Patients with cancer who report on their own quality of life can provide information important in predicting the outcome of their disease, according to researchers from the European Organisation for Research and Treatment of Cancer (EORTC). Until recently, reports from clinicians on issues such as patient age and tumor status were used primarily in determining prognoses, but now researchers have shown conclusively that patient-reported outcomes have considerable value in predicting survival.
Andrew Bottomley, MD
In an article published recently in The Lancet Oncology, Andrew Bottomley, MD, EORTC Assistant Director and Head of the Quality of Life Department, EORTC, Brussels, Belgium, together with colleagues from 7 countries, reported the findings of a meta-analysis of 44 clinical trials carried out between 2006 and 2018 on patients with cancer that report quality-of-life scores.1 “We saw that, each year, the scientific literature was populated with dozens of new analyses showing the value of quality-of-life scores, but these were single analyses, and many of the trials had limited methods,” Dr Bottomley said in a news release issued recently by EORTC. “We decided to try to follow up an earlier EORTC analysis that showed quality of life was important but that methods and standards of its analysis needed improvement,2” he added.
After reviewing the literature, the authors identified 44 phase II or III randomized, controlled trials that met the strict criteria for inclusion in their analysis. They covered results of 28,281 patients across 13 different cancer types. Sample sizes among the studies ranged from 63 to 1,152 patients, and a total of 23,122 patients completed patient-reported outcomes assessments. The main patient-reported outcomes tools used to assess the patients were the EORTC Quality of Life Core questionnaire and the Functional Assessment of Cancer Treatment questionnaire. They were then combined with clinical factor assessments such as performance status, tumor size, and serum markers.
In 41 of the 44 studies included, or 93%, the researchers found that at least one patient-reported outcomes domain, such as physical functioning or pain, was significantly associated with overall survival after other clinical variables had been controlled for.
“This is an important result that, additionally, allowed us to confirm that methods and standards of collecting and analyzing quality-of-life data have improved since the original review some 10 years ago, though we still need some methodologic improvements if we are to optimize the prognostic value of these data. We plan to do a further analysis in 5 years’ time to check that future studies have improved methods further, whether clinical triallists are using these results to stratify patients in trials, and the extent to which they are being used as prognostic indicators,” Dr Bottomley said.
Assessing Quality of Life
Quality-of-life assessment is becoming increasingly important in oncology. Governments are starting to collect data not only from cancer clinical trials, but also from patients undergoing standard hospital care. This cannot only help health services understand patients’ needs, but also allow for quality-of-life mapping across countries and perhaps even more widely. “We are seeing a move not just out of research, and single or multiple hospitals, but into country-level data with all the impact on policy that that implies,” said Dr. Bottomley.
In demanding better standards for future research in the field of prognostic prediction—being able to tell patients what survival duration they can expect—the researchers hope that patients will be able to better adapt their lives to the impact of the cancer diagnosis on their survival. “Although this will not alter practice, it will encourage clinicians to take more interest in patients’ quality-of-life scores and to understand their importance. They are vital in making services and care specific for each cancer patient. ‘Targeted treatment’ is much discussed in the context of pharmaceuticals, but quality-of -ife scores also allow us to ‘target’ the direct needs and concerns of the patient rather than just relying on tumor size or organ-specific problems,” Dr Bottomley concluded. ■
Disclosure: Dr. Bottomley and another investigator were coauthors involved in two trial publications included in the current systematic literature review. For full disclosures of all study authors, visit thelancet.com.
1. Mierzynska M, Piccinin C, Bottomley A, et al: Prognostic value of patient-reported outcomes from international randomised clinical trials on cancer: A systematic review. Lancet Oncol 20: e683-696, 2019.
2. Gotay CC, Kawamoto CT, Bottomley A, et al: The prognostic significance of patient-reported outcomes in cancer clinical trials. J Clin Oncol26:1355–1363, 2008.