A focus session dedicated to quality-of-life (QoL) outcomes in interventional oncology (IO) at this year’s Cardiovascular and Interventional Radiological Society of Europe (CIRSE) annual congress (14–18 September, Lisbon, Portugal) saw experts study the critical importance of patient-reported outcome measures (PROMs) and the growing recognition of these data as key indicators of procedural success in cancer care.
In conversation with Interventional News, Roberto Iezzi (Policlinico Universitario Fondazione Agostino Gemelli, Rome, Italy) extracted key points from his presentation. “The journey is becoming more important than the destination,” he stated, praising the range of effective interventions that have been developed in IO today. “The good news is that we have so many treatment options—the bad news is that we have so many treatment options,” Iezzi deliberated. “Tailored to each patient’s disease and comorbidities, approach to treatment can be more dynamic and the right selection is the most important part of our job”, he added.
Iezzi explained that, today, precision cancer care has come so far as to cure 50% of metastatic cancer cases and extend the life expectancy of the other 50%. He referenced a study published earlier this year by Wörns et al, in which the investigators interviewed patients with hepatocellular carcinoma (HCC) on their treatment goals. Patients described extending overall survival as their most important goal in early-stage HCC, whereas for advanced/unresectable disease, QoL and managing side effects became their key priority.
“Undeniable connection” between QoL and survival
In treating advanced disease, Iezzi described the creation of a new subgroup of ‘chronic’ cancer patients, in whom life-extending treatment is achieved, but quality of life is maintained in careful balance. “This is a future concept,” said Iezzi, teasing new research to be published this year in which he and his colleagues will investigate how much life is sacrificed by cancer patients due to life-extending treatments.
Recent research attempted to evaluate the effect of QoL improvement on patient outcome. Earlier this year, Balitsky et al’s systematic review and meta-analysis of PROMs across Medline and Embase databases suggested that integration of PROMs into treatment improved health-related quality of life (HRQoL) and the overall risk of mortality at 12 weeks. In their report, however, the authors note that improvements in HRQoL dropped off at the 24-week mark and showed no association at 48 weeks.
Their results suggest that QoL improvements could benefit patients in the early phase of treatment. Vlasios Sotirchos (Memorial Sloan Kettering Cancer Center, New York, USA), who presented on the immediate QoL impact that IO treatments have for liver cancer patients, stated that there is an “undeniable connection” between QoL and overall survival in general. He told Interventional News that this could be due to the development of patient-centred treatment plans adapted to individual patient needs reported via PROMs data collection at each patient visit, rather than taking a one-size-fits-all approach. By placing focus on the physical, emotional and social effects of cancer and its treatments, interventionists can help dispel distress and elevate QoL, which Sotirchos stated can be “extremely meaningful” in patients with with cancer at any stage.
A dynamic approach to QoL
Placing QoL at the centre of the algorithm, treatment takes customisable form in Iezzi’s view. “We can select the best multimodality approach—we know that ablation is better than surgery when considering quality of life, and that chemoembolization and radioembolization are better than systemic chemotherapy. This way, we can provide dynamic systemic and locoregional treatment and achieve quality-of-life improving strategies such as chemo-holidays, and then restart treatment with appropriate systemic intensification,” he stated.
Iezzi made clear that setting a well-planned, dynamic treatment plan in motion is all well and good, but without clear communication to manage patient expectations, the overall success of said procedures can be limited. He went on to expand on what defines curative or palliative treatment and the flexibility of these concepts.
“If a 50-year-old man is given 10 years, this is not a curative approach, but, if an 85-year-old man is also given 10 years, this would be considered curative despite the treatment modality. The term palliative has completely changed over the last ten years,” Iezzi said. “Previously, palliation was akin to ‘waiting for death’ whereas today, all treatments are considered palliative due to the dual goal of extending-life years and maintaining good quality of life.”
Addressing the psychological impact of a cancer diagnosis and subsequent treatment on the patient, Iezzi suggested that a psychoncologist should be inducted into the multidisciplinary team. He noted that discussion during the session at CIRSE turned to cultural differences in communication with cancer patients, noting that in Italy patient-physician communication styles are more indirect than those of Canadan interventionists—to which session moderator and native Canadian, Riad Salem (Northwestern University, Evanston, USA) agreed. Providing emotional support throughout the therapeutic process, the implementation of a psychoncologist in routine cancer care could help to standardise PROMs from country to country.
Disparities between countries worldwide are well-documented, Sotirchos added, stating that many patients have limited access to this level of treatment or can experience significant delays in receiving care. “Treatment access inequities impact QoL and addressing this issue should be a priority for healthcare systems,” he said.
Barriers to collecting QoL data Although research conducted by Basch et al found that obtaining PROMs data has a positive impact on the patient and therapy outcomes, the collection of said data has been shown to be burdensome for both patients and centres.
Presenting on why this is during the CIRSE session, Nathalie Kaufmann—chief operating officer and procurator at Next Research—highlighted that, in 10 years of experience conducting CIRSE research, limited staffing, logistical centre issues, and patient refusal and incapacity were detrimental to the collection of PROMs. While about 86% of hospitals participating in CIRSE research projects returned PROMs data overall, most of the questionnaires were completed at baseline visits before treatments and return rates declined thereafter.
She detailed their plan of launching an electronic PROMs questionnaire in 2017–2018 in the hope of improving questionnaire return rates. Despite a lengthy development process improving language functionalities and browser compatibility, no hospital used the online questionnaire throughout the time period.
Centres attributed this to average patient age, which was mid-60s—“this may have created a challenge”, Kaufmann said, however, looking back now, the electronic PROMs tool might not have simplified the data collection process sufficiently.
Today, Kaufmann added that technology and patients’ ability to navigate it has improved, and they intend on conducting a similar study in the near future.
Irrespective of how QoL data will be collected in future, it will remain an essential part of research in IR. In an ideal world, Kaufmann states that PROMs data would be used in routine clinical practice outside of research as well. Demonstrating the value of collecting QoL data during research projects is an important step in this direction.
“Through our research projects we’re sometimes working with centres that are collecting quality-of-life data for the first time and we are then helping to establish processes, such as, if they think their patient might be experiencing depression, how do they communicate with the patient and where can they refer them,” Kaufmann said. “Collecting this data is valuable to the patient and healthcare professional to improve communication between the two,” she added.
“Mandatory” QoL outcome measures in clinical trials
Later in his presentation, Iezzi drew attention to the European Society for Medical Oncology-Magnitude of Clinical Benefit Scale (ESMO-MCBS) grading system to assess the robustness for QoL research. In the introduction to the scale, the authors asserted that QoL—assessed with a validated tool—must be at least a secondary endpoint in future IO trials. Advocating for mandatory QoL questionnaires, Iezzi underlined that particularly in a non-curative setting, these assessments can aid multidisciplinary teams in selecting effective interventions. “It’s important we make patients aware of the real purpose, aim and outcomes of the procedures we are performing,” Iezzi added, so that patient and procedural goals align.
Sotirchos reflected that obtaining QoL metrics has a two-fold benefit for patients and interventionists, and will help to improve outcomes and healthcare policy decisions.
“Due to the multidimensional nature of QoL assessments, including several generic and disease-specific instruments, comparisons across studies can be very challenging,” he said. Yet, Sotirchos averred that, through the development of new technologies and the demonstrated value of recording PROMs to exemplify the benefit of IO procedures, the collection of this data must be prioritised in both clinical trials and routine periprocedural care.
