Symptom burden among patients with renal cell carcinoma (RCC): content for a symptom index

Polygenic score for body mass index in relation to mortality among patients with renal cell cancer

BACKGROUND

The association between body mass index (BMI) and mortality among individuals with renal cell cancer (RCC) is debated, with some observational studies suggesting a lower mortality associated with higher BMI. However, methodological issues such as confounding and reverse causation may bias these findings. Using BMI-associated genetic variants can avoid these biases and generate more valid estimates.

METHODS

In this prospective cohort study, we included 1264 RCC patients (446 deaths) from the UK Biobank. We created a BMI polygenic score (PGS) based on 336 BMI-associated genetic variants. The association between the PGS and mortality (all-cause and RCC-specific) was evaluated by logistic regression (all RCC cases) and Cox regression (906 incident cases). For comparison, the associations of measured pre-diagnostic BMI and waist-to-hip ratio (WHR) with mortality were quantified by Cox regression among incident cases. We stratified these analyses by time between anthropometric measurement and RCC diagnosis to assess the influence of reverse causation.

RESULTS

We did not observe an association between the BMI PGS and all-cause mortality among RCC patients (hazard ratio (HR) per SD increase = 0.98, 95% CI: 0.88,1.10). No association was found for pre-diagnostic BMI (HR per 5 kg/m2 increase = 0.93, 95% CI: 0.83,1.04) or WHR (HR per 0.1 increase = 0.97, 95% CI: 0.83,1.13) with mortality. In patients with anthropometrics measured within 2 years before RCC diagnosis, we observed associations of higher BMI (HR per 5 kg/m2 = 0.76, 95% CI: 0.59,0.98) and WHR (HR = 0.67 per 0.1 increase, 95% CI: 0.45,0.98) with a lower risk of death. Similar patterns were observed for RCC-specific mortality.

CONCLUSION

We found no association between either genetic variants for high BMI or measured pre-diagnostic body adiposity and mortality among RCC patients, and our results suggested a role for reverse causation in the association of obesity with lower mortality. Future studies should be designed carefully to produce unbiased estimates that account for confounding and reverse causation.

Effective symptom relief through continuous integration of palliative care in advanced renal cell carcinoma patients: comprehensive measurement using the palliative care base assessment

Background

Due to modern therapies, survival in metastatic renal cell carcinoma (mRCC) has been significantly prolonged. Nevertheless, patients suffering from advanced disease often present with severe symptoms. Early integration of palliative care into anti-cancer treatment has been shown to improve quality of life and may even prolong survival. Therefore, it is recommended to offer palliative care to patients with complex symptoms at the beginning of an advanced disease stage. To our knowledge, so far, no study has been conducted to examine the role of palliative care in patients with mRCC.

Objectives

This study aimed to assess the symptom burden and quality of life before and after an inpatient palliative care treatment.

Design

The study design is a retrospective observational study.

Methods

We included patients with mRCC, who were admitted to our palliative care unit between 2011 and 2017 due to severe symptoms. The symptom burden was assessed at admission, throughout treatment, and at discharge. The evaluation consisted of the palliative care base assessment and daily documentation of relevant symptoms.

Results

We evaluated 110 hospitalizations of 58 RCC patients. On average, patients were admitted to the palliative care unit 7 years after initial diagnosis (range 1-305 months). The median age was 70.5 years, 69% of the patients were male, 3% female. The main causes for admission were pain (52%) and dyspnea (26%), and the most frequent patient-reported symptoms were fatigue/exhaustion (87%), weakness (83%), and need for assistance with activities of daily living (83%). Multidisciplinary palliative care treatment led to a significant reduction in the median minimal documentation system (MIDOS) symptom score (15.6-9.9, p < 0.001), the median numeric pain rating scale (3-0, p < 0.001), and a significant reduction in mean ratings of the distress thermometer (5.5-3.1, p = 0.016).

Conclusion

Our analysis shows that the integration of palliative care treatment is effective throughout the disease in mRCC and could measurably reduce the symptom burden in our patient population. Palliative care should not be equated with end-of-life care but should rather be integrated throughout advanced disease, particularly as soon as a cure is impossible.

LITESPARK-012: pembrolizumab plus lenvatinib with or without belzutifan or quavonlimab for advanced renal cell carcinoma

Combination treatment with immunotherapy agents and/or vascular endothelial growth factor tyrosine kinase inhibitors are a standard of care for patients with advanced clear cell renal cell carcinoma (ccRCC). Novel therapeutic combinations that include the hypoxia-inducible factor 2α inhibitor belzutifan and the cytotoxic T-lymphocyte-associated protein 4 inhibitor quavonlimab are being investigated for their potential to further improve patient outcomes. This protocol describes the rationale and design of the randomized, phase III LITESPARK-012 study, which will evaluate the efficacy and safety of pembrolizumab plus lenvatinib with or without belzutifan or quavonlimab as first-line treatment for advanced ccRCC. Results from this study may support triplet combination therapies as a potential new standard of care for advanced ccRCC. Clinical trial registry: NCT04736706 (ClinicalTrials.gov).

Testicular Metastasis from Renal Cell Carcinoma: A Systematic Review

Approximately one-third of renal cell carcinoma (RCC) is recognized in its metastatic stage. This systematic review aimed to summarize knowledge on the occurrence and treatment of testicular RCC metastasis. The literature search was performed by two authors independently, with the use of main electronic medical databases (Science Direct, Web of Science, and PubMed) until March 2023 to identify relevant articles that could potentially contribute to this review. Neither language nor publication dates were set as limits. Although we found a total of 51 case reports, only 31 of them contained all the required information. Testicular metastasis in patients with RCC suggests a late stage of the disease. Moreover, it usually does not present typical systemic or specific symptoms except for swelling and enlargement of the affected testis. Knowledge of the possibility of such variants of RCC metastases will allow a clinician to make an appropriate diagnosis and implement adequate treatment without delay, which is crucial in the management of neoplastic disease.

A systematic review to summarize treatment patterns, guidelines, and characteristics of patients with renal cell carcinoma in the Asia-Pacific region

INTRODUCTION

This systematic review evaluated treatment patterns and guidelines in advanced/metastatic and adjuvant renal cell carcinoma (RCC) in the Asia-Pacific region.

AREAS COVERED

Embase, PubMed, and congresses were searched for observational studies and guidelines in accordance with PRISMA. Records published during 2016-2021 (2019-2021 for congresses) were included.

EXPERT OPINION

Nine studies and three guidelines were identified overall. In advanced/metastatic RCC, the most common treatments were tyrosine kinase inhibitors (TKIs) (notably sunitinib: 33-100%) for first-line, and everolimus (13-85%) or axitinib (2-89%) for second-line therapy. In adjuvant RCC, sunitinib was most used (54%), followed by mammalian target of rapamycin inhibitors (mTORis, 27%) with immunotherapy being less common (16%). The guidelines provided varying recommendations for advanced/metastatic RCC. For first-line in advanced/metastatic clear cell RCC (the most common subtype), guidelines recommended mTORis (everolimus for poor-risk patients) (India, 2016); clinical study enrollment for high-risk patients or TKIs for low- to medium-risk patients (China, 2019); or immunotherapy based on survival benefits over sunitinib; dose adjustment was also recommended to manage TKI toxicities (Hong Kong, 2019). The landscape remained more static in the adjuvant setting, but best practice was uncertain. No clear trends were identified in patient characteristics.

A rapid review of patient-reported outcomes investigated in the context of advanced renal cell cancer or advanced hepatocellular cancer

BACKGROUND

Patient-reported outcomes (PROs) are key indicators of health status and functioning, coming directly from the patient. Comprehensive monitoring of PROs enables implementation of person-centred care. Currently, the PROs that patients with advanced renal cell carcinoma (RCC) or hepatocellular carcinoma (HCC) consider of greatest importance remains unknown.

METHODS

A rapid literature review was carried out to identify PROs commonly reported in clinical studies of patients with advanced RCC/HCC. We searched MEDLINE, CINAHL & PsycInfo for relevant peer-reviewed publications in the period from 2000 to 2021. Pre-specified selection criteria were applied to all retrieved records. Findings were integrated into a narrative synthesis.

RESULTS

Eighty-one studies met our selection criteria and were retained. Most research was on advanced RCC (n = 64, 79%); 46 studies (57%) were drug trials. Only twenty-six studies (32%) employed PROs as their primary endpoint. Most PROs concerned physical symptoms (45% RCC, 54% HCC) and emotional wellbeing (19% RCC, 16% HCC). The most common outcome measured was quality of life (65% of the total), followed by fatigue (62%) and pain (54%). Whether selection of these PROs was patient-driven was not reported.

CONCLUSIONS

A wide range of PROs were assessed. Deficits in PROs often cause patients to seek out help; however, which PROs matter the most to people with advanced RCC/HCC must be further clarified. Targeting, monitoring, and responding to the 'right' PROs can enhance provision of person-centred care in advanced RCC/HCC and augment the clinical efficacy of established and emerging targeted therapies.

Should We Always Perform Preoperative Chest Computed Tomography in Patients with cT1a Renal Cell Carcinoma?

No definitive criteria regarding the performance of preoperative chest computed tomography (CT) in patients with cT1a renal cell carcinoma (RCC) exists. We aimed to establish an objective standard for the optimal timing of preoperative chest CT in patients with RCC. Data from 890 patients who underwent surgical treatment for RCC between January 2011 and December 2020 were retrospectively collected. The primary endpoint was detection of lung metastasis on chest CT before nephrectomy. A multivariable logistic regression model predicting positive chest CT scans was used. Predictors included preoperative cTN stage, presence of systemic symptoms, Charlson comorbidity index (CCI), platelet count/hemoglobin ratio, albumin/globulin ratio (AGR), and De Ritis ratio. The overall rate of positive chest CT scans before nephrectomy was 3.03% (27/890). Only one patient had lung metastasis before surgery for cT1a. cT stage (≥cT1b), CCI ≥4, and low AGR were associated with a higher risk of positive chest CT scans. The best cutoff value for AGR was 1.39. After 890-sample bootstrap validation, the concordance index was 0.80. The net benefit of the proposed strategy was superior to that of the select-all and select-none strategies according to decision curve analysis. Therefore, when chest CT scans were performed with a risk of a positive result ≥10%, 532 (59.8%) negative chest CT scans could be prevented. Only 24 (2.7%) potentially positive chest CT scans were misdiagnosed. Therefore, we recommend chest CT in patients with ≥cT1b disease, CCI ≥4, and low AGR.

RESIRT: A Phase 1 Study of Selective Internal Radiation Therapy Using Yttrium-90 Resin Microspheres in Patients With Primary Renal Cell Carcinoma

INTRODUCTION

Selective internal radiation therapy (SIRT) is a potential treatment of primary renal cell carcinoma (RCC) deemed unsuitable for conventional therapy. RESIRT is the first-in-human study to evaluate safety and feasibility of SIRT for primary RCC.

PATIENTS AND METHODS

Patients with RCC, unsuitable for, or who declined conventional therapy, were eligible. A single transfemoral micro-catheter administration of yttrium-90 (Y-90) resin microspheres (SIR-Spheres) was delivered super selectively via the renal artery to the tumour at intended radiation doses of 75, 100, 150, 200, 300 Gy and a final cohort with a procedural endpoint of "imminent stasis," in a dose-escalation design. Post-SIRT follow-up was 12 months. Study endpoints included safety and toxicity 30-days and 12-months post-SIRT and tumour response (RECIST v1.1).

RESULTS

In total, 21 patients were enrolled, mean (SD) age was 75 (9.3) years, WHO performance status was 0 in 81%, 12 (57%) had stage 3 chronic kidney disease, and 7 (33%) had prior contralateral nephrectomy. Overall, 71% of patients completed 12 months of follow-up. Intended doses were delivered without any dose-limiting toxicity. Seventeen out of 21 (81%) patients experienced an adverse event (AE) from any cause within 30 days post-SIRT; all SIRT-related AEs were grade 1 to 2. Best overall tumour responses were partial response 1/21 (4.8%), stable disease 19/21 (90.5%) and progressive disease 1/21 (4.8%).

CONCLUSION

This study demonstrated good tolerability of SIRT at all dose levels including "imminent stasis" in treating primary tumours in RCC patients otherwise unsuitable for conventional therapy. SIRT with Y-90 resin microspheres may be a feasible treatment option for RCC.

A psychometric evaluation of the Functional assessment of cancer therapy-kidney symptom index (FKSI-19) among renal cell carcinoma patients suggesting an alternative two-factor structure

Purpose

To psychometrically evaluate the hypothesized four-factor structure of the 19-item Functional Assessment of Cancer Therapy—Kidney Symptom Index (FKSI-19) health-related quality of life (HRQoL) instrument in a sample of surgically treated renal cell carcinoma (RCC) patients and examine if an alternative factor structure with good psychometric properties may be derived from the available items.

Methods

The model fit of the hypothesized four-factor structure was examined using confirmatory factor analysis on cohort data from 1731 individuals included in the National Swedish Kidney Cancer Register who had undergone surgery for RCC during the three years 2016–2018 and answered the FKSI-19 instrument within 6–12 months after surgery. Exploratory factor analysis was applied to the same dataset to derive a possible alternative factor solution.

Results

The four-factor structure did not reach the thresholds for good model fit using the normed χ²-value or the Comparative Fit Index, although the Standardized Root Mean Square Residual and Root Mean Square Error of Approximation measures indicated good and acceptable model fits, respectively. An alternative 14-item trimmed FKSI version (FKSI-14) with a two-factor structure derived from the available FKSI-19 items was found to measure the same aspects of HRQoL as the full FKSI-19 instrument.

Conclusion

The present study is the first to use psychometric methods for examining the factor structure of the FKSI-19 instrument. The hypothesized four-factor structure of FKSI-19 provided a barely acceptable model fit. The two-factor FKSI-14 structure may be used as an alternative or complement to the four-factor structure when interpreting the FKSI-19 instrument.

Integration of Patient Reported Outcomes in Drug Development in Genitourinary Cancers

PURPOSE OF REVIEW

Patient reported outcomes (PROs) are increasingly utilized in cancer drug development, and are of particular importance in genitourinary cancers due to symptom burden, multiple treatment options with similar efficacy, and often prolonged duration of disease. Here we review current data and perspectives related to use of PROs in drug development for genitourinary cancers, including insights on the regulatory process for drug approval.

RECENT FINDINGS

The FDA is committed to incorporating PRO data into the regulatory process for development and approval of new cancer drugs, but challenges exist due to lack of standardization of PRO instrument choice and analytic approach, missing data, and difficulty isolating treatment effect from disease-related effects. We review guidance for standardization of PRO methodology that is nonetheless tailored to disease state and anticipated effects of treatment. PRO and efficacy data should be simultaneously analyzed and reported for best clinical practice. Multiple disease-specific PRO instruments exist for genitourinary cancers. While clinicians, researchers, and regulatory bodies alike recognize the importance of PROs in cancer drug development, challenges remain regarding implementation of best practices.

Demographic, medical, social-cognitive, and environmental correlates of meeting independent and combined physical activity guidelines in kidney cancer survivors

PURPOSE

Guidelines for cancer survivors recommend both aerobic physical activity (PA) and strength training (ST). Few kidney cancer survivors (KCS) are meeting single-activity or combined guidelines; therefore, examining factors influencing PA participation is warranted. The purpose of this study is to examine demographic, medical, social-cognitive, and environmental correlates of meeting independent (i.e., aerobic-only, strength training (ST)-only) and combined guidelines (i.e., aerobic and ST) in KCS.

METHODS

KCS (N = 651) completed self-reported measures of PA and demographic, medical, social-cognitive, and perceived environmental factors. Built environment was assessed using the geographic information systems (GIS). Multinomial logistic regressions were conducted to determine the correlates of meeting the combined versus independent guidelines.

RESULTS

Compared with meeting neither guideline, meeting aerobic-only guidelines was associated with higher intentions (p < .01) and planning (p < .01); meeting ST-only guidelines was associated with higher intentions (p = .02) and planning (p < .01), lower perceived behavioral control (PBC) (p = .03), healthy weight (p = .01), and older age (p < .01); and meeting the combined guidelines were associated with higher intentions (p < .01), planning (p = .02), higher instrumental attitudes (p < .01), higher education (p = .04), better health (p < .01), and localized cancer (p = .05). Additionally, compared with neither guideline, meeting aerobic-only (p < .01) and combined (p < .01) guidelines was significantly associated with access to workout attire. Compared with neither guideline, meeting aerobic-only guidelines was associated with proximity to retail (p = .02).

CONCLUSION

PA participation correlates may vary based on the modality of interest. Interventions may differ depending on the modality promoted and whether KCS are already meeting single-modality guidelines.

Modality-specific exercise guidelines and quality of life in kidney cancer survivors: A cross-sectional study

OBJECTIVES

Few exercise oncology trials have compared aerobic with strength exercise or compared combined exercise (ie, aerobic and strength training) with aerobic only or strength only. It is unknown what single or combined exercise modality is optimal for quality of life (QoL) in cancer survivors. The purpose of this study is to estimate the prevalence of meeting the combined and independent aerobic and strength exercise guidelines in kidney cancer survivors (KCS) and determine any associations with QoL.

METHODS

One thousand nine hundred eighty-five KCS were identified through a provincial registry in Canada and mailed a survey including exercise and QoL scales.

RESULTS

Completed surveys were received from 703 KCS. Only 10.1% of KCS reported meeting the combined exercise guidelines. Analyses of covariance indicated that, for most QoL outcomes (eg, Functional Assessment of Cancer Therapy-General and Functional Assessment of Cancer Therapy-Fatigue), meeting the combined exercise guideline was superior to meeting either single modality guideline that, in turn, were superior to meeting neither guideline. For the primary outcome of the Trial Outcome Index-Fatigue, meeting the combined exercise guideline was superior to meeting (a) neither guideline (P < 0.001), (b) the strength-only guideline (P = 0.021), and (c) the aerobic-only guideline (P = 0.051). In turn, the aerobic and strength exercise only guidelines were superior to meeting neither guideline (P < 0.001 for aerobic; P = 0.045 for strength) but were not different from each other (P = 0.50).

CONCLUSIONS

Meeting the combined exercise guideline has favorable associations with QoL in KCS, however, very few KCS are meeting the combined guideline.

Quality of life outcomes in patients with localised renal cancer: a literature review

Purpose

Patients with localised renal cell carcinoma (RCC) can expect excellent oncologic outcomes. As such, there has been a shift towards maximising health-related quality of life (HRQoL). A greater understanding of HRQoL outcomes associated with different treatment options for RCC can facilitate patient-centred care, shared decision-making and enable cost utility analyses to guide health policies. The aim of this literature review was to evaluate the evidence regarding HRQoL following different management strategies for localised RCC.

Methods

Three databases were searched to identify studies reporting HRQoL in patients with localised renal cancer, including Medline, the Tuft’s Medical Centre Cost Effectiveness Analysis registry and the EuroQol website.

Results

Considerable methodological heterogeneity was noted. Laparoscopic nephrectomy was associated with significantly better short-term physical function compared to open surgery, although the effect on mental function was inconclusive. Nephron-sparing surgery was associated with better physical function compared to radical surgery. Patients’ perception of remaining renal function was a significant independent predictor of HRQoL, rather than surgery type. Tumour size, stage, post-operative complications, age, body mass index, occupational status, educational level and comorbidities were significant predictors of HRQoL. Only three studies were available regarding non-surgical management options and very little data were available regarding the impact of follow-up protocols and long-term effects of “cancer survivorship.”

Conclusion

There is a need for validated and reproducible RCC-specific HRQoL instruments and standardisation amongst studies to enable comparisons. Increased awareness regarding determinants of poor HRQoL may enable high-risk patients to receive tailored support.

Electronic supplementary material

The online version of this article (10.1007/s00345-018-2415-3) contains supplementary material, which is available to authorized users.

Fatigue among patients with renal cell carcinoma receiving adjuvant sunitinib or sorafenib: patient-reported outcomes of ECOG-ACRIN E2805 trial

BACKGROUND

E2805 was a phase III trial to test whether adjuvant sunitinib or sorafenib could improve disease-free survival compared to placebo in patients with renal cell carcinoma. Patient-reported outcomes (PRO), focusing on fatigue, were evaluated as a secondary endpoint.

PATIENTS AND METHODS

A total of 463 patients participated in the PRO study. Fatigue was measured by the FACIT Fatigue scale and PROMIS Fatigue SF1 measure at baseline, week 10, and week 22. The primary endpoint was change in fatigue score from baseline to week 22, measured by the FACIT Fatigue scale. Secondarily, the psychometric properties of PROMIS Fatigue SF1 were assessed in relation to the FACIT Fatigue scale.

RESULTS

Fatigue got significantly worse on all arms after 2 cycles of treatment, and especially so in patients on sunitinib (- 9.6 vs. - 5.6 on sorafenib vs. - 4.7 on placebo). Fatigue remained stable during week 10 and week 22. Overall, the mean score change between baseline and week 22 was - 7.9 (p < 0.001) on sunitinib, - 6.4 (p < 0.001) on sorafenib and - 5.6 (p < 0.001) on placebo arm. The difference in score change was not statistically significant between the two experimental arms and the placebo arm (difference = - 2.34 [p = 0.110] and - 0.87 [p = 0.535] for sunitinib vs. placebo and sorafenib vs. placebo). PROMIS Fatigue SF1 had good internal consistency reliability and construct and criterion validity, and was highly correlated with the FACIT Fatigue scale score.

CONCLUSIONS

Fatigue got worse during study period, especially in patients on sunitinib. The PROMIS Fatigue SF1 was highly correlated with FACIT Fatigue and produced similar results.

A Randomized Study of Patient Risk Perception for Incidental Renal Findings on Diagnostic Imaging Tests

OBJECTIVE

The purpose of this study is to assess differences in patient distress, risk perception, and treatment preferences for incidental renal findings with descriptive versus combined descriptive and numeric graphical risk information.

MATERIALS AND METHODS

A randomized survey study was conducted for adult patients about to undergo outpatient imaging studies at a large urban academic institution. Two survey arms contained either descriptive or a combination of descriptive and numeric graphical risk information about three hypothetical incidental renal findings at CT: 2-cm (low risk) and 5-cm (high risk) renal tumors and a 2-cm (low risk) renal artery aneurysm. The main outcomes were patient distress, perceived risk (qualitative and quantitative), treatment preference, and valuation of lesion discovery.

RESULTS

Of 374 patients, 299 participated (79.9% response rate). With inclusion of numeric and graphical, rather than only descriptive, risk information about disease progression for a 2-cm renal tumor, patients reported less worry (3.56 vs 4.12 on a 5-point scale; p < 0.001) and favored surgical consultation less often (29.3% vs 46.9%; p = 0.003). The proportion choosing surgical consultation for the 2-cm renal tumor decreased to a similar level as for the renal artery aneurysm with numeric risk information (29.3% [95% CI, 21.7-36.8%] and 27.9% [95% CI, 20.5-35.3%], respectively). Patients overestimated the absolute risk of adverse events regardless of risk information type, but significantly more so when given descriptive information only, and valued the discovery of lesions regardless of risk information type (range, 4.41-4.81 on a 5-point scale).

CONCLUSION

Numeric graphical risk communication for patients about incidental renal lesions may facilitate accurate risk comprehension and support patients in informed decision making.

The psychometric properties of cancer multisymptom assessment instruments: a clinical review

PURPOSE

Various instruments are used to assess both individual and multiple cancer symptoms. We evaluated the psychometric properties of cancer multisymptom assessment instruments.

METHODS

An Ovid MEDLINE search was done. All searches were limited to adults and in English. All instruments published from 2005 to 2014 (and with at least one validity test) were included. We excluded those who only reported content validity. Instruments were categorized by the three major types of symptom measurement scales employed as follows: visual analogue (VAS), verbal rating (VRS), and numerical rating (NRS) scales. They were then examined in two areas: (1) psychometric thoroughness (number of tests) and (2) psychometric strength of evidence (validity, reliability, generalizability). We also assigned an empirical global psychometric quality score (which combined the concepts of thoroughness and strength of evidence) to rank the instruments.

RESULTS

We analyzed 57 instruments (17 original, 40 modifications). They varied in types of scales used, symptom dimensions measured, and time frames evaluated. Of the 57, 10 used VAS, 28 VRS, and 19 NRS. The Edmonton Symptom Assessment System (ESAS), ESAS-Spanish, Hospital Anxiety and Depression Scale (HADS), Profile of Mood States (POMS), Symptom Distress Scale (SDS), M.D. Anderson Symptom Inventory (MDASI)-Russian, and MDASI-Taiwanese were the most comprehensively tested for validity and reliability. The ESAS, ESAS-Spanish, ASDS-2, Memorial Symptom Assessment Scale (MSAS)-SF, POMS, SDS, MDASI (and some translations), and MDASI-Heart Failure all showed good validity and reliability.

CONCLUSIONS

The MDASI appeared to be the best overall from a psychometric perspective. This was followed by the ESAS, ESAS-Spanish, POMS, SDS, and some MDASI translations. VRS-based instruments were most common. There was a wide range of psychometric rigor in validation. Consequently, meta-analysis was not possible. Most cancer multisymptom assessment instruments need further extensive validation to establish the excellent reliability and validity required for clinical utility and meaningful research.

Development and initial validation of the NCCN/FACT symptom index for advanced kidney cancer

OBJECTIVES

There is a need for a brief symptom index for advanced kidney cancer that includes perspectives of both patients and clinicians and is consistent with the Food and Drug Administration's guidance for patient-reported outcome measures. This study developed and examined the preliminary reliability and validity of the new National Comprehensive Cancer Network/Functional Assessment of Cancer Therapy (FACT)-Kidney Symptom Index 19.

METHODS

Fifty patients with advanced kidney cancer provided open-ended and survey responses ranking their most important symptoms. Responses were reconciled with published clinician reports of the most important symptoms. Ten experienced oncologists rated symptoms as disease- or treatment-related. Patients completed quality-of-life and performance status measures.

RESULTS

A 19-item index was produced from symptoms that were rated as most important by patients or clinicians. It includes three subscales: disease-related symptoms (DRS), treatment side effects (TSE), and general function and well-being (FWB). Internal consistency was good for the full instrument (α = 0.83), the DRS subscale (α = 0.76), and the FWB subscale (α = 0.78) but lower for the TSE subscale (α = 0.59). Convergent validity was demonstrated through correlations with the FACT-General. Patients with differing performance status were distinguished by the total score (F2,47 = 17.37; P < .0001), the DRS subscale (F2,47 = 14.22; P < .0001), and the FWB subscale (F2,47 = 13.40; P < .0001) but not the TSE subscale (F2,47 =1.48; P = 0.2380).

CONCLUSIONS

The National Comprehensive Cancer Network/FACT-Kidney Symptom Index 19 combines symptoms deemed most important by patients and clinicians. Preliminary evidence suggests that the total score and DRS and FWB subscales are reliable and valid as summary indexes. The TSE subscale may be least relevant given the advent of newer therapies.

Patient-reported outcomes for axitinib vs sorafenib in metastatic renal cell carcinoma: phase III (AXIS) trial

Background:

Axitinib demonstrated greater progression-free survival vs sorafenib in a phase III study of previously treated patients with metastatic renal cell carcinoma. Here, we report patient-reported kidney-specific symptoms and health status, measured by the Functional Assessment of Cancer Therapy (FACT) Kidney Cancer Symptom Index (FKSI) and the European Quality of Life self-report questionnaire (EQ-5D).

Methods:

In all, 723 patients received axitinib (starting dose 5 mg twice daily (b.i.d.)) or sorafenib (400 mg b.i.d.). The FKSI-15, including the disease-related symptoms (FKSI-DRS) subscale, was administered on day 1 before dosing, every 4 weeks and at end of treatment (EOT)/withdrawal. Statistical methods included a mixed-effects repeated-measures model.

Results:

At baseline, patients in both arms had relatively high mean FSKI-15 and FKSI-DRS scores, comparable to the general US population. Subsequent on-treatment overall mean scores were similar between axitinib and sorafenib, and there was no substantial decline during treatment. Scores substantially worsened at EOT, mainly due to disease progression.

Conclusion:

Patient-reported outcomes were comparable for second-line axitinib and sorafenib and were maintained at relatively high levels while on treatment, but worsened at EOT. As duration of treatment was longer with axitinib than sorafenib, time to worsening of symptoms can be delayed longer with axitinib.

A literature synthesis of symptom prevalence and severity in persons receiving active cancer treatment

PURPOSE

Patients with cancer experience acute and chronic symptoms caused by their underlying disease or by the treatment. While numerous studies have examined the impact of various treatments on symptoms experienced by cancer patients, there are inconsistencies regarding the symptoms measured and reported in treatment trials. This article presents a systematic review of the research literature of the prevalence and severity of symptoms in patients undergoing cancer treatment.

METHODS

A systematic search for studies of persons receiving active cancer treatment was performed with the search terms of "multiple symptoms" and "cancer" for studies involving patients over the age of 18 years and published in English during the years 2001 to 2011. Search outputs were reviewed independently by seven authors, resulting in the synthesis of 21 studies meeting criteria for generation of an Evidence Table reporting symptom prevalence and severity ratings.

RESULTS

Data were extracted from 21 multi-national studies to develop a pooled sample of 4,067 cancer patients in whom the prevalence and severity of individual symptoms was reported. In total, the pooled sample across the 21 studies was comprised of 62% female, with a mean age of 58 years (range 18 to 97 years). A majority (62%) of these studies assessed symptoms in homogeneous samples with respect to tumor site (predominantly breast and lung cancer), while 38% of the included studies utilized samples with mixed diagnoses and treatment regimens. Eighteen instruments and structured interviews were including those measuring single symptoms, multi-symptom inventories, and single symptom items drawn from HRQOL or health status measures. The MD Anderson Symptom Inventory was the most commonly used instrument in the studies analyzed (n = 9 studies; 43%), while the Functional Assessment of Cancer Therapy, Hospital Anxiety and Depression Subscale, Medical Outcomes Survey Short Form-36, and Symptom Distress Scale were each employed in two studies. Forty-seven symptoms were identified across the 21 studies which were then categorized into 17 logical groupings. Symptom prevalence and severity were calculated across the entire cohort and also based upon sample sizes in which the symptoms were measured providing the ability to rank symptoms.

CONCLUSIONS

Symptoms are prevalent and severe among patients with cancer. Therefore, any clinical study seeking to evaluate the impact of treatment on patients should consider including measurement of symptoms. This study demonstrates that a discrete set of symptoms is common across cancer types. This set may serve as the basis for defining a "core" set of symptoms to be recommended for elicitation across cancer clinical trials, particularly among patients with advanced disease.

Associations between physical activity and quality of life in a population-based sample of kidney cancer survivors

BACKGROUND

Physical activity (PA) improves quality of life (QoL) in several cancer survivor groups, but no study to date has focused on kidney cancer survivors (KCS). The purpose of this study was to estimate the prevalence of PA in KCS and determine any associations with QoL.

METHODS

All 1,985 KCS diagnosed between 1996 and 2010 identified through a Canadian provincial Registry were mailed a survey that consisted of the Godin Leisure Time Exercise Questionnaire and several Functional Assessment of Cancer Therapy QoL scales. Standard demographic and medical variables were also reported.

RESULTS

Completed surveys were received from 703 (43%) of the 1,654 KCS that received the survey. Over half (56.3%) were completely sedentary (CS), 17.6% were insufficiently active, 11.9% were active within public health guidelines, and 14.1% exceeded public health guidelines. After adjustment for key demographic and medical covariates, analyses of covariance indicated a dose-response association between PA and most QoL outcomes from CS to within guidelines (WG) with no further improvements for exceeding guidelines. For the primary QoL outcome of patient-reported physical functioning, the overall difference between CS and WG was 8.6 points (95% CI: 4.2-12.9, P < 0.001) which exceeds the minimally important difference of 5.0 points for this scale. Few associations were moderated by demographic or medical variables.

CONCLUSION

Over half of KCS are CS; however, even some PA may be beneficial for QoL.

IMPACT

PA is a modifiable lifestyle factor that may have implications for QoL and disease outcomes in KCS.

Beyond traditional outcomes: improving quality of life in patients with renal cell carcinoma

The introduction of molecular targeted therapies for patients with metastatic renal cell carcinoma has provided treatment options that are more efficacious and better tolerated than cytokine therapy, the previous standard of care. These advances have led to renewed efforts to define the health-related quality of life (HRQOL) impact of disease status stabilization or improvement versus that of treatment-associated adverse events. The distinct classes of targeted agents have unique AE profiles related to their specific targets; therefore, treatment considerations should include the patient's pretreatment HRQOL along with the known HRQOL effects of each drug. With more second- and third-line treatment options available for patients with metastatic renal cell carcinoma, HRQOL outcomes in earlier lines of therapy may guide treatment decisions for subsequent therapy, as poor HRQOL at therapy onset predicts poor survival. Both general and disease-specific instruments are used in clinical trials to reveal the impact of treatment on patient-reported outcomes. In this article, the common instruments used to assess HRQOL and the HRQOL outcomes observed in pivotal trials of targeted therapies are reviewed. Current data indicate that first-line therapy with sunitinib and first-line therapy in poor-prognosis patients with temsirolimus provide improved HRQOL compared with interferon-α. First- and second-line therapy with pazopanib and second-line therapy with everolimus and sorafenib maintained HRQOL levels similar to placebo, indicating that these agents do not worsen HRQOL. The HRQOL effects of bevacizumab plus IFN-α have not been reported. As new agents enter clinical investigation, HRQOL data can help determine their overall role in treatment.

A structured review and guide through studies on health-related quality of life in kidney cancer, hepatocellular carcinoma, and leukemia

Aim of this paper is to review and describe Health-Related Quality of Life (HRQoL) measures applied in kidney cancer, hepatocellular carcinoma, and leukemia patients under drug therapy. A comprehensive search in PubMed was conducted to identify studies assessing quality of life (QoL) in these indications. In total 32 studies, including four studies through reference list checking and 21 different HRQoL instruments, were identified. Six generic, five disease-specific, and 10 domain-specific instruments were identified. In conclusion no overall standards in HRQoL measurement could be observed in the respective indications.

Health-related quality of life in patients with metastatic renal cell carcinoma treated with sunitinib vs interferon-alpha in a phase III trial: final results and geographical analysis

BACKGROUND

In a randomised phase III trial, sunitinib significantly improved efficacy over interferon-alpha (IFN-alpha) as first-line therapy for metastatic renal cell carcinoma (mRCC). We report the final health-related quality of life (HRQoL) results.

METHODS

Patients (n=750) received oral sunitinib 50 mg per day in 6-week cycles (4 weeks on, 2 weeks off treatment) or subcutaneous IFN-alpha 9 million units three times weekly. Health-related quality of life was assessed with nine end points: the Functional Assessment of Cancer Therapy-General and its four subscales, FACT-Kidney Symptom Index (FKSI-15) and its Disease-Related Symptoms subscale (FKSI-DRS), and EQ-5D questionnaire's EQ-5D Index and visual analogue scale. Data were analysed using mixed-effects model (MM), supplemented with pattern-mixture models (PMM), for the total sample and the US and European Union (EU) subgroups.

RESULTS

Patients receiving sunitinib reported better scores in the primary end point, FKSI-DRS, across all patient populations (P<0.05), and in nine, five, and six end points in the total sample, in the US and EU groups respectively (P<0.05). There were no significant differences between the US and EU groups for all end points with the exception of the FKSI item 'I am bothered by side effects of treatment' (P=0.02). In general, MM and PMM results were similar.

CONCLUSION

Patients treated with sunitinib in this study had improved HRQoL, compared with patients treated with IFN-alpha. Treatment differences within the US cohort did not differ from those within the EU cohort.

A review of the literature on the impact of renal cancer therapy on quality of life

AIM

To explore the impact of renal cancer treatment on patients' quality of life.

BACKGROUND

Renal cancer accounts for 95,000 deaths worldwide and its incidence rate is rising. At present there are several therapeutic approaches to the treatment of renal cancer, ranging through surgery, immunological therapies and vaccine treatment. Each of these therapies may have a substantial effect upon patients' quality of life. However, a systematic appraisal of the empirical evidence about treatment impact is lacking.

DESIGN

Literature review.

METHODS

A structured review of the empirical literature on the impact of renal cancer treatment upon quality of life was undertaken. Literature was appraised and themed according to the treatment modalities included in the study.

RESULTS

From 873 papers initially identified 52 were retrieved for detailed scrutiny resulting in a final 16 papers being included in the review.

CONCLUSIONS

This review discusses the complex effect of renal cancer upon a patient's quality of life as treatment modalities change. The need for nursing education and awareness of these issues is therefore highlighted to maximise patient care.

RELEVANCE TO CLINICAL PRACTICE

Understanding the impact of treatment for renal cancer enables nurses to empathise more significantly with patients and also act as mediators in regard to treatment choice and treatment cessation. It also enables nurses to inform and educate renal cancer patients prior to making treatment choices.

Quality of life in patients with metastatic renal cell carcinoma: the importance of patient-reported outcomes

Renal cell carcinoma is the most common form of kidney cancer worldwide, and is associated with poor survival. Approximately a third of patients diagnosed with renal cell carcinoma present with metastatic disease and a further third experience recurrence following treatment for localized disease. Until recently, the cytokines interferon-alpha and interleukin-2 were the only effective treatments available for metastatic renal cell carcinoma and were associated with a modest increase in survival in a limited subset of patients. The prognosis for metastatic renal cell carcinoma has dramatically improved with the development of novel targeted agents including the oral tyrosine kinase inhibitors, sunitinib and sorafenib. However, renal cell carcinoma and the therapies used to treat patients with renal cell carcinoma are associated with a range of symptoms and treatment-related adverse events which contribute to the burden of disease. Common adverse events associated with targeted agents include fatigue, gastrointestinal and skin-associated toxicities. These adverse events, while mostly mild and manageable, affect the patients' health-related quality of life. As this review of the available quality of life data shows, assessment of the impact of the disease and its treatment on health-related quality of life may influence the choice of treatment and highlights the importance of incorporating patient-reported outcomes in clinical trials.

A Comparison of the Renal Cell Carcinoma-Symptom Index (RCC-SI) and the Functional Assessment of Cancer Therapy-Kidney Symptom Index (FKSI)

The development and validation of measures that provide disease-specific, patient-reported outcomes have become increasingly relevant in the care of cancer patients, especially for assessing symptoms from the patient's perspective. Recently, two patient symptom questionnaires were developed for kidney cancer patients, the Renal Cell Carcinoma-Symptom Index (RCC-SI) and the Functional Assessment of Cancer Therapy-Kidney Symptom Index (FKSI). This article describes the development of the revised FKSI scale (FKSI-19) and reconciles its use with the RCC-SI. Fifty participants with advanced kidney cancer commented on their symptoms and concerns about kidney cancer and this input was used to revise FKSI items. These patients also completed the RCC-SI, the Functional Assessment of Cancer Therapy-General (FACT-G), and an older version of the FKSI scale. We qualitatively reviewed item wording and content coverage across the two instruments, examined correlations between the scales, and calculated basic psychometrics on each scale. We found that the FKSI-19 and the RCC-SI addressed similar symptoms. Qualitative and descriptive statistical analyses demonstrated considerable overlap between the two instruments (rho=0.88, P<0.001). Cronbach's alpha for the FKSI-19 and RCC-SI were both good, at 0.86 and 0.92, respectively. The FKSI-19 has some advantages over the RCC-SI. The FKSI-19 has more clarity in item phrasing, is shorter in length, and covers a similar breadth of disease-based symptoms when compared to the RCC-SI.

Sleep and cancer: recent developments

During the past decade, the critical role of sleep in health and disease has been underscored by research that further defines the relationship between sleep and myriad physiologic and psychological functions as well as quality of life. For many years, there was little exploration of the significance of sleep and sleep disorders in cancer patients; however, the past decade has seen a steady growth of inquiry in this area. These investigations have demonstrated the high frequency and significance of sleep disturbance as a symptom in cancer patients. They have also explored the complex interaction between sleep and other common cancer symptoms, most notably fatigue, depression, and pain, and have identified risk factors associated with the development of sleep problems in this population. Although treatment studies lag behind, reports of effective psychological and behavioral interventions for insomnia in cancer patients are increasing. Several studies are addressing pharmacotherapeutic intervention for hot flashes as a potential source of sleep disturbance. Other sleep disorders, most notably obstructive sleep apnea, also occur with some regularity in cancer patients.

Symptom management issues in oncology nursing

Symptoms experienced by patients with cancer can occur as a direct effect of the disease process and be related to side effects of treatment. Many patients with cancer also are older in age and have comorbidities, such as diabetes and heart disease. Comorbid conditions also produce disease and treatment-related symptoms that may have an independent or compounding effect on cancer-related symptoms.