Data validation in an economic evaluation of surgery for colon cancer

Non-medical interventions to enhance return to work for people with cancer

BACKGROUND

People with cancer are 1.4 times more likely to be unemployed than people without a cancer diagnosis. Therefore, it is important to investigate whether programmes to enhance the return-to-work (RTW) process for people who have been diagnosed with cancer are effective. This is an update of a Cochrane review first published in 2011 and updated in 2015.

OBJECTIVES

To evaluate the effectiveness of non-medical interventions aimed at enhancing return to work (RTW) in people with cancer compared to alternative programmes including usual care or no intervention.

SEARCH METHODS

We searched CENTRAL (the Cochrane Library), MEDLINE, Embase, CINAHL, PsycINFO and three trial registers up to 18 August 2021. We also examined the reference lists of included studies and selected reviews, and contacted authors of relevant studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and cluster-RCTs on the effectiveness of psycho-educational, vocational, physical or multidisciplinary interventions enhancing RTW in people with cancer. The primary outcome was RTW measured as either RTW rate or sick leave duration measured at 12 months' follow-up. The secondary outcome was quality of life (QoL).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed RCTs for inclusion, extracted data and rated certainty of the evidence using GRADE. We pooled study results judged to be clinically homogeneous in different comparisons reporting risk ratios (RRs) with 95% confidence intervals (CIs) for RTW and mean differences (MD) or standardised mean differences (SMD) with 95% CIs for QoL.

MAIN RESULTS

We included 15 RCTs involving 1477 people with cancer with 19 evaluations because of multiple treatment groups. In this update, we added eight new RCTs and excluded seven RCTs from the previous versions of this review that were aimed at medical interventions. All included RCTs were conducted in high-income countries, and most were aimed at people with breast cancer (nine RCTs) or prostate cancer (two RCTs). Risk of bias We judged nine RCTs at low risk of bias and six at high risk of bias. The most common type of bias was a lack of blinding (9/15 RCTs). Psycho-educational interventions We found four RCTs comparing psycho-educational interventions including patient education and patient counselling versus care as usual. Psycho-educational interventions probably result in little to no difference in RTW compared to care as usual (RR 1.09, 95% CI 0.96 to 1.24; 4 RCTs, 512 participants; moderate-certainty evidence). This means that in the intervention and control groups, approximately 625 per 1000 participants may have returned to work. The psycho-educational interventions may result in little to no difference in QoL compared to care as usual (MD 1.47, 95% CI -2.38 to 5.32; 1 RCT, 124 participants; low-certainty evidence). Vocational interventions We found one RCT comparing vocational intervention versus care as usual. The evidence was very uncertain about the effect of a vocational intervention on RTW compared to care as usual (RR 0.94, 95% CI 0.78 to 1.13; 1 RCT, 34 participants; very low-certainty evidence). The study did not report QoL. Physical interventions Four RCTs compared a physical intervention programme versus care as usual. These physical intervention programmes included walking, yoga or physical exercise. Physical interventions likely increase RTW compared to care as usual (RR 1.23, 95% CI 1.08 to 1.39; 4 RCTs, 434 participants; moderate-certainty evidence). This means that in the intervention group probably 677 to 871 per 1000 participants RTW compared to 627 per 1000 in the control group (thus, 50 to 244 participants more RTW). Physical interventions may result in little to no difference in QoL compared to care as usual (SMD -0.01, 95% CI -0.33 to 0.32; 1 RCT, 173 participants; low-certainty evidence). The SMD translates back to a 1.8-point difference (95% CI -7.54 to 3.97) on the European Organisation for Research and Treatment of Cancer Quality of life Questionnaire Core 30 (EORTC QLQ-C30). Multidisciplinary interventions Six RCTs compared multidisciplinary interventions (vocational counselling, patient education, patient counselling, physical exercises) to care as usual. Multidisciplinary interventions likely increase RTW compared to care as usual (RR 1.23, 95% CI 1.09 to 1.33; 6 RCTs, 497 participants; moderate-certainty evidence). This means that in the intervention group probably 694 to 844 per 1000 participants RTW compared to 625 per 1000 in the control group (thus, 69 to 217 participants more RTW). Multidisciplinary interventions may result in little to no difference in QoL compared to care as usual (SMD 0.07, 95% CI -0.14 to 0.28; 3 RCTs, 378 participants; low-certainty evidence). The SMD translates back to a 1.4-point difference (95% CI -2.58 to 5.36) on the EORTC QLQ-C30.

AUTHORS' CONCLUSIONS

Physical interventions (four RCTs) and multidisciplinary interventions (six RCTs) likely increase RTW of people with cancer. Psycho-educational interventions (four RCTs) probably result in little to no difference in RTW, while the evidence from vocational interventions (one RCT) is very uncertain. Psycho-educational, physical or multidisciplinary interventions may result in little to no difference in QoL. Future research on enhancing RTW in people with cancer involving multidisciplinary interventions encompassing a physical, psycho-educational and vocational component is needed, and be preferably tailored to the needs of the patient.

The exchangeability of self-reports and administrative health care resource use measurements: assessement of the methodological reporting quality

OBJECTIVE

To assess the exchangeability of self-reported and administrative health care resource use measurements for cost estimation.

STUDY DESIGN AND SETTING

In a systematic review (NHS EED and MEDLINE), reviewers evaluate, in duplicate, the methodological reporting quality of studies comparing the validation evidence of instruments measuring health care resource use. The appraisal tool Methodological Reporting Quality (MeRQ) is developed by merging aspects form the Guidelines for Reporting Reliability and Agreement Studies and the Standards for Reporting Diagnostic Accuracy.

RESULTS

Out of 173 studies, 35 full-text articles are assessed for eligibility. Sixteen articles are included in this study. In seven articles, more than 75% of the reporting criteria assessed by MERQ are considered "good." Most studies score at least "fair" on most of the reporting quality criteria. In the end, six studies score "good" on the minimal criteria for reporting. Varying levels of agreement among the different data sources are found, with correlations ranging from 0.14 up to 0.93 and with occurrences of both random and systematic errors.

CONCLUSION

The validation evidence of the small number of studies with adequate MeRQ cautiously supports the exchangeability of both the self-reported and administrative resource use measurement methods.

Interventions to enhance return-to-work for cancer patients

BACKGROUND

Cancer patients are 1.4 times more likely to be unemployed than healthy people. Therefore it is important to provide cancer patients with programmes to support the return-to-work (RTW) process. This is an update of a Cochrane review first published in 2011.

OBJECTIVES

To evaluate the effectiveness of interventions aimed at enhancing RTW in cancer patients compared to alternative programmes including usual care or no intervention.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, in the Cochrane Library Issue 3, 2014), MEDLINE (January 1966 to March 2014), EMBASE (January 1947 to March 2014), CINAHL (January 1983 to March, 2014), OSH-ROM and OSH Update (January 1960 to March, 2014), PsycINFO (January 1806 to 25 March 2014), DARE (January 1995 to March, 2014), ClinicalTrials.gov, Trialregister.nl and Controlled-trials.com up to 25 March 2014. We also examined the reference lists of included studies and selected reviews, and contacted authors of relevant studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of the effectiveness of psycho-educational, vocational, physical, medical or multidisciplinary interventions enhancing RTW in cancer patients. The primary outcome was RTW measured as either RTW rate or sick leave duration measured at 12 months' follow-up. The secondary outcome was quality of life.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion, assessed the risk of bias and extracted data. We pooled study results we judged to be clinically homogeneous in different comparisons reporting risk ratios (RRs) with 95% confidence intervals (CIs). We assessed the overall quality of the evidence for each comparison using the GRADE approach.

MAIN RESULTS

Fifteen RCTs including 1835 cancer patients met the inclusion criteria and because of multiple arms studies we included 19 evaluations. We judged six studies to have a high risk of bias and nine to have a low risk of bias. All included studies were conducted in high income countries and most studies were aimed at breast cancer patients (seven trials) or prostate cancer patients (two trials).Two studies involved psycho-educational interventions including patient education and teaching self-care behaviours. Results indicated low quality evidence of similar RTW rates for psycho-educational interventions compared to care as usual (RR 1.09, 95% CI 0.88 to 1.35, n = 260 patients) and low quality evidence that there is no difference in the effect of psycho-educational interventions compared to care as usual on quality of life (standardised mean difference (SMD) 0.05, 95% CI -0.2 to 0.3, n = 260 patients). We did not find any studies on vocational interventions. In one study breast cancer patients were offered a physical training programme. Low quality evidence suggested that physical training was not more effective than care as usual in improving RTW (RR 1.20, 95% CI 0.32 to 4.54, n = 28 patients) or quality of life (SMD -0.37, 95% CI -0.99 to 0.25, n = 41 patients).Seven RCTs assessed the effects of a medical intervention on RTW. In all studies a less radical or functioning conserving medical intervention was compared with a more radical treatment. We found low quality evidence that less radical, functioning conserving approaches had similar RTW rates as more radical treatments (RR 1.04, 95% CI 0.96 to 1.09, n = 1097 patients) and moderate quality evidence of no differences in quality of life outcomes (SMD 0.10, 95% CI -0.04 to 0.23, n = 1028 patients).Five RCTs involved multidisciplinary interventions in which vocational counselling was combined with patient education, patient counselling, and biofeedback-assisted behavioral training or physical exercises. Moderate quality evidence showed that multidisciplinary interventions involving physical, psycho-educational and vocational components led to higher RTW rates than care as usual (RR 1.11, 95% CI 1.03 to 1.16, n = 450 patients). We found no differences in the effect of multidisciplinary interventions compared to care as usual on quality of life outcomes (SMD 0.03, 95% CI -0.20 to 0.25, n = 316 patients).

AUTHORS' CONCLUSIONS

We found moderate quality evidence that multidisciplinary interventions enhance the RTW of patients with cancer.

Methods of quality assurance in multicenter trials in laparoscopic colorectal surgery: a systematic review

OBJECTIVES

To assess the risk of bias in multicenter randomized controlled trials (RCTs) investigating laparoscopic colorectal cancer surgery and review the use of quality assurance mechanisms to reduce performance bias.

BACKGROUND

RCTs represent the criterion standard comparison for health care interventions. For trials investigating interventional techniques, performance bias can arise through variation in delivery of the intervention.

METHODS

A comprehensive systematic review was undertaken using MEDLINE and EMBASE databases to identify all large RCTs investigating laparoscopic colorectal cancer surgery. Risk of performance bias was evaluated through assessment of publications and protocols to identify methods used for quality assurance of surgical technique. In addition, the Cochrane Collaboration's "risk of bias" tool was used to evaluate other potential sources of bias.

RESULTS

The literature search identified 48 publications, reporting upon 8 individual RCTs. All studies used mechanisms for quality assurance of laparoscopic colorectal surgery. Methods employed included credentialing of surgeons or units through assessment of experience and expertise, standardization of surgical technique, and monitoring. None report the use of structure objective assessment tools for accrediting expertise. All 8 were assessed as low risk of bias using the Cochrane tool. A framework is proposed for use as a model for quality assurance in future surgical trials.

CONCLUSIONS

Consideration of risk of performance bias is important when appraising trials investigating an interventional technique. Laparoscopic colorectal surgery RCTs have all employed quality assurance mechanisms to reduce risk of performance bias. Further research is indicated to investigate adopting objective assessment tools for quality assurance within multicenter RCTs.

Can colorectal cancer survivors recall their medications and doctor visits reliably?

Background

The evidence on the agreement between self-reported health resource use and administrative records is mixed and no gold standard exists. The objective of this study was to assess self-reported general practitioner (GP) and specialist doctor visits, as well as medication use via telephone interview against national insurance administrative data for colorectal cancer survivors.

Methods

In a sample of 76 adults recently diagnosed with colorectal cancer, data was abstracted from telephone survey items on GP visits, specialist visits and medication use over the previous six months and compared with data on the same individuals from administrative data. Intraclass correlation coefficients (ICC) were used to assess the reliability of frequency of visits and kappa statistics were derived for four broad categories of medicines used for gastrointestinal conditions, cardiovascular disease, psychological conditions and chronic obstructive pulmonary disease. Logistic regression was undertaken to assess factors associated with agreement (yes/no) between the two data sources for doctors’ visits.

Results

Good agreement was found for GP visits (ICC 0.62, 95%CI: 0.38, 0.86) and specialist visits (ICC 0.73, 95%CI: 0.56, 0.91) across the two data sources. When costs were assigned to frequencies, mean costs for the two methods were not significantly different over six months. Over-reporting was more common among men and participants with frequent doctor encounters. Large discrepancies between self-reports and administration records were found for broad types of medications used (44% agreement, kappa 0.13).

Conclusion

Self-reported frequency of doctor’s visits using telephone interviews may be a reasonable substitute for administratively recorded data however, medication use by self-report appears to be unreliable. Administrative records are preferable to self-report for health service use in colorectal cancer survivors with high and complex service needs.

Interventions to enhance return-to-work for cancer patients

BACKGROUND

Cancer survivors are 1.4 times more likely to be unemployed than healthy people. It is therefore important to provide cancer patients with programmes to support the return-to-work process.

OBJECTIVES

To evaluate the effectiveness of interventions aimed at enhancing return-to-work in cancer patients.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, in The Cochrane Library Issue 2, 2010), MEDLINE, EMBASE, CINAHL, OSH-ROM, PsycINFO, DARE, ClinicalTrials.gov, Trialregister.nl and Controlled-trials.com to February 2010, reference lists of included articles and selected reviews, and contacted authors of relevant articles.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and controlled before-after studies (CBAs) of the effectiveness of psychological, vocational, physical, medical or multidisciplinary interventions enhancing return-to-work in cancer patients. The primary outcome was return-to-work measured as either return-to-work rate or sick leave duration. Secondary outcome was quality of life.

DATA COLLECTION AND ANALYSIS

Two authors independently selected trials, assessed the risk of bias and extracted data. We pooled studies with sufficient data, judged to be clinically homogeneous in different comparisons. We assessed the overall quality of the evidence for each comparison using the GRADE approach.

MAIN RESULTS

Fourteen articles reporting 14 RCTs and 4 CBAs were included. These studies involved a total of 1652 participants. Results indicated low quality evidence of similar return-to-work rates for psychological interventions compared to care as usual (odds ratio (OR) = 2.32, 95% confidence interval (CI) 0.94 to 5.71). No vocational interventions were retrieved. Very low evidence suggested that physical training was not more effective than care as usual on improving return-to-work (OR = 1.20, 95% CI 0.32 to 4.54). Eight RCTs on medical interventions showed low quality evidence that functioning conserving approaches had similar return-to-work rates as more radical treatments (OR = 1.53, 95% CI 0.95 to 2.45). Moderate quality evidence showed multidisciplinary interventions involving physical, psychological and vocational components led to higher return-to-work rates than care as usual (OR = 1.87, 95% CI 1.07 to 3.27). No differences in the effect of psychological, physical, medical or multidisciplinary interventions compared to care as usual were found on quality of life outcomes.

AUTHORS' CONCLUSIONS

Moderate quality evidence showed that employed patients with cancer experience return-to-work benefits from multidisciplinary interventions compared to care as usual. More high quality RCTs aimed at enhancing return-to-work in cancer patients are needed.

Laparoscopic colon resection for cancer

LAC has become an acceptable alternative in the treatment of colon carcinoma. New data should elucidate better the potential advantages in postoperative recovery, QOL, and cost reduction. Appropriate credentialing for LAC remains essential for widespread application of LAC while preserving patient safety.