Bringing the Patient Voice into Cancer Care and Research

Ethan Basch, MD, MScNovember 19, 2015

Symptoms

• Common and often debilitating in cancer

• Recognizing symptoms is a key role of doctors and nurses– During cancer treatment– In clinical trials

Symptoms Often Go Undetected• Up to half of

patients’ symptoms are missed during cancer treatment

Nausea

Fatigue

Months

Anorexia

Vomiting

Months

Patient-reported

Clinician-reported

3

Serious Implications

• Under-management of symptoms during cancer treatment

• Under-documentation of symptoms and side effects in clinical trials

Research on “Patient-Reported Outcomes”

• Develop questionnaires and software to enable patient self-reporting of symptoms, physical functioning and “quality of life”

• Test these approaches during routine chemotherapy care and in clinical trials nationally

• Work closely with NCI, FDA, pharmaceutical industry, etc.

UNC is a National Leader in this Area• Angie Smith, MD

• Arlene Chung, MD

• Bryce Reeve, PhD

• Antonia Bennett, PhD

• Bill Wood, MD

• Hy Muss, MD

• Grant Williams, MD

Examples

Pain• Common in cancer, not well controlled

– Reported by 2/3 patients with advanced disease• Inadequate analgesics among 1/3

Particularly True in Prostate Cancer

More than half with advanced disease report clinically meaningful pain (>4 on 0-10 NRS)

1996

• Approved based on an old patient pain questionnaire

1997-2014• Only 1 other oncology drug approved by FDA based

on patient-reported information (Ruxolitinib, 2011)• Surprising, given how common symptoms and

functional impairment are in oncology

FDA introduced a “PRO Guidance”

Outlined standards

- Patient interviews

- Testing

- Relevance to trials

- Implementation, analysis

Groundbreaking… but overly stringent, and industry was largely unwilling and unable to adhere in most cases

Why So Rare?

U.S. Food & Drug

Administration

Researcher Role

• Worked with FDA on approach to PROs in oncology– Outcome: pain intensity– Measure: 0-10 NRS (BPI)– Recall: 24 hours– Meaningful change: 30% or 2 points– Analgesic use: integrated into design– Analysis approaches

Work with Industry

Work with Consensus Groups

Work with National Clinical Practice Guidelines

A Second Example

• Measuring symptom side effects in clinical trials– Clinicians miss many of these– UNC researchers led development of approach for

patients to report their own side effects• Developed for the National Cancer Institute• Called the “PRO-CTCAE”

Developed/Tested Questionnaire and Software

Clinician Reporting Patient Reporting

Shows Better Symptom Detection in Trials

Improves Outcomes during Treatment

• Improved QOL, longer chemotherapy, fewer ER visits

Recent Publications on PRO-CTCAE

Support PRO Software for Many Trials

• UNC Cancer Center “PRO-Core"

Patient-Centered Approaches to Quality of Care

Standards for Patient-Reported Outcome-based Performance Measures

PROs in Geriatrics

• Key to measure the patient experience – risk of comorbidities; functional impairments– E.g., the GA

• Older patients are enthusiastic to self-report• Enables communication• Methods research considerations

– What outcomes, how ask questions, how often, how use the information, how report results?

– Requires interdisciplinary collaboration

Thank You