Abstract
BackgroundMaintenance therapy (MT) with pemetrexed has been shown to improve overall and progression-free survival of patients with non-squamous non-small cell lung cancer (NSCLC), without impairing patients’ health-related quality of life (HRQOL) substantially. Comprehensive data on HRQOL under real-life conditions are necessary to enable informed decision-making. This study aims to (1) assess HRQOL during first-line chemotherapy and subsequent MT and (2) record patients’ and physicians’ reasons leading to clinical decisions on MT.MethodsPatients treated for NSCLC at three Austrian medical centres were included. HRQOL was assessed at every chemotherapy cycle using the EORTC QLQ-C30/+LC13 questionnaire. Semi-structured interviews were conducted before MT initiation and at the time of discontinuation to evaluate patients’ and physicians’ reasons for treatment decisions. Longitudinal QOL analysis was based on linear mixed models.ResultsSixty-one (73%) out of 84 patients were considered for MT. Thirty-six patients (43%) received MT and 29 (35%) discontinued therapy. Decisions on MT initiation (in 20 cases by the physician vs 4 by the patient) and discontinuation (19 vs 10) were mainly voiced by the physician. Treatment toxicity of first-line chemotherapy was the main reason for rejection of MT in patients with stable disease and was more often indicated by patients than clinicians. HRQOL data were collected from 83 patients at 422 assessment time points and indicated significantly lower symptom severity during MT compared with first-line therapy for nausea and vomiting (p = 0.006), sleep disturbances (p < 0.001), appetite loss (p = 0.043), constipation (p = 0.017) and chest pain (p = 0.022), and a deterioration in emotional functioning (p = 0.023) and cognitive functioning (p = 0.044) during MT.ConclusionsOur results indicate that HRQOL and symptom burden improve between first-line treatment to MT in some respects, although some late toxicity persists. Discrepancies between patients’ and physicians’ perception of reasons for rejecting MT were evident. Thus, the integration of patient-reported outcomes, such as HRQOL, is required to enable shared decision-making and personalised healthcare based on mutual understanding of treatment objectives.
Highlights
Maintenance therapy (MT) with pemetrexed has been shown to improve overall and progression-free survival of patients with non-squamous non-small cell lung cancer (NSCLC), without impairing patients’ healthrelated quality of life (HRQOL) substantially
Our results indicate that HRQOL and symptom burden improve between first-line treatment to MT in some respects, some late toxicity persists
Patients responding to first-line therapy with stable disease or a partial/complete response after cycle 4 are considered for subsequent maintenance therapy (MT), either with a new agent such as pemetrexed or erlotinib or with one of the first-line agents such as pemetrexed or bevacizumab [4, 5]
Summary
Maintenance therapy (MT) with pemetrexed has been shown to improve overall and progression-free survival of patients with non-squamous non-small cell lung cancer (NSCLC), without impairing patients’ healthrelated quality of life (HRQOL) substantially. This study aims to (1) assess HRQOL during first-line chemotherapy and subsequent MT and (2) record patients’ and physicians’ reasons leading to clinical decisions on MT. In clinical phase III trials, MT with pemetrexed has been shown to improve overall and progression-free survival of patients suffering from non-squamous NSCLC [6,7,8]. In line with European Society for Medical Oncology guidelines, decision-making about MT must take into account persisting toxicity after first-line chemotherapy, performance status and patients’ choices concerning treatment options [10]. In addition to physician ratings, toxicity can be comprehensively evaluated through patient-reported outcome measures (PROMs) such as the assessment of health-related quality of life (HRQOL)
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