Setting International Standards in Analyzing Patient-Reported Outcomes and Quality of Life Endpoints in Cancer Clinical Trials-Innovative Medicines Initiative (SISAQOL-IMI): stakeholder views, objectives, and procedures

Patient-reported outcomes (PROs), such as symptoms, functioning, and other health-related quality-of-life concepts are gaining a more prominent role in the benefit-risk assessment of cancer therapies. However, varying ways of analysing, presenting, and interpreting PRO data could lead to erroneous and inconsistent decisions on the part of stakeholders, adversely affecting patient care and outcomes. The Setting International Standards in Analyzing Patient-Reported Outcomes and Quality of Life Endpoints in Cancer Clinical Trials-Innovative Medicines Initiative (SISAQOL-IMI) Consortium builds on the existing SISAQOL work to establish recommendations on design, analysis, presentation, and interpretation for PRO data in cancer clinical trials, with an expanded set of topics, including more in-depth recommendations for randomised controlled trials and single-arm studies, and for defining clinically meaningful change. This Policy Review presents international stakeholder views on the need for SISAQOL-IMI, the agreed on and prioritised set of PRO objectives, and a roadmap to ensure that international consensus recommendations are achieved.

What matters most to patients with multiple myeloma? A Pan-European patient preference study

INTRODUCTION

Given the rapid increase in novel treatments for patients with multiple myeloma (MM), this patient preference study aimed to establish which treatment attributes matter most to MM patients and evaluate discrete choice experiment (DCE) and swing weighting (SW) as two elicitation methods for quantifying patients' preferences.

METHODS

A survey incorporating DCE and SW was disseminated among European MM patients. The survey included attributes and levels informed by a previous qualitative study with 24 MM patients. Latent class and mixed logit models were used to estimate the DCE attribute weights and descriptive analyses were performed to derive SW weights. MM patients and patient organisations provided extensive feedback during survey development.

RESULTS

393 MM patients across 21 countries completed the survey (M years since diagnosis=6; M previous therapies=3). Significant differences (p<.01) between participants' attribute weights were revealed depending on participants' prior therapy experience, and their experience with side-effects and symptoms. Multivariate analyses showed that participants across the three MM patient classes identified via the latent class model differed regarding their past number of therapies (F=4.772, p=.009). Patients with the most treatments (class 1) and those with the least treatments (class 3) attached more value to life expectancy versus quality of life-related attributes such as pain, mobility and thinking problems. Conversely, patients with intermediary treatment experience (class 2) attached more value to quality of life-related attributes versus life expectancy. Participants highlighted the difficulty of trading-off between life expectancy and quality of life and between physical and mental health. Participants expressed a need for greater psychological support to cope with their symptoms, treatment side-effects, and uncertainties. With respect to patients' preferences for the DCE or SW questions, 42% had no preference, 32% preferred DCE, and 25% preferred SW.

CONCLUSIONS

Quality of life-related attributes affecting MM patients' physical, mental and psychological health such as pain, mobility and thinking problems were considered very important to MM patients, next to life expectancy. This underscores a need to include such attributes in decision-making by healthcare stakeholders involved in MM drug development, evidence generation, evaluation, and clinical practice. This study highlights DCE as the preferred methodology for understanding relative attribute weights from a patient's perspective.

P-130: The impact of COVID-19 on the treatment regimens of myeloma and AL amyloidosis patients

Background

As the COVID-19 pandemic unfolded in 2020, Myeloma Patients Europe (MPE) recognized that the pandemic was impacting the healthcare and lives of people with myeloma and AL amyloidosis, and their caregivers. Findings from a small UK study suggested that myeloma patients were more likely to die from COVID-19 than members of the general population who contracted the virus [Cook et al, 2020]. Focus groups were conducted to learn more about the impact of COVID-19 on the lives of patients and their families, with a focus on its impact on diagnosis and treatment.

Method

MPE researchers conducted four online focus groups in Europe examining the views and experiences of myeloma and AL amyloidosis patients and caregivers during the COVID-19 pandemic. Fifteen patients and two caregivers took part. Thirteen patients had myeloma and two had AL amyloidosis. Participants were from Spain (n = 6), the UK (n = 2), Belgium (n = 2), Germany (n = 2), the Netherlands (n = 1), Iceland (n = 1), Israel (n = 1), Poland (n = 1), and Romania (n = 1). Eleven patients had been diagnosed within the last few years, while four were living with myeloma for a decade or longer. Ten patients were receiving active treatment for myeloma or AL amyloidosis during the pandemic, while others were in remission.

Results

Sixty percent of study participants reported that the COVID-19 pandemic negatively affected their treatment. Three patients said that medicines given in hospital (by infusion or injection) were delayed due to COVID-19 restrictions. Sometimes, the frequency of these treatments was reduced. In contrast, most patients taking oral medicines (tablets) reported that their treatment continued as normal. Seven participants said their or another patient’s invasive procedure (such as a bone marrow biopsy or stem cell transplant) had been delayed. These procedures took place after approximately 1–6 months later than originally scheduled, once HCPs and patients felt it was safe to do so. One patient reported an improvement in her treatment due to the pandemic restrictions. Her 4- to 5-hour long infusions of daratumumab in hospital had been switched to subcutaneous injections with fewer side-effects.

Conclusions

Findings suggest that COVID-19 had an impact on patients with myeloma and AL Amyloidosis and their treatments. Some aspects of this may be positive, with preference data showing that patients have a preference for oral administrations (Fifer et al, 2020) and as such, switching patients to at home treatment regimens may have both avoided treatment delays and also been in line with patient preferences for treatment administration. MPE suggest that the administration of treatments should be examined regularly. COVID-19 upended existing treatments and other healthcare services, but patients and their healthcare providers should be reviewing options on an ongoing basis to ensure both high quality of care and changes in patient preferences over time.

Patient Preferences for Multiple Myeloma Treatments: A Multinational Qualitative Study

Background: Investigational and marketed drugs for the treatment of multiple myeloma (MM) are associated with a range of characteristics and uncertainties regarding long term side-effects and efficacy. This raises questions about what matters most to patients living with this disease. This study aimed to understand which characteristics MM patients find most important, and hence should be included as attributes and levels in a subsequent quantitative preference survey among MM patients. Methods: This qualitative study involved: (i) a scoping literature review, (ii) discussions with MM patients (n = 24) in Belgium, Finland, Romania, and Spain using Nominal Group Technique, (iii) a qualitative thematic analysis including multi-stakeholder discussions. Results: MM patients voiced significant expectations and hopes that treatments would extend their lives and reduce their cancer signs and symptoms. Participants however raised concerns about life-threatening side-effects that could cause permanent organ damage. Bone fractures and debilitating neuropathic effects (such as chronic tingling sensations) were highlighted as major issues reducing patients' independence and mobility. Patients discussed the negative impact of the following symptoms and side-effects on their daily activities: thinking problems, increased susceptibility to infections, reduced energy, pain, emotional problems, and vision problems. MM patients were concerned with uncertainties regarding the durability of positive treatment outcomes, and the cause, severity, and duration of their symptoms and side-effects. Patients feared short-term positive treatment responses complicated by permanent, severe side-effects and symptoms. Conclusions: This study gained an in-depth understanding of the treatment and disease-related characteristics and types of attribute levels (severity, duration) that are most important to MM patients. Results from this study argue in favor of MM drug development and individual treatment decision-making that focuses not only on extending patients' lives but also on addressing those symptoms and side-effects that significantly impact MM patients' quality of life. This study underscores a need for transparent communication toward MM patients about MM treatment outcomes and uncertainties regarding their long-term efficacy and safety. Finally, this study may help drug developers and decision-makers understand which treatment outcomes and uncertainties are most important to MM patients and therefore should be incorporated in MM drug development, evaluation, and clinical practice.

Myeloma Patient Value Mapping: A Discrete Choice Experiment on Myeloma Treatment Preferences in the UK

BACKGROUND

Myeloma is an incurable life-threatening hematological cancer. Recent treatment developments have seen improvements in survival; however, while patients are living longer, they are living with symptoms and treatment side effects.

OBJECTIVE

To evaluate myeloma patients' preferences for treatment using a discrete choice experiment (DCE). This study set out to define the relative importance of key treatment attributes, characterize the risk-benefit trade-offs in patients' decision-making, and to analyze the predictive power of basic demographic factors.

METHODS

Four hundred seventy-five myeloma patients in the UK were invited to participate by Myeloma UK. Data were collected using DCEs through an online survey. The DCEs presented patients with 10 choice scenarios, each with 2 treatment options described by 7 attributes, and a "no treatment" option. The DCE data were modelled using a latent class model (LCM). The effects of demographic characteristics were also examined.

RESULTS

Not surprisingly, average survival was most important to all patients but there were significant contrasts between the class preferences. The LCM revealed two classes of patients. Patients in Class 1 placed greater importance on average survival and mild-to-moderate side effects, whereas patients in Class 2 focused on the mode of administration and the average out-of-pocket costs. Patients living with others and those diagnosed in the last 5 years were more likely to be in Class 1.

CONCLUSION

Different treatment features were not valued equally among all myeloma patients. This has important implications for healthcare policy decisions and could be used to guide decisions around the value of new myeloma medicines.

Productivity losses in patients with newly diagnosed multiple myeloma following stem cell transplantation and the impact of maintenance therapy

Objective

This study examined productivity losses in European patients with newly diagnosed multiple myeloma (NDMM) undergoing autologous stem cell transplantation (ASCT), to better understand and model the impact of NDMM and lenalidomide maintenance therapy on productivity from a patient and societal perspective.

Methods

A cross‐sectional online patient survey was conducted across the UK, Germany, France, Spain and Italy. A partitioned survival model was used to estimate productivity loss and the impact of maintenance therapy, using human capital (HC) and friction cost approaches.

Results

Of the 115 eligible survey respondents, 76.5% were economically active at the time of diagnosis and highlighted return to work as an important factor affecting their quality of life; only 39.1% of respondents were economically active post‐ASCT. HC analyses estimated average total productivity losses per ASCT patient at EUR 290,601 over a 20‐year period. Modelling the impact of maintenance therapy alone for these patients reduced average productivity losses by just over 10%.

Conclusion

Patients with NDMM aspire to engage in productive lives post‐ASCT, but most are unable to do so. Access to treatments extending remission and supporting engagement in a productive life can have a positive impact both for patients and wider society.

Individual Trade-Offs Between Possible Benefits and Risks of Cancer Treatments: Results from a Stated Preference Study with Patients with Multiple Myeloma

The objectives of this study were to ascertain the treatment preferences of patients with multiple myeloma, considering benefits and risks of particular cancer treatments, and to illustrate how such data may be used to estimate patients' acceptance of new treatments.

Background.

The objectives of this study were to elicit the preferences of patients with multiple myeloma regarding the possible benefits and risks of cancer treatments and to illustrate how such data may be used to estimate patients’ acceptance of new treatments.

Patients and Methods.

Patients with multiple myeloma from the cancer charity Myeloma UK were invited to participate in an online survey based on multicriteria decision analysis and swing weighting to elicit individual stated preferences for the following attributes: (a) 1‐year progression‐free survival (PFS, ranging from 50% to 90%), (b) mild or moderate toxicity for 2 months or longer (ranging from 85% to 45%), and (c) severe or life‐threatening toxicity (ranging from 80% to 20%).

Results.

A total of 560 participants completed the survey. The average weight given to PFS was 0.54, followed by 0.32 for severe or life‐threatening toxicity and 0.14 for mild or moderate chronic toxicity. Participants who ranked severe or life‐threatening toxicity above mild or moderate chronic toxicity (56%) were more frequently younger, working, and looking after dependent family members and had more frequently experienced severe or life‐threatening side effects. The amount of weight given to PFS did not depend on any of the collected covariates. The feasibility of using the collected preference data to estimate the patients’ acceptance of specific multiple myeloma treatments was demonstrated in a subsequent decision analysis example.

Conclusion.

Stated preference studies provide a systematic approach to gain knowledge about the distribution of preferences in the population and about what this implies for patients’ acceptance of specific treatments.

Implications for Practice.

This study demonstrated how quantitative preference statements from a large group of participants can be collected through an online survey and how such information may be used to explore the acceptability of specific treatments based on the attributes studied. Results from such studies have the potential to become an important new tool for gathering patient views and studying heterogeneity in preferences in a systematic way, along with other methods, such as focus groups and expert opinions.

Regenerative medicine: Stroke survivor and carer views and motivations towards a proposed stem cell clinical trial using placebo neurosurgery

BACKGROUND

Few studies explore stroke survivor views and motivations towards stem cell therapy (SCT). This qualitative study explores the views and motivations of both stroke survivors and their partners/carers towards a proposed 2-arm Phase III Randomised Controlled Trial (RCT) comparing intracerebral insertion of stem cells with placebo neurosurgery in stroke survivors with disability.

OBJECTIVE

To explore views and motivations towards a proposed 2-arm stem cell trial and identify factors that may impede and enhance participation.

DESIGN

This study adopts a naturalistic design to explore the complexity of this field, employing a participatory action-research approach comprising a specialized Conversation (World) Café form of focus group. Data were collected via 5 Conversation Cafés with stroke survivors (age 40-75) and partners/carers between June and October 2016. Of 66 participants, 53 (31 male, 22 female) were stroke survivors and 13 (6 female, 7 male) were partners/carers. Qualitative data were analysed using a thematic approach.

DISCUSSION AND CONCLUSION

Stroke survivor views and motivations reflect anticipation of the personal and future benefits of regenerative medicine. Partners/carers sought to balance the value of stroke survivor hope with carrying the weight of hope as carer, a conflict burden adding to known caregiver burden. All participants expressed the need for during and post-trial psychological support. This study provides a rare opportunity to explore the prospective views and motivations of stroke survivors and their partners/carers towards a proposed Phase III 2-arm RCT. This adds weight to qualitative evidence exploring capacity, consent, decision making, perceptions of treatment risk and supports required for clinical trial participation.