An agenda for research into uterine artery embolization: results of an expert panel conference

Expert Consensus Recommendations on the Management of Treatment-emergent Adverse Events Among Men with Prostate Cancer Taking Poly-ADP Ribose Polymerase Inhibitor + Novel Hormonal Therapy Combination Therapy

BACKGROUND AND OBJECTIVE

Recent clinical trials have shown improvement in progression-free survival in men with metastatic prostate cancer (mPC) treated with combination poly-ADP ribose polymerase (PARP) inhibitors (PARPi) and novel hormonal therapy (NHT). Regulatory bodies in the USA, Canada, Europe, and Japan have recently approved this combination therapy for mPC. Common adverse events (AEs) include fatigue, nausea and vomiting, and anemia. Nuanced AE management guidance for these combinations is lacking. The panel objective was to develop expert consensus on AE management in patients with mPC treated with the combination PARPi + NHT.

METHODS

The RAND/University of California Los Angeles modified Delphi Panel method was used. AEs were defined using the Common Terminology Criteria for Adverse Events. Twelve experts (seven medical oncologists, one advanced practice registered nurse, three urologists, and one patient advocate) reviewed the relevant literature; independently rated initial AE management options for the agent suspected of causing the AE for 419 patient scenarios on a 1-9 scale; discussed areas of agreement (AoAs) and disagreement (AoDs) at a March 2023 meeting; and repeated these ratings following the meeting. Second-round ratings formed the basis of guidelines.

KEY FINDINGS AND LIMITATIONS

AoDs decreased from 41% to 21% between the first and second round ratings, with agreement on at least one management strategy for every AE. AoAs included the following: (1) continue therapy with symptomatic treatment for patients with mild AEs; (2) for moderate fatigue, recommend nonpharmacologic treatment, hold treatment temporarily, and restart at a reduced dose when symptoms resolve; (3) for severe nausea or any degree of vomiting where symptomatic treatment fails, hold treatment temporarily and restart at a reduced dose when symptoms resolve; and (4) for hemoglobin 7.1-8.0 g/dl and symptoms of anemia, hold treatment temporarily and restart at a reduced dose after red blood cell transfusion.

CONCLUSIONS AND CLINICAL IMPLICATIONS

This expert guidance can support management of AEs in patients with mPC receiving combination PARPi + NHT therapy.

PATIENT SUMMARY

A panel of experts developed guidelines for adverse event (AE) management in patients with metastatic prostate cancer treated with a combination of poly-ADP ribose polymerase inhibitors and novel hormonal therapy. For mild AEs, continuation of cancer therapy along with symptomatic treatment is recommended. For moderate or severe AEs, cancer therapy should be stopped temporarily and restarted at the same or a reduced dose when AE resolves.

An Adaptation of the RAND/UCLA Modified Delphi Panel Method in the Time of COVID-19

The RAND/UCLA modified Delphi panel method is a formal group consensus process that systematically and quantitatively combines expert opinion and evidence by asking panelists to rate, discuss, then re-rate items. The method has been used to develop medical society guidelines, other clinical practice guidelines, disease classification systems, research agendas, and quality improvement interventions. Traditionally, a group of experts meet in person to discuss results of a first-round survey. After the meeting, experts complete a second-round survey used to develop areas of consensus. During the COVID-19 pandemic, this aspect of the method was not possible. As such, we have adapted the method to conduct virtual RAND/UCLA modified Delphi panels. In this study, we present a targeted literature review to describe and summarize the existing evidence on the RAND/UCLA modified Delphi panel method and outline our adaptation for conducting these panels virtually. Transitioning from in-person to virtual meetings was not without challenges, but there have also been unexpected advantages. The method we describe here can be a cost-effective and efficient alternative for researchers and clinicians.

Uterine artery embolization or myomectomy for women with uterine fibroids: Four-year follow-up of a randomised controlled trial

Objective

To examine the quality of life experienced by women with symptomatic uterine fibroids who had been treated with UAE in comparison to myomectomy. We report the four-year follow-up of the FEMME randomised trial. Two-year follow-up data has been previously reported.

Study Design

Premenopausal women who had symptomatic uterine fibroids amenable to myomectomy or uterine artery embolization were recruited from 29 UK hospitals. Women were excluded if they had significant adenomyosis, any malignancy, pelvic inflammatory disease or had had a previous open myomectomy or uterine artery embolization.

Participants were randomised to myomectomy or embolization in a 1:1 ratio using a minimisation algorithm. Myomectomy could be open abdominal, laparoscopic or hysteroscopic, according to clinician preference. Embolization of the uterine arteries was performed according to local practice, under fluoroscopic guidance.

The primary outcome measure was the Uterine Fibroid Symptom Quality of Life questionnaire, adjusted for baseline score and reported here at four years post-randomisation. Subsequent procedures for fibroids, pregnancy and outcome were amongst secondary outcomes.

Trial registration ISRCTN70772394 https://doi.org/10.1186/ISRCTN70772394

Results

254 women were randomized, 127 to myomectomy (105 underwent myomectomy) and 127 to uterine artery embolization (98 underwent embolization). At four years, 67 (53%) and 81 (64%) completed UFS-QoL quality of life scores. Mean difference in the UFS-QoL at 4 years was 5.0 points (95% CI −1.4 to 11.5; p = 0.13) in favour of myomectomy. There were 15 pregnancies in the UAE group and 7 in the myomectomy group, with a cumulative pregnancy rate to four years of 15% and 6% respectively (hazard ratio: 0.48; 95% CI 0.18–1.28). The cumulative repeat procedure rate to four years was 24% in the UAE group and 13% in the myomectomy group (hazard ratio: 0.53; 95% CI 0.27–1.05).

Conclusions

Myomectomy resulted in greater improvement in quality of life compared with uterine artery embolization, although by four years, this difference was not statistically significant. Missing data may limit the generalisability of this result. The numbers of women becoming pregnant were too small draw a conclusion on the effect of the procedures on fertility.

Delphi procedure in core outcome set development: rating scale and consensus criteria determined outcome selection

OBJECTIVE

The objective of this study was to compare two different rating scales within one Delphi study for defining consensus in core outcome set development and to explore the influence of consensus criteria on the outcome selection.

STUDY DESIGN AND SETTING

Randomized controlled parallel group trial with 1:1 allocation within the first Delphi round of the Core Outcome Set in the Incontinence-Associated Dermatitis project. Outcomes were rated on a three-point or nine-point Likert scale. Decisions about which outcomes to retain were determined by commonly used consensus criteria (i.e., [combinations of] proportions with restricted ranges, central tendency within a specific range, and decrease in variance).

RESULTS

Fifty-seven participants (group 1 = 28, group 2 = 29) rated 58 outcomes. The use of the nine-point scale resulted in almost twice as many outcomes being rated as "critical" compared with the three-point scale (24 vs. 13). Stricter criteria and combining criteria led to less outcomes being identified as "critical".

CONCLUSION

The format of rating scales in Delphi studies for core outcome set development and the definition of the consensus criteria influence outcome selection. The use of the nine-point scale might be recommended to inform the consensus process for a subsequent rating or face-to-face meeting. The three-point scale might be preferred when determining final consensus.

The COMET Handbook: version 1.0

The selection of appropriate outcomes is crucial when designing clinical trials in order to compare the effects of different interventions directly. For the findings to influence policy and practice, the outcomes need to be relevant and important to key stakeholders including patients and the public, health care professionals and others making decisions about health care. It is now widely acknowledged that insufficient attention has been paid to the choice of outcomes measured in clinical trials. Researchers are increasingly addressing this issue through the development and use of a core outcome set, an agreed standardised collection of outcomes which should be measured and reported, as a minimum, in all trials for a specific clinical area.Accumulating work in this area has identified the need for guidance on the development, implementation, evaluation and updating of core outcome sets. This Handbook, developed by the COMET Initiative, brings together current thinking and methodological research regarding those issues. We recommend a four-step process to develop a core outcome set. The aim is to update the contents of the Handbook as further research is identified.

A review of patient and carer participation and the use of qualitative research in the development of core outcome sets

Background

To be meaningful, a core outcome set (COS) should be relevant to all stakeholders including patients and carers. This review aimed to explore the methods by which patients and carers have been included as participants in COS development exercises and, in particular, the use and reporting of qualitative methods.

Methods

In August 2015, a search of the Core Outcomes Measures in Effectiveness Trials (COMET) database was undertaken to identify papers involving patients and carers in COS development. Data were extracted to identify the data collection methods used in COS development, the number of health professionals, patients and carers participating in these, and the reported details of qualitative research undertaken.

Results

Fifty-nine papers reporting patient and carer participation were included in the review, ten of which reported using qualitative methods. Although patients and carers participated in outcome elicitation for inclusion in COS processes, health professionals tended to dominate the prioritisation exercises. Of the ten qualitative papers, only three were reported as a clear pre-designed part of a COS process. Qualitative data were collected using interviews, focus groups or a combination of these. None of the qualitative papers reported an underpinning methodological framework and details regarding data saturation, reflexivity and resource use associated with data collection were often poorly reported. Five papers reported difficulty in achieving a diverse sample of participants and two reported that a large and varied range of outcomes were often identified by participants making subsequent rating and ranking difficult.

Conclusions

Consideration of the best way to include patients and carers throughout the COS development process is needed. Additionally, further work is required to assess the potential role of qualitative methods in COS, to explore the knowledge produced by different qualitative data collection methods, and to evaluate the time and resources required to incorporate qualitative methods into COS development.

Defining a Research Agenda for Patient-Reported Outcomes in Surgery: Using a Delphi Survey of Stakeholders

Importance

Identifying timely and important research questions using relevant patient-reported outcomes (PROs) in surgery remains paramount in the current medical climate. The inaugural Patient-Reported Outcomes in Surgery (PROS) Conference brought together stakeholders in PROs research in surgery with the aim of creating a research agenda to help determine future directions and advance cross-disciplinary collaboration.

Objective

To create a research agenda to help determine future directions and advance cross-disciplinary collaboration on the use of PROs in surgery.

Design, Setting, and Participants

An iterative web-based interface was used to create a conference-based, modified Delphi survey for registrants at the PROS Conference (January 29-30, 2015), including surgeons, PRO researchers, payers, and other stakeholders. In round 1, research items were generated from qualitative review of responses to open-ended prompts. In round 2, items were ranked using a 5-point Likert scale; attendees were also asked to submit any new items. In round 3, the top 30 items and newly submitted items were redistributed for final ranking using a 3-point Likert scale. The top 20 items by mean rating were selected for the research agenda.

Main Outcomes and Measures

An expert-generated research agenda on PROs in surgery.

Results

Of the 143 people registered for the conference, 137 provided valid email addresses. There was a wide range of attendees, with the 3 most common groups being plastic surgeons (28 [19.6%]), general surgeons (19 [13.3%]), and researchers (25 [17.5%]). In round 1, participants submitted 459 items, which were reduced through qualitative review to 53 distinct items across 7 themes of PROs research. A research agenda was formulated after 2 successive rounds of ranking. The research agenda identified 3 themes important for future PROs research in surgery: (1) PROs in the decision-making process, (2) integrating PROs into the electronic health record, and (3) measuring quality in surgery with PROs.

Conclusions and Relevance

The PROS Conference research agenda was created using a modified Delphi survey of stakeholders that will help researchers, surgeons, and funders identify crucial areas of future PROs research in surgery.

Uterine artery embolization versus hysterectomy in the treatment of symptomatic uterine fibroids (EMMY trial): peri- and postprocedural results from a randomized controlled trial

OBJECTIVE

This was a randomized controlled trial to evaluate the safety of uterine artery embolization (UAE) compared with hysterectomy.

STUDY DESIGN

Twenty-eight Dutch hospitals recruited 177 patients with symptomatic uterine fibroids and menorrhagia who were eligible for hysterectomy. Patients were randomized to UAE (n = 88) or hysterectomy (n = 89). In this paper we evaluate the peri- and postprocedural complications, length of hospital stay, unscheduled visits, and readmission rates up to 6 weeks' post-intervention. Analysis was by intention to treat.

RESULTS

Bilateral UAE failure occurred in 4 patients (4.9%). Major complications occurred in 4.9% (UAE) and 2.7% (hysterectomy) of cases (P = .68). The minor complication rate from discharge until 6 weeks after was significantly higher in the UAE group than in the hysterectomy group (58.0% vs 40.0%; RR 1.45 [1.04-2.02]; P = .024). UAE patients were more often readmitted (11.1% vs 0%; P = .003). Total length of hospital stay was significantly shorter in UAE patients (mean [SD]: 2.5 [2.7] vs 5.1 [1.3], P < .001).

CONCLUSION

UAE is a procedure similar to hysterectomy with a low major complication rate and with a reduced length of hospital stay. Higher readmission rates after UAE stress the need for careful postprocedural follow-up.

Patient satisfaction and disease specific quality of life after uterine artery embolization

OBJECTIVES

This study was undertaken to evaluate changes in fibroid specific symptom severity and health-related quality of life (HRQOL) after uterine artery embolization (UAE) and to consider the impact of these changes on satisfaction with the procedure.

STUDY DESIGN

A validated, fibroid specific, symptom, and HRQOL questionnaire was mailed to 80 women who had undergone UAE from 1998 through 2002. Pre- and postprocedure symptom severity and HRQOL scores were obtained. The primary outcome measure was change in fibroid symptoms and HRQOL after UAE. Secondary outcomes included objective measures of patient satisfaction, and the decrease in uterine volume after UAE.

RESULTS

Questionnaires were completed by 64 women (80.0%) at a mean of 32.1 months from UAE (range: 57.5-6 months). After UAE, mean uterine volume decreased by 26.3% (95% CI 19.6-33.0), and 17 of 79 women (21.5%) underwent an additional procedure after a mean of 18.6 months. Symptom severity scores decreased by a mean of 35.2% (95% CI 29.3-41.1) and HRQOL scores increased by a mean of 35.7% (95% CI 28.9-42.4). Satisfaction with UAE was correlated with the change in symptom severity and HRQL scores (P <.0001 and P=.0004, respectively) and the decrease in uterine volume after UAE (P=.0196).

CONCLUSION

Women who undergo UAE have a significant decrease in symptom severity and increase in HRQOL, associated with high levels of satisfaction with the procedure, even when subsequent therapies are pursued.

Hysterectomy Versus Expanded Medical Treatment for Abnormal Uterine Bleeding: Clinical Outcomes in the Medicine or Surgery Trial

OBJECTIVE

To compare clinical outcomes after randomization to hysterectomy versus medical treatment in patients with chronic abnormal uterine bleeding refractory to medroxyprogesterone acetate.

METHODS

We randomly assigned 63 premenopausal women with abnormal uterine bleeding refractory to cyclic medroxyprogesterone acetate treatment to receive either a hysterectomy or expanded medical treatment. Within each randomized group, the specific treatment approach was determined by patient and provider preference. The primary analysis compared changes in clinical outcomes at 6 and 24 months by using an intention-to-treat approach. Secondary as-treated analyses after adjustment for baseline covariates compared participants randomly assigned to medical treatment who continued the medical approach with those who crossed over to hysterectomy.

RESULTS

The intention-to-treat analyses at 6 months revealed greater symptom improvement in the hysterectomy group than in the medicine group for pelvic pain (P <.01), urinary urgency (P =.03), incomplete bladder emptying (P =.03), breast pain (P =.02), and cessation of vaginal bleeding (87% versus 11%, P <.001). Seventeen of 32 women assigned to medicine (53%) eventually crossed over and received a hysterectomy, and by 24 months the statistically significant differences by intention-to-treat were limited to greater improvement in hot flushes (P <.01) and cessation of vaginal bleeding (P <.01). Within-group analyses at year 2 showed statistically significant improvements from baseline on most symptoms for women who had a hysterectomy, whether through randomization or crossover. Women remaining on medical treatments had statistically significant improvements in pelvic pain, pelvic/bladder pressure, and stress incontinence. In a nonrandomized comparison with women who remained on medical treatments through year 2, those crossing over to hysterectomy experienced greater improvements in bleeding (P <.01), pelvic pain (P <.01), low back pain (P =.02), breast pain (P =.01), urinary frequency (P =.01), and urgency (P =.02). However, they also experienced more days off from work or usual activities (P <.01) and more days spent in bed (P <.01) than those who remained on medicine.

CONCLUSION

For patients with abnormal uterine bleeding refractory to medroxyprogesterone acetate, hysterectomy is superior to expanded efforts with oral medications for alleviating clinical symptoms but may lead to more days of restricted activity.

Cost analysis of myomectomy, hysterectomy, and uterine artery embolization

OBJECTIVE

The purpose of this study was to compare inpatient hospital costs of different treatments of uterine fibroid tumors, including myomectomy, hysterectomy, and uterine artery embolization in a teaching hospital.

STUDY DESIGN

We reviewed the hospital database of 545 women with uterine fibroid tumors who were treated with abdominal myomectomy, total abdominal hysterectomy, vaginal hysterectomy, and uterine artery embolization between April 1997 and October 2001.

RESULTS

Women who underwent hysterectomies and uterine artery embolization were significantly older than the women who underwent myomectomy. Uterine artery embolization was associated with the shortest hospital stay, although the hospital stay in the vaginal hysterectomy group was shorter than in the abdominal myomectomy and the total abdominal hysterectomy groups. Compared with other groups, the inpatient cost of nursing in the uterine artery embolization group was the lowest. The total inpatient cost of uterine artery embolization ($1,007.44 +/- $60.65 [Canadian dollars]) was significantly lower than the cost of total abdominal hysterectomy ($1,933.37 +/- $47.68 [Canadian dollars]), abdominal myomectomy ($1,781.73 +/- $47.16 [Canadian dollars]), and vaginal hysterectomy ($1,515.39 +/- $66.72 [Canadian dollars]; P <.001). Sixteen of the 85 patients (18.8%) were hospitalized after uterine artery embolization, mainly for abdominal pain.

CONCLUSION

Compared with abdominal myomectomy, abdominal hysterectomy, and vaginal hysterectomy, uterine artery embolization is associated with a lower hospital cost and a shorter hospital stay. Hospitalization after uterine artery embolization is mainly for abdominal pain after the procedure. A better method of pain control to reduce the rate of hospitalization and its cost is needed.