Quality of life in patients with non-small cell lung cancer treated with chemotherapy

Quality of life in advanced non-small-cell lung cancer: results of a Southwest Oncology Group randomized trial

PURPOSE

The main purpose of this paper is to present the results of a randomized trial comparing the effects of two chemotherapy regimens on the Quality of life (QOL) of patients with advanced non-small-cell lung cancer (NSCLC). Trials in advanced stage disease represent an important treatment context for QOL assessment. A second purpose of this paper is to examine methods for handling the level of missing data commonly observed in the advanced stage disease context.

METHODS

Patients were randomized to receive cisplatin plus vinorelbine or carboplatin plus paclitaxel. The QOL of 222 patients was assessed with the Functional Assessment of Cancer Therapy-Lung (FACT-L) prior to randomization; follow-up assessments occurred at 13 and 25 weeks. Three methods were used to analyze the QOL data: (1) cross-sectional analysis of four patient categories (improved, stable, missing, and declined) based on changes in the FACT-L score, (2) a mixed linear model, and (3) a pattern mixture model. The longitudinal analyses addressed two potential data biases.

RESULTS

Questionnaire submission rates were 91% at baseline, 68% at 13 weeks, and 47% at 25 weeks. The cross-sectional and mixed linear model analyses did not show significant differences by treatment arm in patient-reported QOL. The pattern mixture model analysis, more appropriate given non-ignorable missing data, also found no statistically significant effect of treatment on patient QOL.

CONCLUSION

We present a sensitivity analysis approach with multiple methods for analyzing treatment effects on patient QOL in the presence of substantial, non-ignorable missing data in an advanced stage disease clinical trial. We conclude that the two treatment arms did not differ statistically in their effects on patient QOL over a 25-week treatment period.

Chemotherapy versus best supportive care in stage IV non-small cell lung cancer, non metastatic to the brain

Stage IV non-small cell lung cancer is a fatal disease, with a median survival of 14 months. Systemic chemotherapy is the most common approach. However the impact in overall survival and quality of life still a controversy.

OBJECTIVES

To determine differences in overall survival and quality of life among patients with stage IV non-small cell lung cancer non-metastatic to the brain treated with best supportive care versus systemic chemotherapy.

PATIENTS

From February 1990 through December 1995, 78 eligible patients were admitted with the diagnosis of stage IV non-small cell lung cancer. Patients were divided in 2 groups: Group A (n=31 - treated with best supportive care ), and Group B (n=47 - treated with systemic chemotherapy).

RESULTS

The median survival time was 23 weeks (range 5 - 153 weeks) in Group A and 55 weeks (range 7.4 - 213 weeks) in Group B (p=0.0018). In both groups, the incidence of admission for IV antibiotics and need of blood transfusions were similar. Patients receiving systemic chemotherapy were also stratified into those receiving mytomycin, vinblastin, and cisplatinum, n=25 and those receiving other combination regimens (platinum derivatives associated with other drugs, n=22). Patients receiving mytomycin, vinblastin, and cisplatinum, n=25 had a higher incidence of febrile neutropenia and had their cycles delayed for longer periods of time than the other group. These patients also had a shorter median survival time (51 versus 66 weeks, p=0.005).

CONCLUSION

In patients with stage IV non-small cell lung cancer, non-metastatic to the brain, chemotherapy significantly increases survival compared with best supportive care.

Phase I/II study of stage III and IV non-small cell lung cancer patients taking a specific dietary supplement

This phase I/II study evaluates the influence of selected vegetables (SV) that contain known antitumor components on the survival of stage III-IV non-small cell lung cancer (NSCLC) patients. All patients were treated with conventional therapies. SV was added to the daily diet of 5 stage I patients in the toxicity study group (TG) and 6 stage III and IV patients in the treatment group (SVG), but not to the diet of 13 stage III and IV patients in the control group (CG). Age, Karnofsky performance status (KPS), and body mass index of SVG and CG patients were comparable at entry. KPS declined in the CG patients (79 +/- 8 to 55 +/- 11) but improved in the SVG patients (75 +/- 8 to 80 +/- 13) one to three months after entry. Weight change in the CG, SVG, and TG patients was -12 +/- 5%, -2 +/- 2%, and +4 +/- 4%, respectively. The median survival time and mean survival of the CG patients were 4 and 4.8 months, but in the SVG patients they were 15.5 and 15 months (p < 0.01). No clinical signs of toxicity were found in the TG patients in the 24-month study period. Adding SV to the daily diet of NSCLC patients was found to be nontoxic and associated with improved weight maintenance, KPS, and survival of stage III and IV NSCLC patients.

Quality of life in patients with lung cancer: a review of literature from 1970 to 1995

A review of the literature was carried out covering the last 25 years (1970 to 1995) by searching through the MEDLINE and manually. The review consists of two companion parts. The first includes studies of quality of life in lung cancer patients in general, while the second part is restricted to defined samples of small and non-small cell lung cancer patients. Excluding non-English and review articles, in total 151 citations were identified and all have been reviewed. Over 50 instruments were used to measure quality of life in lung cancer studies. Of these, the European Organisation for Research and Treatment of Cancer Quality of Life Lung Cancer Questionnaire (EORTC QLQ-LC13) in conjunction with the core cancer questionnaire (QLQ-C30) was found to be the best developed instrument, although there were two other lung cancer-specific measures with good reliability and validity. Several topics in this chapter have been highlighted, including the importance of regularly measuring quality of life in lung cancer patients. Progress and achievements in areas such as performance status as a proxy of quality of life measure, psychological morbidity and symptom distress as predictive factors of quality of survival, and communication problems in quality of life studies of lung cancer patients have been emphasized and their implications in lung cancer care discussed. It is argued that palliation of symptoms, psychosocial interventions, and understanding patients' feelings and concerns all contribute to improving quality of life in lung cancer patients. It is concluded that the future challenge in treatment of lung cancer lies not only in improving the survival, but mainly the patients' quality of life regardless of cell type. Clinical trial and epidemiologic population-based outcome studies are recommended to provide this and to allow a better understanding of the contribution of the socioeconomic characteristics of the patients to their pretreatment and posttreatment quality of life.

Phase II trial of dose intensification with cisplatin and carboplatin plus vindesine in patients with inoperable non-small cell lung cancer

We conducted a phase II trial of a regimen that combined cisplatin (CDDP), carboplatin (CBDCA), and vindesine (VDS) in previously untreated patients with non-small cell lung cancer (NSCLC) to evaluate the efficacy and safety of the regimen. Thirty-five patients with inoperable NSCLC entered the study. Cisplatin (CDDP 80 mg/m2) was administered on day 1, and CBDCA 100 mg/m2 and VDS 2 mg/m2) were administered on days 2, 3, and 8. We observed one complete response (CR) and 16 partial responses (PR), with a total response rate of 49% [95% confidence interval (CI) 31-66%]. The overall median survival was 58 weeks; the 1-year survival rate was 60%, and the 2-year survival rate was 23%. Major toxicities were hematologic; leukopenia of grades 3 and 4 occurred in 66% patients, and thrombocytopenia occurred in 23%. Therefore, the dose-intensified regimen of CDDP, CBDCA, and VDS was active in treating patients with inoperable NSCLC, with demonstration of a favorable median survival time.

Modified weekly regimen with vinorelbine as a single agent in unresectable non-small cell lung cancer

After a 26% response rate was reported with a 20/mg/m2/week vinorelbine (VRL) dose, a multicenter phase II trial of a modified weekly VRL treatment protocol (30 mg/m2 days 1 and 8 every 21 days) for unresectable non-small cell lung cancer (NSCLC) was designed to determine its clinical activity, toxicity, and survival of treated patients. As myelotoxicity frequently precludes the administration of VRL, by suppressing the dose that would correspond to day 15 of a weekly protocol, we allowed bone marrow recovery to take place and avoided the administration of the drug at the nadir of the cycle. The trial included 71 consecutive, previously untreated patients with unresectable and measurable disease. A total of 297 three-week treatment courses were administered with an average of 4 courses per patient (range 1-11). Results showed that in spite of attaining a median dose intensity of 19 mg/m2/week, this modified weekly VRL treatment regimen has a low level of activity (7.5% response rate) in NSCLC. Although a more tolerable level of toxicity is achieved, in order to maintain its antitumor activity, the recommended dose of VRL when given alone for NSCLC treatment (30 mg/m2/weekly) should not be decreased.

Constructing health state preference values from descriptive quality of life outcomes: mission impossible?

Descriptive quality of life questionnaires are commonly administered in clinical trials, to evaluate outcomes from the patient's perspective alongside conventional clinical measures. When expressed in single index form as health state preference values (HSPVs), quality of life information is also relevant to economic evaluations. By combining HSPVs with survival information, quality adjusted life years (QALYs) may be derived for cost-utility analysis. Although HSPVs are rarely measured prospectively in cancer clinical trials, the UK Medical Research Council Cancer Therapy Committee recommends the routine administration of two specific quality of life questionnaires: the Rotterdam Symptom Checklist and the Hospital Anxiety Depression Scale. This study explores two potential methods for secondary derivation of HSPVs from these instruments, using data gathered in a clinical trial of two forms of radiotherapy for non-small cell cancer of the bronchus. The first method, secondary mapping to existing utility scales, was found to be infeasible from the above questionnaires. The second method used factor analysis to summarize the descriptive quality of life data collected through the questionnaires. This revealed five distinct factors prevalent in the trial population. Using these factors, simplified health state scenarios were developed from which direct measurement of HSPVs was feasible. As the resulting HSPVs and any QALYs that may be derived from them are cancer specific, their potential value in informing resource allocation would be limited to decisions within oncology services.

The cost-effectiveness of navelbine alone or in combination with cisplatin in comparison to other chemotherapy regimens and best supportive care in stage IV non-small cell lung cancer

An economic evaluation was undertaken, using data from European and Canadian randomised controlled trials of chemotherapy in advanced non-small cell lung cancer (NSCLC), to determine the cost and cost-effectiveness of single-agent vinorelbine (Navelbine, NVB) therapy and NVB in combination with cisplatin (NVB-P) compared to vindesine in combination with cisplatin (VDS-P), standard regimens including VP-16-cisplatin (VP-16-P) and vinblastine-cisplatin (VLB-P) and best supportive care (BSC). The Population Health Model (POHEM) developed by Statistics Canada was used to model the cost of care per patient, the total burden of cost to the Canadian healthcare system and the cost-effectiveness of the therapeutic interventions relative to BSC and to standard chemotherapy regimens, expressed as the cost per life year gained (LYG). Based on this analysis, VLB-P proved to be the most cost-effective chemotherapy regimen relative to BSC, as it increased average survival by 0.27 years while reducing costs by $3265 per case. NVB-P increased survival to a greater degree (0.44 years/patient) while inpatient administration increased costs by $2451 per case, for a cost-effectiveness ratio of $5551 per LYG. Outpatient administration, which reduced the cost of care per case by $473, was shown in the model to be the most cost-effective way to administer this regimen. Relative to VP-16-P and VLB-P, outpatient NVB-P regimen proved to be cost-effective at $7902 and $16404 per LYG, respectively. Based on our estimates, a variety of chemotherapy regimens, including outpatient NVB-P, are cost-effective in the management of advanced (Stage IV) NSCLC and competitive with some commonly used healthcare interventions. Therefore, cost and cost-effectiveness should not be barriers to the utilisation of NVB-P therapy in Canada.

Psychosocial issues and lung cancer: a behavioral approach

OBJECTIVES

To examine the psychosocial issues related to lung cancer with a specific focus on women and quality of life. To review the role of behavioral medicine as an approach to treatment, including individual, family, and group interventions.

DATA SOURCES

Review articles, book chapters, and research studies pertaining to the psychosocial issues encountered by patients with lung cancer and behavioral medicine interventions.

CONCLUSIONS

Behavioral interventions, used in addition to medical treatment, have been shown to reduce the nausea and vomiting associated with chemotherapy, decrease suffering from pain, and diminish anxiety associated with dyspnea. These mind/body approaches help to reduce emotional distress, promote improved quality of life, enhanced coping, a sense of control, and hopefulness.

IMPLICATIONS FOR NURSING PRACTICE

Nurses can play an active role in helping patient's and family members learn new coping skills that will help promote a sense of competence, control, and support. Relaxation, mediation, distraction, social support, and cognitive therapies are a few of the interventions to help enrich the lives of patients and their families.

Quality of life in lung cancer surgical adjuvant trials

The Functional Living Index-Cancer (FLIC) was administered to 438 patients in the Lung Cancer Study Group on whom long-term follow-up was available in 1993. Across all trials, the total FLIC score was predictive for survival even when corrected for extent of disease, although individual items on the FLIC were not. There was no significant impact of a short course of chemotherapy on quality of life. The FLIC is a reliable means of assessing quality of life in lung cancer surgical adjuvant trials.

Is there a role for vindesine in the treatment of non-small cell lung cancer?

Vindesine is a semisynthetic derivative of vinblastine which has been evaluated in clinical studies since the late 1970's. The literature on vindesine in the treatment of non-small cell lung cancer has been reviewed and all aspects of vindesine treatment in this disease has been covered. It is concluded that vindesine as a single agent yields a response rate of 18% based on the treatment of 295 patients included in phase II trials (95% confidence limits 13%-22%). No difference was observed among the three major histologic types of non-small cell lung cancer. In phase III trials, the response rate and confidence limits are at a similar level. Combination chemotherapy including vindesine plus cisplatin ranks among the most active treatments in non-small cell lung cancer and is as active as etoposide plus cisplatin, both with respect to response rate and survival. It has not been documented that the addition of one or two other drugs to the combination of vindesine yields an increase in survival. When best supportive care was compared with a combination of vindesine plus cisplatin, the group with chemotherapy was attributed a survival advantage in all three studies published, and the difference was statistically significant in two of these three studies. Thus, vindesine has a well documented activity in non-small cell lung cancer and ranks among the most active single agents in this disease. Vindesine is also part of several active combination chemotherapies among which the combination of vindesine plus cisplatin is particularly interesting, because it has been repeatedly shown to prolong survival as compared to supportive care. Especially this latter point leads to the conclusion that there is a role for vindesine in the treatment of non-small cell lung cancer. However, the concept of chemotherapy in this disease remains investigational even though the advances seen in recent years clearly merit further studies.

Women with lung cancer: impact on quality of life

The purpose of this study was to describe disruptions in quality of life (QOL) in women suffering from lung cancer, the leading cause of cancer-related death in the United States. QOL was measured with the CARES-SF. Symptom distress was measured with the modified Symptom Distress Scale, and functional status was measured with the Karnofsky Performance Status Scale. Sixty-nine women with lung cancer participated in a one-time data collection. The typical subject was under 65 years of age, married, has had primary or recurrent non-small cell lung cancer for over 12 months, had limited disease, and was not currently receiving treatment. Subjects had greater disruptions in global QOL and its dimensions compared to a normative heterogeneous female cancer sample. The most prevalent serious disruptions were fatigue, difficulty with household chores, worry about ability to care for self, and worry about cancer progression. The global CARES-SF score was moderately correlated to functional status (r = 0.69, p = < 0.001), and to symptom distress (r = 0.72, p = < 0.001). Symptom distress was associated strongly with the physical subscale of QOL (r = 0.80, p = 0.001) and significantly but less strongly with all other dimensions of QOL. Significantly greater differences in disruptions of quality of life occurred in women younger than 65 years (p = 0.04), women with recurrent disease (p = 0.003), and women with low income (p = 0.008). In stepwise regression, symptom distress predicted 53% of the variance followed by functional status (59%) and recurrence (63%) when QOL was the outcome variable.

Influence of pretreatment clinical characteristics on the response rate to mitomycin/vindesine/cisplatin (MVP) in unresectable non-small cell lung cancer. ATTIT (Association pour le Traitement des Tumeurs Intra-Thoraciques)

The authors report their experience with the MVP (mitomycin/vindesine/cisplatin) regimen of the Memorial Sloan-Kettering Cancer Center (MSKCC) which showed the highest response rate in non-small cell lung cancer (NSCLC). The aim was to respect the original reported schedule to appreciate its activity, because the same drug combination with dose and schedule variations used by other investigators has failed to reproduce the original report results. 82 consecutive previously untreated patients with unresectable and/or metastatic NSCLC received mitomycin (8 mg/m2 days 1, 29, 71), vindesine (3 mg/m2, days 1, 8, 15, 22, 29, 43, 57, 71) and cisplatin (120 mg/m2, days 1, 29, 71), with evaluation on day 71. 24 objective responses were noted (29%) (2 complete response/22 partial response) (95% CI 19%-39%), without differences according to histology. Differences in median survival were noted according to the performance status and type of response. Overall survival rates in responding patients were similar to those noted with the original schedules. Analysis of selection criteria showed that there were more patients with bone (P less than 0.01) or liver metastases (P less than 0.05), less women (P less than 0.001) and less adenocarcinoma (P less than 0.001) than the MSKCC trial. A dose intensity analysis showed only a minimal difference in the average weekly doses of vindesine (10% lower than MSKCC trial: 1.8 mg/m2 vs. 2.25 mg/m2). Disease improvement, a subjective response criterion used in the MSKCC trial, was probably underestimated in the current study. We conclude that the potential benefit of chemotherapy with a three-drug combination in NSCLC is greatest in patients with stage IIIa and IIIb disease or stage IV disease with a good performance status and a low metastatic volume.

Supportive care versus supportive care and combination chemotherapy in metastatic non-small cell lung cancer. Does chemotherapy make a difference?

Current chemotherapy treatment of metastatic non-small cell lung cancer has demonstrated some objective responses, but is still largely palliative. This report reviews the results of a randomized trial in patients with advanced metastatic non-small cell lung cancer which compared treatment with supportive care (treatment with palliative radiation, psychosocial support, analgesics, nutritional support) to supportive care plus combination chemotherapy with cisplatin and vinblastine. Although the patients receiving combination chemotherapy had a slightly longer median survival (20.43 weeks versus 13.57 weeks), it was not statistically significant (P = 0.09). In addition, the patients receiving chemotherapy experienced serious toxicity, and showed no significant benefit in terms of quality of life as measured by Karnofsky performance status score. The authors conclude that contemporary combination chemotherapy provides only modest survival benefit to patients with advanced metastatic non-small cell lung cancer and should not be considered standard therapy. Future investigations of chemotherapy in patients with unresectable non-small cell lung cancer should continue to utilize control arms which provide high-quality supportive care.

Quality of life during chemotherapy in non-small cell lung cancer patients

To evaluate the usefulness of chemotherapy in non-small cell lung cancer, objective response, length of remission and survival have been considered the main yardsticks. Subjective improvement and gain in Karnofsky performance status have attracted very little attention. Thirty-one patients with stages III and IV underwent combination chemotherapy with high-dose cisplatin, and were assessed with categorical scales and 100 mm visual analogue scales used by patients themselves to report on several symptoms of their illness. After chemotherapy 17 of 19 patients (89%) gained weight; 20 presented anorexia, 10 of those (50%) improved; 15 had pain, 7 of those (47%) were alleviated; cough was reported in 22, in 10 (45%) it was ameliorated; hemoptysis disappeared in 10 of 11 patients (91%); of the 9 patients who had dyspnea, 7 improved (78%); and astenia was attenuated in 8 of 16 patients (50%). Quality of life was reported improved in 75% of those patients who had considered themselves seriously affected prior to the treatment. When compared with Karnofsky performance status, no relationship was found (r = 0.31). It is concluded that, apart from the objective response achieved, a significant proportion of patients did benefit from treatment as demonstrated by a marked relief of symptoms.