Patients' preferences for adjuvant sorafenib after resection of renal cell carcinoma in the SORCE trial: what makes it worthwhile?

Background: We sought to determine the survival benefits that patients judged sufficient to warrant adjuvant therapy with sorafenib for 1 year, or for 3 years after resection of renal cell carcinoma in the SORCE trial. Methods: SORCE participants from all sites in Australia and New Zealand, and selected sites in the UK, completed a validated preferences questionnaire at months 0, 3, 15, and 42 to elicit the minimum survival benefits they judged sufficient to warrant adjuvant sorafenib for 1 year (versus observation), or for 3 years (versus 1 year). The questionnaires used reference survival times of 5 and 15 years; and reference survival rates at 5 years of 65% and 85%. Results: The 233 participants had a median age of 57 years (range 29-78) and 71% were male. For 1 year of sorafenib versus no adjuvant therapy, the median benefits in survival times judged sufficient to warrant treatment were an extra 9 months beyond 5 years and an extra 1 year beyond 15 years; the median benefit in survival rates were an extra 4% beyond 65% and an extra 3% beyond 85% at 5 years. For 3 years of sorafenib versus 1 year of sorafenib, the median benefit in survival time judged sufficient to warrant extended treatment was an extra 1 year beyond both 5 and 15 years. Participants randomly allocated to treatment with sorafenib judged larger benefits necessary than those allocated to placebo. Participants' preferences were not associated with their baseline characteristics or the interval from randomisation. Conclusion: Most participants judged an extra year of survival necessary to warrant 1 year of adjuvant sorafenib worthwhile, and an additional year of survival to warrant extending the duration of sorafenib from 1 to 3 years. Patients' preferences are important in shared decision making. SORCE trial clinical trials number: NCT00492258.

How do oncologists make decisions about chemotherapy for their older patients with cancer? A survey of Australian oncologists.

PURPOSE: Oncologists are making treatment decisions on increasing numbers of older patients with cancer. Due to comorbidities and frailty that increase with age, such decisions are often complex. We determined factors influencing oncologists' decisions to prescribe chemotherapy for older adults. METHODS: Members of the Medical Oncology Group of Australia (MOGA) were invited to complete an online survey in February to April 2016. RESULTS: Ninety-three oncologists completed the survey of which 69 (74%) were consultants and 24 (26%) were trainees, with most (72, 77%) working predominantly in a public hospital-associated practice. The three highest ranked factors influencing decisions about (a) adjuvant chemotherapy were performance status, survival benefit of treatment, and life expectancy in the absence of cancer and about (b) palliative chemotherapy were performance status, patient preference, and quality of life. Most geriatric health domains are reportedly assessed routinely by the majority of respondents, though few routinely use geriatric screening tools (14%) or geriatric assessments (5%). In hypothetical patient scenarios, oncologists were less likely to prescribe palliative and adjuvant chemotherapy as age and rates of severe toxicity increased. CONCLUSION: Performance status was the most influential factor for oncologists when making a decision about chemotherapy for their older patients, and the importance of other factors differed according to treatment intent. Oncologists were less likely to recommend chemotherapy as patient age and treatment toxicity increased. The low uptake of geriatric assessments or screening tools provides scope for improved clinical assessment of older adults in treatment decision-making.

Impact of physical activity on fatigue and quality of life in people with advanced lung cancer: a randomized controlled trial.

BACKGROUND: Physical activity (PA) improves fatigue and quality of life (QOL) in cancer survivors. Our aim was to assess whether a 2-month PA intervention improves fatigue and QOL for people with advanced lung cancer. METHODS: Participants with advanced lung cancer, Eastern Cooperative Oncology Group performance status (PS) ≤2, >6 months life expectancy, and ability to complete six-min walk test, were stratified (disease stage, PS 0-1 versus 2, centre) and randomized (1:1) in an open-label study to usual care (UC) (nutrition and PA education materials) or experimental intervention (EX): UC plus 2-month supervised weekly PA and behaviour change sessions. Assessments occurred at baseline, 2, 4, and 6 months. The primary endpoint was fatigue [Functional Assessment of Cancer Therapy-Fatigue (FACT-F) questionnaire] at 2 months. The study was designed to detect a difference in mean FACT-F subscale score of 6. Analysis was intention-to-treat using linear mixed models. RESULTS: We recruited 112 patients: 56 (50.4%) were randomized to EX, 55(49.5%) to UC; 1 ineligible. Male 55%; median age 64 years (34-80); 106 (96%) non-small cell lung cancer; 106 (95.5%) stage IV. At 2, 4 and 6 months, 90, 73 and 62 participants were assessed, respectively, with no difference in attrition between groups. There were no significant differences in fatigue between the groups at 2, 4 or 6 months: mean scores at 2 months EX 37.5, UC 36.4 (difference 1.2, 95% CI - 3.5, 5.8, P = 0.62). There were no significant differences in QOL, symptoms, physical or functional status, or survival. CONCLUSIONS: Adherence to the intervention was good but the intervention group did not increase their PA enough compared to the control group, and no difference was seen in fatigue or QOL. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry No. ACTRN12609000971235.

Use of palliative chemotherapy in patients aged 80 years and over with incurable cancer: experience at three Sydney cancer centres.

BACKGROUND: Octogenarians represent a growing population reviewed in medical oncology clinics, yet there is a paucity of data on how chemotherapy is tolerated in this age group. AIM: To describe the use of palliative first-line chemotherapy in patients 80 years and over and factors associated with its use. METHODS: We identified all new patients aged 80 years or older diagnosed with incurable advanced solid organ cancer and seen in one of three Sydney medical oncology outpatient clinics between January 2009 and December 2013. Patient, disease and treatment details were summarised and factors associated with chemotherapy use explored. RESULTS: Of 420 eligible patients, 100 (24%) started first-line chemotherapy. Younger age at diagnosis was the only factor associated with receiving chemotherapy (median 82.9 vs 84.1 years, P = 0.002). A total of 78% of patients had single-agent chemotherapy, and 41% received a full dose for the first cycle. During treatment, 54% experienced toxicity, necessitating dose reduction, delay or omission, and 32% were hospitalised. These events were associated with receipt of combination chemotherapy (OR 5.1; P = 0.04) and full-dose chemotherapy for cycle 1 (OR 3.5; P = 0.02). Radiological disease control was achieved in 60%. Chemotherapy was stopped because of progressive disease (48%), toxicity (37%) or completion of planned course (17%). CONCLUSION: A quarter of patients 80 years and older received first-line palliative chemotherapy. Despite most receiving a modified dose, one third were hospitalised during treatment. These findings highlight the need for careful clinical assessment and selection of older cancer patients for chemotherapy.

Doctor-to-doctor communication of prognosis in metastatic cancer: a review of letters from medical oncologists to referring doctors.

BACKGROUND: Shared understanding of prognosis is vital for optimal, multidisciplinary, clinical decision making. AIMS: This study aims to determine the frequency and nature of prognostic information in medical oncologists' letters to referring doctors for patients with metastatic cancer. METHODS: We reviewed all consultation letters (to June 2014) for new patients with metastatic cancer presenting to medical oncologists at Concord and Macarthur Cancer Centres between June 2012 and June 2013. We recorded the presence and nature of prognostic information in the letters, patients' characteristics and survival. Characteristics associated with inclusion of prognostic information were explored. RESULTS: We analysed 1344 letters pertaining to 272 patients with a median survival of 13 months. The median number of letters per patient was 4 (interquartile range 1-7), with 50% written by trainees. The terms 'metastatic' or 'stage IV cancer' were included in letters for 253 patients (93%), treatment was described as 'palliative' for 174 patients (64%) and the word 'incurable' was included for 93 (34%). Only 31 patients (11%) had a quantitative estimate of prognosis in any correspondence: median or average survival in 14, general time frame in 12 and, best case, typical and worst case scenarios in 5. Inclusion of quantitative prognostic information was not associated with patient age, cancer type, treatment plan, trainee authoring letter or shorter survival. CONCLUSION: Inclusion of quantitative prognostic information in written correspondence from medical oncologists regarding patients with metastatic cancer was infrequent. Encouraging oncologists to include quantitative prognostic information in their letters could improve communication between oncologists, referring doctors and patients.

Better estimates of survival for patients considering adjuvant chemotherapy after surgery for early non-small-cell lung cancer.

INTRODUCTION: The aim of this study was to summarise and describe survival data from contemporary randomised trials of platinum-based adjuvant chemotherapy for patients with non-small-cell lung cancer (NSCLC). The goal was to assist clinicians to provide better estimates of survival for patients considering adjuvant chemotherapy following surgical resection for NSCLC. METHODS: Randomised trials of cisplatin-based adjuvant chemotherapy for resected NSCLC were identified. Survival rates at 1, 2, 5, 7 and 10 years and the following percentiles (scenario): 90th (worst case), 75th (lower typical), median, 25th (upper typical) and 10th (best case) were extracted from each overall survival (OS) curve. RESULTS: Thirty-eight OS curves from 19 trials (7042 patients) were analysed. With adjuvant chemotherapy, the median OS rate (interquartile range) at 1 year was 91% (85-95), 2 years was 73% (69-88), 5 years was 61% (45-65) and 7 years was 49% (38-65). With observation only, the median OS rate (interquartile range) at 1 year was 88% (83-92), 2 years was 74% (65-82), 5 years was 55% (42-58) and 7 years was 40% (34-45). In both arms, survival rates at 2, 5 and 7 years were well estimated by raising the 1-year survival rate to the power of two, five and seven respectively. Few trials reported survival rates at 10 years. CONCLUSION: Simple percentages and their powers provide a useful starting point for estimating and describing survival to patients considering adjuvant chemotherapy after surgery for NSCLC.

Preferences for cancer treatments: an overview of methods and applications in oncology.

This review provides cancer clinicians and researchers with an overview of methods for assessing preferences, with examples and recommendations for their application in oncology. Decisions about cancer treatments involve trade-offs between their relative benefits and harms. An individual's preference for a cancer treatment reflects their evaluation of the relative benefits and harms in comparison with a given alternative or alternatives. Methods of preference assessment include the ranking or rating scale, standard gamble (SG), time trade-off (TTO), visual analogue scale, discrete choice experiment (DCE), and multi-attribute utility instrument (MAUI). The choice of method depends on the purpose of preference assessment; the ranking or rating scale, SG, TTO, and DCEs are best suited to clinical decisions, whereas MAUIs are best suited to health policy decisions. Knowledge of patients' preferences for cancer treatments can better inform clinical decisions about patient management by enabling the tailoring of decisions to individual patients' values, attitudes, and priorities and health policy decisions through economic evaluations of cancer treatments and their suitability for coverage by health payers.

Impact of COVID-19 on cancer service delivery: a follow-up international survey of oncology clinicians.

BACKGROUND: The COVID-19 pandemic has had a vast impact on cancer service delivery around the world. Previously reported results from our international survey of oncology clinicians, conducted through March-April 2020, found that clinicians reported altering management in both the curative and palliative settings and not in proportion to the COVID-19 case burden in their region of practice. This follow-up survey, conducted from 27th September to 7th November 2020, aimed to explore how attitudes and practices evolved over the 2020 pandemic period. PARTICIPANTS AND METHODS: Participants were medical, radiation and surgical oncologist and trainees. Surveys were distributed electronically via ESMO and other collaborating professional societies. Participants were asked to compare their practice prior to the pandemic to both the period of March-April 2020, referred to as the 'early' period, and the current survey period, referred to as the 'later' period. RESULTS: One hundred and seventy-two oncology clinicians completed the survey. The majority of respondents were medical oncologists (n = 136, 79%) and many were from Europe (n = 82, 48%). In the 'early' period, 88% (n = 133) of clinicians reported altering their practice compared to 63% (n = 96) in the 'later' period. Compared to prior to the pandemic, clinicians reported fewer new patient presentations in the 'early' period and a trend towards more patients presenting with advanced disease in the 'later' period. CONCLUSIONS: Results indicate a swing back towards pre-COVID-19 practices despite an increase in the rate of cumulative COVID-19 cases across 2020. The impact of these changes on cancer associated morbidity and mortality remains to be measured over the months and years to come.

A case of uterine tumour resembling ovarian sex cord tumour responding to second-line, single agent anastrazole.

Uterine tumour resembling ovarian sex cord tumour (UTROSCT) are a histological variant of endometrial stromal sarcomas (ESS). There is no established medical management of metastatic UTROSCT or ESS, although there is evidence supporting the use of hormonal therapy. Given the success of aromatase inhibitors in breast cancer, their potential role in ESS and UTROSCT is of current interest. We report the first case of response to second-line, single agent anastrazole in a patient with metastatic UTROSCT.

Estimating typical, best-case and worst-case life expectancy scenarios for patients starting chemotherapy for advanced non-small-cell lung cancer: a systematic review of contemporary randomized trials.

INTRODUCTION: We sought to estimate life expectancy scenarios for patients starting chemotherapy for advanced non-small-cell lung cancer (NSCLC). METHODS: We searched for randomized first-line chemotherapy trials published from January 2000 to April 2008. We recorded median time to progression (TTP) and median overall survival (OS) and extracted the following percentiles (represented scenario) from each OS curve: 90th (worst-case), 75th (lower-typical), 25th (upper-typical) and 10th (best-case). For each OS curve we divided these percentiles (scenarios) in turn by the median to determine if a simple relationship existed between each scenario and the median. RESULTS: From 60 trials (29,657 patients), the mean for median TTP was 4.8 months (interquartile range [IQR] 4.0-5.3), the mean for median OS was 9.2 months (IQR 8.1-10.1) and the mean ratio for median OS to median TTP was 2.0 (IQR 1.7-2.2). The mean (IQR) in months for each OS scenario was: worst-case, 2.4 (1.9-2.7); lower-typical, 4.8 (4.2-5.4); upper-typical, 16.3 (14.4-18.1); and best-case, 25 (21.0-28.0). The mean values (IQR) for each scenario divided by the median were: worst-case/median 0.26 (0.21-0.29); lower-typical/median 0.53 (0.5-0.57); upper-typical/median 1.81 (1.69-1.93) and best-case/median 2.84 (2.57-3.19). These values can be approximated by the simple multiples: 0.25, 0.5, 2 and 3. Independent predictors of longer OS were ECOG PS<2, adenocarcinoma, and longer TTP; all p-values<0.001. CONCLUSION: Simple multiples of an OS curve's median provided accurate estimates of typical (half to double the median), best-case (triple the median), and worst-case (one quarter of the median) life expectancy scenarios for patients starting chemotherapy for advanced NSCLC.