Preferences of melanoma patients to accept adjuvant therapy and toxicity - a qualitative substudy of the GerMelaTox-A project

PURPOSE

Targeted treatment and immunotherapy, both adjuvant treatment options, come with a certain toxicity and can cause severe side effects. To date, data about the underlying reasons for patients to accept or reject specific types of adjuvant therapy is scarce. Therefore, this study investigates the motives of melanoma patients for tolerating or rejecting adjuvant therapy and its side effects.

METHODS

We conducted semi-structured interviews with a subsample of patients to investigate the underlying reasons for treatment decisions in a quantitative treatment-trade off study. Categorisation was conducted using qualitative content analysis.

RESULTS

The 17 participants had a mean age of 55.5 years and 12 were female. The final category system covered three clusters. The cluster "type of therapy and therapy process" described therapy-related aspects that affect acceptability of adjuvant treatments. Prospect of treatment benefit and side effects were important aspects. Route of administration and physician visits should be convenient. The cluster "way of living" described the influence that activities and circumstances of life organisation have on acceptability. Participants wished treatment to affect everyday life as little as possible. Maintaining sufficient quality of life was mentioned to be crucial. The cluster "emotions and feelings" described optimism and hope but also mental strain originating from possible treatment options.

CONCLUSION

Patients in our study indicate high willingness to undergo adjuvant therapy, even when facing toxicity. The evaluation of potential side effects and prospects of treatment benefit is highly individual. Therefore, it is important to consider personal patient preferences to make appropriate and shared decision-making.

Preferences for Adjuvant Immunotherapy in Adults with Resected Stage III Melanoma-A Discrete Choice Experiment

OBJECTIVES

This study aimed to quantify adult preferences for adjuvant immunotherapy for resected melanoma and the influence of varying levels of key attributes and baseline characteristics.

METHODS

A D-efficient design generated 12 choice tasks for two alternative treatments, adjuvant immunotherapy or no adjuvant immunotherapy. Recruitment to the online discrete choice experiment (DCE) occurred via survey dissemination by eight Australian melanoma consumer and professional groups, targeting adults with resected stage III melanoma, considering or having received adjuvant immunotherapy. The DCE included six attributes with two to three levels each, including 3-year risk of recurrence, mild, permanent and fatal adverse events (AEs), drug regimen and annual out-of-pocket costs. A mixed multinomial logit model was used to estimate preferences and calculate marginal rates of substitution and marginal willingness to pay (mWTP).

RESULTS

The DCE was completed by 116 respondents, who chose adjuvant immunotherapy over no adjuvant immunotherapy in 70% of choice tasks. Respondents preferred adjuvant immunotherapy when associated with reduced: probabilities of recurrence, permanent and fatal AEs, and out-of-pocket costs. mWTP for an absolute reduction of 1% in 3-year risk of recurrence was less for respondents with lower rather than higher incomes, AU$794 (US$527) and AU$2190 (US$1454) per year. Respondents accepted an additional 4% chance of a permanent AE to reduce their absolute risk of 3-year recurrence by 1%. Respondents were willing to accept an extra 2% chance of 3-year recurrence to lower their chance of a fatal AE by 1%.

CONCLUSIONS

Almost three-quarters of respondents chose adjuvant immunotherapy over no adjuvant immunotherapy, preferring treatment that improved efficacy and safety. Findings may inform decisions about access to adjuvant immunotherapy following surgery for melanoma.

Patient Preferences in Targeted Pharmacotherapy for Cancers: A Systematic Review of Discrete Choice Experiments

BACKGROUND

Targeted pharmacotherapy has been increasingly applied in cancer treatment due to its breakthroughs. However, the unmet needs of cancer patients are still significant, highlighting the urgency to investigate patient preferences. It is unclear how patients deliberate their choices between different aspects of targeted therapy, including cost, efficacy, and adverse events. Since discrete choice experiments (DCEs) have been widely applied to patient preference elicitation, we reviewed DCEs on targeted therapy for different cancers. We also synthesized evidence on the factors influencing patients' choices and their willingness-to-pay (WTP) for survival when treated by targeted therapy.

METHODS

We searched databases, including PubMed, EMBASE and MEDLINE, up to August 16, 2022, supplemented by a reference screening. The attributes from the selected studies were categorized into three groups: outcomes, costs, and process. We also calculated the relative importance of attributes and WTP for survival whenever possible. The purpose, respondents, explanation, findings, significance (PREFS) checklist was used to evaluate the quality of the included DCE studies.

RESULTS

The review identified 34 eligible studies from 13 countries covering 14 cancers, such as breast, ovarian, kidney, prostate, and skin cancers. It also reveals a rising trend of DCEs on this topic, as most studies were published after 2018. We found that patients placed higher weights on the outcome (e.g., overall survival) and cost attributes than on process attributes. On average, patients were willing to pay $561 (95% confidence interval [CI]: $415-$758) and $716 (95% CI $524-$958) out-of-pocket for a 1-month increase in progression-free survival and overall survival, respectively. PREFS scores of the 34 studies ranged from 2 to 4, with a mean of 3.38 (SD: 0.65), suggesting a reasonable quality based on the checklist. However, most studies (n = 32, 94%) did not assess the impact of non-responses on the results.

CONCLUSIONS

This is the first systematic review focusing on patient preferences for targeted cancer therapy. We showcased novel approaches for evidence synthesis of DCE results, especially the attribute relative importance and WTP. The results may inform stakeholders about patient preferences toward targeted therapy and their WTP estimates. More studies with improved study design and quality are warranted to generate more robust evidence to assist decision making.

Preferences for Immunotherapy in Melanoma: A Systematic Review

BACKGROUND

Immunotherapy improves overall survival for patients with metatstatic melanoma and improves recurrence-free survival in the adjuvant setting, but is costly and has adverse effects. Little is known about the preferences of patients and clinicians regarding immunotherapy. This study aimed to identify factors important to patients and clinicians when deciding about immunotherapy for stages 2-4 melanoma.

METHODS

This study searched the Medline, EMBASE, ECONLIT, PsychINFO, and COCHRANE Systematic Reviews databases from inception to June 2018 for immunotherapy choice and preference studies. Findings were tabulated and summarized, and study reporting was assessed against recommended checklists.

RESULTS

This investigation identified eight studies assessing preferences for melanoma treatment; four studies regarding nivolumab, pembrolizumab, or ipilimumab; and four studies regarding interferon conducted in the United States, Germany, and Australia. The following 10 factors were important to decision-making: overall survival, recurrence-free survival, treatment side effects, dosing regimen, patient or payer cost, patient age, clinician or family/friend treatment recommendation, quality of life, and psychosocial effects. Overall survival was the most important factor for all respondents. The patients judged severe toxicities to be tolerable for small survival gains. The description of information about treatment harms and benefits was limited in most studies.

CONCLUSIONS

Overall survival was of primary importance to patients and clinicians considering immunotherapy. Impaired quality of life due to adverse effects appeared to be a second-order consideration. Future research is required to determine preferences for contemporary combination therapies, extended treatment durations, and avoidance of chronic side effects.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number CRD42018095899.

Approaches to decision-making among late-stage melanoma patients: a multifactorial investigation

Purpose

The treatment decisions of melanoma patients are poorly understood. Most research on cancer patient decision-making focuses on limited components of specific treatment decisions. This study aimed to holistically characterize late-stage melanoma patients’ approaches to treatment decision-making in order to advance understanding of patient influences and supports.

Methods

(1) Exploratory analysis of longitudinal qualitative data to identify themes that characterize patient decision-making. (2) Pattern analysis of decision-making themes using an innovative method for visualizing qualitative data: a hierarchically-clustered heatmap. Participants were 13 advanced melanoma patients at a large academic medical center.

Results

Exploratory analysis revealed eight themes. Heatmap analysis indicated two broad types of patient decision-makers. “Reliant outsiders” relied on providers for medical information, demonstrated low involvement in decision-making, showed a low or later-in-care interest in clinical trials, and expressed altruistic motives. “Active insiders” accessed substantial medical information and expertise in their networks, consulted with other doctors, showed early and substantial interest in trials, demonstrated high involvement in decision-making, and employed multiple decision-making strategies.

Conclusion

We identified and characterized two distinct approaches to decision-making among patients with late-stage melanoma. These differences spanned a wide range of factors (e.g., behaviors, resources, motivations). Enhanced understanding of patients as decision-makers and the factors that shape their decision-making may help providers to better support patient understanding, improve patient-provider communication, and support shared decision-making.