- Email: [email protected]
Patients' Attitudes and Physicians' Perceptions Toward Maintenance Therapy for Advanced Non–Small-cell Lung Cancer: A Multicenter Italian Survey
Original Study
Patients’ Attitudes and Physicians’ Perceptions Toward Maintenance Therapy for Advanced NoneSmall-cell Lung Cancer: A Multicenter Italian Survey Maria Vittoria Pacchiana,1 Enrica Capelletto,1 Simona Carnio,1 Cesare Gridelli,2 Antonio Rossi,2 Domenico Galetta,3 Elisabetta Sara Montagna,3 Paola Bordi,4 Anna Ceribelli,5 Diego Cortinovis,6 Vieri Scotti,7 Olga Martelli,8 Giuseppe Valmadre,9 Alessandro Del Conte,10 Annamaria Miccianza,11 Raffaella Morena,12 Francesco Rosetti,13 Massimo Di Maio,1 Luca Ostacoli,14 Silvia Novello1 Abstract One question is how long patients with advanced nonesmall-cell lung cancer wish to receive therapy. The perceptions of > 100 patients and physicians were analyzed to compare different prognostic conditions. The patients’ attitudes were generally positive and not directly linked to the expected benefits, suggesting that other factors in conjunction with the clinical assessment, such as the doctorepatient relationship, should be considered to understand patients’ motivations. Introduction: Pemetrexed maintenance therapy (MT) after induction with platinum-based chemotherapy has recently become a common treatment strategy for advanced nonsquamous nonesmall-cell lung cancer (NSCLC). However, the benefits of MT should be weighed with consideration of the patients’ perceptions and preferences. The aim of the present study was to evaluate patients’ attitudes toward MT and to describe physicians’ awareness of their patients’ inclinations. Materials and Methods: We administered a 12-question anonymous survey and the Distress Thermometer Questionnaire to patients with advanced or recurrent nonsquamous NSCLC. The survey was also distributed to the referring physicians. Results: From December 2014 to July 2015, 92 patients and 37 physicians were enrolled. All 92 patients completed the questionnaire at T0 (before starting chemotherapy) and 56.5% also did so at T1 (after completion of induction). The physicians completed the survey only at T0. Most patients had a positive attitude toward MT at both T0 (78.9%) and T1 (86.5%), and 100% of the physicians thought their patients would be in favor of MT. The physicians believed that their patients’ attitudes toward MT would decrease proportionally with the reduction in the magnitude of the overall survival increase and expected benefits. The decrease expected by the physicians was much greater than that reported by the patients. This was especially true for an overall survival increase as small as 1 month (51.9% of patients accepting MT vs. 13.5% supposed by physicians) or when the only treatment benefit was radiologic tumor stabilization (69.3% of patients accepting MT vs. 37.8% supposed by physicians).
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Department of Oncology, University of Turin, Orbassano, Italy Division of Medical Oncology, S.G. Moscati Hospital, Avellino, Italy 3 Clinical Cancer Center “Giovanni Paolo II”, Bari, Italy 4 Medical Oncology Unit, University Hospital of Parma, Parma, Italy 5 Medical Oncology Unit, Regina Elena Cancer Institute, Rome, Italy 6 Medical Oncology Unit, San Gerardo Hospital, Monza, Italy 7 Oncology Department, Radiation Therapy Unit, Careggi Hospital, Florence, Italy 8 Medical Oncology Unit, San Giovanni Addolorata Hospital, Rome, Italy 9 Medical Oncology Unit, E. Morelli Hospital, Sondalo, Italy 10 Medical Oncology Unit, Santa Maria degli Angeli Hospital, Pordenone, Italy
1525-7304/$ - see frontmatter ª 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.cllc.2016.10.002
Medical Oncology Unit, D. Camberlingo Francavilla Fontana Hospital, Brindisi, Italy Medical Oncology Unit, Saronno Hospital, Saronno, Italy Oncology and Hematology Unit, ULSS 13, Mirano, Italy 14 Department of Clinical and Biological Science, University of Turin, Orbassano, Italy 13
Submitted: Jul 11, 2016; Revised: Oct 17, 2016; Accepted: Oct 18, 2016 Address for correspondence: Maria Vittoria Pacchiana, PsyD, Department of Oncology, University of Turin, Regione Gonzole 10, Orbassano, TO 10043, Italy E-mail contact: [email protected]
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Maintenance Therapy for Advanced NSCLC: Patients and Physicians Compared Conclusion: NSCLC patients have a generally positive attitude toward MT, which is not directly proportional to the expected benefits and greater than the attitude expected by physicians. Clinical Lung Cancer, Vol. -, No. -, --- ª 2016 Elsevier Inc. All rights reserved. Keywords: Doctor-patient relationship, Maintenance therapy, NSCLC, Patients’ perceptions, Quality of life
Introduction
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The current standard of care for the vast majority of patients with advanced nonesmall-cell lung cancer (NSCLC) is 4 to 6 cycles of platinum-based doublet chemotherapy. However, these schemes have led to a modest prolongation of survival, with < 5% of patients alive at 5 years.1,2 Pemetrexed maintenance therapy (MT) after induction with platinum-based chemotherapy plus pemetrexed (CTX) has recently become a common treatment strategy for NSCLC patients because it has extended survival, delayed disease progression, and maintained quality of life (QoL).3,4 However, MT is a treatment strategy that does not allow for a treatment-free interval; therefore, patients’ perception and preferences should be carefully considered in determining the therapeutic strategy.5-7 Decision-making has been defined as the cognitive process of reaching a decision.8,9 It often involves balancing the benefits and risks among multiple options. Several factors are involved in treatment decisions, including the physician’s personal beliefs, values, expertise, and practice type, perception of life expectancy, medical factors, and communication style. However, several patient factors are also involved, such as personal beliefs, values, and decisional control preferences, previous health-related experience, perception of the decision-making process, and contextual factors, including the availability of a caregiver and the patient’s psychological health.10-12 Many findings in the published data have shown that people with cancer experience distress at some point, which can have negative implications, including reduced health-related QoL, greater longterm distress, poor satisfaction with medical care, and, possibly, reduced survival.13,14 The National Comprehensive Cancer Network defines distress as an unpleasant psychological, emotional, social, and/or spiritual experience that interferes with effective coping. It can include unease, sadness, worry, anger, helplessness, guilt, and so forth.15 Common psychosocial, practical, and physical problems can amplify the feelings of distress, and their assessment offers clinicians opportunities to facilitate planning for targeted clinical services.14 To date, the decision-making preferences of patients with lung cancer and physicians’ perceptions of these preferences, specifically toward MT, have not been prospectively studied. Patients’ attitudes should be considered because this clinical approach, which results in continued therapy after induction chemotherapy rather than an interval without treatment, could change the treatment experience. Information regarding patients’ considerations and perceptions of MT could increase clinicians’ understanding of their treatment preferences; however, few published data are available.16-20 The primary aim of the present study was to evaluate patients’ attitudes toward MT according to the expected benefits, such as overall survival (OS) and QoL, and to compare physicians’ perception of their patients’ attitudes with the attitudes of the
Clinical Lung Cancer Month 2016
patients. Our secondary aim was to evaluate the correlation of different degrees of stress with the patients’ attitudes.
Materials and Methods To the best of our knowledge, no published studies have examined the attitudes of patients with NSCLC and physicians’ perceptions of patients’ attitudes regarding MT. A previous Belgian research study reported by Peeters et al21 explored patients’ attitudes toward MT using a semistructured questionnaire of 10 items that focused on patients’ overall opinion about MT, their acceptance of MT in the case of different median OS benefits, symptom relief, or prolonged radiologic tumor control in the absence of an OS benefit. Their questionnaire also explored some aspects of MT itself, such as treatment administration, frequency, and side effects.21,22 We chose to repeat the same study, after adapting the questionnaire to our different cultural and health contexts and adding an evaluation of the physicians’ perceptions of patients’ attitudes toward MT. The present study was conducted in 2 steps. The first step was revision of the questionnaire. To check the suitability of the items in the original Belgian questionnaire to the Italian context, we conducted a focus group (FG) with oncologists. FGs are defined as “carefully planned series of discussions designed to obtain perceptions on a defined area of interest in a permissive, nonthreatening environment.”23 The primary aim of FGs is to describe and understand the meaning and interpretation to achieve agreement regarding a specific issue from the perspective of the FG participants.24,25 The FG included 8 physicians engaged in lung cancer treatment from different areas of Italy to assess their beliefs about MT for patients with advanced NSCLC. We explored their opinions on the expected clinical benefit from therapy and any risks and their effect on patients in terms of QoL and expectations. Moreover, the setting of communication, the main reactions, and the questions and doubts raised by patients were included. The FG was recorded to inform the participants about the process. The original Belgian questionnaire was then adapted using the information obtained by the FG. Subsequently, we composed a first 12-item semistructured questionnaire addressed to patients and a second one adapted to evaluate the physicians’ perceptions of their patients’ attitudes toward MT. In the second step, the experimental phase, the modified version of the questionnaire was administered to patients about to start or who had just started first-line CTX induction. The inclusion criteria for the patients were age > 18 years, about to start or just starting first-line CTX, epidermal growth factor receptor (EGFR) wild-type status (those with EGFR-mutant NSCLC were eligible but had to have been previously treated with an EGFR tyrosine kinase inhibitor), and the absence of relevant clinical conditions contraindicating the use of CTX.
Maria Vittoria Pacchiana et al Patients were identified by their treating physicians and prospectively recruited by the clinical staff. We excluded patients who could not speak Italian fluently or who had any cognitive impairment that rendered them incapable of informed consent to participate in a survey. All the patients provided written informed consent before study enrollment. The potential subjects were approached in person to participate, and interested patients gave verbal assent and were registered. The patient evaluations were performed at the beginning of chemotherapy (T0) from December 2014 to February 2015 and again at the beginning of MT (T1) from March to July 2015. The physicians completed the survey only once during the study (at T0; Figure 1). The clinical data collected included patient age, gender, area of residence (Northern Italy, Central Italy, Southern Italy), family status, educational level, and whether they had been accompanied by relatives during the consultation. The physician characteristics recorded included age, gender, area of residence, medical specialty, and duration of experience in thoracic oncology.
Assessment The original Belgian self-administered questionnaire was modified using the information from the FG. We prepared a 12-item questionnaire exploring patients’ motivations and expectations in terms of OS and QoL. We added 2 items to consider patients’ level of discomfort resulting from not knowing the treatment duration and confidence in MT (Appendix A; online version).
In addition to the self-administered questionnaire, patients’ psychological distress was evaluated using the Distress Thermometer Questionnaire (DTQ).26 It is a scale on which patients circle their level of distress regarding the parts of life in which they are experiencing problems (ie, practical, family, emotional, spiritual/religious, physical; Appendix B; online version). The physicians’ perceptions of their patients’ experience were assessed using the revised 12-item questionnaire. The physicians were queried regarding the general trend of the attitudes toward MT they encountered in lung cancer patients in their experience (Appendix C; online version). They were interviewed regarding whether, in their experience, patients were motivated to undergo MT if MT would increase their life expectancy by 1 year, 6 months, 3 months, or 1 month or would improve symptom relief or prolong radiologic tumor control in the absence of an OS benefit. The questionnaire also included questions on some aspects of MT itself, such as treatment administration, frequency, and side effects. They were also asked about how much their patients could be influenced to undergo MT according to: the side effects, the uncertainty of the duration of therapy and to their own emotional state.
Results From December 2014 to February 2015, using the inclusion criteria, we identified an initial eligible study population of 92 patients and 37 physicians (Table 1). More than one half of the 92 patients were men (58.7%), and the median age was 63.9 years.
Figure 1 Study Flow
Abbreviations: CTX ¼ platinum-based chemotherapy plus pemetrexed; EGFR ¼ epidermal growth factor receptor; MT ¼ maintenance therapy; NSCLC ¼ nonesmall-cell lung cancer; T0 ¼ baseline (before induction chemotherapy); T1 ¼ after induction chemotherapy but before MT.
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Maintenance Therapy for Advanced NSCLC: Patients and Physicians Compared
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Most patients were married (72.8%), had been accompanied by a relative (93.4%), and had a low educational level (64.1%). The median physician age was 41.1 years, and 51.4% were women. Most of the physicians were oncologists (81.1%), with < 10 years’ experience in thoracic oncology (56.7%). Of the 92 patients, 52 (56.5%) underwent MT and were reassessed from April 2015 to July 2015. Forty patients (43.5%) did not receive MT, 34 (36.9%) because of disease progression after induction chemotherapy and 6 (6.6%) for other reasons. Our survey showed that of the 92 included patients, 78.9% at T0 were in favor of MT and 21.1% were undecided. At T1, 86.5% were in favor and 11.6% were undecided. No patient definitely refused MT. At T0, 100% of the physicians thought their patients would be in favor of MT (Figure 2). Most of the patients considered MT to be acceptable if the expected OS benefit was 3 months (T0, 59.8%; T1, 67.3%), 6 months (T0, 73.9%; T1, 78.9%), or 1 year (T0, 85.9%; T1, 92.2%). The acceptance of MT for an OS benefit of 1 month decreased to 51.9% at T0 and 44.2% at T1 (Figure 2). Also, the great majority of patients (75% and 71.2% at T0 and T1, respectively) showed rather greater acceptance of MT when a relief in symptoms was expected, even without an increase in OS. The patients also reported acceptance of MT with the possibility of radiologic tumor control, even in the absence of an OS benefit or relief of symptoms (69.3% at T0 and 73.1% at T1; Figure 2). When comparing the proportion of patients accepting MT for a median OS benefit of 1 year against the proportion with each of the other scenarios, all the differences were statistically significant using the McNemar test for paired data (Table 2). However, no statistically significant difference was found between the proportion of patients in favor of MT at T0 and the proportion in favor of MT at T1. Thus, receipt of induction chemotherapy had no significant effect on patients’ attitudes toward receiving MT. The assessment of distress showed an equal spread among the distress levels (Figure 3). At T0, 33.7% of patients recorded a score of 7 (maximum score). At T1, 26.9% of the patients recorded a score of 7. This cutoff value of 7 is indicative of severe distress. The most frequently identified problems were in the emotional categories of the DTQ (depression, fear, nervousness, sadness, worry). Moreover, patients reported more physical problems in relation to fatigue, breathing, sleep, and pain. We also evaluated how the presence of stress might affect patients’ willingness to undergo MT. The investigations conducted did not show any significant association between the different levels of distress (divided into 3 categories) and the willingness to undergo MT (regardless of the proposed benefit) at either T0 or T1. The data also did not show any other significant association between other parameters (distress level, age, gender, residence) and patients’ willingness to receive MT. In the comparison between patient attitudes and the physicians’ perceptions of their patients’ attitudes, the data showed agreement between the patients’ (T0, 59.8%; T1, 67.3%) and physicians’ (62.2%) perceptions of the patients attitudes for a life increase expectation of 3 months (Figure 2). When the proposed OS benefit decreased to 1 month, the 2 perceptions split, with 13.5% of
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Table 1 Characteristics of Physicians and Cancer Patients Characteristic
Patients (n [ 92)
Physicians (n [ 37)
Gender (%) Male
58.7
48.6
Female
41.3
51.4
Age (y) Median
63.9
41.1
Range
33-81
26-62
Marital status (%) Single
NA 3.3
Separated/divorced
11.9
Married/cohabitation
72.8
Widower
12
Education level (%)
NA
Primary school
23.8
Middle school
40.3
High school
27.2
College degree or higher
8.7
Relative present (%)
NA
No
3.3
Yes
93.4
Not rated
3.3
Residence (%) North
41.3
45.9
Center
19.6
16.2
South
39.1
37.9
Medical specialty (%)
NA
Oncology
81.1
Pneumology
8.1
Internal medicine
2.7
Other Experience in thoracic oncology (%) <10 y
8.1 NA 56.7
10-20 y
32.5
>20 y
10.8
Abbreviation: NA ¼ not applicable.
physicians believing that the patients would accept MT compared with 51.9% of the patients at T0 and 44.2% at T1 recording acceptance of MT. Concerning patients’ attitudes toward MT with only the expectation of radiologic tumor stabilization in the absence of OS benefit, a discrepancy was again seen between the clinicians’ perception and that of the patients. The latter were clearly in favor of MT (T0, 69.3%; T1, 73.1%). In contrast, only 37.8% of physicians thought their patients would favor MT (Figure 2). However, the physicians and patients were in greater agreement regarding the value of symptom control compared with any gain in OS of < 6 months. In addition, in the case of no defined OS benefit, more physicians (97%) than patients (75%) believed that patients would be favorable to MT, although the percentages remained high for both groups (Table 3). Similar results were reported for a very great OS benefit
Maria Vittoria Pacchiana et al Figure 2 Attitudes Toward Maintenance Therapy (MT) Comparing Patients’ Attitudes and Physicians’ Perception of the Patients Attitudes. (A) “Would You Be Interested in Continuing MT After 4 to 6 Cycles of Chemotherapy, rather than Have a Treatment-free Period?” (B) “Would You Be Interested in Undergoing MT if It Would Improve Your Life Expectancy by About 1 Year, 6 Months, 3 Months, or 1 Month?” (C) “Would You Be Interested in Undergoing MT if It Would Provide No Survival Benefit but Would Result in Symptom Control or Radiologic Tumor Stabilization?”
Abbreviations: OS ¼ overall survival; PHYS ¼ physicians; T0 ¼ baseline (before induction chemotherapy); T1 ¼ after induction chemotherapy but before MT.
(12 months). In contrast, in the case of a very small OS benefit, such as 1 month, the percentage of physicians expecting patients to favor MT was significantly lower (14%) than that of the patients (46%) actually in favor of MT. Also, in the case of no survival difference, but the possibility of radiologic tumor control, more patients (62%) would agree to MT than the physicians would have expected (38%). Finally, with an average expected benefit for pemetrexed of 3 months, no significant differences were seen between the physicians and patients (61% of patients vs. 62% of physicians).
Discussion Our results showed that most patients had a positive attitude toward MT and the attitude of the patients toward MT did not change during therapy from T0 to T1. This probably resulted from the motivation of the patients and their commitment to treatment. These results suggest that the induction treatment experience has no significant effect on patients’ perspectives toward MT. It was interesting that for most patients, MT would be acceptable if the expected gain in OS were minimal. Thus, the increase in the number of OS months was more important to the clinicians’ perceptions than to the patients’ attitudes. Patients attributed a high value to symptom relief, confirming the importance to the patients to maintain a good level of QoL, even without prolongation of OS. The patients were also in favor of MT
for radiologic tumor stabilization. The patients believed that radiologic disease stabilization would also result in stabilization of their clinical condition. The DTQ revealed that our patients had a high distress level, in accordance with the published data. Lung cancer patients are especially prone to psychological distress, which can be increased by feelings of guilt or self-blame owing to their smoking. Regardless, the level of distress was unrelated to patients’ motivation to undergo MT. Those with severe distress must be identified as quickly as possible to approach them with personalized treatment. Finally, a discrepancy was seen between patients’ attitudes toward and physicians’ perceptions of patients’ attitudes toward an MT benefit. In the context of a realistic life expectation of 1 to 3 months, the patients had a level of motivation toward MT greater than what physicians might expect. The patients considered, in addition to the oncologic aims, the significance of chemotherapy in relational terms. That is, the receipt of MT means to patients that they will continue to receive care from the medical team and to feel protected. Thus, for the patients, it was still important to receive MT even for an expected OS benefit of only 1 month.
Conclusion We believe that these findings could help doctorepatient communications and increase the possibility of targeting treatment to
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Maintenance Therapy for Advanced NSCLC: Patients and Physicians Compared Table 2 McNemar Correlation Between Patient Attitudes Toward MT and Decrease in Life Expectancy (Comparison of Paired Data)a Patients Would Choose MT Patients (n)
No/Unsure
Yes
92 (NE ¼ 2)
1-y OS benefit vs. 6-mo OS benefit
.0026
No/unsure
11 (100)
0 (0)
Yes
11 (14)
68 (86)
90 (NE ¼ 2)
<.0001
1-y OS benefit vs. 3-mo OS benefit
No/unsure Yes 89 (NE ¼ 3)
11 (100)
0 (0)
24 (30)
55 (70) <.0001
1-y OS benefit vs. 1-mo OS benefit
No/unsure Yes 89 (NE ¼ 3)
11 (100)
0 (0)
37 (47)
41 (53)
1-y OS benefit vs. no OS difference but symptom control
No/unsure Yes 90 (NE ¼ 2)
.006
9 (82)
2 (18)
14 (18)
64 (82)
Yes
Questionnaire Results at T0 Generic 1-y OS benefit 6-mo OS benefit 3-mo OS benefit 1-mo OS benefit No survival difference but symptom control No survival difference but tumor control
7 (64)
4 (36)
27 (34)
52 (66)
Data in parentheses are percentages. Abbreviations: MT ¼ maintenance therapy; NE ¼ not evaluable; OS ¼ overall survival. a All percentages are row percentages.
patients’ perceptions and needs. Although it could be difficult for physicians to not attribute the maximum relevance to OS, they should remember that patients’ objectives of therapy, in particular, for MT, could be mainly related to symptom control and QoL. Different reports of MT in lung cancer have underlined the importance of considering patient expectations when deciding to administer MT. The results of our trial could help in this context.
Clinical Practice Points
MT after CTX has become a common treatment strategy for
NSCLC patients. Because this strategy does not allow for a treatment-free interval, the benefit of MT should be weighed against the potential
Figure 3 Global Distress Score
Patients Accepting MT 68/91 79/90 68/90 55/90 41/89 66/89
(75) (88) (76) (61) (46) (74)
56/90 (62)
Physicians Believing Their Patients Would Accept MT 36/37 37/37 33/37 23/37 5/37 29/37
(97) (100) (89) (62) (14) (78)
14/37 (38)
P Value (c2) .003 .03 .08 .91 .0005 .62 .01
Data in parentheses are percentages. Abbreviations: MT ¼ maintenance therapy; OS ¼ overall survival; T0 ¼ baseline, before chemotherapy induction.
<.0001
1-y OS benefit vs. no OS difference but tumor control
No/unsure
P Value (vs. 1-y OS Benefit)
Table 3 Physicians’ Perceptions of Patients’ Attitude Toward MT Compared With Patients’ Attitudes Toward MT
burden of long-term treatment; thus, patients’ perceptions and preferences should be considered when determining the best management strategy. Few published studies have explored patients’ opinions and physicians’ perceptions of patients’ attitudes regarding MT. Because structured data were lacking, we developed a pilot protocol to evaluate patients’ attitudes toward MT and the expected benefit. We also sought to provide data regarding physicians’ awareness of patients’ inclinations. Our results showed that 78.9% of patients were in favor of MT at T0 (beginning of CTX) and 86.5% at T1 (beginning of MT), with all physicians believing their patients would be in favor of MT. Patients’ attitudes toward MT did not change during therapy, probably because their motivation was their commitment to treatment. Patients attributed a high value to symptom relief, even without an increase in OS. Patients’ attitudes and physicians’ perception of their patients’ attitudes conflicted in some aspects. We believe these findings could help doctorepatient communications and the possibility of targeting treatment to patients’ perceptions and needs.
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Acknowledgments
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The present study was supported by Women Against Lung Cancer in Europe NPO. We thank the participating patients and their families, the physicians and institutions involved in this study.
25 20
T1
15 10
Disclosure
5 0 ≤4
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NOT RATED
S. Novello is a member of the speaker’s bureau for Eli Lilly, MSD, Roche, and BMS; D. Cortinovis is a scientific consultant for BI, Eli Lilly, and Roche; A. Del Conte is a member of the advisory board for Eli Lilly; M. Di Maio is a consultant for Eli Lilly, Merck Sharp and
Maria Vittoria Pacchiana et al Dohme, Bayer, Novartis, and AstraZeneca and is a member of the speaker’s bureau of Boehringer Ingelheim. D. Galetta is a member of the advisory board for Eli Lilly; C. Gridelli is a member of the advisory board and speaker’s bureau for Eli Lilly; A. Rossi is a member of the advisory board and speaker’s bureau for Eli Lilly. The remaining authors declare that they have no competing interests.
Supplemental Data Supplemental appendix accompanying this article can be found in the online version at http://dx.doi.org/10.1016/j.cllc.2016.10. 002.
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8. Tariman JD, Berry DL, Cochrane B, et al. Preferred and actual participation roles during health care decision making in persons with cancer: a systematic review. Ann Oncol 2010; 21:1145-51. 9. Tariman JD, Berry DL, Cochrane B, et al. Physician, patient and contextual factors affecting treatment decisions in older adults with cancer: a literature review. Oncol Nurs Forum 2012; 39:E70-83. 10. Hirose T, Horichi N, Ohmori T, et al. Patients preferences in chemotherapy for advanced non-small-cell lung cancer. Intern Med 2005; 44:107-13. 11. Kassirer JP. Incorporating patients’ preferences into medical decisions. N Engl J Med 1994; 330:895-6. 12. Schofield PE, Butow PN, Thompson JF, et al. Psychological responses of patients receiving a diagnosis of cancer. Ann Oncol 2003; 14:48-56. 13. Polanski J, Jankowska-Polanska B, Rosinczuk J, et al. Quality of life of patients with lung cancer. Oncol Targets Ther 2016; 9:1023-8. 14. Giese-Davis J, Waller A, Carlson LE, et al. Screening for distress, the 6th vital sign: common problems in cancer outpatients over one year in usual care: associations with marital status, sex, and age. BMC Cancer 2012; 12:441. 15. Howell D, Olsen K. Distress: the 6th vital sign. Curr Oncol 2011; 18:208-10. 16. Bruera E, Sweeney C, Calder K, et al. Patient preferences versus physician perceptions of treatment decisions in cancer care. J Clin Oncol 2001; 19:2883-5. 17. Chu DT, Kim SW, Kuo HP, et al. Patient attitudes towards chemotherapy as assessed by patient versus physician: a prospective observational study in advanced non-small cell lung cancer. Lung Cancer 2007; 56:433-43. 18. Davidson PM, Jiwa M, Goldsmith AJ, et al. Decisions for lung cancer chemotherapy: the influence of physician and patient factors. Support Care Cancer 2011; 19:1261-6. 19. Slevin ML, Stubbs L, Plant HJ, et al. Attitudes to chemotherapy: comparing views of patients with cancer with those of doctors, nurses and general public. BMJ 1990; 300:1458-60. 20. Sørensen JB, Rossel P, Holm S. Patientephysician communication concerning participation in cancer chemotherapy trials. Br J Cancer 2004; 90:328-32. 21. Peeters L, Sibille A, Anrys B, et al. Maintenance therapy for advanced nonesmallcell lung cancer. J Thorac Oncol 2012; 7:1291-5. 22. Dooms CA, Pat KE, Vansteenkiste JF. The effect of chemotherapy on symptom control and quality of life in patients with advanced non-small cell lung cancer. Expert Rev Anticancer Ther 2006; 6:531-44. 23. Krueger RA, Casey MA. Focus Group: A Practical Guide for Applied Research. 3rd ed. Thousand Oaks, CA: Sage Publications; 2000. 24. Barbour RS. Making sense of focus groups. Med Educ 2005; 39:742-50. 25. Morgan DL. Focus Groups as Qualitative Research. 2nd ed. Thousand Oaks, CA: Sage Publications; 1997. 26. Lynch J, Goodhart F, Saunders Y, et al. Screening for psychological distress in patients with lung cancer: results of a clinical audit evaluating the use of the patient Distress Thermometer. Support Care Cancer 2011; 19:193-202.
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Patients’ Attitudes and Physicians’ Perceptions Toward Maintenance Therapy for Advanced NoneSmall-cell Lung Cancer: A Multicenter Italian Survey Maria Vittoria Pacchiana,1 Enrica Capelletto,1 Simona Carnio,1 Cesare Gridelli,2 Antonio Rossi,2 Domenico Galetta,3 Elisabetta Sara Montagna,3 Paola Bordi,4 Anna Ceribelli,5 Diego Cortinovis,6 Vieri Scotti,7 Olga Martelli,8 Giuseppe Valmadre,9 Alessandro Del Conte,10 Annamaria Miccianza,11 Raffaella Morena,12 Francesco Rosetti,13 Massimo Di Maio,1 Luca Ostacoli,14 Silvia Novello1 Abstract One question is how long patients with advanced nonesmall-cell lung cancer wish to receive therapy. The perceptions of > 100 patients and physicians were analyzed to compare different prognostic conditions. The patients’ attitudes were generally positive and not directly linked to the expected benefits, suggesting that other factors in conjunction with the clinical assessment, such as the doctorepatient relationship, should be considered to understand patients’ motivations. Introduction: Pemetrexed maintenance therapy (MT) after induction with platinum-based chemotherapy has recently become a common treatment strategy for advanced nonsquamous nonesmall-cell lung cancer (NSCLC). However, the benefits of MT should be weighed with consideration of the patients’ perceptions and preferences. The aim of the present study was to evaluate patients’ attitudes toward MT and to describe physicians’ awareness of their patients’ inclinations. Materials and Methods: We administered a 12-question anonymous survey and the Distress Thermometer Questionnaire to patients with advanced or recurrent nonsquamous NSCLC. The survey was also distributed to the referring physicians. Results: From December 2014 to July 2015, 92 patients and 37 physicians were enrolled. All 92 patients completed the questionnaire at T0 (before starting chemotherapy) and 56.5% also did so at T1 (after completion of induction). The physicians completed the survey only at T0. Most patients had a positive attitude toward MT at both T0 (78.9%) and T1 (86.5%), and 100% of the physicians thought their patients would be in favor of MT. The physicians believed that their patients’ attitudes toward MT would decrease proportionally with the reduction in the magnitude of the overall survival increase and expected benefits. The decrease expected by the physicians was much greater than that reported by the patients. This was especially true for an overall survival increase as small as 1 month (51.9% of patients accepting MT vs. 13.5% supposed by physicians) or when the only treatment benefit was radiologic tumor stabilization (69.3% of patients accepting MT vs. 37.8% supposed by physicians).
1
11
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12
Department of Oncology, University of Turin, Orbassano, Italy Division of Medical Oncology, S.G. Moscati Hospital, Avellino, Italy 3 Clinical Cancer Center “Giovanni Paolo II”, Bari, Italy 4 Medical Oncology Unit, University Hospital of Parma, Parma, Italy 5 Medical Oncology Unit, Regina Elena Cancer Institute, Rome, Italy 6 Medical Oncology Unit, San Gerardo Hospital, Monza, Italy 7 Oncology Department, Radiation Therapy Unit, Careggi Hospital, Florence, Italy 8 Medical Oncology Unit, San Giovanni Addolorata Hospital, Rome, Italy 9 Medical Oncology Unit, E. Morelli Hospital, Sondalo, Italy 10 Medical Oncology Unit, Santa Maria degli Angeli Hospital, Pordenone, Italy
1525-7304/$ - see frontmatter ª 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.cllc.2016.10.002
Medical Oncology Unit, D. Camberlingo Francavilla Fontana Hospital, Brindisi, Italy Medical Oncology Unit, Saronno Hospital, Saronno, Italy Oncology and Hematology Unit, ULSS 13, Mirano, Italy 14 Department of Clinical and Biological Science, University of Turin, Orbassano, Italy 13
Submitted: Jul 11, 2016; Revised: Oct 17, 2016; Accepted: Oct 18, 2016 Address for correspondence: Maria Vittoria Pacchiana, PsyD, Department of Oncology, University of Turin, Regione Gonzole 10, Orbassano, TO 10043, Italy E-mail contact: [email protected]
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Maintenance Therapy for Advanced NSCLC: Patients and Physicians Compared Conclusion: NSCLC patients have a generally positive attitude toward MT, which is not directly proportional to the expected benefits and greater than the attitude expected by physicians. Clinical Lung Cancer, Vol. -, No. -, --- ª 2016 Elsevier Inc. All rights reserved. Keywords: Doctor-patient relationship, Maintenance therapy, NSCLC, Patients’ perceptions, Quality of life
Introduction
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The current standard of care for the vast majority of patients with advanced nonesmall-cell lung cancer (NSCLC) is 4 to 6 cycles of platinum-based doublet chemotherapy. However, these schemes have led to a modest prolongation of survival, with < 5% of patients alive at 5 years.1,2 Pemetrexed maintenance therapy (MT) after induction with platinum-based chemotherapy plus pemetrexed (CTX) has recently become a common treatment strategy for NSCLC patients because it has extended survival, delayed disease progression, and maintained quality of life (QoL).3,4 However, MT is a treatment strategy that does not allow for a treatment-free interval; therefore, patients’ perception and preferences should be carefully considered in determining the therapeutic strategy.5-7 Decision-making has been defined as the cognitive process of reaching a decision.8,9 It often involves balancing the benefits and risks among multiple options. Several factors are involved in treatment decisions, including the physician’s personal beliefs, values, expertise, and practice type, perception of life expectancy, medical factors, and communication style. However, several patient factors are also involved, such as personal beliefs, values, and decisional control preferences, previous health-related experience, perception of the decision-making process, and contextual factors, including the availability of a caregiver and the patient’s psychological health.10-12 Many findings in the published data have shown that people with cancer experience distress at some point, which can have negative implications, including reduced health-related QoL, greater longterm distress, poor satisfaction with medical care, and, possibly, reduced survival.13,14 The National Comprehensive Cancer Network defines distress as an unpleasant psychological, emotional, social, and/or spiritual experience that interferes with effective coping. It can include unease, sadness, worry, anger, helplessness, guilt, and so forth.15 Common psychosocial, practical, and physical problems can amplify the feelings of distress, and their assessment offers clinicians opportunities to facilitate planning for targeted clinical services.14 To date, the decision-making preferences of patients with lung cancer and physicians’ perceptions of these preferences, specifically toward MT, have not been prospectively studied. Patients’ attitudes should be considered because this clinical approach, which results in continued therapy after induction chemotherapy rather than an interval without treatment, could change the treatment experience. Information regarding patients’ considerations and perceptions of MT could increase clinicians’ understanding of their treatment preferences; however, few published data are available.16-20 The primary aim of the present study was to evaluate patients’ attitudes toward MT according to the expected benefits, such as overall survival (OS) and QoL, and to compare physicians’ perception of their patients’ attitudes with the attitudes of the
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patients. Our secondary aim was to evaluate the correlation of different degrees of stress with the patients’ attitudes.
Materials and Methods To the best of our knowledge, no published studies have examined the attitudes of patients with NSCLC and physicians’ perceptions of patients’ attitudes regarding MT. A previous Belgian research study reported by Peeters et al21 explored patients’ attitudes toward MT using a semistructured questionnaire of 10 items that focused on patients’ overall opinion about MT, their acceptance of MT in the case of different median OS benefits, symptom relief, or prolonged radiologic tumor control in the absence of an OS benefit. Their questionnaire also explored some aspects of MT itself, such as treatment administration, frequency, and side effects.21,22 We chose to repeat the same study, after adapting the questionnaire to our different cultural and health contexts and adding an evaluation of the physicians’ perceptions of patients’ attitudes toward MT. The present study was conducted in 2 steps. The first step was revision of the questionnaire. To check the suitability of the items in the original Belgian questionnaire to the Italian context, we conducted a focus group (FG) with oncologists. FGs are defined as “carefully planned series of discussions designed to obtain perceptions on a defined area of interest in a permissive, nonthreatening environment.”23 The primary aim of FGs is to describe and understand the meaning and interpretation to achieve agreement regarding a specific issue from the perspective of the FG participants.24,25 The FG included 8 physicians engaged in lung cancer treatment from different areas of Italy to assess their beliefs about MT for patients with advanced NSCLC. We explored their opinions on the expected clinical benefit from therapy and any risks and their effect on patients in terms of QoL and expectations. Moreover, the setting of communication, the main reactions, and the questions and doubts raised by patients were included. The FG was recorded to inform the participants about the process. The original Belgian questionnaire was then adapted using the information obtained by the FG. Subsequently, we composed a first 12-item semistructured questionnaire addressed to patients and a second one adapted to evaluate the physicians’ perceptions of their patients’ attitudes toward MT. In the second step, the experimental phase, the modified version of the questionnaire was administered to patients about to start or who had just started first-line CTX induction. The inclusion criteria for the patients were age > 18 years, about to start or just starting first-line CTX, epidermal growth factor receptor (EGFR) wild-type status (those with EGFR-mutant NSCLC were eligible but had to have been previously treated with an EGFR tyrosine kinase inhibitor), and the absence of relevant clinical conditions contraindicating the use of CTX.
Maria Vittoria Pacchiana et al Patients were identified by their treating physicians and prospectively recruited by the clinical staff. We excluded patients who could not speak Italian fluently or who had any cognitive impairment that rendered them incapable of informed consent to participate in a survey. All the patients provided written informed consent before study enrollment. The potential subjects were approached in person to participate, and interested patients gave verbal assent and were registered. The patient evaluations were performed at the beginning of chemotherapy (T0) from December 2014 to February 2015 and again at the beginning of MT (T1) from March to July 2015. The physicians completed the survey only once during the study (at T0; Figure 1). The clinical data collected included patient age, gender, area of residence (Northern Italy, Central Italy, Southern Italy), family status, educational level, and whether they had been accompanied by relatives during the consultation. The physician characteristics recorded included age, gender, area of residence, medical specialty, and duration of experience in thoracic oncology.
Assessment The original Belgian self-administered questionnaire was modified using the information from the FG. We prepared a 12-item questionnaire exploring patients’ motivations and expectations in terms of OS and QoL. We added 2 items to consider patients’ level of discomfort resulting from not knowing the treatment duration and confidence in MT (Appendix A; online version).
In addition to the self-administered questionnaire, patients’ psychological distress was evaluated using the Distress Thermometer Questionnaire (DTQ).26 It is a scale on which patients circle their level of distress regarding the parts of life in which they are experiencing problems (ie, practical, family, emotional, spiritual/religious, physical; Appendix B; online version). The physicians’ perceptions of their patients’ experience were assessed using the revised 12-item questionnaire. The physicians were queried regarding the general trend of the attitudes toward MT they encountered in lung cancer patients in their experience (Appendix C; online version). They were interviewed regarding whether, in their experience, patients were motivated to undergo MT if MT would increase their life expectancy by 1 year, 6 months, 3 months, or 1 month or would improve symptom relief or prolong radiologic tumor control in the absence of an OS benefit. The questionnaire also included questions on some aspects of MT itself, such as treatment administration, frequency, and side effects. They were also asked about how much their patients could be influenced to undergo MT according to: the side effects, the uncertainty of the duration of therapy and to their own emotional state.
Results From December 2014 to February 2015, using the inclusion criteria, we identified an initial eligible study population of 92 patients and 37 physicians (Table 1). More than one half of the 92 patients were men (58.7%), and the median age was 63.9 years.
Figure 1 Study Flow
Abbreviations: CTX ¼ platinum-based chemotherapy plus pemetrexed; EGFR ¼ epidermal growth factor receptor; MT ¼ maintenance therapy; NSCLC ¼ nonesmall-cell lung cancer; T0 ¼ baseline (before induction chemotherapy); T1 ¼ after induction chemotherapy but before MT.
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Maintenance Therapy for Advanced NSCLC: Patients and Physicians Compared
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Most patients were married (72.8%), had been accompanied by a relative (93.4%), and had a low educational level (64.1%). The median physician age was 41.1 years, and 51.4% were women. Most of the physicians were oncologists (81.1%), with < 10 years’ experience in thoracic oncology (56.7%). Of the 92 patients, 52 (56.5%) underwent MT and were reassessed from April 2015 to July 2015. Forty patients (43.5%) did not receive MT, 34 (36.9%) because of disease progression after induction chemotherapy and 6 (6.6%) for other reasons. Our survey showed that of the 92 included patients, 78.9% at T0 were in favor of MT and 21.1% were undecided. At T1, 86.5% were in favor and 11.6% were undecided. No patient definitely refused MT. At T0, 100% of the physicians thought their patients would be in favor of MT (Figure 2). Most of the patients considered MT to be acceptable if the expected OS benefit was 3 months (T0, 59.8%; T1, 67.3%), 6 months (T0, 73.9%; T1, 78.9%), or 1 year (T0, 85.9%; T1, 92.2%). The acceptance of MT for an OS benefit of 1 month decreased to 51.9% at T0 and 44.2% at T1 (Figure 2). Also, the great majority of patients (75% and 71.2% at T0 and T1, respectively) showed rather greater acceptance of MT when a relief in symptoms was expected, even without an increase in OS. The patients also reported acceptance of MT with the possibility of radiologic tumor control, even in the absence of an OS benefit or relief of symptoms (69.3% at T0 and 73.1% at T1; Figure 2). When comparing the proportion of patients accepting MT for a median OS benefit of 1 year against the proportion with each of the other scenarios, all the differences were statistically significant using the McNemar test for paired data (Table 2). However, no statistically significant difference was found between the proportion of patients in favor of MT at T0 and the proportion in favor of MT at T1. Thus, receipt of induction chemotherapy had no significant effect on patients’ attitudes toward receiving MT. The assessment of distress showed an equal spread among the distress levels (Figure 3). At T0, 33.7% of patients recorded a score of 7 (maximum score). At T1, 26.9% of the patients recorded a score of 7. This cutoff value of 7 is indicative of severe distress. The most frequently identified problems were in the emotional categories of the DTQ (depression, fear, nervousness, sadness, worry). Moreover, patients reported more physical problems in relation to fatigue, breathing, sleep, and pain. We also evaluated how the presence of stress might affect patients’ willingness to undergo MT. The investigations conducted did not show any significant association between the different levels of distress (divided into 3 categories) and the willingness to undergo MT (regardless of the proposed benefit) at either T0 or T1. The data also did not show any other significant association between other parameters (distress level, age, gender, residence) and patients’ willingness to receive MT. In the comparison between patient attitudes and the physicians’ perceptions of their patients’ attitudes, the data showed agreement between the patients’ (T0, 59.8%; T1, 67.3%) and physicians’ (62.2%) perceptions of the patients attitudes for a life increase expectation of 3 months (Figure 2). When the proposed OS benefit decreased to 1 month, the 2 perceptions split, with 13.5% of
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Table 1 Characteristics of Physicians and Cancer Patients Characteristic
Patients (n [ 92)
Physicians (n [ 37)
Gender (%) Male
58.7
48.6
Female
41.3
51.4
Age (y) Median
63.9
41.1
Range
33-81
26-62
Marital status (%) Single
NA 3.3
Separated/divorced
11.9
Married/cohabitation
72.8
Widower
12
Education level (%)
NA
Primary school
23.8
Middle school
40.3
High school
27.2
College degree or higher
8.7
Relative present (%)
NA
No
3.3
Yes
93.4
Not rated
3.3
Residence (%) North
41.3
45.9
Center
19.6
16.2
South
39.1
37.9
Medical specialty (%)
NA
Oncology
81.1
Pneumology
8.1
Internal medicine
2.7
Other Experience in thoracic oncology (%) <10 y
8.1 NA 56.7
10-20 y
32.5
>20 y
10.8
Abbreviation: NA ¼ not applicable.
physicians believing that the patients would accept MT compared with 51.9% of the patients at T0 and 44.2% at T1 recording acceptance of MT. Concerning patients’ attitudes toward MT with only the expectation of radiologic tumor stabilization in the absence of OS benefit, a discrepancy was again seen between the clinicians’ perception and that of the patients. The latter were clearly in favor of MT (T0, 69.3%; T1, 73.1%). In contrast, only 37.8% of physicians thought their patients would favor MT (Figure 2). However, the physicians and patients were in greater agreement regarding the value of symptom control compared with any gain in OS of < 6 months. In addition, in the case of no defined OS benefit, more physicians (97%) than patients (75%) believed that patients would be favorable to MT, although the percentages remained high for both groups (Table 3). Similar results were reported for a very great OS benefit
Maria Vittoria Pacchiana et al Figure 2 Attitudes Toward Maintenance Therapy (MT) Comparing Patients’ Attitudes and Physicians’ Perception of the Patients Attitudes. (A) “Would You Be Interested in Continuing MT After 4 to 6 Cycles of Chemotherapy, rather than Have a Treatment-free Period?” (B) “Would You Be Interested in Undergoing MT if It Would Improve Your Life Expectancy by About 1 Year, 6 Months, 3 Months, or 1 Month?” (C) “Would You Be Interested in Undergoing MT if It Would Provide No Survival Benefit but Would Result in Symptom Control or Radiologic Tumor Stabilization?”
Abbreviations: OS ¼ overall survival; PHYS ¼ physicians; T0 ¼ baseline (before induction chemotherapy); T1 ¼ after induction chemotherapy but before MT.
(12 months). In contrast, in the case of a very small OS benefit, such as 1 month, the percentage of physicians expecting patients to favor MT was significantly lower (14%) than that of the patients (46%) actually in favor of MT. Also, in the case of no survival difference, but the possibility of radiologic tumor control, more patients (62%) would agree to MT than the physicians would have expected (38%). Finally, with an average expected benefit for pemetrexed of 3 months, no significant differences were seen between the physicians and patients (61% of patients vs. 62% of physicians).
Discussion Our results showed that most patients had a positive attitude toward MT and the attitude of the patients toward MT did not change during therapy from T0 to T1. This probably resulted from the motivation of the patients and their commitment to treatment. These results suggest that the induction treatment experience has no significant effect on patients’ perspectives toward MT. It was interesting that for most patients, MT would be acceptable if the expected gain in OS were minimal. Thus, the increase in the number of OS months was more important to the clinicians’ perceptions than to the patients’ attitudes. Patients attributed a high value to symptom relief, confirming the importance to the patients to maintain a good level of QoL, even without prolongation of OS. The patients were also in favor of MT
for radiologic tumor stabilization. The patients believed that radiologic disease stabilization would also result in stabilization of their clinical condition. The DTQ revealed that our patients had a high distress level, in accordance with the published data. Lung cancer patients are especially prone to psychological distress, which can be increased by feelings of guilt or self-blame owing to their smoking. Regardless, the level of distress was unrelated to patients’ motivation to undergo MT. Those with severe distress must be identified as quickly as possible to approach them with personalized treatment. Finally, a discrepancy was seen between patients’ attitudes toward and physicians’ perceptions of patients’ attitudes toward an MT benefit. In the context of a realistic life expectation of 1 to 3 months, the patients had a level of motivation toward MT greater than what physicians might expect. The patients considered, in addition to the oncologic aims, the significance of chemotherapy in relational terms. That is, the receipt of MT means to patients that they will continue to receive care from the medical team and to feel protected. Thus, for the patients, it was still important to receive MT even for an expected OS benefit of only 1 month.
Conclusion We believe that these findings could help doctorepatient communications and increase the possibility of targeting treatment to
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Maintenance Therapy for Advanced NSCLC: Patients and Physicians Compared Table 2 McNemar Correlation Between Patient Attitudes Toward MT and Decrease in Life Expectancy (Comparison of Paired Data)a Patients Would Choose MT Patients (n)
No/Unsure
Yes
92 (NE ¼ 2)
1-y OS benefit vs. 6-mo OS benefit
.0026
No/unsure
11 (100)
0 (0)
Yes
11 (14)
68 (86)
90 (NE ¼ 2)
<.0001
1-y OS benefit vs. 3-mo OS benefit
No/unsure Yes 89 (NE ¼ 3)
11 (100)
0 (0)
24 (30)
55 (70) <.0001
1-y OS benefit vs. 1-mo OS benefit
No/unsure Yes 89 (NE ¼ 3)
11 (100)
0 (0)
37 (47)
41 (53)
1-y OS benefit vs. no OS difference but symptom control
No/unsure Yes 90 (NE ¼ 2)
.006
9 (82)
2 (18)
14 (18)
64 (82)
Yes
Questionnaire Results at T0 Generic 1-y OS benefit 6-mo OS benefit 3-mo OS benefit 1-mo OS benefit No survival difference but symptom control No survival difference but tumor control
7 (64)
4 (36)
27 (34)
52 (66)
Data in parentheses are percentages. Abbreviations: MT ¼ maintenance therapy; NE ¼ not evaluable; OS ¼ overall survival. a All percentages are row percentages.
patients’ perceptions and needs. Although it could be difficult for physicians to not attribute the maximum relevance to OS, they should remember that patients’ objectives of therapy, in particular, for MT, could be mainly related to symptom control and QoL. Different reports of MT in lung cancer have underlined the importance of considering patient expectations when deciding to administer MT. The results of our trial could help in this context.
Clinical Practice Points
MT after CTX has become a common treatment strategy for
NSCLC patients. Because this strategy does not allow for a treatment-free interval, the benefit of MT should be weighed against the potential
Figure 3 Global Distress Score
Patients Accepting MT 68/91 79/90 68/90 55/90 41/89 66/89
(75) (88) (76) (61) (46) (74)
56/90 (62)
Physicians Believing Their Patients Would Accept MT 36/37 37/37 33/37 23/37 5/37 29/37
(97) (100) (89) (62) (14) (78)
14/37 (38)
P Value (c2) .003 .03 .08 .91 .0005 .62 .01
Data in parentheses are percentages. Abbreviations: MT ¼ maintenance therapy; OS ¼ overall survival; T0 ¼ baseline, before chemotherapy induction.
<.0001
1-y OS benefit vs. no OS difference but tumor control
No/unsure
P Value (vs. 1-y OS Benefit)
Table 3 Physicians’ Perceptions of Patients’ Attitude Toward MT Compared With Patients’ Attitudes Toward MT
burden of long-term treatment; thus, patients’ perceptions and preferences should be considered when determining the best management strategy. Few published studies have explored patients’ opinions and physicians’ perceptions of patients’ attitudes regarding MT. Because structured data were lacking, we developed a pilot protocol to evaluate patients’ attitudes toward MT and the expected benefit. We also sought to provide data regarding physicians’ awareness of patients’ inclinations. Our results showed that 78.9% of patients were in favor of MT at T0 (beginning of CTX) and 86.5% at T1 (beginning of MT), with all physicians believing their patients would be in favor of MT. Patients’ attitudes toward MT did not change during therapy, probably because their motivation was their commitment to treatment. Patients attributed a high value to symptom relief, even without an increase in OS. Patients’ attitudes and physicians’ perception of their patients’ attitudes conflicted in some aspects. We believe these findings could help doctorepatient communications and the possibility of targeting treatment to patients’ perceptions and needs.
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Acknowledgments
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The present study was supported by Women Against Lung Cancer in Europe NPO. We thank the participating patients and their families, the physicians and institutions involved in this study.
25 20
T1
15 10
Disclosure
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NOT RATED
S. Novello is a member of the speaker’s bureau for Eli Lilly, MSD, Roche, and BMS; D. Cortinovis is a scientific consultant for BI, Eli Lilly, and Roche; A. Del Conte is a member of the advisory board for Eli Lilly; M. Di Maio is a consultant for Eli Lilly, Merck Sharp and
Maria Vittoria Pacchiana et al Dohme, Bayer, Novartis, and AstraZeneca and is a member of the speaker’s bureau of Boehringer Ingelheim. D. Galetta is a member of the advisory board for Eli Lilly; C. Gridelli is a member of the advisory board and speaker’s bureau for Eli Lilly; A. Rossi is a member of the advisory board and speaker’s bureau for Eli Lilly. The remaining authors declare that they have no competing interests.
Supplemental Data Supplemental appendix accompanying this article can be found in the online version at http://dx.doi.org/10.1016/j.cllc.2016.10. 002.
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