Province-Wide Analysis of Patient-Reported Outcomes for Stage IV Non-Small Cell Lung Cancer

Abstract

Background. In Ontario, Canada, patient reported outcomes (PRO) evaluation through Edmonton Symptom Assessment System (ESAS) has been integrated into clinical workflow since 2007. As stage IV non-small cell lung cancer (NSCLC) is associated with substantial disease and treatment-related morbidity, this province-wide study investigated moderateto-severe symptom burden in this population. Methods. ESAS collected from stage IV NSCLC patients diagnosed between 2007-2018 linked to Ontario provincial healthcare system database were studied. ESAS acquired within 12 months following diagnosis were analyzed and the proportion reporting moderate-to-severe scores (ESAS ≥4) in each domain was calculated. Predictors of moderateto-severe scores were identified using multivariable Poisson regression models with robust error variance. Results. Of 22,799 patients, 13,289 (58.3%) completed ESAS (84,373 assessments) in the year following diagnosis. Patients with older age, high comorbidity, and not receiving active cancer therapy had lower ESAS completion. Majority (94.4%) reported at least 1 moderate-to-severe symptoms. Most prevalent were tiredness (84.1%), low wellbeing (80.7%), low appetite (71.7%), and shortness of breath (67.8%). Most symptoms peaked at diagnosis, while declining, remained high in the following year.On multivariable analyses, comorbidity, low income, non-immigrants, and urban residency were associated with moderate-to-severe symptoms. Moderate-to-severe scores in all ESAS domains aside from anxiety were associated with radiotherapy within 2 weeks prior, while drowsiness, low appetite and wellbeing, nausea, and tiredness were associated with systemic therapy within 2 weeks prior. Conclusion. This province-wide PRO analysis showed moderate-to-severe symptoms were prevalent and persistent among metastatic NSCLC patients, underscoring the need to address supportive measures in this population especially around treatments. The Oncologist ;9999:• • Implications for Practice: This is the largest patient reported outcome (PRO) results among lung cancer patients worldwide. Our results demonstrated the worse moderate-to-severe symptoms among stage IV non-small cell lung cancer patients compared to other patients with metastatic, other malignancies such as breast, gastric, or esophageal cancers assessed with similar methodology. These patients symptom severity also peaked early, and persistently high during 1 year follow-up. Symptoms burden was also associated with recent radiation and systemic treatments. This emphasized the importance of early and sustained PRO collection to detect actionable symptom progression, especially around treatments. Moreover, PRO

Systematic self-reporting of patients’ symptoms: improving oncologic care and patients’ satisfaction

“…They reported that, although the severity of symptoms was low, the prevalence of specific symptoms such as tiredness, anxiety, pain and low wellbeing was high. In a similar study by Tjong et al 65 who assessed ESAS scores completed by 13,289 patients, they also observed that the most prevalent symptoms causing patient distress are tiredness, low wellbeing, low appetite and shortness of breath.…”

“…This observation in the study is similar to what has also been reported in similar studies. 40,65 Cuthbert et al 40 conducted a retrospective, population-based cohort study on ESAS scores completed by 1,310 patients. They reported that, although the severity of symptoms was low, the prevalence of specific symptoms such as tiredness, anxiety, pain and low wellbeing was high.…”

Pain and Interventions in Stage IV Non-Small Cell Lung Cancer: A Province-Wide Analysis

“…First, a large proportion of patients were excluded as ESAS scores were not collected. As described previously, patients who did not complete any ESAS were more likely to be older, to have higher comorbidity and to not receive any active cancer treatment [ 13 ].…”

“…Overall symptom burden using ESAS in stage IV NSCLC in Ontario has been previously reported by our research group, which found moderate-to-severe symptoms were prevalent and peaked at diagnosis while remaining high during the first year of follow-up [ 13 ]. The aim of the current study was to examine the intervention use and factors associated with interventions for pain (including palliative care assessment, radiation therapy, nerve block and opiate prescriptions) in stage IV NSCLC.…”

Epidemiology, Patients’ Journey and Healthcare Costs in Early-Stage Non-Small-Cell Lung Carcinoma: A Real-World Evidence Analysis in Italy

“…In this context, the problem of recurrent metastasis in NSCLC patients is crucial, as it causes detrimental rebounds not only on patients themselves and neoplasm prognosis, but also on caregivers, the healthcare system and society [ 4 ]. Unfortunately, despite the improved outcomes of metastatic NSCLC over the last decades, resulting from the introduction of combination chemotherapy, small molecules targeting mutant proteins, 5-year survival of these patients remains low, about 26% in stage IIIB, 10% in stage IVA and less than 1% in stage IVB patients [ 5 ].…”