1
|
Bhat G, Karakasis K, Oza AM. Measuring Quality of Life in Ovarian Cancer Clinical Trials-Can We Improve Objectivity and Cross Trial Comparisons? Cancers (Basel) 2020; 12:E3296. [PMID: 33171791 PMCID: PMC7694966 DOI: 10.3390/cancers12113296] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 11/02/2020] [Accepted: 11/04/2020] [Indexed: 01/01/2023] Open
Abstract
Epithelial ovarian cancer (EOC) remains a lethal disease for the majority of women diagnosed with it worldwide. For the majority of patients, diagnosis occurs late, in the advanced setting. Disease-induced as well as treatment-related adverse events can negatively impact quality of life (QoL). Research to date has captured these data through use of patient-related outcomes (PROs) and, increasingly, has become an area of increased attention and focus in clinical trial reporting. QoL/PRO measurements in EOC clinical trials at different transition points in a patient's journey are increasingly being recognized by patients, clinicians and regulatory agencies as the key determinants of treatment benefit. Various context-specific PROs and PRO endpoints have been described for clinical trials in EOC. Standardized approaches and checklists for incorporating PRO endpoints in clinical trials have been proposed. In a real-world clinical practice setting, PRO/QoL measures, which are meaningful, valid, reliable, feasible and acceptable to patients and clinicians, need to be implemented and used. These may assist by serving as screening tools; helping with the identification of patient preferences to aid in decision making; improving patient-provider communication; facilitating shared decision making. Importantly, they may also improve quality of care through an increasingly patient-centered approach. Potential areas of future research include assessment of anxiety, depression and other mental health issues. In good prognostic groups, such as maintenance clinical trials, following patients beyond progression will capture possible downstream effects related to delaying the psychological trauma of relapse, symptoms due to disease progression and side-effects of subsequent chemotherapy. Identifying PRO endpoints in next-generation-targeted therapies (including immunotherapies) also warrants investigation.
Collapse
Affiliation(s)
| | | | - Amit M. Oza
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 1X6, Canada; (G.B.); (K.K.)
| |
Collapse
|
2
|
Wang W, Liu M, Ding B. Comparison of the short‐term efficacy and serum markers between lobaplatin/paclitaxel‐ And carboplatin/paclitaxel‐based adjuvant chemotherapy in patient with ovarian cancer. J Clin Pharm Ther 2020; 46:166-172. [PMID: 33098169 DOI: 10.1111/jcpt.13276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 08/24/2020] [Accepted: 09/07/2020] [Indexed: 12/28/2022]
Affiliation(s)
- Wei Wang
- Department of Gynecology Shangluo Central Hospital Shanxi China
| | - Ming Liu
- Department of Anesthesiology Shangluo Central Hospital Shanxi China
| | - Boyong Ding
- Department of Oncology Shangluo Central Hospital Shanxi China
| |
Collapse
|
3
|
Gallardo-Rincón D, Toledo-Leyva A, Bahena-González A, Montes-Servín E, Muñoz-Montaño W, Coronel-Martínez J, Oñate-Ocaña LF. Validation of the Mexican-Spanish Version of the EORTC QLQ-OV28 Instrument for the Assessment of Quality of Life in Women with Ovarian Cancer. Arch Med Res 2020; 51:690-699. [PMID: 32768148 DOI: 10.1016/j.arcmed.2020.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 07/03/2020] [Accepted: 07/21/2020] [Indexed: 11/12/2022]
Abstract
BACKGROUND Health-related quality of life (HRQL) is an important outcome measure in Oncology. AIM OF THE STUDY To validate the Mexican-Spanish version of the QLQ-OV28 questionnaire to assess HRQL in women with ovarian cancer (OC). METHODS The QLQ-C30 and QLQ-OV28 instruments were applied to women with OC attending a cancer center in Mexico. The usual psychometric analyses were performed; the Spearman's method was used for correlation analysis, reliability analysis with the Cronbach's alpha, known-group comparisons with the Kruskal-Wallis test, responsiveness was tested employing repeated measures ANOVA, and the association of scale scores and overall survival (OS) were analyzed with the Kaplan-Meier method and Cox's model. RESULTS Two hundred fifty-two women with OC were included in this cohort. The instruments were well accepted and compliance rates were high; patients responded both instruments in <30 min. The QLQ-OV28 internal consistency tests demonstrated good convergent (Correlation coefficients [CC] 0.154‒0.694) and divergent validity (CC 0.003‒0.69). Cronbach's α coefficients of six of eight scales of the QLQ-OV28 instruments were >0.7 (range, 0.567‒0.857). Scales QLQ-OV28 instruments distinguished among clinically distinct groups of patients, particularly after basal serum albumin and basal Ca‒125 levels. The evaluation of responsiveness demonstrated that two scales of the QLQ-OV28 were sensitive to change over time during induction chemotherapy. Six scales of the QLQ-OV28 were associated with OS. CONCLUSIONS The Mexican-Spanish version of the QLQ-OV28 questionnaire is reliable and valid for the assessment of HRQL in patients with OC and can be broadly used in clinical trials.
Collapse
Affiliation(s)
- Dolores Gallardo-Rincón
- Programa de Cáncer de Ovario, Instituto Nacional de Cancerología, Ciudad de México, México; Departamento de Oncología Médica, Instituto Nacional de Cancerología, Ciudad de México, México; Grupo de Investigación en Cáncer de Ovario y Tumores Ginecológicos de México, A.C., Ciudad de México, México
| | - Alfredo Toledo-Leyva
- Programa de Cáncer de Ovario, Instituto Nacional de Cancerología, Ciudad de México, México
| | - Antonio Bahena-González
- Programa de Cáncer de Ovario, Instituto Nacional de Cancerología, Ciudad de México, México; Departamento de Oncología Médica, Instituto Nacional de Cancerología, Ciudad de México, México; Grupo de Investigación en Cáncer de Ovario y Tumores Ginecológicos de México, A.C., Ciudad de México, México
| | | | - Wendy Muñoz-Montaño
- Departamento de Oncología Médica, Instituto Nacional de Cancerología, Ciudad de México, México
| | - Jaime Coronel-Martínez
- Subdirección de Investigación Clínica, Instituto Nacional de Cancerología, Ciudad de México, México
| | - Luis F Oñate-Ocaña
- Grupo de Investigación en Cáncer de Ovario y Tumores Ginecológicos de México, A.C., Ciudad de México, México; Subdirección de Investigación Clínica, Instituto Nacional de Cancerología, Ciudad de México, México.
| |
Collapse
|
4
|
Kargo AS, Coulter A, Jensen PT, Steffensen KD. Proactive use of PROMs in ovarian cancer survivors: a systematic review. J Ovarian Res 2019; 12:63. [PMID: 31307510 PMCID: PMC6631969 DOI: 10.1186/s13048-019-0538-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Accepted: 07/04/2019] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION The use of patient reported outcome measures (PROMs) has increased during the past decade, and the focus on how to use them has resulted in a more proactive application. Studies have shown that proactive use of PROMs during treatment improves patient-clinician communication, leads to better symptom management and may prolong survival among advanced cancer patients. Ovarian cancer is a serious disease in which the majority of patients experience recurrence during the follow-up period and suffer from a number of severe symptoms from underlying disease. This systematic review was conducted to assess the evidence on the proactive use of PROMs as a dialogue tool during follow-up of ovarian cancer patients. RESULTS The following databases were searched for relevant literature; PubMed, EMBASE, CINAHL, and the Cochrane Library. The search was conducted in April 2019 without any filters or limits. A total of 643 publications were identified, and 48 studies were found to be potentially eligible. Of the 48 papers, none met the final inclusion criterion of using PROMs proactively as a dialogue tool for ovarian cancer patients during follow-up. CONCLUSION Studies have shown that PROMs can identify otherwise undetected symptoms. Using PROMs proactively during the consultation has been shown to improve symptom management for patients with some other types of cancer. However, we found no studies that had examined the proactive use of PROMs during follow-up of ovarian cancer patients. Future studies should evaluate if the proactive use of PROMs could facilitate a more individualized and more effective follow-up program tailored to the ovarian cancer patient's needs and preferences.
Collapse
Affiliation(s)
- Anette Stolberg Kargo
- Department of Clinical Oncology, Sygehus Lillebalt, Vejle Sygehus, Beriderbakken 4, DK-7100 Vejle, Denmark
- Institute of Regional Health Research, University of Southern Denmark, Winsløwparken 19, 3, 5000 Odense, Denmark
- Center for Shared Decision Making, Sygehus Lillebalt, Vejle Sygehus, Beriderbakken 4, 7100 Vejle, Denmark
| | - Angela Coulter
- Institute of Regional Health Research, University of Southern Denmark, Winsløwparken 19, 3, 5000 Odense, Denmark
- Center for Shared Decision Making, Sygehus Lillebalt, Vejle Sygehus, Beriderbakken 4, 7100 Vejle, Denmark
| | - Pernille Tine Jensen
- Department of Gynaecology and Obstetrics, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Winsløwparken 19, 3, 5000 Odense, Denmark
| | - Karina Dahl Steffensen
- Department of Clinical Oncology, Sygehus Lillebalt, Vejle Sygehus, Beriderbakken 4, DK-7100 Vejle, Denmark
- Institute of Regional Health Research, University of Southern Denmark, Winsløwparken 19, 3, 5000 Odense, Denmark
- Center for Shared Decision Making, Sygehus Lillebalt, Vejle Sygehus, Beriderbakken 4, 7100 Vejle, Denmark
| |
Collapse
|
5
|
Mercieca-Bebber R, Friedlander M, Calvert M, Stockler M, Kyte D, Kok PS, King MT. A systematic evaluation of compliance and reporting of patient-reported outcome endpoints in ovarian cancer randomised controlled trials: implications for generalisability and clinical practice. J Patient Rep Outcomes 2017; 1:5. [PMID: 29757300 PMCID: PMC5934909 DOI: 10.1186/s41687-017-0008-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 08/07/2017] [Indexed: 11/26/2022] Open
Abstract
Background This study aimed to evaluate the patient-reported outcome (PRO) content of ovarian cancer randomised-controlled trial (RCT) publications, describe PRO compliance, and explore potential relationships among these and completeness of PRO protocol content. Methods Publications of Phase III ovarian cancer RCTs with PRO endpoints were identified by Medline and Cochrane systematic search: January 2000 to February 2016. Two reviewers determined the number of Consolidated Standards of Reporting Trials (CONSORT)-PRO Extension items addressed in publications. Compliance rates (defined as the proportion of participants included in the principal PRO analysis, of those from whom PRO assessments were expected) were extracted. The relationship between CONSORT-PRO score and compliance rates was explored using scatter plots. Additionally CONSORT-PRO score and PRO compliance rates respectively were compared with corresponding PRO protocol scores obtained from a previous study. Results Thirty-six eligible RCTs (n = 33 with secondary PRO endpoint) were identified and analysed. The average number of CONSORT-PRO items addressed in publications was 6.7 (48%; Range 0–13.5/14). Three RCTs did not report PRO results; in 1 case due to poor compliance. Some compliance information was reported in 26 RCTs, but was considered complete for only 10 (28%) RCTs. Compliance rates were poor overall, ranging from 59 to 83%; therefore missing PRO data from 17 to 41% of participants in these trials could have been avoided. Of the 26 (73%) RCTs for which PRO protocol completeness scores were available, 6 RCTs reported complete compliance information and the 3 of these RCTs with highest PRO compliance had highest protocol checklist scores. Conclusions Few RCTs reported PRO compliance information in a manner enabling assessment of the generalisability of PRO results. This information is particularly important in RCTs of advanced ovarian cancer because it is important to be able to determine if missing data was due to worsening illness compared to methodological issues. Poor compliance appeared related to poor PRO protocol content, and in one case prevented PRO results from being reported, highlighting the need to address compliance strategies in the protocol. Adhering to protocol and CONSORT-PRO reporting guidance should improve PRO implementation and reporting respectively in ovarian cancer RCTs and allow results to meaningfully inform clinical practice. Electronic supplementary material The online version of this article (doi:10.1186/s41687-017-0008-3) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Rebecca Mercieca-Bebber
- 1Central Clinical School, Sydney Medical School, University of Sydney, Sydney, NSW Australia.,2Psycho-oncology Co-operative Research Group, School of Psychology, University of Sydney, Level 6 North, Chris O'Brien Lifehouse C39Z, Sydney, NSW Australia
| | - Michael Friedlander
- 3NHMRC Clinical Trials Centre, University of Sydney, Camperdown, NSW Australia.,Australian New Zealand Gynecological Oncology Group (ANZGOG), Camperdown, NSW Australia
| | - Melanie Calvert
- 5Centre for Patient-Reported Outcomes Research, University of Birmingham, Edgbaston, Birmingham, UK
| | - Martin Stockler
- 3NHMRC Clinical Trials Centre, University of Sydney, Camperdown, NSW Australia.,Australian New Zealand Gynecological Oncology Group (ANZGOG), Camperdown, NSW Australia
| | - Derek Kyte
- 5Centre for Patient-Reported Outcomes Research, University of Birmingham, Edgbaston, Birmingham, UK
| | - Peey-Sei Kok
- 3NHMRC Clinical Trials Centre, University of Sydney, Camperdown, NSW Australia.,Australian New Zealand Gynecological Oncology Group (ANZGOG), Camperdown, NSW Australia
| | - Madeleine T King
- 1Central Clinical School, Sydney Medical School, University of Sydney, Sydney, NSW Australia.,2Psycho-oncology Co-operative Research Group, School of Psychology, University of Sydney, Level 6 North, Chris O'Brien Lifehouse C39Z, Sydney, NSW Australia.,Australian New Zealand Gynecological Oncology Group (ANZGOG), Camperdown, NSW Australia
| |
Collapse
|
6
|
Keim-Malpass J, Mihalko SL, Russell G, Case D, Miller B, Avis NE. Problems Experienced by Ovarian Cancer Survivors During Treatment. J Obstet Gynecol Neonatal Nurs 2017; 46:544-554. [PMID: 28583482 DOI: 10.1016/j.jogn.2017.04.134] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/01/2017] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVE To identify problems at different treatment points (early treatment, mid-treatment, early posttreatment, and late posttreatment) among women with ovarian cancer. DESIGN Longitudinal and cross-sectional study design. SETTING An academic and community clinical cancer center in the Southeastern United States. PARTICIPANTS Sixty-eight women with Stage I to IV ovarian cancer. METHODS Variables assessed included reported problems (physical, psychosocial, pain, marital, medical interaction), social support, optimism, and responses to open-ended questions. Analysis involved mixed models for longitudinal repeated measures and unpaired t tests and content analysis to describe responses to open-ended questions. RESULTS Physical and psychosocial problems were greatest during early treatment and decreased throughout the treatment trajectory. Women with greater levels of social support and optimism at baseline had fewer problems over time. Women who did not have trouble paying for basics had fewer problems related to pain and psychological problems. CONCLUSION Problems across all domains must be addressed throughout the treatment trajectory, even after chemotherapy has ended. Nurses are well positioned to refer women appropriately to social workers and clinical navigators across all domains of care and should consider systematic assessment of patient-reported problems as a routine form of practice.
Collapse
|
7
|
Kearns B, Chilcott J, Whyte S, Preston L, Sadler S. Cost-effectiveness of screening for ovarian cancer amongst postmenopausal women: a model-based economic evaluation. BMC Med 2016; 14:200. [PMID: 27919292 PMCID: PMC5139096 DOI: 10.1186/s12916-016-0743-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 11/09/2016] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND The United Kingdom Collaborative Trial of Ovarian Cancer Screening (UKCTOCS) was the biggest ovarian cancer screening trial to date. A non-significant effect of screening on ovarian cancer was reported, but the authors noted a potential delayed effect of screening, and suggested the need for four years further follow-up. There are no UK-based cost-effectiveness analyses of ovarian cancer screening. Hence we assessed the lifetime outcomes associated with, and the cost-effectiveness of, screening for ovarian cancer in the UK, along with the value of further research. METHODS We performed a model-based economic evaluation. Effectiveness data were taken from UKCTOCS, which considered strategies of multimodal screening (MMS), ultrasound screening (USS) and no screening. We conducted systematic reviews to identify the remaining model inputs, and performed a rigorous and transparent prospective evaluation of different methods for extrapolating the effect of screening on ovarian cancer mortality. We considered costs to the UK healthcare system and measured effectiveness using quality-adjusted life years (QALYs). We used value of information methods to estimate the value of further research. RESULTS Over a lifetime, MMS and USS were estimated to be both more expensive and more effective than no screening. USS was dominated by MMS, being both more expensive and less effective. Compared with no screening, MMS cost on average £419 more (95% confidence interval £255 to £578), and generated 0.047 more QALYs (0.002 to 0.088). The incremental cost-effectiveness ratio (ICER) comparing MMS with no screening was £8864 per QALY (£2600 to £51,576). Alternative extrapolation methods increased the ICER, with the highest value being £36,769 (£13,888 to dominated by no screening). Using the UKCTOCS trial horizon, both MMS and USS were dominated by no screening, as they produced fewer QALYs at a greater cost. The value of research into eliminating all uncertainty in long-term effectiveness was estimated to be worth up to £20 million, or approximately £5 million for four years follow-up. CONCLUSIONS Screening for ovarian cancer with MMS is both more effective and more expensive than not screening. Compared to national willingness to pay thresholds, lifetime cost-effectiveness is promising, but there remains considerable uncertainty regarding extrapolated long-term effectiveness.
Collapse
Affiliation(s)
- Ben Kearns
- The University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK.
| | - Jim Chilcott
- The University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK
| | - Sophie Whyte
- The University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK
| | - Louise Preston
- The University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK
| | - Susi Sadler
- The University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK.,University of Exeter Medical School, St Luke's Campus, Heavitree Road, Exeter, EX1 2LU, UK
| |
Collapse
|
8
|
Mercieca-Bebber R, Friedlander M, Kok PS, Calvert M, Kyte D, Stockler M, King MT. The patient-reported outcome content of international ovarian cancer randomised controlled trial protocols. Qual Life Res 2016; 25:2457-2465. [PMID: 27294435 DOI: 10.1007/s11136-016-1339-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE Patient-reported outcomes (PROs) provide the patient's perspective of the impact of treatment. Evidence suggests that PRO content of randomised controlled trials (RCTs) protocols is generally sub-optimal. This study aimed to describe and evaluate the PRO-specific content of ovarian cancer RCT protocols. METHODS Published, phase III, ovarian cancer RCTs with PRO endpoints were identified following a systematic search of Medline and Cochrane databases (Jan 2000 to Feb 2016). Corresponding RCT protocols were downloaded (if published) or obtained by contacting authors. Two investigators independently assessed adherence of PRO-specific content of included protocols to a checklist of 58 recommended PRO protocol items currently being developed by the International Society for Quality of Life Research. Discrepancies were resolved with a third investigator. RESULTS Of 41 eligible trials identified, 26 protocols were assessed (developed 1995-2010). We were unable to obtain the remaining 15 protocols. Protocols addressed a mean of 28 % PRO checklist items (range 8-66 %). Fifteen (58 % of assessed protocols) provided a rationale for PRO assessment, 8 (31 %) described a PRO objective, 24 (92 %) included a PRO assessment schedule, but only 6 (23 %) justified timing of PRO assessments. Twelve protocols (46 %) provided staff data collection instructions, 4 (15 %) included plans for monitoring PRO compliance, and 16 (62 %) included a PRO analysis plan. CONCLUSIONS On average, protocols addressed less than one-third of PRO protocol checklist items. In some cases, key guidance regarding PRO administration was lacking, which may lead to inconsistent and sub-optimal PRO methodology. Efforts are needed to improve PRO protocol content in cancer trials.
Collapse
Affiliation(s)
- Rebecca Mercieca-Bebber
- Central Clinical School, Sydney Medical School, University of Sydney, Sydney, NSW, 2006, Australia. .,Quality of Life Office, Psycho-oncology Co-operative Research Group, School of Psychology, University of Sydney, Level 6 North, Chris O'Brien Lifehouse C39Z, Sydney, NSW, 2006, Australia.
| | - Michael Friedlander
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, 2006, Australia.,Australian New Zealand Gynecological Oncology Group (ANZGOG), Camperdown, NSW, 2050, Australia
| | - Peey-Sei Kok
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, 2006, Australia.,Australian New Zealand Gynecological Oncology Group (ANZGOG), Camperdown, NSW, 2050, Australia
| | - Melanie Calvert
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Derek Kyte
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Martin Stockler
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, 2006, Australia
| | - Madeleine T King
- Central Clinical School, Sydney Medical School, University of Sydney, Sydney, NSW, 2006, Australia.,Quality of Life Office, Psycho-oncology Co-operative Research Group, School of Psychology, University of Sydney, Level 6 North, Chris O'Brien Lifehouse C39Z, Sydney, NSW, 2006, Australia.,Australian New Zealand Gynecological Oncology Group (ANZGOG), Camperdown, NSW, 2050, Australia
| |
Collapse
|
9
|
Ahmed-Lecheheb D, Joly F. Ovarian cancer survivors' quality of life: a systematic review. J Cancer Surviv 2016; 10:789-801. [PMID: 26884372 DOI: 10.1007/s11764-016-0525-8] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 02/09/2016] [Indexed: 12/22/2022]
Abstract
PURPOSE The assessment of quality of life (QOL) among ovarian cancer (OC) patients has mainly focused on the acute phase of treatment. This systematic review examines studies measuring QOL in patients who survived OC after treatment and synthesizes results in order to assess QOL and patient-reported outcome (PRO) data at long-term follow-up. METHODS Articles published in English between 1990 to November 2014 were identified with the databases MEDLINE and PubMed, using the specific keywords "OC survivors" combined with the terms, "QOL," "health-related QOL," and "PROs." Data were reviewed for design, time since end of treatment, measurement tools, and outcomes (categorized in three topics: global QOL compared to controls, treatment sequelae, and intervention strategies). RESULTS The initial search strategy provided 148 articles of which 31 were considered eligible. Most studies focused on epithelial OC, and only a few studies investigated survivors of ovarian germ cell tumor. More than 60 instruments of QOL measures were used in the corpus. Despite the persistence of psychological and physical symptoms, treatment sequelae, sexual problems, and fear of recurrence in some survivors, most studies demonstrated that OC survivors generally have good QOL compared to healthy women. Studies proposing interventions are lacking. CONCLUSIONS AND IMPLICATIONS FOR CANCER SURVIVOR OC survivors experience a wide range of sequelae that may persist for a long time and negatively impact QOL. Further large-scale research is needed to fully understand problems that have significant effects on QOL, in order to develop interventions and treatments suitable for women at need.
Collapse
Affiliation(s)
- D Ahmed-Lecheheb
- U1086 INSERM, Cancers and Preventions, Center François Baclesse, 3 Avenue du General Harris, 14076, Caen, France.
| | - F Joly
- U1086 INSERM, Cancers and Preventions, Center François Baclesse, 3 Avenue du General Harris, 14076, Caen, France.,Medical Oncology Department-Clinical Research Department, Center François Baclesse-CHU Côte de nacre, Caen, France
| |
Collapse
|
10
|
Zhang L, Hu A, Li M, Zhang H, Ren C, An X, Liu C. 4.1N suppresses hypoxia-induced epithelial-mesenchymal transition in epithelial ovarian cancer cells. Mol Med Rep 2015; 13:837-44. [PMID: 26648170 DOI: 10.3892/mmr.2015.4634] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2015] [Accepted: 10/29/2015] [Indexed: 11/06/2022] Open
Abstract
Protein 4.1N (4.1N) is a member of the protein 4.1 family and is essential for the regulation of cell adhesion, motility and signaling. Previous studies have suggested that 4.1N may serve a tumor suppressor role. However, the molecular mechanisms remain unclear. In the current study, the role of 4.1N in the downregulation of hypoxia‑induced factor 1α (HIF‑1α) under hypoxic conditions and therefore the suppression of hypoxia induced epithelial‑mesenchymal transition (EMT) was investigated. The data were obtained from overexpressed and knockdown 4.1N epithelial ovarian cancer (EOC) cell lines. It was identified that 4.1N was capable of regulating the sub‑cellular localization and expression levels of HIF‑1α, by which 4.1N served a dominant role in the suppression of hypoxia‑induced EMT and associated genes. Collectively, the data of the current study identified 4.1N as an inhibitor of hypoxia‑induced tumor progression in EOC cells and highlighted its potential role in EOC therapy.
Collapse
Affiliation(s)
- Letian Zhang
- Department of Pathology, School of Basic Medical Sciences, Peking University Health Science Center, Beijing 100191, P.R. China
| | - Ajin Hu
- Department of Pathology, School of Basic Medical Sciences, Peking University Health Science Center, Beijing 100191, P.R. China
| | - Mengrui Li
- Department of Pathology, School of Basic Medical Sciences, Peking University Health Science Center, Beijing 100191, P.R. China
| | - Hongquan Zhang
- Department of Histology and Embryology, Peking University Health Science Center, Beijing 100191, P.R. China
| | - Caixia Ren
- Department of Histology and Embryology, Peking University Health Science Center, Beijing 100191, P.R. China
| | - Xiuli An
- College of Life Science, Zhengzhou University, Zhengzhou, Henan 450051, P.R. China
| | - Congrong Liu
- Department of Pathology, School of Basic Medical Sciences, Third Hospital, Peking University Health Science Center, Beijing 100191, P.R. China
| |
Collapse
|
11
|
Edwards SJ, Barton S, Thurgar E, Trevor N. Topotecan, pegylated liposomal doxorubicin hydrochloride, paclitaxel, trabectedin and gemcitabine for advanced recurrent or refractory ovarian cancer: a systematic review and economic evaluation. Health Technol Assess 2015; 19:1-480. [PMID: 25626481 DOI: 10.3310/hta19070] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Ovarian cancer is the fifth most common cancer in the UK, and the fourth most common cause of cancer death. Of those people successfully treated with first-line chemotherapy, 55-75% will relapse within 2 years. At this time, it is uncertain which chemotherapy regimen is more clinically effective and cost-effective for the treatment of recurrent, advanced ovarian cancer. OBJECTIVES To determine the comparative clinical effectiveness and cost-effectiveness of topotecan (Hycamtin(®), GlaxoSmithKline), pegylated liposomal doxorubicin hydrochloride (PLDH; Caelyx(®), Schering-Plough), paclitaxel (Taxol(®), Bristol-Myers Squibb), trabectedin (Yondelis(®), PharmaMar) and gemcitabine (Gemzar(®), Eli Lilly and Company) for the treatment of advanced, recurrent ovarian cancer. DATA SOURCES Electronic databases (MEDLINE(®), EMBASE, Cochrane Central Register of Controlled Trials, Health Technology Assessment database, NHS Economic Evaluations Database) and trial registries were searched, and company submissions were reviewed. Databases were searched from inception to May 2013. METHODS A systematic review of the clinical and economic literature was carried out following standard methodological principles. Double-blind, randomised, placebo-controlled trials, evaluating topotecan, PLDH, paclitaxel, trabectedin and gemcitabine, and economic evaluations were included. A network meta-analysis (NMA) was carried out. A de novo economic model was developed. RESULTS For most outcomes measuring clinical response, two networks were constructed: one evaluating platinum-based regimens and one evaluating non-platinum-based regimens. In people with platinum-sensitive disease, NMA found statistically significant benefits for PLDH plus platinum, and paclitaxel plus platinum for overall survival (OS) compared with platinum monotherapy. PLDH plus platinum significantly prolonged progression-free survival (PFS) compared with paclitaxel plus platinum. Of the non-platinum-based treatments, PLDH monotherapy and trabectedin plus PLDH were found to significantly increase OS, but not PFS, compared with topotecan monotherapy. In people with platinum-resistant/-refractory (PRR) disease, NMA found no statistically significant differences for any treatment compared with alternative regimens in OS and PFS. Economic modelling indicated that, for people with platinum-sensitive disease and receiving platinum-based therapy, the estimated probabilistic incremental cost-effectiveness ratio [ICER; incremental cost per additional quality-adjusted life-year (QALY)] for paclitaxel plus platinum compared with platinum was £24,539. Gemcitabine plus carboplatin was extendedly dominated, and PLDH plus platinum was strictly dominated. For people with platinum-sensitive disease and receiving non-platinum-based therapy, the probabilistic ICERs associated with PLDH compared with paclitaxel, and trabectedin plus PLDH compared with PLDH, were estimated to be £25,931 and £81,353, respectively. Topotecan was strictly dominated. For people with PRR disease, the probabilistic ICER associated with topotecan compared with PLDH was estimated to be £324,188. Paclitaxel was strictly dominated. LIMITATIONS As platinum- and non-platinum-based treatments were evaluated separately, the comparative clinical effectiveness and cost-effectiveness of these regimens is uncertain in patients with platinum-sensitive disease. CONCLUSIONS For platinum-sensitive disease, it was not possible to compare the clinical effectiveness and cost-effectiveness of platinum-based therapies with non-platinum-based therapies. For people with platinum-sensitive disease and treated with platinum-based therapies, paclitaxel plus platinum could be considered cost-effective compared with platinum at a threshold of £30,000 per additional QALY. For people with platinum-sensitive disease and treated with non-platinum-based therapies, it is unclear whether PLDH would be considered cost-effective compared with paclitaxel at a threshold of £30,000 per additional QALY; trabectedin plus PLDH is unlikely to be considered cost-effective compared with PLDH. For patients with PRR disease, it is unlikely that topotecan would be considered cost-effective compared with PLDH. Randomised controlled trials comparing platinum with non-platinum-based treatments might help to verify the comparative effectiveness of these regimens. STUDY REGISTRATION This study is registered as PROSPERO CRD42013003555. FUNDING The National Institute for Health Research Health Technology Assessment programme.
Collapse
Affiliation(s)
| | - Samantha Barton
- Senior Health Technology Assessment Analyst, BMJ-TAG, London, UK
| | | | | |
Collapse
|
12
|
Davis L, Carpenter J. A Systematic Review of Nonpharmacologic Interventions for Treatment-Related Symptoms in Women With Ovarian Cancer. Clin J Oncol Nurs 2015; 19:535-42. [DOI: 10.1188/15.cjon.19-05ap] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
13
|
Sopik V, Iqbal J, Rosen B, Narod SA. Why have ovarian cancer mortality rates declined? Part II. Case-fatality. Gynecol Oncol 2015; 138:750-6. [DOI: 10.1016/j.ygyno.2015.06.016] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Revised: 06/09/2015] [Accepted: 06/12/2015] [Indexed: 11/28/2022]
|
14
|
Kim SI, Lee Y, Lim MC, Joo J, Park K, Lee DO, Park SY. Quality of life and sexuality comparison between sexually active ovarian cancer survivors and healthy women. J Gynecol Oncol 2015; 26:148-54. [PMID: 25686396 PMCID: PMC4397231 DOI: 10.3802/jgo.2015.26.2.148] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2014] [Revised: 12/27/2014] [Accepted: 01/07/2015] [Indexed: 11/30/2022] Open
Abstract
Objective compare quality of life (QoL) and sexual functioning between sexually active ovarian cancer survivors and healthy women. Methods A cross-sectional study was performed in 103 successfully treated ovarian cancer survivors and 220 healthy women. All women had engaged in sexual activity within the previous 3 months, and ovarian cancer survivors were under surveillance after primary treatment without evidence of disease. QoL and sexual functioning were assessed using three questionnaires; the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30), Ovarian Cancer Module (EORTC QLQ-OV28), and the Female Sexual Function Index (FSFI). Propensity score matching was used to adjust covariates between the ovarian cancer survivor and healthy women groups. In total, 73 ovarian cancer survivors and 73 healthy women were compared. Results Poorer social functioning (mean, 82.4 vs. 90.9; p=0.010) and more financial difficulties (mean, 16.4 vs. 7.8; p=0.019) were observed among ovarian cancer survivors than among healthy women. Sexuality, both in terms of desire, arousal, lubrication, orgasm, satisfaction, and pain and in terms of interest in sex, sexual activity, and enjoyment of sex (EORTC QLQ-OV28) were similar between the groups. However, vaginal dryness was more problematic in ovarian cancer survivors, with borderline statistical significance (p=0.081). Conclusion Sexuality was not impaired in ovarian cancer survivors who were without evidence of disease after primary treatment and having sexual activities, compared with healthy women, whereas social functioning and financial status did deteriorate. Prospective cohort studies are needed.
Collapse
Affiliation(s)
- Se Ik Kim
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea.; Center for Uterine Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Yumi Lee
- Center for Uterine Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Myong Cheol Lim
- Center for Uterine Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea.; Gynecologic Cancer Branch, Research Institute and Hospital, National Cancer Center, Goyang, Korea.
| | - Jungnam Joo
- Biometric Research Branch, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Kibyung Park
- Biometric Research Branch, Research Institute and Hospital, National Cancer Center, Goyang, Korea.; Jaseng Medical Foundation, Jaseng Hospital of Korean Medicine, Seoul, Korea
| | - Dong Ock Lee
- Center for Uterine Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Sang Yoon Park
- Center for Uterine Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea.; Gynecologic Cancer Branch, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| |
Collapse
|
15
|
Teng FF, Kalloger SE, Brotto L, McAlpine JN. Determinants of quality of life in ovarian cancer survivors: a pilot study. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2014; 36:708-715. [PMID: 25222166 DOI: 10.1016/s1701-2163(15)30513-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Ovarian cancer treatments and outcomes vary substantially, yielding a diverse group of survivors. Few data exist on quality of life (QoL) concerns and the foremost needs of these patients. Our goal was to conduct a pilot study to determine the QoL needs of ovarian cancer survivors to establish priorities for future interventions. METHODS In this cross-sectional study, the European Organization for Research and Treatment of Cancer Quality of Life Questionnaires (EORTC QLQ-C30 and OV28) QoL questionnaires and one investigator-derived questionnaire were administered in an outpatient setting. Clinical parameters were abstracted and tested for associations with QoL measures. RESULTS A total of 102 women consented to participate and completed all components. Their mean age was 58 years (range 29 to 85), with 80% having epithelial ovarian carcinoma and 66% high-grade serous carcinoma. Women with stage I (28%), II (15%), III (47%), and IV (10%) lesions were represented in the primary treatment (25%), surveillance (46%), recurrent (23%), and palliative (7%) phases of the survivorship continuum. Fifty-one percent characterized their disease burden as "quite a bit" or "very much," and this did not vary by histology or diagnoses. Global QoL did not vary by clinico-pathologic parameters. Cardiovascular and respiratory comorbidities were associated with EORTC scores in physical functioning (P=0.027 for cardiovascular and P=0.041 for respiratory), global QoL (P=0.03 for cardiovascular and P=0.039 for respiratory), and sexual health (P=0.025 for cardiovascular). Task completion/memory/concentration, anxiety, and fatigue were the distress categories given highest priority by respondents. CONCLUSION In women with ovarian cancer, clinical factors such as age, stage, and histology did not have a significant impact on QoL. Psychosocial factors have a larger impact on global QoL than physical symptoms.
Collapse
Affiliation(s)
- Flora F Teng
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver BC
| | - Steve E Kalloger
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver BC
| | - Lori Brotto
- Division of Gynaecologic Specialties, Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver BC
| | - Jessica N McAlpine
- Division of Gynaecologic Oncology, Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver BC
| |
Collapse
|
16
|
Cost-effectiveness of early-initiated treatment for advanced-stage epithelial ovarian cancer patients: a modeling study. Int J Gynecol Cancer 2014; 24:75-84. [PMID: 24362714 DOI: 10.1097/igc.0000000000000025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE Between diagnosis and primary treatment of patients with epithelial ovarian cancer (EOC), gaps of several weeks exist. Reducing these time intervals may benefit the patient and may lead to a reduction of costs. We explored the cost-effectiveness of early-initiated treatment of patients with suspected advanced-stage EOC compared with that of current treatment. METHODS A discrete event simulation was used to synthesize all available evidences and to evaluate the health care costs and effects (quality-adjusted life years [QALYs]) of the 2 treatment strategies over lifetime. Overall survival, progression-free survival, health-related quality of life, and costs of the separate events were assumed to remain equal. Other uncertainties were addressed using deterministic and probabilistic sensitivity analyses. RESULTS The treatment times of current and early-initiated treatment were 27 and 24 weeks, respectively. Early-initiated treatment yielded 3.42 QALYs per patient, for a total expected health care cost of €25,654. Current treatment yielded 3.40 QALYs per patient, for a total expected health care cost of €25,607. This resulted in an incremental cost-effectiveness ratio of €2592 per QALY gained for early-initiated treatment compared with that for current treatment. For the willingness to pay for €30,000 or more per QALY, early-initiated treatment had a 100% probability of being cost-effective compared with current treatment under the previously mentioned assumptions. CONCLUSIONS Given the current evidence, early-initiated treatment of patients with suspected advanced-stage EOC leads to additional QALYs and seems to be cost-effective compared with current treatment.
Collapse
|
17
|
Canevari S, Raspagliesi F, Lorusso D. Bevacizumab treatment and quality of life in advanced ovarian cancer. Future Oncol 2014; 9:951-4. [PMID: 23837758 DOI: 10.2217/fon.13.77] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Despite improvements in surgery and chemotherapy treatments, the 5-year survival of ovarian cancer patients is far below 50%. As angiogenesis contributes to tumor growth and metastasis, bevacizumab, an antiangiogenetic monoclonal antibody, was studied in many solid cancers for which evidence of efficacy has been shown in several trials. The ICON7 randomized Phase III trial was designed to evaluate the addition of bevacizumab to standard chemotherapy in ovarian cancer. The ICON7 study demonstrated for patients receiving bevacizumab: a progression-free survival advantage of 2.4 months; an overall survival benefit of 8 months in patients with high risk of progression; and a less than 10-point difference in quality of life (QoL) between the two groups. A detailed assessment of ICON7 QoL confirmed that bevacizumab continuation treatment seems to be associated with a small but clinically significant decrement in QoL. As development of existing and new antiangiogenesis drugs is mainly based on continuation schedules, studies taking into account the evolving interpretation of QoL data are needed.
Collapse
Affiliation(s)
- Silvana Canevari
- Molecular Therapies, Department of Experimental Oncology & Molecular Medicine, Ondazione IRCCS Istituto Nazionale dei Tumori, via Venezian 1, 20133 Milan, Italy
| | | | | |
Collapse
|
18
|
Xi C, Ren C, Hu A, Lin J, Yao Q, Wang Y, Gao Z, An X, Liu C. Defective expression of Protein 4.1N is correlated to tumor progression, aggressive behaviors and chemotherapy resistance in epithelial ovarian cancer. Gynecol Oncol 2013; 131:764-71. [PMID: 23994105 DOI: 10.1016/j.ygyno.2013.08.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Revised: 07/16/2013] [Accepted: 08/08/2013] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Protein 4.1N (4.1N) is a member of the Protein 4.1 family that is involved in cellular processes such as cell adhesion, migration and signaling. In this study, we evaluated the expression of 4.1N protein and its potential roles in epithelial ovarian cancer (EOC) tumorigenesis and progression. METHODS 4.1N protein expression was investigated in a total of 280 samples including 74 normal tissues, 35 benign, 30 borderline and 141 malignant epithelial ovarian tumors by immunohistochemistry. Correlation between 4.1N expression levels and clinicopathologic features was statistically analyzed. The expression of 4.1N in EOC cell lines was examined by western blotting. RESULTS Immunohistochemistry analysis revealed that, although there was no loss of 4.1N expression in normal tissues and benign tumors, absence of Protein 4.1N was significantly more common in EOCs (44.0%) than in borderline tumors (3.3%) (p<0.001). Furthermore, loss or decreased expression of 4.1N protein expression was correlated with malignant potential of the tumors (14.3% in benign tumors, 56.7% in borderline tumors and 92.9% in malignancy) (p<0.001). In EOC samples, loss of 4.1N protein was significantly associated with advanced-stage (p=0.004), ascites (p=0.009), omental metastasis (p=0.018), suboptimal debulking (p=0.024), poorly histological differentiation (p=0.009), high-grade serous carcinoma (p=0.001), short progression-free-survival (p=0.018) and poor chemosensitivity to first-line chemotherapy (p=0.029). Moreover, western blotting analysis revealed that expression of 4.1N protein was lost in 4/8 (50%) EOC cell lines. CONCLUSIONS 4.1N protein expression level was significantly decreased during malignant transformation of epithelial ovarian tumors and that loss of 4.1N expression was closely correlated to poorly differentiated and biologically aggressive EOCs.
Collapse
Affiliation(s)
- Chenguang Xi
- Department of Pathology, Peking University Health Science Center, Beijing 100191, China
| | | | | | | | | | | | | | | | | |
Collapse
|
19
|
Hess LM, Brady WE, Havrilesky LJ, Cohn DE, Monk BJ, Wenzel L, Cella D. Comparison of methods to estimate health state utilities for ovarian cancer using quality of life data: a Gynecologic Oncology Group study. Gynecol Oncol 2013; 128:175-80. [PMID: 23123576 PMCID: PMC3552113 DOI: 10.1016/j.ygyno.2012.10.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2012] [Revised: 10/22/2012] [Accepted: 10/25/2012] [Indexed: 11/20/2022]
Abstract
BACKGROUND Cost-effectiveness/cost-utility analyses are increasingly needed to inform decisions about care. Algorithms have been developed using the Functional Assessment of Cancer Therapy (FACT) quality of life instrument to estimate utility weights for cost analyses. This study was designed to compare these algorithms in the setting of ovarian cancer. METHODS GOG-0152 was a 550-patient randomized phase III trial of interval cytoreduction, and GOG-0172 was a 415-patient randomized phase III trial comparing intravenous versus intraperitoneal therapy among women with advanced ovarian cancer. QOL data were collected via the FACT at four time points in each study. Two published mapping algorithms (Cheung and Dobrez) and a linear transformation method were applied to these data. The agreement between measures was assessed by the concordance correlation coefficient (r(CCC)), and paired t-tests were used to compare means. RESULTS While agreement between the estimation algorithms was good (ranged from 0.72 to 0.81), there were statistically significant (p<0.001) and clinically meaningful differences between the scores: mean scores were higher with Dobrez than with Cheung or the linear transformation method. Scores were also statistically significantly different (p<0.001) between studies. CONCLUSIONS In the absence of prospectively collected utility data, the use of mapping algorithms is feasible, however, the optimal algorithm is not clear. There were significant differences between studies, which highlight the need for validation of these algorithms in specific settings. If cost analyses incorporate mapping algorithms to obtain utility estimates, investigators should take the variability into account.
Collapse
Affiliation(s)
- Lisa M Hess
- Indiana University School of Medicine, Dept. of Public Health & Obstetrics and Gynecology, Indianapolis, IN 46202, USA.
| | | | | | | | | | | | | |
Collapse
|