Outcomes research in cancer symptom management trials: the Radiation Therapy Oncology Group (RTOG) conceptual model

Intensity-Modulated Radiation Therapy Reduces Patient-Reported Chronic Toxicity Compared With Conventional Pelvic Radiation Therapy: Updated Results of a Phase III Trial

Clinical trials frequently include multiple end points that mature at different times. The initial report, typically based on the primary end point, may be published when key planned coprimary or secondary analyses are not yet available. Clinical Trial Updates provide an opportunity to disseminate additional results from studies, published in JCO or elsewhere, for which the primary end point has already been reported.The purpose of this update was to determine differences in patient-reported chronic toxicity and disease outcomes with intensity-modulated radiation therapy (IMRT) compared with conventional pelvic radiation. Patients with cervical and endometrial cancers who received postoperative pelvic radiation were randomly assigned to conventional radiation therapy (CRT) or IMRT. Toxicity and quality of life were assessed using Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events, Expanded Prostate Cancer Index Composite (EPIC) bowel and urinary domains, and Functional Assessment of Cancer Therapy-General. Between 2012 and 2015, 279 eligible patients were enrolled to the study with a median follow-up of 37.8 months. There were no differences in overall survival (P = .53), disease-free survival (P = .21), or locoregional failure (P = .81). One year after RT, patients in the CRT arm experienced more high-level diarrhea frequency (5.8% IMRT v 15.1% CRT, P = .042) and a greater number had to take antidiarrheal medication two or more times a day (1.2% IMRT v 8.6% CRT, P = .036). At 3 years, women in the CRT arm reported a decline in urinary function, whereas the IMRT arm continued to improve (mean change in EPIC urinary score = 0.5, standard deviation = 13.0, IMRT v -6.0, standard deviation = 14.3, CRT, P = .005). In conclusion, IMRT reduces patient-reported chronic GI and urinary toxicity with no difference in treatment efficacy at 3 years.

Symptom science research conducted in community programs funded by the US National Cancer Institute: a 12-year review, 2008 to 2019

PURPOSE

This study was conducted to describe the portfolio of symptom science research conducted through the community oncology network supported by the US National Cancer Institute during the 12-year period 2008 to 2019.

METHODS

The National Cancer Institute conducted a retrospective review of the National Cancer Institute database to identify pediatric and adult symptom management studies that were opened between 2008 and 2019 in the community oncology network and to determine types of studies, accrual patterns, completed studies, and number of publications reporting clinical trial results.

RESULTS

The NCI community oncology network conducted 109 symptom studies between 2008 and 2019. The majority of these studies were phase II and III clinical trials. Neurotoxicities were the most frequently occurring symptom studied, with the majority of those focused on neurocognitive impairments. Gastrointestinal symptoms, pain, and fatigue were the next most frequently studied. A variety of interventions were utilized including pharmacologic, behavioral, complementary and alternative medicines, and radiation therapy. Accrual to symptom studies ranged from a low of 896 participants in 2008 to a high of 3468 participants in 2012. The number of open studies ranged from 8 in 2008 to 35 in 2012.

CONCLUSIONS

Examining the symptom science portfolio of the NCI community oncology network has identified research gaps and has highlighted the need to focus on a mechanistic understanding of symptoms and phenotyping of patients experiencing cancer and treatment-related symptoms. Subsequently, targeted interventions can be developed to prevent or treat these symptoms.

Comparing dosimetric and cancer control outcomes after intensity‑modulated radiation therapy and tomotherapy for advanced cervical cancer

Concurrent chemoradiation therapy (CCRT) is the standard treatment for locally advanced cervical cancer. The present study aimed to compare the therapeutic responses, toxicities and dosimetric parameters between intensity-modulated radiation therapy (IMRT) and tomotherapy (TOMO) in patients with advanced cervical cancer. This retrospective study included 310 patients with stage IIB-IIIB cervical cancer who underwent CCRT, with 155 patients in each group. Intracavitary brachytherapy was performed after a course of external beam radiation therapy (EBRT), or in the last week of pelvic EBRT. The treatment planning aim at point A (defined as a reference location 2 cm above the vaginal fornix and 2 cm beside the mid axis of the uterus) was >85 Gy in an equivalent dose at 2 Gy. There was no statistical difference with regard to clinicopathological characteristics between the two groups (P>0.05). Improved dose conformity and dose homogeneity (P<0.05) were observed in TOMO planning. TOMO provided more efficacious critical organ sparing than IMRT when assessing the percentage of normal tissue receiving at least 20 Gy (V20) for the bladder, the percentage of normal tissue receiving at least 40 Gy (V40) for the femoral head, and the V40 and V20 for the rectum (P<0.05). TOMO demonstrated a greater ability to protect the ovary (P<0.05). The acute radiation toxicity of proctitis and leukopenia were significantly lower in the TOMO group (P<0.05). The chronic radiation toxicity of radiation enterocolitis and cystitis was lower in the TOMO group (P<0.05). Thus, TOMO provided better critical organ sparing than IMRT. The radiation toxicities were acceptable. Therefore, TOMO appears to be a good option for the treatment of stage IIB-IIIB cervical cancer.

Improvement in Patient-Reported Outcomes With Intensity-Modulated Radiotherapy (RT) Compared With Standard RT: A Report From the NRG Oncology RTOG 1203 Study

PURPOSE

In oncology trials, the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE) is the standard tool for reporting adverse events (AEs), but it may underreport symptoms experienced by patients. This analysis of the NRG Oncology RTOG 1203 compared symptom reporting by patients and clinicians during radiotherapy (RT).

PATIENTS AND METHODS

Patients with cervical or endometrial cancer requiring postoperative RT were randomly assigned to standard 4-field RT or intensity-modulated RT (IMRT). Patients completed the 6-item patient-reported outcomes version of the CTCAE (PRO-CTCAE) for GI toxicity assessing abdominal pain, diarrhea, and fecal incontinence at various time points. Patients reported symptoms on a 5-point scale. Clinicians recorded these AEs as CTCAE grades 1 to 5. Clinician- and patient-reported AEs were compared using McNemar's test for rates > 0%.

RESULTS

Of 278 eligible patients, 234 consented and completed the PRO-CTCAE. Patients reported high-grade abdominal pain 19.1% (P < .0001), high-grade diarrhea 38.5% (P < .0001), and fecal incontinence 6.8% more frequently than clinicians. Similar effects were seen between grade ≥ 1 CTCAE toxicity and any-grade patient-reported toxicity. Between-arm comparison of patient-reported high-grade AEs revealed that at 5 weeks of RT, patients who received IMRT experienced fewer GI AEs than patients who received 4-field pelvic RT with regard to frequency of diarrhea (18.2% difference; P = .01), frequency of fecal incontinence (8.2% difference; P = .01), and interference of fecal incontinence (8.5% difference; P = .04).

CONCLUSION

Patient-reported AEs showed a reduction in symptoms with IMRT compared with standard RT, whereas clinician-reported AEs revealed no difference. Clinicians also underreported symptomatic GI AEs compared with patients. This suggests that patient-reported symptomatic AEs are important to assess in this disease setting.

Capturing the patient perspective: patient-reported outcomes as clinical trial endpoints

Just as clinical trial design and rigor have evolved with improvements in methods and processes, so too have methods for capturing patient data in clinical trials. Substantial evidence suggests that standard physician reporting of symptoms for which we lack objective diagnostics (e.g., pain) is often discordant with patient self-report. Current reporting using the National Cancer Institute Common Terminology Criteria for Adverse Events (CTC[AE]) for symptom capture relies on a filtering system, from patient to physician to medical record to medical record abstraction to data entry, with each step requiring interpretation and the possibility of error. In contrast, patient-reported outcomes (PROs) eliminate the filter and rely on direct report. Furthermore, the lack of validation and training in use of the CTC(AE) creates an inadequate data capture system. Inadequacies might be observed as underreporting or overreporting symptom prevalence and severity compared with patient self-report. Inaccuracies in symptom reporting can lead to missing important prognostic information, lack of understanding of patient adherence with therapies, and lack of information for patient decision making. They can also lead to opportunities lost in terms of labeling claims and comparative effectiveness analyses. New developments in patient-reported outcome (PRO) reporting, including the PRO-CTC(AE) and models for incorporation of PROs in clinical trials, might facilitate routine PRO reporting complementary to CTC(AE) in clinical trials. In addition, the cadre of validated PRO instruments already in existence allows for more in-depth, hypothesis-driven evaluations. For standard toxicity reporting, the time has come for mandatory routine PRO symptom reporting complementary to the CTC(AE).

Low interrater reliability in grading of rectal bleeding using National Cancer Institute Common Toxicity Criteria and Radiation Therapy Oncology Group Toxicity scales: a survey of radiation oncologists

PURPOSE

To measure concordance among genitourinary radiation oncologists in using the National Cancer Institute Common Toxicity Criteria (NCI CTC) and Radiation Therapy Oncology Group (RTOG) grading scales to grade rectal bleeding.

METHODS AND MATERIALS

From June 2013 to January 2014, a Web-based survey was sent to 250 American and Canadian academic radiation oncologists who treat prostate cancer. Participants were provided 4 case vignettes in which patients received radiation therapy and developed rectal bleeding and were asked for management plans and to rate the bleeding according to NCI CTC v.4 and RTOG late toxicity grading (scales provided). In 2 cases, participants were also asked whether they would send the patient for colonoscopy. A multilevel, random intercept modeling approach was used to assess sources of variation (case, respondent) in toxicity grading to calculate the intraclass correlation coefficient (ICC). Agreement on a dichotomous grading scale (low grades 1-2 vs high grades 3-4) was also assessed, using the κ statistic for multiple respondents.

RESULTS

Seventy-two radiation oncologists (28%) completed the survey. Forty-seven (65%) reported having either written or been principal investigator on a study using these scales. Agreement between respondents was moderate (ICC 0.52, 95% confidence interval [CI] 0.47-0.58) when using NCI CTC and fair using the RTOG scale (ICC 0.28, 95% CI 0.20-0.40). Respondents who chose an invasive management were more likely to select a higher toxicity grade (P<.0001). Using the dichotomous scale, we observed moderate agreement (κ = 0.42, 95% CI 0.40-0.44) with the NCI CTC scale, but only slight agreement with the RTOG scale (κ = 0.19, 95% CI 0.17-0.21).

CONCLUSION

Low interrater reliability was observed among radiation oncologists grading rectal bleeding using 2 common scales. Clearer definitions of late rectal bleeding toxicity should be constructed to reduce this variability and avoid ambiguity in both reporting and interpretation.

Recommended patient-reported core set of symptoms to measure in adult cancer treatment trials

BACKGROUND

The National Cancer Institute's Symptom Management and Health-Related Quality of Life Steering Committee held a clinical trials planning meeting (September 2011) to identify a core symptom set to be assessed across oncology trials for the purposes of better understanding treatment efficacy and toxicity and to facilitate cross-study comparisons. We report the results of an evidence-synthesis and consensus-building effort that culminated in recommendations for core symptoms to be measured in adult cancer clinical trials that include a patient-reported outcome (PRO).

METHODS

We used a data-driven, consensus-building process. A panel of experts, including patient representatives, conducted a systematic review of the literature (2001-2011) and analyzed six large datasets. Results were reviewed at a multistakeholder meeting, and a final set was derived emphasizing symptom prevalence across diverse cancer populations, impact on health outcomes and quality of life, and attribution to either disease or anticancer treatment.

RESULTS

We recommend that a core set of 12 symptoms--specifically fatigue, insomnia, pain, anorexia (appetite loss), dyspnea, cognitive problems, anxiety (includes worry), nausea, depression (includes sadness), sensory neuropathy, constipation, and diarrhea--be considered for inclusion in clinical trials where a PRO is measured. Inclusion of symptoms and other patient-reported endpoints should be well justified, hypothesis driven, and meaningful to patients.

CONCLUSIONS

This core set will promote consistent assessment of common and clinically relevant disease- and treatment-related symptoms across cancer trials. As such, it provides a foundation to support data harmonization and continued efforts to enhance measurement of patient-centered outcomes in cancer clinical trials and observational studies.

Metrics to assess quality of life after management of early-stage lung cancer

Quality of life (QOL) is a key clinical outcome in patients with lung cancer because of the debilitating nature of the disease and its treatments. In recent years, advances have been made in the assessment of QOL via patient-reported outcomes. A brief history of the evolution of QOL measures in oncology clinical trials and practice is given with specific reference to early-stage lung cancer. The role that QOL can play as a prognostic factor, especially among lung cancer patients, is delineated. The most commonly seen symptoms among lung cancer patients are listed. This review is intended to provide the clinical researcher with a summary of the alternative measures that are both valid and reasonable to consider when assessing QOL in early-stage lung cancer patients. Suggestions for QOL assessment in both a research setting and clinical environment are considered. A review of the most popular QOL assessments in general application to lung cancer and disease-specific measures is provided. An algorithm for selecting appropriate QOL assessments for lung cancer clinical research is provided. The primary conclusion from this work is that scientifically sound investigations into the QOL of early-stage lung cancer patients are feasible and encouraged so that the care of these patients can be optimized.

Added value of health-related quality of life measurement in cancer clinical trials: the experience of the NCIC CTG

Health-related quality-of-life (HRQoL) data are often included in Phase III clinical trials. We evaluate and classify the value added to Phase III trials by HRQoL outcomes, through a review of the National Cancer Institute of Canada Clinical Trials Group clinical trials experience within various cancer patient populations. HRQoL may add value in a variety of ways, including the provision of data that may contrast with or may support the primary study outcome; or that assess a unique perspective or subgroup, not addressed by the primary outcome. Thus, HRQoL data may change the study's interpretation. Even in situations where HRQoL measurement does not alter the clinical interpretation of a trial, important methodologic advances can be made. A classification of the added value of HRQoL information is provided, which may assist in choosing trials for which measurement of HRQoL outcomes will be beneficial.

Taking PROs and patient-centered care seriously: incremental and disruptive ideas for incorporating PROs in oncology practice

Using patient-reported outcomes (PROs) in clinical practice poses challenges for health care teams and organizations to respond to individual patient needs in a timely fashion. Well-validated tools and feasibility studies are available, but successful spread will require knowledge of effective technology dissemination in complex health delivery systems. Given what has been learned about effective implementation, it is reasonable to ask whether the broad adoption of PROs can occur incrementally using current models of care to apply PRO technology. Another approach is to start with patient needs and focus on how to meet those needs most effectively using PROs in new ways of organizing health care.

Health-related quality of life measurement in symptom management trials

There is increasing support for the incorporation of patient-reported outcomes (PROs) into clinical trials in cancer. While the need for inclusion of measures of target symptoms in symptom management trials is clear, arguments can also be made for measurement of a broader range of symptoms, for evaluation of symptom burden, and for evaluation of health-related quality of life (HRQOL) in these trials. What is key to their inclusion is a priori selection of instruments, provision of a theoretic basis for inclusion of instruments, and a clearly described plan of analysis. The federal Food and Drug Administration (FDA) has provided guidance regarding the use of PROs (symptom and HRQOL measures) to support treatment benefit claims in product labeling. Moving forward, research is needed to address methodological issues raised by the FDA and to increase understanding of relationships among symptoms, symptom clusters, HRQOL, and other outcome measures.