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US Food and Drug Administration Analysis of Patient-Reported Diarrhea and Its Impact on Function and Quality of Life in Patients Receiving Treatment for Breast Cancer

Published:November 08, 2021DOI:https://doi.org/10.1016/j.jval.2021.09.007

      Highlights

      • Many trials report “no meaningful difference” in health-related quality of life (HRQL) or function between arms despite observing notable differential toxicity. A possible explanation is that mean change from baseline analyses of function or HRQL can obscure important change in subgroups experiencing symptomatic toxicity.
      • In our case examples, for those patients who remained on treatment and completed patient-reported outcome assessments, there was a greater proportion of patients in the treatment arm reporting diarrhea. Patients reporting more frequent diarrhea reported lower physical functioning and global health status and quality of life than patients with no diarrhea, regardless of treatment arm.
      • When differential toxicity between arms is observed, additional exploratory analyses aided by data visualization that evaluate functioning or HRQL by symptomatic adverse event are needed. This information can further inform the safety and tolerability of the investigational agent under study.

      Abstract

      Objectives

      Many trials conclude “no clinically meaningful detriment” to health-related quality of life (HRQL) or function between arms, even when notable differential toxicity is observed. Mean change from baseline analyses of function or HRQL can possibly obscure important change in subgroups experiencing symptomatic toxicity. We evaluate the impact of diarrhea, a key treatment arm toxicity, on patient-reported HRQL and functioning in clinical trials submitted to US Food and Drug Administration.

      Methods

      This study used 4 randomized, breast cancer trials (adjuvant to late-line metastatic) as case examples. Diarrhea, physical functioning (PF), and global health status and quality of life (GHS/QoL) from the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-C30 were analyzed at baseline and approximately 3 and 6 months.

      Results

      Generally, patients reporting very much diarrhea at months 3 and 6 had worse PF (9-19 points lower) and GHS/QoL (16-19 points lower) than patients reporting no diarrhea regardless of treatment arm. In the change from baseline analysis, patients reporting very much diarrhea also experienced a greater decrease in PF (6-13 points) and GHS/QoL (6-16 points) versus patients reporting no diarrhea in both arms.

      Conclusions

      In trials with moderate to large differences in symptomatic toxicity by arm, reporting “no meaningful difference in functioning and HRQL between arms” based on mean change from baseline analysis is insufficient and may obscure important impacts on subgroups experiencing symptomatic adverse events. Additional exploratory analyses with simple data visualizations evaluating functioning or HRQL in patient subgroups experiencing expected symptomatic toxicities can further inform the safety and tolerability of an investigational agent.

      Keywords

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      References

        • Bordoni R.
        • Ciardiello F.
        • von Pawel J.
        • et al.
        Patient-reported outcomes in OAK: a phase III study of atezolizumab versus docetaxel in advanced non-small-cell lung cancer.
        Clin Lung Cancer. 2018; 19: 441-449.e4
        • Huddart R.A.
        • Hall E.
        • Lewis R.
        • et al.
        Patient-reported quality of life outcomes in patients treated for muscle-invasive bladder cancer with radiotherapy ± chemotherapy in the BC2001 phase III randomised controlled trial.
        Eur Urol. 2020; 77: 260-268
        • Mansfield A.S.
        • Kazarnowicz A.
        • Karaseva N.
        • et al.
        Safety and patient-reported outcomes of atezolizumab, carboplatin, and etoposide in extensive-stage small-cell lung cancer (IMpower133): a randomized phase I/III trial.
        Ann Oncol. 2020; 31: 310-317
        • Saad F.
        • Cella D.
        • Basch E.
        • et al.
        Effect of apalutamide on health-related quality of life in patients with non-metastatic castration-resistant prostate cancer: an analysis of the SPARTAN randomised, placebo-controlled, phase 3 trial.
        Lancet Oncol. 2018; 19: 1404-1416
        • Tombal B.
        • Saad F.
        • Penson D.
        • et al.
        Patient-reported outcomes following enzalutamide or placebo in men with non-metastatic, castration-resistant prostate cancer (PROSPER): a multicentre, randomised, double-blind, phase 3 trial.
        Lancet Oncol. 2019; 20: 556-569
        • Tanniou J.
        • van der Tweel I.
        • Teerenstra S.
        • Roes K.C.
        Subgroup analyses in confirmatory clinical trials: time to be specific about their purposes.
        BMC Med Res Methodol. 2016; 16: 20
        • Kluetz P.G.
        • Slagle A.
        • Papadopoulos E.J.
        • et al.
        Focusing on core patient-reported outcomes in cancer clinical trials: symptomatic adverse events, physical function, and disease-related symptoms.
        Clin Cancer Res. 2016; 22: 1553-1558
        • Fiero M.H.
        • Roydhouse J.K.
        • Vallejo J.
        • King-Kallimanis B.L.
        • Kluetz P.G.
        • Sridhara R.
        US Food and Drug Administration review of statistical analysis of patient-reported outcomes in lung cancer clinical trials approved between January, 2008, and December, 2017.
        Lancet Oncol. 2010; 20: e582-e589
        • Aaronson N.K.
        • Ahmedzai S.
        • Bergman B.
        • et al.
        The European Organization for Research and Treatment of Cancer QLQ-C30: a quality-of-life instrument for use in international clinical trials in oncology.
        J Natl Cancer Inst. 1993; 85: 365-376
      1. Common Terminology Criteria for Adverse Events (CTCAE), version 4.0. U.S. Department of Health and Human Services, National Institute of Health, National Cancer Institute.
        • Gresham G.
        • Diniz M.A.
        • Razaee Z.S.
        • et al.
        Evaluating treatment tolerability in cancer clinical trials using the toxicity index.
        J Natl Cancer Inst. 2020; 112: 1266-1274
        • Roydhouse J.K.
        • King-Kallimanis B.L.
        • Roy P.
        • et al.
        Exploration of baseline patient-reported side effect bother from cancer therapy.
        Clin Trials. 2020; 17: 332-337