

Only one study generated utility values to conduct cost-effectiveness analysis (CEA); most studies used indirect outcomes such as LYG or based their model on previously published data. Health economic evaluations lack specific utilities, further investigations are necessary to conduct reliable CEA in the neurosurgical context.

The Effect of Pet Therapy and Artist Interactions on Quality of Life in Brain Tumor Patients: A Cross-Section of Art and Medicine in Dialog

With the evolution of modern medical treatment strategies, there also comes the realization that many times we reach a point where traditional goals of medical care, such as overall survival or disease-free survival, are not realistic goals for many patients facing devastating illnesses. One such disease is malignant primary brain tumors, known as malignant glioma (MG). With median survival of only 20.9 months following best available standard of care treatment strategies, including surgery, chemotherapy, radiation, and tumor treating fields, MG is one of the deadliest malignancies of the modern era. Along the course of treating patients with MG, clinicians often realize that traditional treatment therapies can at best provide incremental benefit of symptom management without any survival benefit. However, even in these difficult situations, it is possible to make significant positive changes in patients’ health-related quality of life (HRQoL) using creative, non-traditional interventions. In this paper, we describe the initial findings from our project that takes a unique approach to studying the intersections of clinical care and art by using pet therapy and art-making as interventions for patients diagnosed with brain tumors. Our preliminary findings suggest that pet therapy and the ability to reflect as well as speak about their journey through a life-altering disease significantly increases patients’ overall feeling of wellbeing and reduces anxiety about future uncertainty.

Clinical trial endpoints for patients with gliomas

Malignant glioma represents a diverse set of molecularly heterogeneous diseases. Few therapeutic agents have been approved despite decades of clinical trials research and pre-clinical investigation. Attempts to refine neuroimaging criteria and recent discovery of the genomic profiles linking tumor subsets to survival outcomes have spurred discussion on a variety of new approaches in clinical trial design and relevant endpoints. Here we focus on those endpoints in clinical trial design for patients with primary glioma and related issues still to be resolved.

Compliance with patient-reported outcome assessment in glioma patients: predictors for drop out

Background

Patient-reported outcomes are of high importance in clinical neuro-oncology. However, assessment is still suboptimal. We aimed at exploring factors associated with the probability for a) drop out of study and b) death during follow-up.

Methods

Patients were assessed twice during follow-up visits scheduled within 3 to 5 months of each other by using 3 validated patient-reported outcome measures (t1: first assessment, t2: second assessment). As "death" was seen as a competing risk for drop out, univariate competing risk Cox regression models were applied to explore factors associated with dropping out (age, gender, WHO grade, living situation, recurrent surgery, Karnofsky Performance Status, time since diagnosis, and patient-reported outcomes assessed by Distress Thermometer, EORTC-QLQ-C30, EORTC-QLQ-BN20, and SCNS-SF-34G).

Results

Two hundred forty-six patients were eligible, 173 (70%) participated. Patients declining participation were diagnosed with glioblastomas more often than with other gliomas (56% vs 39%). At t2, 32 (18%) patients dropped out, n = 14 death-related, n = 18 for other reasons. Motor dysfunction (EORTC-QLQ-BN20) was associated with higher risk for non-death-related drop out (HR: 1.02; 95% CI, 1.00-1.03; P = .03). Death-related drop out was associated with age (HR: 1.09; 95% CI, 1.03-1.14; P = .002), Karnofsky Performance Status (HR: 0.92; 95% CI, 0.88-0.96; P < .001), lower physical functioning (EORTC-QLQ-C30; HR: 0.98; 95% CI, 0.96-1.00; P = .04) and lower motor functioning (EORTC-QLQ-BN20; HR: 1.020; 95% CI, 1.00-1.04; P = .02).

Conclusion

Patients with motor dysfunction and poorer clinical condition seem to be more likely to drop out of studies applying patient-reported outcome measures. This should be taken into account when planning studies assessing glioma patients and for interpretation of results of patient-reported outcome assessments in clinical routine.

Pediatric low-grade gliomas: implications of the biologic era

For the past decade, it has been recognized that pediatric low-grade gliomas (LGGs) and glial-neuronal tumors carry distinct molecular alterations with resultant aberrant intracellular signaling in the Ras-mitogen-activated protein kinase pathway. The conclusions and recommendations of a consensus conference of how best to integrate the growing body of molecular genetic information into tumor classifications and, more importantly, for future treatment of pediatric LGGs are summarized here. There is uniform agreement that molecular characterization must be incorporated into classification and is increasingly critical for appropriate management. Molecular-targeted therapies should be integrated expeditiously, but also carefully into the management of these tumors and success measured not only by radiographic responses or stability, but also by functional outcomes. These trials need to be carried out with the caveat that the long-term impact of molecularly targeted therapy on the developing nervous system, especially with long duration treatment, is essentially unknown.

Factors associated with supportive care needs in glioma patients in the neuro-oncological outpatient setting

Objective of this study aimed at assessing glioma patients' supportive care needs in a neurosurgical outpatient setting and identifying factors that are associated with needs for support. In three neuro-oncological outpatient departments, glioma patients were assessed for their psychosocial needs using the Supportive Care Needs Survey short-form (SCNS-SF34-G). Associations between clinical, sociodemographic, treatment related factors as well as distress (measured with the distress thermometer) and supportive care needs were explored using multivariable general linear models. One-hundred and seventy three of 244 eligible glioma patients participated, most of them with primary diagnoses of a high-grade glioma (81%). Highest need for support was observed in 'psychological needs' (median 17.5, range 5-45) followed by 'physical and daily living needs' (median 12.5, range 0-25) and 'health system and information needs' (median 11.3, range 0-36). Needs in the psychological area were associated with distress (R² = 0.36) but not with age, sex, Karnofsky performance status (KPS), extend of resection, currently undergoing chemotherapy and whether guidance during assessment was offered. Regarding 'health system and information needs', we observed associations with distress, age, currently undergoing chemotherapy and guidance (R² = 0.31). In the domain 'physical and daily living needs' we found associations with KPS, residual tumor, as well as with distress (R² = 0.37). Glioma patients in neuro-oncological departments report unmet supportive care needs, especially in the psychological domain. Distress is the factor most consistently associated with unmet needs requiring support and could serve as indicator for clinical neuro-oncologists to initiate support.

Determining priority signs and symptoms for use as clinical outcomes assessments in trials including patients with malignant gliomas: Panel 1 Report

Patients with primary brain tumors such as malignant gliomas are highly symptomatic, often from the time of diagnosis. Signs and symptoms (signs/symptoms) can cause functional limitations that often worsen over the disease trajectory and may impact patient quality of life. It is recognized that standard measurements of tumor response do not adequately measure this impact or the impact that a therapy may have to mitigate these signs/symptoms and potentially have clinical benefit. Identifying a core set of signs/symptoms and functional limitations is important for understanding their clinical impact and is the first step to including clinical outcomes assessment in primary brain tumor clinical trials.

Seizure control as a new metric in assessing efficacy of tumor treatment in low-grade glioma trials

Patients with low-grade glioma frequently have brain tumor-related epilepsy, which is more common than in patients with high-grade glioma. Treatment for tumor-associated epilepsy usually comprises a combination of surgery, anti-epileptic drugs (AEDs), chemotherapy, and radiotherapy. Response to tumor-directed treatment is measured primarily by overall survival and progression-free survival. However, seizure frequency has been observed to respond to tumor-directed treatment with chemotherapy or radiotherapy. A review of the current literature regarding seizure assessment for low-grade glioma patients reveals a heterogeneous manner in which seizure response has been reported. There is a need for a systematic approach to seizure assessment and its influence on health-related quality-of-life outcomes in patients enrolled in low-grade glioma therapeutic trials. In view of the need to have an adjunctive metric of tumor response in these patients, a method of seizure assessment as a metric in brain tumor treatment trials is proposed.

Psycho-oncology

Psycho-oncologic care for glioma patients has two important aspects. First, clinical decision making regarding treatment of the tumor should reflect a sound balance between quality and quantity of life. Second, supportive care should be targeted at the symptoms that are most detrimental to perceived quality of life (QOL) of glioma patients, and of their informal caregivers. In this chapter we will first focus on the definition of QOL and the ways of measuring this adequately in clinical trials, and then discuss the impact of the disease itself, and of established and experimental treatment modalities on perceived QOL. Subsequently, we will discuss frequently occurring symptoms that have an impact on the perceived QOL of glioma patients and their caregivers. This will include what is known about the efficacy of symptomatic treatment and maintaining or improving QOL in both patients and caregivers, followed by recommendations for future directions of clinical care and research.

Clinical outcome assessment in malignant glioma trials: measuring signs, symptoms, and functional limitations

The shared goal of all parties developing therapeutics against malignant gliomas is to positively impact the lives of people affected by these cancers. Clinical outcome assessment (COA) tools, including measures of patient-reported outcome, performance outcome, clinician-reported outcome, and observer-reported outcome, allow patient-focused assessments to complement traditional efficacy measures such as overall survival and radiographic endpoints. This review examines the properties of various COA measures used in malignant glioma clinical trials to date and cross references their content to the priority signs, symptoms, and functional limitations defined through a community survey conducted by the National Brain Tumor Society. The overarching goal of this initiative is to identify COA measures that are feasible and have appropriate psychometric properties for use in this patient population as well as highlight where further development is needed.

Facing the future of brain tumor clinical research

This edition of CCR Focus provides critical reviews of several important areas in the field, including the application of findings from genomic investigations of brain tumors to improve diagnosis, clinical trial design, and ultimately optimizing individual patient treatment. Another article is a critical review provided by experts in the field that discusses the recent clinical trials using angiogenesis inhibitors, possible explanations for the results, and how to move forward. There is a concise discussion of the application of immunotherapy to brain tumors by key investigators in this field, reflecting the potential opportunities as well as the disease-specific challenges. Finally, leading pediatric brain tumor investigators provide an overview of the field and insights about the recent seminal discoveries in two pediatric brain tumors, supporting the paradigm that laboratory investigations lead to more precise diagnosis, prognosis, and ultimately better treatment. Herein, an overview of the recent advances and challenges in the area of clinical and translational brain tumor research is provided to set the stage for the contributions that follow.