Lung cancer clinicians' preferences for adjuvant chemotherapy in non-small-cell lung cancer: what makes it worthwhile?

AIMS: We sought (i) lung cancer clinicians' judgements about the smallest survival benefits that would make the harms of adjuvant chemotherapy for non-small-cell lung cancer (NSCLC) worthwhile, (ii) factors associated with their judgements, and (iii) comparisons with breast cancer and colon cancer clinicians surveyed similarly in 2002-2003. METHODS: Delegates at the Australian Lung Cancer Conference 2008 were invited to complete a validated, self-administered questionnaire that used the time trade-off method to determine the minimum survival benefits judged sufficient to make adjuvant chemotherapy worthwhile. The baseline survival times were 3 and 5 years, and the baseline 5-year survival rates were 50% and 65%. Chemotherapy was 4 cycles of cisplatin and vinorelbine. RESULTS: Characteristics of the 156 respondents were: median age 41 years (range 23-62), female 55%, married 83%, with dependent children 62%, respiratory physician 28%, nurse 24%, medical oncologist 14%, radiation oncologist 12%, trial nurse/coordinator 12%, thoracic surgeon 4%. Moderate survival benefits were judged sufficient to make chemotherapy worthwhile. The median benefit judged sufficient was an extra 9 months beyond a baseline survival time of 3 or 5 years. The median benefit judged sufficient was an extra 5% for a baseline survival rate of 65%, versus an extra 10% for a baseline survival rate of 50% (p<0.001). Smaller benefits were judged sufficient by clinicians who were married (p=0.02) or had dependants (p=0.04). Lung cancer clinicians judged smaller benefits sufficient than breast cancer (n=89) and colon cancer (n=72) clinicians in similar prior studies (median required benefit of 9 months versus 12 months, p<0.001). CONCLUSION: Most lung cancer clinicians attending a national lung cancer conference judged moderate improvements in survival sufficient to make adjuvant chemotherapy worthwhile. Smaller benefits were judged sufficient by lung cancer clinicians in 2008 than by breast cancer and colon cancer clinicians 5-6 years earlier. Clinicians should be aware of their own preferences, and explore their patients' preferences, when discussing adjuvant chemotherapy.

Patients' preferences for chemotherapy in non-small-cell lung cancer: a systematic review.

BACKGROUND: Decisions about chemotherapy for NSCLC are complex and involve trade-offs between its benefits, harms and inconveniences. We sought to find, evaluate and summarise studies quantifying the survival benefits that cancer patients judged sufficient to make chemotherapy for NSCLC worthwhile. METHODS: A search of MEDLINE identified 5 papers reporting four studies including 270 patients. Two investigators independently extracted and tabulated relevant findings from each study. RESULTS: Most cancer patients were male, aged over 65 years, had primary lung cancer (65%) and had experienced chemotherapy (62%). Preferences were determined for chemotherapy in metastatic NSCLC (3 papers) and in locally advanced NSCLC (2 papers), but no studies determined preferences for adjuvant chemotherapy. Most cancer patients (>50%) judged moderate survival benefits sufficient to make chemotherapy worthwhile, for example, absolute increases of 10% in survival rates or 6 months in life expectancies. Individual patients' preferences varied widely: benefits judged sufficient ranged from very small (e.g. survival rate of 1%) to very large (e.g. survival rate of 50%). Smaller benefits were judged sufficient to make chemotherapy worthwhile for metastatic rather than locally advanced disease, for less toxic rather than more toxic chemotherapy, and in North American rather than Japanese studies. Four baseline characteristics were weakly associated with judging smaller benefits sufficient: younger age, having dependents, tertiary education and worse quality of life. CONCLUSIONS: The survival benefits patients judged sufficient to make chemotherapy for NSCLC worthwhile were moderate, widely variable, and difficult to predict. Doctors should encourage patients to express their preferences when facing decisions about chemotherapy for NSCLC.

Adjuvant chemotherapy for early colon cancer: what survival benefits make it worthwhile?

BACKGROUND: We sought to determine the minimum survival benefits that patients judged sufficient to make adjuvant chemotherapy for early colon cancer worthwhile, factors associated with these judgments; and, to compare a self-administered questionnaire with a validated, scripted interview. PATIENTS AND METHODS: One twenty three subjects who completed adjuvant chemotherapy for early colon cancer 3-60 months earlier completed a questionnaire; 97 were randomised to complete an interview before or after the questionnaire. Preferences were elicited by the time trade-off method in 4 hypothetical scenarios. Concordance between the interview and questionnaire was assessed with the intraclass correlation coefficient (ICC). RESULTS: Median age was 65 years (range 19-86), 52% were female and 74% had involved lymph nodes. Over 60% of patients judged an additional 1 month beyond life expectancies of 5 years or 15 years, and an additional 1-2% beyond 5-year survival rates of 85% or 65%, sufficient to make chemotherapy worthwhile. Subjects with tertiary education (p=0.003) or aged 75 years or less (p=0.02) judged larger benefits necessary to make chemotherapy worthwhile. Concordance between the interview and questionnaire was high (ICCs 0.71-0.82). CONCLUSIONS: Most subjects judged small survival benefits sufficient to make adjuvant chemotherapy worthwhile. A self-administered questionnaire was a valid and acceptable way of eliciting preferences.

Comparing patients' and their partners' preferences for adjuvant chemotherapy in early breast cancer.

OBJECTIVE: Preferences of women who had completed adjuvant chemotherapy for early breast cancer were compared with those of their partners by determining the smallest benefits they judged sufficient to make adjuvant chemotherapy worthwhile. METHODS: Forty-six women and their partners were interviewed separately, 3-34 months after completing adjuvant chemotherapy. Preferences were elicited using four sets of validated, hypothetical trade-off scenarios about the possible benefits of adjuvant chemotherapy on survival times (5 and 15 years) and survival rates (65% and 85% at 5 years). Agreement within couples was assessed with the intraclass correlation coefficient (ICC). Associations between baseline characteristics, preferences, and agreement within couples were assessed with linear regression after normal score transformation. RESULTS: The mean age of the women was 57 years and of their partners' was 60. Most couples were married (91%). Benefits of an extra 1 day or 0.1% were judged sufficient to make adjuvant chemotherapy worthwhile by 59-72% of women and 54-59% of partners. Agreement was exact in 35-41% of couples and approximate in 59-83%. Agreement was better for scenarios with a worse prognosis (ICC 0.67 and 0.35) than for scenarios with a better prognosis (ICC 0.13 and 0.05). Having dependent children was associated with partners requiring larger benefits but patients requiring smaller benefits to make adjuvant chemotherapy worthwhile (interaction P=0.001). CONCLUSION: Patients' and partners' preferences for adjuvant chemotherapy differed and were influenced by considerations other than length and quality of life. PRACTICE IMPLICATIONS: Clinicians who are aware of these differences can tailor discussions to ensure that all interested parties understand and agree on the goals and benefits of treatment.

Psychosocial factors and patients' preferences for adjuvant chemotherapy in early breast cancer.

PURPOSE: Many women who have had adjuvant chemotherapy for early breast cancer judge small benefits sufficient to make it worthwhile despite significant side effects and inconvenience. The rationality of these preferences has been questioned. We sought to better understand such preferences by assessing associations between preferences and psychosocial factors, and by asking women who judged negligible benefits sufficient to explain why. METHODS: We recruited 83 consecutive consenting women who had completed adjuvant chemotherapy for early breast cancer 3-34 months earlier. Preferences were elicited during a structured, scripted interview using four sets of validated, hypothetical trade-off scenarios about the possible benefits of adjuvant chemotherapy on survival times (5 and 15 years) and rates (65 and 85% at 5 years). Women completed questionnaires measuring anxiety, depression, optimism, quality and quantity of social support, and illness perceptions. RESULTS: More than half the women judged benefits of 1 day or 0.1% sufficient to make adjuvant chemotherapy worthwhile. The most important factors in multivariable models were whether the woman had dependants and number of non-specific symptoms attributed to breast cancer and adjuvant chemotherapy since completing treatment. The proportion of variance explained was modest. Preferences were not associated with: scores for anxiety, optimism, and perceived quality and quantity of social support. Explanations for judging negligible benefits sufficient included minimising regret, parenting concerns, doubts about the information provided and feeling that they had no choice. CONCLUSIONS: Preferences were highly variable and influenced by women's unique circumstances and attitudes, but not by their anxiety or optimism scores.

The European Organization for Research and Treatment of Cancer (EORTC) Quality-of-Life questionnaire cervical cancer module: EORTC QLQ-CX24.

BACKGROUND: The authors report on the development and validation of a cervical cancer module for the European Organization for Research and Treatment of Cancer (EORTC) Quality-of-Life (QoL) questionnaire (QLQ), which was designed to assess disease-specific and treatment-specific aspects of QoL in patients with cervical cancer. METHODS: The cervical cancer module (EORTC QLQ-CX24) was developed in a multicultural, multidisciplinary setting to supplement the EORTC QLQ-C30 core questionnaire. The QLQ-C30 and the cervical cancer module were administered to 346 patients with cervical cancer who underwent radical hysterectomy and received radiotherapy and chemotherapy. Psychometric analyses were performed by using data from 2 independent samples. RESULTS: The QLQ-CX24 consists of 3 multiitem scales and 5 single-item scales. Multitrait scaling analyses revealed high internal consistencies for the subscales with Cronbach alpha coefficients ranging from .72 to .87 (Symptom Experience, .72; Body Image, .86; Sexual/Vaginal Functioning, .87). Convergent and discriminant validity were fulfilled with scaling errors below 3%. The QLQ-CX24 was capable of discriminating between clinical subgroups. All items exhibited good compliance with <3% missing values. Most patients completed the EORTC QLQ-C30 and the QLQ-CX24 in <15 minutes (86%), and many did not require any assistance to complete the questionnaires (65%). CONCLUSIONS: The current psychometric analyses supported the content and construct validity and the reliability of the EORTC QLQ-CX24 module. This newly developed module is a useful instrument for assessing the QoL of patients who are treated for cervical cancer both in clinical trials and in clinical practice.

What survival benefits do premenopausal patients with early breast cancer need to make endocrine therapy worthwhile?

BACKGROUND: Adjuvant endocrine therapies such as tamoxifen, goserelin, and oophorectomy improve survival for premenopausal women diagnosed with early-stage breast cancer. However, these treatments often result in menopausal symptoms, sexual dysfunction, permanent infertility, or the need to delay pregnancy. We aimed to quantify the survival gains that premenopausal patients with early-stage breast cancer require to justify the side-effects and inconvenience of adjuvant endocrine treatments. METHODS: Participants consisted of 102 women who had been diagnosed with early-stage (stage I-II) breast cancer 6-60 months previously, who were aged 40 years or younger at diagnosis, and who had been treated for a minimum of 3 months with endocrine therapy (67 with tamoxifen alone, seven with goserelin alone, and 28 with tamoxifen and goserelin or oophorectomy). 76 patients also received chemotherapy, and 75 received radiotherapy. Participants attended a face-to-face patient-preference interview, in which they were presented with four hypothetical clinical scenarios that were used to quantify the gains in survival rate and life expectancy that women judged necessary to make their endocrine therapy worthwhile. They also completed a questionnaire on standard psychological measures. FINDINGS: About half of participants thought that adjuvant endocrine therapy was worthwhile for an absolute gain in survival of 2% from a baseline of either 65% or 85%, and for a gain in life expectancy of 3 months from a baseline of 5 years and of 6 months for a baseline of 15 years. Women who had had more severe endocrine side-effects required larger gains to make endocrine therapy worthwhile (univariate p=0.02, multivariate p=0.04). INTERPRETATION: Modest gains in survival are sufficient to make adjuvant endocrine treatment worthwhile for premenopausal women with early-stage breast cancer. Knowing and incorporating what women think should enhance shared decision-making.

Reducing Psychological Distress in a Genetic Counseling Consultation for Breast Cancer.

High levels of cancer specific distress have been found before and after genetic counseling for breast cancer. This study investigated the process of reducing distress during 111 genetic counseling consultations for familial breast cancer. Consultations were audiotaped, transcribed, and a detailed coding system developed to measure cues of emotional distress from the patient, and consultant (clinical geneticist or genetic counselor) behaviors before and after the cues. At least 1 emotional cue was given in 64 consultations, with a median of 1 cue per consultation. More emotional cues of distress occurred when the consultant responded empathetically to the first cue of distress. Satisfaction outcomes were largely positive regardless of the consultant's attentiveness to distress. Postconsultation depression scores were significantly reduced if more empathic responses were given, but anxiety remained the same. These results are discussed and recommendations are made for improving patient care.