Decision Aids: Assisting Patients With Multiple Myeloma and Caregivers With Treatment Decision Making

Understanding health outcome preferences of older adults diagnosed with multiple myeloma

INTRODUCTION

Health outcome preferences of older adults with cancer vary based on burden/intensity of treatment and its impact on health outcomes such as survival, quality of life, and functional and cognitive well-being. We studied the association between age and health outcome preferences of adults with multiple myeloma (MM).

MATERIALS AND METHODS

Using a single center prospective cohort study, we identified adults ≥50y with MM who underwent geriatric assessment (GA) within 30 days of initiating a new line of therapy. We assessed health outcome preferences using a nine-item health outcome preference scale where patients were asked to prioritize varying treatment outcomes in a Likert scale. We compared the response patterns for each item by age group (50-69y vs ≥70y) using Mantel-Haenszel chi-squared test. For items significant in bi-variable analysis, we built proportional odds models to study the association between age and health outcome preferences adjusting for sex, race, frailty, and high risk cytogenetics.

RESULTS

We included 119 patients with a median age of 65y. Of these, 58% were male, 56% were non-Hispanic White, and 28% were frail. Older adults (≥70y) versus younger adults (50-69y) were more likely to prioritize health outcomes such as quality of life (53% vs. 34%), functional independence (74% vs. 33%), maintaining cognitive ability (79% vs. 54%), and living free from pain (50% vs 18%) over longer survival (all p values <0.05). In multivariable models, each one interquartile range (IQR) increase in age was associated with increased odds of prioritization of functional independence [adjusted odds ratio (aOR) 2.55, 95% confidence interval (CI) (1.44-4.53)], maintaining cognitive ability [aOR 1.75, 95% CI (1.01-3.02)], and willingness to take milder/ fewer treatments [aOR 2.40, 95% CI (1.36-4.26)] over longer survival. Similarly, each IQR increase in age was associated with decreased odds of prioritization of survival over quality of life [aOR 0.45, 95% CI (0.26-0.78)] and survival over being free from pain [aOR 0.39, 95% CI (0.22-0.69)].

DISCUSSION

Three out of four older adults (age ≥ 70y) with MM rated other outcomes, particularly functional and cognitive well-being, above survival. Determining the most significant treatment outcomes for older adults with MM can aid in establishing treatment goals and enhance shared decision-making.

Multiple Myeloma: Validation of the Values and Preferences Elicitation Questionnaire- Cure and Survival Preference Scale (VPEQ-CSPS)

BACKGROUND

With the emergence of many novel therapies, the treatment decisions for multiple myeloma (MM) are increasingly guided by concerns of quality of life, achievement of cancer-free remission, living a longer overall survival, and a relentless search for a cure; however, the impact of various decision-making factors on patients' actual therapy choices and the patients' desire for cure and survival is mainly unknown. The lack of a valid and reliable measure for uncovering patients' preferences for cure and survival makes it more challenging to put this factor into the actual treatment decision equation.

PURPOSE

This study examined the psychometric properties of the Values and Preferences Elicitation Questionnaire-Cure and Survival Preference Scale (VPEQ-CSPS) instrument.

METHODS

The VPEQ-CSPS instrument was deployed using an anonymous Qualtrics online survey to patients diagnosed with MM within the network of International Myeloma Foundation online patient support groups across the United States. One hundred seventy-four (N = 174) valid responses were obtained and used to examine the validity and reliability of the VPEQ-CSPS.

RESULTS

Exploratory factor analysis (EFA) revealed a Kaiser-Meyer-Olkin value of 0.72 indicating excellent sample adequacy. A statistically significant Bartlett's test of sphericity (P < .001) indicated significant correlations among the variables of the dataset to conduct the EFA. The internal consistency coefficients indicated adequate reliability of the instrument with Cronbach's alpha value at 0.80. The EFA and parallel analysis revealed the 5-item VPEQ-CSPS as a valid and reliable unidimensional scale that can be used by oncology clinicians to elicit their patient's preferences for cure and survival. This new instrument has the potential to contribute to the achievement of shared decision-making for myeloma treatment decisions.

Survey of patients and physicians on shared decision-making in treatment selection in relapsed/refractory multiple myeloma

Shared decision-making (SDM) is a key component of patient-centered healthcare. SDM is particularly pertinent in the relapsed and/or refractory multiple myeloma (RRMM) setting, in which numerous treatment options can present challenges for identifying optimal care. However, few studies have assessed the extent and relevance of SDM and patient-centered communication (PCC) in RRMM. To describe treatment decision-making patterns between physicians and patients in the RRMM setting, we conducted online surveys of patients and physicians in the USA to compare their perspectives on the process of treatment decision-making. We analyzed the surveys descriptively. Two hundred hematologists/oncologists and 200 patients with RRMM receiving second-line (n = 89), third-line (n = 65), and fourth-line (n = 46) therapy participated. Top treatment goals for physicians and patients included extending overall survival (among 76% and 83% of physicians and patients, respectively) and progression-free survival (among 54% and 77% of physicians and patients, respectively), regardless of the number of prior relapses. Thirty percent of physicians believed patients preferred a shared approach to treatment decision-making, while 40% of patients reported most often preferring a shared role in treatment decision-making. One-fourth of patients most often preferred physicians to make the final treatment decision after seriously considering their opinion. Thirty-two percent of physicians and 16% of patients recalled ≥3 treatment options presented at first relapse. Efficacy was a primary treatment goal for patients and physicians. Discrepancies in their perceptions during RRMM treatment decision-making exist, indicating that communication tools are needed to facilitate SDM and PCC.

Patient and Caregiver Experience Decision Factors in Treatment Decision Making: Results of a Systematic Literature Review of Multiple Myeloma Decision Aids

OBJECTIVES

Decision-aids (DAs) may facilitate shared decision-making for patients and caregivers, by providing evidence-based information to assist healthcare professionals, patients, and caregivers in making choices about aspects of care, and/or highlighting decision factors to discuss with the potential of altering the treatment decision. These decision factors may not be well integrated in DAs.

METHODS

A systematic literature review was conducted in the field of multiple myeloma (MM) on peer-reviewed publications, extended with a gray literature search. Data on whether and how patient and caregiver experience elements, other than survival and physical quality of life, were mentioned as decision factors in the identified MM DAs were extracted and analyzed qualitatively.

RESULTS

Seventy MM DAs were found and analyzed; 51% of DAs mentioned any patient non-routinely assessed experience decision factors and only 17% mentioned any caregiver-related information. One hundred and forty potential decision factors were extracted, deduplicated and categorized into the following categories: 1) financial, 2) mode of administration / transportation issues, 3) personal beliefs and values, 4) emotional and social quality of life, 5) other medical information, 6) availability of social support, 7) caregiver burden. None of the DAs presented a comprehensive framework on all seven categories of decision factors being consider when mapping patient and caregiver experience value elements in MM.

CONCLUSIONS

Based on available DAs, we recommend a set of patient and caregiver experience decision factors that have the potential to affect treatment choices of patients with MM, which should be included in DAs, including MM clinical guidelines.