The challenges and achievements involved in implementing Quality of Life research in cancer clinical trials

Improving the clinical meaning of surrogate endpoints: An empirical assessment of clinical progression in phase III oncology trials

Disease progression in clinical trials is commonly defined by radiologic measures. However, clinical progression may be more meaningful to patients, may occur even when radiologic criteria for progression are not met, and often requires a change in therapy in clinical practice. The objective of this study was to determine the utilization of clinical progression criteria within progression-based trial endpoints among phase III trials testing systemic therapies for metastatic solid tumors. The primary manuscripts and protocols of phase III trials were reviewed for whether clinical events, such as refractory pain, tumor bleeding, or neurologic compromise, could constitute a progression event. Univariable logistic regression computed odds ratios (OR) and 95% CI for associations between trial-level covariates and clinical progression. A total of 216 trials enrolling 148,190 patients were included, with publication dates from 2006 through 2020. A major change in clinical status was included in the progression criteria of 13% of trials (n = 27), most commonly as a secondary endpoint (n = 22). Only 59% of trials (n = 16) reported distinct clinical progression outcomes that constituted the composite surrogate endpoint. Compared with other disease sites, genitourinary trials were more likely to include clinical progression definitions (16/33 [48%] vs. 11/183 [6%]; OR, 14.72; 95% CI, 5.99 to 37.84; p < .0001). While major tumor-related clinical events were seldom considered as disease progression events, increased attention to clinical progression may improve the meaningfulness and clinical applicability of surrogate endpoints for patients with metastatic solid tumors.

Treatment, healthcare utilization and outcomes in patients with glioblastoma in Ontario: a 10-year cohort study

BACKGROUND AND PURPOSE

Glioblastoma (GBM) is the most common malignant primary brain tumour in adults. Receipt of adjuvant therapies has been shown to exert a significant positive effect on patient survival. Little is known however about how changes in standards of care and healthcare system factors, such as access, affect real-world outcomes. In this study, we provide an overview of GBM in Ontario and examine elements of care, including treatment patterns, healthcare utilization, and overall survival, from 2010 to 2019, to interpret the impact of the changes in practice standards and expansion of the care network within this period.

METHODS

Using linked health-administrative databases from Ontario, Canada, we conducted a population-based cohort study to examine the clinical and biological characteristics, treatment, and healthcare utilization patterns of adult GBM patients diagnosed between 2010 and 2019. The primary outcomes were enrollment in adjuvant chemoradiation treatment and 1-, 2-, and 5-year survival. All analyses were performed using the Statistical Analysis Software (SAS).

RESULTS

5392 patients were diagnosed with GBM in Ontario from 2010 to 2019 (58% male, 42% female). The median age at diagnosis was 64. Receipt of adjuvant chemoradiation within one year of diagnosis increased from 51% in 2010 to 63% in 2019. 1-year, 2-year, and 5-year overall survival for all patients remained stable, ranging between 40 and 43%, 15-19%, and 5-7%, respectively. For patients above the age of 65, however, 1-year survival increased from 19% in 2010 to 26% in 2019.

INTERPRETATION

Regionalization enabled access to treatment closer to home for many patients. Over the last decade, receipt of adjuvant chemoradiation increased among elderly patients, but the improvement in 1-year overall survival over time was accounted for by sociodemographic and clinical covariates. Our findings support the efforts for regionalization of services to improve accessibility.

CONCLUSION

This Ontario-based study provides insight into the effect of practice evolution and healthcare utilization on the overall survival of patients with GBM. Overall survival for most patients with glioblastoma has remained stagnant over the past decade. Changes in treatment standards and expansion of access to treating centres have been associated with prolonged survival in elderly glioblastoma patients.

Lower limb function and quality of life after ILP for soft-tissue sarcoma

BACKGROUND

Isolated limb perfusion with TNF-alpha and melphalan (TM-ILP) in combination with complete tumor resection is an effective treatment option for non-resectable soft-tissue sarcoma of the extremities, with limb salvage rates greater than 80%. The aim of this study was to assess quality of life (QoL) after TM-ILP, also with regard to long-term survival.

METHODS

We retrospectively examined 27 patients who had primarily non-resectable soft-tissue sarcoma of the leg and who had undergone TM-ILP and complete tumor resection (with limb-sparing intent) during their follow-up examinations using the Quality of Life Questionnaire (QLQ-C30) and the German Short Musculoskeletal Function Assessment (SMFA-D). The results from the QLQ-C30 were compared to the reference values for the general population, to the "all cancer patients" reference values (both reference values published by the European Organization for Research and Treatment of Cancer (EORTC)), and to the reference values of a historical amputation group from the literature. The results of the SMFA were compared with those from a reference group of healthy individuals.

RESULTS

Surprisingly, we found that the global health status/QoL in the TM-ILP group was not significantly different from the general population or from patients with amputation, but it was higher than that of patients with cancer in general. Concerning the SMFA, we did find functional impairments in patients after TM-ILP compared to the reference group. With regard to long-term survival, we found no time-dependent deterioration in QoL for longer time intervals after treatment.

CONCLUSIONS

These results support the use of TM-ILP in limb-sparing multimodal therapy settings from a quality-of-life perspective, but they also encourage further research on this matter.

Evaluation of health-related quality of life and its main influencing factors in a Polish population of patients with bone metastases

PURPOSE

Regardless of cancer type, the skeleton is one of the most common sites for cancer spread. Health-related Quality of Life (HRQoL) can be considered a primary endpoint in clinical trials concerning cancer patients with palliative disease. The proper measurement of this endpoint requires valid and reliable instruments. The aim of this study was to evaluate HRQoL and its main influencing factors using validated EORTC tools - the QLQ-C30 and the QLQ-BM22 in Polish population of patients with skeletal metastases.

METHODS

Patients with bone metastases and histologically confirmed malignancy were qualified for the study. They filled out a personal questionnaire, the Polish version of the EORTC QLQ-C30 and its supplementary module QLQ-BM22. The influence of numerous socio-clinical factors such as age, gender, working status, level of education, performance status, primary location, and previous treatment received was assessed.

RESULTS

One hundred and ten patients (65 women) were enrolled into this study (mean age ±SD; 57.8±13.8). The most significant HRQoL issues were fatigue (59.29/100); pain (56.97/100) and insomnia (56.36/100). Men coped worse with pain (p=0.013), fatigue (p=0.050), nausea and vomiting (p=0.024) and financial difficulties (p=0.016) than women.

CONCLUSIONS

The main factors influencing HRQoL in Polish patients with bone metastases are fatigue, pain and insomnia, and as such should be a primary focus of patient-centered care in this group.

Psychometric properties of the Arabic version of EORTC QLQ-C15-PAL among cancer patients in Jordan

PURPOSE

Health related quality of life (HRQOL) is an important outcome in cancer care and needs assessment by a valid questionnaire. HRQOL questionnaires need to be validated after translations to other languages and cultural settings. The purpose of this study is to evaluate the psychometric properties of the Arabic version of the European Organization for Research and Treatment of Cancer Quality of Life 15 items Questionnaire for Palliative Care (EORTC QLQ-C15-PAL).

METHODS

This is a cross-sectional study of a convenient sample of inpatients with cancer.

RESULTS

One hundred seventy-five patients completed the EORTC QLQ-C15-PAL questionnaire. Cronbach's alpha coefficient met the 0.7 alpha criterion. Confirmatory factor analysis met the goodness of fit criteria; goodness-of-fit index (GFI), comparative fit index (CFI), normed fit index (NFI) and non-normed fit index (NNFI) >0.90 and root mean square error of approximation (RMSEA) <0.06. All item-scale correlation coefficients exceeded the set value of 0.40, indicating satisfactory convergent validity. In terms of discriminant validity, all items in the questionnaire showed a higher item-scale correlation than item-other scale correlation, except for items 1 and 2 (physical function scale) that showed a higher correlation with fatigue. Construct validity was tested by item inter scale correlation coefficient. All constructs had correlation coefficient <0.70. External validity was tested by comparison of scores of patients who had metastasis and who did not have metastasis. Significant differences (P value <0.05) were found in all scales except for nausea. Age groups were compared and showed significant differences for physical function, fatigue, and global score of HRQOL.

CONCLUSION

The Arabic version of the EORTC QLQ-C15-PAL is valid and reliable.

Quality of Life Variables Assessment, Before and After Pancreatoduodenectomy (PD): Prospective Study

INTRODUCTION

The treatment of pancreatic cancer is a complex problem, due to late diagnosis, the need for specialized surgical treatment, the large number of relapses and poor survival.

OBJECTIVE

To evaluate the quality of life of patients with periampulary pancreatic cancer before and after pancreatoduodenectomy (PD).

MATERIAL & METHOD

The sample was collected in the "Attikon" University General Hospital (Chaidari). It consists of 20 subjects with a mean age of 65.9 years (SD = 10,2 years). For the quality of life measurement, we used the (EORTC) QLQ-C30 version 3.0., as well as the EORTC QOL-PAN26.

RESULTS

From the sample of 20 patients who participated, full data were collected for 18 of them during the first month, 17 during the third month and 16 during the sixth month.Regarding symptoms, as they were recorded with the QLQ-30 questionnaire, there was a significant increase of fatigue, a significant reduction of pain and constipation, while economic difficulties increased.  As for the mean and median values for the dimensions of the PAN-26 questionnaire during monitoring, there was a significant decrease in pancreatic and liver pain symptoms during follow-up, while the gastrointestinal symptoms increased in frequency. In addition, the body image and sexuality worsened.

CONCLUSIONS

The surgical treatment of pancreatic cancer with pancreatoduodenectomy (PD), according to the early survey data using the (EORTC) QLQ-C30 version3.0, and the EORTC QOL-PAN26 questionnaires, seems to have a favorable impact on quality of life, as evidenced by the improvement of most parameters evaluated during the study period.

Joint modeling of survival and longitudinal non-survival data: current methods and issues. Report of the DIA Bayesian joint modeling working group

Explicitly modeling underlying relationships between a survival endpoint and processes that generate longitudinal measured or reported outcomes potentially could improve the efficiency of clinical trials and provide greater insight into the various dimensions of the clinical effect of interventions included in the trials. Various strategies have been proposed for using longitudinal findings to elucidate intervention effects on clinical outcomes such as survival. The application of specifically Bayesian approaches for constructing models that address longitudinal and survival outcomes explicitly has been recently addressed in the literature. We review currently available methods for carrying out joint analyses, including issues of implementation and interpretation, identify software tools that can be used to carry out the necessary calculations, and review applications of the methodology.

End Points and Trial Design in Geriatric Oncology Research: A Joint European Organisation for Research and Treatment of Cancer–Alliance for Clinical Trials in Oncology–International Society of Geriatric Oncology Position Article

Selecting the most appropriate end points for clinical trials is important to assess the value of new treatment strategies. Well-established end points for clinical research exist in oncology but may not be as relevant to the older cancer population because of competing risks of death and potentially increased impact of therapy on global functioning and quality of life. This article discusses specific clinical end points and their advantages and disadvantages for older individuals.

Randomized or single-arm phase II trials can provide insight into the range of efficacy and toxicity in older populations but ideally need to be confirmed in phase III trials, which are unfortunately often hindered by the severe heterogeneity of the older cancer population, difficulties with selection bias depending on inclusion criteria, physician perception, and barriers in willingness to participate. All clinical trials in oncology should be without an upper age limit to allow entry of eligible older adults. In settings where so-called standard therapy is not feasible, specific trials for older patients with cancer might be required, integrating meaningful measures of outcome. Not all questions can be answered in randomized clinical trials, and large observational cohort studies or registries within the community setting should be established (preferably in parallel to randomized trials) so that treatment patterns across different settings can be compared with impact on outcome. Obligatory integration of a comparable form of geriatric assessment is recommended in future studies, and regulatory organizations such as the European Medicines Agency and US Food and Drug Administration should require adequate collection of data on efficacy and toxicity of new drugs in fit and frail elderly subpopulations.

A prospective evaluation of patients' health-related quality of life during auto-SCT: a 3-year follow-up

Few studies have evaluated long-term health-related quality of life (HRQL) in patients during auto-SCT. This prospective study examined HRQL in 96 eligible patients before, during and up to 3 years after auto-SCT. The aim of the study was to make a comprehensive assessment of the frequency and severity of different symptoms in patients undergoing auto-SCT. The European Organization for Treatment and Research of Cancer Quality of Life Questionnaire (EORTC QLQ C-30) was administered 13 times. The second week during treatment was the period when patients had the lowest HRQL regarding both total quality of life and function and symptom scales. The patients recovered quickly and just two months after transplantation the baseline values were restored. Three years after transplantation most of the items in the questionnaire had stabilized, except role function and dyspnea, which had improved. There were significant differences between multiple myeloma (MM) and lymphoma patients' physical function, quality of life, fatigue and pain during week 2. At the 3-year follow-up, lymphoma patients indicated a better HRQL than MM patients. The quick recovery of patients after transplantation suggests that treatment is well tolerated; however, the supportive care could be improved at week 2, especially for the lymphoma patients.

A 'short walk' is longer before radiotherapy than afterwards: a qualitative study questioning the baseline and follow-up design

Background

Numerous studies have indirectly demonstrated changes in the content of respondents' QoL appraisal process over time by revealing response-shift effects. This is the first known study to qualitatively examine the assumption of consistency in the content of the cognitive processes underlying QoL appraisal over time. Specific objectives are to examine whether the content of each distinct cognitive process underlying QoL appraisal is (dis)similar over time and whether patterns of (dis)similarity can be discerned across and within patients and/or items.

Methods

We conducted cognitive think-aloud interviews with 50 cancer patients prior to and following radiotherapy to elicit cognitive processes underlying the assessment of 7 EORTC QLQ-C30 items. Qualitative analysis of patients' responses at baseline and follow-up was independently carried out by 2 researchers by means of an analysis scheme based on the cognitive process models of Tourangeau et al. and Rapkin & Schwartz.

Results

The interviews yielded 342 comparisons of baseline and follow-up responses, which were analyzed according to the five cognitive processes underlying QoL appraisal. The content of comprehension/frame of reference changed in 188 comparisons; retrieval/sampling strategy in 246; standards of comparison in 152; judgment/combinatory algorithm in 113; and reporting and response selection in 141 comparisons. Overall, in 322 comparisons of responses (94%) the content of at least one cognitive component changed over time. We could not discern patterns of (dis)similarity since the content of each of the cognitive processes differed across and within patients and/or items. Additionally, differences found in the content of a cognitive process for one item was not found to influence dissimilarity in the content of that same cognitive process for the subsequent item.

Conclusions

The assumption of consistency in the content of the cognitive processes underlying QoL appraisal over time was not found to be in line with the cognitive processes described by the respondents. Additionally, we could not discern patterns of (dis)similarity across and within patients and/or items. In building on cognitive process models and the response shift literature, this study contributes to a better understanding of patient-reported QoL appraisal over time.

EORTC elderly task force position paper: approach to the older cancer patient

As a result of an increasing life expectancy, the incidence of cancer cases diagnosed in the older population is rising. Indeed, cancer incidence is 11-fold higher in persons over the age of 65 than in younger ones. Despite this high incidence of cancer in older patients, solid data regarding the most appropriate approach and best treatment for older cancer patients are still lacking, mostly due to under-representation of these patients in prospective clinical trials. The clinical behaviour of common malignant diseases, e.g. breast, ovarian and lung cancers, lymphomas and acute leukaemias, may be different in older patients because of intrinsic variation of the neoplastic cells and the ability of the tumour host to support neoplastic growth. The decision to treat or not these patients should be based on patients' functional age rather than the chronological age. Assessment of patients' functional age includes the evaluation of health, functional status, nutrition, cognition and the psychosocial and economic context. The purpose of this paper is to focus on the influence of age on cancer presentation and cancer management in older cancer patients and to provide suggestions on clinical trial development and methodology in this population.

Patient-reported outcomes after cytotoxic chemotherapy in metastatic castration-resistant prostate cancer: a systematic review

BACKGROUND

In the clinical setting of metastatic castration-resistant prostate cancer the aim of treatment is palliation. Palliation can refer to symptom management or non-curative treatments. Patient-reported outcome is any outcome based on data provided by patients. The aim of this paper is to perform a systematic review of clinical trials including a patient-reported outcome assessment in patients treated with cytotoxic chemotherapy, and to compare their results by traditional medical and patient-reported outcomes assessment.

METHODS

In November 2009 a literature search for published studies was undertaken. Selected phase-3 studies were primarily evaluated on the quality of patient-reported outcomes reporting and assessment methodology.

FINDINGS

Health-related quality of life assessment was the most common endpoint, pain control the second one. Results of patient-reported and traditional endpoints analysis are resumed, as well as methodology assessment and quality of patient-reported outcomes reporting. Frequently, methodologic limitations affect patient-reported outcomes assessment in clinical trials, either data analysis, particularly not reporting individual scores of health-related quality of life questionnaires, statistical corrections, limited efforts to avoid missing data, or lacking report of duration of palliative response.

CONCLUSIONS

Results of trials can differ if different outcomes, medical or patient-reported, are considered in the analysis. Cytotoxic chemotherapy of metastatic castration-resistant prostate cancer is a challenging issue. A survival benefit is reported only for docetaxel, but this treatment is not always feasible. In all patients, initiation of chemotherapy should be based on patient's preferences within discussion of individual risk and benefit, particularly in patients with extensive asymptomatic and symptomatic metastases.

Technology and quality of life outcomes

OBJECTIVES

To discuss recent technological advances in quality of life (QOL) data collection and guidance for use in research and clinical practice. The use of telephone-, computer-, and web/internet-based technologies to collect QOL data, reliability and validity issues, and cost will be discussed, along with the potential pitfalls associated with these technologies.

DATA SOURCES

Health care literature and web resources.

CONCLUSION

Technology has provided researchers and clinicians with an opportunity to collect QOL data from patients that were previously not accessible. Most technologies offer a variety of options, such as language choice, formatting options for the delivery of questions, and data management services. Choosing the appropriate technology for use in research and/or clinical practice primarily depends on the purpose for QOL data collection.

IMPLICATIONS FOR NURSING PRACTICE

Technology is changing the way nurses assess QOL in patients with cancer and provide care. As stakeholders in the health care delivery system and patient advocates, nurses must be intimately involved in the evaluation and use of new technologies that impact QOL and/or the delivery of care.

EORTC Elderly Task Force experts' opinion for the treatment of colon cancer in older patients

As a result of an increasing life expectancy, the incidence of colon cancer in the older population is rising. As a consequence oncologists and their older patients commonly face the dilemma of whether or not to give/receive treatment for colon cancer. However, the paucity of large, well conducted prospective trials makes it difficult to provide evidence-based clinical recommendations for these patients. The current evidence supports the safety and efficacy of treatment for colon cancer in fit older patients and demonstrates that treatment outcome can be similar to that of their younger counterparts. However, it should be noted that these data are derived from retrospective studies which are likely to suffer from selection bias. Despite a growing body of data, further work is still needed to establish optimal strategies to care for this special population and prospective specific trials for older colon cancer patients are clearly needed.

Reporting and interpretation of SF-36 outcomes in randomised trials: systematic review

OBJECTIVE

To determine how often health surveys and quality of life evaluations reach different conclusions from those of primary efficacy outcomes and whether discordant results make a difference in the interpretation of trial findings.

DESIGN

Systematic review.

DATA SOURCES

PubMed, contact with authors for missing information, and author survey for unpublished SF-36 data.

STUDY SELECTION

Randomised trials with SF-36 outcomes (the most extensively validated and used health survey instrument for appraising quality of life) that were published in 2005 in 22 journals with a high impact factor.

DATA EXTRACTION

Analyses on the two composite and eight subdomain SF-36 scores that corresponded to the time and mode of analysis of the primary efficacy outcome.

RESULTS

Of 1057 screened trials, 52 were identified as randomised trials with SF-36 results (66 separate comparisons). Only eight trials reported all 10 SF-36 scores in the published articles. For 21 of the 66 comparisons, SF-36 results were discordant for statistical significance compared with the results for primary efficacy outcomes. Of 17 statistically significant SF-36 scores where primary outcomes were not also statistically significant in the same direction, the magnitude of effect was small in six, moderate in six, large in three, and not reported in two. Authors modified the interpretation of study findings based on SF-36 results in only two of the 21 discordant cases. Among 100 additional randomly selected trials not reporting any SF-36 information, at least five had collected SF-36 data but only one had analysed it.

CONCLUSIONS

SF-36 measurements sometimes produce different results from those of the primary efficacy outcomes but rarely modify the overall interpretation of randomised trials. Quality of life and health related survey information should be utilised more systematically in randomised trials.

Psychosocial consequences of genetic counseling: a population-based follow-up study

We aimed to examine the psychosocial impact of genetic counseling for hereditary breast and ovarian cancer 1 year following genetic counseling. We conducted a population-based prospective follow-up study of 213 women who received genetic counseling for hereditary breast and ovarian cancer, 319 women who underwent mammography (Reference Group I), and a random sample of 1,070 women from the general population (Reference Group II). The prevalence of anxiety decreased by 4.7% (95% CI: -3.5; 12.8) from baseline to 1 year of follow-up in the Genetic Counseling Group. Likewise, it decreased by 2.5% (95% CI: -4.5; 9.5) in Reference Group I and by 1.1% (95% CI: -2.3; 4.7) in Reference Group II. The prevalence of depression increased equally (1-3%) in the three study groups. 52% of the women referred for genetic counseling experienced cancer-specific distress at baseline and this proportion decreased to 41% after 12 months of follow-up. This decrease of 10.8% (95% CI: 1.4; 20.8) exceeded the decrease observed in both Reference Groups. However, it was statistically significant only in the case of Reference Group II (p=0.006). Our findings indicate that genetic counseling can help alleviate cancer-specific distress among women with a family history of breast and ovarian cancer. Further, genetic counseling does not appear to have an adverse impact on general anxiety, symptoms of depression, or health-related quality of life.

Clarifying quality of life assessment: do theoretical models capture the underlying cognitive processes?

OBJECTIVE

To develop an analysis scheme capturing the cognitive processes underlying QoL assessment to increase our understanding on how to interpret responses to QoL items. Tourangeau et al.'s (The psychology of survey response, 2000) and Rapkin and Schwartz' (Health Qual Life Outcomes 2:14, 2004) cognitive process models form the basis for this analysis scheme.

METHODS

We conducted think aloud interviews with six cancer patients prior to and following radiotherapy to elicit the cognitive processes underlying the assessment of 7 EORTC QLQ-C30 items. Content analysis was carried out by two to four researchers independently. Eighty text fragments were analyzed inductively and combined in an iterative process with deductive analyses based on both models.

RESULTS

We have developed a comprehensive analysis scheme feasible for analyzing the cognitive processes underlying QoL assessment qualitatively. All cognitive components of both models could be distinguished in our data. The cognitive component 'reporting and response selection' needed extension to fully capture the cognitive processes used.

CONCLUSION

The two models combined are useful in describing the cognitive processes cancer patients use in answering QoL items, and as such facilitate insight into patients' self-reported QoL assessments. Interestingly, the content of the cognitive processes not only differed between patients but also between items within patients and over time.

Depression and functional impairment independently contribute to decreased quality of life in cancer patients prior to chemotherapy

BACKGROUND

An inverse association either between depression or impaired functional status and quality of life (QoL) has been reported for cancer patients, but the independent effect of depression or depressive symptoms and of functional impairment on QoL is unclear.

PATIENTS AND METHODS

We investigated the prevalence of depression or depressive symptoms with the Beck Depression Inventory (BDI), the functional impairment with the ECOG-Performance-Status (ECOG-PS) and the QoL with the EORTC-QLQ-C30 questionnaire in a sample of 175 hospitalised cancer patients prior to the start of chemotherapy.

RESULTS

Sixteen of 175 patients (9.1%) screened positive for major depression, 29 (16.6%) had mild to moderate depressive symptoms. In 11 of 15 scales of the EORTC-QLQ-C30 questionnaire depression or depressive symptoms were significantly associated with worse QoL in univariate analysis and in 12 of 15 scales poor ECOG-PS was significantly associated with worse QoL. In multivariate analysis including ECOG-PS and BDI, the effect of depression and/ or depressive symptoms on QoL was persistent in seven scales: global QoL, physical- and role functioning, fatigue, nausea & vomiting, pain, and constipation, that of ECOG-PS in five scales: global QoL, emotional functioning, nausea & vomiting, pain, and appetite loss.

CONCLUSIONS

Signs of major depression or depressive symptoms and impaired functional status contribute independently to poorer QoL in cancer patients prior to chemotherapy.

The need for education on health related-quality of life

BACKGROUND

Health-related quality of life is increasingly recognised as an important outcome measure that complements existing measures of clinical effectiveness. The education available on this subject for different healthcare professionals is varied. This article describes the design, implementation and evaluation of a Special Study Module on Health-Related Quality of Life for undergraduate medical students at the University of Birmingham.

METHODS

The course involves 10 hours of "guided discovery learning" covering core concepts of Health-Related Quality of Life assessment including methodological considerations, use in clinical trials, routine practice and in health policy followed by self-directed learning. The taught components aim to provide students with the skills and knowledge to enable them to explore and evaluate the use of quality of life assessments in a particular patient group, or setting, through self-directed learning supported by tutorials.

RESULTS

The use of case studies, recent publications and research, and discussion with a research oncology nurse in task-based learning appeared to provide students with a stimulating environment in which to develop their ideas and was reflected in the diverse range of subjects chosen by students for self-directed study and the positive feedback on the module. Course evaluation and student assessment suggests that quality of life education appears to integrate well within the medical curriculum and allows students to develop and utilise skills of time-management and independent, self-directed learning that can be applied in any context.

CONCLUSION

We suggest that education and training initiatives in quality of life may improve the quality of studies, and help bridge the gap between research and clinical practice. Resources for curriculum development on health-related quality of life have been developed by the International Society for Quality of Life Research and may prove a useful tool to educators interested in this area.

Prognostic value of health-related quality-of-life data in predicting survival in patients with anaplastic oligodendrogliomas, from a phase III EORTC brain cancer group study

PURPOSE

This is one of a few studies that have explored the value of baseline symptoms and health-related quality of life (HRQOL) in predicting survival in patients with brain cancer.

PATIENTS AND METHODS

Baseline HRQOL scores (from the European Organisation for Research and Treatment of Cancer [EORTC] Quality of Life Questionnaire C30 and the EORTC Brain Cancer Module) were examined in 247 patients with anaplastic oligodendrogliomas to determine the relationship with overall survival by using Cox proportional hazards regression models. Refined techniques as the bootstrap resampling procedure and the computation of C indexes and R2 coefficients were used to explore the stability of the models as well as better assess the potential benefit of using HRQOL to predict survival in clinical practice and research.

RESULTS

Classical analysis controlled for major clinical prognostic factors selected emotional functioning (P = .0016), communication deficit (P = .0261), future uncertainty (P = .0481), and weakness of legs (P = .0001) as statistically significant prognostic factors of survival. However, several issues question the validity of these findings and no single model was found to be preferable over all others. C indexes, which estimate the probability of a model to correctly predict which patient among a randomly chosen pair of patients will survive longer, and R2 coefficients, which measure the proportion of variability explained by the model, did not exhibit major improvement when adding selected or all HRQOL scores to clinical factors.

CONCLUSION

While classical techniques lead to positive results, more refined analyses suggest that baseline HRQOL scores add relatively little to clinical factors to predict survival. These results may have implications for future use of HRQOL as a prognostic factor for patients with cancer.

Integrating Patient-Reported Outcomes Into Cancer Symptom Management Clinical Trials Supported by the National Cancer Institute–Sponsored Clinical Trials Networks

Patient-reported outcomes (PROs) are often the primary end point in symptom management trials. The scientific field of PROs is evolving, as evidenced by the US Food and Drug Administration's February 2007 release of a draft guidance for using PROs in effectiveness claims for drug labeling. This article presents issues encountered during use of PROs in National Cancer Institute–sponsored symptom management trials. Selected trials are presented that exemplify the challenges often seen in symptom management trials, and solutions are described. The examples presented include defining the appropriate end point, selecting and validating assessments, and answering the research questions through statistical analysis and interpretation. Progress has been made in addressing some of the unique challenges of PRO-based symptom management research. Many challenges still remain, but a foundational body of work now exists for more consistent and rigorous application of PROs into symptom management trials. There remains a need for more research in several methodologic aspects of design, analysis, and interpretation of symptom management trials.

Quality of life and/or symptom control in randomized clinical trials for patients with advanced cancer

BACKGROUND

Measures reflecting quality of life (QoL) or symptom control should be included as major endpoints in most phase III trials for patients with advanced cancer. Here we review the use of such endpoints.

METHODS

We evaluated methodological aspects relating to QoL or symptom control in randomized controlled trials (RCTs) that included >or=150 patients, published from 1994 to 2004, using a 10-point checklist.

RESULTS

Of 112 RCTs that met our criteria, few were rated as high quality: 22% defined QoL or symptom control as a primary endpoint; 19% established an a priori hypothesis relevant to palliation and 21% defined minimal differences in QoL or symptom scores that were clinically meaningful. Most trials (81%) analyzed differences between mean or median scores across groups and only 21% defined the proportion of individual patients who met criteria for palliative response. Only 15% of the studies met more than 5/10 criteria from our checklist. There was improvement over time in methodology and reporting.

CONCLUSIONS

Current standards for analyzing QoL and symptom control in RCTs are poor. Definition of a palliative endpoint, with an a priori hypothesis, is essential; defining the proportion of patients with palliative response is preferred. The proposed checklist could raise standards of reporting in future RCTs.

Quality-of-life in elderly patients with cancer: a short review

BACKGROUND

Prolongation of survival and maintenance or improvement of health-related quality-of-life (HRQoL) are the two important goals within the treatment of individual patients. Due to the severity of symptoms and the toxicity of treatment, HRQoL has become a major area of concern when treating cancer patients in general and elderly patients in particular.

PATIENTS AND METHODS

We present a literature review of HRQoL aspects in elderly patients with cancer and especially address the topic whether impairments in the different tools of a comprehensive geriatric assessment (CGA) are associated with decreased HRQoL in elderly cancer patients.

RESULTS

Elderly cancer patients tend to weight their HRQoL as more important than gain in survival, when compared to younger patients. An age-dependent decrease in different scales of HRQoL is reported in patients and normative samples. HRQoL is also a predictor of survival. The variation of HRQoL can be used in trials comparing different treatment options. In individual patients, regular measurement of HRQoL aims to improve patients-centred care. Age related impairments of different areas of CGA are associated with decreased HRQoL in elderly cancer patients.

CONCLUSIONS

HRQoL is an important outcome with elderly cancer patients and should be assessed regularly and thoroughly.

The prognostic value of health-related quality-of-life data in predicting survival in glioblastoma cancer patients: results from an international randomised phase III EORTC Brain Tumour and Radiation Oncology Groups, and NCIC Clinical Trials Group study

This is one of the few studies that have explored the value of baseline symptoms and health-related quality of life (HRQOL) in predicting survival in brain cancer patients. Baseline HRQOL scores (from the EORTC QLQ-C30 and the Brain Cancer Module (BN 20)) were examined in 490 newly diagnosed glioblastoma cancer patients for the relationship with overall survival by using Cox proportional hazards regression models. Refined techniques as the bootstrap re-sampling procedure and the computation of C-indexes and R²-coefficients were used to try and validate the model. Classical analysis controlled for major clinical prognostic factors selected cognitive functioning (P=0.0001), global health status (P=0.0055) and social functioning (P<0.0001) as statistically significant prognostic factors of survival. However, several issues question the validity of these findings. C-indexes and R²-coefficients, which are measures of the predictive ability of the models, did not exhibit major improvements when adding selected or all HRQOL scores to clinical factors. While classical techniques lead to positive results, more refined analyses suggest that baseline HRQOL scores add relatively little to clinical factors to predict survival. These results may have implications for future use of HRQOL as a prognostic factor in cancer patients.

Prospective multicentric randomized phase III study of imatinib in patients with advanced gastrointestinal stromal tumors comparing interruption versus continuation of treatment beyond 1 year: the French Sarcoma Group

PURPOSE

Imatinib is the standard treatment of advanced GI stromal tumors (GISTs). It is not known whether imatinib may be stopped in patients in whom disease is controlled.

METHODS

This prospective, randomized, multicentric phase III study was designed to compare continuous (CONT) compared with interrupted (INT) imatinib beyond 1 year of treatment in patients with advanced GIST. The primary end point was progression-free survival. Secondary end points included overall survival, response rate after reinitiation of imatinib, and quality of life. Early stopping rules in cases of rapid progression of disease were defined, with preplanned interim analyses.

RESULTS

Between May 2002 and April 2004, 182 patients with advanced GIST were enrolled. Between May 2003 and April 2004, 98 patients in response or stable disease under imatinib reached more than 1 year of follow-up. Forty were not eligible for randomization, and 58 patients were randomly assigned, 32 and 26 patients in the INT and CONT arms, respectively. As of October 15, 2005, eight of 26 patients in the CONT group and 26 of 32 patients in the INT group had documented disease progression (P < .0001). Twenty-four of 26 patients with documented progression in the INT arm responded to imatinib reintroduction. No differences in overall survival or imatinib resistance were observed between the two arms. Quality of life evaluated 6 months after random assignment using the 30-item Quality of Life Questionnaire was not significantly different between the two groups of randomly assigned patients.

CONCLUSION

Imatinib interruption results in rapid progression in most patients with advanced GIST, and cannot be recommended in routine practice unless patient experience significant toxicity

Issues for Statisticians in Conducting Analyses and Translating Results for Quality of Life End Points in Clinical Trials

Quality of life (QOL) end points in pharmaceutical clinical trials are at a crossroads. On the one hand, much has been learned in recent years of how to efficiently and effectively measure patient QOL. On the other hand, investigators and regulatory agencies still struggle with exactly how to assess the results of QOL end points and other patient-reported outcomes. Statisticians are often left in the position of having to bridge the gap between investigators who want to assess patient QOL and regulatory bodies who want a sound scientific rationale and analysis plan for doing so. Unfortunately, little has been written specifically for the statistical audience to assist in this translation. The purpose of this paper is to attempt to bridge this gap. We will describe the language and methods that have been successful in translating the psychometric and statistical challenges into understandable findings for investigators and regulatory agencies. One of the most important advances is the development of a general guideline for assessing clinical significance, namely the "half standard deviation" method based on the empirical rule effect size (ERES) approach. We populate the paper with concrete examples of how QOL data need not be treated any different, in terms of statistical analysis, than tumor response or other clinical end points.

Anaemia-related impairment in quality of life in elderly cancer patients prior to chemotherapy

PURPOSE

Quality of life (QoL) of patients with cancer is a major area of concern for both patients and their physicians.

PATIENTS AND METHODS

We investigated QoL with the EORTC-QLQ-C30 questionnaire with reference to anaemia and Karnofsky Performance Status (KPS) prior to the start of chemotherapy in 477 patients: 195 elderly cancer patients (Group A), 152 younger cancer patients (Group B), and 130 patients aged 60 years or older admitted for non-cancer related disorders (Group C).

RESULTS

In univariate analysis QoL was significantly worse in 8 out of 15 scales in anaemic compared to non anaemic patients in Group A, in 2 in Group B, and in 7 in Group C. In ANOVA analysis including KPS and haemoglobin status, the influence of anaemia and KPS independently persists in most scales in Group A, in some in Group C, but not in Group B.

CONCLUSIONS

Anaemia and functional impairment are independently related to QoL in elderly cancer and elderly medical patients, but not in younger cancer patients.

Total laparoscopic versus open surgery for stage 1 endometrial cancer: The LACE randomized controlled trial

PURPOSE

Endometrial cancer is the most common gynaecological malignancy in Australia and the US. Current standard treatment involves open surgery to remove the uterus, and both tubes and ovaries (TAH). The Laparoscopic Approach to Cancer of the Endometrium (LACE) trial was designed to assess equivalence of performing this in a total laparoscopic approach (TLH).

METHODS

Patient recruitment was designed to proceed along two stages to accommodate for a potential increase in patient requests of laparoscopic surgery. During the first stage, patients are randomised in a 2:1 allocation to receive TLH or TAH, with the primary endpoint quality of life (QoL) at 6 month post-surgery, requiring 180 patients to be enrolled to have 80% power at alpha=0.05 to detect a clinically significant difference of 8 points on the Functional Assessment of Cancer General (FACT-G) QoL instrument. If additional recruitment of patients seems impossible after accrual of 180 patients, this cohort will be followed for 4 years, and disease free survival (DFS) of patients treated by TLH will be compared to DFS within the endometrial cancer population. During the second stage, recruitment will be extended to a total of 590 patients in a 1:1 TLH:TAH allocation, to assess the equivalence with respect to DFS with 80% power and alpha=0.05. Equivalence will be assumed if the difference in DFS does not exceed 7% at 4 years. Secondary outcomes include treatment related morbidity; costs and cost-effectiveness; patterns of recurrence; and overall survival. All data from this multicentre study will be entered using online electronic case report forms (e-CRF), allowing real time assessment of data completeness and patient follow-up.

CONCLUSIONS

The LACE trial will establish the equivalence of a TLH approach for patients with stage 1 endometrial cancer following a two stage protocol to accommodate potential threats to patient recruitment through requests for laparoscopic surgery.

Breast surgery: minimally invasive diagnosis and treatment

The increasingly large proportion of elderly women in the United States population carries a disproportionate burden of breast cancer. The advent of minimally invasive surgical techniques applicable to breast disease has brought new opportunities to diagnose and treat breast cancer in the older population. This article reviews issues important to the evolving field of breast cancer management in older women: cancer risk and screening considerations, diagnosis and biopsy approaches, and surgical treatment options based on current studies and recommendations.

Assessment of quality of life outcomes in the treatment of advanced colorectal malignancies

QOL assessment in oncology has made great strides in recent years. There was a difficult time initially, during which QOL tools were "thrown in" to many clinical trials as an afterthought, without a pre-specified scientific question. As expected from such a scattershot approach, the results were underwhelming and disappointing. The disappointing results from this period led many practitioners to question the value added by QOL assessment in oncology clinical trials. This healthy skepticism has led to a renaissance period, in which situation-specific and disease-specific QOL assessments have been developed and have contributed substantial information to the cause of the disease, the effects of treatments, and the experiences of cancer patients. Today, there is a dawning recognition that asking the patient directly about their QOL using the same scientific rigor required of other clinical outcomes can provide valuable data for prognosis, treatment, symptom management, and supportive care. With time and further successful experiences like those cited in this article, QOL assessment may eventually become as routinely collected and integrated into oncology clinical practice as pain and blood pressure assessments are today.

Health related quality of life outcomes in cancer clinical trials

Over the last decade, health related quality of life (HRQOL) investigations have become an increasingly important part of many cancer clinical trial research programs. This paper presents a review of all HRQOL studies published by the European Organisation for Research and Treatment of Cancer (EORTC), one of the largest clinical trials organisations in Europe. The findings highlight 24 clinical trials that have been published to date, enrolling over 9000 patients. HRQOL is fully integrated into EORTC phase III trials. In many trials, HRQOL provides a valuable source of additional information useful to both clinician and patient when making treatment decisions. Furthermore, several trials have found that the combined use of clinical information along with HRQOL data has led to the development of new standards of care in several different cancer sites. With more than 40 ongoing HRQOL studies in the EORTC, we expect HRQOL to play an even greater role over the coming decade in helping establish the optimal treatment and care approach for cancer patients.

Quality of life in gastric cancer

AIM: To summarize the empirical research on assessing quality of life (QOL) in patients with gastric carcinoma.

METHODS: Literature searches were conducted in MedLine from 1966 to February 2004.

RESULTS: Twenty-six studies were identified. QOL was used as an outcome measure in virtually all identified studies, such as those examining the effects of gastric cancer and various medical or surgical treatments in the patients. QOL was assessed mainly with generic measures; the social dimensions of QOL were largely neglected. The lack of gastric cancer-specific QOL measures hampers QOL research up to now. The gastric cancer-specific EORTC-QLQ-STO22 and the FACT-Ga are important additions to the arsenal of disease-specific QOL measures. In most of the studies, the label QOL is used for questionnaires, which only assess symptoms or performance status, or are physician-reported rather than patient-reported outcomes.

CONCLUSION: QOL in patients with gastric cancer deserves more systematic studies, especially as one of the outcome measures in randomized clinical trials. Results of studies that include QOL in patients with gastric cancer should be applied in clinical care, which aims at improving QOL of these patients.

Health-related quality of life in survivors of locally advanced breast cancer: an international randomised controlled phase III trial

BACKGROUND

Dose-intensive chemotherapy has generated much interest in the treatment of patients with locally advanced breast cancer because it might offer a survival benefit. We aimed to compare the effects of such an approach with those of standard chemotherapy on health-related quality of life (HRQOL).

METHODS

224 patients with locally advanced breast cancer were randomly assigned to 75 mg/m(2) cyclophosphamide given orally on days 1-14, and 60 mg/m(2) epirubicin and 500 mg/m(2) fluorouracil both given intravenously on days 1 and 8, for six cycles every 28 days (6 months' treatment; standard treatment) and 224 patients to 830 mg/m(2) cyclophosphamide and 120 mg/m(2) epirubicin both given intravenously on day 1, and 5 microg/kg filgrastim per day given subcutaneously on days 2-13, for six cycles every 14 days (3 months' treatment; dose-intensive treatment). HRQOL was assessed by use of the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30). Baseline assessments were done before randomisation; then once a month for the first 3 months; and at months 6, 9, 12, 18, 26, 34, 42, 48, and 54. The primary endpoint was progression-free survival; secondary endpoints were HRQOL, response, safety, overall response, and health economics. Analyses were by intention to treat.

FINDINGS

Previously reported data showed that groups did not differ in progression-free survival. Patients assigned shorter, intensified treatment had a significantly lower overall HRQOL score during the first 3 months than did those assigned standard treatment (mean score at 3 months 41.8 [SD 1.78] vs 49.6 [1.64], p=0.0015). However, scores returned to near baseline, with no difference between groups, at 12 months (62.6 [1.97] vs 65.6 [2.04], p=0.3007). Over the remaining 2 years, the groups showed few significant differences in HRQOL.

INTERPRETATION

Dose-intensive treatment only has a temporary effect on HRQOL, thus enabling more research on intensive treatment for patients with locally advanced breast cancer.

What are we trying to measure? Rethinking approaches to health outcome assessment for the older person with cancer

The health burden of cancer within the older population is well recognized. For many of these patients, interventions and treatments will focus predominantly on improvements in health outcomes. There has been substantial interest in the development and application of health outcome assessments for use in cancer patients, yet in comparison, there has been less focus on the older person with cancer. This paper will review current perspectives on health outcome assessment in older people with cancer; the methodological challenges associated with this work and present recommendations for future work, including the potential application of a 'user-generated' approach to health outcome assessment in the older person with cancer.

Health-related quality of life in women previously treated for early-stage breast cancer

This study describes health-related quality of life (HRQOL) in women previously treated for early stage breast cancer relative to general population and breast cancer norms. It also identifies correlates and multivariate predictors of physical and mental HRQOL. 2582 women who were up to four years post-treatment for early stage breast cancer completed the RAND-36 Health Survey and reported personal and cancer-related information. Participants reported generally high HRQOL that was comparable to norms for women in the general population and other women with breast cancer. In multivariate analyses, better physical HRQOL was associated with fewer psychological symptoms, lower body mass index, better sleep quality, and more physical activity. Better mental HRQOL was associated with better sleep quality, fewer life events, less pain, and fewer gastrointestinal symptoms. Interventions targeting psychosocial symptoms, weight reduction, physical activity, sleep hygiene, and pain could result in improved HRQOL in these women.

Quality of life and trial adherence among participants in the prostate, lung, colorectal, and ovarian cancer screening trial

BACKGROUND

The National Cancer Institute's Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial was designed to examine whether annual screening tests for these four tumor sites result in reduced disease-related mortality. We assessed the impact of trial participation on both health-related quality of life (HRQL) and trial adherence.

METHODS

Participants (N = 432; 217 in the control arm and 215 in screening arm) were accrued from the Georgetown University PLCO site from May through December 1998. Screening-arm participants were interviewed by telephone at baseline (prescreening), shortly after notification of screening results (short-term follow-up), and 9 months after notification of screening results (intermediate-term follow up). Control-arm participants completed a baseline and 1-year follow-up assessment. Logistic regression analyses were conducted.

RESULTS

Participants reported high levels of HRQL and satisfaction with their decision to participate. Screening-arm participants with abnormal screening results had a higher level of intrusive thoughts about cancer than those with all normal results (odds ratio [OR] = 2.9, 95% confidence interval [CI] = 1.3 to 6.3) at the short-term follow-up but not at the intermediate-term follow-up (when abnormal test results were known to be false positive; OR = 1.9, 95% CI = 0.89 to 4.2). Trial adherence was statistically significantly better among participants who had received all normal results in the previous year's screening tests (93.7% versus 78.7%; OR = 3.7, CI = 1.1 to 12.0) than in those who received at least one abnormal result. In the control arm, adherence (defined as returning annual questionnaires) was positively associated with education (OR = 3.4, 95% CI = 1.4 to 8.4) and sex, with women being more likely to return questionnaires than men (OR = 2.1, 95% CI = 1.05 to 4.4).

CONCLUSIONS

It is feasible to collect HRQL measures as part of a large cancer screening trial. Prior abnormal screening results were related to short-term HRQL but not to intermediate-term HRQL. Trial adherence was poorer among those who had received previous false-positive results. These results suggest several methods for improving adherence in this and other subgroups.

Use of health-related quality of life in prescribing research. Part 2: methodological considerations for the assessment of health-related quality of life in clinical trials

This article aims to address key methodological issues that should be considered when assessing health-related quality of life (HRQoL) in a clinical trial. These include justification for the selection of HRQoL as a primary or secondary outcome and choice of an appropriate instrument to assess HRQoL, which meets basic psychometric properties. In addition we consider ways to minimize bias within the trial through optimization of compliance and timing of assessments.

The economics of the colony-stimulating factors in the prevention and treatment of febrile neutropenia

Healthcare costs continue to rise with hospitalization representing the single largest component of direct medical costs associated with cancer care. Neutropenia and its complications including febrile neutropenia remain the major dose-limiting toxicity associated with systemic cancer chemotherapy. Febrile neutropenia often occurs early in the course of chemotherapy and is associated with substantial morbidity, mortality and cost. The colony-stimulating factors (CSFs) have been used effectively in a variety of clinical settings to prevent or treat febrile neutropenia and to assist patients receiving dose-intensive chemotherapy. A meta-analysis of the available randomized controlled trials (RCTs) has confirmed the efficacy of prophylactic CSFs. Economic models based on measures of resource utilization derived from RCTs have provided estimates of expected treatment costs along with febrile neutropenia risk threshold estimates for the cost saving use of the CSFs. Recent studies have demonstrated the potential value of targeting the CSFs toward patients at greatest risk based on accurate and valid predictive models.

Sleep management training for cancer patients with insomnia

Insomnia is a common phenomenon in cancer patients; nevertheless, there are only a few intervention results published covering this topic. We examined the effects of a multi-modal psychological sleep management programme combining relaxation techniques, sleep hygiene, cognitive techniques and advice in stimulus control technique on various sleep and quality-of-life variables. We compared two intervention groups up to 6 months after treatment, one with progressive muscle relaxation (n=80), the other with autogenic training (n=71). A control group (n=78) received only a standard rehabilitation programme. It was a heterogeneous sample of adult patients (mean age 58 years) predominantly with breast, kidney or prostate cancer staying for 3 or 4 weeks in an oncological rehabilitation clinic. In comparison to the control group, the analysis of variance for repeated measures (R-MANOVA) showed significant improvements over time, indicating that intervention group participants benefited with moderate- or large-scale effects on sleep latency (p<0.001), sleep duration (p<0.001), sleep efficiency (p<0.001), sleep quality (p<0.001), sleep medication (p<0.05) and daytime dysfunction (p<0.05). In quality-of-life subscales, there was mainly improvement over time. This may indicate a benefit of the rehabilitation treatment in general. No evidence was found for any differences between the two intervention groups. The results suggest that the use of a multi-modal psychological sleep intervention could enhance various sleep parameters and well being of patients. The efficacy on quality of life is still under review.

A randomized trial comparing 35Gy in ten fractions with 60Gy in 30 fractions of cerebral irradiation for glioblastoma multiforme and older patients with anaplastic astrocytoma

A randomized prospective clinical trial was conducted to compare conventional high dose radiotherapy with hypofractionated, short course radiotherapy in poor prognosis patients with high grade glioma. The primary endpoint was overall survival.