Analysis of Patient Reported Outcomes for Stage IV Non-Small Cell Lung Cancer Patients in Ontario

Abstract

Stage IV non-small cell lung cancer (NSCLC) is associated with substantial disease and treatment-related morbidity. In Ontario, Canada, patient reported outcomes (PRO) evaluation through Edmonton Symptom Assessment System (ESAS) has been integrated into clinical workflow since 2007. ESAS elicits patients' self-reported severity of common cancer-associated symptoms at clinical encounters. ESAS domains are anxiety, depression, drowsiness, appetite, nausea, pain, shortness of breath, tiredness, and well-being. This province-wide study investigated moderate-to-severe symptom burden in this population.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 and plotted over time. Potential covariates of moderate-to-severe scores: lung cancer treatments, age, sex, Elixhauser comorbidity index, immigration status, income quintiles, and time since diagnosis were analyzed using multivariable Poisson regression models with robust error variance.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. Almost all patients (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%). Monthly peaks and nadirs of these symptoms were: 67.6% (month 1) and 47.0% (month 12) for tiredness; 64.6% (month 1) and 43.3% (month 10) for lack of wellbeing; 50.5% (month 1) and 33.1%. All symptoms severity peaked at 1 or 2 months after diagnosis and demonstrated downwards trajectories in the subsequent months. On multivariable analyses, moderate-to-severe scores in all ESAS domains 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. Comorbidity, low income, non-immigrants, and urban residency were also associated with moderate-to-severe symptoms.This province-wide PRO analysis showed moderate-to-severe symptoms were highly prevalent and persistent among metastatic NSCLC patients, underscoring the need to address supportive measures in this population especially around treatments. In-person PRO completions were lower among patients who are older, highly comorbid, and not receiving active treatment, arguably more vulnerable patients. Implementation of virtual PRO may lower barrier to care, allowing timely identification of symptoms that may be amenable to intervention in these patients.